Iranian Healthcare Workers Research Articles

Prevalence of needlestick injuries among health-care workers in iranian hospitals: An updated systematic review and meta-analysis

Background: Needlestick and sharp injuries have been identified as the most dangerous factor among health-care workers. The Centers for Disease Control and Prevention estimates that 385,000 health-care workers experience needlestick each year. Methods: The aim of this study was to determine the prevalence of needlestick injuries (NSIs) in Iranian health-care workers. In this review and meta-analysis, the local and international databases such as Scopus, Medline, PubMed, ScienceDirect, Web of Science, Google Scholar, Scientific Information Database (SID), and Magiran were searched using keywords including “prevalence” OR “needle” OR “needle stick” OR “Sharp injury” OR “Iranian personnel's” OR “Iranian health care workers” OR “Iranian hospitals” OR “Iran.” The original researches that determined the prevalence of NSIs among Iranian health-care workers and published from January 2005 to June 2019 were included in the current study. The pooled prevalence of NSIs was determined using a random-effects model with a 95% confidence interval. All analyses were performed using STATA version 11 (Stata Corporation, College Station, TX, USA). P

Is latent tuberculosis infection challenging in Iranian health care workers? A systematic review and meta-analysis.

The high chances of getting latent tuberculosis infection (LTBI) among health care workers (HCWs) will an enormous problem in low and upper-middle-income countries. Search strategies were done through both national and international databases include SID, Barakat knowledge network system, Irandoc, Magiran, Iranian national library, web of science, Scopus, PubMed/MEDLINE, OVID, EMBASE, the Cochrane library, and Google Scholar search engine. The Persian and the English languages were used as the filter in national and international databases, respectively. Medical Subject Headings (MeSH) terms was used to controlling comprehensive vocabulary. The search terms were conducted without time limitation till January 01, 2019. The prevalence of LTBI in Iranian's HCWs, based on the PPD test was 27.13% [CI95%: 18.64-37.7]. The highest prevalence of LTBI in Iranian's HCWs were estimated 41.4% [CI95%: 25.4-59.5] in the north, and 33.8% [CI95%: 21.1-49.3] in the west. The lowest prevalence of LTBI was evaluated 18.2% [CI95%: 3.4-58.2] in the south of Iran. The prevalence of LTBI in Iranian's HCWs who had work-experience more than 20 years old were estimated 20.49% [CI95%: 11-34.97]. In the PPD test, the prevalence of LTBI in Iranian's HCWs who had received the Bacille Calmette-Guérin (BCG) was estimated 15% [CI95%: 3.6-47.73]. While, in the QFT, the prevalence of LTBI in Iranian's HCWs in non-vaccinated was estimated 25.71% [CI95%: 13.96-42.49]. This meta-analysis shows the highest prevalence of LTBI in Iranian's HCWs in the north and the west probably due to neighboring countries like Azerbaijan and Iraq, respectively. It seems that Iranian's HCWs have not received the necessary training to prevent of TB. We also found that BCG was not able to protect Iranian's HCWs from TB infections, completely.

Factors Affecting Breast Self-examination Behavior Among Female Healthcare Workers in Iran: The Role of Social Support Theory.

ObjectivesIn women, breast cancer is the most common cancer and the leading cause of cancer death. Screening tests are the basis for early diagnosis. In Iranian women, the mortality rate of breast cancer is high due to insufficient screening examinations and delayed visits for care. Therefore, this study aimed to determine the factors affecting breast self-examinations among Iranian women employed in medical careers.MethodsThis cross-sectional study included 501 women working in the medical professions at Hamadan University of Medical Sciences in western Iran in 2018. The subjects were selected by stratified random sampling. Data were collected using a researcher-developed, self-report questionnaire that contained demographic information and questions based on protection motivation theory and social support theory. Descriptive data analysis was conducted using SPSS version 23 and model fitting with PLS version 2.ResultsThe mean age of the participants was 37.1±8.3 years, and most of the women (80.4%) were married. Most women had a bachelor’s degree (67.5%). The findings of this study showed that the coping appraisal construct was a predictor of protection motivation (β=0.380, p<0.05), and protection motivation (β=0.604, p<0.05) was a predictor of breast self-examination behavior. Additionally, social support theory (β=0.202, p<0.05) had a significant positive effect on breast self-examination behavior.ConclusionsThe frequency of practicing self-examinations among women employees in the medical sector was low; considering the influence of social support as a factor promoting screening, it is necessary to pay attention to influential people in women’s lives when designing educational interventions.

Screening of healthcare workers for latent tuberculosis infection in the low tuberculosis burden country: QuantiFERON-TB gold in tube test or tuberculin skin test?

Healthcare workers (HCWs) are an important group at increased risk for exposure to various infectious agents including Mycobacterium tuberculosis. Unfortunately, there is very limited data on the prevalence of latent tuberculosis infection (LTBI) among HCWs in Iran. The aim of this study was to analyze the prevalence of LTBI among HCW’s of Children Medical Center (CMC), an Iranian referral hospital, and to compare the feasibility of using tuberculin skin test (TST) and QuantiFERON-TB gold in tube test (QFT-GIT) to screen the LTBI among this population. Informed consent was obtained before the study questionnaire was completed. Participants were then evaluated for LTBI using QFT-GIT test followed immediately by TST. The prevalence of latent TB infection in the 101 HCWs, based on QFT-GIT positivity, was 47% (n = 47), while based on TST test a higher prevalence was observed (n = 57, 57%). Forty-five (45%) subjects were positive for both tests, whereas 14 (14%) were positive by either test. Among the TST positive cases, 21% (n = 12) were negative for QFT-GIT. The overall agreement of TST and QFT-GIT was 86% ([45 + 42]/101] and a moderate correlation between these two tests was observed (Kappa value 0.72). The use of QFT-GIT test as a second step in TST-positive cases offers an appropriate tool for LTBI detection in our country where all HCWs are BCG-vaccinated. To enable the effective control and prevention of TB in healthcare settings in Iran, specific and detailed guidelines for dealing with LTBI are highly required. All newly hired HCWs should receive baseline testing for LTBI before commencing employment. In addition, HCWs who work in high-risk departments should receive regular follow-up screening for LTBI.

Factors Affecting Income Inequity Among Healthcare Workers in Iran: A Commentary

Factors Affecting Income Inequity Among Healthcare Workers in Iran: A Commentary

Frequency of metabolic syndrome and its associated factors in health care workers

BackgroundIn recent decades, metabolic syndrome is one of the most important public health risk factors. Having this in mind, the present study was conducted to evaluate the frequency of metabolic syndrome and its associated risk factors in healthcare workers. MethodThis study is a cross-sectional study conducted on 410 healthcare workers in a teaching hospital in Iran. Demographic, occupational, and psychosocial characteristics were assessed using questionnaire. Assessment of metabolic syndrome of hospital staff was performed at workplace during their medical examination. ResultsThe frequency of metabolic syndrome was found to be 22.4%. This relationship was found among blood pressure and occupational stress, despite the fact that there was no significant relationship between metabolic syndrome and occupational stress. Higher age, having shift work, and inactivity were associated with metabolic syndrome. ConclusionConsidering the high frequency of metabolic syndrome among Iranian healthcare workers, it is advised that effective management should be employed to correct the occupational and psychosocial factors associated with this syndrome.

Psychometric Properties of Persian Version of the Short-Form Workplace Social Capital Questionnaire for Female Health Workers.

Background: The workplace social capital is one of the important features of clinical work environment that improves the productivity and quality of services and safety through trust and social participation. Evaluation of workplace social capital requires a valid and reliable scale. The short-form workplace social capital questionnaire developed by Kouvonen has long been used to evaluate the workplace social capital. Objective: To evaluate the psychometric properties of the Persian version of the questionnaire among a group of female Iranian health care workers. Methods: The Persian version of the short-form questionnaire of workplace social capital was finalized after translation and back-translation. 500 female health care workers completed the questionnaire. Then, the content validity and the construct validity of the questionnaire were assessed. The reliability of the questionnaire was assessed by Cronbach's α, θ, and McDonald's Ω. The construct reliability and ICC were also evaluated. Results: Based on the maximum likelihood exploratory factor analysis (n=250) and confirmatory factor analysis (n=250), two factors were identified. The factors could explain 65% of the total variance observed. The model had an acceptable fit: GFI=0.953, CFI=0.973, IFI=0.974, NFI=0.953, PNFI=0.522, RAMSEA=0.090, CMIN/DF=2.751, RMR=0.042. Convergent and divergent validity as well as internal consistency and construct reliability of the questionnaire were confirmed. Conclusion: The Persian version of Kouvonen workplace social capital has acceptable validity and reliability. The questionnaire can thus be used in future studies to assess the workplace social capital in Iranian health care workers.

Common Causes Associated With Occupational Injuries in Iranian Health Care Workers: A Systematic Review and Meta-Analysis Study

Introduction: Occupational injuries are the most important hazards threatening health care workers (HCWs) and cause contact with infectious agents and the transmission of diseases such as AIDS and hepatitis B and C. This study is a meta-analysis of studies on the common causes of occupational injuries in Iran. Methods: In this meta-analysis, all articles on injuries to HCWs in Iran published on local and international databases during the period 2000-2016 were assessed for eligibility. Using the keywords occupational injury, needle stick injury, healthcare workers, and Iran, searches of local and international databases were conducted. From 60 articles screened, 19 were determined to be relevant and were subsequently analyzed. Results: The results of this meta-analysis showed that needles and injections were the most common causes of occupational injuries in HCWs. The pooled prevalence of needle stick was estimated to be 52.95% (46.05%-59.84%) based on the reports of 19 studies with a total of 8703 participants. The pooled prevalence rate of injections was estimated to be 33.56% (27.43%-37.90%). Conclusion: The results showed that routine activities of HCWs most commonly result in occupational injuries. Given the high prevalence of needles and injections as causes of occupational injuries in Iranian HCWs, more attention and the development of effective strategies to reduce these injuries are necessary.

Qualitative Fit Testing of Medium - Size N95/FFP2 Respirators on Iranian Health Care Workers

Background: How tight fitting respirators fit on the users face is an important factor in their effectiveness. Objectives: The aim of this study was to investigate the qualitative fitting of N95/FFP2 respirators among Health Care Workers (HCWs) in six educational hospitals affiliated to Shiraz University of Medical Sciences, Shiraz, Iran. Methods: This cross - sectional study was carried out on 284 HCWs. They were using medium size respirators of flat - fold FFP2 (3M - model; 8222 and SPC - model; 8226) and cup - shaped N95 respirators (3M - model; 8210). At first, a medical evaluation questionnaire was completed by all employees. Qualitative fit testing was performed by JSP kit (Oxford, England). Critical face anthropometric dimensions in fitting of respirators were measured using sliding caliper. All data analysis was performed with SPSS version 21 and STATA 13. Results: In this study, only 10.6% of the participants passed the qualitative fit test. Cup - shaped respirators had better fitting compared to flat - fold respirators. A total of 10.2% of the individuals who were using N95 respirators were not medically competent to wear a respirator. Most individuals who passed the fit test were placed in the medium cell (10%) of fit testing NIOSH Bivariate panel. Conclusions: Studied medium size of N95/FFP2 respirators could not provide proper fitting on the face of Iranian HCWs. More studies with different sizes and models of available respirators in the Iran market is required to find the most appropriate respirators to provide proper fit on Iranian HCWs.

The Prevalence of Needlestick Injuries and Exposure to Blood and Body Fluids Among Iranian Healthcare Workers: A Systematic Review

Introduction: This study aimed to systematically review previous studies conducted in Iran on the prevalence of injuries caused by needlestick, sharp, and cutting instruments and exposure to blood and body fluids. Methods: In this systematic review, all published full-text articles authored by Iranian researchers in Farsi or English in the field of needlestick injuries among healthcare workers during the period 2001-2016 were examined. Searches were performed on Iranian databases such as Scientific Information Database (SID), Iran Magazine Information Bank (Mag Iran), Iranian Journals of Nursing (N Index), and Directory of Medical Sciences Articles (Iran Medex) as well as international databases including Google Scholar, ISI Web of Knowledge, Scopus, PubMed, Science Direct, and CINAHL. Results: The prevalence of injuries caused by needles ranged from 10.0% to 84.29% in different studies. The prevalence of exposure to blood and body fluids ranged from 13.46% to 79%. Conclusions: The results indicated that almost half of Iranian healthcare workers during their daily work are at the risk of needlestick injury and exposure to blood and body fluids. Hence, research and needlestick injury reduction strategies should be emphasized, and modifications should be made to organizational factors such as the development of educational programs, prevention along with performance monitoring, engineering factors such as redesigning tools to promote safety, and behavioral factors such as behavior modification of capping needles.

The First Digital Immunization Registry for Healthcare Workers in Iran

The First Digital Immunization Registry for Healthcare Workers in Iran

Effective factors on not using the N95 respirators among health care workers: Application of Fuzzy Delphi and Fuzzy Analytic Hierarchy Process (FAHP).

Using respiratory protective equipment (RPE) including N95 respirators is one of the most important ways to protect health care workers (HCWs) against respiratory hazards. The aim of this study was to identify and prioritize the problems and obstacles in using N95 respirators among HCWs in Iran. In this cross-sectional study, problems and obstacles in using N95 respirators were identified and ranked by experts, using Fuzzy Delphi and Fuzzy Analytic Hierarchy Process (FAHP). Additionally, HCWs were asked to give their opinions about obstacles in using N95 respirators in order to form an opinion. Of 15 important obstacles in using N95 respirators identified by Fuzzy Delphi method, 6 factors were entered into the FAHP model: heat around the face, inaccessibility to respirator, difficulty breathing, pressure on the nose, trouble communicating with patients and colleagues, and no one does it. Identified problems and obstacles in using N95 respirators could be controlled during the selection of respirators, as well as by training and administrative measures.

Nasal carriage rate of methicillin resistant Staphylococcus aureus among Iranian healthcare workers: a systematic review and meta-analysis.

Globally, methicillin-resistant Staphylococcus aureus (MRSA) remains a major cause of healthcare-associated infections. Healthcare workers (HCWs), patients and the environment may act as reservoirs for the spread of MRSA to patients and other HCWs. Screening and eradication of MRSA colonization is an effective method of reducing the MRSA infection rate. There are limited data on the prevalence of MRSA among Iranian HCWs. We performed a systematic search by using different electronic databases including Medline (via PubMed), Embase, Web of Science, and Iranian Databases (from January 2000 to July 2016). Meta-analysis was performed using the Comprehensive Meta-Analysis (Biostat V2.2) software. The meta-analyses showed that the prevalence of S. aureus and MRSA among HCWs were 22.7% [95% confidence interval (CI): 19.3-26.6] and 32.8% (95% CI: 26.0-40.4) respectively. The high rate of nasal MRSA carriage among Iranian HCWs has been attributed to poor compliance to hand hygiene, injudicious use of antibiotics, and ineffective infection control and prevention measures. The rational use of antibiotics plus strict infection control are the main pillars for controlling multidrug resistant microorganisms such as MRSA in the hospital setting. These measurements should be applied nationally.

Immune response to hepatitis B vaccine among north Iranian healthcare workers and its related factors.

Hepatitis B virus (HBV) is an important occupational risk among healthcare workers (HCWs). Vaccination is the most cost-effective method of preventing and controlling HBV infection. Several factors have been suggested to effect response to the vaccine. The present study aimed to evaluate vaccine response among north Iranian HCWs and to determine the factors influencing vaccine response. Response to the standard three-dose vaccination regimen was evaluated in term of anti-hepatitis B surface antigen level among 1,010 HCWs using an enzyme-linked immunosorbent assay (ELISA) method. Logistic regression was applied to predict antibody response, with related factors including sex, age, years of working experience, marital status, history of transfusion, smoking, history of needle stick injury, rheumatic disease, steroid use, and elapsed time from vaccination measurement. Of the 1,010 HCWs, 898 (88.9%) acquired protective levels of antibody (> 10 IU/mL). Compared with those < 30 years of age, HCWs older than 50 years and between 40 and 50 years of age were more likely to have non-protective anti-HBs levels (odds ratio = 4.48; p = 0.001 and odds ratio = 1.85; p = 0.03, respectively). HBV vaccine efficacy and immune response were satisfactory among north Iranian HCWs. Since it is predicted that anti-HBs levels decrease with aging, testing for anti-HBs titer is desirable for HCWs older than 50 years of age.

Hepatitis B Vaccination Efficacy in Iranian Healthcare Workers: A Meta-Analysis Study

Context: Despite various studies, there is no overall estimation about the efficacy of Hepatitis B virus (HBV) vaccine among healthcare workers (including healthcare personnel and healthcare students). The present meta-analysis study was conducted to investigate the efficacy of HBV vaccine in healthcare workers in Iran. Evidence Acquisition: This study was performed according to the PRISMA guidelines for systematic review and meta-analysis studies. A comprehensive search was conducted using national and international databases including: Magiran, Iranmedex, IranDoc, SID, Medlib, Scopus, Pubmed, Science Direct, Cochrane, Embase, Web of Science, Springer, wiley online library, Trials Register, DOAJ, and Google Scholar search engine without time limit up to 2016. Just papers which were qualified according to inclusion criteria were examined. The data were analyzed using meta-analysis method in STATA software Ver.11.1. Results: 1726 healthcare workers had been examined in 12 studies. The efficacy of HBV vaccine, 1 - 6 months after the injection of the third dose was determined to be 93.1% (95% CI: 90.3 - 97); this rate was 95.9% (95% CI: 93.1 - 98.6) for male and 91.3% (95% CI: 87.1% - 95.5%) for female participants. HBV vaccine efficacy was 90.9% (95% CI: 86.5-95.3) for 8 studies conducted on healthcare personnel and 97.3% (95% CI: 94.7-97.7) for 3 studies on healthcare students. Conclusions: Immunogenicity of HBV vaccine was 90 - 97 in healthcare workers. Hence, the complete course of vaccination is sufficient for prevention of HBV and there is no need for booster dose or dose re-administration.

Radiation Protection Knowledge, Attitude and Practice (RP-KAP) as Predictors of Job Stress Among Radiation Workers in Tehran Province, Iran.

BackgroundIn recent years, much attention has been paid to occupational stress, but relatively little or no research has been conducted on the influence of knowledge, attitude, and practice of radiation protection (RP-KAP) on job stress among radiation workersObjectivesThis study aims to assess job stress among health care workers in Iran who are occupationally exposed to radiation in order to determine the effects of KAP on self-protection against radiation on their job stress.Materials and MethodsThe population in this descriptive cross-sectional study comprised 670 healthcare workers, including 428 staff with a degree in radiology and 242 other medical personnel who were working in 16 hospitals affiliated with Tehran University of Medical Sciences (TUMS) in Tehran, Iran. The census method was used to sample the workers. In total, 264 staff with a degree in radiology and 149 other medical personnel completed the job content questionnaire (JCQ) and the RP-KAP questionnaire from May to November 2014.ResultsThe prevalence rate of job stress was 22.5% based on calculation formulas and possible scores on the JCQ. Sex, RP-knowledge, attitude, practice, and in-service training predicted 41.8% of the variance in job stress. According to the results of the binary logistic regression, workers with higher scores on knowledge (OR = 0.82, 95% CI: 0.75 - 0.90), attitude (OR = 0.71, 95% CI: 0.63 - 0.82), and practice (OR = 0.78, 95% CI: 0.72 - 0.86) and those who had participated in training programs had significantly lower rates of job stress (OR = 0.51, 95% CI: 0.28 - 0.93).ConclusionsThe effects of RP knowledge, attitude, and practice on job stress were significant. In order to reduce job stress in radiation environments, ongoing training programs related to self-care and protection principles are recommended.

Nurse Harassment: A Forgotten Issue.

Dear Editor, In the clinical setting of nursing, nurses play a specific role. Most nurses are female and as a part of their duty, perform hard work and face stressful situations, problems, and risks. An important problem worth mentioning is the harassment of nurses, an expected problem as most nurses are female. However, unfortunately, this has become a forgotten issue. In developing countries such as Thailand, newspapers often report cases of nurse harassment. Many of these are cases of serious harassment and even murder (for example, the famous Nuanchawee case of nurse harassment and murder in Thailand, which is documented at Mahidol University, medical museum in Bangkok, Thailand). Nevertheless, there are only a few scientific reports on this issue. Fute et al. recently reported a prevalence of as high as 13.02% of sexual harassment of nurses in Ethiopia (1). In another report from Malaysia, Suhaila and Rampal stated that, “the prevalence of sexual harassment among registered nurses in the workplace was high and self-perception profile of the victims of sexual harassment was the main contributing factor to the problem” (2). Fallahi Khoshknab et al. have also reported a high prevalence of violence against Iranian healthcare workers, including nurses (3). Noteworthy is the fact that although several guidelines are available for working in a clinical settings, there is scarcity of specific instructions pertaining to the protection of the workforce (4). To be specific, there is no clear protocol for prevention of sexual harassment of nurses, an important issue for the nursing society to combat! To address this problem, the author suggests the following solutions: (a) a good security system in hospitals, such as closed circuit television, must be established; (b) nurses should be trained on self-protection against any harassment; (c) an instruction should be enforced that forbids the traveling of nurses on duty to a secluded place, especially at night; and (d) legal control and penalty for cases of harassment must be strengthened.

Hepatitis A Virus Infection, Vaccination and Iranian Healthcare Workers.

Context:Hepatitis A virus (HAV) infection is an important public health problem. It is estimated that about 1.4 million cases of HAV infection occur every year worldwide. Non-immune healthcare workers (HCWs) can be at higher risk of HAV infection in comparison to general population and an appropriate preventive method should be considered for them.Evidence Acquisition:For finding related articles, a comprehensive search was performed in Scopus, PubMed and Google Scholar and all appropriate combinations of following keywords were considered; “healthcare provider”, “healthcare personnel”, “healthcare worker”, “nurse” “medical students”, “Iran”, “Hepatitis A” and “vaccination”. Also we did a search in Persian language in Google scholar and scientific information database (SID) to find related Persian literature.Results:A gradual shift in age of HAV infection has been seen from childhood toward adulthood. Data about HAV seropositivity among Iranian HCWs are very limited. However based on the recent studies, it seems that HAV seropositivity has been reduced among HCWs in comparison with the past. All recent studies have suggested HAV vaccination for HCWs.Conclusions:Available limited studies show that Iranian healthcare personnel need HAV vaccination. However, for selecting an appropriate preventive method for this high risk group, more original studies are still needed.

Lack of optimum practice among health care workers regarding tuberculosis in Iran: A knowledge, attitude, and practice study

Lack of knowledge toward tuberculosis (TB) among health care workers (HCWs) increases the risk of developing TB. The aim of this study was to assess the level of knowledge, attitude, and practice of HCWs in Iran. We conducted a cross-sectional study in 50 universities of medical sciences throughout Iran. A questionnaire was developed to assess the knowledge, attitude, and practice of participants. The values of Cronbach α coefficients for the knowledge and attitude questions were .76 and .75, respectively. The mean scores of knowledge, attitude, and practice among TB laboratory staff regarding TB was 82.6 (95% confidence interval [CI], 82.0-83.7), 87.6 (95% CI, 87.1-88.0), and 57.9 (95% CI, 56.9-58.9), respectively. The mean scores of knowledge, attitude, and practice among non-TB laboratory staff regarding TB was 69.5 (95% CI, 67.9-71.1), 50.7 (95% CI, 50.1-51.4), and 40.82 (95% CI, 38.2-43.4), respectively. TB laboratory staff scored relatively well in knowledge and attitude of TB, but they scored lower in practice regarding TB. Non-TB laboratory staff had lower scores than TB laboratory staff in knowledge, attitude, and practice. There is a major gap between knowledge and attitude and practice in both groups. It is therefore essential to plan for the continuing in-service training of HCWs and public training of the general population regarding TB.

Iranian healthcare workers' perspective on hand hygiene: a qualitative study.

Hand hygiene (HH) has been identified as one of the simplest, but most important, methods to prevent cross-infection in healthcare facilities. In spite of this fact, the HH compliance rate remains low among healthcare workers (HCWs). Several factors may affect HH behavior. In this study, we aimed to assess various aspects of HH from the perspective of HCWs. This qualitative study was conducted in two hospital settings in Shiraz, Iran. Eight focus group discussions (FGDs) and six in-depth interview sessions were held with ICU and surgical ward nurses, attending physicians, medical and nursing students and supporting staff. Each FGD and interview was transcribed verbatim, open codes were extracted, and thematic analysis was conducted. Three themes emerged from the thematic analysis including: "the relationship between personal factors and HH compliance," "the relationship between environmental factors and HH compliance" and "the impact of the health system on HH adherence, including the role of adequate health systems, administrative obligations and the effect of surveillance systems." Several factors played a significant role in improving HCWs HH compliance, such as the regular adherence to health system tenets. HH compliance may be improved through application of realistic policies and better supervision. In addition, appropriate education may positively affect HH behavior and attitudes.