The effects of conjugated linoleic acid supplementation on anthropometrics and body composition indices in adults: a systematic review and dose-response meta-analysis.

Prior meta-analytic investigations over a decade ago rather inconclusively indicated that conjugated linoleic acid (CLA) supplementation could improve anthropometric and body composition indices in the general adult population. More recent investigations have emerged, and an up-to-date systematic review and meta-analysis on this topic must be improved. Therefore, this investigation provides a comprehensive systematic review and meta-analysis of randomised controlled trials (RCT) on the impact of CLA supplementation on anthropometric and body composition (body mass (BM), BMI, waist circumference (WC), fat mass (FM), body fat percentage (BFP) and fat-free mass (FFM)) markers in adults. Online databases search, including PubMed, Scopus, the Cochrane Library and Web of Science up to March 2022, were utilised to retrieve RCT examining the effect of CLA supplementation on anthropometric and body composition markers in adults. Meta-analysis was carried out using a random-effects model. The I2 index was used as an index of statistical heterogeneity of RCT. Among the initial 8351 studies identified from electronic databases search, seventy RCT with ninety-six effect sizes involving 4159 participants were included for data analyses. The results of random-effects modelling demonstrated that CLA supplementation significantly reduced BM (weighted mean difference (WMD): -0·35, 95 % CI (-0·54, -0·15), P < 0·001), BMI (WMD: -0·15, 95 % CI (-0·24, -0·06), P = 0·001), WC (WMD: -0·62, 95% CI (-1·04, -0·20), P = 0·004), FM (WMD: -0·44, 95 % CI (-0·66, -0·23), P < 0·001), BFP (WMD: -0·77 %, 95 % CI (-1·09, -0·45), P < 0·001) and increased FFM (WMD: 0·27, 95 % CI (0·09, 0·45), P = 0·003). The high-quality subgroup showed that CLA supplementation fails to change FM and BFP. However, according to high-quality studies, CLA intake resulted in small but significant increases in FFM and decreases in BM and BMI. This meta-analysis study suggests that CLA supplementation may result in a small but significant improvement in anthropometric and body composition markers in an adult population. However, data from high-quality studies failed to show CLA's body fat-lowering properties. Moreover, it should be noted that the weight-loss properties of CLA were small and may not reach clinical importance.

Development and psychometric evaluation of a Risky Sexual Behaviour Scale for Married Women (RSBS-MW) in Iran: a mixed-method study.

A valid and reliable culture-based scale for the evaluation of risky sexual behaviours for married Iranian women is lacking. This study aimed to develop, and psychometrically test, a risky sexual behaviour scale for married Iranian women. A mixed-method sequential exploratory design was conducted from 2016 to 2020 in Tehran, Iran. First, a qualitative study was employed to define the concept of risky sexual behaviour using 16 semi-structured individual interviews and 10 focus group discussions (n = 100). Then, an item pool was generated, and the scale was developed. Finally, in the quantitative study, the psychometric properties of the scale were evaluated by validity and reliability tests. A maximum likelihood extraction with promax rotation was performed on 400 sexually active married women to assess the construct validity. The six components: (i) 'quality of sexual relations'; (ii) 'unusual pleasures in sexual relations'; (iii) 'sexual coercion'; (iv) 'verbal violence in sexual relations'; (v) 'self-care in sexual relations'; and (vi) 'concealment in sexual relations' could explain 57.49% of the total observed variance. The findings showed that the 27-item Risky Sexual Behaviour Scale (RSBS-MW) for married women in Iran has excellent internal consistency (α = 0.94) and stability (ICC = 0.98). Health care providers can use it to access risky sexual behaviours in married Iranian women.

Job burnout among nurses during COVID-19 pandemic: A systematic review.

BACKGROUND: Nurses are in close contact with COVID-19 patients and due to the high risk of infection, they experience fear and anxiety that can result in burnout. This study aimed to review the studies on burnout among nurses during the COVID-19 epidemic. MATERIALS AND METHODS: The study followed the guideline for Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA). Using the keywords: "burnout," "nurse," and "COVID-19" and with the help of Boolean operators, "AND" and "OR" the online databases, namely PubMed, Scopus, Google Scholar, Web of Science, and Science Direct were searched. Articles published from the first of February 2020 to 30 October, 2020 were retrieved. After the quality appraisal, the required data were extracted and analyzed. RESULTS: Out of 85 articles identified in the initial search, and after removing duplicates and those that did not have the required data, seven articles entered the analysis. Among these articles, four (57.14%) reported moderate burnout and three articles (42.86) reported high level of burnout among nurses during the COVID-19 pandemic. CONCLUSIONS: A majority of the studies reported that nurses experienced a moderate level of burnout during the COVID-19 pandemic. Given the prevalence of burnout in nurses and because nurses are the largest portion of the healthcare providers who are in close contact with patients infected by COVID-19, it is necessary for health care policymakers to adopt strategies for preventing or reducing burnout among nurses.

HIV serostatus disclosure to sexual partner: a survey among women in Tehran, Iran.

BACKGROUND: Disclosure of HIV-positive status in women is associated with many factors. Consequently, status disclosure remains a challenge for Iranian women living with HIV. This study aimed to assess the prevalence, related factors, and reflections of HIV-positive status disclosure to a sexual partner(s) among Iranian women living with HIV. METHODS: A cross-sectional study was conducted on 170 HIV-seropositive women. Participants were selected from patients registered in the largest HIV clinic and HIV-positive club of Iran. The "HIV disclosure" questionnaire had 38-items and all the interviews were administered by the researcher. Data were analyzed using SPSS version 21.0 software. We used a logistic regression method to calculate the crude odds ratio (COR) and the adjusted odds ratio (AOR) for self-disclosure as the independent predictor variable and the dependent variable, respectively. RESULTS: One hundred and seventy HIV-positive women were enrolled. Most of them had disclosed their HIV status to at least one person (94.1%) and their sexual partners (86.5%). In the univariate analysis, being married (COR = 18.66, 95% CI 5.63-61.87), living with a sexual partner (COR = 4.72, 95% CI 1.92-11.62), being aware of sexual partners' HIV status (COR = 6.20, 95% CI 1.79-21.49), and gaining the support of sexual partner (COR = 9.08, 95% CI 3.48-23.64) were associated with higher odds of HIV status disclosure. In the multivariate analysis, being aware of sexual partners' HIV status, and gaining the support of sexual partners remained associated with HIV status disclosure. Most women reported a positive reflection from their sexual partners after disclosure, however, negative reflections from society were more common compared to sexual partners and family members. CONCLUSION: This study shows high overall HIV disclosure proportions. It should be noted that a large number of women were infected by their sexual partners, especially by their spouses. The high rate of transmission in married people indicates an urgent need for more emphasis on appropriate prevention behaviors by infected partners.

The effect of almond intake on glycemic control: A systematic review and dose-response meta-analysis of randomized controlled trials.

Number trials have evaluated the effect of almond intake on glycemic control in adults; however, the results remain equivocal. Therefore, the present meta-analysis aims to examine the effectiveness of almond intake on glycemic parameters. Online databases including PubMed, Scopus, ISI web of science, Embase, and Cochrane Library were searched up to August 2021 for trials that examined the effect of almond intake on glycemic control parameters including fasting blood sugar (FBS), insulin, HOMA-IR, and HbA1C. Treatment effects were expressed as mean difference (MD) and the standard deviation (SD) of outcomes. To estimate the overall effect of almond intake, we used the random-effects model. In total, 24 studies with 31 arms were included in our analysis. The meta-analysis revealed that almond intake did not significantly change the concentrations of FBS, HbA1c, insulin levels, and HOMA-IR. In conclusion, there is currently no convincing evidence that almonds have a clear beneficial effect on glycemic control. Future studies are needed before any confirmed conclusion could be drowned.

Investigating the effect of educational intervention based on the Pender's health promotion model on lifestyle and self-efficacy of the patients with diabetic foot ulcer: A clinical trial.

BACKGROUND: This study aimed to investigate the effect of educational intervention based on the Pender's health promotion model (HPM) on lifestyle and self-efficacy of the patients with diabetic foot ulcer. MATERIALS AND METHODS: In this clinical trial conducted in 2019, 74 patients based on inclusion criteria were selected through convenience sampling and allocated to two groups of intervention (n = 37) and control (n = 37) using the randomized permuted block method. In this study, Demographic characteristics and localized Diabetes Foot Care Self-Efficacy Scale and Health-Promoting Lifestyle Profile Questionnaire for diabetic foot care were completed by two groups. The obtained data were analyzed using SPSS 16 and through descriptive and comparative statistics, independent t-test, paired t-test, and ANCOVA. RESULTS: After the intervention, the mean score of the intervention group significantly increased in all lifestyle dimensions (P < 0.001). Furthermore, the mean score of self-effcacy increased in the intervention group after the intervention (P < 0.001). Comparing the change in the mean scores of lifestyle and self-efficacy in both the groups 50 days after the intervention, an increase was observed in the mean scores of self-efficacy (P < 0.001) as well as those of lifestyle and its dimensions in the intervention group compared to those in the control group (P < 0.001). CONCLUSION: Educational intervention based on the Pender's HPM can promote the self-efficacy, lifestyle, and its dimensions in the patients with diabetic foot ulcers. The results of this study can be used in educational interventions aiming at patients with diabetic foot ulcers to change their lifestyle and improve their self-efficacy.

Healthcare professionals-related factors affecting parents' participation in decision making for neonates with life-threatening conditions: A qualitative study.

RATIONALE, AIMS, AND OBJECTIVES: Neonates with life-threatening conditions face complex clinical circumstances that confront parents and professionals with ethical decisions. Parents' participation in decision making has not gained sufficient attention in practice. Understanding factors affecting parents' participation is required. This study is part of a comprehensive project that explored the process of parents' participation in decision making for neonates with life-threatening conditions. The current study aimed to explore healthcare professionals-related factors affecting parents' participation in decision-making for neonates with life-threatening conditions. METHODS: A grounded theory methodology was used in the comprehensive project. Twenty-two interviews/68 hours of observation were conducted. Data were concurrently analysed throughout data generation and constant comparative analysis. Data collected until theoretical saturation was reached, the extracted categories were coherent and the emerging theory made sense. After coding stages, the core category and the relationships with other main categories involved in the process of parents' participation in decision-making were developed. For this study, the category reflecting healthcare professionals-related factors affecting parents' participation in decision-making was reported. RESULTS: Four themes were found: risk aversion including fear of litigation, fear of being accountable to the parents, and fear of bearing emotional distress; unprofessionalism including poor adherence to professional ethics, inadequate skill/knowledge, poor communication, and nurses' negligence in playing their professional role; information deficiencies including insufficient information, conflicting information, and complex and technical information, and clashes of attitudes including conflict about parents' participation in decision-making and conflict about the best interest of neonates. CONCLUSION: Professionals should be aware of their role in involving parents in decision making. Training professionals on family centred care principle and communication skills contribute to support parents emotionally and respond empathically to their negative expressions. Training on ethics, development, and dissemination of guidelines and rules of conduct can make professionals more sensitive to ethical aspects of their work and may reduce their fear of litigation.

Exploring the care received by HPV-positive married women at a colposcopy clinic in Tehran, Iran: A qualitative study.

OBJECTIVES: Patient experience is the focus of individual care and services to meet patient needs, but this depends on how health care providers deliver their services. The aim of this study was to explore the perceptions of human papilloma virus (HPV)-positive married women from the care they received from health professionals at a colposcopy clinic in Tehran, Iran. MATERIALS AND METHODS: Three focus group discussions were conducted between September and December 2016 with 30 women who had recently been referred to the clinic for cervical screening or colposcopy. Samples were collected by a purposeful sampling method in Tehran, the capital of Iran. The focus group discussions were carefully recorded at the same time as data collection. After ensuring the data saturation, interviews were terminated and data were categorized. Data was analyzed by direct conventional content analysis using MAXQDA-10. RESULTS: Two themes and three sub-themes resulted from the data analysis, including emotional responses (anxiety and fear of women), and appropriate/inappropriate behavior of the healthcare providers. CONCLUSION: Healthcare providers, by identifying factors that affect patient's stress, could help reduce the negative outcomes such as patients' emotional responses to HPV positive results.

The need for renovating patient education in kidney transplantation: A qualitative study.

BACKGROUND: Many kidney transplant recipients lack the knowledge, abilities, and support they need for self-care. On the other hand, most kidney transplant centers do not have a well-planned and specific training program for them, and educational interventions for kidney transplant recipients have not been adequately effective. This study aimed to describe strategies for improving patient education in kidney transplantation. MATERIALS AND METHODS: Data were collected through semi-structured individual and group interviews with 24 patients, family members, and health-care staff in one of the main kidney transplant centers in Tehran. Participants were selected purposefully, and qualitative content analysis was used to analyze the data. RESULTS: The main finding emerged from the data was the shift from current patient education program to patient- and family-centered education (PFCE). The strategies to achieve this goal were categorized into four main categories including "continuous patient and family education" (pre- and posttransplant patient education), "facilitating the process" (using new technologies, teamwork education, and patient and family accessibility), "strengthening human resources" (empowerment health-care team, allocation of human resources, promoting staffs' motivation, and updating educational content and materials), and "monitoring and evaluation" (correcting patient education recording, supervising the patient education, and appropriate educational evaluation). CONCLUSIONS: Transforming from the current patient education program to PFCE seems to be essential to increase the effectiveness of patient education in kidney transplant process. To this end, providing continuous patient and family education, facilitating the processes, strengthening human resources, and monitoring and evaluation in health-care organizations conducting the kidney transplantation is necessary.

Mobile-Based Technology for the Management of Chronic Diseases in the Elderly: A Feasibility Study.

INTRODUCTION: Population aging and related issues are among the most important challenges in different countries. It seems that the use of remote technology can provide the elderly with better healthcare services and can help them to manage chronic diseases. This research aimed to investigate the experts' views about the feasibility of using mobile-based technology to manage chronic diseases in the elderly. METHODS: This was a survey study which was completed in 2018. The participants were the faculty members of the department of geriatrics across the country (n=33). In order to collect data, two questionnaires were used. The first questionnaire contained questions related to the five dimensions of a feasibility study and the second questionnaire consisted of five open questions about the opportunities, threats, strengths and weaknesses of using mobile-based technology in chronic disease management. The qualitative data were analyzed by using content analysis method and the quantitative data were analyzed by using descriptive statistics. RESULTS: From the participants' perspectives, it was feasible to use mobile-based technology in chronic disease management for elderly people. The mean values for five feasibility dimensions were as follows: ethico-legal dimension (4.09±1.01), scheduling dimension (3.70±1.03), economic dimension (3.47±1.04), operational dimension (3.42±1.12) and technical dimension (3.07±1.27). While such a technology can help increasing the accessibility of healthcare services, raising health literacy, and saving time and costs, the main threats, namely; the misinterpretation of information and the possibility of breeching confidentiality should not be underestimated. CONCLUSION: The results showed that mHealth and remote medical technologies can be used for chronic disease management among elderly people. However, these technologies have some strengths and weaknesses. In order to succeed in the development and implementation of these projects, it is essential to consider probable threats and weaknesses before implementing the applications.

Psychometric Evaluation of a Persian Version of the Cardiac Depression Scale in Iranian Patients With Acute Myocardial Infarction.

PURPOSE: The aim of this study was to validate a Persian version of the Cardiac Depression Scale (CDS) in Iranian patients with acute myocardial infarction (AMI). METHODS: The CDS was forward translated from English into Persian and back-translated to English. Validity was assessed using face, content, and construct validity. Also Cronbach's alpha (α), theta (), and McDonald's omega coefficient were used to evaluate the reliability. RESULTS: Construct validity of the scale showed two factors with eigenvalues greater than one. The Cronbach's α, , McDonald's omega, and construct reliability were greater than .70. CONCLUSION: The Persian version of the CDS has a two-factor structure (i.e., death anxiety and life satisfaction) and has acceptable reliability and validity. Therefore, the validated instrument can be used in future studies to assess depression in patients with AMI in Iranians.

Facilitating factors of self-care among HIV-positive young women in Iran: a qualitative study.

Background Providing care for chronic disease such as HIV is a growing challenge in the world. In order to address the challenges of linkage and care in chronic disease management, we need to identify factors that can influence people to get more involved in self-care. This study was part of an extensive qualitative study conducted in Tehran, Iran in 2016. Methods The data were collected through semi-structured interviews conducted on 25 women with HIV, and were analyzed using grounded theory. Four main themes were identified as facilitating self-care among participants: health system support, clinicians' support, family support and improved life expectancy. Sub-themes that emerged were free HIV tests; free medication; free membership in positive clubs; free psychological consultation; positive attitudes and friendly behavior from clinic staff; telephone follow up; support from husbands, mothers and peers; hope for recovery; hope for the future; and love for own children. Results Our results showed that, providing appropriate support and services, as well as a positive attitude of society towards HIV positive women, can contribute to adherence to self-care in young women with HIV. Conclusion Understanding the facilitating factors based on the patients' experiences can contribute to the development of new policies and procedures to improve the care of these patients.

Dietary fiber and risk of irritable bowel syndrome: a case-control study.

AIM: The purpose of this study was to determine the relationship between dietary fiber intake and risk of irritable bowel syndrome (IBS). BACKGROUND: Patients with IBS are usually concerned about their diet, which can exacerbate or relieve their symptoms. METHODS: In this case-control study, ninety cases and 355 controls were selected from a gastroenterology clinic. Dietary intakes of participants were assessed using a validated and reliable food frequency questionnaire (FFQ). Dietary fiber was calculated according to United States Department of Agriculture (USDA) food composition table. RESULTS: Dietary total fiber intake was significantly associated with lower risk of IBS. The adjusted odds ratio (OR) comparing the highest tertile of dietary total fiber with the lowest tertile was 0.14 (95% CI = 0.71-0.28; P-test for trend <0.001); however, there was no significant association or dose-response trend for higher intakes of soluble, and insoluble fiber separately with risk of IBS. CONCLUSION: Our data indicate that dietary fiber is inversely associated with the risk of IBS. Further prospective studies are needed to confirm these data.

Designing and validation: a questionnaire of hope for family members of patients hospitalized in intensive care unit.

BACKGROUND: Families of patients are faced with stressors in the intensive care unit (ICU) that cannot be controlled sometimes. Having hope is one of the strategies for obtaining self-control in patients' families, which deals with such situations. OBJECTIVE: The purpose of this study was to design and validate a questionnaire of hope for family members of patients hospitalized in intensive care units. METHODS: This study was conducted for family members of patients hospitalized in the intensive care units of Kurdistan and Tehran provinces, in Iran, between the years 2015-2016. In this study, 126 family members were selected using convenience sampling. The study was conducted using a questionnaire of hope scale for family members of patients hospitalized in intensive care units and demographic characteristics. During the study, construct and criterion validity of the tool was determined. The Reliability was determined using internal consistency and test-retest coefficient. Data were analyzed through factor analysis, correlation coefficient and Cronbach's alpha. Construct validity of the scale was analyzed using exploratory factor analysis (EFA). RESULTS: Participants in this study included 12 family members of patients hospitalized in the intensive care units. Cronbach's alpha coefficients obtained from analysis of questionnaires completed by family members of patients was 0.916. Cronbach's alpha under the first scale (compatibility) was 0.898, Cronbach's alpha of the second subscale (self-confidence) was 87%, Cronbach's alpha under the third subscale (Sense of responsibility) was 0.770. The fourth subscale (Looking to the future) was 0.571. Pearson correlation coefficients between the scores obtained from two family members responses to the hope scale were 0.939 which showed that scale stability was average. As a result, exploratory factor analysis, four factors were found that were named according to the statements of each group. CONCLUSION: Consistency coefficients between the two tests was 0.939 that the stability over time the questionnaire was confirmed. A questionnaire of hope in the intensive care unit can measure different dimensions of hope to the families of these patients and help to improve the care of these patients. Validity and reliability of "scale for hope of families of these patients" was appropriate and it could be used to measure hope in families of these patients.

Qualitative study of HIV related stigma and discrimination: What women say in Iran.

INTRODUCTION: HIV-related stigma is a major social problem of people living with HIV. Stigma against these people, especially women, interferes with the prevention, diagnosis and treatment of HIV. This study examined the experiences of HIV infected women who were stigmatized, as well as the strategies used to tackle the issue. METHODS: Twenty-five women living with HIV were examined using in-depth, semi-structured interviews. The data obtained was analyzed using content analysis method in MAXQDA10. RESULTS: The finding of this study was classified into four themes: fear, shame, rejection by family or friends and feelings of frustration. The participant strategies adopted to the perceived stigma and discrimination included isolation, nondisclosure, and loss of follow-up. CONCLUSIONS: HIV in women has different social interposition. It is necessary to intervene, so as to alleviate the effect of stigma on HIV infected women, in order that they gain the ability to accomplish wellness, increase life span and improve quality of life. Nurses, midwives and other professionals need to be involved to ensure public policy in providing supportive environments, and decrease stigma.

Attrition among Iranian nursing students: A qualitative study.

Attrition is a major challenge facing nursing students that results in substantial costs on the education, health, and treatment systems across countries and can have an unwanted effect on the quality and quantity of health services provided as well as on the health of citizens. This descriptive study investigated nursing students' perceptions toward factors influencing attrition. We conducted a qualitative study using a content analysis approach. Nineteen students enrolled in nursing bachelor program were recruited using purposive and snowball sampling. Data were collected using face-to-face interviews, focus group interviews, and participant observation, and analysed using conventional content analysis approach. Attrition factors were categorized into two themes: 'before admission' and 'after admission'. The most important factors were obligation to choose nursing in the National Entrance Exam, poor management in workforce provision and improper supervision, discrepancy between expectations and experiences, and being work abused in clinical training. Authorities in education and practice sectors can use these findings to improve the quality of clinical and theoretical education and to avoid nursing student attrition. This can be achieved through an increase in community awareness of the identity of nursing, efficient management of workforce provision and clear and concise supervision of activities in both theoretical and clinical fields.

Barriers to self-care in women of reproductive age with HIV/AIDS in Iran: a qualitative study.

INTRODUCTION: Although increasing attention is paid to HIV/AIDS, patients with HIV still experience several barriers to self-care. These barriers have been previously identified in small quantitative studies on women with HIV, but qualitative studies are required to clarify barriers to self-care. METHODS: We conducted our study using the grounded theory methodological approach. A total of 28 women with HIV and their family members, were interviewed. The data were analyzed with the Corbin and Strauss method (1998). RESULTS: The key barriers to self-care in women with HIV/AIDS included social stigma, addiction, psychological problems, medication side-effects and financial problems. CONCLUSION: Women with HIV/AIDS face several barriers to self-care. Therefore, when designing self-care models for these women, social and financial barriers should be identified. Mental health treatment should also be incorporated into such models and patients' access to health care services should be facilitated.

Skills Required for Nursing Career Advancement: A Qualitative Study.

BACKGROUND: Nurses require certain skills for progression in their field. Identifying these skills can provide the context for nursing career advancement. OBJECTIVES: This study aimed to identify the skills needed for nurses' career advancement. MATERIALS AND METHODS: A qualitative approach using content analysis was adopted to study a purposive sample of eighteen nurses working in teaching hospitals affiliated with the Qazvin, Shahid Beheshti, and Iran Universities of Medical Sciences. The data were collected through semi-structured interviews, and analyzed using conventional content analysis. RESULTS: The three themes extracted from the data included interpersonal capabilities, competency for career success, and personal capacities. The results showed that acquiring a variety of skills is essential for career advancement. CONCLUSIONS: The findings showed that personal, interpersonal, and functional skills can facilitate nurses' career advancement. The effects of these skills on career advancement depend on a variety of conditions that require further studies.

Physical violence against health care workers: A nationwide study from Iran.

BACKGROUND: Workplace violence is a serious and problematic phenomenon in health care settings. Research shows that health care workers are at the highest risk of such violence. The aim of this study was to address the frequency of physical violence against Iranian health personnel, their response to such violence, as well as the contributing factors to physical violence. MATERIALS AND METHODS: A cross-sectional study was conducted in 2011, in which 6500 out of 57,000 health personnel working in some teaching hospitals were selected using multi-stage random sampling. Data were collected using the questionnaire of "Workplace Violence in the Health Sector" developed by the International Labor Organization, the International Council of Nurses, the World Health Organization, and the Public Services International. RESULTS: The findings revealed that 23.5% of the participants were exposed to physical violence in the 12 months prior to the study. Nurses were the main victims of physical violence (78%) and patients' families were the main perpetrators of violence (56%). The most common reaction of victims to physical violence was asking the aggressor to stop violence (45%). Lack of people's knowledge of employees' tasks was the most common contributing factor to physical violence (49.2%). CONCLUSIONS: Based on the results, legislating appropriate laws in order to prevent and control violence in the workplace is necessary. Moreover, developing educational programs to manage the incidence of physical violence should be on health centers' agenda.