Journal of School of Public Health and

---

Background and Aims: Generalized Structural Equation Modeling (GSEM) is a family of statistical techniques utilized in the analysis of multivariate, categorical and ordinal data in order to measure latent variables and their connection with each other. The aim of this study is to consider the structure of data, and introducing GSEM to medical science researchers and presenting a practical example of in medical science researches.

Materials and Methods: An introduction to Structural Equation Modeling (SEM), along with its advantages and disadvantages was presented, and also GSEM and its all kind of forms was specified. An example to study hypertension risk factors in patients suffering from diabetes was carried out, which was a demonstration of using GSEM method for binary response variables. The data includes a random sample of 2716 people from Golestan province cohort studies.

Results: Age, body mass index, abdominal obesity, residence place, socioeconomic status, salt intake had direct effect on hypertension. Race, education, vitamin D and physical activity had direct and reverse effect on hypertension (p.value<0.05).

Discussion: Unlike SEM, the limitative hypothesis that our data should have a normal distribution do not needed in this model, also GSEM is powerful tool in the analysis of categorized data. Nevertheless this method cannot perform goodness of fit test, and adjustment and modification method of the model directly, and that they are some limitation in using this method.

---

Background and Aim: All hospitals need to be monitored and continuously evaluated. Pabon Lasso graphical model assesses the efficiency of hospitals using a combination of their input data and performance indicators. The aim of this study was to determine the effects of Iran Health System Evolution Plan on Tehran University of Medical Sciences (TUMS) hospitals’ performance indicators using the Pabon Lasso model in 2016.
Materials and Methods: This was a descriptive-analytical and cross-sectional study including 8 general and specialized hospitals. The hospital input data and performance indicators were collected by permission of TUMS Vice-chancellor’s Office for Therapeutic Services. Chi-square and the two-sample T2 tests were used for data analysis, and hospital performance was assessed using the Pabon Lasso Model.
Results: The results showed that the number of TUMS hospitals located in zones 3 and 4 had increased after implementation of the Iran Health System Evolution Plan, which indicates improved efficiency of these hospitals, as confirmed by the chi-square test.
Conclusion: Based on the Pabon Lasso graphical model, it can be concluded that the performance indicators of the hospitals show improvements in performance after implementation of the Iran Health System Evolution Plan. The successful experience in the management of the hospitals in this study can act as a practical guide for managers of other hospitals throughout the country for better management. 

---

Background and Aim: The trade-off between monetary wealth and fatal safety risks is explained by the value of statistical life, an efficient tool widely used to evaluate projects and allocate appropriate resources for road safety. The objective of this study was to estimate the statistical significance of life in order to improve road safety in the city of Ardabil, Iran.
Materials and Methods: Data were collected, in 2017, using a questionnaire for interviewing 300 drivers traveling daily in the city and analyzed using the stated choice method and the mixed logit model. First the purpose of the interview was explained to the drivers and, after they agreed to collaborate, the interviews were conducted. The authors pledged to keep the information confidential.
Results: The statistical value of life and of the injury for road safety improvement were estimated to be 1,077,551,000 and 1,178,570 Iranian Rials, respectively. The richer people, older people and those with university education were more willing to pay for road safety improvements.
Conclusion: One of the strategies for economic investment in improving road safety can be conducting collaborative research projects with other institutions, as well as using the experiences of countries successful in this field. In addition, road safety improvement projects can, in order to absorb capital, target richer people.                                                       

---

Background and Aim: The present study aimed to determine the stages of changes and cognitive and behavioral processes (Transtheorical model) in the use of nutrients in overweight middle-aged women.
Materials and Methods: The present study was a descriptive-analytic. The research sample consisted of 281 middle-aged women with overweight referring to comprehensive health centers in Isfahan. Personal characteristics, stage of change and behavior and cognitive behavioral processes, and FFQ questionnaire (168-item) were completed by Questioning, and then the information entered the N4 and SPSS 18 software, and information was analyzed using descriptive and analytical tests.
Results: 57.7% of the people were inactive (pre-thinking, thinking, preparation) and 42.3% of them were in active phase. There was a significant difference between the different stages of change and the use of behavior change processes (p=0.001) And Benfrown's test shows the increasing use of cognitive and behavioral processes during the stage of change in use of nutrients (p<0.001).
Conclusion: The difference in the mean of changes processes during the stage of change show the impact of these processes on the nutritional individual's behavior, which is recommended to use stage of change and behavioral change processes for education nutrition behavioral.

---

Background and Aim: Along with the expansion of health systems, the importance of primary health care as the basis of an efficient health system is more evident and the quality of the provided services at this level becomes more important. In this way, the present study attempts to collect patterns used to improve the quality of primary health care.
Materials and Methods: The present study is a systematic review. The advanced search was done in the Web of Science, Scopus, Embase, PubMed, Cochrane, SID, MagIran, IranDoc, and Google Scholar databases in title, abstracts and keywords fields. Inclusion criteria include a comprehensive attitude, focus on primary health services, English or Persian language, published between 2006 and 2018. Exclusion criteria include studies that focus outside of primary health care. The quality of the studies was evaluated using the JBI checklist. Two independent researchers conducted the task of selecting studies, extracting data and evaluating the quality of studies, and disagreement cases were resolved by the third researcher.
Results: After screening and reviewing the criteria for the entry of 10095 studies, 11 studies were finally included. The quality of the four studies was evaluated average and the rest of the quality was high. Two studies have provided patterns for improving the quality of primary health care, three evaluated the effectiveness of quality improvement tools, and five presented conceptual frameworks.
Conclusion: A total of eight types of systems extracted to assess and improve the quality of primary health services. Studies on primary health care have been used at various levels of personal, professional, practical and national policy, and have developed models, tools and frameworks that each of them can be used separately or combined for different situations with regard to the limitations and facilities mentioned and improve health outcomes.

---

Background and Aim: Good governance results in better health outcomes for the society thorugh improving health system performance. The governance of Iran health stsyem faces some challenges. Hence, this study aimed to propose and verify a model for strengthening Iranian health system governance.
Materials and Methods: This descriptive study was conducted in 2016 using the Delphi method. A health governance model with six dimentions including sturucture, communication, regulation, policy making and planning, stewardship and evaluation and accreditation has been proposed. Then, the proposed model verified using 25 Iranian healthcare experts’ opinions in two rounds.
Results: Developing an integrated health system model comprising health system enablers and results, downsizing and reducing the number of directorates in ministry of health,determining basic principles for regulation, enhancing communication with other external organizations affecting people health, using more evidence in policy making and planning, developing a strategic plan and national health policy, enhancing leadership, management and stewardship; and developing comprehensive systemic standards for evaluation and accreditation of healthcare organizations are recommended to enhance the effectiveness and efficiency of Iran health system governance.
Conclusion: Iran health system governance faces numerous challenges. Using successful countries’ experience and internal health care experts’ opinions help to reduce the current challenges and achieve health system goals.
 

---

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: 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: High concentrations of particulate matter-25 (PM_2.5) have been the cause of the unhealthiest days in Tehran, Iran in recent years. This study was conducted with the aim of the spatio-temporal analysis of traffic volume and its relationship with PM_2.5 pollutant concentrations in Tehran metropolis, Tehran during 2015-2018, using the Geographic Information System (GIS).
Materials and Methods: In this study in different regions of Tehran, the Inverse Distance Weighting (IDW) model was used for prediction and zoning of the PM_2.5 concentrations and traffic volume during the period 2015-2018. In addition, the association between the PM_2.5 concentrations and traffic volume was determined based on the Geographically Weighted Regression (GWR) model.
Results: The findings showed that the southern and southwestern regions of Tehran had the highest PM_2.5 pollutant concentration (annual average more than 40 μg/m³), while the eastern and northern regions had the highest traffic volume. In addition, based on the GWR model, the eastern regions were found to have the highest local R² values (between 0.36 and 0.70).
Conclusion: In most regions of Tehran, no strong association can be found between high concentrations of PM_2.5 and traffic volume. However, based on the findings of this study we cannot reject the relationship between traffic volume and PM_2.5 pollutant but postulate other sources to be the main reason for the high concentrations of PM_2.5. Thus, in the first step, these sources should be identified, followed by adopting strategies for traffic volume control and reduction aiming at having a cleaner air in Tehran.

---

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.
 

---

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.
 

---

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.
 

---

Background and Aim: The objective of this study was to gain a deep understanding of the importance (expected services) and performance (services provided) of mental health services to determine the priority indicators of mental health to help design higher quality and more effective community mental health interventions.
Materials and Methods: This was a mixed-method study including all the mental health executives and practitioners (n=998) in Iran. In the quantitative part, the Importance-Performance Analysis (IPA) model was used to determine the importance and performance of the current mental health programs in the primary health care (PHC) system, and in the qualitative part complementary explanations were analyzed using the thematic analysis method.
Results: The findings show that there were gaps between the expected services and the services provided in the mental health program. Thus, the following points should be taken into account to be able to improve the mental health services: 1. Strengthening the domestic violence prevention program as regards spouse misbehavior and misbehavior towards children; 2. Continuation of lifestyle skills and parenting programs, 3. Self-care in mental health and drug use programs; 4. psychiatric disorders diagnosis and care and a healthy adolescents program is desirable and necessary, but revising and modifying the suicide prevention program (as regards costs and treatment) are essential. 5. In addition, the psycho-social intervention programs in disasters, addiction harm reduction program, strengthening family foundation and the Competent Family Program are of low importance in formulating a strategy.
Conclusion: Corrective actions based on the prioritizations determined can be included in the working agenda of the managers of mental health care systems at the primary levels to improve the quality of mental health services.
 

---

Background and Aim: Cement production is the source of 7% of global CO2 emissions. In order to reduce emissions by 0.7% annually until 2030, the cement industries can adopt the circular economy model. The present study aimed to assess the environmental sustainability of the Sufian cement industry based on the circular economy model.
Materials and Methods: Based on the circular economy model of the Ellen MacArthur Foundation, this research was conducted in three steps in the Sufian Cement Factory in 2021-22: Step1. Data were collected on fuel consumption, electricity, water, production waste, released gases and costs; Step 2. Based on literature review and experts opinions strategies and solutions to move towards a circular economy were determined; Step 3. The index of linearity and rotation in the current and future state was calculated for the Sufian cement industry.
Results: The data obtained showed that the Sufian cement industry is currently heavily dependent on primary raw materials and operates in a linear economy. Implementing the recommended strategies would be expected to reduce the linearity index to below 1 and increase the rotation index to above 0.1. These findings indicate a positive shift towards a circular economy.
Conclusion: The findings of this study reveal that the Sufian cement industry is currently totally based on linear economy, but it can, through implementing the relevant strategies, potentially transit to a circular economy, which will increase the factory’s net profit, protect resources and reduce CO2 emissions.
 

---

Background and Aim: The Integrated and Comprehensive Geriatric Care Program (ICGCP) of the Ministry of Health and Medical Education (MOHME), Iran was designed about a decade ago and is being implemented to maintain and improve the health of the elderly. The program has not been evaluated so far. A comprehensive evaluation of this program is deemed necessary to determine whether this program requires revision or process improvement. Therefore, this study aimed to evaluate the ICGCP of MOHME using the Context, Input, Process, Product (CIPP) model in Qom province.
Materials and Methods: This descriptive-analytical cross-sectional study included the entire personnel of the health centers in Qom province as the statistical population. The data collection tool was a two-section questionnaire containing items on demographic information and a researcher-made evaluation questionnaire of the current elderly care program based on the four areas of the CIPP evaluation model. Participants meeting the study's inclusion criteria were enrolled through census sampling. The data were analyzed using the SPSS software version 24.
Results:  The mean age of the participants was 34.92 ± 6.98 years, 140 (84.3%) being females. Data analysis showed the following results as Mean ± SD: (1). A regards the context, for the items "Target group's need for the program" and "Identification of the potential of other influential organizations in program implementation": 3.71 ± 1.01 and 2.21 ± 0.99, respectively. (2). As regards input, for the items "Identification of program audiences" and "Necessary budget and funding for the program": 3.70 ± 0.95 and 2.23 ± 0.95, respectively. (3). As regards process, for the items "Program evaluation by officials and executing personnel," and "Recording and tracking issues during the program”: 3.16 ± 0.90 and 2.69 ± 0.85, respectively. (4). As regards product, for the items "Satisfaction with work, commitment and work ethic" and "Conducting case studies in this area":  3.65 ± 0.81 and 2.64 ± 1.01, respectively. In the overall program evaluation, the mean scores for "Program necessity" and "Program delivery quality" were 2.88 ± 0.89 and 2.12 ± 0.80, respectively.
Conclusion: The evaluation of the ICGCP of the Ministry of Health and Medical Education using the CIPP model identified the strengths and weaknesses of this program based on the opinions of health center personnel in Qom province. Policymakers and other relevant authorities can use these findings to enhance the program further.