Identifying Barriers to Self-advocacy in Women With Multiple Sclerosis in Iran: A Qualitative Study

Objective: Chronic Multiple Sclerosis (MS) often occurs in middle-aged people, who are supposed to take their most important roles in the family and community and thus affect their self-advocacy. This study aimed to identify the barriers to self-advocacy in women with MS. Materials & Methods: This study was conducted using a qualitative content analysis method. The participants were 10 female members of the MS Association of Khuzestan Province of Iran aged 30-40 years with different educational levels, marital status, and occupations. They were selected using a purposive sampling method. The study data were collected through semi-structured interviews and continued until data saturation from June to November 2019. The content analysis was performed using Lundman and Graneheim’s qualitative content analysis method with an inductive approach conducted continuously and simultaneously with data collection. To evaluate the validity and reliability of qualitative data, we used Lincoln and Guba criteria (credibility, dependability, conformability, and transferability). Results: The data analysis revealed 900 codes, 21 subcategories, and 6 themes of family barriers, medical barriers, job-related barriers, environmental barriers, sociocultural barriers, and psychological barriers. Conclusion: Women with MS face a variety of barriers to self-advocacy; most of them are related to family, environment, and society, in addition to personal barriers. Social support and the availability of sufficient and appropriate information about MS can play an important role in confronting these women with mentioned barriers and realizing their self-advocacy.

Negative Effects of the COVID-19 Pandemic on Home Integration, Community Integration, and Productive Activities

Objective: Social participation in daily living the activities requires the maintenance of a variety of social relationships with others and engagement in various social activities. Proper social participation increases the feeling of attachment, provides a stable sense of identity, and increases one’s sense of worth, belonging, and dependence on society. Lack of social participation leads to anxiety, loneliness, depression, panic, mental disorders and many other mental problems and affects society in general. A new coronavirus, called COVID-19, was identified in late December 2019 in China. After just one year, it has been reportedly infected more than 85 million people (up to January 1, 2021) worldwide, and more than 1.8 million have died. Two public health measures to break the transmission chain include quarantine and social distancing. These measures restrict gatherings or separate individuals. Due to these measures in many countries, people’s participation in many social activities has been disrupted. The purpose of this study is to survey the negative effects of the COVID-19 pandemic on home integration, community integration and productive activities. Materials & Methods: This cross-sectional study was conducted in June 2020 by using the Community Integration Questionnaire (CIQ) which measures home integration, community integration, and productive activities, along with a demographic form which were sent to 461 participants in Iran (Mean ±SD age= 36.86±5.8 years) on WhatsApp or via email and completed online. Participants were selected from among college students, patients, people with disabilities, their families and relatives, and others who could use smartphones, computers, tablets, and laptops. The effects of Covid-19 were evaluated by analyzing the CIQ scores before and after the pandemic in SPSS v. 22 software. Results: Comparing the CIQ scores before and after the pandemic, results showed that it significantly reduced home integration (P<0.0001), social integration (P<0.0001), productive activities (P<0.0001) and total score (P<0.0001). Conclusion: The COVID-19 pandemic has disrupted the social life of people. In addition to health threats of this disease, the fear of being infected and losing loved ones, job, educational opportunities, recreation, freedom and support, have profound psychological effects. Not only getting infected, but also the fear of getting infected can lead to a lack of access to resources that can improve people’s resistance to this disease. The COVID-19 pandemic has direct and indirect psychological and social effects and can affect mental health. In order to reduce the negative psychosocial effects of quarantine and social distancing, the implementation of national strategies to promote social participation by Information and Communication Technology-based programs is recommended.

Effect of Using Wii Balance Board on Functional Balance of Children With Ataxic Cerebral Palsy

Objective: Ataxic cerebral palsy accounts for 5%-10% of the population with cerebral palsy. This palsy is characterized by poor balance and coordination, clumsiness, and involuntary tremor. As a result, balance training is one of the essential parts of the rehabilitation programs for children with ataxic cerebral palsy. Wii Balance Board (WBB) is an efficient tool for balance training in children with different physical problems, including cerebral palsy. This study aims to assess the effect of WBB-based balance training on functional balance and the persistence of its effect two months after the intervention in children with ataxic cerebral palsy. Materials & Methods: This is a single-case study with a pre-test, post-test and follow-up design conducted on 3 children (2 girls and 1 boy) with ataxic cerebral palsy (Mean±SD age=10.56±1.09 years). They were classified at levels I and II of the gross motor function classification system. They received conventional occupational therapy three sessions per week, each for 45 minutes in the baseline and follow-up phases. In the intervention phase, each session consisted of 25 minutes of routine rehabilitation followed by 20 minutes of WBB-based balance training for 3 months (12 hours). The changes were evaluated by the Pediatric Balance Scale (PBS) and Timed Up And Go (TUG) test, three times in the baseline phase, three times in the intervention phase (at the end of 12th, 24th, and 36th sessions), and two times in the follow-up phase (one and two months after the intervention). Assessments were done by a pediatric occupational therapist who was unaware of the study process. Finally, the results were analyzed using the Percentage of Nonoverlapping Data (PND), 2 Standard Deviations (2SD), Hedges’s g, and the visual analysis method. Results: The results of the PBS and TUG test showed the improvement of functional balance in all children in the intervention phase and maintained in the follow-up phase. The PND of PBS and TUG test results was 100% for all children, indicating that balance training by the WBB improved functional balance in the intervention and follow-up phases compared to the baseline. Hedeges’ g value for all participants was more than 0.8, indicating a significant difference between the baseline and follow-up phases. The 2SD results showed a significant increase in the PBS score and a significant reduction in the TUG test duration in all children. Furthermore, the visual analysis revealed a significant improvement in the functional balance of all children in the intervention phase and the stability of these changes in the follow-up phase. Conclusion: Balance training by the WBB is an effective method for improving the functional balance of children with ataxic cerebral palsy. Further studies are needed using a larger sample size to confirm its effectiveness.

Economic Profile of Iranian Rehabilitation Services: 2002-2017

Objective: The role of the service sector in general and healthcare services in particular have been promoting in Iran’s economy. The implementation of the Health System Transformation Plan and the injection of new financial resources into this sector have raised concerns about the health system function. Thus, this is the first attempt to estimate and evaluate the share of rehabilitation services in the Iranian economic and health systems. Materials & Methods: The study utilized longitudinal trend analysis using the National Health Accounts data during 2002-2015. National Health Accounts, through input-output tables, breaks down the share of different sources of financing for different functions of the health system. According to this method, both the share of rehabilitation services in Iran’s economy and the financing sources of these activities have been calculated and compared to other countries. Data on Iran's National Health Accounts has been collected from the Statistical Center of Iran. International data is collected from the World Health Organization's National Health Accounts and the databases of the Organization for Economic Cooperation and Development member countries. Results: Expenditures related to rehabilitation services in Iran increased from 884 billion rials in 2002 to more than 2967 billion rials in 1396, equivalent to 0.02% of Iran's GDP in that year. The share of rehabilitation expenditures in total health expenditures in 2007 was at its highest level (0.3%). In the following years, it has always had a decreasing trend. In 1396 it reached about 22.0%, the lowest amount during 16 Last year. Comparing the economic share of rehabilitation of the country's economic activities with different countries shows that the position of this sector is in no way comparable to developed countries and is even lower than many developing countries. Tunisia, Tonga, and Moldova have a similar situation to Iran's economy, with rehabilitation services accounting for about 0.05 to 0.1 percent of their total economic activity. Comparison of the prevalence of disability in these countries with Iran shows that these countries had a lower prevalence than Iran. Examination of the share of various sources shows that out-of-pocket payments with households with 6.37 percent, the most, and the government with 7.18 percent had the least role in financing rehabilitation services. It is noteworthy that this figure was about 65% before implementing the health system transformation plan. Social insurance in 2017 also covered only 6.24% of rehabilitation costs. Conclusion: Inaccessibility of people with disabilities to healthcare services is a very serious issue in the world. The rehabilitation services expenditures have always been mentioned as one of the most important barriers of accessing to these services. Following the implementation of the Health Transformation Plan, the share of rehabilitation activities in Iran’s health market has been shrunk.

Guide to Social Work Intervention for Community Re-entry of Offenders With a History of Violence Against Individuals

Objective: The re-entry of offenders to the community after their imprisonment is a sensitive and important stage and should always be considered by governmental and non-governmental organizations. The proper transition from prison to the community occurs when rehabilitation and social reintegration programs are developed and implemented based on the real needs of individuals. Social work is one of the professions that can help the judicial system with this issue. Many graduates of this profession provide social work services to prisoners and their families. Therefore, it is necessary to identify effective operational solutions in accordance with the conditions of the country and formulate a specific framework. This study aims to prepare a guideline for specialized social work intervention for community re-entry of offenders with a history of violence against individuals. Materials & Methods: In this study, a qualitative approach was used to prepare the specialized guideline. First, the initial barriers and facilitators of successful community re-entry for offenders with a history of violence against individuals were prepared using thematic analysis. Then, based on the protocols of the social work process, the initial draft was developed. Next, at a focus group discussion session with faculty members and experts, the draft was reviewed and improved. To assess its applicability, we used the Appraisal of Guidelines for Research and Evaluation (AGREE) tool. Results: Intertwined concerns, protective shields, welfare/economic security, social support, and achieving relative independence were identified as the five dimensions of successful community re-entry. The specialized social work interventions were presented after approval in four main stages: preparation for the case plan, development of the case plan, interventions and actions, and monitoring and review of interventions. The results of evaluation by AGREE tool showed an overall acceptable average of 58.7% (82.9% for scope and purpose, 88.1% for stakeholder involvement, 85.6% for rigor of development, 83% for clarity of presentation, 84.9% for applicability, and 89.8% for editorial independence). The users of this guideline are social workers and other professions related to prisons and training and security organizations, especially after-release care centers. Conclusion: Investing in rehabilitation programs for prisoners is one of the best and most cost-effective ways to prevent the reoccurrence of violence, which not only has beneficial effects on those concerned but also promotes public safety. This issue becomes important when social reintegration and rehabilitation programs are developed based on scientific approaches and perspectives. Future studies on the effectiveness of the developed guideline, considering the local conditions, can help identify the effective factors of re-entry to the community in newly released prisoners. The skills and capabilities of social workers in presenting specialized interventions and establishing professional and inter-organizational communication, supporting rules and programs, motivation, and enthusiasm of the offender to change can all contribute to the success of this guideline in achieving the defined goals.

A Comparative Study on the Burden of Disease of Schizophrenia, Bipolar Disorder Type I, and Autism Spectrum Disorder on the Family Caregivers in Iran

Objective: Patients with severe psychiatric diseases, due to the debilitating and chronic nature of these diseases, requires prolonged care by family and other rated people. In addition to the patient, these diseases affect the caregiver and create high psychological, social, and individual pressure to take care of themselves. This study aims to compare the burden of schizophrenia, Bipolar Disorder (BD) type 1, and Autism Spectrum Disorder (ASD) on the family caregivers in Iran. Materials & Methods: In this descriptive-analytical study, using the non-probability sampling method, 450 family caregivers of patients with schizophrenia, BD type 1, and ASD were selected based on the inclusion criteria. Data collection tools comprised a demographic checklist, short-form Zarit Burden Interview (ZBI-12), and the Depression, Anxiety, and Stress Scale (DASS). The questionnaires were distributed to the patients selected from the Psychiatric Institute of Tehran, Iran Psychiatric Hospital, and Ali Asghar Hospital. The collected data were analyzed using descriptive statistics, ANOVA for evaluating the relationship of demographic factors with the amount and severity of disease burden, and interclass correlation coefficient in SPSS v. 22. Results: The disease burden was higher on caregivers of ASD patients, followed by that of BD type 1 and schizophrenia patients. The highest and lowest hours of care were related to the ASD and schizophrenia groups, respectively. Women made up the majority of family caregivers. The educational level of family caregivers was higher in the BD type 1 group and was lower in the schizophrenia group. Most caregivers in the BD type 1 group were employed, while most of them in the schizophrenia group were housewives. The lowest and highest income levels were related to the family caregivers of ASD and schizophrenia groups, respectively. The highest and lowest hospitalization frequencies were seen in the BD type 1 and ASD groups, respectively. Conclusion: The burden of three diseases on the family caregivers is high. It is recommended that state-run consulting and screening centers be more active in this field. Because of the low-income level of some family caregivers, it is better to plan for more employment of family caregivers with the assistance of governmental and non-governmental organizations. It is better to hold strategic classes for the family caregivers to reduce their disease burden. Different methods to reduce the burden of diseases in caregivers, such as lowering care hours and using respite care and respite recess and dividing tasks between caregivers, using social or daycare services, can reduce their symptoms of depression and anxiety. Their depression and anxiety should be monitored, and pharmacological and non-pharmacological measures should be used for their treatment.

The Relationship Between Parenting Styles and Moral Development of Preschool Children Mediated by Children’s Attachment

Objective: Family is like a school where parents teach the lessons of humanity and morality, which are the foundation of human happiness, to their children. Moral development is an essential part of children’s understanding of moral rules and principles. The lack of moral development, along with anxiety, and depression exposes children to antisocial and suicidal behaviors. Moral development is associated with parenting styles and attachment. This study aims to investigate the relationship between parenting styles and moral development of preschool children mediated by children’s attachment. Materials & Methods: This descriptive correlational study was conducted on 128 children (64 girls and 64 boys) selected from 8 preschools in Tehran Province, Iran, in 2020 using a cluster sampling technique. The study data were collected using three questionnaires: Baumrind Parenting Styles Questionnaire (PSQ), the Kinship Center Attachment Questionnaire (KCAQ), and Lotfabadi Moral Development Questionnaire (MDQ). The first two tools were completed by mothers of children, while the MDQ was completed by children. The Kolmogorov-Simonov test, correlation test (Enter method), analysis of variance, and multiple regression analysis were used for data analysis in SPSS v. 21. Results: The regression analysis results showed that parenting styles had a significant relationship with moral development (R=0.74, Adjusted R2=0.54, P=0.000). Also, attachment had a significant association with moral development (R=0.71, Adjusted R2=0.49, P=0.000). With one unit change in permissive, authoritarian, and authoritative parenting styles, the moral development of preschool children can be predicted by 43.5%, 19%, and 37.6%, respectively. Moreover, with one unit change in positive adjustment/development, negative behavior, emotional reactivity, and distancing from caregiver support dimensions of attachment, the moral development of preschool children can be predicted by 33.6%, 38.4%, -26.4%, and -11.4%, respectively. Also, the results of the Sobel test showed that the attachment variable was the mediator of the relationship of parenting styles with moral development (z=2.29>1.96). Conclusion: The moral development of children is related to permissive, authoritarian, and authoritative parenting styles. Besides, children’s attachment can mediate the relationship between parenting styles and moral development. More planning and follow-up are needed to improve the moral development of preschool children. When parents are consistent in their parenting styles, they provide their children with assertive and trusting behaviors. They should listen to their children and promote dialogue with them. Their discipline should be accompanied by warmness, logic, and flexibility and give their children the freedom to some extent. This treatment can help children develop their social behavior.

Challenges of Accessing and Using Rehabilitation Services in People With Autism Spectrum Disorder: A Systematic Review

Objective: One of the essential needs of patients with Autism Spectrum Disorder (ASD) and their families is the rehabilitation services to improve patients’ performance in social interactions and communication. However, access and use of these services pose many challenges for patients with ASD and service providers. This study systematically reviews the challenges of access and use of rehabilitation services for patients with ASD. Materials & Methods: This is a systematic review of the articles published from 2010 to 2020 in Persian and English on the challenges of accessing and using rehabilitation services for patients with ASD. The search was conducted in online databases of Google Scholar, PubMed, Scopus, ProQuest, Science Direct, SID, and MagIran using the keywords of “challenge”, “utilization”, “accessibility”, “rehabilitation”, “healthcare”, and “autism”. The initial search yielded 142 articles. After checking their titles, 102 articles were removed because they were irrelevant or duplicates, and 40 remained. Finally, 14 studies were selected for the review after checking their abstracts and considering the inclusion criteria. Results: In general, due to the nature of ASD, patients and their families have many challenges in accessing and using rehabilitation services. Their essential challenges were high costs of services, insufficient insurance coverage, lack of parental involvement in healthcare, scarcity of some essential services, lack of access to specialists in ASD, no government support, long waiting times, no transportation, lack of information of parents about how to access the required services, heterogeneity of services provided in different centers, inefficiency in diagnosing and screening people with ASD, lack of rehabilitation monitoring, incoordination between autism centers, challenges related to the structure and maintenance of services, and low manpower of service providers. Conclusion: People with ASD face several challenges in accessing and using rehabilitation services. Our study results can be helpful for the effective use of rehabilitation services by these patients, improving their living conditions, and ultimately their quality of life. Recognizing these challenges can pave the way for policymakers, intervention managers, and planners to take more effective steps for providing rehabilitation services to patients with ASD as their human rights. The authorities should pay more attention to existing resources, adopt and implement the necessary programs, solve the identified challenges, and reform the administrative structures of autism rehabilitation.

Relationship of Leisure Time Activities With Fatigue and Mental Health Problems in People With Multiple Sclerosi

Objective: One of the essential aspects of life in patients with Multiple Sclerosis (MS) is leisure time activities. One of the duties of occupational therapists is the evaluation and implementation of therapeutic interventions in the field of leisure for patients with neurological disorders such as MS. However, before presenting any intervention for increasing the ability of MS patients to spend their leisure time, it is necessary to study the concept of this field scientifically and systematically and identify and evaluate the factors affecting it. Many symptoms of MS, such as fatigue and mental health problems, may affect leisure activities. This study examines the relationship of leisure time activities with fatigue and mental health problems (stress, anxiety, and depression) in MS patients. Materials & Methods: This research is a cross-sectional study. The study population consisted of all MS patients referred to Imam Khomeini Clinic, Mobasher Kashani Hospital, and MS Association in Hamadan City, Iran, in 2019. Of them, 99 (70 women, 29 men) with a Mean±SD age of 32.28±8.26 years were selected by using a convenience sampling method and based on the inclusion and exclusion criteria. For data collection, we used the MS leisure questionnaire, Fatigue Severity Scale (FSS), Visual Analog Fatigue Scale (VAFS), Expanded Disability Status Scale (EDSS), and Depression-Anxiety-Stress Scale (DASS). After obtaining written informed consent from the patients, the study questionnaires were completed by them. The collected data were analyzed in SPSS v. 16. The Spearman correlation test was used to examine the relationship of leisure time activities with fatigue and mental health problems. Results: There was a significant relationship between leisure activities and fatigue tests of VAFS (P=0.003) and FSS (P=0.001). Fatigue showed a high negative correlation with all leisure domains (r=0.350, P=0.001) of difficult, social, spiritual/religious, out-of-home physical, and art/cultural activities and reduced them. The overall score of DASS was significantly correlated with leisure time spiritual/religious activity (r= -0.263), out-of-home physical activity (r= -0.213) and art/cultural activity (r= -0.205). Regarding its subscales, anxiety showed a significant correlation only with leisure time social activities (r= -0.259), stress with spiritual/religious activities (r= -0.212), and depression with all domains of leisure time activities except for difficult activities (P≤0.005) Conclusion: Leisure time activities are associated with fatigue and mental health problems (stress, anxiety, and depression) in MS patients. Stress and anxiety only affect their leisure time social activities. Fatigue or mental health problems can reduce the amount of leisure time.

The Strategies Used by Visually Impaired and Blind People in Iran to Cope With Difficulty Performing Daily Living Activities

Objective: This study was conducted to investigate the strategies used by visually impaired and blind people in Iran to cope with difficulty performing daily living activities. Materials & Methods: This research is a qualitative study using a content analysis method. The participants were 18 visually impaired and blind people who were purposefully selected from those referred to the Visual Aid Research Center of Iran University of Medical Sciences in Tehran City, Iran. A semi-structured interview was first used using general questions about some daily living activities to discover the participants’ experiences. Attempts were made to allow participants to express their experiences independently without the help of the interviewer. The interviews were recorded as an audio file. After the interview, the audio files were transcribed and analyzed using thematic content analysis. The key sentences were extracted from the main texts, and the strategies or concepts extracted from those sentences were identified. Common strategies were put under one category. After the data saturation, when no new concept was found in the sentences, the interviews ended. By examining similar strategies in a category, subcategories were defined, and finally, similar subcategories were placed in a more general category, and the main themes or strategies were identified. Results: The Mean±SD age of the participants was 39.5±11 years, ranging from 22 to 66 years. Of 18 participants, 7 were blind, 7 had severe visual impairment, and 4 had moderate visual impairment. Their duration of blindness or visual impairment was more than five years. In terms of education, 7 had no high school diploma, and 11 had a high school diploma or higher degree. Vision loss was congenital in some subjects and acquired in others. We extracted 8 main themes or strategies used by the subjects to cope with difficulty performing daily living activities. These themes are trust in others, use of alternative senses, efficient vision care, use of technology, optimization of the living environment, avoiding a specific activity, increasing emotional intelligence, and use of intelligence and memory. Conclusion: The strategies used by the visually impaired and blind people in Iran are entirely personal and innovative and play an influential role in increasing their quality of life. According to their own statements, these strategies can solve their many problems in performing daily living activities.