Journal of School of Public Health and

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In this descriptive study, we compared the amount of public spending on health researchandtheprocessforallocationofresearchfundsbetweenIranandseveraldeveloped countries.
The study made it clear that the State&aposs total per capita spending on research and the percentage of the total government budget and the Gross Domestic Product spent on research were considerably lower than in most developed nations. The administrative process for obtaining funds was long and tedious, and private sector spending on health research was negligible (in contrast to Western countries, where the most research is funded by the private sector). The results of this study could have important implications for health care planning and research administration in Iran.

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Approximately 21% of children and adolescents experience signs and symptoms of aDSM-1V disorder during the course of a school year, yet fewer than 20% of those needingmental health services actually receive any. Research suggests that schools and teacherscan help promote mental health, delect children at risk, and refer them for psychiatricassistance. This study aims to determine the effects of an educational intervention onteachers' knowledge, attitude, self-reliance and practice.This study was carried out in 24 State-run elementary schools in the city of Khorramabadin Lorestan province. Iran, during the academic years 2001 - 3.Of the 64 teachers initially selected, 57 agreed to participate in the study 27 of these wereplaced in the intervention group and the remaining 30 in the control group.The intervention group attended a 3-day workshop. Self- administered questionnaireswere filled before and after the workshop, and at the end of the project data were collectedfrom teachers and students. Statistical analysis was done by the SPSS package, usingmainly nonparametric tests.49% of the participants were men, 42% had a high school diploma and others haduniversity degrees. Findings showed significant improvements in teachers' knowledge.attitude, and practice in the intervention group. Nosuchimprovement was observed incontrols. Teachers in the intervention group were able to identify and refer 106 suspectedcases, of whom 79 had a mental disorder confirmed by a psychiatrist. Within the sameperiod, only 2 cases had been referred by the control group. Students' knowledge, themain criteria of teachers' practice in mental health education, had significantly improvedin the intervention but not in the control group. Results suggest that female teachers hadhigher KAP levels than their male colleagues.The study confirms that trained teachers have the capabilities required for participating inSchool - Based Mental Health Services. It also appears that schools are indeed a crucialplace for helping children in need of mental health services.

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This cross- sectional study was done to assess the prevalence of chronic cough by age and date of birth (age-period-cohort analysis). Using data from two National Health Surveys in 1991 and 1999 (involving cross-sectional general population samples), we studied all cases of chronic cough recorded during the period of 1991 to 1999 in people aged 2 to 70 years. A birth cohort analysis was performed on the data. Comparison with earlier surveys showed that the prevalence of chronic cough had fallen from 4.5% to 1.8%. Age-period-cohort analyses of the age effect revealed that prevalence rate of chronic cough increased with age but in every age group it actually decreased after the 8-year period. The fact that different trends are observed in cross-sectional and cohort data points to a strong cohort effect. the prevalence of chronic cough is strongly determined by a person’s year of birth. Also for any given age group, prevalence rates were lower in younger compared to older cohorts.

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The aims of the present study were to assess preparedness and function of health system in the management of withdrawal symptoms in opioid dependents after Bam earthquake, the methods that medical staff used for identification of dependents, the viewpoints of the medical staff as well as opioid dependents about the roles of health system, and the appropriate methods for managing opioid dependence after disaster. This qualitative study was carried out in the city of Bam, one of its nearby villages and eight hospitals in Tehran and Kerman, admitting earthquake victims. Our analysis was based on 163 semi-structured interviews, with drug abusers, their family members, people living in Bam, service providers, and the authorities. No specific training for drug abuse was reported by medical staff. No guideline or program was available for prevention and management of drug dependence in disasters. Most of the medical staff had negative attitudes toward involvement in treatment of opioid dependence. During the first two weeks after the earthquake, medical management of the withdrawal symptoms was inadequate. Most of the interviewees suggested managing the withdrawal symptoms with prescribing opioid agonists and then treating the opioid dependence following improvement of physical injuries and stability of social situation. In disaster situations, the consequences of inadequate management of opioid dependence can be ominous. Such consequences consist of a change in incidence of substance use, intensity of use and dependence, type of substance and route of use to more dangerous ways. Therefore, a practical protocol (disaster planning) is needed for prevention and management of substance dependence in the times of crises.

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Natural disasters cause millions of death and disability and major financial losses world wide every year. The major concern of our health system has already been to reduce physical mortality and morbidity. While such events may be a considerable source of stress for the survivors and cause serious and long-lasting psychiatric complications. The purpose of this study was to assess the function of rescuers in mental health service delivery to survivors of Bam earthquake in four steps Rescuing, Emergency services, Transportation of the injured survivors and Treatment in the first 2 weeks after the earthquake. For reaching the purpose 4 groups of the survivors were selected: first group was the healthy survivors (>15 years) living in Bam after the earthquake, the second group was healthy survivors (<15 years) living in Bam after the earthquake, the third group was the injured survivors admitted in Kerman and Tehran hospitals and the last group was the Relatives who accompanied the injured survivors. 2 weeks after the earthquake a questionnaire including questions about, demographic data, function of rescuers in rescuing and emergency services steps, informing the survivors of their relatives condition and Condoling with the survivors and mental health services delivery was filled for each of the cases. In all groups, more than 85% of the cases who needed help and rescued from the load of the earthquake were rescued by their relatives and rescuers of the Red Crescent Society or other governmental organization just had a little portion (5%)in this field. Only 25%of the cases who needed help and rescuing from the load of the earthquake were rescued in the first hour after the earthquake. Only 40% of the cases were sympathized by their rescuers. About 65% of the cases had enough information about their relatives. 40% of the cases were prevented from crying by rescuers. Only 30% of the cases said that they knew addict individuals who were hot given alternative materials. 30/% of the children had played during 2 weeks after earthquake and 42/% of them had facilities for playing. Regarding to all studied groups rescue activities, primary care services and transfers have been performed by relatives and domestic people , therefore general training and organizing CBO (community Based organization) for providing services in disasters especially in regions which are at high risk of earthquake will be useful for reducing the injuries. According to this research rescuers are in serious need of training in mental health services and that major areas of education need are: using counseling techniques, providing the necessary information for the survivors and stress management techniques.

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Background and Aim: Domestic violence against women is a major public health problem throughout the world. Feelings of shame, guilt and fear on the part of women, together with an unresponsive health care system continue to silence and isolate women who suffer abuse and negligence- with major effects on their physical and mental health. Mental health consequences include depression, anxiety, stress disorders, and somatization. This study estimates the prevalence of domestic violence and its associated effects on the victims' mental health.
Materials and Methods: This cross-sectional study used data from 1189 married women over the age of 15, selected randomly among the residents of Tehran.
Results: The overall prevalence of domestic violence was 35.7%. Thirty percent of the subjects had experienced physical violence, 29% suffered mental violence and 10% had been victims of sexual violence many of these women had suffered all the three types. The most frequent types of physical violence included beating in the form of kicks, punches, and slaps (91%) common types of mental abuse included humiliation, verbal abuse and insults (93%), and threats of violence (83%). Data on mental health status indicate that overall, as many as 34.1% of women could be suffering from disorders such as depression and anxiety. The risk of psychiatric disease was 3.5 times higher in victims of violence compared to other women (OR = 3.5, CI 95% = 2.72 - 4.58). Major factors contributing to domestic violence were husband addiction, low economic status, and the number of children (P<0.001). These results are consistent with the current literature on domestic violence and illustrate the high prevalence of this phenomenon. Victims are commonly depressed and have a higher rate of anxiety.
Conclusion: Violence is an important indicator of women’s health. Screening programs for domestic violence could be effective, along with community support and referral to health care and legal facilities. It is also crucial to promote knowledge and awareness of violence among health care providers. This study shows that a community-wide effort to establish links between health care settings and community services may be important in addressing the needs of victims.

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Background and Aim: The present article attempts to define the current trend for age at first marriage, based on the nationwide Health Survey of 1999 and using the Brass model.

Material and Methods: The national Health survey was conducted in 1999 and involved 1/1000 of the total population, selected via cluster sampling (clusters of 8 households each).

The sample used for the present study consisted of 16000 women aged 15-49, including 3026 women in Tehran province. Variables used for analysis were current age, marital status, age at first marriage and residential area (urban/rural). The mean age at first marriage for married women was 17.8 years (sd=3.7) for the whole country, and 18.2 years (sd=3.7) for Tehran province.

Results: The Brass model fitted to the data revealed a significant decreasing trend for the proportion of married women in all age groups, especially in the 15-19 year-old category.

Conclusion: This obviously indicates an upward trend for age at first marriage.

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Background and Aim:  One of the biggest problems faced by parents of handicapped children is the child's health care. This study investigates patterns of heath care utilization and the related factors in children with mental impairment.

Material and Methods: This cross-sectional study involved 110 children (≤14 year old) with developmental disabilities in Tehran. Parents were selected by systematic random sampling for face-to-face interview.  Statistical analysis was based on negative binomial regression.

Results: Over 99% of the surveyed children received ambulatory care and 15 % had been hospitalized over the preceding year 0.9% had never used health services. These children had utilized health services 207+18 times in a year. Among these services 38+3 were not subsidized by the State. Factors affecting service utilization were parent information (p<0.033) and referral to the proper service delivery points (p<0.029).

Conclusion: Appropriate interventions are required to address the above-mentioned factors and improve service utilization.

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Background and Aim: Public-private partnership is a type of privatization in which the public sector continues to participate in the provision of services. Based on an agreement between the Ministry of Health and the Ministry of Cooperatives, Tabriz University of Medical Sciences started the process of creating health cooperatives in the Eastern Azerbaijan Province. In this study we compare the function of various health service processes between public health centers and health cooperatives.

Material and Methods: This study looks at coverage, quality and continuity of primary health care in 9 health centers handed over to cooperatives as compared to 18 current public health centers. Data were collected over a period of three months and analyzed by the SPSS-10 statistical package. Chi-Square and t tests were used for data analysis.

Results: Family planning coverage rates, infant health care, 1- to 6-year-old health care, prenatal care and the number of households covered by volunteers were all higher in cooperatives compared to public health centers. The mean care delivery volume was smaller in health cooperatives. The mean numbers of screening visits, outpatient visits, control visits, consultations, injections and dressings as well as follow-ups were higher in health cooperatives. Despite the greater numbers of family planning visits, vaccinations, health certificates issued and water chlorimetry tests in the public sector, the differences were not statistically significant. Concordance of data between forms and registers was higher in health cooperatives in the case of child health care, periodic visits and vaccination forms.

Conclusion: Compared to the public sector, health service delivery through cooperatives not only functions well but also yields better indices in many health domains. This is an example that a private institutions functioning under the supervision of the public sector can implement nationwide health care programs better than the public sector itself.

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Background and Aim: Hospitals are among the most important health and medical institutions responsible for promoting health, and provision of appropriate health services requires a healthy, hygienic and safe environment. This research was done with the aim of assessing the environmental health situation Qom hospitals in 2005.

Materials and Methods: This research is an applied descriptive - analytic study on hospitals in QOM Province. Data were gathered using survey and observation methods and a two-part questionnaire. The first part of the questionnaire consisted of 45 items covering demographic data on hospitals and hospital managers. The second part comprised 363 questions about the environmental health situation as well as diagnostic, treating and support services. The questionnaires were filled after validity and reliability tests in eight hospitals in Qom Province. For statistical analysis, we performed Mann-Whitney and Kruskal-Wallis tests and calculated Spearman's coefficient, using the software package SPSS.

Results: Poor environmental health was observed in 25% of the radiology wards, kitchens and laundries. The situation was assessed as "appropriate" in 12.5% of laboratories and central sterilization (CSR), 25% of emergency services, 50% of ICU wards and 71% of surgery and recovery rooms, and it was intermediate of the other wards. Overall, the level of compliance with the principles of environmental health was average, i.e. about 72.5 percent. Further analysis of data showed that the situation was better in private, non-teaching hospitals compared to government-run and teaching hospitals. However, environmental health was found to improve with an increase in the number of active hospital beds and the managers' experience in their current job. It declined with increasing hospital age and increasing age of the hospital managers.

Conclusion: Overall, the environmental health situation in Qom hospitals was found to be at an intermediate level. Hence, these hospitals have a long way to go before they can achieve the appropriate level of environmental health

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Background and Aim: There are no occupational health data concerning the prevalence of mental disorders in Iranian hospital nurses. Such information may be a prerequisite for efficient occupational mental health interventions. The aim of this study was to determine mental health status among shift work hospital nurses.

Materials and Methods: This paper reports the findings of a cross-sectional survey that was part of a larger quasi-experimental study. We selected and evaluated 1195 nurses in 12 general hospitals in Shiraz (capital of Fars Province), using the 28-item version of the General Health Questionnaire (GHQ). We used structured observations in accordance with an occupational health checklist to assess working environment during the work period.

Results: Results indicated that 28.7% of nurses were in poor mental health. Mental disease was more common among females than males (p<0.05). Prevalence rates for anxiety and somatic symptoms were 42.2% and 35.5% respectively. The prevalence of depression was 11.9% and social dysfunction, 79.5%. There was a significant relationship between shift work and anxiety as well as sleep disorders (p< 0.05). Associations were also found between marital status and depression and between gender and social dysfunction (p< 0.001).

Conclusion: Prevalence figures for mental disorders are similar to those from nationwide surveys but it seems that social dysfunction and anxiety disorders are more common in nurses compared to the general population aged 15 and over. More attention must be paid to the health of shift work nurses (especially female staff). This can take the form of shift work health education programs, occupational health counseling, and periodic examinations.

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Background and Aim: Puberty is a critical period in a woman's life. An important step in strategies designed to promote family and community health is determination of girls' health priorities and needs assessment at puberty. This study aims to illustrate the efficiency of need assessment approach in exploring and comparing the viewpoints of mothers, teachers and adolescent girls on girls' pubertal health in the context of the school. The findings would help plan better programs aiming at changing the heatlh behaviour of girls.
Materials and Methods: In this qualitative study 12 guidance school girls, 12 mothers and 7 teachers from District 6, Tehran were selected to participate in focus group discussions to prepare a semi-structured questionnaire. The content analysis method was used to analyze the results of discussions with the participants and complete the final questionnaire.
Results: The findings reveal the efficiency of the need assessment approach as follows: a wide discrepancy in viewpoints of the three study groups was identified in terms of pubertal health priorities, health needs of the girls, and pubertal health educational priorities. In addition, the results show a lack of a notion of comprehensive sex health education in the school.
Conclusion: The findings indicate that the need assessment approach is a useful way to plan and implement appropriate health education programs for adolescent girls.

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Backgrounds and Aim: Increased life expectancies and decreased fertility rates have led to ageing populations worldwide. This phenomenon is one of the most important public health challenges of the current century. Previous studies have shown that identifying factors affecting lifestyle and educational needs help in designing new strategies for health promotion. This study was conducted to investigate the preparedness of the elderly to adopt a healthy lifestyle and factors affecting it in the City of Tehran in 2007.
Materials and Methods: This qualtative study included 60 elderly persons from Tehran elderly centers, using the focus group discussion method. Sampling was targeted and a qualitative methodology was used for analysis of the data collected.
Results: The results shows that different elderly persons have different views with regard to what physical and mental health is and what factors cause healthiness. They believe that regular physical activity is very beneficial but that there are many difficulties in performing regular physical activity. Most of the subjects are in the prepation, action and maintenance stages as regards physical activity. On the other hand, nearly all the subjects are in the precontemplation stage with regard to fruit and vegetable consumption, despite the many obstacles in following a healthy diet.
Conclution: The findings of this study show that many factors influence adoption of a healthy lifestyle by the elderly. Bearing these factors in mind, appropriate educational strategies aiming at facilitating adoption of a healthy lifestyle can be designed.

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Background and Aim: The district health information system (DHIS) converts raw data into useful manegerial information. The main purpose of DHIS is to improve quality of health services in service delivery points. This study was conducted to investigate the DHIS performance.

Materials and Methods: A total of 200 health service-delivery units were selected by systematic random sampling, and the calculation of 47 primary health care indicators was assessed by the provincial health center statistics supervisor.

Results: On the average, 41.9% of the indicators had been calculated in each unit. In the district health center, the proportions of outcome measures and process performance indicators calculated were 50% and 5.6%, respectively. On the basis of the indicators obtainable from the vital horoscope, 79% of the indicators in the district health center and 66% of those in the health service-delivery units had been calculated. Finally, there were 97 disease-surveillance forms, 35 environment-health forms, 21 family-health forms, and 23 other forms at the district level.

Conclusion: Re-designing the structure of the health information management process and determining indicator packages at the district and service-delivery level are vital steps for improving the health information system at the district level.

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Background and Aim: Environmental health impact assessment of industrial estates will help greatly in better planning for sustainable development and reducing disease risk in a community. The objective of this study was to assess the positive and negative effects of establishing an industrial estate in Jovein, Sabzevar, Iran in 2006-7 and suggest managerial strategies to reduce undesirable environmental health impacts.

Methods and Materials: A modified Leopold Matrix and Scaling checklist method was used. The existing environmental situation was investigated and then environmental impact assessment alternatives were determined, bearing in mind the amounts and kinds of predicted pollutants in the construction and operational phases . The assessment was made considering the immediate, direct, and indirect impacts in the short and long terms. It was attempted to use a wide range of values of different factors (-5, +5) in order to estimate the impact of all activities on the environmental status.

Results: The results of the study are presented with two alternatives, i.e., "No" (conducting the project with no concern for environmental issues), and "Yes" (performance of the project with application of methods to reduce the environmental harmful impacts), when establishing the industrial estate, in the construction and operation phases. The impact assessment with the "No" alternative scored -791, meaning that execution of the project had to be rejected. However, after reducing the harmful impacts the score rose to +252, indicating that the project would be accepted.

Conclusion: The method of reducing harmful environmental impacts along with environmental management programs introduced are accepted in this study. It is recommended that the Ministry of Health and Medical Education and The Iranian Environmental Protection Agency collaborate closely in the area of environmental health impact assessment of industries and industrial estates.

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Background and Aim: By definition, the ratio of output to input in any firm is called efficiency. In general, there are two main approaches for measuring efficiency ─ parametric and non-parametric. The objective of this study was to assess the efficiency of Health Services Workshops in Iran in 2006.

Methods and Materials: The efficiency of Health Services Workshops in Iran in 2006 was assessed using the non-parametric method, based on linear programming. More specifically, the Data Envelopment Analysis (D.E.A) was used. The most important feature of the Data Envelopment Analysis (D.E.A) is its applicability for the firms that operate under a multiple input-and-output framework. Assessment of efficiency was based on 2 assumptions, namely, fixed and variable efficiency.

Results: The data show that, based on fixed efficiency, the efficiency in the Bushehr, Fars, Kerman, Mazandaran and Yazd provinces is the highest, the average being 80%, which means that the idle capacity is 20% . Based on the variable efficiency. assumption, in Ilam, Chahar Mahal-and-Bakhtiari, Semnan, and Kohgiluyeh Boyerahmad provinces the efficiency is 85% (idle capacity = 20%).

Conclusion: On the whole, the Chaharmahal-Bakhtiyari province is the most efficient in holding Health Services Workshops in Iran. Therefore, other provinces should follow this province as an example when planning to increase their efficiency.

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Background and Aim: Despite the fact that the proportion of youth population is very high in Iran, there is no well designed, comprehensive reproductive health program for the youth. This prompted the health planners to evaluate all the existing centers that deliver reproductive health services to the youth in the country in order to identify the weaknesses and strengths of the services and the centers.

Materials and Methods: A descriptive analytic study was conducted from March 2006 to March 2007, in coordination with the Vice-chancellor for Health of Universities of Medical Sciences, through Offices for Health of the Youth and Schools (OHYS). Five health centers, namely, Tehran, Semnan, Bam, Chabahar, and Fassa Health Centers (the only centers delivering reproductive health services to the youth) were included in the study. They were assessed for structure and physical facilities, job satisfaction of the personnel, satisfaction of the youth consulting them, and the services (including consultative services) delivered. The data were gathered through questionnaires using a checklist and analyzed by the SPSS-13 software.

Results: The health center personnel thought that the quality of services delivered at the centers was low. They also believed that the physical facilities, including equipment in the clinical examination room, furniture, cleanliness of the premises, and entertainment facilities, were not of an acceptable standard. About 64% of the personnel of the health centers personnel expressed job satisfaction. On the other hand, 39% of the young people consulting the centers expressed full, and 54% relative, satisfaction with the services they were receiving the remaining 7% were not content at all. The highest rate of satisfaction was with the psychologist, physician, and midwife, so that 95% of the clients recommended the centers to other young people seeking reproductive health services. Finally, the clients said that in most of the centers paramedical personnel, including nutrition officers (50%) and midwives with a Master's degree (17.5%), were insufficient.

Conclusion: It is suggested that a comprehensive service package be developed to be used in all the health centers, rather than each center deliver services based on the existing facilities and individual preferences. Such a package should be based on the national reproductive health programs (according to the medical education curricula). Intersectoral collaboration (particularly from the Ministry of Education and cultural organizations) is also very essential.

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Background and Aim: Monitoring and evaluation are basic components of any health program. Control charts show clearly the process performance trend longitudinally and help managers and staff to detect general and specific variations and evaluate the process performance correctly. This study was conducted to design and utilize control charts in the primary health care (PHC) system.

Materials and Methods: This study was conducted in two stages. In the first stage, the average weekly, monthly and seasonal delays in receiving health services were compared retrospectively. In the second stage, appropriate control charts were introduced with due consideration of the PHC system.

Results: More than 95% of the weekly average delays were below the upper control limit, while in 100% of the cases the monthly and seasonal averages were under the upper control limit.

Conclusion:  Desirable health outcomes result from appropriate services. It is necessary to monitor health processes coverage and performance with simple and specific indicators. With regard to the health process outputs in the PHC system, it is suggested that the R-X, np and C charts be used in monitoring processes.

The control charts help the service providers to determine and manage process performance by gathering simple, applicable data. Some of the advantages of using these charts are the possibility of longitudinal surveys, simplicity of the calculation methods, and their high applicability. 

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Background and Aim: Rapid growth of Iran's population attracted attention of the authorities after the 1986 national census. This led to population control and family planning programs to be considered as a priority. Appropriate strategies of the family planning program led to a very fast decrease in population growth and fertility indices: and use of contraceptive techniquies rate increased from 49% in 1989 to 73.8% in 2007. This study aimed at reviewing family planning program in Iran (FPPI) during the last four decades and discussing the reasons for its success, as it can be a guide for future efforts aimed at improving other aspects of reproductive health.

Materials and Methods: The method used was systematic reviewing of articles indexed in Medline and University Jihad Scientific Database, reports of the Demographic and Health Project, the Iranian Statistical Center National Censuses, and the Ministry of Health and Medical Education reports on knowledge, attitude and practice.

Results: FPPI initiated officially in 1966 faced with limited success. Following the 1986 national census, population control was announced as a public policy, supported by the leaders. A supportive environment was created by mass media. Establishment of the Departments of Population and FP in the Ministry of Health made possible reorganizing family planning services: expanding coverage of PHC services, including FP services training skilled personnel providing free contraceptives and vasectomy and tubectomy services. Involvement of volunteers and NGOs helped in strengthening community actions. In order to develop personal skills, in addition to face-to-face FP counseling in the health centers, FP education in schools, colleges, workplaces, army and pre-marriage classes was also imparted. Promotion of men's participation in FPPI, by providing male methods of contraception, such as vasectomy or condom use, was also considered. There was also cooperation and support on the part of nongovernmental and international organizations.

Conclusion: Based on the findings, it may be concluded that the principles of health promotion can explain the FPP achievements in Iran. This model can be used in expanding other reproductive health programs in Iran.

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Background and Aim: Today cardiovascular diseases are the main cause of disability and mortality in many countries. This study was performed to determine the effect of health education based on the Health Belief Model on the knowledge, attitude and practice of housewives in Isfahan, Iran regarding improving their nutritional behavior for preventing heart disease.

Materials and Methods: This was a quasi-experimental intervention, including 68 Isfahani housewives randomly divided into an experimental (n=34) and a control (n=34) group. Data were collected using a standard health belief model (HBM) and a food-frequency (FFQ) questionnaire. The experimental group attended, after a pre-test, 6 weekly education sessions. The HBM questionnaire was completed 3 times (before and immediately, and 2 months, after education), while the FFQ questionnaire was completed twice (before and 2 months after education) by the housewives. The data were analyzed using SPSS16 software, the statistical tests being t-test, and repeated measure ANOVA.

Results: The two groups were not significantly different with regard to demographic variables. Similarly, before the intervention they were statistically similar with respect to the scores of the HBM components (P>0.05). After the intervention, significant differences appeared between the experimental and the control groups with regard to all the components (knowledge, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived efficacy, and performance in all cases, P<0.001)

Conclusion: Based on the findings, it can be concluded that the intervention had a positive impact on the feeding pattern of the women and was effective in increasing or improving their knowledge, attitude and practice.