Journal of School of Public Health and

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Background and Aim: Considering the acute and chronic effects of organic solvents to which vehicle painters are exposed for long periods of time, their evaluation and control is crucial for protection of health of the employees. This study aimed to find the most influential factors on exposure to, and spreading pollution with, benzene, toluene, xylem, and etylebenzene (BTEX) in order to be able to choose the best control measures.
Materials and Methods: In a motor-vehicle company the vehicle painting process was studied in detail and the solvents used in paints and in spreading organic solvent stations were identified. Based on the types and concentrations of the variables being studied, using the NIOSH method a total of 240 air samples were collected (5 samples for each variable and the respective controls) and analyzed. The SPSS version 11.5 was used for data analysis, the statistical tests being multi-regression and analysis of variance.
Results: Exposure to benzene in all occupational tasks, as well as to toluene in top coating and undercoating stations exceeded, while exposure to etylebenzene and xylene did not reach, the respective permitted exposure limits (p<0.05). The most effective factors on exposure to all the four solvents were, in order of effectiveness, occupational task, gun type, and the type of paint sued (p<0.05).
Conclusion: The effects of the variables studies – occupational task, gun and paint types – on exposure to BTEX relate to differences in occupational task work load, the type of gun used, and the paint organic solvent formulation. The reason for the potentially high exposure to benzene is its presence as an impurity in the paint solvents. Thus, it is highly recommended that in the process of control and evaluation special attention be paid to these factors.

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Background and Aim: Many researchers have studied survival (time to death) of gastric cancer patients. Although gastric cancer diagnosed in early stages can be cured by surgery, chance of relapse still exists after operation. Hence, we should consider both events, that is, relapse of the disease and death, in order to be able to make a more precise estimation for survival of the patients. The purpose of this study was to use the competing risks method to estimate the cumulative incidence functions (CIF) of the relapse of disease and death and consequently to estimate the postoperative disease-free survival.
Materials and Methods: A total of 330 patients admitted to Iran Cancer Institute and operated between March 1995 and March 1999 were enrolled in the study. They were followed up for at least 5 years to estimate their 5-year disease-free survival. Information on their demographic, clinical, and therapeutic characteristics, as well as on the type and time of occurrence of the first event (relapse of disease or death) after surgery was collected from their medical records. The direct parametric method was applied to estimate CIFs of relapse of the disease and death, while to adjust the effects of some covariates the parametric regression model was used. Data analysis was done using the R software and a p-value <0.05 was considered statistically significant. The findings were compared with the results obtained on the basis of data analysis in which the competing events were not considered.
Results: The median follow-up time was 37.9 months. Of all the patients 13% experienced relapse and 60.9% death as the first event after surgery. The CIFs of relapse of disease and death 5 years after operation, with due consideration of covariates, were estimated at 11.0% and 68.6%, respectively. Age, stage of disease, and complementary treatment were statistically associated with the CIF of death, while only complementary treatment was related to the CIF of relapse. Older patients and those in more advanced stages of disease were more likely to die after operation. Moreover, while complementary treatment after operation decreased the CIF of relapse of disease, it increased the CIF of death. The disease-free survival of patients 5 years after surgery was 20.(consideringtheeffectsofsomecovariates).
Conclusion: The competing risks method is recommended for analyzing survival data because of its capability in considering different events and, therefore, making it possible to make more precise estimations. By using this method, considering smaller variance estimates for model parameters and also narrow confidence intervals for the cumulative incidence functions of competing events, it is expected to obtain more precise results. Unfortunately, the results have revealed that the disease-free survival of gastric cancer patients is low in Iran.

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Background and Aim: Thalassemia, a heterogeneous disease, is one of the most common single-gene diseases worldwide. The aim of this study was to find associations between hematological indices and severity of beta-globin gene mutations in beta-thalassemia carriers.
Materials and Methods: In this cross-sectional study, 30 beta-goblin gene mutations (b+ and b○) in 1206 unrelated beta-thalassemia carriers were investigated. In addition, their hematological indices, including CBC and electrophoresis results, were determined. The association between genetic findings and hematological parameters (mean corpuscular volume (MCV) and mean hematocrit corpuscular hematocrit (MCH)) were determined using the SPSS software, the statistical test being the t-test.
Results: The results indicated that b+-thalassemia carriers had higher MCV and MCH means than b○-thalassemia carriers. These findings would certainly have practical implications in public health.
Conclusion: The results show a significant correlation between two hematological indices and certain types of mutations in beta-thalassemia carriers.

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Background and Aim: Today in most of the work environments, such as nuclear, military and chemical industries, human error may result in catastrophic events. A common characteristic of large technological systems is that massive amounts of potentially dangerous materials are kept in one single unit controlled by control room operators. A control room is indeed the heart of a system of this type and any error in task performance by the operators may have undesirable consequences which could never be compensated. In this study we aimed to identify and assess human errors in the control room of the Aromatic Unit of Bouali-Sina Petrochemical Company, Iran using the CREAM method.
Materials and Methods: This was a cross-sectional and analytical-descriptive study carried out in the control room of the Aromatic Unit of Bouali-Sina Petrochemical Company, Iran with 39 operators. After a job analysis by the hierarchical task analysis (HTA), probable control modes and cognitive failure probability were determined for occupational tasks using the basic and the extended CREAM methodologies.
Results: Based on the results of the basic CREAM method, control modes for the tasks of action, Boardman and shift control supervisor were determined as Opportunistic Control mode, while for the task of control room head it was obtained as Tactical control mode. With regard to the error types, the following results were obtained on the basis of the extended method of CREAM: execution failure (51.70%), interpretation failure (19.55%), planning failure (14.94%), and observation failure (13.81%).
Conclusion: The basic CREAM method showed the common performance factors (CPCs) leading to reduced performance reliability to be the number of simultaneous tasks, time of day (circadian rhythm), and adequacy and quality of training and experience. These factors caused the operators to choose an opportunistic control mode. In addition, based on the extended CREAM method results, the most noticeable cognitive failure was execution failure. In addition, the most important cognitive activities related to the control process in the control room were communication, execution, diagnosis, monitoring, and planning. Based on these findings, providing instructions and guidelines for work procedures, holding training courses, shift work scheduling, optimization of the communication systems and modifications in the control software are essential to minimize human errors in the Bouali Sina Petrochemical Company control room.

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Background and Aim: Presently not sufficient attention is paid to adolescent health promotion in many countries, because of the widespread belief that adolescents are generally healthy. The purpose of this study was to evaluate predictors of adolescent girls' quality of life using path analysis based on Pender's health promotion model.

Materials and Methods: The Pender's health promotion model served as the framework of this cross-sectional study, which included a total of 500 adolescent girls (grades 9-11) selected by stratified random sampling from 20 high schools for girls in 4 districts of Kashan province, Iran. Inclusion criteria were being in grades 9-11 and a written informed consent (from teachers, parents and the girls themselves). Data were collected through interviewing the girls, the interviewers being trained persons, using several standard questionnaires (for perceived self-efficacy, perceived affect, perceived barriers, perceived social support health promoting lifestyle, and health-related quality of life). Data analysis was done using SPSS18 and LISREL 8.8, the statistical test being path analysis.

Results: All constructs of the health promotion model and health promoting lifestyle were significantly related to adolescent girls' quality of life. Perceived self-efficacy (β=0.70, p<0/01) and perceived affect (β=0.21, p<0/01) had the highest correlation with the quality of life. The model and the health-promoting lifestyle as a mediator accounted for 73% and 39% of variance in adolescent girls' quality of life, respectively.

Conclusion: The findings of this study indicate that the health promotion model can be used to explain and predict the quality of life of adolescent girls. Thus, the Pender's health promotion model is recommended to health planners for promoting the quality of life in this population.

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Background and Aim: Safety climate is a psychological phenomenon and a sub-component of safety culture, which is usually reflected in the shared workforce's perceptions about the state of safety at any particular time. It can provide an indication of the priority of safety in an organization with regard to other priorities such as production or quality. The objective of this study was to assess the safety climate profile in a steel manufacturing plant in Iran and using the results to improve the level of safety.

Materials and Methods: In this cross-sectional study, the UK Loughborough University Safety Climate Assessment Toolkit was used to assess the safety climate in a steel-manufacturing industry in Iran. Information was collected through interviews and questionnaires, focus group discussions, and direct observations in the filed. Safety climate scores were calculated in 17 themes.

Results: A graphic representation of the safety climate scores obtained showed that safety climate in the company is at the medium level (4.80 ± 2). The highest and lowest scores were for dimensions of personal priority and need for safety (8.6± 0.8) and accidents and incidents (1±0.00). A non-significant correlation was found between worker's education and work experience on the one hand and their attitude towards safety on the other hand (p>0.05). Both management commitment and personal priority were associated with the workers' age (p= 0.03 and 0.02, respectively), while work environment was associated only with employment status (p = 0.04). 

Conclusion: Safety climate assessment can be a proactive safety performance indicator used to improve the level of safety in an organisation.

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Background and Aim: Determining the degree of conformity of respirator cartridges with the accepted standards is very important for ensuring their respiratory protection efficiency. The aim of this study was to determine the degree of conformity of organic vapor-respirator cartridges used in different petrochemical companies with the EN 14387:2004 standard.

Materials and Methods: In the first phase of the study, the respirator cartridges used in petrochemical complexes were identified and their specifications obtained from their manufacturers and the relevant technical catalogues. In the second phase, 3 samples of each of the cartridge models were chosen and tested according to the EN 14387:2004 standard. An instrument was especially designed for measuring the breakthrough time of the cartridges. 

Results: The results showed that the minimum and maximum breakthrough times of cartridges were 29 and 142 minutes, respectively. From all the 10 different cartridge models tested, one had a service life of lower than the minimum standard breakthrough time of 70 minutes.

Conclusion: Considering the existence of a non-standard type of cartridge among the samples studied, it is essential to launch a program aiming at ensuring the conformity of cartridge efficiency with the respective standards. Such a program should be developed and implemented by such responsible organizations as the Institute of Standard and Industrial Research of Iran and the Center for Occupational Health and Safety Research and Training of Iran.

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Background and Aim: Many studies show that the only way to control diabetes and prevent its debilitating complications is continuous self-care. This study aimed to determine factors affecting self-care behavior of diabetic women in Khoy City, Iran based the extended theory of reasoned action (ETRA).

Materials and Methods: A sample of 352 women with type 2 diabetes referring to a Diabetes Clinic in Khoy City in West Azarbaijan Province, Iran participated in the study. Appropriate instruments were designed to measure the relevant variables (diabetes knowledge, personal beliefs, subjective norm, self-efficacy and behavioral intention, and self-care behavior) based on ETRA. Reliability and validity of the instruments were determined prior to the study. Statistical analysis of the data was done using the SPSS-version 16 software.

Results: Based on the data obtained, the proposed model could predict and explain 41% and 26.2% of the variance of behavioral intention and self-care, respectively, in women with type-2 diabetes. The data also indicated that among the constructs of the model perceived self-efficacy was the strongest predictor for intention for self-care behavior. This construct affected both directly and indirectly self-care behavior. The next strongest predictors were attitudes, social pressures, social norms, and intervals between visiting patients by the treating team.

Conclusion: The proposed model can predict self-care behavior very well. Thus, it may form the basis for educational interventions aiming at promoting self-care and, ultimately, controlling diabetes.

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Background and Aim:  Community assessment is a process by which a clear picture of the community assets, strengths, resources, and needs is obtained with active participation of the community itself, followed by prioritization of the community needs and formulating strategies and programs to solve the problems. This study was conducted to identify and prioritize problems and needs of the Azerbaijan Borough in Tehran city, Iran, with active participation of the people.

Materials and Methods: This study was conducted to determine the attitudes and beliefs of the community members about their community needs and problems. The study was based on a model designed in North Carolina, US. In this model, the assessment process is performed in eight steps.  In the first seven steps problems are identified and prioritized, and in step 8 a plan of action is developed to deal with the problem selected.

Results: A total of 40 problems were identified and divided into several groups. The most important problems were as follows: social problems environmental health problems educational and cultural problems, civil rights and urban services distribution and use of drugs lack of family counseling centers shortage of parks and playgrounds for neighborhood children lack of supervision by municipal contractors on urban cleaning and lack of mental health services specially for the elderly.

Conclusion: Several types of problems, including health, as well as non-health - social, cultural and economic - problems were identified. Community assessment provides an appropriate opportunity for active participation of community members and makes available sufficient information for sound decision-making. Thus, community assessment can be regarded as a suitable technique for identifying and prioritizing community needs.

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Background and Aim: Experience at the national and international levels shows that internal evaluation, especially at the level of academic departments, can play a critical role in warranting having a university with high standards. The objectives of the present research project were to determine (a). the quality of the structural elements of the Epidemiology and Biostatistics Department (EBD) School of Public Health,  Tehran University of Medical Sciences,  and (b). The strengths, weaknesses, opportunities and threats, on the basis of which action could be taken to improve the quality of activities in the Department.

Materials and Methods: The study was conducted with the collaboration of the head and faculty members, all of the students (residents, Ph.D. and M.S. students), and the graduates, of the EBD. Nine variables were studied, namely, 1). Aims and objectives 2). Organizational and management structure 3). Faculty members 4). Students 5). Teaching and learning process 6). Courses and curricula 7). Graduates 8). Research and educational facilities and equipment and 9). Research activities of the faculty members. First the initial weight of the 9 variables were  determined by opinion poll carried out among all the faculty members of EBD. Then unrelated data were identified through proper tests and omitted and the final weights extracted. The tools used to collect the data included interview, observation, and 7 self-prepared questionnaires and 2 check lists.

Results: The mean score for the 9 factors studied was 59.8%, the range being between 37.0% (for objectives and mission) and 72.0% (for graduates).

Conclusion: The graduate domain is one of the key areas in internal evaluation of the Department of Epidemiology and Biostatistics. On the other hand, the lower score for objective and aims domain implicates the need for future intervention in this domain.

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Background and Aim: In social marketing, the common techniques of commercial marketing are used to increase the chances of acceptability of an idea or action by the target group. In this study, we determined the impact of an intervention based on social marketing to reduce risky driving behaviors among taxi drivers in Tehran.

Materials and Methods: This was a quasi-experimental study, consisting of a quantitative and a qualitative part, on taxi-drivers in 2 regions (an intervention and a control groups) in the City of Tehran. Based on a formative research approach, the components of social marketing, namely, the product (reminder message for concentrating on avoidance of two target behaviors, tailgating and not driving between lines), price, place and promotion were determined. An 8-week educational program was implemented, the components being installation of stickers before the driver's eyes, distributing a pamphlet, and transferring messages through taxi route supervisors as opinion leaders. After six weeks, risky driving behaviors were assessed by checklists and compared.

Results: The intervention resulted in statistically significant reductions in the two target behaviors in the intervention group as compared with the control group. Furthermore, logistic regression showed that the odds ratio for avoiding both behaviors increased significantly in the intervention group. 

Conclusion: Determining specific target groups, designing interventions based on actual needs and wants of the target group, and focusing on the factors influencing the behavior market are the basic elements of social marketing. Due consideration of these elements when designing behavioral interventions would lead to reductions in risky driving behaviors.

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Background and Aim: Visceral leishmaniasis is a systemic parasitic disease with a high fatality rate in under-5-year-old children. The disease is endemic in some parts of Iran, particularly in the north-west region. In 2001 a visceral leishmaniasis (VL) surveillance system was established for children aged ≤ 12 years in the primary health system in Meshkin-Shahr District, Ardebil Province, situated in the north-west of Islamic Republic of Iran.

Materials and Methods: All cases with clinical signs and symptoms of VL and confirmed positive by the direct agglutination test (DAT) were referred for physical examination and treatment.

Results: The mean annual incidence of VL decreased significantly from 1.88 per 1000 children before (1985-2000), to 0.77 per 1000 child population after (2001-07), the intervention. In the control area with no surveillance, it increased from 0.11 to 0.23 per 1000.

Conclusion: Early detection of VL using serological tests and timely treatment of cases can decrease the mortality and morbidity rates of VL in endemic areas.

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Background and Aim: Omega-3 fatty acids can reduce inflammation in diabetic patients via special mechanisms. The objective the current study was to investigate the effects dietary omega-3 fatty acid supplementation on the serum levels of C-reactive protein (CRP), interleukin-2 (IL-2), and tumor necrosis factor-alpha (TNF-α) in type 2 diabetes patients.

Materials and Methods: This randomized double-blind placebo-controlled clinical trial was conducted on 57 subjects with type-2 diabetes. The participants were randomly assigned to one of 2 groups receiving either an omega-3 fatty acid supplement (containing 1584 mg eicosapentaenoic acid, 828 mg docosahexaenoic acid, and 338 mg other omega-3 fatty acids) or a placebo tablet (containing 2100 mg sunflower oil) for a period of 8 weeks.

Results: The serum TNF-α  and IL-2 concentrations decreased significantly in the omega-3 fatty acid group in comparison with the placebo group (in both cases, p<0.01). The intervention did not bring about any statistically significant changes in the serum CRP concentrations.

Conclusion: Considering the beneficial effects of omega-3 dietary fatty acid supplements on the 2 inflammatory biomarkers, namely TNF-α and IL-2, type-2 diabetes patients are recommended to consume such supplements or foodstuffs rich in omega-3 fatty acids, e.g., fish.

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Background and Aim: Fleas are the most important ectoparasites of humans and domestic animals. Their bites are painful, usually accompanied with itching in addition, they transmit diseases such as plague, tularemia, and endemic typhus. The aim of this study was to identify species of fleas in the rural areas and animal farms in Boyerahmad

Materials and Methods: This study, conducted for 6 months, from April to September 2007, included 30 villages of the Boyerahmad District (30 ° 9'-31 ° 32 'N: 49 ° 57'- 50 ° 42'). To collect fleas, the common catch methods, such as fly paper, light trap, etc. were District, Kohgiloye-and-Boyerahmad Province, Iran.

used. The samples collected were kept in 70%-ethanol, and then, after clarifying and dehydration, were identified in the laboratory using valid keys.
Results: A total of 2435 fleas (54% males and 46% females) belonging to two families (Placida and Ceratophylidae), 4 genera and 7 species were collected. The most common species was Xenopsylla buxtoni (24.7%), followed by the dog flea, Ctenocephalides canis (21.4%), the cat flea, Ctenocephalides felis (18.5%), Xenopsylla astia (14.5%), Xenopsylla nuttalli (7.6%), Pulex irritans (7.2%), and N. fasciatus (6.1%). The fleas abundance (mean ± SE) in human and animal habitats was found to be  0.7±0.06 and 3.4± 0.2, respectively.  

Conclusion: On the whole, the flea species are quite diverse and abundant in the rural areas of Boyerahmad District in human and, particularly, animal habitats. This is a serious problem. Measures should be taken to control the fleas, particularly in rural areas.

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Background and Aim: There is evidence showing that increased inflammatory mediators and reduced serum levels of polyunsaturated fatty acids may be present in patients with neurodevelopment and psychiatric disorders, e.g.  attention-deficit/ hyperactivity disorder. (ADHD). The objective of this study was to determine the effects of dietary omega-3 fatty acid supplementation on hyperactivity, attention deficit, and serum inflammatory mediators in children with ADHD

Materials and Methods: This was an 8-week randomized double-blind clinical trial. The participants were 103 6 to12-year old children with ADHD receiving effective maintenance therapy, who were assigned randomly to receive either a daily omega-3 supplement (635 mg eicosapentaenoic acid and 195 mg docosahexaenoic acid (intervention group) or a placebo visually similar to the omega-3 capsules (placebo group). The serum levels of C-reactive protein (CRP) and interleukin-6 (IL-6) were determined at baseline and at the end of the period. In addition, the abbreviated 10-item Conners parent rating scale (CPRS) was completed for each child before and after the intervention. 

Results: The intervention brought about statistically significant reductions in the levels of CRP and IL-6 and a significant improvement in the CPRS score in the omega-3 group.

Conclusion: The findings indicate that dietary omega-3 fatty acid supplementation can have desirable effects on hyperactivity, attention deficit and inflammatory mediators in children with ADHD.

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Background and Aim: The aim of this study was to assess the adherence to anti-retroviral prophylaxis after occupational and non-occupational exposure to human immunodeficiency virus (HIV) in patients consulting the Voluntary Counseling and Testing Center (VCT) of Imam Khomeini Hospital, Tehran during the period 2008 to 2009.

Materials and Methods: In this prospective study, patients were selected, the required information about them was recorded, and adherence to anti-retroviral drugs (including Ziduvudin, Lamivudin and Efavirens) was determined based on self-report by the patients. Eighty-nine exposed patients were followed monthly for 4 months, and in the case of low-adherence (less than 95%) they were asked for the reason(s) for noncompliance.

Results: Of the 89 patients, 55 were men (61.8%) and 34 (38/2%) were women with a mean age of 30.16± 8.39 years 47 participants (52.8%) were single and 42 (47.1%) married 27 subjects (30.3%) were physicians, 35 (39.3%) nurses and 27 (30.3%) had occupations outside the healthcare system. From among the 36 subjects (40.5%) who stopped the treatment, 24 (27.0%) stopped it correctly (that is, when the serological test proved to be negative), while 12 (13.4%) did not stop it on a sound basis. Fifty-three subjects (59.6%) completed the prophylaxis. Adherence was found to be significantly associated with age and marital status (p<0.05).

Conclusion: The main reason for stopping the prophylaxis (a negative serological test result of the resource patient) was more pronounced than previous studies, which indicates the higher availability of the resource patient.

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Background and Aim: Coronary artery disease (CAD) and its complications at a low age are more serious and more progressive than at higher age. Because of this difference in the natural history of the disease as a function of age, this study was conducted to compare CAD risk factors between two age groups, namely people below and above 45 years old.

Materials and Methods: Two groups of 200 hospitalized CAD patients each, one below, and one above, 45 years old were selected by simple random sampling between 2005 and 2007. Two groups were similar with regard to dates and duration of hospitalization. The following data were collected from the patients' hospital files and analyzed using SPSS/Win: age, sex and marital status area of residence a history of smoking, diabetes, and hypertension a family history of early-onset cardiovascular disease (CVD) weight and height and lipid profile. The logistic regression test was used to compare the variables between the two groups.

Results: The following variables were found to be positively associated with CAD in the under-45 year group: smoking history (OR=2.54 p=0.009), a history of early-onset CVD (OR=3.15 p=0.009), low high- density lipoprotein cholesterol (HDLc) (OR=5.53 p<0.001), and high blood cholesterol (OR=3.96 p<0.006).

Conclusion: The most important coronary heart disease risk factors at a lower age are smoking, a history of early-onset CVD, low blood HDLc, and high total blood cholesterol.

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Data missing, which occurs for different reasons, is an unavoidable problem in epidemiological studies. It is quite widespread and, therefore, it is considered as a challenge in research design and data analysis by many methodologists. Complete case analysis is often used in studies with missing data however, this approach may result in inaccurate estimates and inferences due to bias associated with missing data. It is possible to obtain more accurate results through data repairing methods. Ordinary, simple strategies, such as single imputation methods, have drawbacks and limitations in practice. It has, however, been demonstrated that using modern imputation techniques can, despite their complexity, reduce bias dramatically in many situations, if used appropriately and properly. In this review, application of multiple imputations, as a novel technique for handling missing data in health and epidemiological research, is briefly discussed

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Background and Aim: Female genital mutilation (FGM) comprises all procedures that involve partial or total removal of the external female genitalia for non-medical reasons.The World Health Organization has estimated that 100 to 140 million girls and women worldwide are currently living with the adverse consequences of FGM. Two of the major incentives for FGM are traditions and social pressure, and the practice is mostly carried out by traditional circumcisers. Not only FGM has no health benefits for girls and women, but it has immediate and long-term complications. The objective of this study was to determine the prevalence of female genital mutilation and factors associated with it among women consulting health centers in Ravansar City, Iran

Materials and Methods: A cross-sectional study was conducted on 348 women consulting 5 health centers in Ravansar City, Iran. Data were collected using a structured questionnaire and SPSS.16 was used for data analysis.

Results: The prevalence of FGM was 55.7% and the mean age of the women undergoing FGM was 9.2±14.2 years. The prevalence increased with age. Almost in all cases the operation had been performed by traditional local circumcisers. The data also showed that 96.2% of the mothers and 87.6% of the sisters of the subjects had also been mutilated. There were statistically significant associations between FGM and several independent variables as follows: the mutilated women's age (0.001) and education level (p<0.001) their mothers' education level (p=0.006) and their awareness of, and attitude towards, mutilation (p<0.001).

Conclusion: FGM is prevalent among Ravansar women. Religious leaders and health personnel should attempt to discourage FGM. Promoting public awareness of FGM and its undesirable consequences is essential. Research shows that if a community itself decides to abandon FGM, the practice can be eliminated rapidly.

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Background and Aim: Demographic, physical, social and psychological factors make breastfeeding and its maintenance complex. Despite extensive breastfeeding promotion programs, no progress has been achieved. As breastfeeding is a phenomenon embedded in culture and folk perceptions, identification of its key determinants is essential when designing policies and implementing programs.

Materials and Methods: In this qualitative study, data were collected from 35 health professionals through a 4-day group interview using a structured questionnaire (open-end questions). The participants were purposefully recruited from among the health professionals attending a 4-day breastfeeding promotion workshop.

Results: The determinants of breastfeeding were categorized into 2 main domains, namely, people's perception of breastfeeding phenomenon and approaches employed in its promotion. The former domain was described by beliefs, demographic characteristics, social variables, and indigenous theories, and the later by practice in the cultural and social context, policies, interactions and practical skills.

Conclusion: From the participants' perspective, misperceptions of people can determine the degree of success or failure of a breastfeeding promotion program. Our findings confirm that people's perceptions are deeply influenced by their demographic characteristics, folk theories and social variables. As regards the breastfeeding promotion domain, the barriers are social-cultural factors rooted in the local beliefs and folk theories. The participants listed the breastfeeding promotion determinants as lactation policies and health providers' performance related to their skill in effective communication with mothers. Our findings also indicate that wrong beliefs, maternal and child diseases, caesarian section, and mothers' employment were believed to be deterrents in promoting breastfeeding in the community and that pediatricians, obstetricians and other health professionals can play key roles in the field. Based on our findings, we can further conclude that the phenomenon of breastfeeding and its maintenance are deep-rooted in social structure and cultural diversity. When designing and implementing breastfeeding promotion programs, local variables and determinants should be taken into consideration.