Journal of School of Public Health and

---

---

Background and Aim: For achievement of equity in the population health the implementation of health in all policies is essential. The most crucial intervention in this approach is inter-sectoral collaboration.
 Materials and Methods: This was a qualitative study based on the national policy framework. Data were collected using literature review, in-depth interviews and focus group discussions with the stakeholders. The results were categorized into three sections, namely, situational analysis and factors affecting it, developing goals and objectives, and requirements and interventions.
 Results: Currently inter-sectoral collaboration in the Iranian health system potentially allows to have health in all policies policy in terms of explicit legislative support, national macro-policies/upstream documents and organizational structure. It will require proper planning as regards designing and institutionalizing appropriate mechanisms for collaboration, as well as cultural and skills capacity building, for stakeholders within and outside the health sector.
Conclusion: The findings of this study can be used in annual operational planning of the High Council of Health and Food Security secretariat.

---

Background and Aim: Economic evaluation of health interventions by comparing the relevant costs and benefits will result in optimum allocation of resources and increasing the effectiveness of the health system and, through improving equity and increasing accessibility to health services, will lead to increased effectiveness of the health system. The purpose of this study was to critically evaluate the Cost Effectiveness Analysis (CEA) studies on health interventions worldwide.
Materials and Methods: A critical review of the published CEA studies on health interventions was conducted. Seven databases including PubMed, Cochrane Database of Systematic Reviews, Web of science, Science Direct, Scopus, Springer Link, and SID were searched between 1975 and 2018, using appropriate keywords. The retrieved articles were evaluated using the Drummond (2005) quality assessment checklist. Overall, 173 articles met the entry criteria and were included in this study.
Results: CEA of health-related interventions were classified into six categories, namely, studies on immunization, education, nutrition, sexually transmitted diseases prevention, gynecological diseases prevention and vector-borne diseases and, eventually, cost-effective interventions were identified. Further analysis of the data showed that the methods used in health intervention CEA studies are very heterogeneous and lack sufficient scientific quality especially in developing countries. Researchers working in this area should pay more attention when designing studies and follow valid guidelines for CEA, particularly as regards research methods, sample size, CEA model, cost and benefit calculations, determining effectiveness, timeframe and, finally,  analysis of  the sensitivity and validity the research data.
Conclusion: The number of cost effectiveness analysis and cost utility studies has increased greatly during the last two decades. In order to improve the quality of these studies it is essential to revise the guidelines and procedures for economic evaluation of health interventions and train and update researchers in this area.

---

Background and Aim: Nowadays foodborne diseases are a serious concern globally. Due to unsound use of antibiotics various pathogens are involved in foodborne diseases, S. aureus being the most common cause of food poisoning. Methicillin-resistant Staphylococcus aureus (MRSA) strains are a serious threat for the public’s health worldwide. The objective of this study was to determine the extent of contamination of foods offered in the South of Tehran, Iran with MRSA strains in 2018-19.
Materials and Methods: In this descriptive study, 560 food samples were collected from different regions in the south of Tehran, Shahr-e-Rey and Islamshahr between June 2018 and May 2019 and sent to a laboratory to determine the presence of S. aureus according to the Iranian National Standard No.1194 methods. In addition, the antibiotic sensitivity of the S. aureus species was determined using the Disk Diffusion Test.
Results: Of the 560 samples, 49 (8.7%) were found to be contaminated with S.aureus. Pastry, traditional ice cream and raw protein foods were the most contaminated foodstuffs. Four 4 (8.2%) of the 49 S. aureus isolates were found to be resistant to methicillin.
Conclusion: Considering the importance of S. aureus in causing food poisoning and the possibility of transfer of species resistant to antibiotics, especially methicillin, through foods, it is vital to pay special attention to sound use of antibiotics.    

---

Background and aim: Despite rapid diagnostic and therapeutic advances, patients with chronic coronary artery disease (CCAD) should adopt self-care behaviors. This study aimed to determine predictors of perceived health competence among CCAD patients in Tehran, Iran in 2019-2020.
Materials and Methods: This cross-sectional study was conducted among 700 patients with CCAD referred to Shahid-Rajaie Cardiovascular Center in Tehran selected using the available sampling method. Data were collected using the perceived health competence scale (PHCS), 12-item quality of life scale and Modanloo's adherence to treatment scale questionnaires. The content validity ratio and content validity index were used to determine validity, and the Cronbach's alpha to determine reliability, of the PHCS questionnaire. Data analysis was performed using descriptive statistics, Pearson correlation coefficient, Structural Equation Modeling (SEM), the software being SPSS₂₅.
Results: The multivariate regression analysis showed that perceived health competence had statistically significant direct associations with physical (β = 1.08, p< 0.001) and psychological (β = 0.85, p< 0.001) domains of quality of life, commitment to treatment (β = 0.12, p =0.01), willingness to participate in treatment (β = 0.12, p = 0.05) and uncertainty about implementation (p = 0.1, p‹ 0.001) of adherence to treatment. There was a significant indirect association between age and perceived health competence (β = -0.13, p = 0.03).
Conclusion: Based on the findings, considering a “very good” and a “poor” mean score for adherence and the quality of life among the patients, respectively, adopting strategies for promoting quality of life in both the physical and mental dimensions can lead to improvements in perceived health competence in cardiovascular patients. In addition, it seems that focusing on subscales of “willingness to participate in treatment” might help in improving the patients' perceived health competence.

---

Background and Aim: It is essential to take action to strengthen the national primary health care (PHC) system. The purpose of this study was to conduct a comprehensive review to find ways to strengthen the PHC system in Iran based on the experiences of different countries.
Materials and Methods: This was a comprehensive review study. The relevant studies were retrieved using Science Direct, PubMed, Google Scholar, Scopus, Web of Science, Magiran, Iranmedex and SID databases. Inclusion criteria included all the studies that specifically focused on the factors enhancing the PHC system between 1998 and 2017. Finally, 30 articles were selected.
Results: Strategies for strengthening the PHC system were examined from two different angles: factors that facilitate the performance of the health care team, and ways to improve the implementation of PHC. In addition, strategies have been recommended for the following in order to strengthen the PHC system in Iran: trust-based relationships; widespread implementation of the National PHC Program with a focus on personnel training; teaching healthy lifestyle behaviors and drug side-effects; investing in information technology in the health sector in areas such as immunization, child care and prevention of chronic diseases.
Conclusion: Strengthening primary health care requires coordination and inter-sectoral collaboration; involvement and will of a wide range of health and non-health organizations; government support; strengthening of the referral system and the family physician; strengthening the health team; self-care and community participation; a public health-oriented and preventive approach in macro-policies; and, finally,  allocating more resources to the health sector.

---

Background and Aim: “Active ageing” is the process of optimizing opportunities for health, participation and security of the elderly in order to enhance their quality of life. This study aimed to measure the Active Ageing Index (AAI) in Tehran at the individual level and determine its determinants.    
Materials and Methods: This quantitative cross-sectional study included 590 old people 55 years old and above, selected by randomized cluster sampling and interviewed at their homes in various areas of Tehran. The AAI tool, which includes 4 domains ─ employment, participation, secure/safe life and an empowering environment ─ and 22 indicators was used to measure active ageing. The association between individual characteristics of older people and their AAI scores was determined using the mixed-effect linear regression analysis method, with the STATA software.
Results: The overall AAI score in Tehran was found to be 26.8 out of 100, it being 33.9 and 20.6 for men and women, respectively. Being a women, older, poorer, and living alone or in a large family resulted in significantly lower AAI scores as compared to being a man, younger, richer, living with others, and living in a smaller family.
Conclusion: Iranian older people, particularly women, are experiencing relatively inactive lives. Their AAI scores are particularly low in the third and fourth domains. Considering the high rate of population aging in Iran, providing a safe environment for an active life for the elderly, particularly for the groups found to have a less active life, is a top priority.

---

Background and Aim: Patient education is an essential component of diabetes control, and increasing the health knowledge of diabetic patients based on suitable educational theories is crucial. This study aimed to determine the effect of educational intervention using the Transtheoretical Model (TTM) on improving the nutritional habits among patients with type-2 diabetes mellitus in Maragheh city, Iran during 2017-2018.
Materials and Methods: This study was a randomized controlled trial conducted on 136 diabetic patients under coverage of Maragheh health centers, Maragheh city, Iran, randomly divided into two groups of intervention and control (68 participants in each group). The data collection tool was a three-part questionnaire with questions/items related to demographic characteristics and nutritional habits, as well as constructs of TTM and HbA1c based on the TTM. The educational program included four weekly sessions of 45-60 minutes each. The data were analyzed using the SPSS₁₆ software, the statistical tests being descriptive and inferential tests such as ANCOVA; the significance level was set as a p-value < 0.05.
Results: Before the intervention, the comparison and control groups did not differ significantly as regards demographic variables, HbA1c, TTM constructs and nutritional habits (p<0.05). After the educational intervention, the mean scores of nutritional habits, constructs of TTM and HbA1c were statistically significant in patients with type 2 diabetes (p <0.01).
Conclusion: The study results reveal that the application of transtheorical model can improve the nutritional habits of diabetic patients.

---

Background and Aim: Prostitution is one of the alarming social harms in any population with considerable challenges and concerns. Many prostitutes have been victims of unfavorable social conditions. The purpose of this study was to determine and explain the goals, service patterns, challenges and proposed solutions for the Program of Rehabilitation of Socially Harmed Women in the Iranian Welfare Organization (IWO).
Materials and Methods: A qualitative study was conducted in 2016. The participants included managers and experts of the general departments of the IWO in 31 provinces, 21 members of public mediators and stakeholder organizations, and 5 senior staff managers and senior experts of the IWO Deputy Director’s Office for Social Affairs. Data were collected using document analysis and in-depth individual interviews and focus group discussions and analyzed using the content analysis method.
Results: Based on the data collected, the challenges of the program implementation were found to be as follows: non-acceptance of these women by the society, identity problems of the children borne to them (legally), poor chances of employment, sexual abuse of the women by the employers and mental disorders of the women, as well as poor intersectoral collaboration in IWO and lack of sufficient manpower. Proposed solutions for improvement of the situation included increasing financial credits, creating a national database, informing and sensitizing the people and approving some new judicial laws, as well as reforming some of the existing judicial laws.
Conclusion: Despite the services delivered in this national program, the program faces challenges at the government and public levels. In order to improve the current situation, it is essential to apply the proposed solutions, as well as review and modify the relevant processes.

---

Background and Aim:  The strategies of hospitals in confronting the Covid-19 crisis is extremely important in the control and management of this epidemic. Exploring the challenges and suitable strategies for controlling biological epidemics in Tehran University of Medical Sciences (TUMS) hospitals might pave the way for better management of possible similar crises in the future.
Materials and Methods: This was a qualitative, exploratory and inductive study including 22 health professionals from TUMS involved in the management of the disease. Data were collected using semi-structured interviews and analysed by thematic analysis, using MAXQDA.
Results: The most important challenges identified were related to the lack of preparedness at the macro-level, impracticability of controlling the use of personal protection equipment (PPE)  and the consumption of medications, as well as provision of equipment, medications and protecting medical devices. The effective strategies and interventions in the pandemic were grouped into the following categories: manpower, education, communications, clinical work, decision-making and organizational activities.
Conclusion: Preventive measures and preparedness before the onset of the crisis have not received sufficient attention. Hospitals could have an important role in confronting the crisis through promoting work efficiency and standards. Timely prevention and preparedness before a pandemic as regards medications, personal protection equipment and diagnostics are extremely essential, as are timely and flexible decisions by crisis committees and the control of manpower emotions flux during crisis management.

---

Background and Aim: In 2020 the rank of Iran in happiness index and gender inequality were reported to be rather low, they being, among 153 countries, 118 and 113, respectively. This study aimed to investigate the relationship between gender inequality and happiness in Iran's provinces.
Materials and Methods: This ecological study was conducted based on secondary analysis of data on happiness index, as the dependent variable, and gender inequality, as the main independent variable, in 31 Iranian provinces, the statistical population being people over 10 years old. The sources of data on other background variables were previous national studies and the national statistical yearbook. Analysis of the data was done using descriptive statistics, Pearson correlation coefficient and multiple linear regression.
Results: No significant relationship was found between gender inequality and happiness (p<0.05) in the provinces. Neither was found any relationship between the background variables and happiness. However, the mean age of the population and gender inequality were inversely associated (p<0.05), meaning that with an increase in the mean age gender inequality would decrease.
Conclusion: The fact that no statistically significant association was found between the various variables and happiness in Iran’s provinces could be due to the small sample size.
We would recommend to investigate further this topic at the individual level and with a larger sample size.

---

Background and Aim: Despite the increasing prevalence of infection with some blood-borne viruses, no standard precautions have been developed so far based on the Health Belief Model (HBM). This study aimed to assess, based on the HBM, the predictors of adherence to standard precautions in preventing needle stick injuries among the Personnel of Sanandaj Teaching Hospitals, Sanandaj City, Iran in 2020.
Materials and Methods: This cross-sectional study included 444 medical and non-medical staff members of the Sanandaj teaching hospitals in Sanandaj City, Iran, using a researcher-developed questionnaire. Descriptive and analytical data analysis was performed using Mann-Whitney U and Kruskal-Wallis tests, Pearson correlation coefficient, one-way analysis of variance, multivariate regression and the chi-square test, the software being SPSS version 22.
Results: The results of multivariate regression analysis showed that from among the HBM constructs, three constructs, namely perceived sensitivity (p=0.033), perceived benefits (p=0.032) and self-efficacy (p=0.001), were the predictors of staff duty performance (implementation of  standard precautions) in preventing needle stick injuries. As regards the implementation of standard precautions, 22%, 75.3% and 2.7% of the staff members had a low, medium and high performance level, respectively.
Conclusion: The constructs of perceived sensitivity, perceived benefits and self-efficacy are the strongest predictors in adherence to standard precautions.

---

Background and Aim: The health system financing is the process of collecting, pooling and managing financial resources and purchasing healthcare services. Health financing plays an important role in achieving the health system goals and objectives specially universal health coverage. The aim of this study was to strategically analyze the Iranian health financing system and recommend strategies to strengthen it.
Materials and Methods: Using the scoping review method, all published studies about the strengths, weaknesses, opportunities and threats of the Iranian health financing system were searched in eight databases including "PubMed", "Scopus", "Science Direct", "Embase", "ProQuest", "SID" and "Magiran", as well as the "National Database of Medical Science Theses" and two search engines, namely, "Google" and "Google scholar". Finally, 29 studies were selected and analyzed using the framework analysis method and MAXQDA software. 
Results: Extended health insurance coverage, reduced out-of-pocket payments following the national health transformation plan, and increased healthcare tariffs were the strengths of the Iranian health financing system. On the other hand, regressive financing, high out-of-pocket payments and increased number of health insurance companies were the weaknesses of Iran’s health financing system. Political sanctions, financial crises and increased healthcare demands were the threats, while supportive laws, the NGO’s financial support, increased number of health care organizations and modern technologies were among the important opportunities for the Iranian health financing system. Increasing the health system financial resources through prepayments, structural and policy unification of health insurance system, health service tariff reform and enhancing health system efficiency and healthcare services quality are essential to strengthen the Iranian health financing system.
Conclusion: The Iranian health financing system is not resilient and faces several challenges. The health system policy-makers and senior managers should adopt the recommended strategies to strengthen the national health financing system.

---

Background and Aim: The realist review has been introduced to review and synthesize the evidence related to the implementation of complex healthcare interventions. This method interprets the results of an intervention by explaining the causal relationships between the intervention and the results. This study aimed to explain the methodology of realist review in the health system.
Materials and Methods: This study was conducted using the scoping review. The following databases were used to find articles using appropriate search strategies and relevant key words: Pubmed, Scopus, Science Direct, and Embase electronic databases, as well as Google Scholar and Google search engines. Finally 49 articles were selected (in the period between January 1990 and December 2020) for review.
Results: The realist review is a theory-based approach to synthesize evidence related to the complex interventions, explaining the reasons for the successes or failures of interventions based on the causal relationships between the interventions, contexts, mechanisms and outcomes. A protocol was introduced to conduct a realist review composed of three phases ─ explaining, development and correcting the intervention program theory ─ and including seven steps of determining research questions; explaining the initial program theory; developing search strategies; collecting, evaluating and selecting evidence; synthesizing evidence; modifying the initial theory; and making suggestions. In addition, the structure of a realist review article was described and a checklist for evaluation of a realist review study was introduced.
Conclusion: The realist review is a suitable method for reviewing the complex health system interventions, explaining how an intervention relates to the results obtained. A realist review explains how, under what conditions and for whom a health and therapeutic intervention works.

---

Background and Aim: Patients with diabetes need continous support for sustainable self-care behaviors. The use of supportive forces to improve the level of self-management of diabetes is felt. The aim of this study was to compare the effectiveness of direct and indirect virtual educational interventions on the promotion of self-management behaviors and diabetes control in women with type 2 diabetes. The study was conducted in 2019.
Materials and Methods: This clinical trial study included 100 females with type 2 diabetes under the coverage of three health centers affiliated to Tehran University of Medical Sciences, randomly divided into two groups of direct and indirect education (50 subjects in either group). A questionnaire was used as the standard tool of diabetes self-management. The education imparted to the subjects was based on the latest version of Diabetes Self-Management Education (DSME), and the educational sessions were based on the Stanford University's self-management model, including six 90-minute sessions during three weeks. Data were analyzed using SPSS-16 statistical software, the statistical tests being covariance analysis, etc.        
Results: There were no statistically significant differences between the direct and indirect educational groups as regards the self-management scores and HbA1c levels in the first and second pre-tests (p<0.05). However, both the self-management scores and HbA1c levels of the two groups, determined at 3- and 6-month follow-ups, were found to be statistically significantly different (p<0.05).               
Conclusion: The findings of this study indicate the feasibility of using volunteers, after empowering them properly, to implement diabetes self-management educational interventions.              

---

Background and Aim: According to the definition proposed by WHO, social health is a health dimension that impacts, or is affected by, the two physical and mental dimensions. Based on the definition given by the Academy of Medical Sciences of Islamic Republic of Iran, social health includes reciprocal qualitative and quantitative behaviors by individuals towards welfare of the society. Pro-social behaviors and an encouraging environment are considered as the two main components of social health promotion. The purpose of this study was to identify pro-social behaviors in the Iranian society.
Materials and Methods: This was a qualitative study. Data were collected using 1). Literature review based on sources related to Iranian culture and religious advice, as well as published international experiences, and 2). Expert opinions based on focus group discussions on eight specialized disciplines. The data obtained were content analyzed.
Results: Analysis of the data of this study showed twenty pro-social behaviors (possible to be categorized into three domains/areas of social thinking, speech and expression, and behavior):
acceptance of diversity and altruism, understanding human rights, not telling lies, cooperation, humbleness, donation/free contribution, being critical, patience and forgiveness, lack of distrust/suspicion, speaking competence, proper balance/equilibrium, sense of responsibility, brotherhood, personal discipline/order, fidelity, trustworthiness, consultation, cultural exchange, self-identity and, finally, respecting the environment.
Conclusion: Behavior change requires applying evidence-based models, e.g., social marketing. It is, thus, suggested that after investigating and surveying pro-social behaviors in the Iranian society, barriers to pro-social behaviors should be investigated and social marketing programs be developed and implemented aiming to help improve these behaviors.

---

Background and Aim:  The health financing system is the process of collecting, pooling and managing financial resources to purchase health services. Sustainable financing of the Iranian health system is crucial for achieving universal health coverage. The purpose of this study was to identify strategies for sustainable financing of the Iranian health system.
Materials and Methods:  This study was conducted using the scoping review in 2020. The following databases and search engines were searched systematically between 21.03.2002 and 21.09.2020 to find studies related to sustainable financing strategies for the Iranian health system: PubMed, Web of Science, Scopus and Embase, Magiran, Iranmedex and SID databases, and two search engines; i.e., "Google" and "Google scholar”. Finally, 47 studies were selected and analyzed using the MAXQDA software and the framework analysis method.
Results: A total of 40 strategies were identified for strengthening the sustainability of Iran's health financing system, which were grouped into three categories: collecting funds, pooling funds and purchasing health services. The most frequently cited strategies for sustainable financing of the Iranian health system were the following: increasing the health share of gross domestics product, expanding tax revenues, pre-payment methods of health financing, strengthening public-private partnership, increasing the efficiency of the health system, reducing health system costs, consolidating insurance funds, eliminating insurance overlaps, value-based health service tariffs, optimizing health services support packages, and fixed payment methods based on  the performance of the health service providers.
Conclusion: The Iran's health financing system must be strengthened in such a way as to make it possible to collect, pool and manage sufficient financial resources to be used to purchase health services for the people to ultimately ensure universal health coverage leading to the promotion of the public’s health.

---

Background and Aim: The Primary Health Care (PHC) system is the most comprehensive, equitable and efficient way to promote people's health and social welfare by providing preventive, curative, rehabilitative and palliatvie services in a place close to where people live and work. Iran's PHC system faces challenges that limit its effectiveness and efficiency. The aim of this study was to identify strategies to strengthen Iran's PHC system.
Materials and Methods: A realistic review method was used in this research. Published articles on strategies to strengthen the PHC system between 1978 and 2019 were searched in eight databases and Google scholar search engine. Finally, 29 articles were found to be eligible for inclusion in this study; framework analysis was done using the MAXQDA-10 software. 
Results: Twenty-nine strategies were identified for strengthening the PHC system. A well designed PHC system is one with the following characteristics: realistic goals and appropriate strategies  equipped with necessary resources, organized in multidisciplinary teams that provide comprehensive and quality health services (intervention program), with strong governance and leadership, financing, work force, equipment and medicines, information systems and robust health services delivery processes and well adpated to the external environment (context). Such a PHC system will increase healthcare providers’ satisfaction and commitment, as well as the  patients’ trust, participation and satisfaction (the mechanism) and, finally, promotes, restores, and maintains the people health (result).
Conclusion: A strong PHC system is a pre-requisite for strengthening a health system. Various strategies such as strengthening management and leadership, improving organizational structure and culture, improving the information system, empowering human resources and increasing population coverage can lead to an improved PHC system. Historical, social, cultural and economic factors affecting the health system should be considered in redesigning and stregtening a PHC system.
 

---

Background and Aim: The aim of this study was to determine the risk factors of growth failure of one-year old children in the suburban regions of Bandar-e-Abbas City based on a population-based cohort study conducted by Bandar Abbas Health Research Station, affiliated to School of Public Health, Tehran University of Medical Sciences in the south of Iran.
Materials and Methods: In this prospective cohort study in 2021, data on the growth of 540 one-year old infants obtained in a cohort study aiming to identify contributors to mother and child health in the suburbs of Bandar-e-Abbas City, Iran were used. The outcomes included weight, height, and head circumference growth failures among one-year infants. Data analysis was performed using the STATA software version 14, the statistical tests being descriptive statistics and univariate and multiple logistic regressions.
Results: Low birth weight was found to increase the odds of one-year-old children’s weight growth failure 3.05 times (the adjusted odds ratio, OR = 3.05; 95% CI: 8.91-1.04). A low socioeconomic status reduced the odds of head circumference growth failure 59% (the adjusted OR = 0.41; 95% CI: 0.19-0.89), and a low birth weight increased the odds of head circumference growth failure 2.46 times (adjusted OR = 2.46; 95% CI: 1.01-5.97). None of the maternal and childhood factors were related to the one-year-old child height growth failure.
Conclusion: The findings of this study show that low birth weight increases the odds of normal body growth and head circumference growth failures at the age on one year, while a low socioeconomic status reduces the odds of head circumference growth failure. There are no relations between any of the maternal and childhood factors and height growth failure at the age of one year.
 

---

Background and Aim: The practice of breastfeeding among mothers is affected by their knowledge of, and attitude to, it. Therefore, this study aimed to determine the effect of intervention, using the transtheoretical model (TTM), on the knowledge, attitude and practice of exclusive breastfeeding among pregnant women in the third trimester referred to Golestan University of Medical Sciences in hospitals in 2021.
Materials and Methods: This quasi-experimental intervention was conducted on 120 pregnant women in the third trimester of pregnancy randomly assigned to an intervention (n = 60) or a control (n = 60) group using the permuted block randomization. The data collection tools were a two-part questionnaire to collect data on demographic and obstetric characteristics and a researcher-made questionnaire based on the TTM. Due to the coronavirus Epidemic the education was conducted partly face-to face in five 30-minute sessions three times a week observing the health protocols and partly virtually via WhatsApp and Telegram messenger (audio file, video tutorial, electronic pamphlets and posters). The data collected one and six months after the intervention were analyzed using the SPSS software version 16, the tests being descriptive and inferential tests.
Results: The mean scores of knowledge, attitude, practice and the TTM constructs were not statistically significant between the intervention and control groups before the education intervention. One and six months after the intervention the mean scores of knowledge, attitude and practice and the TTM constructs, as well as perceived barriers and benefits in decision-making and self-efficacy were found to be significantly different between the intervention and control groups (p< 0.001).
Conclusion: Based on the findings it seems that breastfeeding education of pregnant women based on the transtheoretical model can improve their knowledge, attitude and practice as regards exclusive breastfeeding.