Design and evaluation of mobile application for adolescents' self-care: protocol for a randomized controlled field trial.

BACKGROUND: Adolescence is a critical stage for the development of self-care. Many adolescents use mobile apps to monitor and improve their health. Health information technology plays a significant role in the field of self-care. This article provides a protocol for a study to design and evaluate mobile applications for adolescent self-care. METHODS: The present research is a combination of applied development study, methodological, and intervention experimental. This study will be done in three stages: The first stage is the design and evaluation of a mobile application for adolescent self-care. The second stage is, designing and evaluating the psychometric properties of the "Questionnaire for Measuring Adolescent Self-Care Performance." This questionnaire will be used before and after using the application in the third stage. The third stage is determining the effectiveness of self-care interventions based on mobile applications among adolescents. The target group will be adolescents aged 10-19 from the schools of Amol City. In the first stage, the opinions of 30 people adolescents, parents, and experts will be used. In the second stage, the number of samples will be 10 times the number of items in the questionnaire. In the third stage, 50 people will be in the intervention group and 50 people will be in the control group. Descriptive statistics will be used for data analysis. Between-group and intra-group comparisons will be calculated about quantitative variables, independent t-test and paired t-test, and analysis of variance. The chi-square test and Fisher's exact test will be used in SPSS 16 software to test the homogeneity of qualitative variables between the two groups. DISCUSSION: In the first stage, based on the opinions received from the target group, a user-centered educational application for self-care of adolescents will be designed. In the second stage, after determining the validity and reliability, a questionnaire will be designed to measure the self-care performance of adolescents. In the third stage, using an intervention study for 3 months, the effectiveness of the training will be determined through the designed application. Our findings are scheduled for a full analysis, with expectations that analyses will be completed by September 2023.

Design and usability evaluation of a mobile application for self-care among Iranian adolescents.

BACKGROUND: Mobile phones can be an ideal platform to engage adolescents to maintain, improve, and promote self-care. Therefore, the current study aims to design and evaluate the usability of a mobile application for self-care in adolescents with a user-centered approach. METHODS: The current applied developmental study was done in four steps. The first step, polling and examining opinions was conducted through in-depth semi-structured interviews, with the aim of user-centered mobile application design with the involvement of 30 participants. The second step, extracting and compiling the educational content related to the main themes of the self-care app, was obtained from national and international guidelines and instructions, including the World Health Organization, the Center for Disease Control and Prevention, the Ministry of Health and Medical Education, etc. In the third step, the initial version of the mobile application was developed. In the fourth step, app usability was evaluated by 30 participants from the target group, 2 weeks after using the app, using the MAUQ questionnaire. RESULTS: In the first step, 789 codes, 12 sub-categories, and 3 categories were extracted. These codes were used in the design of the mobile application. In the second step, educational information was prepared and arranged in 5 sections (physical activity, nutrition, personal hygiene, risky behaviors and safety and events) in the form of text, images and short videos. In the third step, the mobile application was designed based on step 1 and 2. This application operates in online mode and under the Android operating system. the initial version of the mobile application was developed using JavaScript and Typescript programming languages in a Visual Studio Code environment. In the fourth step, the participants the overall level of usability of the application as very good with an average of 6.28 ± 0.55. The highest average score was given to the user interface and satisfaction with an average score of 6.43 ± 0.58. CONCLUSIONS: The "My-Care" app is a collaboratively designed smartphone app for adolescents that targets 5 dimensions of physical self-care. This app has the potential to teach, assess, and promote self-care among adolescents.

Homologous versus Heterologous prime-boost COVID-19 Vaccination in autologous hematopoietic stem cell transplantation recipients: a blinded randomized controlled trial.

Background/Purpose: Optimizing vaccine efficacy is of particular concern in patients undergoing hematopoietic stem cell transplantation (HSCT), which mainly have an inadequate immune response to primary SARS-CoV-2 vaccination. This investigation aimed to explore the potential prime-boost COVID-19 vaccination strategies following autologous (auto-) HSCT. Methods: In a randomized clinical trial, patients who had already received two primary doses of receptor-binding domain (RBD) tetanus toxoid (TT) conjugated SARS-CoV-2 vaccine during three to nine months after auto-HSCT were randomized to receive either a homologous RBD-TT conjugated or heterologous inactivated booster dose four weeks after the primary vaccination course. The primary outcome was comparing the anti-S IgG Immune status ratio (ISR) four weeks after the heterologous versus homologous booster dose. The assessment of safety and reactogenicity adverse events was considered as the secondary outcome. Results: Sixty-one auto-HSCT recipients were recruited and randomly assigned to receive either homologous or heterologous booster doses four weeks after the primary vaccination course. The mean ISR was 3.40 (95% CI: 2.63- 4.16) before the booster dose with a 90.0% seropositive rate. The ISR raised to 5.12 (95% CI: 4.15- 6.08) with a 100% seropositive rate after heterologous (P= 0.0064) and to 3.42 (95% CI: 2.67- 4.17) with a 93.0% seropositivity after the homologous booster doses (P= 0.96). In addition, the heterologous group suffered more AEs following the booster dosage than the homologous group, but this difference was not statistically significant (p = 0.955). In multivariable analysis, the prime-boost vaccination strategy (heterologous versus homologous), the level of ISR before the booster dose, and the length of time between auto-HSCT and booster dose were the positive predictors of serologic response to a booster dose. No serious adverse event is attributed to booster vaccination. Conclusion: In patients who were primed with two SARS-CoV-2 vaccine doses during the first year after auto-HSCT, heterologous prime-boost COVID-19 vaccination with inactivated platform resulted in considerably enhanced serologic response and non-significantly higher reactogenicity adverse events than homologous RBD-TT conjugated prime-boost COVID-19 vaccination strategy.

Joint Modeling of In Vitro Fertilization Outcomes among A Population of Iranian Infertile Couples: A Historical Cohort.

BACKGROUND: Women who undergo in vitro fertilization (IVF) cycles should successfully go via multiple stages (i.e., clinical pregnancy, no abortion under 12 weeks, no abortion under 20 weeks, and delivery) to achieve a live birth. In this study, data from multiple IVF cycles and its multiple stages were reanalyzed to illustrate the success factors associated with various stages of IVF cycles in a population of Iranian infertile women. MATERIALS AND METHODS: This historical cohort study includes 3676 assisted reproductive technology (ART) cycles. Covariates take into account in this study were women's age, type of infertility (primary, secondary), body mass index (BMI), cause of infertility, history of abortion, duration of infertility, number of oocytes, number of embryos, fertilization rate, semen factors (Spermogram) and having polycystic ovarian syndrome (PCOS) during IVF cycles. Joint modeling was fitted to apply informative cluster size. RESULTS: Increasing age un women was associated with an increase in the BMI and a positive history of abortion and PCOS, and also, an increase in the number of treatment cycles, while in men was associated with the negative spermogram. With the increase in the number of treatment cycles, the result of the IVF success decreased, but with the increase in the number of embryos, fertilization rate and also, quality and / or quantity parameters of spermogram, we encountered with an increase in the IVF success rate. CONCLUSION: It seems that a joint model of the number of treatment cycles and the result of IVF is a valuable statistical model that does not ignore the significant effect of cycle numbers, while this issue is ignored usually in the univariate models.

Process and components of disaster risk communication in health systems: A thematic analysis.

Risk communication (RC) is one of the necessary functions in disaster management. Establishing communication processes such as planning, transparency of policies and guidelines, RC expert training, providing communication infrastructure and evaluation in the shortest period reduces confusion and management inconsistency. One of the existing challenges is not knowing the exact dimensions of risk communication and its components in disasters. The aim was to identify the components of disaster risk communication in the health system. This research was conducted by systematic review and searching of the databases of PubMed, Scopus, Web of Science, ProQuest, Google Scholar and ScienceOpen 2000-2021 to identify the components of disaster risk communication in the health system. Thematic content analysis was used for data analysis. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 chart was used for systematic search, and a modified Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) was used for quality determination. Out of 12 342 articles extracted, 25 studies were included for analysis. The components of disaster risk communication were analysed in 6 categories and 19 subcategories. These categories include communication (communication processes, communication features and infrastructure), information (content production, content characteristics and publishing), risk communication management (risk perception assessment, planning, coordination and logistics), monitoring and control (monitoring and evaluation, accreditation, documentation), education and training (public and organisational) and ethics and values (culture and social beliefs, ethics and trust). According to this research, the establishment of communication infrastructure and advanced equipment such as various structured formats for communication and artificial intelligence; online and offline communication support systems; and timely and accurate notice can help achieve goals such as coordination and organisation in the health system and increase social participation. Contribution: This study has clarified and explained all the main components and measures of risk communication that can be used for planning scientifically.

Effectiveness of educational intervention on reducing oxidative stress caused by occupational stress in nurses: A health promotion approach.

BACKGROUND: Nursing is one of the most stressful occupations. Educational intervention regarding stress management can play an important role in reducing occupational stress among nurses The present study aimed to determine the effectiveness of educational intervention on reducing oxidative stress caused by occupational stress in nurses: A health promotion approach in a hospital in western Iran. MATERIALS AND METHODS: The present interventional study was performed in 2019 among 92 nurses working at the Kosar Hospital located in the city of Sanandaj in the country of Iran. Occupational stress was evaluated using the Osipow Occupational Stress Questionnaire. Oxidative stress was measured by taking blood samples and measuring the enzymatic activity of superoxide dismutase (SOD), malondialdehyde, and catalase (CAT) using SOD, malondialdehyde (MDA), and CAT kits. Educational intervention was carried out in the second stage. Three months after the intervention, data were taken again. RESULTS: The results of the present study indicated that there was a significant difference in occupational stress between before and after the educational intervention (P < 0.05). A significant reduction in MDA (P = 0.038) and SOD (P = 0.048) was observed after educational intervention, but this was not the case for CAT (P = 0.592). There was no significant correlation between occupational stress with oxidative stress parameters before and after the educational intervention (P < 0.05). No significant difference in occupational stress was observed between men and women. Among the oxidative stress parameters under evaluation, MDA was higher among men compared to women and this was statistically significant. CONCLUSIONS: Educational intervention regarding occupational stress is effective in reducing oxidative stress among nurses. The group meetings teach stress management to the participants and enable them to better manage their stress by utilizing their own capabilities. Thus, attention to this issue is vital in maintaining the mental and physical health of nurses and, in turn, improves the quality of care rendered.

Factors Affecting Resiliency Among Volunteers in Disasters: A Systematic Literature Review.

OBJECTIVE: Volunteers need considerable resiliency to cope with formidable challenges during their operations in disaster scenes. The present study was conducted to identify factors affecting the different aspects of resiliency among volunteers in disasters. MATERIAL AND METHODS: The databases of Web of Science, Scopus, PubMed, ProQuest, Google Scholar, World Health Organization Library, International Committee of the Red Cross (ICRC) Library, PsycArticles, and SafetyLit were searched until September 29, 2018. The main search terms were resiliency, disaster, humanitarian aid worker, and volunteer. RESULTS: A total of 548 documents were obtained and screened based on the inclusion and exclusion criteria. A number of 8 documents was selected for the final analysis. The main factors contributing to the resilience of volunteers at the 3 stages of pre-, during, and post-disasters were classified into 3 groups of individual, environmental, and organizational. Important factors affecting resilience of volunteers in disasters included previous disaster response experience and disaster-related training. CONCLUSION: Resiliency should be deemed integral to relief operations. Considering the main factors affecting volunteers' resiliency, it is highly suggested that organizations active in humanitarian endeavors explore the factors impacting on resilience among their volunteers via various research methods and seek to select those with higher degrees of resilience in order to avert untoward consequences in their missions.

Spatial analysis and geoclimatic factors associated with the incidence of acute lymphoblastic leukemia in Iran during 2006-2014: An environmental epidemiological study.

BACKGROUND AND OBJECTIVES: The present study aims to determine the cumulative incidence rate of acute lymphoblastic leukemia (ALL), the degree of spatial autocorrelation and clustering of ALL, the hotspot and coldspots of ALL and geoclimatic conditions affecting the incidence of ALL in Iran and to draw a comparison between global and local regression models. MATERIALS AND METHODS: In this ecological study, an exploratory-etiologic multiple-group method has been adopted to investigate all children under 15 years of age with ALL in Iran during 2006-2014. Data analysis was performed using Mann Whitney U, Pearson correlation coefficients (PCCs), Global Moran's I, Optimized hotspot analysis (OHSA), Global Poisson regression (GPR), Geographically Weighted Poisson Regression (GWPR) at a significant level of α = 0.05. RESULTS: The cumulative incidence rate of ALL was estimated at 21,315 per 100,000 Iranian children under 15 years of age. The value of Global Moran's I index was estimated 0.338 and significant (<0.001 P-value). Coldspots were observed in north and northwest of Iran and hotspots were identified in south, southwest and mid-east of Iran. In the present study, Max Temperature of Warmest Month (MTWM) and Direct Normal Irradiation (DNI) were risk factors and Precipitation of the Coldest Quarter (PCQ) and Altitude (AL) were protective factors in the incidence of ALL, even though the non-stationarity of local coefficients and local t-values was clear. GWPR, by capturing and applying spatial heterogeneity and spatial autocorrelation, had a greater performance and goodness of fit than GPR. DISCUSSION: ALL has created spatial clusters in Iran. The incidence of ALL is the result of synergistic interaction between environmental, infectious, geographical and genetic risk factors. It is recommended to use of local models in ecological studies.

Identification of high-risk and low-risk clusters and estimation of the relative risk of acute lymphoblastic leukemia in provinces of Iran during 2006-2014 period: A geo-epidemiological study.

BACKGROUND: The present study was conducted to determine the epidemiological status, identify high-risk and low-risk clusters, and estimate the relative risk (RR) of acute lymphoblastic leukemia (ALL) in provinces of Iran. MATERIALS AND METHODS: This is an ecological study carried out using an Exploratory Multiple-Group design on 3769 children under 15 years of age with ALL from 2006 to 2014. Data analysis was performed using Mann-Whitney U, Global Moran's I and Kuldorff's purely spatial scan statistic tests at a significance level of 0.05. RESULTS: The average annual incidence rate of ALL during 2006-2014 period was 2.25/100,000 children under 15 years of age. The most likely high-risk cluster with log-likelihood ratio (LLR) =327.47 is located in the southwestern part of Iran with a radius of 294.93 km and a centrality of 30.77 N and 50.83 E, which contained 1276 patients with a RR of 2.56. It includes Fars, Bushehr, Kohgiluyeh and Boyer-Ahmad, Khuzestan and Chahar Mahall and Bakhtiari provinces. On the other hand, the most likely low-risk cluster with 517 patients, and a RR 0.49 and LLR = 227.03 was identified in the northwestern part of Iran with a radius of 270.38 km and a centrality of 37.25 N and 49.49 E. It includes Zanjan, Qazvin, Gilan and East Azerbaijan, Ardabil, Alborz and Tehran provinces. CONCLUSION: High-risk clusters were observed in Southwestern, central, and eastern Iran, while low-risk clusters were identified in Northern and Western Iran.

Geographical Pathology of Acute Lymphoblastic Leukemia in Iran with Evaluation of Incidence Trends of This Disease Using Joinpoint Regression Analysis.

BACKGROUND: The aim of present study is to determine the spatial-temporal epidemiology of acute lymphoblastic leukemia (ALL) in Iranian children. METHODS: This ecological study was performed using an exploratory mixed design. The study population consists of 3769 children with ALL who were reported in the National Cancer Registry Program of Iran from 2006 to 2014. Data analysis was conducted using Mann-Whitney U, joinpoint regression analysis, Global Moran's I and Anselin Local Moran's I. RESULTS: The average annual incidence rate of ALL was 2.25 per 100000 children under 15 years of age during the study period, which was 1.37 times higher in males. The average annual percentage change (AAPC) of the disease was 7.1%, which is higher than that of developed countries. The incidence of ALL was higher in spring and summer and its peak incidence was at the age of 2-5. Spatial autocorrelation of the ALL was 0.358 and significant (P value <0.001). The high-risk cluster of ALL was identified in Fars and Kohgiluyeh and Boyer-Ahmad provinces and the low-risk cluster in Kermanshah, Zanjan and Kurdistan provinces. CONCLUSION: The incidence of ALL is on rise in Iranian children and appropriate healthcare services are required to prevent new cases of this disease in high-risk areas.

Developing a Valid and Reliable Gender Analysis Tool Applied in Disaster Management: A Community-Based Survey.

OBJECTIVES: Women and men are assigned roles and responsibilities based on their gender in all contexts. Measuring gender-based differences through gender analysis can help understand who will be at greater risk in disasters. Thus, the present study is aimed to develop a valid and reliable gender analysis tool to collect accurate and necessary gender-disaggregated information in disaster-affected regions. METHODS: A mix method approach using qualitative and quantitative studies was applied for conducting this study. A total of 20 people affected by the earthquakes and floods and 10 key informants were interviewed in the qualitative stage. The validity and reliability of the tool were measured using the experts as well as women and men living in the destroyed villages of Razavi Khorasan province during the quantitative stage. The Graneheim approach and SPSS software were used to analyze the data collected in both stages. RESULTS: At the first stage, 7 categories were extracted from the data, namely, livelihood status, social status, health, household/family management, reconstruction, welfare and educational facilities, and disaster prevention. The results of content validity ratio (0.69) and content validity index (0.88) confirmed that the tool is valid. The amount of Cronbach's alpha (0.75) and test-retest (0.83) examination indicated that the tool was also reliable. The results of content validity and reliability measurements approved that the gender analysis tool can be applied for postdisaster gender analysis surveys. CONCLUSIONS: It is highly suggested to use the information provided by the gender analysis tool for future disaster management plans, programs, and policies in health systems.

Water safety in drought: an indigenous knowledge-based qualitative study.

The indigenous knowledge of our ancestors provides valuable information on how to prevent negative health impacts on water hygiene in the event of drought. The present study aimed to explore the role of indigenous knowledge in maintaining water safety in drought conditions. A qualitative content analysis method using in-depth semi-structured interviews was used to collect and analyze the data. The current research was carried out from April 2017 to June 2018. A purposive sampling method was used to select 15 participants. Trustworthiness was applied with the Lincoln and Guba approach and data were analyzed using Graneheim and Lundman's method. Two categories including drinking water storage and water collection were extracted from the data. Each category includes different strategies to deal with water. Water storage includes water quantity and water quality. Water collection consists of collection methods and rules. Indigenous knowledge is an indispensable component of community disaster resilience. It can be transferred to other communities and employed to empower affected communities. But using the knowledge without scientific considerations cannot guarantee peoples' health throughout the drought periods.

Temporal trend and spatial distribution of acute lymphoblastic leukemia in Iranian children during 2006-2014: a mixed ecological study.

OBJECTIVES: The present study investigated the spatiotemporal epidemiological status of acute lymphoblastic leukemia (ALL), the most common childhood cancer, in Iran. METHODS: Using an exploratory mixed design, this ecological study examined 3,769 under-15 children with ALL recorded in the National Cancer Registry of Iran during 2006-2014. Data were analyzed using the Mann-Whitney U test, the Getis-Ord general G (GOGG) index, optimized hot spot analysis, and Pearson correlation coefficients (PCC) at a significance level of 0.05. RESULTS: The average annual incidence of the disease was 2.25 per 100,000 under-15 children, and the cumulative incidence rate (CIR) was 21.31 per 100,000 under-15 children. Patients' mean age was 5.90 years (standard deviation, 3.68), and the peak incidence was observed among 2-year to 5-year-olds. No significant difference was found in mean age between boys and girls (p=0.261). The incidence of ALL was more common during spring and summer than in other seasons. The GOGG index was 0.039 and significant (p<0.001). Hot spots were identified in south, central, and eastern Iran and cold spots in the north and west of Iran. The PCC between the CIR and latitude was negative (r=-0.507; p=0.003) but that between the CIR and longitude was positive (r=0.347; p=0.055). CONCLUSIONS: The incidence of ALL in Iranian children was lower than that observed in developed countries, but showed an increasing trend. It can be argued that the incidence of ALL is due to synergistic interactions between environmental, infectious, geographical, and genetic risk factors.

Performance of Bayesian outbreak detection algorithm in the syndromic surveillance of influenza-like illness in small region.

Early warning for Infectious disease outbreak is an important public health policy concern, and finding a reliable method for early warning remains one of the active fields for researchers. The purpose of this study was to evaluate the performance of the Bayesian outbreak detection algorithm in the surveillance of influenza-like illness in small regions. The Bayesian outbreak detection algorithm (BODA) and modified cumulative sum control chart algorithm (CUSUM) were applied to daily counts of influenza-like illness in Tehran, Iran. We used data from September 2016 through August 2017 to provide background counts for the algorithms, and data from September 2017 through August 2018 used for testing the algorithms. The performances of the BODA and modified CUSUM algorithms were compared with the results coming from experts' signal inspections. The data of syndromic surveillance of influenza-like illness in Tehran had a median daily counts of 7 (IQR = 3-14). The data showed significant seasonal trends and holiday and day-of-the-week effects. The utility of the BODA algorithm in real-time detection of the influenza outbreak was better than the modified CUSUM algorithm. Moreover, the best performance was when a trend included in the analysis. The BODA algorithm was able to detect the influenza outbreaks with 4-5 days delay, with the least false-positive alarm. Applying the BODA algorithm as an outbreak detection method in influenza-like syndromic surveillance might be useful in early detection of the outbreaks in small regions.

Geographical distribution of at fault drivers involved in fatal traffic collisions in Tehran, Iran.

OBJECTIVES: According to Traffic Police, about 35% of deaths and more than 50% of injuries caused by traffic collision in the roads of Tehran are among drivers and car occupants. This study was conducted to determine areas with the highest number of traffic collisions and perform spatial analysis of traffic collisions involving drivers in Tehran during April 2014 to March 2017. METHODS: The present study was a cross-sectional and descriptive-analytic research. In this study, all traffic collision that driver was accounted (100 percent or less) for crash occurrence which resulted in the death of at least one person (driver, pedestrian or passenger) were included in the analyses. Geographic information system software was used to show spatial distribution of events from zoning maps. Moran index was used in the mathematical analysis in order to determine the distribution pattern of the events from and Getis-Ord G statistics was applied to analyze the hot spots (high risk points). RESULTS: A total number of 519 traffic collisions were investigated in this study. Moreover, 283 cases (54.5%) of the incidents took place in direct routes and 236 cases (45.5%) occurred at intersections. The most frequent events were in the region 4 (57 cases) and the least frequent events were reported in the region 10 (6 cases). Moran statistics show that the distribution of the studied events significantly follows the cluster pattern (p<0.001). CONCLUSIONS: The northeastern and northwest margins of Tehran are the most prone areas for drivers involved with traffic collisions leading to death. Most traffic collisions leading to death take place at highways located at the entrance and exit points of Tehran and highways in regions 2 and 5.

The spatial distribution of colorectal cancer relative risk in Iran: a nationwide spatial study.

AIM: The aim of this study was to estimate the standardized incidence rate (SIR) and also the relative risk (RR) of colorectal cancer (CRC) in Iran and to determine the distribution of CRC risk in a map after adjusting socioeconomic risk factors. BACKGROUND: The growth of CRC incidence rate in Iran is a major public health problem and identifying high-risk regions is essential for further intervention. METHODS: For this cross-sectional study, all CRC cases that occurred in 30 Iranian provinces between 2005 and 2008 were collected according to the International Classification of Diseases (ICD-10). In addition, socioeconomic information was extracted from statistical center of Iran. Bayesian and Poison regression models were fitted to identify significant covariates. For RR estimating, the spatial analysis using GIS technique was carried out. RESULTS: The Bayesian method with increasing precision of the parameter estimates had a better fit. According to spatial model, East Azerbaijan province had a high (11.14) and South Khorasan province had a low (0.22) risk of CRC in the period of study. SIR for the male population was 1.92 ± 3.25, and for the female population it was 1.85 ± 3.37. CONCLUSION: There is a non-uniform spatial pattern of CRC risk in Iran. According to the results, North, Northwest and some parts of West and Central provinces of Iran are identified as high-risk areas; thus, it is recommended that health policymakers, especially in these areas, have more intervention measures. Further studies are needed to map the RR adjusted for nutrition factors.

Spatiality in small area estimation: A new structure with a simulation study.

In numerous practical applications, data from neighbouring small areas present spatial correlation. More recently, an extension of the Fay-Herriot model through the Simultaneously Auto- Rregressive (SAR) process has been considered. The Conditional Auto-Regressive (CAR) structure is also a popular choice. The reasons of using these structures are theoretical properties, computational advantages and relative ease of interpretation. However, the assumption of the non-singularity of matrix (Im-ρW) is a problem. We introduce here a novel structure of the covariance matrix when approaching spatiality in small area estimation (SAE) comparing that with the commonly used SAR process. As an example, we present synthetic data on grape production with spatial correlation for 274 municipalities in the region of Tuscany as base data simulating data at each area and comparing the results. The SAR process had the smallest Root Average Mean Square Error (RAMSE) for all conditions. The RAMSE also generally decreased with increasing sample size. In addition, the RAMSE valuess did not show a specific behaviour but only spatially correlation coefficient changes led to a stronger decrease of RAMSE values than the SAR model when our new structure was applied. The new approach presented here is more flexible than the SAR process without severe increasing RAMSE values.

Factors with the Highest Impact on Road Traffic Deaths in Iran; an Ecological Study.

INTRODUCTION: The largest proportion of road traffic deaths (RTDs) happen in Low and Middle Income Countries (LMICs). The efforts for decreasing RTDs can be successful if there is precise information about its related risk factors. This study aimed to determine economic, population, road, and vehicle factors with the highest impacts on RTDs in Iran. METHODS: This is an ecological study, which has been done using covariates including: the population density, economic growth, urbanization, distance traveled (km) in 100 thousand people, the length of urban roads, the length of rural roads and the Vehicle per 1000 population for each province of Iran in 2015. The covariates considered had been gathered from different sources and to determine which one of the covariates has an effect on RTDs, the Negative Binomial (NB) regression model was used. RESULTS: The mean number of RTDs per 100000 population was 474 ± 70.59 in 2015. The highest and lowest rates of death belonged to Fars and Qom provinces, respectively. The results of the univariate model showed the population density as the only covariate of RTDs (p=0.001). Also, among other covariates, GDP was the only variable with a p-value equal to 0.2. In the multivariate NB model, it was seen that the population density (p=0.001), and GDP (p=0.02) significantly correlated with RTDs. For a unit (Million Rial) increase in the GDP of the province, the number of deaths decreased by as much as 0.0014. In addition, for a unit increase in population density, the number of deaths went up by as much as 30. CONCLUSION: Population density and GDP had positive and negative effects on the number of fatal road traffic injuries, respectively. By considering these factors in presentational and controlling programs on road traffic injuries, it is possible to decrease the RTDs.

Designing and Testing a Treatment Adherence Model Based on the Roy Adaptation Model in Patients With Heart Failure: Protocol for a Mixed Methods Study.

BACKGROUND: Adherence to treatment is an important factor to decrease repeated and costly hospitalization owing to heart failure (HF). The explanation and prediction of medication adherence and other lifestyle recommendations in chronic diseases, including HF, are complex. Theories lead to a better understanding of complex situations as well as the process of changing behavior and explain the reasons for the existence of a problem. OBJECTIVE: The aim of this study is to report a protocol for a mixed methods study setting out to investigate the empirical validity of the Roy Adaptation Model as a conceptual framework for explaining and predicting adherence to treatment in patients with HF in Iran. METHODS: This mixed methods study consists of an exploratory sequential design to be conducted in 2 phases. The first phase involves identifying the factors associated with treatment adherence in patients with HF through content analysis of the literature and elucidating the perception of participants in the context of Iranian health care where the model of adherence to treatment is designed based on the Roy Adaptation Model. The second phase addresses the interrelationships among variables in the model through a descriptive study using structural equation modeling. Finally, following the summarization and separate interpretation of the qualitative findings and quantitative results, a decision is made about the extent to and ways in which the results of the quantitative stage can be generalized or tested for the qualitative findings. RESULTS: Content analysis of the literature in part 1 of the first phase was completed in 2017. Collection and analysis of qualitative data in part 2 of the first phase will be completed soon. The results are expected to be submitted for publication in 2019. Then, the second phase-the quantitative study-will be conducted. CONCLUSIONS: The results of this study will provide valuable information about the empirical validity of the Roy Adaptation Model as a conceptual framework for explaining and predicting adherence to treatment in patients with HF, which, to date, have received little attention. The results can be used as a guide for nursing practice and care provision to patients with HF and also to design and implement effective interventions to improve treatment adherence in these patients. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/13317.

Health risk of phthalates in water environment: Occurrence in water resources, bottled water, and tap water, and burden of disease from exposure through drinking water in tehran, Iran.

Occurrence of phthalates in water resources, bottled water, and tap water, and health risk of exposure to the phthalates through drinking water in Tehran, Iran, 2018 were studied. The six phthalates with the most health and environmental concerns, including di-(2-ethylhexyl) phthalate (DEHP), butyl benzyl phthalate (BBP), di-n-butyl phthalate (DBP), diethyl phthalate (DEP), dimethyl phthalate (DMP), and di-n-octyl phthalate (DNOP) were monitored in drinking water and water resources. The average levels (±standard deviation: SD) of the total phthalates in drinking water from the water distribution system, bottled water, surface waters, and ground waters were determined to be 0.76 ±â€¯0.19, 0.96 ±â€¯0.10, 1.06 ±â€¯0.23, and 0.77 ±â€¯0.06 µg/L, respectively. The dominant compounds in the phthalates were DMP and DEHP causing a contribution to the total phthalate levels higher than 60% in all the water sources. The phthalate levels of drinking water significantly increased by contact of hot water with disposable plastic and paper cups and by sunlight exposure of bottled water (p value < 0.05). The hazard quotients (HQs) of DEHP, BBP, DBP, and DEP for all ages both sexes combined were determined to be 1.56 × 10-4, 1.01 × 10-5, 1.80 × 10-5, and 1.29 × 10-6, respectively that were much lower than the boundary value of 1.0. The disability-adjusted life years (DALYs) and DALY rate (per 100,000 people) attributable to DEHP intake through drinking water for all ages both sexes combined were estimated to be 6.385 (uncertainty interval: UI 95% 1.892 to 22.133), and 0.073 (0.022-0.255), respectively. The proportion of mortality in the attributable DALYs was over 96%. The attributable DALY rate exhibited no significant difference by sex, but was considerably affected by age in a manner that the DALY rates ranged from 0.052 (0.015-0.175) in the age group 65 y plus to 0.099 (0.026-0.304) in the age group 5 to 9 y. Both the carcinogenic and non-carcinogenic health risks of the phthalates in drinking water were considered to be very low. The results can also be of importance in terms of developing frameworks to expand the domain of burden of disease study to the other environmental risks.