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1.  Development and validation of a health belief model based instrument for measuring factors influencing exercise behaviors to prevent osteoporosis in pre-menopausal women (HOPE) 
Background
The health belief model (HBM) is the most commonly used conceptual framework for evaluating osteoporosis health belief and behaviors. The purpose of this study was to develop and evaluate the psychometric properties of a health belief model based questionnaire for exercise behavior for preventing osteoporosis among women aged 30 years and over.
Methods
This was a cross sectional study of a convenience sample of women aged 30 years and over in Tehran, Iran using a theory-based instrument (HOPE). The instrument contained 39 items covering issues relate to osteoporosis prevention behavior. In this methodological study, exploratory and confirmatory factor analyses were used for psychometric evaluation. The Cronbach’s alpha coefficient and Intraclass Correlation Coefficient (ICC) was used to evaluate the reliability of the scale.
Results
In all 240 women participated in the study. The mean age of participant was 39.2 ± 7.8 years. The initial analysis extracted nine factors for the questionnaire that jointly accounted for 66.5% of variance observed. Confirmatory factor analysis showed that the data obtained was fit with Health Belief Model (HBM) and self-regulation construct (X2 = 1132.80, df = 629, P < 0.0001, CFI = 0.94, GFI = 0.91, RMSEA = 0.05 and SRMR = 0.06). The Cronbach’s alpha coefficient for the subscales ranged from 0.72 to 0.90 and Intraclass Correlation Coefficient (ICC) ranged from 0.71 to 0.98; well above acceptable thresholds.
Conclusions
The HOPE was found to be appropriate instrument for measuring health belief and self-regulation for prevention of osteoporosis.
doi:10.1186/1471-2474-15-61
PMCID: PMC3996026  PMID: 24581300
2.  Sexual behavioral abstine HIV/AIDS questionnaire: Validation study of an Iranian questionnaire 
Background:
This study was designed to assess the validity and reliability of the designed sexual, behavioral abstinence, and avoidance of high-risk situation questionnaire (SBAHAQ), with an aim to construct an appropriate development tool in the Iranian population.
Materials and Methods:
A descriptive–analytic study was conducted among female undergraduate students of Tehran University, who were selected through cluster random sampling. After reviewing the questionnaires and investigating face and content validity, internal consistency of the questionnaire was assessed by Cronbach's alpha. Explanatory and confirmatory factor analysis was conducted using SPSS and AMOS 16 Software, respectively.
Results:
The sample consisted of 348 female university students with a mean age of 20.69 ± 1.63 years. The content validity ratio (CVR) coefficient was 0.85 and the reliability of each section of the questionnaire was as follows: Perceived benefit (PB; 0.87), behavioral intention (BI; 0.77), and self-efficacy (SE; 0.85) (Cronbach's alpha totally was 0.83). Explanatory factor analysis showed three factors, including SE, PB, and BI, with the total variance of 61% and Kaiser–Meyer–Olkin (KMO) index of 88%. These factors were also confirmed by confirmatory factor analysis [adjusted goodness of fitness index (AGFI) = 0.939, root mean square error of approximation (RMSEA) = 0.039].
Conclusion:
This study showed the designed questionnaire provided adequate construct validity and reliability, and could be adequately used to measure sexual abstinence and avoidance of high-risk situations among female students.
doi:10.4103/2277-9531.127564
PMCID: PMC3977414  PMID: 24741650
HIV; questionnaires; sexual abstinence; sexual behavior
3.  The transtheoretical model (TTM) questionnaire for smoking cessation: psychometric properties of the Iranian version 
BMC Public Health  2013;13:1186.
Background
The transtheoretical model (TTM) is a common framework for studies of smoking cessation. Using the TTM, several instruments were developed to measure to what extent interventions could make changes in people’s behavior. The current study aimed to test the validity and reliability of the Persian version of a TTM based questionnaire for smoking cessation in Iran.
Methods
This was a cross-sectional validation study among adult male smokers using the TTM Questionnaire. Backward-forward procedure was applied to translate the questionnaire from English into Persian (the Iranian language). The confirmatory factor analyses were performed to test validity. The internal consistency and stability of the questionnaire was examined using Cronbach’s alpha coefficient and Intraclass Correlation Coefficient (ICC).
Results
In all 150 male smokers were entered into the study. The mean age of participants was 36.51 ± 7.94 years. The results obtained from confirmatory factor analysis revealed that the data was fit to the model: the goodness of fit index (GFI) = 0.92; the comparative fit index (CFI) = 0.91; the root mean square error of approximation (RMSEA) = 0.065 (95% CI = 0.063-0.067), and the relative chi-square (x2/df) = 1.87, p < 0.001. The Cronbach’s alpha ranged from 0.60 to 0.84 indicating an acceptable result. Also Intraclass Correlation of Coefficient (ICC) ranged from 0.61 to 0.83 corresponding to a satisfactory finding.
Conclusion
The current study provided psychometric evidence for an appropriate, reliable, and valid tool to determine smoking behaviors among Iranian adult smokers. Indeed the findings from this study could be applied in designing smoking cessation interventions in Iran.
doi:10.1186/1471-2458-13-1186
PMCID: PMC3878568  PMID: 24341503
5.  Prevalence and Determinants of Male Adolescents’ Smoking in Iran: An Explanation Based on the Theory of Planned Behavior 
Background
Adolescent smoking problem has still remained as a public health concern, but factors that attributing to the initiation of adolescent smoking are not well known in Iran.
Objectives
The aim of this study is to estimate the prevalence of smoking, and its associations among high school male adolescents in Iran, in the context of the theory of planned behavior (TPB).
Patients and Methods
This was a cross-sectional study involving male adolescent students (high school) in the city of Zarandieh, Iran. A multiple-stage sampling protocol was used. The participants completed an anonymous, voluntary, and self-report questionnaire. Prevalence was estimated, and demographic variables, psychological factors, and the theory of planned behavior components were used to indicate factors contributing to adolescents’ cigarette smoking.
Results
In all, 365 students were entered the study. The mean age of respondents was 16.49 ± 1.11 years. The prevalence of current smoking was 15.1%. The result obtained from logistic regression analysis revealed that all theory of planned behavior (TPB) components [knowledge (OR = 0.75; 95% CI: (0.59-0.97), attitude (OR = 0.75; 95% CI: (0.65-0.86), self-efficacy (OR = 0.82; 95% CI: (0.71-0.95), subjective norms (OR = 0.84; 95% CI: (0.72-0.98)] were significant predating factors for adolescents smoking habits. In addition, having parents who smoke (OR = 4.75; 95% CI: (1.38-12.35), smoking friends (OR = 3.76; 95% CI: (1.20-11.76), and smoking siblings (OR = 4.21; 95% CI: (1.17-11.16) were significant contributing factors to adolescents’ cigarette smoking behavior.
Conclusions
The results showed that the prevalence of cigarette smoking in adolescents was high, and the theory of planned behavior (TPB) components were significant predictors of cigarette smoking. It seems that interventions targeting adolescents’ smoking habits might benefit using the TPB model.
doi:10.5812/ircmj.3378
PMCID: PMC3745745  PMID: 23983996
Smoking; Adolescence
6.  Promoting sexual abstinence intention among female university students: A quasi-experimental study 
Background:
The effectiveness of a theory-based educational intervention on intension for sexual abstinence among female university students was evaluated.
Materials and Methods:
Female students were recruited from humanity sciences department through cluster sampling. Educational intervention was applied for four 90-min sessions and by application of cognitive theories during 4 weeks.
Results:
One hundred and nine female students with mean age of 20.74 ± 1.57 years took part in the study. Despite the similarity of two groups of intervention (n = 53) and control (n = 59) at baseline, there were significant differences between the two groups in mean scores of the variables, knowledge (4.62 ± 1.38 vs. 3.53 ± 1.61), perceived susceptibility (14.05 ± 1.51 vs. 12.37 ± 2.11), and perceived benefits (28.41 ± 2.14 vs. 27.51 ± 3.05), at follow-up time after 3 months (P < 0.05). Additionally, these variables were observed with improvement over 3 months in the intervention group (P < 0.05). However, this study showed no significant effect on the behavior intention and self-efficacy.
Conclusion:
This study showed that educational intervention could improve knowledge, perceived benefits, and self-efficacy of the female students regarding HIV/AIDS.
PMCID: PMC3719224  PMID: 23900294
Attitude; health education; human immunodeficiency virus; knowledge; sexual abstinence
7.  Development and psychometric properties of a new social support scale for self-care in middle-aged patients with type II diabetes (S4-MAD) 
BMC Public Health  2012;12:1035.
Background
Social support has proved to be one of the most effective factors on the success of diabetic self-care. This study aimed to develop a scale for evaluating social support for self-care in middle-aged patients (30–60 years old) with type II diabetes.
Methods
This was a two-phase qualitative and quantitative study. The study was conducted during 2009 to 2011 in Tehran, Iran. In the qualitative part, a sample of diabetic patients participated in four focus group discussions in order to develop a preliminary item pool. Consequently, content and face validity were performed to provide a pre-final version of the questionnaire. Then, in a quantitative study, reliability (internal consistency and test-retest analysis), validity and factor analysis (both exploratory and confirmatory) were performed to assess psychometric properties of the scale.
Results
A 38-item questionnaire was developed through the qualitative phase. It was reduced to a 33-item after content validity. Exploratory factor analysis loaded a 30-item with a five-factor solution (nutrition, physical activity, self monitoring of blood glucose, foot care and smoking) that jointly accounted for 72.3% of observed variance. The confirmatory factor analysis indicated a good fit to the data. The Cronbach’s alpha coefficient showed excellent internal consistency (alpha=0.94), and test-retest of the scale with 2-weeks intervals indicated an appropriate stability for the scale (ICC=0.87).
Conclusion
The findings showed that the designed questionnaire was a valid and reliable instrument for measuring social support for self-care in middle-aged patients with type II diabetes. It is an easy to use questionnaire and contains the most significant diabetes related behaviors that need continuous support for self-care.
doi:10.1186/1471-2458-12-1035
PMCID: PMC3520699  PMID: 23190685
8.  The Prediction of Physical Activity Intention and Behavior in Elderly Male Residents of a Nursing Home: A Comparison of Two Behavioral Theories 
Background: Regular physical activity is ranked as a leading health indicator. Despite the extensive benefits of physical activity, elder people are much less active than desired. Using Theory of Planned Behavior (TPB) and the self-efficacy construct, this study examined the prediction of physical activity intention and behavior in a sample of elderly male resident of a nursing home.
Methods: In a cross-sectional study of the residents of Kahrizak Nursing Home in Tehran, Iran, elderly men who were 60 years or older, capable of independent living, mobility, and verbal communication were asked to complete measures of the TPB, self-efficacy and physical activity behavior.
Results: A hierarchical step-wise multiple regression analysis indicated that affective/instrumental attitude, subjective norm, and perceived behavioral control (PBC) explained 32.8% of the variance in physical activity intention, and self-efficacy provided an additional 2.7%. In a reverse step regression, the TPB variables explained an additional 12.2% of physical activity intention. In a multiple regression analysis on physical activity behavior, affective/instrumental attitude, subjective norm, perceived behavioral control (PBC) and intention explained 15.7% of the variance in physical activity behavior while self-efficacy contributed an additional 5.6%. In the reverse step regression, TPB predictors contributed an additional 3.0% in explaining the variance in physical activity behavior.
Conclusion: The results indicate that in addition to the TPB, self-efficacy may also play an important role in the prediction of behavior, and should be included in the design of physical activity programs for elderly men of nursing home residents.
PMCID: PMC3470291  PMID: 23115427
Attitude; intention; elderly; self-efficacy
9.  Psychometric Properties of the Iranian Version of the Behavioral Regulation in Exercise Questionnaire-2 (BREQ-2) 
Health Promotion Perspectives  2011;1(2):95-104.
Background: The Behavioral Regulation in Exercise Questionnaire (BREQ) and the BREQ-2 are the most commonly used measures of behavioural regulation in exercise psychology. The purpose of the study was to assess the validity and reliability of the Iranian version of the BREQ-2 on a sample of university students.
Methods: The BREQ-2 was translated into Persian by qualified experts and the psychometric properties of the instrument were assessed. Content validity was established, using a panel of 12 Iranian experts in the areas of health education, psychology, and exercise. Construct validity was assessed via confirmatory factor analysis (CFA), using LISREL 8.80 (N = 418). The reliability of the BREQ-2 was assessed, using a 2-week test-retest to establish its stability and Cronbach’s Alpha to estimate its internal consistency.
Results: The Iranian version of the BREQ-2 was slightly modified to improve content validity. Primary results of confirmatory factor analysis did not fully support the 5-factor uncorrelated model. The model was modified; and the fit indices indicated that the 5-factor correlated model was the best fit. The scale was found to have acceptable internal consistency (α > 0.7) and test-retest reliability (intra-class correlation coefficient [ICC] > 0.80).
Conclusion: The Iranian BREQ-2 has acceptable validity and reliability in the study sample and may be used in relevant studies to assess behavioural regulation in similar samples.
doi:10.5681/hpp.2011.010
PMCID: PMC3963623  PMID: 24688905
Validity, reliability; BREQ; Self-Determination Theory; Students; Exercise
10.  Factors Influencing Physical Activity Behavior among Iranian Women with Type 2 Diabetes Using the Extended Theory of Reasoned Action 
Diabetes & Metabolism Journal  2011;35(5):513-522.
Background
Findings of most studies indicate that the only way to control diabetes and prevent its debilitating effects is through the continuous performance of self-care behaviors. Physical activity is a non-pharmacological method of diabetes treatment and because of its positive effects on diabetic patients, it is being increasingly considered by researchers and practitioners. This study aimed at determining factors influencing physical activity among diabetic women in Iran, using the extended theory of reasoned action in Iran.
Methods
A sample of 352 women with type 2 diabetes, referring to a Diabetes Clinic in Khoy, Iran, participated in the study. Appropriate instruments were designed to measure the desired variables (knowledge of diabetes, personal beliefs, subjective norms, perceived self-efficacy, behavioral intention and physical activity behavior). The reliability and validity of the instruments were examined and approved. Statistical analyses of the study were conducted by inferential statistical techniques (independent t-test, correlations and regressions) using the SPSS package.
Results
The findings of this investigation indicated that among the constructs of the model, self efficacy was the strongest predictor of intentions among women with type 2 diabetes and both directly and indirectly affected physical activity. In addition to self efficacy, diabetic patients' physical activity also was influenced by other variables of the model and sociodemographic factors.
Conclusion
Our findings suggest that the high ability of the theory of reasoned action extended by self-efficacy in forecasting and explaining physical activity can be a base for educational intervention. Educational interventions based on the proposed model are necessary for improving diabetics' physical activity behavior and controlling disease.
doi:10.4093/dmj.2011.35.5.513
PMCID: PMC3221027  PMID: 22111043
Diabetes mellitus; Motor activity; Self efficacy; Theory of reasoned action
11.  Development and psychometric properties of a belief-based Physical Activity Questionnaire for Diabetic Patients (PAQ-DP) 
Background
This study carried out to develop a scale for assessing diabetic patients' perceptions about physical activity and to test its psychometric properties (The Physical Activity Questionnaire for Diabetic Patients-PAQ-DP).
Methods
An item pool extracted from the Theory of Planned Behavior literature was generated. Then an expert panel evaluated the items by assessing content validity index and content validity ratio. Consequently exploratory factor analysis (EFA) was performed to indicate the scale constructs. In addition reliability analyses including internal consistency and test-retest analysis were carried out.
Results
In all a sample of 127 women with diabetes participated in the study. Twenty-two items were initially extracted from the literature. A six-factor solution (containing 19 items) emerged as a result of an exploratory factor analysis namely: instrumental attitude, subjective norm, perceived behavioral control, affective attitude, self-identity, and intention explaining 60.30% of the variance observed. Additional analyses indicated satisfactory results for internal consistency (Cronbach's alpha ranging from 0.54 to 0.8) and intraclass correlation coefficients (ranging from 0.40 to 0.92).
Conclusions
The Physical Activity Questionnaire for Diabetic Patients (PAQ-DP) is the first instrument that applies the Theory of Planned Behavior in its constructs. The findings indicated that the PAQ-DP is a reliable and valid measure for assessing physical activity perceptions and now is available and can be used in future studies.
doi:10.1186/1471-2288-10-104
PMCID: PMC2998522  PMID: 21062466
12.  Determinants of glycemic control in female diabetic patients: a study from Iran 
Background
Since microvascular and macrovascular complications are reduced through strict glycemic control, this study carried out to identify the factors that affect glycemic control.
Methods
A cross-sectional design was carried out to examine the role of demographic, anthropometric, clinical and other relevant characteristics in a sample of 103 female diabetic patients in Tehran, Iran. Personal interviews were conducted to collect data. Then blood sampling collected and the patients were divided into two outcome groups (controlled and uncontrolled diabetes). The groups were compared on the basis of their characteristics using both univariate and multivariate analyses.
Results
In all 103 patients were entered into the study. The mean age of patients was 46.38 (SD = 11.42) years. Overall, the mean value of HbA1c for the whole sample was 7.5 (SD = 2.35) and 56.3% had HbA1c ≥ 7%. The findings obtained from univariate analysis revealed that there were no significant differences between controlled and uncontrolled patients. However, in multivariate analysis the waist circumference was found to be a significant predictor of increased level of HbA1c (OR = 1.04, 95% CI = 1-1.08, P = 0.04).
Conclusions
The findings suggest that increased level of HbA1c is associated with waist circumference that is a modifiable factor. It seems that physical activity might be a solution to overcome this health problem. A larger study to identify other factors also is recommended.
doi:10.1186/1476-511X-9-83
PMCID: PMC2931513  PMID: 20701805
13.  Experiences of stigma in healthcare settings among adults living with HIV in the Islamic Republic of Iran 
Background
People living with HIV (PLHIV) sometimes experience discrimination. There is little understanding of the causes, forms and consequences of this stigma in Islamic countries. This qualitative study explored perceptions and experiences of PLHIV regarding both the quality of healthcare and the attitudes and behaviours of their healthcare providers in the Islamic Republic of Iran.
Methods
In-depth, semi-structured interviews were held with a purposively selected group of 69 PLHIV recruited from two HIV care clinics in Tehran. Data were analyzed using the content analysis approach.
Results and discussion
Nearly all participants reported experiencing stigma and discrimination by their healthcare providers in a variety of contexts. Participants perceived that their healthcare providers' fear of being infected with HIV, coupled with religious and negative value-based assumptions about PLHIV, led to high levels of stigma. Participants mentioned at least four major forms of stigma: (1) refusal of care; (2) sub-optimal care; (3) excessive precautions and physical distancing; and (4) humiliation and blaming. The participants' healthcare-seeking behavioural reactions to perceived stigma and discrimination included avoiding or delaying seeking care, not disclosing HIV status when seeking healthcare, and using spiritual healing. In addition, emotional responses to perceived acts of stigma included feeling undeserving of care, diminished motivation to stay healthy, feeling angry and vengeful, and experiencing emotional stress.
Conclusions
While previous studies demonstrate that most Iranian healthcare providers report fairly positive attitudes towards PLHIV, our participants' experiences tell a different story. Therefore, it is imperative to engage both healthcare providers and PLHIV in designing interventions targeting stigma in healthcare settings. Additionally, specialized training programmes in universal precautions for health providers will lead to stigma reduction. National policies to strengthen medical training and to provide funding for stigma-reduction programming are strongly recommended. Investigating Islamic literature and instruction, as well as requesting official public statements from religious leaders regarding stigma and discrimination in healthcare settings, should be used in educational intervention programmes targeting healthcare providers. Finally, further studies are needed to investigate the role of the physician and religion in the local context.
doi:10.1186/1758-2652-13-27
PMCID: PMC2919446  PMID: 20649967
14.  Motorcyclists' reactions to safety helmet law: a qualitative study 
BMC Public Health  2009;9:393.
Background
Extensive body of the literature reveals that proper use of helmets is an effective way to reduce the severity of injuries and fatalities among motorcyclists. However, many motorcyclists do not use safety helmet properly. This study aimed to empirically explore reactions of motorcyclists to the safety helmet laws, in Iran.
Methods
Qualitative data were collected via four focus groups and 11 in-depth interviews. Participants were 28 male motorcyclists who never used a safety helmet during rides, and 4 male police officers. All transcripts, codes and categories were read for several times to exhaust identifiable major themes. During this process data were reduced from text to codes and themes.
Results
Five major themes emerged from the data analyses, including themes related to the following: (1) circumventing or dodging police officers; (2) simulating a helmet wearing behavior; (3) accepting the probability of receiving a ticket; (4) taking advantage of the police neglect and carelessness; and (5) using a cheap or convenient helmet.
Conclusion
Our findings suggest certain levels of reckless driving among the participating motorcyclists in this study. They also point to a system of law enforcement that operates haphazardly and fails to consistently penalize those who deviate from it. Further studies are needed to investigate how "risks" are perceived and relate to "reactions", and how a 'culture of masculinity' may encourage risk tolerance and a disposition toward lawlessness and carelessness among male motorcyclists. Also, there is a need for the development and implementation of multidimensional interventions that would offer socio-culturally sensitive educational and motivational messages to the motorcyclists and the in-service traffic-enforcement officers in Iran.
doi:10.1186/1471-2458-9-393
PMCID: PMC2770492  PMID: 19843325
15.  A school-based randomized controlled trial to improve physical activity among Iranian high school girls 
Background
Physical activity (PA) rates decline precipitously during the high school years and are consistently lower among adolescent girls than adolescent boys. Due to cultural barriers, this problem might be exacerbated in female Iranian adolescents. However, little intervention research has been conducted to try to increase PA participation rates with this population. Because PA interventions in schools have the potential to reach many children and adolescents, this study reports on PA intervention research conducted in all-female Iranian high schools.
Methods
A randomized controlled trial was conducted to examine the effects of two six-month tailored interventions on potential determinants of PA and PA behavior. Students (N = 161) were randomly allocated to one of three conditions: an intervention based on Pender's Health Promotion model (HP), an intervention based on an integration of the health promotion model and selected constructs from the Transtheoretical model (THP), and a control group (CON). Measures were administered prior to the intervention, at post-intervention and at a six-month follow-up.
Results
Repeated measure ANOVAs showed a significant interaction between group and time for perceived benefits, self efficacy, interpersonal norms, social support, behavioral processes, and PA behavior, indicating that both intervention groups significantly improved across the 24-week intervention, whereas the control group did not. Participants in the THP group showed greater use of counter conditioning and stimulus control at post-intervention and at follow-up. While there were no significant differences in PA between the HP and CON groups at follow-up, a significant difference was still found between the THP and the CON group.
Conclusion
This study provides the first evidence of the effectiveness of a PA intervention based on Pender's HP model combined with selected aspects of the TTM on potential determinants to increase PA among Iranian high school girls.
doi:10.1186/1479-5868-5-18
PMCID: PMC2386503  PMID: 18387174

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