Journal of School of Public Health and

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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.              

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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.
 

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Background and Aim: Cardiovascular diseases are the most common cause of death in most countries of the world, hypertension being the most important cause of disability. The aim of this study conducted in 2020-2021 was to determine the effect of educational intervention on the nutritional knowledge, illness perception and dietary adherence in hypertensive middle aged women based on the transtheoretical model (TTM).
Materials and Methods: This was a quasi-experimental study on middle-aged women (30-59 years old) suffering from hypertension referred to the  health centers and health bases in the 21st district of Tehran in 2020-2021. A total of 164 subjects were randomly assigned to the intervention (n=82) or control (n=82) group by randomized quadruple blocks. A multifaceted questionnaire was completed for both the control and intervention groups and their blood pressure measured. This was followed by  a one-month virtual education for the intervention group in the form of a WhatsApp group and designing and developing fifty-six podcasts and educational clips with a maximum duration of four minutes based on the transtheoretical model constructs. After a lapse of one and six months both groups completed the questionnaire again and their blood pressure was measured. Descriptive statistics and general linear model were used for data analysis using the SPSS version 25 (p<0.05).
Results: Before the intervention the mean age of the subjects was 50.16 years and their systolic and diastolic blood pressures were 1.35 and 1.84 mmHg, respectively, and there were no statistically significantly differences between the two groups as regards contextual variables, constructs of nutritional awareness, disease perception, diet adherence, systolic and diastolic blood pressures and body mass index (as an ananthropometric index) and transtheoretical model constructs. Data one month after the intervention revealed significant differences (p<0/001) between the two groups (p <0/001) as regards the constructs of nutritional awareness, disease perception, self-sufficiency construct of the transtheoretical model and systolic blood pressure. Six months after the intervention significant differences were observed between the two groups as regatds  nutritional awareness constructs, disease perception (p<0.007), diet adherence (p<0.001), stages of change constructs (p<0.001) and self-sufficiency (p<0.001) of the transtheoretical model.
Conclusion: The results of this study show that educational intervention based on the transtheoretical model in middle-aged women with hypertension can increase their nutritional knowledge, illness perception, self-sufficiency, self-adequacy and diet adherence.
 

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Background and Aim: Delivering health services to the elderly is one of the most important responsibilities of the health care system of any country. In order to improve the provision of health services to the elderly population under its coverage, the National Social Security Organization conducted this study with the aim of designing, implementing and evaluating a model for providing outpatient health care services to the elderly population under the coverage of its Tehran Province Office. 
Materials and Methods: This was a sequential-exploratory mixed-method study. The initial model was developed and validated using the integrated review method and the final model using the Delphi technique and group discussions with experts. Then the educational program was developed and implemented for the health team. Assessment of the effectiveness of the program was done using a researcher-made knowledge and attitude questionnaire (pre- and post-test). The model was then implemented in the Khandan-e-Hakim Clinic. The effectiveness of the model implementation was determined based on the qualitative content analysis of the interviews with the elderly and qualitative content analysis of the health team comments.
Results: The outpatient care model of the elderly included an organized clinical process consisting of 6 phases. The mean age of the health team members was 45.7±15.11 years. The difference between the health team satisfaction total scores before and after participating in the educational program was statistically significant (P≤0.05). Further analysis of the data showed, based on the interviews with the elderly, the main categories to be "assessment of cognitive function, mood and behavior", "physical assessment", "appreciation of the health and dignity of the elderly" and "satisfaction of the elderly and their companions". Analysis of the comments of the health team revealed their satisfaction with the implementation of the model.
Conclusion: The introduced model can make possible rapid identification of health problems and timely intervention in the elderly population. This implementation model will help disease prevention and complications at different levels. The findings of this study can help service providers to provide better care and health services for the elderly.
 

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correlation coefficient, and multiple regression analysis were performed using SPSS 27.
Results: The results of multiple regression analysis showed the effect of nutritional knowledge variables on nutritional behavior (p <0.001, β = 0.159) and physical activity knowledge on nutritional behavior (p = 0.008, β = 0.120) if the Physical activity knowledge variable was not effective on physical activity behavior and also nutritional knowledge variable had no effect on physical activity behavior.
Conclusion: Increasing knowledge of nutrition and physical activity improves students' nutritional behavior, but this increase in knowledge does not affect physical activity behavior. The sedentary lifestyle and the presence of the Covid-19 pandemic appear to have significantly reduced physical activity. By increasing knowledge, nutritional behavior and physical activity can be improved to some extent
 

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Background and Aim: Economic complexity indicates the availability of knowledge within a country. Increasing economic complexity indicates an increased capacity of producing a diverse set of complex products. The complexity of the economic structure of a country is the main factor affecting social choices and human abilities, including but not limited to, employment and learning opportunities, and the employment status of an individual is an important determinant of his/her health status. Therefore, the production of advanced products depends to a large extent on the quality of human capital and knowledge. On the other hand, knowledge and education are widely recognized as promoting factors of the health of the population.
Materials and Methods: This research investigated the effect of the economic complexity index (ECI) on the health outcomes in seventeen selected countries in the region using panel data in the period 2001-2019 by using the quantile regression and the OLS ordinary least squares methods.
Results: Based on the findings of this study, ECI, globalization, economic growth and trade openness variables will improve health. However, despite this, the institutional quality variables, politics and urban population have not improved health in the countries studied.
Conclusion: The results of this research are particularly relevant to developing economies that usually suffer from poor health and low levels of economic complexity.
 

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Background and Aim: Food preferences and health literacy ─ key determinants of food choices in childhood and adolescence ─ are determinants of chronic diseases in adulthood. This study aimed to determine associations between food preferences, health literacy and body mass index (BMI) among elementary school students in Malekan city, east Azarbayejan Province, Iran in 2021-2022.
Materials and Methods: This cross-sectional descriptive-analytical study included 582 male and female primary-schoolers in the fourth, fifth and sixth grades in both the public and private  schools in Malekan County (Malekan, Lilan, and Mubarakshahr) selected by the two-stage randomized cluster method. A questionnaire including background questions and questions about health literacy and a researcher-made checklist of food preferences was used to collect data online using the Pros-Online Platform. The content validity ratio and index were used to determine validity and Cronbach's alpha index to check for the reliability of the questionnaire (CVI=0.98, CVR=0.91, Cronbach's alpha > 0.7). Data were analyzed using Mann-Whitney, t-test, one-way analysis of variance, Kruskal-Wallis and Chi-square tests at a significance level of 0.05 using SPSS 26.
Results: The average health literacy score of all the students was rather low (52.9±00.33), that of the female students (55.7±36.49) being slightly higher than that of the boys (49. 9±29.79). Further analysis of the data showed that there was a statistically significant relationship between the students' food preferences and health literacy variables (p<0.001). Furthermore, statistically significant relationships were observed between the students' BMI and their food preferences (p˂0.001) and health literacy (p˂0.001).
Conclusion: Considering the low level of health literacy of the adolescents and a positive relationship between health literacy, food preferences and BMI in adolescents, it can be concluded that increasing their health literacy will improve their healthy food choices. Therefore, it seems that interventions based on a theoretical framework aiming at increasing the students’ health literacy and improving their food preferences can be beneficial to them as a potential strategy for improving their healthy eating patterns resulting in preventing overweight and obesity.                
 

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Background and Aim: Considering the quality of prenatal care services, indentification of the avoidable and inevitable maternal factors and proper promotion of the knowledge and skills of health care service providers is vital for providing suitable preventive and interventional services with the aim of ensuring a successful pregnancy and proper management in the health care system.  This study was conducted to compare the adverse pregnancy outcomes among women with or without a history of Covid-19 in the pregnancy and postpartum stages covered by the Babol University of Medical Sciences, Babol, Iran.
Materials and Methods: This was a descriptive-analytical cross-sectional study including 4124 women, either pregnant or after a recent childbirth (with or without Covid-19) between 20.2.2020  and  29.3.2022, registered in the Sib electronic system (hereinafter Sib) of Babol University of Medical Sciences, Babol, Iran. Using a checklist developed and validated by an expert panel data were collected on the prevalence of maternal and neonatal outcomes in mothers with or without a history of Covid-19 and compared. The data collected were analyzed with SPSS 24 using descriptive tests such as chi-square and Fisher's exact test and STATA version 22, and the adverse outcomes with high frequencies following Covid-19 were determined.
Results: Analysis of the data showed the following to be the most common outcomes among mothers with a history of Covid-19: 1. obstetric complications and maternal disorders/diseases (hypertension, type-2 diabetes mellitus, at least one case of bleeding during pregnancy, premature/delayed birth and premature rupture of the amniotic sac, n= 457, 27.8%); 2. medical and surgical problems (unhealthy pregnancy weight gain and thromboembolic events, n=206, 12.5%). In addition, there was a statistically significant difference between the two groups of pregnant mothers with and without a Covid-19 infection as regards medical and surgical problems (P=0.001) and obstetric complications and maternal diseases (p=0.002). As regards the adverse neonatal outcomes in pregnant mothers with and without a history of Covid-19, there was a statistically significant difference between the two groups in terms of Apgar score at minutes 1 and 5 (p≥0.001) and exclusive breastfeeding (P=0.001) and the presence of Covid-19 symptoms in the baby (p<0.001).
Conclusion: Based on the findings of this study it seems that Covid-19 infection during pregnancy is associated with a higher risk of some of the undesirable maternal and neonatal outcomes.  Therefore, it is essential to plan and implement programs for health education, creation of a sound attitude towards better management, enhancement of the skills and capabilities of the health-care providers and, finally, promotion of the knowledge of service recipients. 
 

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Background and Aim: The health system is trying to prevent unnecessary referrals to higher levels by providing tiered services and thus reduce the cost of health care. Therefore, this study was conducted in Zahedan City, Iran with the aim of finding the causes of referrals from level 1 to higher tiers in rural areas.
Materials and methods: This cross-sectional study was conducted on 458 rural patients referred to the second level in the rural areas of Zahedan City, Iran. Data were collected from the family health files available in the Sib system and analyzed using the SPSS-16 statistical software, the statistical tests being descriptive statistics (percentage, frequency) and Chi-square test.
Results: The highest (57.6%) and lowest (4.1%) proportions of referrals to the second level of service provision were found to have been in 2018 and 2016, respectively. From among the referred patients nearly 50% had been referred due to the need for a higher expertise, thus most referrals (67.2%) were to specialists. Further analysis of the data showed that only in 23.6% of the cases there was a feedback from the higher level to the first level.
Conclusion: The findings show that referrals from family physicians to higher levels in the health system requires higher medical expertise and patient insistence. In addition, feedback to the first level of service provision has not received proper attention. Establishing interactions between physicians and other health service levels, refresher training of physicians, emphasizing the importance of providing feedback and promoting the awareness of patients can reduce to a large extent inappropriate referrals.