Factors in the Provision of High Quality Midwifery Care: A Qualitative Content Analysis.

Introduction: In recent years, health care has faced many changes. Thereupon, it would be beneficial to investigate the quality of midwifery care and its related factors. Many factors contribute to the provision of quality care, and recognizing factors to ensure the quality of midwifery care. This qualitative study was conducted to explain the factors that affect the provision and quality of midwifery care. Methods: This qualitative study with content analysis approach was conducted between June 2017 and February 2018 on 15 midwives working in private and public maternity hospitals in the city of Qom. The participants were selected by purposeful sampling. Semi-structured and in-depth interviews were performed with open ended questions to find out how midwives describe high quality midwifery care. Data were analyzed by conventional content analysis method through MAXQDA-11 software. Results: The findings of this study revealed two main themes, including individual factors (personal efficiency, staffs' psychological status, value-centeredness, cultural-educational issues, and professional attachment), and professional-organizational factors (professional characteristics, patient characteristics, personal-professional welfare, professional empowerment system, value-centered culture of organization, and organizational monitoring and evaluation). Conclusion: The results of this study showed that individual and professional factors are associated with the quality of midwifery care. Midwives who participated in this study believed that providing high quality midwifery care requires a broad range of prerequisites. Since high quality midwifery care decreases maternal and infant mortality and morbidity, it is imperative for policymakers to pay attention to all the factors that contribute to the quality of midwifery care.

Comparison of pain catastrophizing and anxiety in patients with dyspareunia and healthy women: a cross-sectional study.

Despite the prominent role of cognitive-affective variables, such as pain catastrophizing and anxiety in chronic pain, little is known about their relationship with dyspareunia. This study compared pain-catastrophizing and anxiety in reproductive-aged women with and without dyspareunia. A controlled cross-sectional study was conducted on 398 married women in Iran selected by convenience sampling. Sampling was performed both online and in person. Data were collected using a checklist designed for the study, including background characteristics, self-reported dyspareunia, and two standard questionnaires: the Pain Catastrophizing Scale (PCS) and the Spielberger State-Trait Anxiety Inventory-6 (STAI-6). Results showed that 49.5% of the women reported dyspareunia in the previous six months, with a reduced figure of 42% and 31% when using more specific criteria for dyspareunia. Women with dyspareunia had significantly higher scores for pain catastrophizing and anxiety than the control group without dyspareunia. Pain-catastrophizing was associated with aversion to genital contact and body image dissatisfaction. Anxiety was correlated with age, marriage duration, and sexual abuse. Managing anxiety and catastrophizing thoughts may help dyspareunia patients better cope with pain.

Women's Concerns and Experiences of Fetal Anomaly Screening Process: A Qualitative Study.

Background: Advanced technologies in antenatal screening provide complex and accurate information about the fetus that allows for early intervention, but it increases pregnant women's concerns about fetal health. This study aimed to investigate the concerns and experiences of Iranian pregnant women in the fetal anomaly screening process. Methods: This qualitative study was performed from September 2018 to June 2019 in Tehran, Iran. Twenty pregnant women who referred to prenatal care clinics, four specialists, and two midwives took part in this study. The sampling was done purposefully until data saturation. Qualitative interviews were analyzed using the content analysis approach and Graneheim and Lundman's method. The MAXQDA 10 was used for data management. Results: The pregnant women who participated in the study were 22-40 years old. The following 4 themes were obtained from the analysis: the challenge of deciding to perform the tests, bitter pregnancy experience, challenges of facing an abortion, and unmet needs of pregnant women by the health system. Conclusion: The findings indicate that pregnant women need real information and support. Designing and implementing interventions that reduce the psychological impact of performing fetal anomaly screening tests can highlight the potential benefits for pregnant women's health.

Effect of WebQuest-based education on critical thinking and academic self-efficacy of midwifery students: Study protocol of a randomized, controlled crossover trial.

BACKGROUND AND AIM: Critical thinking fills the gap between theoretical and clinical teaching and increases the power of clinical decision-making. WebQuest is an innovative, learner-centered, and effort-driven learning approach that uses computer technology to engage and motivate learners. In WebQuest, learners are compelled to use the latest information available on the web as a tool to promote higher levels of thinking. However, we did not find a study that used WebQuest to improve students' critical thinking and academic self-efficacy. The aim of this study will be to investigate the effect of WebQuest-based education on the critical thinking of midwifery students. MATERIALS AND METHODS: This superiority randomized, controlled crossover trial will be carried out among fifth-semester undergraduate midwifery students. Participants will be allocated to one of two event groups (A and B) using block randomization. In the first sequence (FS) (four weeks) of study, both groups will simultaneously attend two different education groups (WebQuest and traditional). During the FS, WebQuest will be used to teach group A participants, while group B participants will be treated as the control group (CG) and be taught using a traditional presentation. In the second sequence (SS), the interventions will be crossed over. Participants in both groups will complete the sociodemographic questionnaire, the California Critical Thinking Skills Test (CCTST), the California Critical Thinking Disposition Inventory (CCTDI), and the Academic Self-Efficacy Beliefs Questionnaire (ASEBQ) once before the first sequence of the study, during the washout period, and at the end of the second sequence of the study. The teaching satisfaction questionnaire will be completed at the end of the study. DISCUSSION: The results of this study can be used as a basis for teaching midwifery students using WebQuest as a new teaching method.

Overcoming Reproductive and Psychological Concerns of Breast Cancer Survivors: A Randomized Controlled Trial.

Objective: After developing breast cancer, women experience changes in their sexuality, femininity, and fertility. These changes lead to poor mental health and increased psychological stress. Therefore, this study aimed to investigate the effects of Good Enough Sex (GES)-based, couple-centered group counseling on reproductive and sexual concerns of breast cancer survivors. Materials and methods: This was a quantitative randomized controlled clinical trial (RCT) conducted at Omid Hospital, West Azerbaijan, Urmia, Iran from March 2018 to October 2020. After completing the informed consent forms, 100 women were assigned to the intervention and control groups (50 individuals per group) using a randomized block design. The intervention included four 90-120-minute sexual counseling sessions with 2 and 3 month follow-ups. The data were collected using the socio-demographic and clinical characteristics, the Persian version of Depression, Anxiety and Stress Scale (DASS-21), Reproductive Concerns after Cancer (RCAC) scale, and Female Sexual Function Index adaptation for Breast Cancer patients (FSFI-BC). Data were collected, from control and intervention groups, at three intervals; before, besides two months and three months post intervention, then were analyzed in SPSS 20 using descriptive and repeated measures analysis of variance (ANOVA) test. Results: Significant reduction in the mean score of DASS-21, RCAC and improvement of FSFI-BC is reported between the intervention and control groups in favor of intervention group (P<0.001). However, no significant differences are observed within intervention group over two- and three-months post intervention (P > 0.05). Conclusion: The designed Good Enough Sex (GES)-based, couple-centered group counseling effectively reduced reproductive and sexual concerns of females' breast cancer survivors. Therefore, these training and counseling programs can be organized by relevant service centers to promote the reproductive health of women with breast cancer.

Mixed-methods study protocol for explanation of pregnant women's concerns about antenatal anomaly screening process: Designing, implementing and evaluation of intervention.

AIM: This study aims to investigate the concerns of Iranian pregnant women in the antenatal anomaly screening process (AASP) and propose an intervention to reduce these concerns. DESIGN: This exploratory sequential mixed-methods study is conducted in three stages (qualitative, intervention design and quantitative), in Tehran. METHODS: A qualitative study is carried out to collect pregnant women's concerns during the AASP. Then, a two-step procedure is implemented. In the first step (expert session), the concerns extracted in the qualitative part are prioritized. Next, the interventions used to reduce the concerns of pregnant women in the AASP are reviewed by considering the priority determined in the previous stage. The information obtained from this step is used to design intervention. Ultimately, a randomized controlled trial is used to evaluate the effectiveness of the intervention. DISCUSSION: The results can be used for framing policies in health systems to address pregnant women's concerns in the AASP and to promote their mental health.

The Effect of Good Enough Sex (GES) Model-Based Sexual Counseling Intervention on the Body Image in Women Surviving Breast Cancer: A Randomized Clinical Trial.

INTRODUCTION: Women undergoing breast cancer treatment experience a number of changes, including loss or deformity of one or both breasts, surgical wounds, skin changes, and weight gain. These changes are very closely related to physical appearance and body image and often lead to reduced mental health, marital quality and psychological stress.  Objective: This study aimed to determine the effect of Good Enough Sex (GES) model-based counseling intervention on the body image in women surviving breast cancer. PATIENTS AND METHODS: This randomized clinical trial was a kind of quantitative study with control group carried out on 100 women (50 women in the intervention group and 50 women in the control group) who randomly entered into the study after completing the informed consent form. The intervention included 4 sessions of 120-190 minute sexual counseling with 2 and 3 months follow-up. The data were collected consisting of demographic characteristics and disease-related information, Body Image Scale (BIS) and analyzed using ANOVA repeated measures. RESULTS: The results showed a statistically significant difference between the mean of body image in the intervention and control groups (P <0.001). CONCLUSION: The educational and counseling intervention program based on a socio-psychological model was effective in improving the body image among women surviving breast cancer. The inclusion of educational and counseling programs in service centers in this regard has an effective role in the reproductive health of women with breast cancer. TRIAL REGISTRATION: Registration of trial protocol has been approved in Iranian registry of clinical trials (IRCT20120609009975N8, https://en.irct.ir/trial/42030, ethical code; IR.TUMS.FNM.REC.1396.4865).
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Self-care behaviors in high-risk women for breast cancer: A randomized clinical trial using health belief model education.

BACKGROUND: Breast cancer is the most common cancer in Iranian women. The number of people with this disease is increasing across the world. Positive family history is one of the risk factors for developing breast cancer. However, early detection is the main method to fight this disease. This study was conducted to examine the effect of education based on the health belief model (HBM) on self-care behaviors among first-degree relatives of patients with breast cancer. METHODS: This clinical trial was conducted in 2016 on 80 women in Tehran city, Iran. Data were collected using a three-part questionnaire regarding demographic data, the HBM, and self-care behaviors. The educational program based on the HBM was held in 4 ninety-minute training sessions through lectures, group discussions, question and answer, image presentations, and PowerPoint presentations. The questionnaires were completed before and 2 months following the intervention by intervention and control groups. Data were analyzed using descriptive and inferential statistics through the SPSS16 software. RESULTS: The mean score of the HBM constructs before the intervention in the groups had no statistically significant differences (P > 0.05). Eight weeks after the intervention, the mean score of the constructs of the HBM in the intervention group significantly increased and a statistically significant increase in the mean score of self-care in the intervention group compared to the preintervention was found, so that the self-care behavior score in the intervention group was 0.69 ± 0.09 before the intervention and was changed to 0.74 ± 0.09 after the intervention (P < 0.0001). CONCLUSION: Our results suggest that education based on the HBM was effective in promoting self-care behaviors among first-degree relatives of breast cancer patients. Therefore, education based on HBM may have an important implication for breast cancer prevention in Iran.

Exploring Reproductive Health Education Needs in Infertile Women in Iran: A Qualitative Study.

OBJECTIVES: An inadequate understanding of infertility can affect individuals' self-efficacy and ability to perform self-care; thus, reproductive health education is an important part of infertility treatment. The present qualitative study aimed to explore the experiences and educational needs of infertile women with regard to reproductive health. METHODS: In this qualitative study, we utilized a content analysis approach. Purposive sampling was performed to ensure maximum diversity. In total, 23 individual interviews were conducted with 20 Iranian women with infertility and 3 key informants between July 2018 and February 2019 in northern Iran. Data were collected through in-depth, semi-structured interviews. Data analysis was performed using a conventional content analysis approach. RESULTS: Reproductive health education needs were identified by analyzing interview data from 4 main categories: familiarity with the fertility process and preparation for pregnancy, recognition of infertility and expectations around seeking treatment, recognition of preventive actions associated with reproductive health, and correction of false beliefs. Recognizing the causes of infertility and understanding the different approaches to infertility treatment are among the most important educational needs of infertile women. The potential for neglect of health-related issues due to concerns about fertility and the maternal experience necessitates education about preventive measures for cervical cancer, breast cancer, and sexually transmitted infections. Correcting misconceptions, including those related to contraceptives and traditional medicine, can also help promote reproductive health. CONCLUSIONS: In infertile women, the educational needs associated with reproductive health are multifaceted. Satisfying these needs can help achieve optimal treatment results and promote reproductive health.

Pregnancy and Motherhood Concerns Surrounding Women with Multiple Sclerosis: A Qualitative Content Analysis.

BACKGROUND: There is a high prevalence of multiple sclerosis (MS) among Iranian women of reproductive age. However, very few studies have been conducted in Iran to assess the experiences with and concerns about pregnancy and motherhood of such patients. The present study was conducted to better understand the experiences and concerns of women with MS about pregnancy and motherhood. METHODS: The present qualitative study was conducted from August 2016 to January 2017 among Iranian women with MS visiting the Iran MS Society in Tehran, Iran. The purposive sampling method was used to recruit the participants and the sampling was continued until data saturation. Based on the inclusion criteria, a total of 25 women with MS were recruited in the study. The data were collected by in-depth semi-structured face-to-face interviews and analyzed using the MAXQDA 10 software. RESULTS: The analysis of the interview data resulted in four main categories, namely "Pregnancy concerns", "Fear of failing as a parent", "Feeling of threatened fertility", and "Lack of social support". The results showed that Iranian women with MS avoided pregnancy due to the negative effects of the disease on their physical abilities and on life in general. They were also concerned about possible infertility, the effect of MS medications on their menstrual cycle, and the limitations of infertility treatments due to the presence of MS. These concerns led them to postpone pregnancy and lose time or opt for voluntary childlessness and consequently miss out on the experience of motherhood. CONCLUSION: MS poses a serious challenge to women who consider getting pregnant and wish to experience motherhood. Health care professionals should support such patients to overcome their concerns and indecisiveness by providing appropriate information and counseling.

Discriminatory Accuracy of the Gail Model for Breast Cancer Risk Assessment among Iranian Women.

BACKGROUND: The Gail model is the most well-known tool for breast cancer risk assessment worldwide. Although it was validated in various Western populations, inconsistent results were reported from Asian populations. We used data from a large case-control study and evaluated the discriminatory accuracy of the Gail model for breast cancer risk assessment among the Iranian female population. METHODS: We used data from 942 breast cancer patients and 975 healthy controls at the Cancer Institute of Iran, Tehran, Iran, in 2016. We refitted the Gail model to our case-control data (the IR-Gail model). We compared the discriminatory power of the IR-Gail with the original Gail model, using ROC curve analyses and estimation of the area under the ROC curve (AUC). RESULTS: Except for the history of biopsies that showed an extremely high relative risk (OR=9.1), the observed ORs were similar to the estimates observed in Gail's study. Incidence rates of breast cancer were extremely lower in Iran than in the USA, leading to a lower average absolute risk among the Iranian population (2.78, ±SD 2.45). The AUC was significantly improved after refitting the model, but it remained modest (0.636 vs. 0.627, ΔAUC = 0.009, bootstrapped P=0.008). We reported that the cut-point of 1.67 suggested in the Gail study did not discriminate between breast cancer patients and controls among the Iranian female population. CONCLUSION: Although the coefficients from the local study improved the discriminatory accuracy of the model, it remained modest. Cohort studies are warranted to evaluate the validity of the model for Iranian women.

Sexual Health Literacy, a Strategy for the Challenges of Sexual Life of Infertile Women: A Qualitative Study.

BACKGROUND: Sexual health literacy enables an understanding and application of sexual health information and has benefits beyond health. Health literacy is an important element for achieving cognitive skills in health promotion. One of the most important problems in sexual health and sexual function in women is infertility. This study aims to explore the dimensions of sexual health literacy among women with infertility. MATERIALS AND METHODS: In this qualitative study, a total of 18 individual interviews with 15 Iranian women with infertility, and three key informants, were conducted in infertility centers in Rasht (the North of Iran). Data were collected through in-depth semi-structured interviews using interview guide questions. Data were analyzed using the conventional content analysis approach. RESULTS: Five themes emerged: informational needs of sexual health, information seeking, informational perception, validation of information, and information application. Sexual issues are taboo in Iranian culture. They are not taught in health and educational centers. All the participants believed that there was a lack of information about the sexual response cycle, preventing sexually transmitted infections, targeted intercourse, and consequences of infertility in sexual life. Participants mentioned the embarrassment, privacy, and lack of centers for sexual health as information-seeking barriers. Searching different sources and questioning the informants were ways for understanding information. Women evaluated the accuracy of the information by considering the validity of the source of information, comparing information from different sources, and asking the experts. They applied the information received about sexual health, satisfaction, and especially targeted intercourse to increase the chance of pregnancy. CONCLUSION: Sexual health literacy in infertile women includes different dimensions. It can help promote sexual health, satisfaction, and increasing the chance of pregnancy.

Self-efficacy of the First-degree Relatives of Patients with Breast Cancer in the Prevention of Cancer: Using the Health Belief Model.

Breast cancer is the most common type of cancer in women. The best method to fight this disease is early diagnosis. The aim of this study was to investigate the effect of education based on the health belief model on self-efficacy of the first-degree relatives of patients with breast cancer. This randomized clinical trial was conducted in Tehran in 2016 on 80 first-degree relatives of patients with breast cancer. After purposive sampling, the subjects were assigned to interventions and control groups using the randomized block design. The data collection tool was a questionnaire including questions about demographic data, health belief model, and self-efficacy. The educational intervention was held during four 90-min sessions. The questionnaires were completed before and 8 weeks after the intervention in both groups. The data were analyzed using the SPSS16 software. The educational intervention led to a significant increase in susceptibility (d = 1.17, 95%CI 0.69, 1.66), seriousness (d = 1.11, 95%CI 0.62, 1.59), benefits (d = 1.58, 95%CI 1.06, 2.09), and significant decrease in perceived barriers (d = - 0.73, 95%CI 0.27, 1.19) scores in the intervention group. The self-efficacy score in the intervention group was increased from 7.58 to 9.20, which was statistically significant (d = 1.72, 95%CI 1.19, 2.25). However, in the control group, there was no significant difference in self-efficacy score before and after the intervention (p = 0.45). The present study confirmed the effectiveness of the health belief model in promoting self-efficacy of the first-degree relatives of patients with breast cancer. Therefore, it is recommended that this education program is implemented for women, especially the first-degree relatives of patients with breast cancer.

Post-Divorce Regret among Iranian Women: A Qualitative Study.

BACKGROUND: Post-divorce regret is a context-based phenomenon and in every community it is affected by the personal, social and cultural factors of that community. This study was conducted to investigate the post-divorce regret among Iranian women. METHODS: This qualitative content analysis study was conducted from November 2015 to December 2017 in Tehran. 15 divorced women were selected through purposeful and snowball sampling. The data were collected through in-depth individual semi-structured interviews. Interview with participant no. 13 was conducted in two sessions (not having enough time for a long interview). Data were analyzed using Graneheim and Lundman's proposed method. The MAXQDA 10 software was used for the management of data. RESULTS: Four main categories and 12 subcategories of data were extracted. The main categories and their subcategories were identity threat (stigma, becoming a sex object, discrimination), loss of independence (economic dependence, lack of independence in choosing a place to live, being controlled), vague future (concerns about children's future, little chance of having an appropriate remarriage, fear of loneliness) and the absence of the husband and his role (emotional and sexual needs, children's need for their father, need for a supporter and security). CONCLUSION: The findings of this study showed that many of the participants had got involved in multiple social, economic and support problems after divorce. Most of the participants were not able to adjust to life after their divorce and consequently regretted their decision to divorce. Therefore, it is necessary to provide the appropriate social and economic support for these women based on the culture of the society.

Exploring Effective Contextual Factors for Regular Cervical Cancer Screening in Iranian Women: A Qualitative Study

Background: Adherence to regular screening programs for cervical cancer in Iranian women is not common. The aim of this study was to explore contextual factors influencing behavior and compliance with guidelines. Methods: This qualitative content analysis study was conducted in 2016-2017 in Hamadan city, Iran. Semi-structured in-depth interviews were conducted with 31 participants who were selected purposefully on referring to health centers. Twenty-three were women with various experiences of cervical cancer screening and 8 were health care providers (4 midwives, 1 gynecologist, 1 general practitioner and 1 family health expert). Guba and Lincoln criteria were used for tustworthiness. MAXQDA10 software was employed for data analysis. Results: Four themes were extracted from the data: an opportunity maker system, opportunities to become acquainted, concerns for healthy living, and perception of cancer. Conclusion: The results showed sensitivity of health care providers and their appropriate performance in relation to regular screening behavior of women is very important. Women's perception of cancer and its curability is another factor with a major effect on screening behavior. Opportunities for people to become acquainted with the Pap smear in a variety of ways and concern for healthy living and the need to have a healthy life to ensure quality of life were also found to be important.

"Life behind the mask": Sexual life of Iranian women with multiple sclerosis.

BACKGROUND: Multiple sclerosis (MS) is a debilitating and life-long disease that affects the sexual life of people. However, in Iran little attention has been paid to the sexual life of women with MS. OBJECTIVE: The aim of this study was to understand the sexual life and experiences of Iranian women with multiple sclerosis. METHODS: A qualitative study was designed, and face-to-face semi-structured interviews were conducted with twenty-five women with MS. The interviews were tape-recorded and transcribed verbatim. Data were analyzed using a content analysis approach and through MAXQDA.10 software. RESULTS: The main themes identified during the analysis were: (1) limited sexual activity, (2) sex life behind the mask, and (3) lack of sexual support during the rehabilitation process. In fact, the participants in this study expressed that their sexual activity was negatively affected by MS. They were trying to hide their sexual problems, and present themselves to their husbands differently from what they are, which can be considered as sex life behind the mask. Furthermore, Iranian women with MS received little sexual support from the rehabilitation team. CONCLUSIONS: Hiding sexual problems from husbands is thought to be a common practice and behavior among Iranian women with MS. Understanding this insight and its consequences can assist the rehabilitation team in helping and solving sexual problems of women with MS. Moreover, sexual awareness and education should be extended, especially among the husbands of women with MS.

Sexual dysfunction levels in iranian women suffering from multiple sclerosis.

OBJECTIVE: Sexual dysfunction (SD) is a common complaint in women who suffer from Multiple Sclerosis (MS), which has been categorized in three levels (primary, secondary, and tertiary) in previous studies. This study was conducted to assess the prevalence of sexual dysfunction (SD) at each level, and to identify associated factors and their impacts on SD in married women who suffer from Multiple Sclerosis. This study was conducted in Iran where the cultural barriers are recognized as important challenges in sexual function. METHODS: This is a single center study that was carried out in Iran MS Society. A total of 182 married women with MS (aged between 18 and 49 years) were participated in this study. We used the structured and self-report questionnaires including Multiple Sclerosis Intimacy and Sexuality Questionnaire-19 (MSISQ-19), together with socio-demographic and clinical questions, such as Expanded Disability Status Scale (EDSS), Fatigue Severity Scale (FSS) and Beck Depression Inventory (BDI) to collect the data. Pearson's correlation coefficients and analysis of variance (ANOVA) were performed for data analysis. RESULTS: Sexual dysfunction was reported in 149 patients (81.9%), including 136 (74.7%) women with primary SD, 70 (38.5%) women with secondary SD and 81 (44.5%) with tertiary SD. The most prevalent symptoms at each level of SD were orgasmic problems, spasticity and worries about sexual satisfaction of partners, respectively. The total score of MSISQ-19 was associated with education (P<0.001), income status (P<0.001), age (P<0.001), number of children (P<0.05), marriage duration (P<0.05), EDSS score (P<0.01), fatigue (P<0.01), depression (P<0.001), length of disease (P<0.01) and length of drug medication therapies (P<0.01). CONCLUSION: According to this study, sexual dysfunction, especially primary SD was one of the most prevalent problems among women with MS. In addition, this study showed a complex and multifactorial nature for SD among these women. In order to provide an appropriate treatment and management of SD, associated factors and their impacts should be considered.

Cervical Cancer Screening in Iranian Women: Healthcare Practitioner Perceptions and Views

Background: Although regular screening for cervical cancer with the Papanicolaou test is an important element for reducing the incidence and mortality of cervical cancer, the actual screening program in Iranian women is not sufficiently comprehensive at present. The purpose of this study was to explore healthcare provider perceptions of factors affecting cervical cancer screening in Iranian women. Methods: In this qualitative study performed from September 2015 to August 2016 in Hamadan, Iran, we conducted semi-structured in depth interviews with 14 healthcare providers selected purposefully. All interviews were recorded, transcribed and analyzed according to a conventional thematic analysis approach. MAXQDA10 software was employed for data analysis. Results: Four themes were extracted from data: "Inefficient management of cervical cancer screening process, Personal and professional characteristics of health care providers, Individual barriers and facilitators, Need for health system authorities to pay attention". Conclusion: Increased official attention to screening, and identifying challenges and providing strategies based on these challenges will help in achieving a successful screening program. It is necessary to attend to professional features of medical science students and increase the skills of interaction with clients in addition to academic training. Efforts should be made to increase trust in healthcare providers regarding the Pap test and receptiveness of society to this screening modality through informing the public, with encouragement through the media.

The effectiveness of the Permission, Limited Information, Specific suggestions, Intensive Therapy (PLISSIT) model based sexual counseling on the sexual function of women with Multiple Sclerosis who are sexually active.

OBJECTIVE: This study was conducted to evaluate the effectiveness of sexual counseling based on the Permission, Limited Information, Specific Suggestion, Intensive Therapy (PLISSIT) model on the Sexual Dysfunction (SD) of married sexually active women who suffer from Multiple Sclerosis (MS). This is the first sexual intervention applied by a midwife as a health professional on MS patients in Iran where the cultural and religious limitations are important challenging issues. STUDY DESIGN: This randomized clinical trial was carried out in Iranian Community of Support for MS Patients in Tehran, Iran. The participating women who had a definite diagnosis of MS and SD, Expanded Disability Status Scale (EDSS) scores <7, and aged 18-55 years were randomly assigned to experimental (EG, n=43) and control group (CG, n=45). Participants in the EG group received 4 weekly sexual counseling sessions based on the PLISSIT model (90-120min per session). MAIN OUTCOME MEASURES: Sexual function was assessed three times (before the intervention, and 2 months and 3 months after the intervention) using the Female Sexual Function Index (FSFI). Chi-square test, Fisher's exact test, and Repeated Measures ANOVA were employed to analyze the data. RESULTS: The mean total FSFI score of the women in EG improved at 2 and 3 months after the intervention when it was compared with the FSFI score before the intervention (p<0.05). There was no significant difference in the total FSFI score when the data of 3 evaluations was compared in CG. A significant increase in the mean score of 6 subgroups was seen in EG (p<0.05) but not in CG. CONCLUSION: According to this study, utilizing the PLISSIT model as a framework for sexual counseling can improve sexual function in women who are sexually active and suffer from SD due to MS.

Help seeking behavior of women with self-discovered breast cancer symptoms: a meta-ethnographic synthesis of patient delay.

BACKGROUND AND OBJECTIVE: Patient delay makes a critical contribution to late diagnosis and poor survival in cases of breast cancer. Identifying the factors that influence patient delay could provide information for adopting strategies that shorten this delay. The aim of this meta-ethnography was to synthesize existing qualitative evidence in order to gain a new understanding of help seeking behavior in women with self-discovered breast cancer symptoms and to determine the factors that influence patient delay. METHODS: The design was a meta-ethnography approach. A systematic search of the articles was performed in different databases including Elsevier, PubMed, ProQuest and SCOPUS. Qualitative studies with a focus on help seeking behaviors in women with self-discovered breast cancer symptoms and patient delay, published in the English language between 1990 and 2013 were included. The quality appraisal of the articles was carried out using the Critical Appraisal Skills Programme qualitative research checklist and 13 articles met the inclusion criteria. The synthesis was conducted according to Noblit and Hare's meta-ethnographic approach (1988), through reciprocal translational analysis and lines-of-argument. FINDINGS: The synthesis led to identification of eight repeated key concepts including: symptom detection, initial symptom interpretation, symptom monitoring, social interaction, emotional reaction, priority of medical help, appraisal of health services and personal-environmental factors. Symptom interpretation is identified as the important step of the help seeking process and which changed across the process through active monitoring of their symptoms, social interactions and emotional reactions. The perceived seriousness of the situation, priority to receive medical attention, perceived inaccessibility and unacceptability of the health care system influenced women's decision-making about utilizing health services. CONCLUSION: Help seeking processes are influenced by multiple factors. Educational programs aimed at correcting misunderstandings, erroneous social beliefs and improving self-awareness could provide key strategies to improve health policy which would reduce patient delay.