erbil j. nurs. midwifery, vol. 2, no. (2),nov, 2019 the year of the nurse and midwife: an effort worth joining? eva said; msc degree of adult nursing, chief at nursing and midwifery development centre, erbil, iraq. evasaid1@gmail.com 84 the world health organization has designated the year 2020 as the year of the nurse and midwife in tribute to florence nightingale who was born 200 years ago. the decision to dedicate a whole year to nursing and midwifery has not been made only to remember and celebrate the founder of modern nursing. it was made to recognize the importance of these caring professions for global health and the health care systems and for society as a whole. there is no doubt that nurses and midwives worldwide will embrace the year of the nurse and midwife and will use it to reflect on the past, present and future of their work, think about the challenges they have faced and the achievements they have accomplished. there will be events to remind ourselves and others why we have become nurses and midwives and to contemplate on how we can advance our professions for the health and wellbeing of the people. what does the year of the nurse and midwife mean for nurses and midwives in the kurdistan region? it provides an opportunity, a possibility to move away from the status of stagnation and raise to the challenge of finally reforming the system of nursing and midwifery and establishing them as legitimate professions with the vital role to play in the improvement of the health care system in the region. it can not be denied that over the last decade there has been some progress despite the country facing political, economic and social difficulties. we have seen that nurses and midwives have resilience and determination to cope with challenging times and that there are many who look to the future and work hard to improve the current situation. however, more is needed. nursing and midwifery services in the kurdistan region have been based on routine functioning for years and attempts for change have been largely unsuccessful. why? there is a myriad of reasons ranging from the legislative and regulatory vacuum and outdated governance structure, lack of leadership and unity within the professions themselves, to the difficulties with organizational effectiveness and professional competence of individual nurses and midwives. the year of the nurse and midwife provides us with the perfect opportunity to thoroughly and formally assess where we are now and seriously consider where we want to be and how to get there. we should not forget that we are not alone. there is a global community of nurses and midwives whose experience and support is invaluable for our own development. all we have to do is look, listen, learn, create, and apply within our own context, frame our efforts into a powerful message, find our voice, and ways for that voice to be heard. isn’t it an effort worth joining? erbil journal of nursing & midwifery “nurses are the “bridge” of healthcare in january of 2019, the world health organization (who) had a meeting where the director– general of the w.h.o., dr. tedros adhanom ghebreyesus, made the official proposal to declare 2020 the year of the nurse and the midwife. editorial mailto:evasaid1@gmail.com https://doi.org/10.15218/ejnm.2018.13 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article maternal vitamin d3 status and association with low birth weight infant abstract introduction vitamin d affects fetal growth by its interaction with ca2+ homeostasis and parathyroid hormone. few studies have been conducted to detect vitamin d status in mothers in iran. in recent study, nearly half of our mothers had vitamin d deficiency. low vitamin d and osteomalacia in south asian pregnant women have been widely reported [1,2]. some investigations have pointed to the effect of micronutrients on birth weight [3]. vitamin d stressing has a key role in fetal growth by its interaction with parathyroid hormone and calcium homeostasis. studies have confirmed that insufficient prenatal levels of vitamin d has a strong effect on poor bone mineralization, which has a significant association with small-for-gestationalage births [4]. low birth weight (lbw) refers to background and objective: maternal vitamin d levels may affect fetal growth and cause adverse pregnancy outcomes including low birth weight in neonatal stage. this study was designed to evaluate and determine if the deficiency of maternal vitamin d associated and affected the growth development of birth weight of neonates. methods: this study was carried-out on 200 neonates through a cross-sectional study, that used data from the nursery ward at maternity teaching hospital hospitals in kurdistan, iraq during a one year period from march 2016 to march 2017. the neonates were divided into two group two groups, neonates with birth weight< 2500 gr (n=45) and neonates with birth weight>2500 gr (n = 55). we depend on the data classifications on medical history, physical examination using a questionnaire method for neonate classifications. birth time blood samples of their mothers were analyzed for serum 25-(oh)-vitamin d using enzyme linked immunosorbent assay method. maternal vitamin d status was compared in the two groups. results: the mean maternal vitamin d level was 24 nmol/l. for mothers with low birth weight and 22 (48.89 %) for mothers with vitamin d deficiency. seventeen (37.77 %) and 6 (13.34 %) of the mothers with low birth weight had insufficient vitamin d and 6 (13.34 %) had normal vitamin d levels. the mothers with normal birth weight had a mean vitamin d level of 38.10 nmol/l and the mothers of low levels reached to 10 nmol/l (18.18 %), those of insufficiency vitamin d was 20 nmol/l (36.36 %) and those of sufficient vitamin d 25 nmol/l (45.46 %). conclusion: mothers with low vitamin d levels are more likely to have neonates with low birth weight. increasing the vitamin d levels through nutrition is important for improving the neonatal body weight. keywords: infant, low birth weight, vitamin d deficiency raghad farhad ahmed; maternity teaching hospital/ erbil directorate of health/ ministry of health, erbil, iraq. (correspondence: blackpears2001@yahoo.com) hanaa al.ani; department of nursing, college of nursing, hawler medical university, erbil, iraq. 101 erbil journal of nursing & midwifery received: 1/8/2018 accepted: 17/9/2018 published: 3011/2018 mailto:blackpears2001@yahoo.com https://doi.org/10.15218/ejnm.2018.13 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article term or preterm neonates with birth weight < 2500 gr. these neonates may be small for gestational age or have intrauterine growth restriction. mortality rate in such neonates is 40 times more than those with normal weight [3]. vitamin d deficiency has been seen among people all over the world [5]. the aim of this study was to evaluate the relationship between maternal vitamin d status and neonate birth weight because research suggest that low serum maternal vitamin d may impair fetal growth and cause adverse pregnancy outcomes including intrauterine growth restriction and neonatal low birth weight. two-hundred mothers participated in this cross-sectional study. data were collected from the labor ward of maternity teaching hospitals in kurdistan, iraq from march 2016 to march 2017. we took a blood sample after delivery and sent it to a private laboratory. the neonates were divided into two groups, neonates with birth weight < 2500 gr (n=45) and neonates with birth weight >2500 gr (n = 55), depending on the data classifications including from medical history, physical examination, and anthropometric measurements of neonates using a questionnaire method for neonates classifications. birth time blood samples of their mothers were analyzed for serum 25-(oh)-vitamin d and maternal vitamin d status was compared in studied groups. the inclusion criteria include otherwise healthy women aged 21 to 35 years, having a singleton pregnancy and a term pregnancy. the exclusion criteria included mothers with preeclampsia, eclampsia, postpartum hemorrhage, insulin dependent diabetes mellitus, systemic and chronic disease, hematologic disorders, infections. questionnaires filled out and recorded neonatal birth weight and height, gestational age, mode of delivery, mother’s age, parity, race, mother’s education and clinical vitamin d deficiency symptoms. immediately after birth, 5 ml of mother’s blood was collected, labeled and sent to laboratory to assay serum 25(oh)-vit d level by 25-hydroxy vitamin d enzyme immunoassay method. depending on mothers’ 25(oh)-vitamin d level, all mothers were categorized in deficient (< 25 nmol/l), insufficient (should be defined at thresholds of 75 nmol/l or even higher which would require a much higher intake to reach.)[6,7]. (25-50 nmol/ l), normal (> 50nmol/l). statistical analysis of the data was carried-out using spsspc+ version 16. data are presented as mean and standard deviation for continuous variables and n% for categorical variables. the chi square, t test, chi-square test and logistic regression were applied where applicable at the level of significance (p < 0.05). the mean ±sd of maternal serum vitamin d level in all 200 mothers was 33.26 ± 2.65 nmol/l, mean ± sd of age was 23.32± 3.61 years, and mean ± sd gestational age in weeks was 38.11± 17.38. other demographic characteristics are shown in table 1. methods 102 erbil journal of nursing & midwifery results table 1: demographic characteristics of the study sample demographic characteristics mean ± sd gestational age/ week 38.11± 17.38 maternal age/year 23.32± 3.61 birth weight/gm 2645.2± 35.39 neonatal height (cm) 46.08± 4.31 head-circumference (cm) 33.51±3.39 maternal serum vitamin d nmol/l 33.26 ± 2.65 https://doi.org/10.15218/ejnm.2018.13 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article there was a significant difference, with 70% of the mothers with sufficient level of vitamin d giving birth to neonates with birth weight ≥ 2500 gm and 50% of mothers with deficient vitamin d giving birth to neonates with low birth weight. in table 4, there was no significant difference in the mode of delivery with maternal vit.d level (p= 0.3220). table 2 shows the differences of serum vitamin d levels among mothers with normal birth weight neonates (39.14±3.15) and mothers of lbw neonates (27.38±2.15), (p < 0.01). table 3 shows the vitamin d serum level in mothers with lbw & normal birth weight neonates. * (p < 0.01) * (p < 0.01) *(p = 0.3220) 103 erbil journal of nursing & midwifery table 2: maternal vitamin d level in both study groups groups vit d serum level mothers with neonate ≥ 2500 gm 39.14±3.15 mothers with neonate ≤ 2500 gm 27.38±2.15 table 3: level of vitamin d and relationship with neonatal birth weight sufficiency n (%) insufficiency n(%) deficiency n (%) mothers of normal birth weight neonate 70 (70 ) 20 (20 ) 10 (10 ) mothers of lbw neonate 15 (15 %) 35 (35 %) 50 (50) table 4: relationship of vit d and mode of delivery mode of delivery hypovitaminosis d normal vit.d level n % n % cesarean section 45 46.4 52 53.6 normal vaginal delivery 55 53.4 48 46.6 https://doi.org/10.15218/ejnm.2018.13 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article 36 erbil journal of nursing & midwifery the results from this study are comparable to both national and international studies reporting on the high prevalence of vitamin d deficiency in pregnant women. vitamin d has well-defined classical functions related to calcium metabolism and bone health, as well as non-classical effects that may influence other aspects of health. there has been considerable recent interest in the role of vitamin d on outcomes related to pregnancy and young child health, but few efforts have been made to systematically consolidate this evidence to inform the research and policy agenda for low-income countries [8]. vitamin d affects fetal growth by its interaction with ca2+ homeostasis and parathyroid hormone. few studies have been conducted to detect vitamin d status in mothers in iran. in recent study, nearly half of our mothers had vitamin d deficiency. hypovitaminosis d and osteomalacia in south asian pregnant women have been widely reported, too [1,2]. our results suggested that there is a significant correlation between lbw and maternal vitamin d deficiency. our results agree with findings from bodnar et al. (2010), which found positive relationship between vitamin d deficiency in white mothers and neonatal lbw and a significant correlation between lbw and maternal vitamin d deficiency [9,10]. they showed a positive relationship between vitamin d deficiency in white mothers and neonatal lbw. another study from the ali aghar hospital of the iran university of medical sciences, tehran, iran also showed that maternal vitamin d deficiency may increase the risk of low birth weight neonate and that adding supplements of vitamin d could be beneficial on pregnancy outcomes. safety of vitamin d supplements and fortification have been proved by discussion some articles. mothers using vitamin d supplementation (400-4000 iu/day) in 1216 weeks showed lower preterm risks [11]. while, those of vit d deficient mothers (25 hydroxy vit d < 30) have two-times the chance of giving birth small for gestational age (sga) babies in compare to those with adequate vitamin d status [12]. the world health organization (who) has shown the importance of micronutrients including vitamin d, in increasing about 77 gr birth weights and 25% decrease of lbw [3]. this recommendation was contentious as many researchers have argued that insufficiency should be defined at thresholds of 75 nmol/l or even higher, which would require a much higher intake [6,7]. several recent reviews have covered a rapidly growing body of literature on vitamin d during pregnancy [14],, although few have taken a systematic approach (18) and only a couple have focused on the implications for low income country settings [13]. this recommendation was based on the amount of intake necessary to sustain blood levels of 25(oh)d above 50nmol/l for populations with minimal sunlight exposure and was developed solely based on outcomes related to skeletal health [7]. this recommendation was contentious as many researchers have argued that insufficiency should be defined at thresholds of 75 nmol/l or even higher which would require a much higher intake to reach [6,7]. although a significant difference was found between the mode of delivery and mother’s vit d status, our finding was against investigation from dror et al [14]. our results indicated that the high prevalence of vitamin d deficiency has been seen among women especially in developing countries and that neonatal low birth weight (lbw) could be related to conclusions 104 https://doi.org/10.15218/ejnm.2018.13 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article maternal vitamin d deficiency. modifying maternal nutrition behavior and vitamin d level could be beneficial on prevention of low birth weight. however, more research in this field would contribute to an improvement in maternal and neonatal health. conflict of interest the author report no conflict of interest [1] sioen i, mouratidou t, kaufman jm, bammann k, michels n, pigeot i, et al. determinants of vitamin d status in young children: results from the belgian arm of the idefics (identification and prevention of dietaryand lifestyleinduced health effects in children and infants) study. public health nutrition. 2012;15:1093–9. [2] patel m, beg m, akhtar n, ahmad j, farooqui kh. serum calcium, vitamin d and parathyroid hormone relationship among diabetic and nondiabetic pregnant women and their neonates. diabetes & metabolic syndrome: clinical research & reviews. 2010;4:204–9. [3] thorne-lyman a, fawzi w. vitamin d during pregnancy and maternal, neonatal and infant health outcomes:a systematic review and meta-analysis. pediatric and perinatal epidemiology. 2012;26:75–90. [4] bodnar l m, catov j m, zmuda j m, cooper m e, parrott ms, roberts j m, et al. maternal serum 25-hydroxyvitamin d concentrations are associated with small-for-gestational age births in white women. journal nutrition. 2010; 140:999–1006. [5] fernández-alonso am, dionis-sánchez ec, chedraui p, gonzález-salmerón md, pérez-lópez fr. women's health research group. spanish vitamin d and women's health research group.firsttrimester maternal serum 25hydroxyvitamin d-status and pregnancy outcome. international journal of gynaecology and obstetrics. 2012;116:6– 9. [6] leffelaar er, vrijkotte tg, van eijsden m. maternal early pregnancy vitamin d status in relation to fetal and neonatal growth: results of the multi-ethnic amsterdam born children and their development cohort. british journal nutrition. 2010;104:108–17. [7] dror d, king j, durand d, allen l. association of modifiable and nonmodifiable factors with vitamin d status in pregnant women and neonates in oakland. journal of the academy of nutrition and dietetics. 2011; (111):111–6. [8] bodnar lm, simhan hn, powers rw, frank mp, cooperstein e, roberts jm. high prevalence of vitamin d insufficiency in black and white pregnant women residing in the northern united states and their neonates. journal nutrition. 2007;137(2):447–52. [9] merewood a, mehta sd, chen tc, bauchner h, holick mf. association between vitamin d deficiency and primary cesarean section. journal of clinical endocrinology and metabolism. 2009; 94(3):940–945. [10] martin rj, fanaroff aa, walsh mc. (2005): fanaroff and martin's neonatal-perinatal medicine: diseases of the fetus and infant. 8th ed. mosby; 2005. [11] thorne-lyman a, fawzi ww. vitamin d during pregnancy and maternal, neonatal and infant health outcomes: a systematic review and meta-analysis. 105 erbil journal of nursing & midwifery refrences https://www.ncbi.nlm.nih.gov/pubmed/?term=thorne-lyman%20a%5bauthor%5d&cauthor=true&cauthor_uid=22742603 https://www.ncbi.nlm.nih.gov/pubmed/?term=fawzi%20ww%5bauthor%5d&cauthor=true&cauthor_uid=22742603 https://doi.org/10.15218/ejnm.2018.13 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article paediatric and perinatal epidemiology. 2012 jul;26 suppl 1:75-90. [12] arabi a, el rassi r, el-hajj fuleihan g. hypovitaminosis d in developing countries-prevalence, risk factors and outcomes. nature reviews endocrinology. 2010;6(10):550–561. [13] barrera d, avila e, hernandez g, halhali a, biruete b, larrea f, et al. estradiol and progesterone synthesis in human placenta is stimulated by calcitriol. journal of steroid biochemistry and molecular biology. 2007;103(35):529–532. [14] hollis bw. vitamin d requirement during pregnancy and lactation. journal of bone and mineral research. 2007;22 (suppl 2):v39–44. [15] holick mf. vitamin d deficiency. new england journal of medicine.2007; 357:266–281. [16] patel m, beg m, akhtar n, ahmad j, farooqui kh. serum calcium, vitamin d and parathyroid hormone relationship among diabetic and nondiabetic pregnant women and their neonates. diabetes & metabolic syndrome.clinical research & reviews. 2010;4:204–9. [17] institute of medicine. (2011): dietary reference intakes for calcium and vitamin d. washington, dc: the national academies press. [18] mahomed k, gulmezoglu am. vitamin d supplementation in pregnancy. cochrane database of systematic reviews. 2000 ;(2):cd000228. [19] dawodu a, wagner cl. mother-child vitamin d deficiency: an international perspective. archives of disease in childhood. 2007; 92(9):737–740. [20] aghajafari f, nagulesapillai t, ronksley pe, tough sc, o'beirne m, rabi dm. association between maternal serum 25-hydroxyvitamin d level and pregnancy and neonatal outcomes: systematic review and meta-analysis of observational studies. british medical journal. 2013;346:f1169. doi: 10.1136/bmj.f1169. [21] scholl to, chen x. vitamin d intake during pregnancy: association with maternal characteristics and infant birth weight. early human development. 2009;85(4):231–4. 106 erbil journal of nursing & midwifery https://www.ncbi.nlm.nih.gov/pubmed/22742603 https://www.ncbi.nlm.nih.gov/pubmed/22742603 https://doi.org/10.15218/ejnm.2020.09 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article quality of pre-cardiac catheterization nursing care at the surgical specialty hospital cardiac center in erbil city abstract introduction coronary heart disease is the single leading cause of death worldwide. according to the world health organization (who), 16.7 million people worldwide die of cardiovascular diseases (cvd) each year. by 2020, the who estimates 25 million cvd deaths globally [1].cardiac catheterization is one of the most common invasive procedures. it is a test that produces detailed pictures of the heart. cardiac catheterization is considered the gold standard for the diagnosis, evaluation and treatment of cardiac diseases [2].according to the statistical data from the cardiac center in erbil the number of cardiac catheterizations has doubled from 2008 to 2015 (1521, 3750 respectively) [3]. over an 8,000 million cardiac cath procedures are performed annually in the united states, and it has established itself as the most common hospital procedure in senior americans over the age of 65 years [4].in western counties it is used approximately six thousand procedures per one million inhabitants, per year [5].although the cardiac catheterization has reduced morbidity and mortality for cardiovascular disease, this invasive procedure is not free background and objectives: cardiac catheterization is an invasive procedure, also is a diagnostic and therapeutic procedure of the heart and blood vessel. a major role of nurses is to provide care to the patients before procedure. the aim of the study is to assess the quality of nursing care for patients undergoing cardiac catheterization in cardiac center in erbil city. methods: this descriptive study was conducted on all nurses who perform pre cardiac catheterization nursing care in the surgical specialty hospital cardiac centre in erbil city. a questionnaire and checklist was designed for the purpose of the study. data were collected through the part one interview with nurses and part two was checklist observation of nursing care. frequency and kendall test was used for data analysis. result: the mean ± sd of age was 25.36 ±2.16 years. gender was more than half of the nurses were female, were male (45.5 %), single (63.6%), most (90.9) of them were nurses graduated from hawler medical technical institute, the length of experience in nursing (63.6%) had experience of 1-5 years, duration of work for nurses (72.7%) in cardiac catheterization worked for 1-5 years, and none of them attended any training program on cardiac catheterization in the kurdistan region or abroad. in general, there was no significant association between the quality of pre cardiac catheterization nursing care and their socio-demographic characteristics of the nurses. conclusion: nursing care had sometimes to never level, but need continuous knowledge and training course regarding nursing care. future research is required to affirm these determinations. keywords: cardiac catheterization; nursing care; quality. yousif bakr omer; department of nursing, college of nursing, hawler medical university, erbil, iraq. )correspondence: yousif.omar@hmu.edu.krd ) 75 erbil journal of nursing & midwifery received: 28/4/2019 accepted: 23/9/2019 published: 30/5/2020 mailto:yousif.baker@nur.hmu.edu.krd https://doi.org/10.15218/ejnm.2020.09 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article of complications. however, it is very safe when performed by an experienced team [6].in addition nurses knowledge in this area was in adequate indicated in study done by [7].therefore, this study was conducted to assess the socio demographic data of the nurses working in the cardiac center and quality of the nursing care regarding patient preparation for cardiac catheterization. this study was conducted from the 15th july to the 23rd august 2018 on all nurses who perform pre cardiac catheterization nursing care in the surgical specialty hospital cardiac centre in erbil city of kurdistan region-iraq. the sample was selected according to the following criterion: all nurses in catheterization unit. a questionnaire and checklist format was developed for purpose of data collection; it contained of two parts; part one (questionnaire) consisted of socio-demographic characteristics of the nurses, and part two (checklist) consisted of observation of nursing care which includes 29 items and each item has 3 responses that are ranked from 3 to 1 and the researcher selects one response that is more suitable with his nursing care. it also observes nursing care level as the following: 3 always, 2 sometimes, 1 never. the ethical approvals for conducting this study were obtained from ethical committee in college of nursing / hawler medical university. the researcher observed each nurses three times (three observations) in one day. the researcher observed each nurse while taking care of the patients without their orientation. later the researcher filled up the checklist. in order to analysis the results of the study data were entered in spss (version 23) frequency, percentage and kendall test (it used to test for associations in hypothesis testing, the purpose is to investigate the possible association in the underlying variables when sample size is small) was used for analyzing of data. table 1 show that the majority of the age (81.8) was in the age group 23-26 years old, the mean age and sd of the participants was 25.36 ±2.16 years. gender (54.5) was more than half of the nurses were female, single (63.6), most (90.9) of them were nurses graduated from hawler medical technical institute, the length of experience in nursing (63.6) had experience of 15 years, duration of work for nurses (72.7) in cardiac catheterization worked for 1-5 years, and none of them attended any training course program on cardiac catheterization in the kurdistan region or abroad. table 2 shows the nursing care before cardiac catheterization. the highest mean scores (3.0) were allocated to the following activities items such as: check the patient medical record, administers the prescribed medication, shave and clean the area before the catheter insertion site, instruct the patient to warning the hospital gown, check and record blood pressure, applying ecg to the patient, and keep the patient privacy. this means that all the nurses did carry out those activities in patient. (higher mean higher quality patient care), the lowest mean score (1.0) allocated to the activity items such as: check the patient height and weight, and administrative the mild sedative. table 3 shows the level of overall quality of nursing care for patient's undergoing pre cardiac catheterization. the highest percentage of the level of the nursing care (81.8) was at the fair level, and the lowest percentage (18.2) of nursing care was good level, while the mean score of overall quality of care was 2.18, which indicated that the quality of care of all nurses is fair. 76 erbil journal of nursing & midwifery methods results https://doi.org/10.15218/ejnm.2020.09 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article the relationship between the length of experience in nursing and overall quality of pre cardiac catheterization nursing care: the highest percentages of the nurses (63.6) had 1 – 5 years of experiences in nursing care, while the none (0.0) of the nurses had >10 years of experiences in nursing care that means the numbers of nurses with fair score were more in comparing with good score of the nurses. the result of the study showed that there was a non-significant relationship between length of experience in nursing and overall quality of nursing care (p = 0.108), because most of them were appointed recently. the relationship between the duration of work in this unit and overall quality of pre cardiac catheterization nursing care: the highest percentage of the nurses (72.7) had 1 – 5 years of work in this area of patient care, while the none (0.0) of the nurse over 6 years of work in the cardiac catheterization unit. moreover, the numbers of the nurses with fair score were more in comparing with good score of the nurses. the result of the study showed that there was a nonsignificant relationship between duration of work in this unit and overall quality of nursing care (p = 0.145). table 4 shows the following results: the relationship between the age and overall quality of pre cardiac catheterization nursing care. the highest percentages (81.8) were in the age group 23-26 years old, while the lowest percentage (18.2) of the nurses' age group was for above 27 years old. moreover, there were more nurses with score fair than nurses with the good score. finding of the study indicated that there was a non-significant relationship between age and overall quality of nursing care (p = .350). the relationship between the gender and overall quality of pre cardiac catheterization nursing care: the higher percentages of nurses (54.5) were female, and lowest percentages (45.5) were male, the numbers of nurses with fair score were more in comparing with the good score of the nurses. there was a significant relationship between gender and overall quality of nursing care (p = 0.085). the relationship between the qualification and overall of pre cardiac catheterization nursing care: the data indicated that the highest percentages of nurses (90.9) were in nursing institute, just one nurses (9.1) was graduated from college of nursing, all of them with fair score just one of them with good score. the result of the study shows that there was a non-significant relationship between marital status and overall quality of nursing care (p = 0.247). the relationship between the marital status and overall of pre cardiac catheterization nursing care: the data indicated that the highest percentages of nurses (63.6) were single, while the lowest percentages (36.4) were married, also it mean the numbers of the nurses with fair score were more than the good score when comparing between them. the result of the study shows that there was a non-significant relationship between marital status and overall quality of nursing care (p = 0.674). 77 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.09 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 78 erbil journal of nursing & midwifery table 1: socio demographic characteristic of cardiac catheterization nurses socio demographic of nurses n = 11 f (%) age (years) 23 -26 9 (81.8) 27 – 30 2 (18.2) m ± sd 25.36± 2.16 gender male 5 (45.5) female 6 (54.5) qualification nursing institute 10 (90.9) nursing college 1 (9.1) marital status single 7 (63.6) married 4 (36.4) length of experience in nursing (years) <1 3 (27.3) 1 – 5 7 (63.6) 6 – 10 1 (9.1) duration of work in the cardiac catheterization unit(years) <1 3 (27.3) 1 – 5 8 (72.7) attending training course program in cardiac catheterization patient care yes 0 (0) no 11 (100) table 2: quality of pre cardiac catheterization nursing care items (activities) always sometimes never f (%) f (%) f (%) check the patient medical record 11 (100) 0 (0) 0 (0) 3 ask the patient past or present illnesses and that biographic 0 (0) 6 (54.5) 5 (45.5) 1.55 explain the risk and complication of the procedure 0 (0) 4 (36.4) 7 (63.6) 1.36 check characteristics of pain associated with procedure 0 (0) 1 (9.1) 10 (90.9) 1.09 explain the procedure to the patient 0 (0) 10 (90.9) 1 (9.1) 1.91 asking the patient about allergy 1 (9.1) 7 (63.6) 3 (27.3) 1.82 notify the patient about which drugs should be given before the procedures(e.g. aspirin, clopedogril) 5 (45.5) 6 (54.5) 0 (0) 2.45 administers the prescribed medication 11 (100) 0 (0) 0 (0) 3 provide psychological support 0 (0) 2 (18.2) 9 (81.8) 1.18 ask the patient to empty bladder 1 (9.1) 7 (63.6) 3 (27.3) 1.82 instruct the patient to npo(nothing by mouth) 8 (72.7) 3 (27.3) 0 (0) 2.73 shave and clean the area before the catheter insertion site 11 (100) 0 (0) 0 (0) 3 instruct the patient to warning the hospital gown 11 (100) 0 (0) 0 (0) 3 check and record body temperature 0 (0) 3 (27.3) 8 (72.7) 1.27 check and record blood pressure 11 (100) 0 (0) 0 (0) 3 check and record pulse rate 2 (18.2) 5 (54.5) 4 (36.4) 1.82 check and record respiratory status (depth, rate, sound, and other abnormality) 0 (0) 2 (18.2) 9 (81.8) 1.18 check the patient height and weight 0 (0) 0 (0) 11 (100) 1 check the laboratory test(cbp ,pt, s creatine ,blood sugar, s.electrolytes , chest xray, virology screen) 6 (54.5) 5 (45.5) 0 (0) 2.55 remove dentures, hearing aids or glasses of the patient 5 (45.5) 6 (54.5) 0 (0) 2.45 insert iv line 7 (63.6) 4 (36.4) 0 (0) 2.64 obtain formal agreement with signature of patient 11 (100) 0 (0) 0 (0) 3 training the patient for relaxation techniques 0 (0) 1 (9.1) 10 (90.9) 1.09 administrative the mild sedative 0 (0) 0 (0) 11 (100) 1.0 check peripheral pulse 0 (0) 7 (63.6) 4 (36.4) 1.64 appling ecg to the patient 11 (100) 0 (0) 0 (0) 3 checking echo 10 (90.9) 1 (9.1) 0 (0) 2.91 notify the patient about which drugs should be stopped before the procedures (e.g. insulin, warfare, daonil) 2 (18.2) 7 (63.6) 2 (18.2) 2 keep the patient privacy 11 (100) 0 (0) 0 (0) 3 https://doi.org/10.15218/ejnm.2020.09 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 79 erbil journal of nursing & midwifery the main important point is assessment of quality of pre nursing care for patient undergoing cardiac catheterization; all nurses participated in this study worked in the catheterization ward in cardiac center and the researcher worked on it. the highest percentage of the study sample's (nurses) age was from 23– 26 years old and their mean age was 25 years. this result agreed with the results of descriptive study done on 11nurses working in cardiac center hospital in iraq, who found that the majority of nurses age were in 20-23 years [7]. more than half of the study samples were females and the remainder were males. this study agree with the study done by de vito dabbs et al. (1999) on twelve nurses working in cardiac catheterization unit in the united states they found all nurses in this unit were female [8]. on the other side, this study against with a quasiexperimental study had done by hassan and hassan (2012) on 80 nurses working in cardiac unit kirkuk teaching hospitals [9]. the result showed that the female nurses more higher than the female; actually6 female to 5 male. the reason for this variation may be the majority of nurses graduated from medical institute and college of nursing was female. qualification of the nurses working in cardiac catheterization unit, all of them were graduated from hawler medical technical institute except one of the graduated from college of nursing. most of them were nurses graduated from hawler medical technical institute. the present finding supported by the previous descriptive study which done by omar (2014) in cardiac center/ erbil city [7]. the result of the current study has founded that the highest percentage of the nurses was single, this result comes along with descriptive study that conducted by ozdemir (2007) in turkey, who found that the highest percentage of the study sample was unmarried table 3: overall quality of pre cardiac catheterization nursing care table 4: relationship between overall qualities of pre cardiac catheterization nursing care and socio-demographic items level of quality of post (ptca) nursing care f (%) good ( 59-87 ) 2 (18.2) fair ( 30-58) 9 (81.8) mean score and standard deviation of overall quality of care 2.18 ± 0.4 items p-value of kendal test decision age 0.350 ns gender 0.085 ns qualification 0.247 ns marital status 0.674 ns length of experience in nursing 0.108 ns duration of work in the cardiac catheterization unit 0.145 ns discussion https://doi.org/10.15218/ejnm.2020.09 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 80 erbil journal of nursing & midwifery instruction were seven activities of nurses carried out only. overall quality of pre cardiac catheterization nursing care 81.8% of the nurses were at fair level compared to 18.2% were at good level. while the mean score of overall quality of care was 2.18 which indicated also fair level of patient care. there was near a significant relationship between overall quality of pre cardiac catheterization nursing care and gender, there was a nonsignificant relationship between overall quality of pre cardiac catheterization nursing care and sociodemographic characteristics of the nurses (age, marital status, length of experience in nursing, and duration of work in the cardiac catheterization unit). before all great thanks are almighty for allah the merciful and compassionate. i would like to thank dr. yousif m. younis the dean of college of nursing hawler medical university for his encouragement. thanks a lot to all staff who participated in this study in catheterization unit in surgical specialty hospital especially mr. chalak who has a team leader in this unit. my special thanks are extended to assist. lec. kayfe jamil for his help and statistically guidance. no potential conflict of interest was reported by the author. [1] world health organization (2016). who cardiovascular disease. world health organization; (2016). [cited accessed 2018 july 25], available from: htt://www.who. int/cardiovasculardisease/en/index.html. [2] hajbaghery, m. a, moradi t. & mohseni, r., (2014). effects of a multimodal preparation package on vital signs of patients waiting for coronary angiography. nursing and midwifery studies; 3(1). [10]. the present study not congruent with the study done by aziz and lafi (2011) on 32 nurses in a centre of heart disease in sulaimani city, they found that the highest percentages of nurses were married [11]. the characteristic of experience in nursing and the duration of work for nurses in this unit revealed that most of nurses were from 1-5 years, the result of the present study was supported by descriptive quantitative study on 38 nurses who are working in al-saddar, alhaqeem and emergency hospital/iraq, who found that 57.9 of the nurse's experience was 1-9 years [12]. this study similar to study of al-batayneh (2001) who revealed that the most of the nurses working with cardiac patients in baghdad hospital/iraq, had same period of experience in ccu because situation of baghdad forced many nurses to go out of iraq for finding a job [13]. in regard with training program for nurses in cardiac catheterization unit in erbil city, the results indicated none of the nurses had been attended to any training courses neither in erbil nor abroad regarding patient care at this unit. the main reason may be either, the hospital is not giving chance for nurses to improve their skills of patient care or may be nurses are not interested to improve their skills, whether in or out of the country. most of the study samples were young, single, female nurse, had 1-5 years in nursing of experience in the catheterization unit. all nurses worked in this unit were graduated from hawler medical technical institute and none of them attended to any training program to improve their nursing care rendering to these patients. in general quality of pre cardiac catheterization nursing care was at fair level according to the results of the mean score. in other word, out of twenty nine activities of patient conclusion acknowledgment conflict of interest references https://doi.org/10.15218/ejnm.2020.09 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 81 [13] kadhim, m.h. evaluation of nurses’ practices toward patients who undergo percutaneous coronary intervention in iraq. (2006). msc theses. university of baghdad, college of nursing. iraq. [3] statistical record from cardiac center, (2018). [cited 2018 jun 20]. [4] andreas b. the effect of changing position and early ambulation after cardiac catheterization on patients’ outcomes. british journal of cardiac nursing,(2008). volume 3 is. 9, pp 398-406. [5] buzatto, l. l. & zanei, s. v. patients’ anxiety before cardiac catheterization. einstein, (2010). 8(4): 483-7. [6] adaryani, m.r., ahmadi, f. muhammad i, s., and asghari-jafarabadi, m. the effect of three positioning methods on patient outcomes after cardiac catheterization. advising nursing. (2009). [internet]. [ cited 2013 july 8], 65 (2), 417-434. iran. available from: www.ncbi.nlm.nih.gov/pubmed/19191940. [7] bakr,y.,o. quality of post catheterization nursing care in surgical specialty hospitalcardiac center in erbil city., (2014). [8] de vito dabbs a., walsh r.m., beck j., demko s.l., and kanaskie m.l.. nursing assessment of patient readiness for ambulation after cardiac catheterization. medical surgical nursing.(1999). [internet]. [cited 2013 july 11], 8(5),309-14. usa. available from: http://www.ncbi.nlm.nih.gov/ pubmed/10661169. [9] hassan, s. m. and hassan, h.s. effectiveness of nursing education program on nurses knowledge toward arrhythmia in kirkuk's teaching hospitals. (2012).fibms dissertation. university of kirkuk, college of nursing. iraq. available from: http://www.iasj.net/ iasj?func=fulltext&aid=65396. [10] özdemir, l., . nurses’ knowledge and practice involving patients’ resuming sexual activity following myocardial infarction: implications for training. australian journal of advanced nursing. (2007).[internet]. [cited 2013 august 8], 26 (1), 42-52. australian. available from:http://www.ajan.com.au/ vol26/26-1v2.pdf. [11] aziz, s.o. and lafi, s.y. evaluation of nurses’ practices provided to the patients who undergo open heart surgery in sulaimani center of heart diseases (s.c.h.d). , (2011).kufa journal for nursing science. [internet]. [cited 2013 july 11], 3(1), 69. iraq. available from: www.iasj.net/iasj?func=fulltext&aid=74815. [12] alftlawy, d.m. determination of nurses' knowledge toward care provided to patients with acute myocardial infarction in al-najaf city.(2011).[internet]. [cited 2013 july 11]. iraq. available from: www.iasj.net/iasj? func=fulltext&aid=60589. erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.16 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article effect of a health educational program on patients knowledge regarding heart failure: a quasi-experimental study abstract introduction heart failure (hf), a state in which the heart muscle is unable to pump enough blood throughout the body, is considered a worldwide problem in the 21st century with increasing effect on healthcare systems [1]. prevalence of hf is rising in both industrialized and developing countries, according to the american heart association (aha), about 1 in 5 over age 40 years suffer from hf [2].heart failure is one causes of hospitalization of patients over 65 years old, it costs around 2% of the entire budget of health care in many developed countries [3]. the disease has a substantial effect on physical ability, quality of life, public health and the cost of healthcare. this can happen to many backgrounds and objective: heart failure is a major public health problem in the world with a significant load of disease on population and the individual, this burden of disease can be measured in terms of mortality, readmission rate, and healthcare costs. adequate knowledge about the disease is an effective strategy to prevent further disease complication. the study aimed to determine the effect of a health education program on heart failure patients regarding their disease through a pre-post-test approach. methods: a quasi-experimental study with the application of pre and post-test approach for both the study and control group at hawler teaching hospital, rizgary teaching hospital and rojhalat hospital on patients with heart failure. a non-probability purposive sampling technique used on 400 heart failure patients chosen to include in the study. the study samples were divided into two groups; 200 patients as a study group and exposed to the health education program, and the other 200 patients were not exposed to the health education program and considered as the control group. the measurement of the effectiveness of a health education program through the knowledge assessment includes six main domains like general information, risk factors, causes, clinical manifestation, diagnosis, and management of heart failure. statistical data analysis achieved through descriptive and inferential data analysis. results: the results indicated that a health education program was effective among patients regarding management heart failure. it also indicates that there is good improvement with highly significant differences in study group between pre and post-test, in overall items. conclusion: the study concluded that the educational program is an appropriate and effective way to improve the patient's knowledge about heart failure. keywords: health educational program; knowledge; heart failure; mortality younus khudhur baeez; department of nursing, college of nursing, kirkuk university, kirkuk , iraq. (correspondence: : yuns34@yahoo.com ) yousif mohammed younis; department of nursing, college of nursing, hawler medical university, erbil, iraq. 125 erbil journal of nursing & midwifery received: 17/7/2019 accepted: 12/9/2019 published: 30/11/2019 mailto::%20yuns34@yahoo.com https://doi.org/10.15218/ejnm.2019.16 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article patients being readmitted to the hospital every year, which cause a continuous growing burden of hf on society [4,5]. patients may have many medical conditions, along with many medications, no social support, and other factors limiting the success of some treatment options. in addition, patients with hf may have low knowledge about their medication, weight and sodium management, and activity modification. for this, patients need healthcare and increased knowledge about hf to produce changes in health behaviour [6,7]. nurses have an important role in the reassessment of heart failure disease, controlling the hemodynamic function and management of hf[8]. nursing implications help to minimize patient suffering from hf, the patients who are provided with care acquired from programs show a significant effect on morbidity and mortality reduction. hence, the nurse should become adequately prepared as an educator to manage a patient with hf [9]. most heart failure management program’s goals are to make patient receive ideal medical care by assessing needs and implementing medical management, device therapy teaching, self -care, follow-up, and psychosocial health care [10]. advancing patients on self-care management can help in behavioural reinforcement and accompanied with effective outcomes, including subjective symptoms, weight observation, low salt diet, improve exercise, medication intake, and a plan for management in case of symptoms agitation. additional knowledge is important in improving patients’ results and to maintain patient condition in the hospital and the outpatient [11]. studies have shown that half of the patients with heart failure who have been re-admitted to hospital can be prevented from re-entering the hospital if they continue with the prescribed treatment [12].patients, as well as their caretakers, level of knowledge, is significantly related to their level of adherence to recommended care regimens [13].patients knowledge is an essential component for the treatment of their disease [14]. heart failure requires a strong focus on the education of patients and their families to improve their knowledge of self-care and compliance [15]. a quasi-experimental study was carried out through with the application of pre and post-test approach for both case and control group, the study was conducted at intensive care unit (icu) and medical ward at hawler and rizgary teaching hospital, as well as rojhalat emergency hospital. a non-probability purposive sampling technique used on 400 heart failure patients chosen to include in the study, the sample size were determined through the formula " sample size= z2pq/ d2 ". the samples of the study were divided into two groups; 200 patients as a case group were exposed to the health education program and the other 200 patients are not exposed to the health education program, considered as the control group. the two groups have the same demographic characteristic. the educational program is designed and based on the patients need assessment and from reviewing the relative scientific literature, and previous studies. the content of the program is evaluated by experts in different fields, revision is made on the content of the program from based on these experts recommendation and suggestions. to evaluate the effectiveness of the educational program on patient knowledge, the researcher constructs a questionnaire interview form for the purpose of data collection, which contains six main domains:general information 10 items, risk factors 10 items, causes 5 items, clinical manifestation 8 items, diagnosis 4 items, 126 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2019.16 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article the study showed that most of the case group were at age group of (75-79) years old with mean of age and standard deviation 76.68 ± 6.67, while the majority of the control group were at age (70-74) years old with mean of age and standard deviation 75.44 ± 6.32, these findings agree with the result of cross-sectional study done by gianluigi and lars, on 199 heart failure patients and they concluded that the majority of the patients age was above 70 years old [16]. moreover, the result of the present study agrees with the study on heart failure, the finding of their study revealed that the mean of age and slandered deviation was 75.2. ± 6.18 [17]. according to the cases group main domains knowledge along pre-post periods, the results showed that the gms of patients knowledge regarding heart failure in the study group has been improved after exposure to a health education program, and this was indicated by the significant difference between pre-test and post-test of the results. moreover, regarding the control group main domains knowledge along pre-post periods, the study indicated that changes in the case group were significantly higher than that of the control group. the study comes along mahramus et al, who founded in his study that there is a significant improvement in patients' knowledge regarding heart failure after imparted the study samples with a health education program [18]. furthermore, the study in agreement with sundel, who stated that providing heart failure education classes to patients can be successful in increasing their knowledge [19].for summarizing the overall knowledge assessment along pre-post periods in case-control groups, it could be concluded that suggested educational program could be applicable for case and management of hf 4 items. the content validity of the program and study instruments are determined by a panel of experts, reliability of the tools was determined through the use of test-retest approach obtained through evaluating 20 patients selected from above hospitals with interval period of two weeks. the result of the reliability coefficient was 0.91 for patients knowledge related to heart failure. the statistical data analysis approaches were used in order to analyze and assess the results of the study under the application of the statistical package (spss) ver. 22.0: descriptive data analysis: frequencies, percentages, mean of the score (ms), grand mean of scores (gms), standard deviation (sd), relative sufficiency (rs%), as well as inferential data analysis: the independent-samples t-test to compares means for two groups of cases, and matched paired-samples t-test (mp t-test) to computes the differences between values of the two variables for each case and tests whether the average differs from zero. respect to study socio-demographical characteristics in table (1), results show that study groups had recorded no significant differences at p>0.05, except in age groups, and levels of education, which represented significant different at p<0.05, rather than most of the studied group's individuals distribution concerning age, and levels of education were very similar. in regards to age, the majority of study groups were at the age group of (7579) years old with mean of age and standard deviation 76.68 ± 6.67, while the majority of the control group were at age (70 -74) years old with mean of age and standard deviation 75.44 ± 6.32. 127 erbil journal of nursing & midwifery results discussion https://doi.org/10.15218/ejnm.2019.16 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article group, since the absence of significant differences between the two groups 128 erbil journal of nursing & midwifery socio-demographical characteristics. classes study group control group p-value no. (%) no. (%) age < 65 8 (4) 0 (0) 0.015 (s) 65 – 69 23 (11.5) 32 (16) 70 – 74 45 (22.5) 64 (32) 75 – 79 64 (32) 58 (29.9) 80 – 84 38 (19) 33 (16.5) 85 – 89 14 (7) 9 (4.5) 90 > 8 (4) 4 (2) mean ± sd 76.68 ± 6.67 75.44 ± 6.32 gender male 105 (52.5) 104 (52) 0.920 (ns) female 95 (47.5) 96 (48) levels of education illiterate 101 (50.5) 139 (69.5) 0.001 (hs) read and write 31 (15.5) 15 (7.5) primary 16 (8) 14 (7) intermediate 13 (6.5) 11 (5.5) preparatory 11 (5.5) 12 (6) institute graduate 11 (5.5) 4 (2) college graduate 17 (8.5) 5 (2.5) occupation before disease employed 33 (16.5) 24 (12) 0.107 (ns) unemployed 33 (16.5) 42 (21) house wife 78 (39) 93 (46.5) selfemployed 23 (11.5) 22 (11) retired 33 (16.5) 19 (9.5) occupation after disease returned to work 12 (6) 13 (6.5) 0.836 (ns) out of work 188 (94) 187 (93.5) marital status married 134 (67) 132 (66) 0.832 (ns) widowed 66 (33) 68 (34) residential area urban 179 (89.5) 185 (92.5) 0.295 (ns) rural 21 (10.5) 15 (7.5) regarding knowledge of patients with heart failure. table 1: socio-demographical characteristics of the samples https://doi.org/10.15218/ejnm.2019.16 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article 129 erbil journal of nursing & midwifery table 2: cases group main domains knowledge along pre-post periods main domains group no. gms sd se t-test p-value general information pre 200 0.563 0.193 0.014 -20.14 < 0.001(vhs) post 200 0.782 0.128 0.009 risk factors pre 200 0.223 0.178 0.013 -34.60 < 0.001(vhs) post 200 0.620 0.157 0.011 causes pre 200 0.354 0.208 0.015 -22.69 < 0.001(vhs) post 200 0.692 0.191 0.014 clinical manifestation pre 200 0.636 0.170 0.012 -20.66 < 0.001(vhs) post 200 0.854 0.120 0.008 diagnosis pre 200 0.393 0.317 0.022 -17.34 < 0.001(vhs) post 200 0.770 0.249 0.018 management pre 200 0.386 0.212 0.015 -16.77 < 0.001(vhs) post 200 0.719 0.259 0.018 (*) hs: highly significant at p<0.01; ns: non-significant at p>0.05; testing based on matched paired t-test; gms=grand mean of score table 3: control group main domains knowledge along pre-post periods main domains group no. gms sd se t-test p-value general information pre 200 0.566 0.170 0.012 -7.79 < 0.001(vhs) post 200 0.623 0.153 0.011 risk factors pre 200 0.195 0.164 0.012 -5.70 < 0.001(vhs) post 200 0.257 0.207 0.015 causes pre 200 0.353 0.180 0.013 -6.42 < 0.001(vhs) post 200 0.415 0.221 0.016 clinical manifestation pre 200 0.630 0.159 0.011 -5.74 < 0.001(vhs) post 200 0.661 0.159 0.011 diagnosis pre 200 0.400 0.321 0.023 -5.45 < 0.001(vhs) post 200 0.465 0.325 0.023 management pre 200 0.373 0.226 0.016 -4.93 < 0.001(vhs) post 200 0.429 0.249 0.018 (*) hs: highly significant at p<0.01; ns: non-significant at p>0.05; testing based on matched paired t-test; gms=grand mean of score https://doi.org/10.15218/ejnm.2019.16 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article in conclusion, the current study data showed that implementing an education program regarding heart failure in erbil city had increased patients' knowledge about their disease as well as improved their health status. we would like to express thanks to all heart failure patients who participate in the study and thank their families for their collaboration. we would like also to thank all health staff in the hawler teaching hospital, rizgary teaching hospital and rozhalat emergency hospital for their facilities and cooperation over the periods of the study. before starting the research procedures, official approval was obtained from the research ethics committee at the college of nursing from hawler medical university. written permission was obtained from the directorate of the health of erbil city in order to facilitate data collection, after that, informed consent was obtained from the hf patients who engaged in the study prior to data collection. the authors declare that there is no conflict of interest. [1] anne m, jette r, karsten m, charlotte s, and klas k. patients with heart failure as codesigners of an educational website: implications for medical education. international journal of medical education. 2017; 8, 47– 58. doi: 10.5116/ijme.5898.309e [2] boback z and gregg c. epidemiology and aetiology of heart failure. nature reviews. cardiology.2016;13(6):368–378. doi: 10.1038/nrcardio.2016.25. [3] wladimir l, christine k, and peter k. cost-ofillness studies in heart failure: a systematic review 2004–2016. biomedical central cardiovascular disorders, 2018; 18: 74. doi: 10.1186/s12872-018-0815-3 [4] colleen k, zubin j, and larry a. hospital readmissions reduction program. circulation. 2015; 131(20): 1796–1803. doi: 10.1161/ circulationaha.114.010270 [5] aaron l, michael r, maya k, juan p, frances s, katie g, et al. preventing 30-day hospital readmissions: a systematic review and metaanalysis of randomized trials. journal of the american medical association. 2014; 174 (7):1095–1107.doi:10.1001/ jamainternmed.2014.1608 [6] kathleen l, kathleen d, gemma k, debra k, mariann p, lynne w, et al. team management of patients with heart failure. a statement for healthcare professionals from the cardiovascular nursing council of the american heart association. circulation. 2000;102:2443–2456.https:// doi.org/10.1161/01.cir.102.19.2443 130 erbil journal of nursing & midwifery table 4: overall main domains knowledge along pre-post periods in case-control groups groups group no. gms sd se t-test p-value case pre 200 0.426 0.106 0.008 -46.4 < 0.001(vhs) post 200 0.739 0.085 0.006 control pre 200 0.419 0.098 0.007 -7.92 < 0.001(vhs) post 200 0.475 0.128 0.009 (*) hs: highly significant. at p<0.01; testing based on matched paired t-test. conclusion acknowledgement ethical considerations conflict of interest references https://doi.org/10.15218/ejnm.2019.16 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article [7] jessica d, daniel j, kris s, and britta i. pilot program to improve self-management of patients with heart failure by redesigning care. coordination. nursing research and practice.2014;836921. doi: 10.1155/2014/836921 [8] jillian r. the key roles for the nurse in acute heart failure management. cardiac failure review. 2015; 1(2): 123–127. doi: 10.15420/ cfr.2015.1.2.123 [9] james k, theodore a, kathy a, and dominique l. diagnosis and treatment of depression in patients with congestive heart failure: a review of the literature. primary care companion for cns disorder. 2013; 15 (4), 1315. doi: 10.4088/pcc.13r01511 [10] tiny j, torben l, anna s. practical guide on home health in heart failure patients. international journal of integrated care. 2013; 13: e043. https://www.ncbi.nlm.nih. gov/ pmc/articles/pmc3821536/ [11] laura k, lawrence j, and chery a. strategies to reduce dietary sodium intake. current treatment options in cardiovascular medicine. 2012; 14(4): 425–434. doi: 10.1007/ s11936-012-0182-9 [12] nahid a, and genevieve l. management of chronic heart failure in the older population. journal of geriatric cardiology. 2014; 11(4): 329–337.doi:10.11909/j.issn.16715411.2014.04.008 [13] andrew j, myint a, and gboyega a. factors that positively influence adherence to antiretroviral therapy by hiv and/or aids patients and their caregivers. african journal of primary health care & family medicine.. 2011; 3(1): 196. doi: 10.4102/phcfm.v3i1.196 [14] saurabh r, prateek s, and jegadeesh r. role of self-care in the management of diabetes mellitus. journal of diabetes and metabolic disorders.. 2013; 12: 14. doi: 10.1186/22516581-12-14 [15] tiny j, jan c, barbara r, and anna s. factors related to self-care in heart failure patients according to the middle-range theory of self-care of chronic illness: a literature update. current heart failure reports. 2017; 14 (2): 71–77. doi: 10.1007/s11897-017-0324-1 [16] gianluigi s, and lars h. global public health burden of heart failure. cardiac failure review.. 2017 apr; 3(1): 7–11. doi: 10.15420/ cfr.2016:25:2 [17] naseer a, hassan h. effectiveness of educational program on nurses' practices toward cardiac rehabilitation for patients with heart 131 erbil journal of nursing & midwifery attack, kufa journal of nursing science. 2013; 5(1): 3-6. available from: https:// www.iasj.net/iasj?func=fulltext&aid=99767 [18] mahramus t, frewin s. chamberlain l, wilson d, and sole m. assessment of an educational intervention on nurses' knowledge and retention of heart failure self-care principles and the teach-back method. heart lung. 2014; 43(3):204-12. doi: 10.1016/ j.hrtlng.2013.11.012. [19] sundel s. an educational intervention to evaluate nurses' knowledge of heart failure. journal of continuing education in nursing.. 2018; 49(7):315-321. doi: 10.3928/00220124-20180613-07. https://doi.org/10.15218/ejnm.2018.11 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article depression and anxiety among iraqi women: a systematic review abstract introduction women’s mental health is increasingly being recognized as an essential public health subject. this is true considering that by 2020, the world health organization (who) projects that depression will be the leading cause of disability among women [1]. an estimated 4.4% (322 million people) live with depression and 3.6% (263 million people) live with anxiety globally [2]. women represent a greater proportion of the population diagnosed with both depression and anxiety [2]. because the global rate of mental illness diagnoses increased nearly 20% over 10 years from 2005 to 2015, , mental illness in the form background and objective: maternal mental health is considered an important subject among leading public health experts. women are two to three times more likely to be diagnosed with mental illness compared to men. according to the world health organization, depression will be the biggest contributor to burden of disease among women by 2020. chronic stress, experiencing war, and history of abuse are associated with mental illness. iraq has experienced years of challenging circumstances due to the political and social environment as well as physical barriers to health care services. this paper presents findings from literature about mental illness among iraqi women. methods: a comprehensive literature review was conducted using pubmed, google scholar, and ebsco academic search complete to identify studies focused on mental illness in iraq. search terms included: maternal, anxiety, depression, iraq, middle eastern and north african region, and women. cross-sectional, cohort, and case-control studies were included. results: five papers were found that focused exclusively on mental illness in iraq. two described maternal mental illness and three focused on mental illness in the general population, with two of the three including information specific to women. results suggest that the rate of mental illness among iraqi women is not different from women in other countries. however, because there is a difference of seven years between the iraqifocused study and other global studies, additional new research is required to best compare rates. interestingly, iraqi women experience maternal mental illness at higher rates than other women. while the global average rate for mental illness in pregnancy or the postpartum period is estimated at 15-20%, 37.5% of iraqi women experience anxiety and 28.5% experience depression. conclusion: additional study focusing on women’s health and maternal mental health is necessary to describe women at highest risk for mental illness and to inform strategies to prevent and manage maternal mental health to promote women’s health. keywords: mental disorder; women; mental health; iraq; kurdistan kathryn mishkin; global institute for health and human rights, university at albany, ny usa (correspondence: kmishkin@albany.edu) bibi chaterpateah; global institute for health and human rights, university at albany, ny usa valerie bresier; global institute for health and human rights, university at albany, ny usa jaleen fraser; global institute for health and human rights, university at albany, ny usa 85 erbil journal of nursing & midwifery received: 6/6/2018 accepted: 22/10/2018 published: 30/11/2018 https://doi.org/10.15218/ejnm.2018.11 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article of depression and anxiety is important for women’s health [3]. leading public health experts have begun to recognize maternal mental health as a growing topic of concern [4, 5]. defined as occurring in pregnancy and up to one year after pregnancy, maternal mental illness in the form of depression and anxiety are estimated to impact 15 to 20 percent of women globally [4]. this is because maternal depression and anxiety impact quality of life significantly through symptomology of loneliness; obsessive thoughts; feeling a loss of control and/or guilt; diminished concentration; loss of interest in activities; and fear of harming themselves and their infants [6]. while rare, women with maternal mental illness are at higher risk of attempting suicide than women without maternal mental illness [7, 8]. comorbidity of these mental illnesses occurs routinely in the maternal period, with one study estimating that up to 80% of women who experienced maternal anxiety also experienced depression [9]. a 2013 who systematic review of mental disorders during pregnancy and the year after birth found that women in lowand middle-income countries including nigeria, vietnam, bangladesh, pakistan, ethiopia, india, zimbabwe, uganda, and thailand experienced maternal depression and anxiety at higher rates (20%) than among women in high-income countries (16%) [10]. women are diagnosed with depression more often than men in both the middle eastern and north african (mena) region and the rest of the world [11]. depression is consistently ranked among the top 25 leading causes for disability adjusted life years in the mena region [12], with depression and post-traumatic stress disorder considered the most common disorders. [11].because of the timeliness of this topic, this paper presents a literature review focused on depression and anxiety among women in iraq. the citizens and residents of this country have experienced years of challenging conditions due to conflict, political issues, and physical barriers to health care because of distance and quality of transportation [13]. because factors including socioeconomic status [14-16], chronic stress [14-16], and history of abuse [17-21] are associated with mental illness, it is likely that iraqi women are at especially high risk of developing these disorders. furthermore, the underdeveloped mental health infrastructure within iraq serves as a significant challenge to providing patients with needed services, for example there are only four psychiatrists per one million residents [22]. as a result, one doctors without borders study finds that institution-level and community-level mental health services are lacking [22]. to describe women’s depression and anxiety in iraq, a comprehensive systematic literature review was conducted in 2018 using pubmed, google scholar, and ebsco academic search complete. studies were included if they were published between 2000 and 2017 and if they indicated an official measurement tool for the mental illness. search terms were in english and included: “maternal”, “anxiety”, “depression” “perinatal”, “postnatal”, “postpartum”, “prevalence”, “iraq,” “mena region”, “women”, “risk factor.” cross-sectional, cohort, and case-control studies were included. while little is known about mental illness in the form of depression and anxiety in methods 86 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2018.11 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article additionally, depressive disorders were three times more prevalent among females than males, and the lifetime prevalence of severe depression was significantly different by gender, with prevalence higher among women [4.9%] than men (2.1%) [23]. women were also significantly more likely to experience anxiety disorders compared to men, with 1.26 women experiencing anxiety for every 1 man [23]. among women, depressive disorders were more common among those with lower levels of education and among those who had been previously married and are now either divorced, widowed, or separated [23]. people who have been affected by war are also at a greater risk for depressive disorders [23]. research focused on attitudes towards mental illness among iraqis demonstrates that there are differences in how men and women perceive mental illness. women are more likely to consider mental illness to be as a result of genetic inheritance or due to social situations, men are more likely to consider mental illness to be due to personal weakness or as a form of punishment from god [13]. barriers to mental health service provision are due to a shortage of the public health infrastructure in general, where providers, medications, and supply chain are lacking [6]. maternal mental health has also not been the focus of much research in iraq. two studies were identified including one that focused on maternal depression and one that focused on maternal anxiety. these studies are described in table 2. a maternal depression study was conducted in maternal health centers in erbil city, kurdistan region and screened women at six to eight weeks postpartum in iraq, some surveys have been conducted to estimate the prevalence in the country. in 2015, the who estimated that 1,263,249 people were living with depression and 1,520,493 were living with anxiety in iraq [3]. the only comprehensive national survey that collected prevalence rates of mental disorders to-date was the 2006/2007 iraq mental health survey (hereafter referred to as imhs 2006/7), which sampled households to estimate mental illness prevalence overall and by region. major depressive disorder was found to be the most common mental health disorder in iraq, affecting about 475,000 iraqi adults aged 18 years and older [23]. of these cases, 46% were severe or very severe cases, as defined by suicidal thoughts and ideations [23]. however, these numbers increased over the course of eight years. the lifetime prevalence rate for any disorder was 18% on average [24], 21.13% in the kurdistan region, and 15.69% in the south/center region [23]. urban areas had a higher prevalence rate (4.06%) for severe depressive disorders, compared to rural areas [2.51%] [23]. furthermore, 3.5% indicated they had considered suicide recently [23]. among children younger than 16 years, 37.4% were estimated to live with any mental disorder, with girls affected 22 times more often than boys [25]. few reports or articles have been written about the prevalence of depression and anxiety explicitly among women. using reports that exist for adults in general, it is possible to obtain women-specific information. this information is displayed in table 1. for example, the imhs 2007/7 indicated that women are significantly more likely to experience lifetime prevalence for any mental illness disorder is (19.5%) compared to men (13.7%) [23]. 87 erbil journal of nursing & midwifery maternal mental illness in iraq mental illness among women in iraq https://doi.org/10.15218/ejnm.2018.11 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article the kurdish language [6]. the study found a prevalence rate of postpartum depression to be 28.5%, with the prevalence lower among younger women compared to older [6]. postpartum depression was significantly associated with low socioeconomic status, having a prior history of psychiatric illness, having a family history of psychiatric illness, cesarean section delivery, and a history of physical and/or sexual abuse [6]. this study served as the first validation of the edinburgh postpartum depression scale (epds) in the kurdish language [6]. a case-control study focused on maternal anxiety demonstrated that women living in mosul identified a prevalence rate of 43.5% using the american psychiatric association scale [26]. women who delivered prematurely were 1.8 times more likely to suffer from anxiety than women who delivered full term (95% ci: 1.19–2.72; p<0.01) [26]. adjusting for covariates, women who delivered prematurely were 2.16 times more likely to suffer from anxiety than women who delivered full term (95% ci: 1.28-3.64; p<0.001). 88 erbil journal of nursing & midwifery table 1: mental illness among women in iraq as identified through national surveys study type mental illness year pub. size sample year data collect description highlighted results iraq family health survey report 2006/7 depression anxiety 2009 9345 20062007 sample one adult per household across country, aged 18+ years using composite international diagnostic interview 19.5% lifetime prevalence women 14.1% lifetime prev. anxiety women 4.9% lifetime prev. depression women; mental health in iraq: issues and challenges depression anxiety 2013 4332 20072008 opinion article est. 100 psychiatrists total in country barriers to mental health services include scarcity of resources, lack of access, stigma public perception of mental health in iraq stigma of mental illness 2010 418 2010 nonexperimental random field research survey in baghdad; systematic sampling of adults aged 18 years and older women more likely than men to consider mental illness to be due to: genetic inheritance [31% vs. 25%]; bad things happening to a person [45% vs. 40%]; men more likely than women to consider mental illness to be due to: personal weakness [39% vs 36%] god’s punishment [18% vs. 14%] https://doi.org/10.15218/ejnm.2018.11 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article this paper presents the first systematic review of the literature describing women’s mental health and women’s maternal mental health in iraq. while very little literature exists, what has been written suggests that women are at high 89 erbil journal of nursing & midwifery discussion table 2: literature focused on maternal mental illness in iraq study, authors type mental illness location year pub. size sample year data collect sample description measurement tool results risk factors for preterm birth in iraq: a case control study anxiety mosul 2006 200 2003 -2004 women with live preterm birth 2937 weeks american psychiatric association scale 43.5% had anxiety symptomology. preterm birth associated with maternal anxiety screening for postpartum depression using kurdish version of edinburg postnatal depression. depression erbil 2011 1000 2010 women ages 14 to 48 years, 6-8 weeks postpartum edinburgh postpartum depression scale 28.5% had depression symptomology. depression significantly associated with low ses [p=0.002], unplanned pregnancy [p=0.008], self/ family history of psychiatric illness [p<0.001], cesarean delivery [p=0.019], physical/sexual abuse [p<0.001] https://doi.org/10.15218/ejnm.2018.11 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article 2006/7 demonstrated that kurdistan’s prevalence rate was 21% compared to 15% in the south/center region, and because women were demonstrated to experience symptomology significantly more frequently than men [23], it would be helpful to understand the role that region played in rates among women. this same analysis may be applied for other sociodemographic characteristics as well as behavioral characteristics. further study related to maternal mental health is needed in iraq as well. the two studies included in this literature review suggest that iraqi women experience mental illness at significantly higher rates than women in other countries. whereas the global prevalence rate for maternal depression and anxiety is between 15-20% [4], the two studies cited reported rates of 28.5% and 43.5%, respectively. it is unclear why women in iraq would report mental illness symptomology at such high rates. due to the recent violence in wars, women may have been impacted through experiencing sexual and physical violence or through widowhood or separation from their husbands [23]. research has found that physical and sexual abuse is closely associated with a history of abuse [17-21] and with chronic stress [14-16], so women may be particularly susceptible to mental illness during pregnancy and one year postpartum. recommendations include more research focused on maternal mental health in order to understand which women are at highest risk and also to inform larger-scale strategies for maternal mental health prevention and management. finally, development of the iraqi workforce to identify and treat mental illness is needed. midwives are in the unique situation of being able to provide physical care and emotional support to women in pregnancy, labor, and after delivery [5]. risk of mental illness because of social and cultural norms and events. there are also significant barriers to receiving mental health services because of infrastructure challenges and perceptions of stigma at the population level. the prevalence rates of mental illness among women suggest that iraqi women suffer from mental illness about as frequently as women in other areas of the world. globally, the who estimates that the average prevalence rate for mental illness is higher in low-income countries (20%) compared to women in high-income countries (16%) [10]. this proves to be true for iraq, a low-income country, as the prevalence rate of mental illness for women is 19.5% [23]. it is worth noting that the most recent national survey of mental illness among women occurred over 10 years ago in 2007 [23]. because other countries have reported mental illness prevalence much more recently, comparing the prevalence rates of iraq and other low-income countries might not be useful, especially as prevalence rates of mental illness have been increasing since 2003 [3]. new comprehensive research exploring mental illness throughout the country is needed to update our understanding of how many in the population is impacted by depression and anxiety. without this research, it is nearly impossible to appropriately make cross-national comparison of rates of mental illness. additionally, new research is needed to focus exclusively on women. while the imhs 2006/7 presented mental illness rates by gender and across regions, age groups, etc., it did not stratify rates by gender and other factors. without stratified rates by gender, it is difficult to describe how women within different regions may be disproportionately affected by mental illness. for example, because the imhs 90 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.11 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article [1] world health organization. mental health aspects of women’s reproductive health: a global review of the literature . geneva: world health organization; 2009. [2] fisher j, cabral de mello m, patel v, rahman a, tran t, holton s, et al. prevalence and determinants of common perinatal mental disorders in women in and lower-middle-income countries: a systematic review. bulletin of the world health organization. 2012;90(2):139g49g. [3] world health organazation. depression and other common mental disorders global health estimates. geneva, switzerland: who; 2017. [4] world health organization. mental health aspects of women’s reproductive health: a global review of the literature. geneva: who; 2009. [5] humberstone s. mental illness in pregnancy: midwives supporting women and safeguarding babies. practicing midwife. 2015;18(9):18-20. [6] ahmed hm, alalaf sk, al-tawil ng. screening for postpartum depression using kurdish version of edinburgh postnatal depression scale. archives of gynecology and obstetrics. 2012;285[5]:124955. [7] wallace me, hoyert d, williams c, mendola p. pregnancy-associated homicide and suicide in 37 us states with enhanced pregnancy surveillance. american journal of obstetrics and gynecology. 2016;215(3): e1-364.e10. doi: 10.1016/j.ajog.2016.03.040 [8] appleby l, mortensen pb, faragher eb. suicide and other causes of mortality after post-partum psychiatric admission. the british journal of psychiatry. 1998;173:209-11. [9] kendig s, keats jp, hoffman mc, kay lb, miller es, simas tam, et al. consensus bundle on maternal mental health: perinatal depression and anxiety. obstetrics while organizational barriers to midwives providing mental health services exist in the form of heavy workload and time constraints, findings from one study conducted in the united kingdom suggest that 50% of midwives reported inadequate knowledge about maternal mental health as a key barrier for deliveries mental health care [27]. investment in education for midwives and health care providers attending pregnant women should be a priority in order to improve delivery of mental health services, especially in iraq. furthermore, it is recommended that cultural appropriateness and competency should be a top priority of the training, especially among highly stigmatized populations [27]. in conclusion, this paper presents findings from literature about mental illness among iraqi women. results from this literature review suggest that the prevalence of mental illness among iraqi women is not different from women in other countries. however, much of the literature is out-of-date. new research is needed to compare depression and anxiety prevalence among women between iraq and other countries. interestingly, iraqi women experience maternal mental illness at higher rates than other women. while the global average rate for mental illness in pregnancy or the postpartum period is estimated at 15-20%, nearly 40% of iraqi women experience anxiety and nearly 30% experience depression. new research focused on women’s health and maternal mental health is required to describe women at highest risk for mental illness and to inform strategies to prevent and manage maternal mental health to promote women’s health. the authors report no conflict of interests. 91 erbil journal of nursing & midwifery conclusions conflict of interest references https://doi.org/10.15218/ejnm.2018.11 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article [18] miller p, lawrie sm, hodges a, clafferty r, cosway r, et al. genetic liability, illicit drug use, life stress and psychotic symptoms: preliminary findings from the edinburgh study of people at high risk for schizophrenia. social psychiatry and psychiatric epidemiology. 2001;36(7):33842. [19] honkalampi k, hintikka j, haatainen k, koivumaa-honkanen h, tanskanen a, viinamaki h. adverse childhood experiences, stressful life events or demographic factors: which are important in women's depression? a 2-year follow-up population study. australian and new zealand journal of psychiatry. 2005;39 [7]:627-32. [20] seng js, low lk, sperlich m, ronis dl, liberzon i. prevalence, trauma history, and risk for posttraumatic stress disorder among nulliparous women in maternity care. obstetrics and gynecology. 2009;114(4):839-47. [21] leigh b, milgrom j. risk factors for antenatal depression, postnatal depression and parenting stress. bmc psychiatry. 2008;8:24. doi: 10.1186/1471-244x-824 [22] healing iraqis: the challenges of providing mental health care in iraq. 2013. [23] world health organization. iraq mental health survey 2006/7report. 2009. [24] alhasnawi s, sadik s, rasheed m, baban a, al-alak mm, othman ay, et al. the prevalence and correlates of dsm-iv disorders in the iraq mental health survey [imhs]. world psychiatry. 2009;8 (2):97-109. [25] al-jawadi aa, abdul-rhman s. prevalence of childhood and early adolescence mental disorders among children attending primary health care centers in mosul, iraq: a cross-sectional study. bmc public health. 2007;7:274. doi: 10.1186/1471-2458-7274 & gynecology. 2017;129(3):422430. doi: 10.1097/ aog.0000000000001902. [10] fisher j, de mello, m., patel, v., rahman, a., tran, t., holton, s., et al. prevalence and determinants of common perinatal mental disorders in women in lowand lower-middle-income countries: a systematic review. bull world health organazation. 2011;90(2):139-149h. doi: 10.2471/blt.11.091850 [11] pocock l. mental health issues in the middle east an overview. middle east journal of psychiatry and alzheimers. 2017;7(1). [12] university of washington. the global burden of disease: generating evidence, guiding policy. human development network, world bank; 2010. [13] sadik s, bradley m, al-hasoon s, jenkins r. public perception of mental health in iraq. international journal of mental health systems. 2010;4(1):26. doi: 10.1186/1752-4458-4-26 [14] hobel cj, goldstein a, barrett es. psychosocial stress and pregnancy outcome. clinical obstetrics and gynecology. 2008;51(2):333-48. doi: 10.1097/ grf.0b013e31816f2709. [15] olfson m, mechanic d, hansell s, boyer ca, walkup j. prediction of homelessness within three months of discharge among inpatients with schizophrenia. psychiatric services. 1999;50(5):667-73. doi: 10.1176/ps.50.5.667 [16] crawford dm, trotter ec, hartshorn kjs, whitbeck lb. pregnancy and mental health of young homeless women. american journal of orthopsychiatry. 2011;81(2):173-83. doi: 10.1111/j.19390025.2011.01086.x [17] read j, van os j, morrison ap, ross ca. childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications. acta psychiatrica scandinavica. 2005;112(5):33050. doi:10.1111/j.16000447.2005.00634.x 92 erbil journal of nursing & midwifery https://dx.doi.org/10.1186%2f1471-244x-8-24 https://dx.doi.org/10.1186%2f1471-244x-8-24 https://dx.doi.org/10.1186%2f1471-2458-7-274 https://dx.doi.org/10.1186%2f1471-2458-7-274 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3302553/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3302553/ https://dx.doi.org/10.2471%2fblt.11.091850 https://doi.org/10.15218/ejnm.2018.11 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article [26] al-dabbagh sa, al-taee wy. risk factors for pre-term birth in iraq: a case-control study. bmc pregnancy and childbirth. 2006;18(6):13. doi:10.1186/1471-23936-13 [27] higgins a, downes c, monahan m, gill a, lamb sa, carroll m. barriers to midwives and nurses addressing mental health issues with women during the perinatal period: the mind mothers study. journal of clinical nursing. 2018;27(9– 10);18721883. doi: 10.1111/jocn.14252 93 erbil journal of nursing & midwifery https://doi.org/10.1186/1471-2393-6-13 https://doi.org/10.1186/1471-2393-6-13 https://doi.org/10.15218/ejnm.2019.03 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article quality of life of patients undergoing maintenance hemodialysis in erbil city abstract introduction chronic kidney disease (ckd) is an increasing worldwide public health concern. it is distinguished by an irreversible deterioration of renal function that can lead to endstage renal disease (esrd), which necessitates therapy with renal replacement therapy (rrt) such as renal transplant or hemodialysis (hd). hd is one of the most effective therapeutic techniques for patients with esrd second to renal transplantation but is costly and tiresome therapy for patients with esrd*1+ current statistics indicate an increase in patient’s life time background and objectives: chronic renal disease is one of the developing issues everywhere throughout the world. health related quality of life is a critical, yet is disregarded part of chronic kidney disease care. alongside survival and different kinds of clinical results, patient quality of life is an important marker of the effectiveness of the medical care they get. the study aimed to evaluate the quality of life of patients undergoing maintenance hemodialysis in erbil city. methods: a descriptive study design conducted in the erbil dialysis centre and dialysis unit at erbil teaching hospital. the sample include 262 end stage renal failure patients undergoing hemodialysis for at least 2 months, the kidney diseases quality of life short form questionnaire were used to obtain the information through structured interview. the study lasted from 24 march to 30 may 2018. the data were analyzed through descriptive statistical approach, chi-square test and person correlation analysis. results: participants were 262 patients with mean age of 55.55 ±13.831 years, 52.3% were female, 92% were married, 46.2% were illiterate and 66.4% were from rural area. the overall quality of life score was higher in male patients than female. about 61% of patients had below average quality of life. regarding the quality of life domains, out of seven domains only two of them (symptoms/ problems and quality of social interaction domains) were at average level of quality of life, the rest domains were below average level. the results of the study revealed that there is significant relationship between quality of life score and level of education. conclusion: according to the finding of the study, the patients with end stage renal failure undergoing hemodialysis had poor quality of life in most domains and the study found that there were a significant relationship between patients education and there quality of life. keywords: end stage renal failure, hemodialysis, quality of life, kidney diseases quality of life short form . haval mohammed qader; department of nursing, college of nursing, hawler medical university, erbil, iraq. vian afan naqshbandi; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: haval.mohammed@nur.hmu.edu.krd ) 19 erbil journal of nursing & midwifery received: 25/7/2018 accepted: 17/12/2018 published: 30/5/2019 https://doi.org/10.15218/ejnm.2019.03 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article due to haemodialysis. dialysis like other treatment types can result in improvement and remission of patients. however, the side effects of dialysis may reduce the quality of life (qol) of patients and lead to faintness and inability in various aspects of life*2+. world health organization’s (who) defined qol as “individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns”. it is a broad ranging concept affected by the person’s complex physical health, psychological state, level of independence, social relationships, personal beliefs and their relationship to salient features of their environment*3+. quality of life measures are subjective or objective, functional or satisfaction-based, and generic or disease-specific. recent studies showed an association between assessment of qol and morbidity and mortality in end-stage renal disease patients. *4+. according to sapkota and his colleagues has been estimated that over 1.1 million people are currently on maintenance hemodialysis (mhd) globally and this figure is increasing by 7% every year*5+. the end-stage renal disease (esrd) patients initiating renal replacement therapy (rrt) experience significant morbidity and limitations in quality of life*6,7+. substantial reductions in patients’ involvement in social and recreational activities, freedom, and abilities to work and travel, which have been associated with poorer overall health status and survival*6,8+. health-related quality of life (hrqol) has become increasingly important as an outcome measure of renal replacement therapy (rrt). the traditional focus on the improvement of survival has recently shifted to include a much stronger emphasis on quality of life*11+. health-related quality of life (hrqol) represents the impact of the disease or its treatment on the subjective feelings of patients about their physical, mental, spiritual, emotional, social and functional wellbeing. (hrqol) deteriorates as kidney function worsens and is an independent risk factor for mortality in dialysis patients*12+. this study aimed to assess the quality of life of patients with end stage renal failure undergoing maintenance hemodialysis in erbil city and to find out the association between quality of life and sociodemographic characteristics (age, gender, marital status and educational level). a descriptive study was conducted with patients with end stage renal failure undergoing hemodialysis treatment in erbil city. the study conducted at erbil dialysis center and dialysis unit at erbil teaching hospital during march 24 to may 30, 2018. the sample of the study included all adult patients with end stage renal failure who had maintenance hemodialysis were attending to erbil dialysis center and dialysis unit at erbil teaching hospital; three session per week which include 125 males and 137 females, the patient with psychological disorder, very tired patients and new cases were excluded. the researcher obtained official acceptance letter for conducting this study; oral informed consent obtained from participant in the study. a questionnaire prepared by the researcher to obtain data for this study and the kidney diseases quality of life short form kdqol sf questionnaire were used. the questionnaire is reliable and recommended by the national kidney foundation. the pilot study was carried out in february 2018, the results of two checking (test and re-test) were analysed to find out the reliability by calculating methods 20 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.03 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article level in the all domains except symptoms/ problems and quality of social interaction domains which ranked average level. cronbach's coefficient correlation it was 0.82. structured interview utilized to obtained patients responds about the questionnaire. the data collected within the first 2 hours after the initiation of hemodialysis in order to ensure that patients were not suffering from any dialysis-related discomfort. each interview spent approximately 20 – 25 minutes. each item (question) is put on a 0 to 100 range so that the lowest and highest possible score were set at 0 and 100, respectively. scores represented the percentage of total possible score achieved. the scores for each domain were classified in categories of below average ≥33, average 34-67, and above average 68-100 according to the kdqol of medical education institute *13+. data were organized and coded into the computer files; statistical package for social science (spss) version 23 omit was used. descriptive statistical analysis (frequency, percentage, mean and standard deviation) and chi-square test or fisher’s exact test for categorical variables was used. the correlation between domains performed using person correlation coefficient. a total of 262 end stage renal failure (esrd) patients with a mean age of 55.55 ±13.83 years on hd were included, and the highest percentage of the patients 39.3% were within the age groups 48-62 years and there were more females than males 52.3% vs 47.7%. most of them were married 92%. near of half of the sample was illiterate 46.2%. about 66.4% of the study population were living in rural areas. the baseline demographic characteristics are shown in table 1. table 2 shows the distribution of scores for the seven domains of kdqol sf. most of the domains scores ranked below average 21 results erbil journal of nursing & midwifery table 1: sociodemographic characteristics of study samples variables f (n =262) % mean age ± standard deviation 55.55 ±13.831 age groups 18-32 20 7.63 % 33-47 47 17.93 % 48-62 103 39.31 % 63-77 83 31.7 % 78-92 9 3.43 % gender male 125 47.7 % female 137 52.3% marital status single 16 6.1 % married 241 92.0 % widow/ widowed 4 1.5 % separated 1 0.4 % educational level illiterate 121 46.2 % primary school 74 28.24 % intermediate school 47 17.93 % high school or vocational 11 4.2 % institute and above 9 3.43 % residential area rural 174 66.4 % urban 88 33.6 % https://doi.org/10.15218/ejnm.2019.03 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article 22 table 2: sociodemographic characteristics of study samples erbil journal of nursing & midwifery table 3: association of quality of life levels of patients with their sociodemographic characteristics. variables frequency (n =262) % mean age ± standard deviation 55.55 ±13.831 age groups 18-32 20 7.63 % 33-47 47 17.93 % 48-62 103 39.31 % 63-77 83 31.7 % 78-92 9 3.43 % gender male 125 47.7 % female 137 52.3% marital status single 16 6.1 % married 241 92.0 % widow/ widowed 4 1.5 % separated 1 0.4 % educational level illiterate 121 46.2 % primary school 74 28.24 % intermediate school 47 17.93 % high school or vocational 11 4.2 % institute and above 9 3.43 % residential area rural 174 66.4 % urban 88 33.6 % sociodemographic characteristics overall qol score above average average below average pvalue frequency (%) frequency (%) frequency (%) gender 0.271 male 0 (0) 53 (42.4) 72 (57.6) female 0 (0) 49 (35.8) 88 (64.2) age groups (years) 0.491 18-32 0 (0) 8 (40) 12 (60) 33-47 0 (0) 19 (40.4) 28 (59.6) 48-62 0 (0) 43 (41.7) 60 (58.3) 63-77 0 (0) 31 (37.3) 52 (62.7) 78-92 0 (0) 1 (11.1) 8 (88.9) educational level 0.012 illiterate 0 (0) 35 (28.9) 86 (71.1) primary school 0 (0) 31 (41.9) 43 (58.1) intermediate school 0 (0) 23 (48.9) 24 (51.1) high school or vocational 0 (0) 7 (63.6) 4 (36.4) institute and above 0 (0) 6 (66.67) 3 (33.33) marital status 0.434 single 0 (0) 8 (50) 8 (50) married 0 (0) 91 (37.8) 150 (62.2) widow 0 (0) 2 (50) 2 (50) separated 0 (0) 1 (100) 0 (0) https://doi.org/10.15218/ejnm.2019.03 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article end stage renal failure (esrf) is a chronic disease which causes a high level of hindrance in different aspects of the patient’s life, leading to poor quality of life (qol). end stage renal failure impacts qol of patients with adverse effects observed in domains of symptoms/ problems, effects of kidney disease on daily life, burden of kidney disease, cognitive function, sexual function and sleep domains. the mean age of esrf patients undergoing hd in most developing countries is lower than that in developed countries *14+. the mean age of current study is 55.55 (±13.83) which agree with the result of previous study done on 286 patients with mean age of 54.71(±14.12) *15+. the reasons behind this difference are the delay of detecting renal disease and failure to controlling and preventive renal failure, both of which result in faster deterioration of renal function and progression of esrd. more than half of the patients in this study were female, which is consistent with previous studies that showed more than half of correspondents were female*16+. the majority of patients ranged within the age groups of (48-62 years). this is in line with other studies that the majority of study sample was more than 40 years*14+. the results of present study revealed that the near of half of patients were illiterate. which is in the line with the study carried out by brzanji which aimed to assess quality of life for dialysis patients in kirkuk city which showed that the more than half of patients were illiterate *17+. regarding the marital status, most of the patients were married. our finding was consistent with other study done in nepal, aimed to assess qol in patients undergoing hemodialysis and evaluated the effects of various sociodemographic factors affecting qol in that the most of the participant were married *18+. regarding the residency, the majority of the study samples were from rural areas. our result comes with other study done in the india *19+. the present study showed that the highest percentage of patients was ranked below average overall qol scores; the remaining of the sample was ranked average qol. the majority of the male and female sample was ranked below average, while in a comparison between male and female, the male patients have better qol than female patients. the finding agrees with other study done in brazil showed that women had lower qol in physical role scores, symptoms/problems, physical functioning, emotional well-being, energy and fatigue mean score *15+. acording to ramatillah the reasons for poor qol in women seem to be related to psychological and social factors, rather than the illness itself (20). the result showed that there is no significant relationship between gender of sample and overall qol at p<0.05. more than half of the age group (48-62 years) ranked below average qol. the finding is in line with other study done in malaysia *20+. the result showed that there is no significant relationship between age groups of the sample and overall qol at p<0.05. in association of overall qol and level of education, the qol level of majority of illiterate patients was ranked below average whereas minority of them were ranked average qol. the results of present study showed that there is a significant relationship between level of education of the sample and overall qol at p<0.05. the present study illustrate that the illiterate patient have poor qol. the finding agrees with other studies done by vk anu et al *12+ and joshi et al *16+ were showed that illiterate patient have poor qol. the possible reason behind this may be that 23 erbil journal of nursing & midwifery discussion https://doi.org/10.15218/ejnm.2019.03 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article illiterate patients have poor knowledge regarding disease condition and its management so that they cannot implicate it on their lives for the better outcomes. the results of the current study showed that the qol levels of majority of married patients were ranked below average while more than one third of them were ranked average qol. we found that the married patient have better qol than unmarried patient, a finding consistent with other study *21+. in erbil, due to extended family structure, even unmarried people usually get adequate emotional and financial support from their families, the emotional and financial support where is most often linked to marriage. the results of present study showed that there is no significant relationship between marital status of sample and overall qol at p<0.05. the present study explored all domains that ranked below average qol level except symptoms/problems and quality of social interaction domains which ranked average qol level. the findings of this study agree with other studies because qol scores were poor across all domains and the highest score was for quality of social interaction *22+. a similar trend of very low scores in burden of kidney disease domain and relatively good scores in symptom and problem domain have been noted in other study conducted by kamau et al. *23+. the study stated that the majority of the hemodialysis patients there were below average level of qol and the study found that there is a significant relationship between educational level and qol. we would like to thank all the patients who participated in this study and dialysis staff of erbil dialysis centre and dialysis unit at erbil teaching hospital, for their support and cooperation during the study period. we are especially thankful to mr. dara albanna for his role and contribution in data analysis. the authors report no conflict of interests. *1+ aropadi an, mason g, rettore e, ronco c. cost of peritoneal dialysis and haemodialysis across the world. nephrology dialysis transplantation. 2013 oct;28(10):2553–69. *2+ shdaifat ea, abdul manaf mr. quality of life among jordanian patients on haemodialysis and their caregivers. bmc public health. 2012 nov 27;12(2):a14. *3+ romero m, vivas-consuelo d, alvis-guzman n. is health related quality of life (hrqol) a valid indicator for health systems evaluation? springerplus. 2013 dec 11;2:664. *4+ kimmel pl, patel ss. quality of life in patients with chronic kidney disease: focus on end-stage renal disease treated with hemodialysis. seminars in nephrology. 2006 jan;26(1):68–79. *5+ sapkota a, sedhain a, rai mk. quality of life of adult clients on renal replacement therapies in nepal. journal of renal care. 2013 dec;39(4):228–35. *6+ murtagh fem, addington-hall j, higginson ij. the prevalence of symptoms in end-stage renal disease: a systematic review. advances in chronic kidney disease. 2007 jan;14(1):82 –99. *7+ wu aw, fink ne, marsh-manzi jvr, meyer kb, finkelstein fo, chapman mm, et al. changes in quality of life during hemodialysis and peritoneal dialysis treatment: generic and disease specific measures. journal of the american society of nephrology. 2004 mar;15(3):743–53. *8+ johansen kl, chertow gm, kutner ng, dalrymple ls, grimes ba, kaysen ga. low level of self-reported physical activity in ambulatory patients new to dialysis. kidney international. 2010 dec;78(11):1164–70. *9+ lee mb, bargman jm. survival by dialysis modality-who cares? clinical journal of the american society of nephrology. 2016 jun 6;11(6):1083–7. 24 erbil journal of nursing & midwifery conclusions acknowledgment conflicts of interest references https://doi.org/10.15218/ejnm.2019.03 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *20+ abdelghany ma, nienaa eee and ya. assessment of health-related quality of life in patients receiving regular hemodialysis. journal of nephrology & therapeutics *internet+. 2016 apr 9 *cited 2018 jul 9+;2016. available from: https:// www.omicsonline.org/peer-reviewed/ assessment-of-healthrelated-quality-of-lifein-patients-receiving-regular-hemodialysis72051.html *21+ kamau e, kayima j, otieno cf. the determinants of health related quality of life of patients on maintenance haemodialysis at kenyatta national hospital, kenya. east african medical journal. 2014 oct;91(10):368– 74. *10+ joshi vd. quality of life in end stage renal disease patients. world journal of nephrology. 2014 nov 6;3(4):308–16. *11+ kdqol complete *internet+. *cited 2018 jun 26+. available from: https://www.kdqolcomplete.org/ *12+ anu vk, pushpa p, kumar ss. quality of life of patients undergong haemodialysis at b.p. koirala institute of health sciences. journal of manmohan memorial institute of health sciences. 2014 feb 22;1(2):19–25. *13+ oliveira apb, schmidt db, amatneeks tm, santos jcd, cavallet lhr, michel rb. quality of life in hemodialysis patients and the relationship with mortality, hospitalizations and poor treatment adherence. journal brasileiro de nefrologia. 2016 dec;38(4):411–20. *14+ yusop nbm, mun cy, shariff zm, huat cb. factors associated with quality of life among hemodialysis patients in malaysia. plos one. 2013 dec 16;8(12):e84152. *15+ brzanji ryhriaa-. quality of life for hemodialysis patients in kirkuk governorate / iraq. kufa journal for nursing sciences *internet+. 2014 feb 26 *cited 2018 jun 25+;3(3). available from: http://www.uokufa.edu.iq/ journals/index.php/kjns/article/view/2245 *16+ joshi u, subedi r, poudel p, ghimire pr, panta s, sigdel mr. assessment of quality of life in patients undergoing hemodialysis using whoqol-bref questionnaire: a multicenter study. international journal of nephrology and renovascular disease. 2017;10:195–203. *17+ manavalan m, majumdar a, harichandra kumar kt, priyamvada ps. assessment of health-related quality of life and its determinants in patients with chronic kidney disease. indian journal of nephrology. 2017;27 (1):37–43. *18+ ramatillah dl, syed sulaiman sa, khan ah, meng ol. quality of life among patients undergoing hemodialysis in penang, malaysia. journal of pharmacy and bioallied sciences. 2017;9(4):229–38. *19+ ogutmen b, yildirim a, sever ms, bozfakioglu s, ataman r, erek e, et al. health-related quality of life after kidney transplantation in comparison intermittent hemodialysis, peritoneal dialysis, and normal controls. transplantation proceedings. 2006 mar;38(2):419 –21. 25 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.04 ejnm, vol. 1, no. (1), may, 2018 original article nurse/midwives' practices during labor and delivery in maternity teaching hospital in erbil city abstract introduction labor is a process by which the fetus, placenta, and membranes are expelled through the birth canal *1+. birth is a lifechanging event and the care given to women during labor has the potential to affect them both physically and emotionally in the short and long term *2+. the maternal mortality ratio at this hospital is the second highest in the region at 84 per 100,000 births, placing iraq in a group of 68 countries globally, which account for 97% of all maternal and child deaths. this is mainly the result of poor birth practices, inadequate referral or availability of emergency obstetric care, and a high level of anemia among pregnant women (35%), which particularly affects rural women and those in the southern and central governorates of the country *3+. complications of labor and birth can lead to maternal and infant mortality *4+, these include: premature rupture of the membranes, prolonged labor, retained placenta, excessive vaginal bleeding, malpositioning of the fetus, hypertonic uterine, primary inertia, prolonged latent background and objective: labor is a life-changing event and is a high-risk time for both the fetus and the mother which affects them physically and emotionally, so proper care during labor and delivery is important. the study assessed the quality of the labor and delivery care by nurse/midwives. methods: a study was carried out to observe nurse/midwives’ practices during the stages of labor and delivery. the study was conducted in the delivery room of the maternity teaching hospital in erbil city, during the period 28th february 2013 to 20th may 2013. the non-probability sample included 15 midwives who gave care to mothers during labor. data were collected through a questionnaire format and observation checklist. results: midwives did not perform the following practice during labor and delivery: preparing the mother (84%), checking vital signs (93.3%), using aseptic technique for fixing a cannula (96.6%), providing privacy for the mother (84%), and using sterile technique for vaginal examination, catheterization, and episiotomy (91.6%) (91.7%) (92.5%) respectively, monitoring uterine contraction (98.3%), checking the progress of labor (93.4%) and selecting a suitable position for delivery (93%). conclusion: nurse/midwives did not provide proper care during labor and delivery. improvements in their practice through training courses and changing hospital and delivery room policies is recommended. keywords: midwife; practice; quality; labor; delivery. lana abdul-hamed muhammad nuriy; college of nursing, sulaimaniya university, sulaimaniya, iraq. hamdia mirkhan ahmed; department of midwifery, college of nursing, hawler medical university, erbil, iraq. (correspondence: hamdia.mirkhan@nur.hmu.edu.krd) 23 erbil journal of nursing & midwifery received: 2/9/2017 accepted: 2/11/2017 published: 5/5/2018 https://doi.org/10.15218/ejnm.2018.04 ejnm, vol. 1, no. (1), may, 2018 original article phase, precipitate labor, uterine rupture, amniotic fluid embolism, prolapse of the umbilical cord, and meconium staining. the risks of maternal post-partum infection, hemorrhage, and infant mortality are higher in women who have a prolonged labor than those who do not. continuous monitoring of a woman in labour and her fetus, and providing emotional support for her and her family are essential. the nurse plays a key role in providing this physical and emotional care *5+. there is an emphasis on proper care during labor in order to reduce the rate of maternal, fetal, and neonatal deaths during the perinatal period. desired outcomes are achieved by structured nursing and midwifery care, which consists of a formalized approach to assessment of and intervention for a mother and fetus during labor. the main components are: normalize the environment; palpate to assess fetal position; encourage maternal position; assess labor pain; demonstrate cognitive, behavioral, and sensory intervention to manage labor pain; assess maternal emotional status; and use interventions to reduce emotional distress *6+. childbirth is not a joyous event for some; it maybe a time of pain, fear, suffering, and even death. during labor and delivery, the nurse/midwives should administer sensitive and appropriate care based on the particular needs of the mother and her family. the aim of care in a normal birth is to achieve a healthy mother and fetus with the least possible level of interventio consistent with safety. therefore, the intention of this study was to find out nurse/ midwives’ practices in the labor room, regarding care during the active first phase and the second, third, and early fourth stage of labor. an observational study was implemented to observe the practices of 15 (from a total of 22) nurse/midwives during their care of the different stages of labor and delivery in the maternity teaching hospital in erbil city, during the period 28th february 2013 to 20th may 2013. the maternity teaching hospital in erbil city is the oldest and the only governmental maternity teaching hospital in the area. the study approved by scientific and ethical committee of college of nursing/hawler medical university and erbil general directorate of health. nurse/midwives who were giving care during the stages of labor on three working shifts: morning (8:00am 1:00pm), evening (1:00pm -8:00pm), and night (8:00pm 8:00am), and those who had at least one year experience and above in delivery room were included. nurse/ midwives who were not available during the period of data collection and those who were giving care for complicated labor such as prolonged labor and primi para’s mothers were excluded. a questionnaire was designed by the researcher which consisted of nurse/midwives' background information, in addition of an observational check list to observe nurse/midwives practices during all four stages of labor through reviewing of related literature regarding standard labor and delivery care. data were collected through interviews for collecting background information of nurse/ midwives’ which took 5-10 minute, and direct observation of nurse/midwives' practices during the four stages of labor and delivery. the observation check list used included the following items: preparing mother before delivery, preparing the trolley, fixing the cannula, giving medication and fluid, sterile technique during vaginal examination, monitoring contractions, checking progress technique, monitoring amniotic membranes and fluid, catheterization technique, preparing the table for delivery, episiotomy technique, conduct during the actual delivery, newborn care methods 24 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.04 ejnm, vol. 1, no. (1), may, 2018 original article more than half of nurse/midwives (53.3%) had 1– 9 years’ experience in the labor room, and 40% of the nurse/midwives worked the evening shift. the majority of them (73.3%) had participated in training courses regarding care during labor and delivery. sixty percent of them were satisfied with working in the delivery room; however only (40%) believed that they were responsible for giving full care in all stages of labor (see table 2). the result of the current study indicate that during the active phase of labor, the majority (84%) of nurse/midwives did not prepared the mothers. a high percentage (60%) of nurse/midwives did not prepare the trolley, which contains the equipment required for care during labor. the majority (93.3%) of nurse/midwives did not check the mother’s vital signs. also a high waiting for placental separation signs, placenta delivery with care after its delivery. the duration of an observation depended on the mother’s situation. those observations, which were not completed during one shift were dropped. the nurse/ midwives were not informed regarding the researcher's observations. each nurse/ midwives was observed four times on different shifts. the items of the observation checklist were rated as done=1, not done =2. validity of the questionnaire and the checklist were determined through a panel of 19 experts from different related specialties. a pilot study was conducted with six nurse/midwives representing 40% of the total possible study sample. split – half reliability was determined and measured through the computation of the person-product moment correlation. the correlation coefficient was r = 0.853 = 85.3% which is statistically adequate. rights and confidentiality of the participants were respected in all phases of the study. through an informed consent process, explanation of the type and purpose of the study, confidentiality, voluntary participation and free will to withdraw were explained. it was also explained that the data were for study purposes only. the observations of the researcher were not shared with the nurse/ midwives to prevent the probability of bias in conducting the study. data were prepared, and entered into the statistical package for social science (spss, version 21). data were analyzed through the application of frequency, percentage, chisquare, and t-test. the mean age and standard deviation of the 15 nurse/midwives participants was 38.80±9.48. more than half (53.3 %) were married and had graduated from a secondary school of nursing or midwifery (see table 1). 25 results erbil journal of nursing & midwifery table 1: sociodemographic characteristic of nurse/midwives socio-demographic characteristics no (%) age 2025 1 (6.7) 26 – 30 3 (20) 3135 2 (13.3) ≥36 9 (60) m ± sd 38.80±9.48. marital status married 8 (53.3) single 5 (33.3) divorced 1 (6.7) widowed 1 (6.7) level of education college of nursing / midwifery 2 (13.7) diploma of nursing / midwifery 1 (6.7) secondary school of nursing/midwifery 8 (53.3) primary school of nursing 2 (13.3) training course of nursing 2 (13.3) https://doi.org/10.15218/ejnm.2018.04 ejnm, vol. 1, no. (1), may, 2018 original article percentage (96.6%) and (91.6%) of them did not use aseptic techniques during fixing cannula and during vaginal examination, respectively. almost all nurse/midwives (98.3%) did not monitor contractions, and many (93.4%) = did not check the steps of labor process over half (68.3%) of nurse / midwives monitored amniotic membrane for intact or ruptured status and characteristic of amniotic fluid. no nurse/midwives monitored the fetal heart rate. during the 2nd stage of labor, the majority of nurse/ midwives prepared the table for delivery in appropriate way (90%) and conducted the actual delivery (81.7%). in the second stage of labor, the majority of them did not perform following practices: using sterile technique during catheterization, selecting a suitable position for delivery, and performing episiotomy under sterile techniques. regarding practice of nurse/ midwives during the 3rd stage of labor, the majority(66.7%) waited for placental separation signs, did not perform newborn care after delivery (61.7%) ;and did not perform placenta delivery and care after its delivery (93.3%) in addition, 63.3% of nurse/ midwives they did not document delivery event (see table 3, 4). the results of the current study indicated that there were no significant differences in nurse/midwives practices during the four observations regarding preparing the mother, checking vital signs of mother, fixing the cannula under sterile technique, providing privacy for the mother, using sterile technique for the vaginal examination, monitoring contraction, checking progress of labor, monitoring amniotic membranes and fluid and monitoring fetal heart rate. while there was statistically significant differences in the practices of nurse/midwives during the four observations regarding preparing the trolley and giving medication as prescribed (see table 5). as indicated in table 6,there are statistically significant differences in the practices of nurse/midwives in the second stage of labor during the four observations regarding newborn care after delivery. there were no significant differences in their practices during the four observations regarding sterile technique during catheterization, preparing the table for delivery with full equipment, selecting a suitable position for delivery, performing an episiotomy under sterile technique, conducting the actual delivery, waiting for placental separation signs, and delivery of placenta with care after its delivery. 26 table 2: professional background of nurse/ midwives erbil journal of nursing & midwifery professional background of nurse/midwives no. (%) experience in deliver room 1-9 8 (53.3) 10-17 3 (20) 1825 2 (13.3) 26 – 33 2 (13.3) working shifts morning shift 4 (26.7) evening shift 6 (40) night shift 5 (33.3) participation in training course regarding care during labor and delivery yes no 11 4 (73.3) (26.7) satisfaction with working in delivery room yes no 9 6 (60) (40) responsibility for giving full care for mother during all stages of labor yes no 6 9 (40) (60) https://doi.org/10.15218/ejnm.2018.04 ejnm, vol. 1, no. (1), may, 2018 original article * episiotomy done for 27 mothers n= 27 table 4: nurse/midwives practice during 2nd and 3rd stage of labor 27 table 3: overall nurse/midwives’ practice during first stage of labor (n=60) erbil journal of nursing & midwifery items yes no no. (%) no. (%) prepare the mother 10 (16) 50 (84) prepare the trolley 24 (40) 36 (60) check mother’s vital signs 4 (6.6) 56 (93.3) fix the cannula under complete aseptic technique 2 (3.4) 58 (96.6) giving medication as prescribe 24 (40) 36 (60) provide privacy of the mother 10 (16) 50 (84) using sterile technique for vaginal examination 5 (8.4) 55 (91.6) monitoring uterine contraction 1 (1.7) 59 (98.3) checking progressing for labour 4 (6.6) 56 (93.4) monitoring amniotic membrane and liquor 41 (68.3) 19 (31.7) checking fetal heart rate 0 (0) 60 (100) items n=60 yes no practice in second stage of labor no. % no. % use sterile technique during catheterization 5 (8.3) 55 (91.7) prepare the table for delivery in appropriate way 54 (90) 6 (10) select suitable position for delivery 3 (5) 57 (93) performing episiotomy under sterile technique (92.5) 25 (3.3) 2 ٭ conduct of actual delivery 49 (81.7) 11 (18.3) new born care after delivery 23 (38.3) 37 (61.7) practice in third stage of labor waiting for placental separation signs 40 (66.7) 20 (33.3) placenta delivery with care after its delivery 4 (6.7) 56 (93.3) documentation of delivery 22 (36.7) 38 (63.3) https://doi.org/10.15218/ejnm.2018.04 ejnm, vol. 1, no. (1), may, 2018 original article * fisher's exact test was applied. 28 erbil journal of nursing & midwifery table 5: differences of practices in first stage of labor during four observations items observations p-value first n (%) second n (%) third n (%) fourth n (%) prepare the mother yes 1(11.1) 4(44.4) 3(22.2) 2(22.2)٭ 0.854 ns no 14(28) 11(22.0) 12(24.0) 13(26.0) prepare the trolley yes 3(12.5) 9(37.5) 5(16.7) 8(33.3) 0.047 s no 12(35.3) 6(14.7) 10(29.4) 7(20.6) monitoring mother vital sign yes 2(40) 2(20) 2(20) 1(20) 0.539 ns no 13(24.5) 13(24.5) 13(24.5) 14(26.4) fix the cannula under complete aseptic technique yes 15(26.8) 13(23.2) 14(25) 14(25) 0.529 ns no 0 (0) 2(20) 1(50) 1(50) give medication as prescribed yes 3(12.5) 9(37.5) 5(16.7) 8(33.3) 0.047 s no 12(35.3) 6(14.7) 10(29.4) 7(20.6) provide privacy for mother yes 1(20) 1(11.1) 3(40.0) 2(40) 0.306 ns no 14(26.4) 14(26.4) 12(22.6) 13(24.5) using sterile technique for vaginal examination yes 1(20) 1(11.2) 3(40) 2(40) 0.306 ns no 14(26.4) 14(26.4) 12(22.6) 13(24.5) monitoring uterine contraction yes 0(0) 1(100) 1(12) 0(0) 0.656 ns no 15(26.3) 15(22.8) 14(24.6) 15(26.3) checking progressing of labour yes 0(0) 2(100) 1(0) 0(0) 0.362 ns no 15(26.3) 13(22.8) 14(24.6) 15(26.3) monitoring amniotic membrane and liquor yes 8(20.5) 9(23.1) 12(30.8) 10(25.6) 0.315 ns no 7(36.8) 6(26.3) 3(10.5) 5(26.3) https://doi.org/10.15218/ejnm.2018.04 ejnm, vol. 1, no. (1), may, 2018 original article early fourth stage care was completely missed. this improper practice may be due to a crowded delivery room, which has 21 occupied beds with 5 nurse/midwives on the morning shift and 3 nurse/midwives on the evening and night shifts. other reasons for the lack of adherence to proper the practices of 15 nurse/midwives during the four stages of labor indicated improper practice as observed by the researcher. the majority of nurse/midwives did not properly do their complete responsibilities during labor and delivery. the 29 erbil journal of nursing & midwifery table 6: differences of nurse/midwives practices in 2nd and 3rd stage of labor during four observations items of second stage observations p-value first n (%) second n (%) third n (%) fourth n (%) use sterile technique during catheterization yes 3(60) 0(0) 1(20) 1(20) 0.356 ns no 10(25.6) 11(28.2) 8(20.5) 10(25.6) prepare table for delivery yes 14(24.1) 14(24.1) 14(24.1) 15(27.8) 0.419 ns no 1(33.3) 1(33.3) 1(33.3) 0(0) select suitable position for delivery yes 1(50) 1(50) 1(50) 0(0) 0.519 ns no 14(24.6) 14(24.6) 14(24.6) 15(26.3) performing episiotomy under sterile technique yes 1(50) 1(50) 0(0) 0(0) 0.175 ns no 6(24) 4(16) 7(28) 8(32) conduct of actual delivery yes 13(26.5) 12(24.5) 12(24.5) 12(24.5) 0.938 ns no 2(20) 3(20) 3(30) 3(30) new born care after delivery yes 8(36.4) 7(27.3) 5(22.7) 3(13.6) 0.052 s no 7(18.9) 8(21.6) 10(27) 12(32.4) items of third stage waiting for placental separation signs yes 9(22.5) 12(27.5) 11(27.5) 9(22.5) 0.728 ns no 6(27.8) 3(16.7) 4(22.2) 6(33.3) delivery of placenta with care after its delivery yes 1(11) 2(50) 1(25) 2(50) 0.571 ns no 14(25.9) 13(24.1) 14(25.9) 13(24.1) documentation of delivery yes 1(100) 0(0.0) 40(71.4) 16(28.6) 0.356 ns no 37(64.9) 20(35.1) 20(60) 40(71.4) discussion https://doi.org/10.15218/ejnm.2018.04 ejnm, vol. 1, no. (1), may, 2018 original article wellbeing during the active stage of labor, monitoring help the midwives and the mother in achieving spontaneous vaginal delivery with low risk of both morbidity and mortality *10+. a crosssectional descriptive study by mathibe-neke et al. in south africa concluded that the proper monitoring of women during labor and continuous accurate recording on the partograph is a critical not only in intervening appropriately, but also for minimizing unnecessary interventions. furthermore, accurate partograph recordkeeping enables an effective communication between healthcare professionals who manage the mother during labor *12+. the result of the current study indicated that the majority of nurse/midwives prepared the table for delivery in the appropriate way with full equipment. this maybe due to their experience in working in the delivery room. preparing the place and table of birth for the delivery is one of the nurse/midwives’ responsibilities, and the table is set with equipment such as sponges, drapes, scissors, basins, clamps, bulb syringe, vaginal packing, sterile gowns, and gloves, and is covered with a sterile towel, for up to 8 hours. finding of the current study showed that the majority of nurse/midwives waited for the placental separation signs. this result is in agreement with the findings of a study conducted in baghdad, which reported that there was high mean score with a positive trend in nurse/midwives’ practice regarding the 3rd stage of labor in waiting for placental separation signs *7+. in the current study, the majority of nurse/ midwives did not perform the placenta delivery correctly including proper care after its delivery. active management of the third stage of labor (amtsl) is a feasible and inexpensive intervention that can help save thousands of women’s lives. it involves three procedures: the use of an practice include the absence of guidelines to follow during care, unclear and overlapping the job descriptions of the nurse/ midwives and physicians, inadequate training course, unclear policies regarding care during labor and delivery, no identified role of nurse/midwives in documentation of finding with their signature, different level of education among nurse/midwives, and a lack of proper respect and communication with mothers. the current findings were was in agreement with finding of a study conducted in bagdad. the researcher assessed 75 nurse/midwives practices concerning perinatal care throughout stages of labor, indicated that a low mean score and negative trends in all the following items regarding the practices during first stage of labor in monitoring and recording vital signs, checking uterine contraction, monitoring the fetal heart rate, conducting vaginal examination and rupture of membranes *7+. a descriptive study was utilized to assess the quality of midwifery care in labor and delivery room for (96) mothers in iran. the results indicated that the lowest score was related to the assessment of vital signs, lack of emotional support, and inadequate hand washing *8+. the policies in the maternity teaching hospital in erbil city, identify that checking vital signs and monitoring the fhr is done by physician, for that reason the nurse/ midwives did not check vital signs. in spite of the fact that the partograph sheet was on the mother’s chart, neither the nurse/ midwives nor the physician used it for monitoring the mother’s situation in the delivery room. partogram is a clear way to record the history, physical examination information and recording mother’s labor progress *9+. partogram use is routine in the management of labor in many countries around the world, and can be helpful in the management and decision-making process to monitor fetal and maternal 30 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.04 ejnm, vol. 1, no. (1), may, 2018 original article ry and nursing care for patient with episiotomy the researchers of this similar study concluded that, none of the midwives gave the mother advice about pain relief, did not give information about hygiene, food intake, and they did not observe for complication post episiotomy in the first two hours *14+. nurse/midwives working in the delivery room did not render proper care during labor and delivery and most of their responsibilities were neglected. further studies to find the causes of this finding are necessary. improvements in nurse/ midwives practices through proper training courses and changing hospital and delivery room policy is recommended. the author reported no conflict of interests. *1+ cunningham fg, leveno k, bloom s, hauth j, gilstrap l, & wenstrom k. williams obstetrics. 23rd ed. usa. mcgraw-hill companies; 2010. *2+ nice clinical guidelines, no. 55. london. national collaborating centre for women's and children's health (uk). intrapartum care: care of healthy women and their babies during childbirth. rcog press; 2007. *3+ uncti (united nations country team iraq). maternal and child health. 2012. available from: http:// uniraq.org/flipnewsletter/un%20iraq% 20newsletter%20-%20march%202012/mobile/ index.html#p=15, *accessed 19 jun 2014+ *4+ littleton l & engebretson j. maternal neonatal and women's health nursing. usa. delmar thomson learning. 2002. *5+ pillitteri a. maternal & child health nursing: care of the childbearing & childrearing family 6th edition philadelphia. lippincott williams & wilkins. 2010. *6+ hodnett e, stremler r, willan a, weston j, lowe n, simpson k, et al. effect on birth outcomes of a formalized approach to care in hospital labor assessment units. bmj. *internet+; 2008; 377 (100): 10211136. available from: http://www.ncbi.nlm.nih.gov. *accessed 20 jul 2015+ *7+ rasheid, a. m. and ali, r. m. (2008). assessment of nurse – midwives practices concerning perinatal care throughout stages of labor. university of baghdad: karbala j. med. *internet+. *cited 2013 february 10+. uterotonic agent (preferably oxytocin) within one minute following the delivery of the baby, delivery of the placenta with controlled cord traction, and massage of the uterus after delivery of the placenta, with palpation of the uterus to assess the need for continued massage for the two hour period following delivery of the placenta *9+. in the current study during observation in the fourth stage of labor, the researcher identified that some practices and interventions for mothers were not carry out by nurse/midwives. after the delivery of the placenta they leave the mothers and their cleaning to be done by assistant and relatives of mothers and physicians were responsible for checking the mothers’ vital signs, checking the vagina for any tears or lacerations, and repairing of episiotomy. the nurse/midwives did not give instruction to the mother about perineal care, food intake, and breastfeeding. this may be due to a lack of knowledge regarding care. and a shortage of staffs and they are hurry in their job and may due to over load and crowding in delivery room. there can occur some life threatening complications during the immediate postpartum period the responsibility of nurse/midwives in the 4th stage is to frequently check the woman's physical wellbeing and blood loss, feel if the uterus is contracting, take her blood pressure and pulse as well as check her genitals for any tears or grazes, and put in stitches if necessary. during the first hour, frequent physical assessment of the mother is required. , it is necessary to take vital signs frequently, encourage the mother to pass urine within half an hour after delivery, encouraged to breastfeeding her baby as preferably within half an hour of delivery*13+. the findings of the current study are almost similar with the results of a study conducted in khartoum, to assess midwife31 erbil journal of nursing & midwifery conclusion conflicts of interest references https://doi.org/10.15218/ejnm.2018.04 ejnm, vol. 1, no. (1), may, 2018 original article 2008; 2(8,9). available from: http://www.iasj.net/iasj? func=fulltext&aid=19189. *accessed 2 feb 2015+ *8+ simbar m, ghafari f, tork zahrani s, majd h. (2009). assessment of quality of midwifery care in labor and delivery words of selected kurdistan medical science university. 2009; 22(3): 266-277. available from: http://www.emeraldinsight.com/journals. *accessed 12 feb 2015+ *9+ who. the who pantograph. available from: http:// books.mcai.org.uk/2.3.%20managing%20normal% 20labour%20and%20delivery.1.5mb/part3.htm. *accessed 20 may 2015+ *10+ lavender, t., aifirevic, z. & walkinshaw s. effect of different partogram action lines on birth outcome . 2006. *11+ mathibe-neke jm, lebeko f. l. 2 and motupa b. the partograph: a labour management tool or a midwifery record? 2013; 5(8), doi 10.5897/ijnm2013.0115 issn 2141-2456 © 2013 available from: http:// www.academicjournals.org/article/ article1385033884_mathibe-neke%20et%20al.pdf. *accessed 15 mar 2015+ *12+ popphi. active management of the third stage of labor data obtained from home deliveries in the cirebon district. 2006. available from: https:// www.path.org/publications/files/ mchn_popphi_amtsl_rpt_cirebon.pdf. *accessed 4 jun 2015+ *13+ kaur n, kaur spk.skill development of nurses in managing the fourth stage of labour. saha nursing and midwifery research journal.2014;10(1). *14+ khaier mgm. assessment of midwifery and nursing care for patients with episiotomy in albanjadeed teaching hospital. thesis , univerisity of medical sciences and technology,2006. 32 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.02 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article evaluation of effectiveness of wet cupping versus blood donation on hematological parameters in healthy young adults abstract introduction therapeutic phlebotomy also known as venesection or bloodletting is the therapeutic removal of blood from the body that has been practiced since ancient times to treat illnesses [1]. it began in egypt around 3000 years ago then spread around the world [2, 3]. its use gradually declined in the late 19th century and it was almost abandoned during the 20th century [4, 5]. in the past, bloodletting was practiced using lancets, cupping, and the application of leeches for localized bleeding to virtually treat illnesses [6, 5]. at present day, however, therapeutic phlebotomy is being used in modern medicine as an essential part of the treatment for various disorders including hemochromatosis, polycythemia vera and porphyria cutanea tarda [7]. despite significant advances in conventional medicine, there is a high prevalence and increased public interest background and objectives: therapeutic phlebotomy is the removal of blood from the body that has been practiced since ancient time for treating illnesses. recently, interest in wetcupping to treat various hematological disorders particularly polycythemia in public has grown. the present study aims to evaluate the effectiveness of wet-cupping versus blood donation on hematological parameters. methods: in this pre and post-test experimental study, a total of 60 healthy young adults were purposively assigned non-randomly either in cupping (n=30) or blood donation (n=30) groups. blood samples were collected from all subjects to measure hematological parameters before and one week after interventions. subjects of wet-cupping and blood donation were matched in age and baseline hematological parameters. the hematological parameters were analyzed using hematology analyzer (symex, japan). results: the findings of the study showed a significant difference in hematological parameters of wet-cupping and blood donation including hemoglobin level (hb) (14.87 g/dl vs. 14.39 g/dl), packed cell volume (pcv) (44.78 % vs. 42.91 %), and red blood cell (rbc) (5.27 1012/ul vs. 4.94 1012/ul), respectively. while the values of other parameters were not different significantly; mean cell volume (mcv) (85.15 fl vs. 86.95 fl), mean corpuscular hemoglobin (mch) (28.31 pg vs. 29.20 pg), mean corpuscular hemoglobin concentration (mchc) (33.24 g/dl vs. 33.57 g/dl), red cell distribution width (rdw) (12.53 % vs. 12.40 %), platelet (245.77 109/l vs. 246.27 109/l), and white blood cell (wbc) (7.47 109/ l vs. 7.47 109/l), respectively. conclusion: the present study concluded that both wet-cupping and blood donation are effective interventions in reducing hb, pcv, and rbc along with increase platelets in blood donation only. keywords: wet-cupping; blood donation; hematological parameters zuhair rishdi mustafa; department of nursing, college of nursing, university of duhok, duhok, iraq. )correspondence: zuhair.mustafa@uod.ac ) sabri khalaf sheiko; department of medicine, college of medicine, university of duhok, duhok, iraq. 11 erbil journal of nursing & midwifery received: 7/4/2019 accepted: 23/9/2019 published: 30/5/2020 mailto:zuhair.mustafa@uod.ac https://doi.org/10.15218/ejnm.2020.02 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article in complementary and alternative medicine (cam) [8].cupping is a method that uses local evacuation or distraction of morbid blood by glasses or cups. generally, cupping is of two types; wet which means cupping with bloodletting and dry cupping means cupping without bloodletting [9]. nevertheless, the mechanism of action of cupping therapy is not entirely understood [10]. few randomized control trials have investigated the effectiveness of wetcupping with various limitations [11]. in general, the body of cam literature on cupping is inconclusive [12]. positive outcomes are reported in many developing countries compared with the negative results reported by the industrialized world [11]. in iraq, information and exact statistics on the prevalence of cam use specifically cupping therapy is not yet available [13]. interest in wet-cupping among the public to treat various hematological disorders, particularly polycythemia, has grown considerably in recent years. therefore, the effectiveness of wet-cupping on hematological parameters has not been sufficiently investigated. the current clinical trial was performed to investigate the effectiveness of wet-cupping versus blood donation on hematological indicators. the author hypothesized that wet-cupping is more effective in reducing packed cell volume (pcv) compared to other categories of complete blood count while the blood donation was speculated to be more effective in hemoglobin level. study design and sampling in the present quasi-experimental study, a total of 80 healthy adult male aged between 22 and 62 years were purposively screened for eligibility criteria after obtaining official permission. the participants were optionally allocated non-randomly to cupping therapy (n=40) and blood donation (n=40) groups according to inclusion and exclusion criteria. the subjects of the study were kurdish volunteers from the community and were the staff of the duhok governorates over four months from november 2018 to february 2019. the subjects were matched in age and hematological parameters before final analysis, therefore, 10 cases were excluded from each group to make homogeneity. finally, 30 subjects were included in each group of the study. those persons who agreed to participate in the study were referred to the study clinician (second author) for complete physician and clinical examinations. the hematological parameters were analyzed using hematology analyzer (symex, japan). the inclusion criteria for the selection of the subject were: aged ≥18 years old, male, and regardless of socio-demographic perspectives, hemoglobin (hb) level ≥13.5 gm/dl, and weight ≥55 kg. the participants diagnosed with the organ failures (hepatic failure, heart failure, and renal failure), anemia, cancer, hemophilia or similar hematological conditions were excluded from the study. moreover, those utilizing pacemakers, taking chemotherapy, immunosuppressive drugs, anticoagulants, who had a previous blood donation within three months, who had a previous blood transfusion within six months, or who had wetcupping less than three months ago were not included in the study. also, the patients at risk of hypotension as diagnosed by the clinician were excluded from both interventions, cupping and blood donation. clinical procedures and treatment. wet-cupping procedure: wet-cupping was completed by the first author (nurse practitioner/under the supervision of a certified clinician) in a private clinic. before cupping therapy, the 40 participants were requested to fast for 4 hours to allow blood to be distributed in the body but not in the stomach for digestion. cupping was 12 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2020.02 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article of rest and 250 ml of fruit juice. moreover, the participants were advised to avoid bathing and swimming for 12 hours following the cupping procedure to prevent delays in wound healing. figure 1: a view of points on the skin in which wet-cupping therapy was applied blood donation: the reference population referred to duhok blood donation centre and consisted of 40 male volunteer blood donors. all participants were referred for the procedure following performing the required coordination. according to the roles of the bank, the subjects with a hemoglobin level of ≥ 13.5 g/dl, with a minimum weight of ≥ 55kg, not fasting, not taking any medication during the last 48 hours were included in the procedure. each subject donated a total of 450 ml of whole blood according to the blood bank policy from their antecubital vein. each participant was offered a few minutes of rest and 250 ml of fruit juice as a measure against fainting due to blood donation. measurement and data collection baseline information: the baseline and demographic characteristics of the subjects, including age, smoking (yes/ no) and its attributes were defined as light smoker: those who smoked 1-9 cigarettes/day, moderate smoker: those who smoked 1019 cigarettes/day, and heavy smoker: those who smoked ≥20 cigarettes/day or hookah [16]. in addition, current chronic diseases (yes/ no), past medical history/ past surgical history (yes/no), occupation, education level, place of residence (urban/ rural), recent blood donation/cupping at room temperature between 20 to 25 degrees celsius to avoid vasoconstriction caused by cold weather. before the intervention, the steps of the protocol were explained to the participants. blood pressure was measured before the procedure began as a pre-test assessment. all participants were requested to be in the prone position in bed with raising legs 30 degrees to avoid fainting. a manual hand suction pump was used for cupping procedure with disposable cups of capacity 100 ml each. five sites of the upper back were selected including: over seventh cervical vertebra, bilateral peri-spinal areas of the neck, and thoracic spine for the procedure (see figure 1) [14]. an antiseptic solution (70% ethanol) was used to clean the application areas. each procedure lasted for around 20 minutes and was conducted aseptically in five steps as follows [15]. scarification: the cups were removed, and ten superficial horizontal incisions 0.1-0.2 mm in depth and 1–2 cm in length parallel to each other were made on each chosen area of the skin using sterile surgical blades size 15. this technique avoids scar lesion and enhances faster healing. blood-letting: the cups were re-applied on the skin, and the suctioning was repeated. the cups were left on the designated areas of the skin for 10 minutes then the blood sucked out through the incisions. negative pressure was repeated by pumping every 3 minutes to enhance suctioning as cups filled with the blood and decreased suctioning ability. removal: the cups were removed after 10 minutes and the used cups, blood, and surgical blades were discarded safely. clean and dressing: the selection areas for cupping were disinfected using povidone iodine 4 % followed by placement of sterile pads. as a measure against adverse reactions such as fainting due to bloodletting, all participants were offered a few minutes 13 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.02 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article the independent t-test, chi-square, or fisher’s; exact tests. the paired t-test was performed for examining the difference of hematological parameters between pre and post-intervention in both groups. the effect size (cohen’s d) was calculated by g*power 3.3.9. also, independent t-test was performed to examine the difference in hematological indicators between postintervention study groups. the multivariate analysis model was performed to investigate the predictors of hematological parameters in both study groups. the null hypothesis was rejected in a p-value of less than 0.05. the statistical calculations were performed in the statistical package for social sciences (spss: 25 ibm). the total sample size required for the present study was calculated based on the measurement of rbc from the first 5 cases of each group separately. the mean (sta. deviation) of the first five cases of the cupping group was 5.30 (sd: 0.43). based on our expectation to a reduction to 5.0 (sd: 0.28) following the procedure, t-test: two dependent means (matched pairs), the actual power of 0.95, α: 0.05, and the effect size: 0.79, 23 subjects were required for the study. the mean (sta. deviation) of the first five cases of blood donation group was 5.44 (sd: 0.30). according to the expectation of the authors to a reduction to 5.12 (sd: 0.38); t-test: two dependent means (matched pairs); actual power of 0.95; t: 2.10, α: 0.05, and the effect size: 0.84, a total of 18 persons were required for the study. ethical approval. the ethical approval of the present clinical trial was obtained from the research ethics committee of general directorate of health of duhok as reference number: 17102018-8 and written informed consent from all participants before clinical assessment. 14 erbil journal of nursing & midwifery therapy (yes/ no), and blood pressure were collected through the self-reported technique. for the eligibility criteria, the volunteers were screened through laboratory tests and physical examinations. two ml of venous blood was collected before the commencement of procedures to test hematological parameters. subjects with hb level ≥ 13.5 g/dl were considered to be illegible for the study according to the blood bank policy, although this is not in line with world health organization 2012 guidelines on assessing donor suitability for blood donation [17], which stated that the recommended hb level for donation should not be less than 13.0 g/dl for males. the blood pressure of the subjects was measured from both arms upon the subjects sitting after a few minutes of rest using blood pressure mercury (alpk2 japan). hematological parameters testing after blood sample was obtained from veins through standard procedure, two ml of blood was collected by a tube with ethylenediamine tetraacetic acid (edta) anticoagulant for hematologic tests directly before and after the procedures and analyzed within 1-2 hours after obtaining the blood sample, meanwhile, the samples were kept in refrigerator. preand post cupping and blood donation hematological values were measured in the blood. parameters such as hb, pcv, rbc, mcv, mch, mchc, rdw, platelet, and wbc were analyzed using hematology analyzer (symex, japan). the descriptive purposes of the study were determined in frequency and distribution or mean and standard deviation. the homogeneity of the hematological parameters and age in both study groups were examined in an independent t-test. also, the comparison of baseline information of both groups was examined in https://doi.org/10.15218/ejnm.2020.02 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 15 erbil journal of nursing & midwifery two ml of blood was obtained from participants one week later after interventions. the analysis of the results showed that subjects of wet-cupping and blood donation groups were similar in age (37.67 vs. 38.13 years, p= 0.790), chronic disease (p=0.222), smoking (p=0.121), residency (p=0.274), and past surgical history (p=0.390), see table 1. however, subjects in cupping were more likely to have a less professional occupation as well as a lower level of education compared to their counterparts in blood donation group (p= 0.007 and p=0.004) respectively (table 1). the hematological parameters between the subjects of both study groups were matched before final analysis. in line with the inclusion criteria, the mean values of hb for both wet-cupping and blood donation were 15.33 and 15.63 g/dl, p= 0.065) respectively (table 2). table 1: comparison of general information between the subjects in cupping therapy and blood donation characteristics (n=60) cupping (n=30) blood donation (n=30) p-value (two-sided) age (year) range 37.67 (6.57) 22-49 38.13 (6.91) 25-52 0.790* chronic disease 9 (30) 5 (16.7) 0.222** smoker 18 (60) 12 (40) 0.121** smoking type moderate heavy 1 (5.6) 17 (94.4) 3 (25) 9 (75) 0.274*** residency urban rural 29 (96.7) 1 (3.3) 30 (100) 0 (0) 1.00*** occupation unemployed (students) worker governmental employed profession 1 (3.3) 13 (43.3) 16 (53.3) 0 (0) 1 (3.3) 4 (13.3) 20 (66.7) 5 (16.7) 0.007*** education illiterate primary school graduate intermediate school graduate high school graduate institute graduate college graduate postgraduate graduate 8 (26.7) 3 (10) 8 (26.7) 3 (10) 4 (13.3) 4 (13.3) 0 (0) 5 (16.7) 0 (0) 1 (3.3) 6 (20) 5 (16.7) 6 (20) 7 (23.3) 0.004*** past surgical history 10 (33.3) 7 (23.3) 0.390** *independent t-test, **chi-square, and ***fishers’ exact tests were performed for statistical analyses. the bold numbers show significant differences. results https://doi.org/10.15218/ejnm.2020.02 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 16 erbil journal of nursing & midwifery the complications found in subjects underwent wet-cupping therapy were bullae formation (n=3), discomfort in the region that underwent cupping (n=1), and dizziness (n=1). also, the complications in blood donation were local reactions (hematomas due to extravasation during procedure (n=1), dizziness (n=1), hypotension (n=1), and local reactions (hematoma due to extravasation after procedure) (n=3) (not shown in tables). the present study found a significant difference between pre and one week later assessment in some hematological parameters in both cupping and blood donation groups. in the cupping group, significant changes were observed in hb level (md: mean difference: -0.46, p=<0.001), pcv (md: -1.64, p=<0.001), and rbc (md: -0.17, p=<0.001).however,no significant changes were observed in mcv (md: -0.40, p=0.256), mch (md: +0.03, p=0.740), mchc (md: +0.19, p=0.123), rdw (md: +0.07, p=0.529), platelet (md: +7.20, p=0.081), and wbc (md: -0.32, p=0.083) p=<0.001). similarly, significant differences were seen in the blood donation group in hb level (md: -1.25, p=<0.001), pcv (md: 3.98, p=<0.001), rbc (md: -0.46, p=<0.001). correspondingly as cupping intervention, the other parameters in blood donation group did not change significantly; including mcv (md: -0.17, p=0.652), mch (md: +0.18, p=0.097), mchc (md: +0.20, p=0.117), rdw (md: -0.09, p=0.365), and wbc (md= -1.20, p=0.460), but a significant increase in the platelet count (md: +14.43, p=0.011) was observed (table 3). in a comparison of post-intervention of hematological parameters between cupping and blood donation groups, there was a significant difference in some indicators. the subjects in wet-cupping therapy had a higher level of hb (14.87 g/dl vs. 14.39 g/dl, p=0.018), pcv (44.78 % vs. 42.91 %, p=0.009), and rbc (5.27 1012/ul vs. 4.94 1012/ul, p=0.001), respectively. the subjects were comparable in other hematological parameters (p>0.05), see table 4. the different hematological parameters between two study groups (hb, pcv, and rbc) were considered dependent variables and other baseline and hematological factors as independent variables in the multivariate analysis model. the analysis did not find any another predictor for this difference except the intervention (table 5). table 2: comparison of pre-intervention assessment of hematological parameters between cupping and blood donation groups independent t-test was performed for statistical analyses. hematological parameters (n=60) cupping (n=30) donation (n=30) p-value (two-sided) mean sd mean sd hb (g/dl) 15.33 0.70 15.63 0.54 0.065 pcv (%) 46.42 2.68 46.89 1.79 0.431 rbc (1012/ul) 5.44 0.39 5.40 0.29 0.655 mcv (fl) 85.55 3.91 87.11 3.48 0.108 mch (pg) 28.28 1.51 29.02 1.56 0.068 mchc (g/dl) 33.05 0.80 33.37 1.12 0.215 rdw (%) 12.45 0.80 12.50 0.49 0.801 platelet (109/l) 238.57 44.83 231.83 53.40 0.599 wbc (109/l) 7.79 2.04 8.67 8.48 0.584 https://doi.org/10.15218/ejnm.2020.02 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 17 erbil journal of nursing & midwifery cupping (n=30) pre mean pre sd post mean post sd mean difference p-value (two-sided) hb (g/dl) 15.33 0.70 14.87 0.81 -0.46 <0.001 pcv (%) 46.42 2.68 44.78 2.59 -1.64 <0.001 rbc (1012/ul) 5.44 0.39 5.27 0.37 -0.17 <0.001 mcv (fl) 85.55 3.91 85.15 3.72 -0.40 0.256 mch (pg) 28.28 1.51 28.31 1.60 +0.03 0.740 mchc (g/dl) 33.05 0.80 33.24 0.86 +0.19 0.123 rdw (%) 12.45 0.80 12.53 0.68 +0.07 0.529 platelet (109/l) 238.57 44.83 245.77 48.27 +7.20 0.081 wbc (109/l) 7.79 2.04 7.47 1.950 -0.32 0.083 blood donation (n=30) pre mean pre sd post mean post sd mean difference p-value (two-sided) hb (g/dl) 15.63 0.54 14.39 0.73 -1.25 <0.001 pcv (%) 46.89 1.79 42.91 2.82 -3.98 <0.001 rbc (1012/ul) 5.40 0.29 4.94 0.36 -0.46 <0.001 mcv (fl) 87.11 3.48 86.95 3.63 -0.17 0.652 mch (pg) 29.02 1.56 29.20 1.44 +0.18 0.097 mchc (g/dl) 33.37 1.12 33.57 0.94 +0.20 0.117 rdw (%) 12.50 0.49 12.40 0.57 -0.09 0.365 platelet (109/l) 231.83 53.40 246.27 55.13 +14.43 0.011 wbc (109/l) 8.67 8.48 7.47 1.40 -1.20 0.460 table 3: comparison of hematological parameters before and after intervention in cupping and blood donation groups paired t-test was performed for statistical analysis. the bold numbers show significant differences. table 4: comparison of post-intervention assessment of hematological parameters between cupping and blood donation groups hematological parameters (n=60) cupping (n=30) donation (n=30) p-value (two-sided) mean sd mean sd hb (g/dl) 14.87 0.81 14.39 0.738 0.018 pcv (%) 44.78 2.59 42.91 2.82 0.009 rbc (1012/ul) 5.27 0.37 4.94 0.36 0.001 mcv (fl) 85.15 3.72 86.95 3.63 0.064 mch (pg) 28.31 1.60 29.20 1.44 0.028 mchc (g/dl) 33.24 0.86 33.57 0.94 0.165 rdw (%) 12.53 0.68 12.40 0.57 0.446 platelet (109/l) 245.77 48.27 246.27 55.13 0.970 wbc (109/l) 7.47 1.95 7.47 1.40 > 0.99 independent t-test was performed for statistical analyses. the bold numbers show significant differences. https://doi.org/10.15218/ejnm.2020.02 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 18 erbil journal of nursing & midwifery table 5: predictors of hb, rbc, and pcv in cupping and blood donation groups predictors dependent variable f score p-value partial eta squared (effect size) study intervention hb 6.646 0.020 0.281 pcv 6.644 0.020 0.281 rbc 6.534 0.020 0.278 smoking type hb 0.302 0.590 0.017 pcv 0.280 0.604 0.016 rbc 0.198 0.662 0.012 chronic disease hb 0.011 0.989 0.001 pcv 0.008 0.992 0.001 rbc 0.013 0.987 0.002 psh hb 0.193 0.666 0.011 pcv 0.148 0.705 0.009 rbc 0.061 0.808 0.004 age hb 0.097 0.759 0.006 pcv 0.100 0.755 0.006 rbc 0.146 0.707 0.009 mcv (fl) hb 0.006 0.938 < 0.001 pcv 0.011 0.919 0.001 rbc 0.140 0.713 0.008 mch mch (pg) hb 0.003 0.960 < 0.001 pcv 0.006 0.939 < 0.001 rbc 0.036 0.852 0.002 mchc (g/dl) hb 0.058 0.813 0.003 pcv 0.184 0.673 0.011 rbc 0.301 0.591 0.017 rdw (%) hb 2.176 0.158 0.113 pcv 2.261 0.151 0.117 rbc 2.460 0.135 0.126 platelet (109/l) hb 1.063 0.317 0.059 pcv 1.025 0.326 0.057 rbc 0.919 0.351 0.051 wbc (109/l) hb < 0.001 0.986 < 0.001 pcv < 0.001 0.992 < 0.001 rbc 0.001 0.970 < 0.001 multivariate analysis model was performed for statistical analysis. https://doi.org/10.15218/ejnm.2020.02 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 19 erbil journal of nursing & midwifery the present investigation showed both wet-cupping and blood donation interventions are effective to reduce hb, pcv, and rbc, but blood donation is more powerful than cupping in the reduction of the hematological parameters. furthermore, some indicators including platelet count elevated in subjects who underwent blood donation. during the last few decades, there has been considerable interest in wet-cupping among the public. the effectiveness of wet-cupping on hematological parameters has not been fully explored. studies on the effect of blood donation on hematological parameters are well documented in the literature. whereas, no research investigated the outcomes of wetcupping on same parameters except the few studies that examined the blood withdrawn from the wetcupping and compared to venous blood. for example, a study by mahdavi and colleagues was carried out in 56 healthy volunteer men 2040 years old. blood samples from cupping showed a significant increase in hb, hct, rbc, mch, viscosity and platelet count as compared to venous blood samples. in contrast, no significant difference was observed in wbc, mch, and mcv [18]. the authors hypothesized that hb concentration and rbcs count are so dense in cupping samples which were relatively high compared to those in venous blood samples. the results of our study are in line with this study except for platelet count in which no significant change occurred post wet-cupping. however, there are contradictory findings as well. abdullah et al. [19] compared cupping blood and venous blood samples of ten healthy male and female individuals through a pilot study and concluded that all parameters have similar values to those observed in the initial assessment. it is believed that blood donation reduces hematological parameters. our findings reveal significant changes in most hematological parameters after the intervention. as mentioned earlier, studies on the effectiveness of blood donation on hematological changes are well documented in the literature although they did not measure rbc count. for example, a study by cliville et al. [20] addressed variations in hematological and other parameters in 30 patients of both genders. there was a significant decrease in hb and hct levels after the donation of the blood. this resulted in an increase in reticulocytes, mcv and rdw. however, the platelet count and wbc count remained unchanged. similar findings were reported by beyan and colleagues [21]. moreover, das et al. [22] examined hematological values preand post-donation procedure and concluded that the values of hb, hct, platelet, and wbc counts were dropped significantly among the donors. the findings of our study are in agreement with these studies except platelet count that increased significantly in our study after therapeutic phlebotomy. this could be due to a possible change in erythropoietin levels following blood donation caused iron depletion and platelet count enrichment [23]. in view of the fact that erythropoietin may increase platelet count by stimulating bone marrow thrombopoiesis [24]. although some drawbacks of repeated blood donation have been documented in the literature such as a poor iron condition in repeated blood donors [25], nevertheless several benefits were also reported in the literature including polycythemia, hemochromatosis, porphyria cutanea tarda, and sickle cell disease [7, 26]. furthermore, phlebotomy can lower the risk of cardiovascular disease by decreasing whole blood viscosity, discussion https://doi.org/10.15218/ejnm.2020.02 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 20 erbil journal of nursing & midwifery plasma viscosity, hct, and fibrinogen, and iron stores [5, 27]. in this region, a recent study by getta and ahmad et al [28] investigated the purpose of blood donation and identified the main reasons for blood donations among regular donors were relieving headaches (45%), polycythemia, neck and shoulder pains, dizziness, insomnia, and sleepiness. while the reasons for donations by the first time donors were to help relatives (31%), it is evident that the benefits of blood donation outweighed its drawbacks. concerning the safety of wetcupping, this intervention is generally safe based on outcomes of a meta-analysis done by cao et al. [29]. therefore, the cupping procedure in the current study was also safe with minimal side effects occurring during the procedure such as bullae formation in one cup area, discomfort in the region that underwent cupping, and dizziness. blood donation on the other hand was also relatively safe except for a few complaints that occurred during donation including dizziness, hypotension, and local hematomas as a result of extravasation which arose a week later. strength and limitation the strong point of the study must be traced in the design and the strict inclusion and exclusion criteria. while, the authors faced an issue to include females in the study due to the cultural aspects of the region. the present study concluded that both wet-cupping and blood donation are effective interventions in reducing hb, pcv, and rbc along with increase platelets in blood donation only. the present study found cupping therapy as a safe procedure the authors would like to present their profound thanks to mr. deldar m. abdulah for his kind review and those persons accepted to participate in the procedure. the authors were only financial supporters of the study. the authors report no conflicts of interest to declare [1] hyson jm. leech therapy: a history. journal of the history of dentistry.2005 53(1):p: 257. [2] parapia la. history of bloodletting by phlebotomy. british journal of haematology.2008;143(4):p: 490-5. [3] greenstone g. the history of bloodletting. bc medical journal. 2010;52(1):p: 12-4. [4] orosz jj. a short history of bloodletting. artificial organs.1981;5(3):p: 226-8. [5] depalma rg, hayes vw, zacharski lr. bloodletting: past and present. journal of the american college of surgeons.2007;205 (1):p: 132-44. [6] curtis p. family practice history: bloodletting. canadian family physician.1981;27:p: 1030. [7] assi tb, baz e. current applications of therapeutic phlebotomy. blood transfusion.2014; 12(suppl 1):p: s75. [8] elolemy at, albedah am. public knowledge, attitude and practice of complementary and alternative medicine in riyadh region, saudi arabia. oman medical journal.2012;27(1):p: 20. [9] saad b, said o. greco-arab and islamic herbal medicine: traditional system, ethics, safety, efficacy, and regulatory issues: john wiley & sons; 2011. [10] al-bedah am, elsubai is, qureshi na, aboushanab ts, ali gi, el-olemy at, et al. the medical perspective of cupping therapy: effects and mechanisms of action. journal of traditional and complementary medicine. 2018;9(2). [11] albedah a, khalil m, elolemy a, elsubai i, khalil a. hijama (cupping): a review of the evidence. focus on alternative and complementary therapies.2011; 16(1):p: 12-6. [12] uddin smm, haq a, sheikh h. the use of hijama (wet cupping) in alternative and complementary medicine: efficacious or perilous? journal of acupuncture and meridian studies.2016; 9(6):p: 285-6. conclusion acknowledgments: funding: conflicts of interest: references https://doi.org/10.15218/ejnm.2020.02 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 21 erbil journal of nursing & midwifery [13] ibrahim ir, hassali ma, saleem f, al tukmagi hf, dawood ot. use of complementary and alternative medicines: a cross-sectional study among hypertensive patients in iraq. journal of pharmaceutical health services research.2018; 9(1):p: 59-65. [14] qureshi na, alkhamees oa, alsanad sm. cupping therapy (al-hijamah) points: a powerful standardization tool for cupping procedures? journal of complementary and alternative medical research.2017;p: 1-13. [15] benli ar, sunay d. changing efficacy of wet cupping therapy in migraine with lunar phase: a self-controlled interventional study. medical science monitor.2017; 23:p: 6162-6167. [16] okuyemi ks, ahluwalia js, richter kp, mayo ms, resnicow k. differences among african american light, moderate, and heavy smokers. nicotine tob research.2001; 3(1):p: 4550. [17] world health organization. blood donor selection: guidelines on assessing donor suitability for blood donation: world health organization; 2012. [18] mahdavi mrv, ghazanfari t, aghajani m, danyali f, naseri m. evaluation of the effects of traditional cupping on the biochemical, hematological and immunological factors of human venous blood. a compendium of essays on alternative therapy.2012;p: 67-88. [19] abdullah sa, najib mnm, dali af, sulaiman s, editors. malay cupping therapy: a haematological analysis pilot study. regional conference on science, technology and social sciences (rcstss 2014); 2016: springer. [20] cliville x, bofill c, joven j, monasterio j, viscor g, vernis m, et al. hemorheological, coagulative and fibrinolytic changes during autologous blood donation. clinical hemorheology and microcirculation.1998;18 (4):p: 265-72. [21] beyan c, çetin t, kaptan ka, nevruz o. effect of plateletpheresis on complete blood count values using three different cell separator systems in healthy donors. transfusion and apheresis science. 29(1):p: 45-7. 2003. [22] das ss, chaudhary r, verma sk, ojha s, khetan d. preand post donation haematological values in healthy donors undergoing platel etpheresis with five different systems. blood transfusion = trasfusionedel sangue.2009; 7(3):p: 188-92. [23] franchini m. platelet count increase following phlebotomy in iron overloaded patients with liver cirrhosis. hematology. 2003;8 (4):p: 259-62. [24] stohlawetz pj, dzirlo l, hergovich n, lack ner e, mensik c, eichler hg, et al. effects of erythropoietin on platelet reactivity and thrombopoiesis in humans. blood.2000;95 (9):p: 2983-9. [25] birgegård g, schneider k, ulfberg j. high incidence of iron depletion and restless leg syndrome (rls) in regular blood donors: intravenous iron sucrose substitution more effective than oral iron. vox sanguinis.2010; 99(4):p: 354-61. [26] kim kh, oh ky. clinical applications of therapeutic phlebotomy. journal of blood medicine.2016;7:p: 139. [27] holsworth jr r, cho y, weidman j, sloop g, cyr js. cardiovascular benefits of phlebotomy: relationship to changes in hemorheological variables. perfusion.2014; 29(2):p: 10216. [28] getta ha, ahmad ha, rahman hs, ahmed ga, abdullah r. medical and laboratory assessment for regular blood donors in sulaimani blood bank, iraq. patient preference and adherence. 2018;12:p: 939. [29] cao h, li x, liu j. an updated review of the efficacy of cupping therapy. plos one. 2012;7(2):p: e31793. https://doi.org/10.15218/ejnm.2019.12 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article chronic obstructive pulmonary disease as a cardiovascular diseases risk factor in erbil abstract introduction chronic obstructive pulmonary disease (copd), which includes emphysema, asthma and chronic bronchitis, has been recognized as the most common cause of morbidity and mortality worldwide [1]. it is characterized by an obstruction of the lung airflow and not fully reversible due to long-term inflammatory process throughout the airways, parenchyma, and pulmonary vasculature [2]. approximately 20% of adult populations have reduced forced expiratory volume in the first second (fev1) values, which indicate impaired lung function [3]. asthma, copd, and fibrotic lung disease have been background and objectives: chronic obstructive pulmonary disease (copd) has been reported as the most common cause of morbidity and mortality all over the world. the present study aimed to investigate a possible link between chronic obstructive pulmonary disease and increased risk of cardiovascular disease in erbil, the kurdistan region of iraq. methods: a quantitative, case-control study was conducted on 159 patients with copd as the case croup and 159 adult people without copd as control group. case groups were patients who have copd and admitted to the medical ward at hawler teaching hospital and rzgary teaching hospital. control groups were those without copd and went to city park and mala-fandy primary health center. data was collected from january 2018 to august 2018 through direct interview and using a questionnaire. a spirometer machine was used to confirm the diagnosis of copd. data analysis was carried out through descriptive statistics (frequency and percentage), skeunosis-kurtosis test, t-test, mann-whitney u test, pearson's chi-squared test, and univariate logistic regression. results: compared to the control group, patients with chronic obstructive pulmonary disease were found to be at a significantly higher risk of developing hypertension, diabetes, ischemic heart disease, dyslipidemia, and lung cancer. moreover, there was an inverse correlation between increased severity of chronic obstructive pulmonary disease and increased hypertension and stroke. in addition, chronic obstructive pulmonary disease, hypertension, diabetes, and dyslipidemia were found to be significant risk factors for ischemic heart disease. conclusions: the risk of cardiovascular comorbidities was significantly higher in the patients with chronic obstructive pulmonary disease and there is a significant association between chronic obstructive pulmonary disease and cardiovascular comorbidities. keywords: cardiovascular diseases, chronic obstructive pulmonary disease, comorbidity goran aboobaker osman; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: goran.osman@hmu.edu.krd) halmat authman rasheed; department of nursing, college of nursing, hawler medical university, erbil, iraq. yousif mohammed younis; department of nursing, college of nursing, hawler medical university, erbil, iraq. newroz khazi aziz; department of nursing, college of nursing, hawler medical university, erbil, iraq. hemin khlid saber; department of medicine, college of medicine, hawler medical university, erbil, iraq. 93 erbil journal of nursing & midwifery received: 4/4/2019 accepted: 8/5/2019 published: 30/5/2019 mailto:goran..osman@hmu.edu.krd https://doi.org/10.15218/ejnm.2019.12 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article recognized in adult individuals whose level of fev1 is reduced [4]. low-grade systemic inflammation has also been associated with atherosclerosis, stroke and ischemic heart disease. these conditions are important risk factors for cardiovascular morbidity and mortality among copd patients [4]. limited physical activity and cigarette smoke play a role in increased cardiovascular disease [5]. studies have found that many patients diagnosed with copd eventually die from cardiovascular disease; particularly ischemic heart disease [6,7]. cigarette smoking could be an independent risk factor as it is one of the most common shared risk factors in both copd and cardiovascular disease patients [8]. high prevalence of diabetes, dyslipidemia and hypertension was observed in copd patients which was related with an increased risk of ischemic heart disease [9]. the aim of this study was to determine whether or not copd is associated with increased risk of cardiovascular disease compared to the control group. a quantitative case – control study was carried out from january 2017 to may 2019 to determine whether or not obstructive lung disease patients present greater cardiovascular diseases and comorbidity than control subjects in the erbil, kurdistan region of iraq. this study was approved by the scientific and ethical committee at hawler medical university/ college of nursing. prior to data collection, all study participants were informed about the aim and characteristics of the study. they gave their written consent for participation. a questionnaire was constructed and spirometer machine was used to collect the necessary data. two experts in the field were present in order to approve and review the validity of the questionnaire. the questionnaire consisted of two sections. the first section was socio-demographical characteristics of patients. the second section was composed of questions regarding presence of cardiovascular disease, comorbidities of obstructive lung disease, and severity of chronic obstructive pulmonary disease. a spirometer is a tool used to confirm the diagnosis of copd. reduced forced expiratory volume in the first second (fev1), <80% of the predicted value in combination with an (forced expiratory volume in the first second (fev1) / forced vital capacity (fvc) fev1/fvc, <70% indicates the limitation of lung airflow that is not fully reversible [10,11]. global initiative on obstructive lung disease criteria was used to categorize the severity of airflow limitation into stages: i: fev1 ≥ 80%, ii: fev1= 50–80, iii: fev1= 30–50, iv: fev1<30 [1].the matching criteria for the case group as well as for the control group were: age over 40 years old and cigarette smoking history. the inclusion criteria for case groups were patients who have copd and admitted to the medical ward at hawler teaching hospital and rizgary teaching hospital. control groups were those without copd and went to city park for recreation and mala-fandy primary health center. a total of 159 cases and 159 controls were selected purposively. during the time of data collection, only 159 patients were diagnosed with copd. in order to have an equal number of cases and controls, 159 controls were selected to participate in the study. all continuous variables were presented by mean and standard deviation. frequency and percentage are used to express the result of the categorical variables. the skeunosis-kurtosis test was used to test the normality distribution of continuous variables. t-test was used to find the differences between groups in quantitative studies for those variables with normal methods 94 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.12 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article found with case and control groups. with the exception of stroke (7.5% in case and 10.1% in control) and anemia (13.8% in case and 15.1% in control), the prevalence of all diseases was greater in copd patients than in controls. ischemic heart disease and hypertension were the greatest comorbidities in copd group (82.4% and 71.7%) respectively. when the case group was classified by copd severity using the global initiative on obstructive lung disease criteria, it was found that hypertension (p = 0.111) and stroke significantly decreased as the severity of the disease increased (and p < 0.001). there were no significant differences between the stages of copd for diabetes and dyslipidemia. in stage iv of copd, the prevalence of ischemic heart disease was greater than in stage iii (p= 0.256). however, there were no differences between the other stages. in addition, no significant differences were found between the stages for heart failure (table 3). distribution and mann–whitney u test for non-normally distributed variables. pearson’s chi-squared test was used to analyze the association between qualitative variables. in order to find the relationship between cardiovascular disease and chronic obstructive pulmonary disease patients, the univariate logistic regression was used. results with p < 0.05 were considered statistically significant. the demographic and respiratory function characteristics of the participants are shown in table 1. significant differences were found in the pulmonary function tests and there were no significant differences in terms of age. there were no differences between the groups in the distribution by sex, body mass index and cigarette smoking habits. majority of patients were found to be in first and second stage of copd. table 2 shows the prevalence of cardiovascular disease and comorbidities that were 95 results erbil journal of nursing & midwifery table 1: demographical characteristics and respiratory function of the study participants characteristics case n(%) /m±sd control n(%) /m±sd p value sex males 104(65.4) 104(65.4) > 0.999 females 55(34.6) 55(34.6) age (years) 62.05 ± 11.09 61.73 ± 11.47 0.800 bmi 26.23 ± 4.03 25.86 ± 3.17 0.354 pack-years 1.086 ± 0.60 1.15 ± 0.67 0.398 fev (%) 55.49 ± 18.06 80.01 ± 20.76 < 0.001 fvc (%) 47.70 ± 16.73 67.15 ± 16.89 < 0.001 fev/fvc (%) 56.44 ± 10.37 74.86 ± 5.30 < 0.001 gold stages of copd i 26(16.4) ii 126(79.2) iii 3(1.9) iiii 4(2.5) https://doi.org/10.15218/ejnm.2019.12 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article the prevalence of ischemic heart disease was greater in the presence of diabetes mellitus (p = 0.005), hypertension (p < 0.001), and dyslipidemia (p < 0.001) as well as cigarette smoking (p < 0.001). however, there were no significant differences between ihd and age group. meanwhile, the prevalence of heart failure was also higher in the presence of dyslipidemia (p = 0.013). the chi-squared analysis was used to find the association between cardiovascular and age groups. in this case, the bonferroni correction showed that there is no significant difference in age group (table 4). table 5 demonstrated that chronic obstructive pulmonary disease patients have greater risks for having hypertension (odds ratio [or]: 7.77; 95% confidence interval [ci]: 4.71-12.82), diabetes mellitus (or: 4.52; 95% ci: 2.77-7.37), and dyslipidemia (or: 17.05; 95% ci: 9.7229.89). a univariate logistic regression analysis showed that copd, hypertension, diabetes, and dyslipidemia were risk factors for ischemic heart disease. 96 table 2: prevalence of cardiovascular disease and comorbidities among study sample erbil journal of nursing & midwifery table 3: prevalence of cardiovascular disease and comorbidities in patients with chronic obstructive pulmonary disease classified by degrees of severity. cvd and co-morbidities case n (%) control n (%) p -value ischemic heart disease 131(82.4) 14 (8.8) < 0.001 heart failure hypertension 21 (13.2) 114 (71.7) 5 (3.1) 39 (24.5) 0.001 < 0.001 dyslipidemia stroke diabetes 124 (78) 12 (7.5) 89 (56) 34 (21.4) 16 (10.1) 28 (17.6) < 0.001 0.429 < 0.001 anemia 22 (13.8) 24 (15.1) 0.750 comorbidities i: fev1 ≥ 80% ii: fev1= 50–80 iii: fev1= 30–50 iv: fev1<30 p-value hypertension 22 (19.3%) 85 (74.6%) 3 (2.6%) 4 (3.5%) 0.111 stroke 2 (16.7%) 8 (66.7%) 2 (16.7%) 0 (0%) 0.001 idh 24 (18.3%) 100 (76.3%) 3 (2.3%) 4 (3.1%) 0.256 heart failure 2 (9.5%) 18 (85.7%) 0(0%) 1 (4.8%) 0.624 dyslipidemia 23 (18.5%) 96 (77.5%) 2 (1.6%) 3 (2.4%) 0.543 diabetes 13 (14.6%) 71 (79.8%) 3 (3.4%) 2 (2.2%) 0.423 anemia 2 (9.1%) 18 (81.8%) 1 (4.5%) 1 (4.5%) 0.528 https://doi.org/10.15218/ejnm.2019.12 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article 97 table 4: prevalence of cardiovascular disease in patients with chronic obstructive pulmonary disease according to risk factors. erbil journal of nursing & midwifery risk factors ihd n (%) hf n (%) hypertension yes no 107 (81.7%) 17(81%) 24 (18.3%) 4(19%) diabetes yes no 80 (61.1%) 11(52.4%) 51 (38.9%) 10(47.6%) dyslipidemia yes no 120 (91.6%) 12 (57.1%) 11 (8.4%) 9(42.9%) anemia yes no 19 (14.5%) 5 (23.8%) 112(85.5%) 16(76.2%) age group/year 40-51 52-63 64-75 76-87 31 (23.7%) 0 (0%) 39 (29.8%) 5 (23.8%) 43 (32.8%) 11 (52.4%) 18 (13.7%) 5 (23.8%) cigarette/ day 5-18 19-32 33-46 47-60 0 (0%) 0 (19%) 23(17.6%) 7 (33.3%) 47 (35.9%) 7 (33.3%) 61 (46.6%) 7 (33.3%) table 5: risk factors for ischemic heart disease, results of the logistic univariate regression analysis. risk factors or 95% cr pvalue copd 1.18 0.71-1.96 0.019 gender 0.83 0.52 – 1.33 0.45 age 1.14 0.90-1.44 0.19 hypertension 7.77 4.71-12.82 0.001 diabetes 4.52 2.77-7.37 0.001 smoking 0.91 0.63 – 1.43 0.52 dyslipidemia 17.05 9.7229.89 0.001 https://doi.org/10.15218/ejnm.2019.12 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article as revealed by the results of the present study, the mean age of case and control groups was similar. in a study conducted by de lucas-ramos et al. (2008), it was observed that patients in the copd group were older than those in the control group [8]. the results also indicated that the two groups were not significantly different in terms of their sex. this finding is in agreement with other previously conducted studies [8, 1]. moreover, no significant difference was observed between the two groups regarding their bmi. this finding is not similar to the study conducted by de lucas-ramos et al. (2012) who reported that the patients with copd and controls had different bmi [1]. this difference might be related to the difference between the two studies in terms of their sample size. it was also seen that smoking among copd patients was not a risk factor for cardiovascular diseases, because as seen in table 1, there was no significant difference between the two groups in terms of their pack-years. this finding is not in agreement with those of the study carried out by de lucas-ramos et al. (2012) [1]. according to the results, fev, fvc and fev/fvc were significantly different in the two groups. similar findings have been reported in previously conducted studies [12, 13]. the results of the present study also showed that there was a significant difference between the patients with copd and the control group patients in terms of most of the comorbidities including hypertension, diabetes, ischemic heart disease, heart failure, dyslipidemia, and lung cancer. this finding is in agreement with those of the studies conducted by de lucasramos et al. (2012), lópez varela et al. (2013), and chatila et al. (2008) [1, 14, 15]. however, the two groups were not significantly different in terms of some comorbidities such as stroke, anemia, and low dietary intake. this finding is not in agreement with the one reported by de lucas-ramos et al. (2012) who reported a significant difference between the copd patients and the controls regarding anemia [1]. according to the results of data analysis, there was a significant inverse relationship between decreased hypertension and stroke and increased severity of copd. this finding is in agreement with those of the studies carried out by imaizumi et al. (2015) and shujaat et al. (2007) who reported that as severity of copd rises, the levels of stroke and hypertension drop. this is could be due to small number of cases who were in stage iii and iv [16, 17]. other comorbidities; however, were not found to have a significant association with severity of copd. moreover, the results revealed that there is a significant relationship between ischemic heart disease and diabetes mellitus, hypertension, dyslipidemia, and cigarette smoking. therefore, these comorbidities can be regarded as risk factors for ischemic heart disease. this finding is similar to the results of previously conducted studies [18-20].the results of data analysis in the present study also indicated that the risk of developing hypertension, diabetes mellitus, and dyslipidemia was significantly higher in patients with copd compared to the control group. this finding is in agreement with the results of the previously conducted studies as well[1, 21, 22]. in conclusion, patients with copd were confirmed to be at an increased risk of cardiovascular comorbidities, and there is a significant association between these two variables. however, the detailed mechanism of this relationship should be studied in the future studies. 98 erbil journal of nursing & midwifery counclusion discussion https://doi.org/10.15218/ejnm.2019.12 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article ((english edition)). 2008; 44(5):233-238. [7] finkelstein j, cha e, scharf sm. chronic obstructive pulmonary disease as an independent risk factor for cardiovascular morbidity. international journal of chronic obstructive pulmonary disease. 2009; 4: 337-349. [8] tanaka k, senjyu h, tawara y, tanaka t, asai m, tabusadani m, et al. effects of systematic intervention for chronic obstructive pulmonary disease on follow-up and smoking cessation rates and changes of the pulmonary function: a 7-year longitudinal study in a japanese rural city. internal medicine. 2018; 57(16): 2315-2323. [9] chen w, thomas j, sadatsafavi m, fitzgerald jm. risk of cardiovascular comorbidity in patients with chronic obstructive pulmonary disease: a systematic review and metaanalysis. the lancet respiratory medicine. 2015; 3(8): 631-639. [10] vestbo j, hurd ss, agustí ag, jones pw, vogelmeier c, anzueto a, , fabbri lm, martinez fj, nishimura m, stockley ra., et al. global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: gold executive summary. american journal of respiratory and critical care medicine. 2013;187(4):347-365.johns dp, walters ja, walters eh. diagnosis and early detection of copd using spirometry. journal of thoracic disease.2014; 6(11):1557. [11] sin dd, wu l, man sf.the relationship between reduced lung function and cardiovascular mortality: a population-based study and a systematic review of the literature. the author report no conflict of interests [1] de lucas-ramos p, izquierdo-alonso jl, moro jm, frances jf, lozano pv, bellón-cano, jm.,et al. chronic obstructive pulmonary disease as a cardiovascular risk factor. results of a case–control study (consiste study). international journal of chronic obstructive pulmonary disease. 2012; 7:679. [2] sin dd, man sp. chronic obstructive pulmonary disease as a risk factor for cardiovascular morbidity and mortality. proceedings of the american thoracic society. 2005; 2(1): 811. [3] sin dd, man sp. why are patients with chronic obstructive pulmonary disease at increased risk of cardiovascular diseases? the potential role of systemic inflammation in chronic obstructive pulmonary disease. circulation. 2003; 107(11):1514-1519. [4] huiart l, ernst p, suissa s. cardiovascular morbidity and mortality in copd. chest journal. 2005;128(4):2640–6. [5] watz h, waschki b, meyer t, magnussen h. physical activity in patients with copd. european respiratory journal. 2009; 33(2):262– 272. [6] de lucas-ramos p, izquierdo-alonso jl, moro jm, bellón-cano jm, ancochea-bermúdez j, calle-rubio m, calvo-corbella e, et al. cardiovascular risk factors in chronic obstructive pulmonary disease: results of the arce study. archivos de bronconeumología 99 erbil journal of nursing & midwifery conflict of interest references https://doi.org/10.15218/ejnm.2019.12 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article patients with ischemic heart disease. the inertia study. revista espanola de cardiologia. 2010; 63: 1428-1437. [20] ho tw, huang ct, ruan sy, tsai yj, lai f, yu cj. diabetes mellitus in patients with chronic obstructive pulmonary disease-the impact on mortality. plos one. 2017;12 (4):e0175794. published 2017 apr 14. doi:10.1371/journal.pone.0175794 [21] takahashi t, yoshihisa a, sugimoto k. associations between diabetes mellitus and pulmonary hypertension in chronic respiratory disease patients. plos one. 2018;13 (10):e0205008. published 2018 oct 9. doi:10.1371/journal.pone.0205008 chest. 2005; 127(6): 1952–1959. [12] mihalache a, fitting jw, nicod lp. chronic obstructive pulmonary disease and its links with cardiovascular risk factors. revue medicale suisse. 2015; 11 (495): 2151–2156, 2015. [13] lópez varela mv, montes de oca m, halbert r.platino team. comorbidities and health status in individuals with and without copd in five latin american cities: the platino study. arch bronconeumol. 2013; 49 (11): 468-474 [14] chatila wm, thomashow bm, minai oa, criner gj, make bj. comorbidities in chronic obstructive pulmonary disease. proceedings of the american thoracic society. 2008;5 (4):549-55. [15] imaizumi y, eguchi k, kario k. lung disease and hypertension. pulse (basel). 2015;2(14):103-12. [16] shujaat a, minkin r, eden e. pulmonary hypertension and chronic corpulmonale in copd. international journal of chronic obstructive pulmonary disease. 2007;2(3):27382. [17] leon bm, maddox tm. diabetes and cardiovascular disease: epidemiology, biological mechanisms, treatment recommendations and future research. world journal of diabetes. 2015;6(13):1246-58. [18] petrie jr, guzik tj, touyz rm. diabetes, hypertension, and cardiovascular disease: clinical insights and vascular mechanisms. canadian journal of cardiol. 2018; 34(5):575-584. [19] lazaro p, murga n, aguilar d, hernandezpresa ma: therapeutic inertia in the outpatient management of dyslipidemia in 100 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.03 ejnm, vol. 1, no. (1), may, 2018 original article nurses’ knowledge regarding heart failure education principles in erbil teaching hospital abstract introduction heart failure (hf) has become a major public health problems, with the prevalence of over 23 million worldwide *1+. it is a condition in which the heart is unable to adequately pump blood throughout the body or unable to prevent blood from “backing up” into the lungs *2+. most of hf patients are not looked after by specialists and have little knowledge of their condition and its treatment *1+. therefore, it is common reason for hospital readmissions, and subsequently, a major contributor to rising health care costs *3+. it has also been reported that medicare spends more money on heart failure treatment than it does background and objective: heart failure is a major public health problem often associated with a decreased quality of life and high mortality rate. to optimize the quality of management and support patients to care for themselves in their own home, they need to be welleducated about all aspects of the heart failure. this study aims to investigate nurses’ knowledge regarding the treatments that can be taught to heart failure patients to improve self-care. methods: cross-sectional study, 64 nurses out of 85 working at three public hospitals in erbil city took part, the data was collected from 15th february to 15th march, 2017 through interviews using a questionnaire schedule. the data was analyzed using statistical package for the social science (spss) program version 20. results: majority of the participants were young (87.6% within the range of 21-40), male (62.5%), and graduated with a technical diploma (60.9%). more than half of them (53.1%) have between 1–5 years of nursing experience, 50% of the nurses work in the surgical specialty hospital cardiac centre and 43.8% of them have general knowledge of cardiac care. the majority of participants achieved a good knowledge score (70.3%). there was a significant association between level of knowledge of nurses working in the surgical specialty hospital cardiac centre and rizgary teaching hospital, while few of them are in hawler teaching hospital (53.3%, 26.7% and 20% respectively p <0.002). conclusion: the study concluded that the nurses have good knowledge score, but still need continuous knowledge and practical training to educate patients regarding heart failure. high level of significance was found between the levels of knowledge and the working area. keywords: nurse; knowledge; heart failure; education principles. bootan hasan ahmed ; department of nursing, college of nursing, hawler medical university, erbil, iraq. sideeq sadir ali; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: sideeq.sadir@nur.hmu.edu.krd) vian afan naqshbandi; department of nursing, college of nursing, hawler medical university, erbil, iraq. ribwar arsalan mohammed; department of nursing, college of nursing, university of rparin, sulaimaniya , iraq. 15 erbil journal of nursing & midwifery received: 2/9/2017 accepted: 28/10/2017 published: 5/5/2018 https://doi.org/10.15218/ejnm.2018.03 ejnm, vol. 1, no. (1), may, 2018 original article on mis and all forms of cancer combined *4+. thirty to forty percent of hf patients are readmitted within six months of their previous hospitalization *5+. hence, education of heart failure patients and their families is critical. failure of these patients to comply with physicians and other healthcare providers’ instructions is sometimes a cause of heart failure exacerbation. a significant reason for patient’s failure to comply is lack of understanding as well as poor discharge planning that are associated with improved patient outcomes *6+. therefore, hf patients need to be welleducated on various aspects of hf so that they can be successful in their selfmanagement of hf, this will enable them to manage their disease in their home environment. a number of studies have been conducted regarding guidelines and heart failure management among nurses. a study examined nurse’s knowledge of heart failure education topics at a regional midwestern hospital *3+. in addition, six other studies have assessed knowledge of nurse regarding hf education principles *7, 8, 9, 10, 11, 12+. although, such studies have provided important information on nurse’s knowledge regarding hf topics that need to be taught to hf patients, however, hf patients are not homogenous in their demography, disease pathogenesis, treatment protocol, and side effects of the treatments and level of education. nurses can play an essential role in educating hf patients on hf self-care. this education enables patients to successfully manage their hf at home and minimize hospital readmission *3+. therefore, the aim of this study was to investigate nurses’ knowledge regarding self-care of patients with hf and to find out association between nurses' knowledge with their socio-demographic characteristics. this cross-sectional study was carried out in three public hospitals (medical word of rizgary teaching and hawler teaching hospital also three units of the surgical specialty hospital cardiac centre; surgical, cardiac catheterization and outpatient unit) at erbil city/ kurdistan region during the period from 15th february to 15th march, 2017. among the 85 nurses that worked at medical words of rizgary teaching hospital, surgical specialty hospital cardiac centre and hawler teaching hospital, 64 participated. the first hospital was rizgary teaching hospital, during conducting this study the hospital was under reconstruction and 18 nurses accept to participate in this study from 21. the second hospital was surgical specialty hospital cardiac center in which 45 nurses were asked to participate; 32 nurses here agreed to participate in this study. the third hospital was hawler teaching hospital, in this hospital nurses who work in coronary care unit and medical ward were asked to be involved in this study, 18 nurses confirmed their participation out of 22. inclusion criteria were; nurses who have experience in delivering direct care to hf patients, and have at least one of the following levels of education diploma, bachelor degree, master of science or phd in nursing. nurses who did not agree to participate in this study or did not have experience of caring of hf patients were excluded. this study was approved by the scientific and ethics committee of the college of nursing at hawler medical university. institutional approval for conducting the study was also obtained from general directorate of health in erbil and the three hospitals mentioned above. confidentiality regarding personal issues of the persons was ensured. at first a self-assessment of the nurses’ knowledge of heart failure was methods 16 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.03 ejnm, vol. 1, no. (1), may, 2018 original article patients in hospital were between 1 – 5 years. with regards to educational level, most of the study sample graduated from a nursing institute (60.9%) (table 1). in addition, half of the participants (50%) worked in the surgical specialty hospital cardiac centre. finally 43.8% of nurses thought that they had good understanding of heart failure education topics. table 2 shows the knowledge levels of the 64 participants regarding heart failure education principles. the highest correct knowledge score for the first section was for the question “swelling of the abdomen may indicate retention of excess fluid due to worsening heart failure” (75%), while the lowest knowledge score was for the question “patients with heart failure should decrease activity and most forms of active exercise should be avoided” (10.9%). regarding second section the highest correct knowledge score was for the question “new onset or worsening of fatigue” (78.1%) while the lowest knowledge score was for the question “dizziness or lightheadedness when arising that disappears within 10-15 minutes” (46.9%). table 3 focuses on the overall knowledge of the nurses regarding heart failure; the table shows that majority of the nurses had a good knowledge and received average score 70.3%, while 9.4% had poor knowledge. it also demonstrates that only 20.3% of the nurses had high knowledge levels. table 4 illustrates relationships between the nurses overall knowledge levels and their socio-demographic data. in general, there was no significant association between the level of knowledge and the socio-demographic characteristics of the nurses except “place of work or hospital” which was significantly higher for those nurses working in the surgical specialty hospital cardiac centre and rizgary conducted. the questionnaire consisted of 19-question with two options “true” and “false” which measured nurses’ knowledge of heart failure topics *5+. questions were about diet (3 questions), fluid or weight monitoring (6 questions), signs and symptoms of worsening heart failure (6 questions), medications (2 questions), and exercise (2 questions). socio-demographic characteristics of the study sample were collected including age, level of education and years of experience working with heart failure patients. the final question was an open-ended question to explore the topics related to heart failure for which nurses would like more education. as a comparative measure of the knowledge of heart failure education principles, the overall true score was expected to be 87.5% or greater for nurses who regularly cared for heart failure patients—this means 17 to 18 correct answers out of 20 possible *7+. for the first the questions regarding hf knowledge nurses' responses to the questions were divided into three categories ‘poor knowledge’, ‘good knowledge’ and ‘high knowledge’. the score of poor knowledge ranged from 1% 33%, good knowledge ranged from 34% 67%. high knowledge’ ranged from 68% 100%. data was then entered into statistical package for the social science (spss), version 20 and analyzed by applying two statistical approaches: descriptive data analysis (frequency, percentage, mean) and inferential data analysis (chi-square test). the majority of the study samples (43.8%) were within the both ranges 21-30 and 31-40 years old. the mean age and standard deviation (m ± sd) of the nurses were 32.47 ± 7.176. majority of the study participants were male (62.5%). the years of experience of more than half of the nurses (53.1%) with the heart failure 17 results erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.03 ejnm, vol. 1, no. (1), may, 2018 original article and rizgary teaching hospital than hawler teaching hospital (53.3%, 26.7% and 20% respectively p-value <0.002). this study assessed the level of knowledge of sixty four nurses in three public hospitals in erbil city. educational support by a nurse for heart failure patient in a hospital and at home significantly increases self-care behavior *13+. out of 19 questionnaire items; the highest knowledge scored was for the question “if patients take their medications as directed and follow the suggested lifestyle” in part one and the lowest score was in the question “patients with heart failure should decrease activity and most forms of active exercise should be avoided” also from part one. in general, the participants answered most of the questions in part one (knowledge regarding heart failure education principles) incorrectly and answered part two of the questionnaire (knowledge regarding some of the signs and symptoms significant or not significant for heart failure patient) mostly correctly. the fact that more questions were answered incorrectly than correctly, may be because the nurses did not do any training courses to improve their knowledge or neglected to obtaining the knowledge, because most of them (43.8%) were happy with their level of knowledge, or it could be due to the fact that most of them (53.1%) had low levels of experience working with heart failure patients in hospital. standfuss, (2012), reported; nurses have important position in educating patients regarding heart failure, also they are in a key position to educate patients to effectively manage their heart failure independently *3+. the results of this study was supported by the cross-sectional, descriptive study that conducted by knopp, (2009) in a western montana at us, which 18 table 1: sociodemographic characteristics discussion erbil journal of nursing & midwifery socio-demographic characteristics n= 64 f % age group (years) 21-30 28 (43.8) 31-40 28 (43.8) 41> 8 (12.5) m ± sd 32.47± 7.176 gender male 40 (62.5) female 24 (37.5) years of experience with heart failure 1 – 5 years 34 (53.1) 6 – 11 years 19 (29.7) 12-17 years 9 (14.1) above 18 years 2 (3.1) educational levels associated nurse 5 (7.8) technical diploma 39 (60.9) baccalaureate 17 (26.6) master 3 (4.7) place of work rizgary teaching hospital 18 (28.1) hawler teaching hospital 14 (21.9) surgical specialty hospital cardiac centre 32 (50) good understanding of heart failure education topics strongly agree 2 (3.1) agree 28 (43.8) neither agree or disagree 24 (37.5) disagree strongly 6 (9.4) disagree 4 (6.3) total 64 (100) https://doi.org/10.15218/ejnm.2018.03 ejnm, vol. 1, no. (1), may, 2018 original article 19 table 2: knowledge of nurses regarding heart failure education principles erbil journal of nursing & midwifery knowledge of nurses false true f % f % knowledge regarding heart failure education principles if patients feel thirsty, it is ok to remove fluid limits and allow them to drink. 34 (53.1) 30 (46.9) as long as no salt is added to foods, there are no dietary restrictions for patients with hf. 26 (40.6) 38 (59.4) it is ok to use potassium-based salt substitutes (like “nosalt” or “salt sense”) to season food. 32 (50) 32 (50) lean deli meats are an acceptable food choice as part of the patient’s diet. 46 (71.9) 18 (28.1) coughing and nausea/poor appetite are common symptoms of advanced heart failure. 22 (34.4) 42 (65.6) patients with heart failure should decrease activity and most forms of active exercise should be avoided. 57 (89.1) 7 (10.9) when patients have aches and pains, aspirin and nonsteroidal anti-inflammatory. 26 (40.6) 38 (59.4) if patients take their medications as directed and follow the suggested lifestyle. 13 (20.3) 51 (79.7) if a patient adds extra pillows at night to relieve shortness of breath, this does not. 48 (75) 16 (25) if a patient wakes up at night with difficulty breathing, and the breathing difficulty is relieved by getting out of bed and moving around, this does not mean that the hf. 40 (62.5) 24 (37.5) swelling of the abdomen may indicate retention of excess fluid due to worsening hf. 16 (25) 48 (75) once the patient’s hf symptoms are gone, there is no need for daily obtaining. 32 (50) 32 (50) if the patient gains more than 3 pounds in 48 hours without other hf symptoms, they should not be concerned. 35 (54.7) 29 (45.3) when assessing weight results, today’s weight should be compared with the patient’s weight from yesterday, not the patient’s ideal or “dry” weight. 17 (26.6) 47 (73.4) knowledge regarding some of the sing and symptom significant or not significant for heart failure patient. bp recording of 80/56 without any hf symptoms. 27 (42.2) 37 (57.8) weight gain of 3 pounds in 5 days without symptoms. 28 (43.8) 36 (56.3) dizziness or lightheadedness when arising that disappears within 10-15 minutes. 30 (46.9) 34 (53.1) new onset or worsening of fatigue. 14 (21.9) 50 (78.1) new onset or worsening of leg weakness or decreased ability to exercise. 18 (28.1) 46 (71.9) https://doi.org/10.15218/ejnm.2018.03 ejnm, vol. 1, no. (1), may, 2018 original article demonstrated that nurses working in a western montana hospital may not be sufficiently knowledgeable regarding the hf education guidelines *5+. the results of this study do not correlate with the study of fowler, (2012), where the mean score of nurses’ knowledge was 80% on the pretest with 16 correct answers out of 20 (80%) *14+. the nurses had a good knowledge 20 erbil journal of nursing & midwifery table 3: overall knowledge of the nurses regarding heart failure overall knowledge n= 64 f % poor knowledge 6 (9.4) good knowledge 45 (70.3) high knowledge 13 (20.3) table 4: association between nurses' overall knowledge and socio-demographic data socio-demographic characteristics overall knowledge total p value poor good high no. (%) no. (%) no. (%) age group (years) 21-30 4 (66.7) 22 (48.9) 2 (15.4) 28 0.153 31-40 2 (33.3) 17 (37.8) 9 (69.2) 28 41> 0 (0) 6 (13.3) 2 (15.4) 8 gender male 3 (50) 28 (62.2) 9 (69.2) 40 0.722 female 3 (50) 17 (37.8) 4 (30.8) 24 years of experience with heart failure patients in hospital? 1 – 5 years 5 (83.3) 22 (48.9) 7 (53.8) 34 0.626 6 – 11 years 1 (16.7) 15 (33.3) 3 (23.1) 19 12-17 years 0 (0) 6 (13.3) 3 (23.1) 9 above 18 years 0 (0) 2 (4.4) 0 (0) 2 educational levels associated nurse 1 (16.7) 3 (6.7) 1 (7.7) 5 0.613 technical diploma 5 (83.3) 28 (62.2) 6 (46.2) 39 baccalaureate 0 (0) 12 (26.7) 5 (38.5) 17 master 0 (0) 2 (4.4) 1 (7.7) 3 hospital rizgary teaching hospital 2 (33.3) 12 (26.7) 4 (30.8) 18 0.002 hawler teaching hospital 0 (0) 9 (20) 5 (38.5) 14 surgical specialty hospital cardiac centre 4 (66.7) 24 (53.3) 4 (30.8) 32 feeling of the nurses regarding good understanding of heart failure education topics strongly agree 1 (16.7) 1 (2.2) 0 (0) 2 0.136 agree 2 (33.3) 21 (46.7) 5 (38.5) 28 neither agree or disagree 1 (16.7) 17 (37.8) 6 (46.2) 24 disagree strongly 2 (33.3) 2 (4.4) 2 (15.4) 6 disagree 0 (0) 4 (8.9) 0 (0) 4 total 6 45 13 64 https://doi.org/10.15218/ejnm.2018.03 ejnm, vol. 1, no. (1), may, 2018 original article of knowledge and the nurses educational level in the study groups *3+. overall level of knowledge with socio-demographic characteristics except place of work, this may be due to the low number of the nurses who participated in this study from rizgary and hawler teaching hospital. in addition, 50% of the participants were in the surgical specialty hospital cardiac centre. the results correlate with the study conducted by the standfuss (2012); where no statistically significant difference found between overall mean score. limitations of the study the result of the study showed no statistically significant relationship between the level of knowledge and majority of the variables. this may be due to limitations such as; low sample size of participants due to some of the eligible nurses refusing to participate in the study. in addition it was difficult on occasions to arrange appointments with the nurses. finally, the nurses had insufficient information due to lack of resources for receiving information. the study concluded that the nurses had a good level of knowledge, but generally did not have enough information about heart failure. most of the nurses did not interact well with the patients in giving information, and generally no significant relationship was found between the nurse’s level of knowledge and other characteristics, except from the place of work. there are no conflicts of interest and sources of financial support for any of the authors. in relation to the signs and symptoms of hf, but in terms of how to education the patients the knowledge level of participants was low. with reference to the knowledge of the participants regarding heart failure (table 3); the majority of them had a good level of knowledge at 70.3%, 20.3% had high knowledge and only 9.4% of them had poor knowledge. this could be due to fact that the majority of the nurses were interested in receiving hf information, but don’t have opportunities to improve their knowledge. it also could be due to the level of education of majority of participants which was at the level of nursing institute (60.9%). the study revealed that nurses are key providers of patient education during admission and predischarge, as well as through directed teaching sessions which in turn improve clinical outcomes and reduce cost of care *15-17, 7+. the result of this study is support that of garris (2014) a quasiexperimental program development with a pretest, intervention, and post-test to increase nurses’ knowledge regarding hf education; pre-tests scores ranged from 6090 out of possible 100, with a mean score of 73.3% *18+. the results also agree with the study conducted by willette et al. (2014) which surveyed 49 nurses who regularly provided care to patients with hf at a hospital in the southeastern united states; here the mean hf self-management knowledge score was 15.97 (79.85% correct) *19+. conversely, the results are below that of the study by hart et al. 2010 on 122 nurses from a healthcare system located in the southeastern usa, where the nurses were highly knowledgeable about multiple areas of hf with, 90% of the sample correctly answering the item *20+.regarding the relationship between the overall knowledge of the nurses with socio-demographic data; there was no any significant association noticed between 21 erbil journal of nursing & midwifery conclusion conflicts of interest https://doi.org/10.15218/ejnm.2018.03 ejnm, vol. 1, no. (1), may, 2018 original article (4):371-7. *11+ lakasing e, francis h. diagnosis and management of heart failure: edin lakasing and heather francis discuss the causes, features, investigation and management of heart failure. primary health care. 2006 jun 1; 16(5):36-9. *12+ nicholas m. heart failure: pathophysiology, treatment and nursing care. nursing standard. 2004 nov 30; 19(11):46-52. *13+ jaarsma t, halfens r, huijer abu-saad h, dracup k, gorgels t, van ree j, et al. effects of education and support on self-care and resource utilization in patients with heart failure. european heart journal. 1999 may 1; 20(9):673-82. *14+ fowler s. improving community health nurses' knowledge of heart failure education principles: a descriptive study. home healthcare now. 2012 feb 1; 30(2):91-9. available from: www.homehealthcarenurseonline.com *accessed: 7 june 2017+. *15+ heart failure society of america. executive summary: hfsa 2010 comprehensive heart failure practice guideline. journal of cardiac failure. 2010 jun 30; 16(6):475-539. *16+ mitchell km. rural nurse knowledge of heart failure self-care principles (doctoral dissertation, montana state university-bozeman, college of nursing). 2014; available from: http://scholarworks.montana.edu/ xmlui/handle/1/3396 *accessed: 7 june 2017+. *17+ mccauley km, bixby mb, naylor md. advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure. disease management. 2006 oct 1; 9(5):302-10. *18+ garris am. nurses' knowledge related to heart failure essentials. 2014; available from: http:// digitalcommons.ric.edu/school_of_nursing/42 *accessed: 7 june 2017+. *19+ willette ew, surrells d, davis ll, bush ct. nurses' knowledge of heart failure self-management. progress in cardiovascular nursing. 2007 sep 1; 22 (4):190-5. *20+ hart pl, spiva l, kimble lp. nurses’ knowledge of heart failure education principles survey: a psychometric study. journal of clinical nursing. 2011 nov 1; 20(21-22):3020-8. available from: doi:10.1111/ j.1365-2702.2011.03717.x. *accessed: 7 june 2017+. *1+ blue l, lang e, mcmurray jj, davie ap, mcdonagh ta, murdoch dr, et al. randomised controlled trial of specialist nurse intervention in heart failure. bmj. 2001 sep 29; 323(7315):715-8. *2+ center for disease control. heart failure fact sheet. 2006; available from: https://www.cdc.gov/dhdsp/ data_statistics/fact_sheets/docs/fs_heart_failure.pdf *accessed: 1 may 2017+. *3+ standfuss cj. nurses' knowledge of heart failure education topics at a regional midwestern hospital (doctoral dissertation, minnesota state university, mankato). 2012; available from: http:// cornerstone.lib.mnsu.edu/etds *accessed: 1 may 2017+. *4+ massie bm, shah nb. evolving trends in the epidemiologic factors of heart failure: rationale for preventive strategies and comprehensive disease management. american heart journal. 1997 jun 1; 133(6):703-12. doi: 10.1016/s0002-8703(97)70173-x *accessed: 7 june 2017+. *5+ knopp am. nurses' knowledge of heart failure guidelines in a western montana hospital (doctoral dissertation, montana state university-bozeman, college of nursing). 2009; available from: http:// citeseerx.ist.psu.edu/viewdoc/download? doi=10.1.1.552.3574&rep=rep1&type=pdf *accessed: 1 may 2017+. *6+ bonow ro, bennett s, casey de, ganiats tg, hlatky ma, konstam ma, et al. acc/aha clinical performance measures for adults with chronic heart failure: a report of the american college of cardiology/ american heart association task force on performance measures (writing committee to develop heart failure clinical performance measures) endorsed by the heart failure society of america. journal of the american college of cardiology. 2005 sep 20; 46 (6):1144-78. available from: http:// circ.ahajournals.org/cgi/content/full/112/12/1853 *accessed: 1 may 2017+. *7+ albert nm, collier s, sumodi v, wilkinson s, hammel jp, vopat l, et al. nurses's knowledge of heart failure education principles. heart & lung: the journal of acute and critical care. 2002 apr 30; 31(2):102-12. *8+ fonarow gc, stevenson lw, walden ja, livingston na, steimle ae, hamilton ma, et al. impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure. journal of the american college of cardiology. 1997 jul 31; 30(3):725-32. *9+ koelling tm, johnson ml, cody rj, aaronson kd. discharge education improves clinical outcomes in patients with chronic heart failure. circulation. 2005 jan 18; 111(2):179-85. *10+ labeau s, vandijck dm, claes b, van aken p, blot si, executive board of the flemish society for critical care nurses. critical care nurses’ knowledge of evidence-based guidelines for preventing ventilatorassociated pneumonia: an evaluation questionnaire. american journal of critical care. 2007 jul 1; 16 22 erbil journal of nursing & midwifery references https://doi.org/10.15218/ejnm.2019.11 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article assessment of occupational health and safety measures’ knowledge and experienced types of hazards among nursing staff in rania hospital abstract introduction numerous changes in the nature of work and workplace risks have occurred. those changes have many impacts on the work environment, demographics of the work force composition, and health care delivery mechanisms. the analysis of these trends suggests that work-health interaction continues to grow in advance including the quality of performance, reducing hazards in workplace and health delivery strategies [1,2]. workers represent half of the global population and contribute greatly to the economic and social value of background and objectives: in recent years, significant developments have occurred in occupational health and safety programs designed to prevent and control work–related illness and injury. the aims of the study were to assess knowledge of nurses on occupational health and safety measures in hospital and their experienced type of occupational hazards’. methods: a quantitative descriptive study of non-probability sample was conducted on 50 nurses in rania general hospital. data was collected from 10th august 2017 to 25th december 2017. a questionnaire was developed for the purpose of data collection which included socio-demographic attributes of the study sample and questions on occupational hazards and occupational health and safety measures. frequency, percentage and chisquare tests were used for data analysis. results: proper disposal of waste (90%), acquainting rights and obligations / career and your job descriptions (88%), using protective clothing (86%), having vaccination against infectious diseases within the health facility (76%), providing a clinic for employees at work place (74%), prompt reporting of accidents/injuries (72%) were the most items which nurses implied to them according their knowledge. nurses mentioned that they experienced following occupational hazards in the hospital: physical 48%, psychological 28%, mechanical/electrical 12%, chemical 22% and biological 10%. there was a significant and highly significant association between years of experience and level of education of nurses with their overall knowledge on occupational health and safety measures, respectively but not with their age. conclusions: nurses did not have complete knowledge regarding occupational health and safety measures and they experienced different types of hazards during their working years. keywords: occupational health, occupational hazards, work-related injuries, workrelated illness, work safety, health and safety. shakhawan azad ahmed; department of community health nursing, college of nursing, university of raparin, rania, sulaymaniyah, iraq. (correspondence: shaxawanazad641@gmail.com ) omar hussein shareef; department of community health nursing, college of nursing, university of sulaymaniyah, sulaymaniyah, iraq. 85 erbil journal of nursing & midwifery received: 15/10/2018 accepted: 18/4/2019 published: 30/11/2019 mailto:shaxawanazad641@gmail.com https://doi.org/10.15218/ejnm.2019.11 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article contemporary society. a substantial part of the general morbidity of the working population is related to work [3-4]. additionally, too many workers are still exposed to unacceptable levels of occupational risks. they remain victims of occupational diseases and work accidents, lose their working capacity and income potential with limited access to occupational health services [5, 6]. occupational injuries and illness arise from unsafe conditions or activities in the work environment and are usually preventable. occupational injuries include but are not limited to exposure to chemicals, injuries from sharp objects or machinery, injuries from unsafe working environments such as slippery or uneven floors, poor ventilation, and improper functioning of electricity. the occupational health care provider has a crucial role in addressing work place risks. indeed the roles of occupational hazards in the work place are to prevent injury and illness, as well as the treatment of injured or ill workers [7, 8]. this is especially true for health care providers and, in particular, nurses. nurses face occupational risks every single day as they work to provide critical health care to their patients. those risks include, but are not limited to, exposure to infectious diseases, exposure to chemicals, heavy lifting and physical stress, and needle sticks. occupational health nurses have performed critical roles in the planning and delivery of worksite health and safety services. these are comprehensive and costeffective services which must continue to grow. the requirements in health care costs and the concern about health care quality have increased significantly. for that reason, safety measures have been established in different settings around the world, including primary care and management of non-work-related health problems in the health services programs [9-10]. we must be aware of our ultimate goal of ensuring that all workers in the world benefit from full physical and mental health. it is still far from being achieved despite the availability of effective interventions for occupational health. occupational health hazards consist of the biological, physical, mechanical, ergonomic, chemical, psychosocial hazards [1]. the aims of this study were to assess 1) occupational and safety measures orientation, 2) knowledge on occupational health and safety in hospital and its association with their age, level of education and year of experience, 3) type of occupational hazards’ experienced among nurses in rania general hospital. a quantitative descriptive study of nonprobability purposive sample was conducted on 50 nurses from 120 nurses who work in rania general hospital who were available during data collection. data was collected in the period from august 2017 to december 2017. the sample of hospital nurses were selected from different hospital departments including emergency, pharmacy, radiology, surgical and operational room and coronary care unit. a questionnaire was developed for the purpose of data collection in the study. the first part included socio-demographic attributes of the participants. occupational health and safety measures, occupational health hazards and supportive activities were the main domains in the second part of the questionnaire. six experts in the field reviewed the question are and checklist who suggested some modification in order to improve internal validity of the tool while the reliable of the questionnaire result of correlation was (r=0.78) for the entire questionnaire by test and retest. the study was approved by the scientific committee of college of nursing at methods 86 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.11 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article the majority of the study sample (82%) thought that effective occupational health and safety policies have impact on job performance in the hospital. sixty four per cent of nurses got training sessions regarding occupational health and safety measures. more than half the nurse (58%) mentioned that they had periodic educational program regarding that and 52% attend symposium about it (table 2). the majority of the study sample mentioned that following are components of occupational health and safety measures: proper disposal of waste (90%), acquainting rights and obligations / career and your job descriptions (88%), using protective clothing (86%), having vaccination against infectious diseases within the health facility (76%), providing a clinic for employees at work place (74%), prompt reporting of accidents/injuries (72%). only 26% of the study sample mentioned that they have a medical file within the health facility (table 3). nurses mentioned that they experienced following occupational hazards in the hospital: physical 48%, psychological 28%, mechanical/electrical 12%, chemical 22% and biological 10% (table 4). table 5 shows that there was significant and highly significant association between years of experience and level of education of nurses with their overall knowledge on occupational health and safety measures, respectively but not with their age. table 5, displays the relationship between level of nurses’ education and their knowledge. the distribution of the level of education among participants showed that 84% graduated from medical institute. this finding is significant for the kurdistan region. for several years colleges of nursing and nursing institutions have worked to improve the level of knowledge and university of raparin, as well as university of sulaimanyah. the formal permission was given by administration of the hospital. data was collected through face to face interview technique and analysis by spss version 21. variables were analyzed utilizing descriptive and inferential statistics. descriptive statistical analyses included frequency, percentage, correlation coefficient and chi-square. the highest percentage (48%) of the nurses were aged between 22-29 years. the majority were male (64%). regarding of the years of experience, half of them (44%) had 1-5 years. the majority of the nurses (84%) graduated from medical institutes while the lowest percentage of them (4%) are graduates primary nursing school and college. the majority of the sample (74%) were married while the lowest percentage of them (24%) were single (table 1). 87 erbil journal of nursing & midwifery results items f (%) age group 22-29 24 (48) 30-37 21 (42) 38-46 5 (10) gender male 32 (64) female 18 (36) years of experiences 1-5 22 (44) 6-10 17 (34) 11-16 11 (22) level of education primary nursing school 2 (4) secondary nursing school 4 (8) medical institute 42 (84) college of nursing 2 (4) marital status single 12 )24( married 37 )74( divorced 1 )2( total 05 )155( table1: distribution of the nurse's sociodemographic of the study sample https://doi.org/10.15218/ejnm.2019.11 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article education of their graduates. this finding indicates that education is critical to nursing practice in the hospitals. the findings suggest that future study of an educational intervention aimed at non graduates who are working as nurses is critical. at the same time, there appears to be a significant relationship between years of experience and knowledge as identified in table 5. 88 erbil journal of nursing & midwifery table 3: knowledge regarding occupational health and safety measures in hospital table 2: occupational and safety measures orientation among study sample no not sure yes items no (%) f % f (%) f (12) 6 (6) 3 (82) 41 do you think effective occupational health and safety policies have any impact on job performance in the hospital? 1 (34) 17 (2) 1 (64) 32 did you get training sessions about occupational health and safety measures? 2 (38) 19 (4) 2 (58) 29 did you have periodic educational program in your department regarding occupational health and safety measures? 2 (44) 22 (4) 2 (52) 26 did you attend any symposia regarding occupational health and safety measures? 3 no not sure yes items no (%) f (%) f (%) f (8) 4 (2) 1 (90) 45 proper disposal of waste. 1 (26) 13 (14) 7 (60) 30 regular monitoring on safety and health standards to ensure if they are complied with. 2 (6) 4 (6) 3 (86) 43 using protective clothing 3 (14) 7 (14) 7 (72) 36 prompt reporting of accidents/injuries 4 (44) 22 (14) 7 (42) 21 re-training on safety and health practices 0 (30) 15 (12) 6 (58) 29 having a safety committee in the hospital 6 (26) 13 (14) 7 (60) 30 having written copy of occupational health and safety policy of the hospital in department 7 (30) 15 (18) 9 (52) 26 providing protective devices especially the safety of the work environment 8 (16) 8 (8) 4 (76) 38 having vaccination against infectious diseases within the health facility 9 (8) 4 (4) 2 (88) 44 acquainting rights and obligations / career and your job descriptions 15 (68) 34 (6) 3 (26) 13 having a medical file within the health facility 11 (16) 8 (10) 5 (74) 37 providing a clinic for employees at work place 12 (36) 18 (26) 13 (38) 19 reporting the accident to the appropriate authorities 13 https://doi.org/10.15218/ejnm.2019.11 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article 89 erbil journal of nursing & midwifery no not sure yes items no (%) f (%) f (%) f (44) 22 (8) 4 (48) 24 physical: falling, sliding, back injuries, muscle, needle stick? 1 (54) 27 (18) 9 (28) 14 psychological: work pressure, the violence of the patient and his family? 2 (72) 36 (16) 8 (12) 6 mechanical, electrical: electrical injuries when using electrical appliances? 3 (72) 36 (6) 3 (22) 11 chemical: exposure to chemicals such as acids and toxins and those that lead to a fire or explosion, and cleaning materials and dust? 4 (90) 45 (0) 0.0 (10) 5 biological: bacteria, viruses and mildew? 0 table 4: type of occupational hazards’ experienced by study sample no not sure yes p-value f ( %) f (%) f (%) age group years 22-29 248 (36.9) 65 (9.7) 359 (53.4) 5.948 ns 30-37 227 (38.6) 72 (12.1) 290 (49.3) 38-48 50 (35.7) 15 (10.7) 75 (53.6) level of education primary nursing school 10 (17.9) 3 (5.4) 43 (76.9) 5.550 hs secondary nursing school 51 (45.5) 15 (13.4) 46 (41.1) medical institute 444 (37.8) 124 (10.5) 608 (51.7) nursing college 22 (29.3) 7 (2.51) 27 (58.2) years of experiences 1-5 216 (35.1) 72 (11.7) 328 (53.2) 5.51 s 6-10 195 )41( 48 (10.1) 233 (48.9) 11-16 114 )37( 31 (10.1) 163 (52.9) table 0: association between age, level of education, years of experience of the study sample and their overall knowledge on occupational health and safety measures in hospital https://doi.org/10.15218/ejnm.2019.11 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article table 5, displays the relationship between level of nurses’ education and their knowledge. the distribution of the level of education among participants showed that 84% graduated from medical institute. this finding is significant for the kurdistan region. for several years colleges of nursing and nursing institutions have worked to improve the level of knowledge and education of their graduates. this finding indicates that education is critical to nursing practice in the hospitals. the findings suggest that future study of an educational intervention aimed at non graduates who are working as nurses is critical. at the same time, there appears to be a significant relationship between years of experience and knowledge as identified in table 5. this is worth noting as “learning on the job” and by being exposed to nurses who have greater knowledge could have an effect on nursing practice. this must be studied further. regarding educational programs on occupational health and safety, the findings indicate that 82% of the nurses surveyed think that they should have training on occupational health and safety. this is highly significant to the overall study and should inform future educational interventions. only 52% of those surveyed indicated that they had any safety training during orientation. indeed, the results from these results are extremely significant to future studies and any interventions that are planned for occupational health and safety. the current study explored that, using all the necessary personal protective equipment was associated with reduced exposure to both biological and non-biological hazards. this finding supports evidence by hayden et al., who reported that use personal protective equipment reduced acquisition of illnesses in hospital settings [12]. indeed, use and compliance with utilization of personal protective equipment has for long been recognized as important infection control measure in the healthcare industry [13,14] which should be emphasized to minimize exposure to occupational hazards. these findings are largely comparable to previous studies conducted in low and middle income countries. ziraba in uganda, nsubuga in uganda, orij in nigeria, de castro in philippines, and adib-hajbaghery in iran reported that sharp related injuries and stress were the major health related hazards experienced by healthcare workers in their studies [15-16]. although many health facilities provided special waste disposal containers for medical wastes and safety tools and equipment as control measures for occupational health hazards, simple measures like hand washing were not fully embraced. the proportion of health workers who reported washing hands after recommended procedures was lower than has been reported by previous studies [17,18]. the study also found that, respondents who experienced work related pressures were more likely to report occupational hazards. work related pressures have been reported to have negative impacts including the compromise of patient care thus resulting to a diminished quality of life for both healthcare workers and patients [19]. the findings with regard to training of staff are also comparable with those of a study that was carried out on the relationship between employees' perceptions of safety and organizational culture where insufficient safety training was the root cause of major accidents at the work place since employees did not have the knowledge and skills to identify potential hazards [20,21]. in a similar study, organizations which emphasized on safety through training and other managerial practices observed an 90 erbil journal of nursing & midwifery discussion https://doi.org/10.15218/ejnm.2019.11 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article [3] gitlin df, schindler ba, stern ta, epstein sa, lamdan rm, mccarty ta, et al: worley ll. recommended guidelines for consultationliaison psychiatric training in psychiatry residency programs: a report from the academy of psychosomatic medicine task force on psychiatric resident training in consultationliaison psychiatry. psychosomatics: journal of consultation and liaison psychiatry. 1996 jan. [4] hayden mk, blom dw, lyle ea, moore cg, weinstein ra. risk of hand or glove contamination after contact with patients colonized with vancomycin-resistant enterococcus or the colonized patients' environment. infection control & hospital epidemiology. 2008 feb;29(2):149-54. [5] singer aj, clark ra. cutaneous wound healing. new england journal of medicine. 1999 sep 2;341(10):738-46. [6] marais bj, raviglione mc, donald pr, harries ad, kritski al, graham sm,et al: scale-up of services and research priorities for diagnosis, management,2010 jun 19;375(9732):217991.. [7] rafael e, parker je. occupational and environmental medicine in the united states. international archives of occupational and environmental health. 1998 apr 1;71(3):15561. [8] nicholson pj. occupational health in the european union. occupational medicine. 2002 mar 1;52(2):80-4. [9] conway pm, campanini p, sartori s, dotti r, costa g. main and interactive effects of shiftwork, age and work stress on health in an italian sample of healthcare workers. applied ergonomics. 2008 sep 1;39(5):630-9. [10] de castro ab, cabrera sl, gee gc, fujishiro k, tagalog ea. occupational health and safety issues among nurses in the philippines. aaohn journal. 2009 apr;57(4):149-57. [11] yassi a. utilizing data systems to develop and monitor occupational health programs in a large canadian hospital. methods of information in medicine. 1998;37(02):125-9. [12] brott t, adams jr hp, olinger cp, marler jr, barsan wg, biller j, et al: measurements of acute cerebral infarction: a clinical examination scale. stroke. 1989 jul;20(7):864-70. increase in safety compliance among their employees [23]. other similar study further reported that employees who have received safety training will likely report less work-related injuries than their untrained counterparts [22]. the study showed that the most significant factor in relation to occupational health and safety practice was related to nurses’ knowledge. it is important to continue to train nurses in university and institution educational settings on the importance of occupational health and safety. it is also recommended that all hospitals should establish an orientation unit related to occupational health and safety not only for their new nursing employees, but also for all employees. third, it is important to have and evaluate continuing educational programs on occupational health and safety. overall, this study is important in informing future interventions and practice for nurses on occupational health and safety. the authors reported no conflict of interests. [1] bolyard ea, tablan oc, williams ww, pearson ml, shapiro cn, deitchman sd, hospital infection control practices advisory committee. guideline for infection control in healthcare personnel, 1998. infection control & hospital epidemiology. 1998 jun;19 (6):407-63. [2] burgel bj, childre f. the occupational health nurse as the trusted clinician in the 21st century. workplace health & safety. 2012 apr;60 (4):143-50. 91 erbil journal of nursing & midwifery conflict of interest references conclusion https://doi.org/10.15218/ejnm.2019.11 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article [13] ndejjo r, musinguzi g, yu x, buregyeya e, musoke d, wang js, halage aa, whalen c, bazeyo w, williams p, ssempebwa j. occupational health hazards among healthcare workers in kampala, uganda. journal of environmental and public health. 2015;2015. [14] nsubuga fm, jaakkola ms. needle stick injuries among nurses in sub‐saharan africa. tropical medicine & international health. 2005 aug;10(8):773-81. [15] ejilemele aa, ojulu ac. knowledge, attitude and practice of aspects of laboratory safety in pathology laboratories at the university of port harcourt teaching hospital, nigeria. nigerian journal of clinical practice. 2005;8 (2):102-6. [16] colligan mj, cohen a. the role of training in promoting workplace safety and health. the psychology of workplace safety. 2004:22348. [17] siegel jd, rhinehart e, jackson m, chiarello l. 2007 guideline for isolation precautions preventing transmission of infectious agents in healthcare settings. [18] feinstein js. the relationship between socioeconomic status and health: a review of the literature. milbank quarterly. 1993 jan 1;71 (2):279-322. [19] ziraba ak, bwogi j, namale a, wainaina cw, mayanja-kizza h. sero-prevalence and risk factors for hepatitis b virus infection among health care workers in a tertiary hospital in uganda. bmc infectious diseases. 2010 dec;10(1):191. [20] o'toole m. the relationship between employees' perceptions of safety and organizational culture. journal of safety research. 2002 jun 1;33(2):231-43. [21] cooren f, kuhn t, cornelissen jp, clark t. communication, organizing and organization: an overview and introduction to the special issue. organization studies. 2011 sep;32 (9):1149-70. [22] wasswa p, nalwadda ck, buregyeya e, gitta sn, anguzu p, nuwaha f. implementation of infection control in health facilities in arua district, uganda: a cross-sectional study. bmc infectious diseases. 2015 dec;15(1):268 [23] colligan mj, cohen a. the role of training in promoting workplace safety and health. the psychology of workplace safety. 2004:22348. 92 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.05 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article risk of suicide among women survived domestic violence in erbil governorate abstract introduction violence against women is a serious human rights abuse and global public health issue. women around the world are facing different forms of violence, such as physical, psychological, and sexual. the perpetrators could be strangers and/or family members who are known as domestic violence and intimate partner abuse *1+. domestic violence is defined according to the department of justice of united states of america (usa) as “a pattern of abusive behavior in any relationship that is used by one partner to gain or maintain power and control over another intimate partner”. the act of violence could be physical, sexual, emotional, economic, or psychological actions or threats of actions that put a direct or indirect risk on the safety and security of another family member. this includes any behaviors that intimidate, manipulate, humiliate, isolate, frighten, background and objectives: domestic violence is a global issue leading to many medical and mental health consequences. a stable family relationship is mandatory for physical and mental health. the current study aimed at assessing the risk of suicide as a consequence of domestic violence among the survived women in erbil governorate. methods: a cross-sectional study was conducted from 1st january 2018 to 31st december 2018. a sample of 105 women survived from domestic violence was recruited through a non-probability snowball sampling technique. data were collected through direct interview with survivals using an adapted version of the ready-made questionnaire format of columbia-suicide severity rating scale. the questionnaire was used for interviewing the women about (socio-demographic, violence, and risk of suicide). the validity and reliability of the instrument was checked. data were analyzed by using the frequency, percentage and fisher exact test from the statistical package for social science version 23. results: the results of the study revealed that, the mean age of the study sample was 33.16 years old. 62.9% were married, and 63.8% were housewives. 33.3% of violence conducted was marital rape, in 26.2% of the cases; the violence was continuous throughout the past year. 76.2% of women wished for death and 57.1% thought of suicide. the suicidal risk was mostly linked to rape and sexual violence, were 100% of raped cases wished for death, and 62.5% of them had set a suicidal plan. conclusion: domestic violence has a direct relation to the risk of suicide among women survived domestic violence. keywords: suicide, domestic-violence, human, female, mental health diana aprem kako; department of nursing, college of nursing, hawler medical university, erbil, iraq. abdulqadir hussen gardi; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: diana.kako@yahoo.com ) 34 erbil journal of nursing & midwifery received: 10/9/2018 accepted: 17/12/2018 published: 30/5/2019 mailto:diana.kako@yahoo.com https://doi.org/10.15218/ejnm.2019.05 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article terrorize, threaten, blame, hurt, injure, or wound someone within the context of family *2+. throughout the history, violence against women was a private indoor matter. in fact, women beating were legal to some extent under the justification of disciplining. it wasn’t until 1911 when the first court in the usa was established with the goal of solving domestic problems, that wife beating was made illegal in all states of the united states by 1920. the women’s movement of the 1960’s and the anti-rape movement of the 1970’s encouraged survivors of domestic violence to report, which led to the formation of women’s crisis centers and hotlines *3+. in the kurdistan region of iraq (krg) the parliament passed the act of combating domestic violence in 2011 *4+. such act of violence increases the risk for mental health disorder among survivals. multiple studies have been conducted about domestic violence and its effect on mental and physical health, in all of the studies, results indicated that intimate partner violence is a factor contributing to mental disorders *5+. “mental disorder is a syndrome characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” *6+. women who survive domestic violence incur $4.1 billion per year in direct costs for medical and mental health services *7+. globally domestic violence is also contributing to women’s mortality through suicide including in egypt (61%), brazil (48%), india (64%), indonesia (11%), and in the philippines (28%) of women had a significant correlation between domestic violence and suicidal ideation *8+. in the kurdistan region of iraq (krg) in the first 10 months of 2017, 20 suicide cases were reported which had a direct link to domestic violence *9+. mental disorders are usually associated with significant distress in social, occupational, and other important activities *10+. according to world health organization (who), women survived from domestic violence are suffering from emotional distress, and survivals are in a higher risk for suicide comparing to other women *11+. who also reported that women are more victims of domestic violence then strangers’ violence, and the lifetime prevalence of physical or sexual partner violence, or both, varied from (15%) to (71%) *1+. the main objective of this study was to assess the risk of suicide as a consequence of domestic violence among the survived women. a cross-sectional study was conducted among women survived from domestic violence to find the risk of suicide as a consequence of domestic violence among the survived women. duration of the study was from 1st january 2018 to 31st december 2018 in different locations in erbil governorate. the study sample were 105 women survived from domestic violence, they were selected via using the snowball sampling technique to establish a representative sample of the targeted population, according to the study’s inclusion and exclusion criteria; women and girls who aged equal and more than 18 years old were included based on their informed consent. data were collected from women safe spaces which are specialized for providing psychological support for women, and also part of data were collected from women shelter. selected women were not diagnosed with any mental disorders before methods 35 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.05 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article and occupation. the second part assessed the types and forms of violence, were participants been asked about the form of violence whether it is physical violence which includes beating, burning, hair pulling, and any other violent act that have a negative impact on the body; or sexual violence which is defined by who as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work” *1+. the psychological and emotional violence, which includes the acts or threats of acts resulting in emotional and psychological disturbance of the survivals. marital rape which is a rape conducted by the intimate partner. and the last type of violence which is financial abuse was the violence is been conducted by preventing the survivals to access their financial rights, or when the survival financial income is taken off by the perpetrator. the frequency of violence act was assessed during the last year, either is contentious or been in certain point of time such as weekly or monthly, or whether the violence occurred only once during the previous year. the last part of the questionnaire assessed the level and severity of suicide risk, which has been adopted from the columbiasuicide severity rating scale (c-ssrs). the scale contains six questions about participant’s thoughts, action, and feeling in the past month, with yes or no answer for each question, determining the stage of suicide risk that may be suicidal wishes, thoughts, intentions, plans, and suicidal behaviors *15+. the questionnaire was validated through a panel of experts from different scientific the occurrence of violence, and they had not been through any other accidents such as fire, traffic, terrorist, and robbery attack. the sample size was estimated based on the formula of. in which is standard normal variety at 5% type one error when proportion with a 95% level of confidence and a margin of error of 5%, = 1.96. p-value <0.05. the d is the absolute error and it’s equal to 0.05. and p stands for the expected portion of population based on published data, in the current study, as there is no formal published percentage of domestic violence cases in erbil, the investigator calculated percentage of domestic violence cases based on report of who were they stated that 1 in 3 women are affected by domestic violence, thus referring to proportion of women in erbil population, which is 466803 *12+, and assuming that 1 in 3 women are affected by violence, thus the p= 33.3%. referring to this equation; the total estimated study sample was (339) cases *14+, *13+. referring to the sensitivity and social stigma of domestic violence, lack of reporting, and time limitation; the investigator could reach only to 105 cases. a pilot study on 15 cases was carried out for obtaining the "inter-rater reliability test. internal consistency of the study was obtained through applying pearson correlation (r) which was (0.92); it indicates that there is a strong positive correlation. direct face to face interview through questionnaire was conducted by the authors, after obtaining verbal consent from the study sample. the data collection tool was modified from the ready-made questionnaire and expert recommendation. the questionnaire consisted of three parts. the first part was on socio-demographic characteristics of study sample. this part composed questions about the age of the participants, the marital status, and level of education, location, 36 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.05 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article backgrounds related to nursing and medicine. the expert responses were based on agreement or disagreement with items of the questionnaire. the experts agreed to the contents of the questionnaire with some modifications regarding the biographic part and the expert also added more detail in the violence part. the investigator took into consideration their comments and prepared the final version of the questionnaire accordingly. prior to data collection, the formal permission was obtained from the ethical committee at the college of nursing, hawler medical university. furthermore, the informed oral consent was taken from the candidate who participated in the study, after confirmation of confidentiality, anonymity and participants self-determination by the researcher. formal permission was also obtained from the directorate of labor and social affairs and directorate of women correctional center. after data collection, the statistical package for social science (spss, version 23) was used for data processing and statistical analysis. the statistical analysis included descriptive statistical analysis such as frequency and percentage to describe the basic features of the data in a study and provide simple summaries about the sample and the measures. inferential statistical analyses as chi-square and fisher exact test were implemented to make judgment about inferences from our data to more general conditions. the confidence interval was 95%. the p-value of each test ≤ 0.05 considered as statistically significant. table 1 shows the general sociodemographic characteristics of the study sample, the age of participants ranged from 18-59 years old, with the mean age of 33.16 years old. regarding the marital status of the survivals, the highest percentage (62.9%) were married, while divorced and single were 14.3% and 13.3% respectively. the education level of participants showed that the highest percentage (40%) was secondary school graduated and the percentage of the institute and/or college graduated was 30.5%. as for the occupation, the highest percentages of the women (63.8%) were housewives and 13.3% had semiskilled manual occupations. for the residency of participants; the results showed that 80% of survivals were living in urban areas. 37 erbil journal of nursing & midwifery results table 1: socio-demographic characteristics of the survived females of domestic violence characteristics (n=105) frequency distribution age (year) range: 18-59 mean ± st. deviation 33.16 ± 9.28 f (%) marital status single married divorced widowed separated 14 (13.3) 66 (62.9) 15 (14.3) 7 (6.7) 3 (2.9) education illiterate read and write primary school graduate secondary school graduate institute/college postgraduate 7 (6.7) 12 (11.4) 8 (7.6) 42 (40) 32 (30.5) 4 (3.8) occupation associate professional occupations skilled manual and non-manual occupation semi-skilled manual occupations unskilled manual occupations house wife student 4 (3.8) 3 (2.9) 14 (13.3) 5 (4.8) 67 (63.8) 12 (11.4) residential area urban rural 84 (80) 21 (20) https://doi.org/10.15218/ejnm.2019.05 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article regarding the type of violence; as it shows in the table 2; the result shows that most common type of violence conducted (33.3%) was marital rape. physical violence and emotional violence come in the second and third place with the percentage of 26.7% and 21.9%. the study results of recurrence of violence in past year indicated that the violent act was continuous in 36.2% of the cases while 20% of participants were subjected to violence once per month. regarding the perpetrator; the violent act was conducted by the intimate partner in the most of cases (70.5%). table 3 shows different level of suicide risk; were the results indicated that, most of the participants (76.2%) wished for death, while 57.1% of participants had suicidal thoughts without any suicidal plans. 35.2% of the study, sample thought of suicide in addition to setting a special suicidal plan meanwhile more than half of the participants (64.8%) did not plan for the suicide. suicide attempt was positive in 17.1% of the participants. regarding the association between the perpetrator and risk of suicide, as it shown in the table 4, result revealed that majority of cases (71.3%) who survived from violence conducted by their intimate partner, wished for death; the results were statistically significant with p-value= 0.01. results also demonstrate a significant relationship between perpetrator and suicidal thoughts, were 70% of survivors from 38 erbil journal of nursing & midwifery table 2: forms of domestic violence among survived females of violence. violence characteristics (n=105) frequency distribution f (%) violence type physical violence sexual violence emotional violence rape marital rape financial abuse 28 (26.7) 6 (5.7) 23 (21.9) 8 (7.6) 35 (33.3) 5 (4.8) frequency of violence continuous once per week 1/month 1/3months 1 / 6 months 1/ year 38 (36.2) 20 (19) 21 (20) 5 (4.8) 6 (5.7) 15 (14.3) violence perpetrator intimate partner brother father second degree relative children 74 (70.5) 5 (4.8) 10 (9.5) 11 (10.5) 5 (4.8) table 3: suicide risk assessment among women survived domestic violence depressive disorders frequency distribution f (%) death wish yes no 80 (76.2) 25 (23.8) 60 (57.1) 45 (42.9) 37 (35.2) 68 (64.8) 18 (17.1) 87 (82.9) suicidal thought yes no thought plan yes no suicidal behavior yes no https://doi.org/10.15218/ejnm.2019.05 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article intimate partner violence had active suicidal thoughts, with p-value= 0.01. regarding active suicidal thought with suicidal plan, however generally most of the cases didn’t have specific suicidal plan, yet 62.2% of as for the association between risk of suicide and type of violence, result showed that 40% of women who were raped by their spouse, wished for death and also had thought of suicide, the result was highly significant with p-value = 0.001. regarding the active suicidal thoughts with plans, table 5 revealed that, 37.8% of women cases who faced violence from their intimate partner had set a specific suicidal plan, the relation were statistically significant with p-value= 0.01. who survived marital rape and 24.3% of physical violence survivals had set suicidal plan. results were considered statistically significant with p-value= 0.03. regarding suicidal behaviors, while 50% marital raped women had suicidal behavior, the relationship was statistically non-significant. 39 erbil journal of nursing & midwifery table 4: association between perpetrator and risk of suicide risk of suicide intimate partner f (%) brother f (%) father f (%) second degree relative f (%) p-value * dead wish yes no 57 (71.3) 17 (68) 1 (1.3) 4 (16) 7 (8.8) 3 (12) 15 (18.8) 1 (4) 0.013** suicidal though yes no 42 (70) 32 (71.1) 0 (0.0) 5 (11.1) 6 (10) 4 (8.9) 12 (20) 4 (8.9) 0.013** suicidal plan yes no 23 (62.2) 51 (75) 0 (0.0) 5 (7.4) 4 (10.8) 6 (8.8) 10 (27) 6 (8.8) 0.019** suicidal behavior yes no 12 (66.7) 62 (71.3) 0 (0.0) 5 (5.7) 4 (22.2) 6 (6.9) 2 (11.1) 14 (16.1) 0.165*** risk of suicide violence types p-value * physical violence f (%) sexual violence f (%) emotional violence f (%) rape f (%) marital rape f (%) financial abuse f (%) death wish yes no 15 (18.7) 13 (52) 6 (7.5) 0 (0.0) 16 (20) 7 (28) 8 (10) 0 (0.0) 32 (40) 3 (12) 3 (3.8) 2 (8) 0.001** suicidal thoughts yes no 11 (18.2) 17 (37.8) 6 (10) 0 (0.0) 14 (23.3) 9 (20) 5 (8.3) 3 (6.7) 24 (40) 11 (24.4) 0 (0.0) 5 (11.1) 0.001** suicidal plan yes no 9 (24.3) 19 (27.9) 4 (10.8) 2 (2.9) 5 (13.5) 18 (26.5) 5 (13.5) 3 (4.4) 14 (37.8) 21 (30.9) 0 (0.0) 5 (7.4) 0.039*** suicidal behavior yes no 3 (16.7) 25 (26.7) 0 (0.0) 6 (6.9) 4 (22.2) 19 (21.8) 2 (11.1) 6 (6.9) 9 (50) 26 (29.9) 0 (0.0) 5 (5.7) 0.222**** table 5: association between different types of domestic violence and risk of suicide *fishers’ exact test was performed for statistical analysis, ** significant, *** non-significant *fishers’ exact test was performed for statistical analyses. ** highly significant **** significant **** non-significant https://doi.org/10.15218/ejnm.2019.05 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article regarding the type of violence conducted against the study sample, the heights percentage (33.3%) was marital rape which is forcing the partner on sexual intercourse. similar findings of sexual violence by the intimate partner were reported in erbil 12.1% *16+, 42.2% in iran *19+, 16.4% in spain *20+, and 12% in china *21+. such a high percentage of intimate partner sexual violence could be linked to the social and cultural norms were in most contexts marital rape is not recognized as a violation of women rights. men and to some extent women believe that the intimate partner has the right of sexual intercourse at any time, and the wife is not to refuse or object. in most of the cases (36.2%) the violence was continuous in the past year, which means the survived women were living in a stressful situation most of their time, and also the violence could happen during pregnancy and in front of their children. regarding the perpetrator; violence was mostly conducted by an intimate partner (70%), these results were also reported by who, as they found that most of the violence faced by women are committed by their intimate partner, who also reported that; worldwide, almost one third (30%) of women who have been in a relationship report that they have experienced some form of physical and/or sexual violence by their intimate partner in their lifetime *13+. regarding the risk of suicide; results of this study revealed that generally there is a high risk of suicide among women survived from domestic violence, the majority of the study sample (76.2 %) wished that they were dead. 57.1% of them randomly thought of suicide and imagined their death, but they had no actual suicidal plan. meanwhile 35.2% of survivals thought of suicide and had a suicidal plan and they were thinking of implementing the suicidal plan, among them 17.1% attempted for the aim of the current study was to assess the risk of suicide among women survived domestic violence. regarding the sociodemographic characteristics, the highest percentage of the study sample was in their age of thirties, mean ± sd of participant’s age was 33.16 ± 9.28, minimum age 18 years old and maximum age 59 years old. most of them were married, and they were mostly secondary school graduated, and the majority of the study samples were housewives and they were living in urban areas. these results were similar to the findings of a study conducted in krg by alatrushi et al, as they also found that majority of women suffering from domestic violence are in between 25-34 years old *16+, and also according to the who multicountry study on women’s health and domestic violence, results showed that (13%) to (61%) of women who reported on domestic violence are between 15 and 49 years old *11+. regarding educational background, the results indicated that the violence has mostly occurred among women who had less degree of formal education. results of the current study were similar to a study conducted in erbil by namir altawil, about the association of violence against women with religion and culture in erbil iraq, were only half of the participants (50.4%) had more than 12 years of formal education *17+. women who are less educated usually have less knowledge about the law, and they are less independent financially as most of them are housewives, thus it’s make them an easier target of violence because they don’t ask for their rights. results were also supported by a study conducted in usa, on the risk factors for intimate partner violence (ipv), were they reported that having a school degree of less than high school will increase the risk of ipv *18+. 40 erbil journal of nursing & midwifery discussion https://doi.org/10.15218/ejnm.2019.05 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article contemplated suicide, and rape victims were also 13 times more likely to have attempted suicide *23+. domestic violence has a direct link to the deterioration of mental health; women survived from domestic violence are at high risk of suicide due to the violence that they face. domestic violence is always seen as a private family issue, were reporting against violence act will put the survival in risk of social stigma and also the risk of honor killing by family members, which increase the stress on the survivals, leading to depression and eventually put the survivals at a higher risk of suicide. the authors have no any conflict of interest *1+ garcia-moreno c, jansen hafm, ellsberg m, heise l, watts ch, who multi-country study on women’s health and domestic violence against women. lancet london england. 2006 7;368 (9543):1260_9. available from: https://www.ncbi.nlm.nih.gov/ pubmed/17027732 *accessed 19th july 2018+. *2+ the united states department of justices. domestic violence. 2017. available from: https://www.justice.gov/ovw/domesticviolence*accessed 19th may 2018+. *3+ orloff le, feldman p. domestic violence and sexual assault public policy timeline highlighting accomplishments on behalf of immigrants and women of color. national immigrant women’s advocacy project; 2017. available from: http://library.niwap.org/wpcontent/uploads/herstory-2016.pdf *accessed 23th feb 2018+. *4+ parliament of kurdistan. the act of combating domestic violence in kurdistan region -iraq 2011. available from: http:// www.ekrg.org/files/pdf/ combat_domestic_violence_english.pdf *accessed 10th october 2017+. suicide or arranged everything for suicide but changed their mind in the last minute before acting the plan. globally domestic violence was found to be a risk factor for suicide in women. in krg in the first 10 months of 2017, 20 suicide cases were reported which had a direct link to domestic violence *9+. referring to a study published in indian journal of psychiatry in 2015; results showed a significant relationship between domestic violence and suicidal ideations, in egypt 61%, brazil 48%, india 64%, indonesia 11%, and in the philippines 28% of women who had suicide ideation, it was due to domestic violence problems *8+. davis (2010), reported that approximately 30% of suicides in 16 states of the usa in 2005 were precipitated by intimate partner problems *22+. as for the association between type of violence and different level of suicide, results demonstrate that wishing for death were mostly associated with survivors who experienced marital rape, and this is usually related to the social stigma that women and girls are facing when they goes through such experience, as marital rape is not recognized as violence; in some cases the survivors are looking at as the main guilty person and they may face the risk of divorce or physical violence if they reject such violence by their spouse, were women are expecting protection and affection from their intimate partner, such act of violence by the intimate partner will cause extreme depression and emotional disturbance to the women leading to suicidal thoughts. living in an environment where same violence act is repeated many times is very likely to create frustration leading to suicidal plan as it occurred in 37.8% of marital rape survived women. kilpatrick (2000), found that 33% of the rape survivals have thought of suicide, and they were 4.1 times more likely than non-crime victims to have 41 erbil journal of nursing & midwifery conclusion conflicts of interest references https://doi.org/10.15218/ejnm.2019.05 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *13+ world health organization. violence against women. 2017. available from: http:// www.who.int/news-room/fact-sheets/ detail/violence-against-women *accessed 27th aug 2018+. *14+ charan j, biswas t. how to calculate sample size for different study designs in medical research? indian journal of psychological medicine. 2013;35 (2):121–6. available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc3775042/ *accessed 12th oct 2017+. *15+ posner k, brent d, lucas c, gould m, stanley b, brown g, et al. columbia-suicide severity rating scale (c-ssrs). 2008. available from: http://cssrs.columbia.edu/wp-content/ uploads/c-ssrs1-14-09-screening.pdf *accessed 27th oct 2017+. *16+ al-atrushi hh, al-tawil ng, shabila np, alhadithi ts. intimate partner violence against women in the erbil city of the kurdistan region, iraq. bmc women’s health. 2013 oct 10;13:37. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc3852841/ *accessed 12th oct 2017+. *17+ al-tawil ng. association of violence against women with religion and culture in erbil iraq: a cross-sectional study. bmc public health. 2012 sep 17;12:800. available from: https:// bmcpublichealth.biomedcentral.com/ articles/10.1186/1471-2458-12-800 *accessed 12th oct 2017+. *18+ walton-moss bj, manganello j, frye v, campbell jc. risk factors for intimate partner violence and associated injury among urban women. journal of community health. 2005 oct 1;30(5):377–89. available from: https://www.ncbi.nlm.nih.gov/ pubmed/16175959 *accessed 3d july 2018+. *19+ aghlmand s, akbari f, lameei a, mohammad k, small r, arab m. developing evidencebased maternity care in iran: a quality improvement study. bmc pregnancy childbirth. 2008;8:20. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc2443790/ *accessed 3d july 2018+. *20+ pico-alfonso ma, garcia-linares mi, celdanavarro n, blasco-ros c, echeburúa e, martinez m. the impact of physical, psychological, and sexual intimate male partner violence on women’s mental health: depressive symptoms, posttraumatic stress disorder, state anxiety, and suicide. journal of women’s health. 2006 jun;15(5):599–611. *5+ campbell jc. health consequences of intimate partner violence. the lancet. 2002 apr 13;359 (9314):1331–6. available from: http://opendoorsproject.ca/wp-content/ uploads/2016/06/campbell-2002-healthconsequences-of-int-partner-violence-1.pdf *accessed 13th march 2018+. *6+ heugten d.v – van der kloet d and heugten v. t. the classification of psychiatric disorders according to dsm-5 deserves an internationally standardized psychological test battery on symptom level. frontiers in psychology. 2015. 6:1108. doi: 10.3389/ fpsyg.2015.01108. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc4523712/ *accessed 4th aug 2018+. *7+ carrell se, hoekstra m. family business or social problem? the cost of unreported domestic violence. 2011. available from: http://faculty.econ.ucdavis.edu/faculty/ scarrell/reporting.pdf *accessed 12th july 2018+. *8+ vijayakumar l. suicide in women. indian journal of psychiatry. 2015 jul;57:(6):233–8. available from: http:// www.indianjpsychiatry.org/article.asp? issn=00195545;year=2015;volume=57;issue=6;spage=2 33;epage=238;aulast=vijayakumar *accessed 4th aug 2018+. *9+ directorate of combating violence against women. statistics of violence against women in 2017. 2017. available from: http:// bgtakrg.org/index.php/statics/item/8302017 *accessed 4th nov 2017+. *10+ maisel er. the new definition of a mental disorder. 2013. available from: http:// www.psychologytoday.com/blog/rethinkingmental-health/201307/the-new-definitionmental-disorder *accessed 10th october 2017+. *11+ world health organization. who multicountry study on women’s health and domestic violence against women. 2005. available from: http:// apps.who.intirisbitstream/10665/43310/1/9 241593512_eng.pdf *accessed 12th july 2018+. *12+ world population review. population of cities in iraq.2018. available from: http:// worldpopulationreview.com/countries/iraqpopulation/cities/ *accessed 14th july 2018+. 42 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.05 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article available from: http://www.ehu.eus/ echeburua/pdfs/21-pico-alfonso_et_al.pdf *accessed 14th may 2018+. *21+ xu x, zhu f, o’campo p, koenig ma, mock v, campbell j. prevalence of and risk factors for intimate partner violence in china. american journal of public health. 2005 jan;95 (1):78–85. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc1449856/ *accessed 4th aug 2018+. *22+ davis r. domestic violence related deaths. 2010. available from: http://mediaradar.org/ docs/davisdomesticviolencerelateddeaths.pdf *accessed 27th aug 2018+. *23+ kilpatrick dg. mental health impact of rape. 2000. available from: https://mainwebv.musc.edu/vawprevention/research/ mentalimpact.shtml*accessed 27th aug 2018+. 43 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.05 ejnm, vol. 1, no. (1), may, 2018 original article quality of immediate nursing care provided to newborn at maternity teaching hospital in erbil city abstract introduction the health of a nation is the wealth of the nation and today's children are tomorrow’s adults. birth is a major challenge to the newborn to transfer successfully from intrauterine to extra uterine life. delivery and the first few hours of life are critical period for further growth and development of the infant. newborn baby is considered to be tiny and powerless, completely dependent on others for life. within one minute of birth the normal newborn adapts from a dependent fetal existence to an independent one *1+. most babies are background and objective: quality of nursing care and competent health care providers, particularly skilled birth attendants, are essential requirements for providing care for both mothers and newborns. the current study aimed to assess quality of nursing care provided immediately after birth to newborn by nurse/midwives at maternity teaching hospital in erbil city. methods: an observational study conducted during 2014. samples of 25 nurse/midwives were purposively selected from nurses working at delivery room. data were collected through the use of questionnaire format and observation checklist structured by researcher. the questionnaire format was used for interviewing nurse/midwives about (sociodemographic, professional background and nurses/midwives workload), while the checklist, which consisted of eight domains, was used for observing nurse/midwives during newborn care. a panel of experts checked the validity of the instrument when reliability was measured with computation of pearson product moment correlation. data were analyzed through the application of descriptive and inferential statistical tests. results: the results revealed that the highest percentage 40% of the nurse/midwives were graduated from preparatory midwifery school, 64% of the nurse/midwives haven’t attended training course about immediate neonatal care. 100% of nurse /midwives do not washed their hands before and after performing each procedure and haven’t any role in initiation of newborns breathing. there were not significant associations between overall quality of immediate nursing care and nurse/midwife's qualification, experience years and training course. conclusion: quality of immediate nursing care provided after birth to newborn by most of nurse/midwives was poor. the study recommended improving nurse /midwives qualifications and skills, through training courses and application of a guideline for improving quality of immediate neonatal care at delivery room. keywords: immediate nursing care; newborn ; delivery room. kurdistan mirza jamsheer; raparein pediatric teaching hospital , erbil, iraq. norhan zeki shaker; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: norhan.zeki@nur.hmu.edu.krd) 33 erbil journal of nursing & midwifery received: 27/8/2017 accepted: 11/11/2017 published: 5/5/2018 https://doi.org/10.15218/ejnm.2018.05 ejnm, vol. 1, no. (1), may, 2018 original article born healthy and at term. the care they receive during the first hours, days, and weeks of life can determine whether they remain healthy or not *2+. newborn care is very important for the proper development and healthy life of baby. it is crucial period in the lives. new born under-goes many profound changes at the movement of birth like respiratory change, thermal change and circulatory change *3+. the professional health care in general and nurses particularly play a vital role to ensure that the new born has best possible beginning of life and the nurse must be aware of the potential problems and be alert to the infant’s changing condition and to intervene appropriately while being necessary *1+. in erbil city the rate of infant mortality was 9.56 per 1000 live births in 2003 and this rate was increased to 23.9 per 1000 live births in 2011 *4+. because nurse/midwife is the first health care provider who has direct contact with the neonate during birth and nurses will never know the quality of care they offer until it is being assessed. therefore researchers thought that conducting of current study is important to assess the nurse’s performance in the delivery room based on the standards of care developed by world health organization. this study aims to assess the quality of nursing care provided immediately after birth for newborn at maternity teaching hospital in erbil city. an observational study was carried during 2014. the study conducted at delivery of maternity teaching hospital (mth) in erbil city kurdistan region / iraq. the delivery unit in this hospital consists of 9 rooms, first room for pelvic examination, and the second room for hepatitis cases when the reminder rooms for normal vaginal delivery and each room contain 2-3 beds and 1-2 neonate bassinette. a non-probability purposive sample of 25 nurse/midwives working in three shifts of (morning, evening, night) at mth recruited for the study. all nurses / midwives who were working at delivery room, giving immediate nursing care to newborn babies; delivered within 37 to 42 weeks of gestation by normal vaginal delivery and weighing 2.5 to 3.8 kg were included in the study. while neonates with prematurity, birth asphyxia; congenital malformation; have been born to mothers with (pregnancy induced hypertension, diabetes mellitus, hiv, hepatitis b and hepatitis c positive) were excluded from the study. after review the related literatures and visiting the delivery room the study instrument were developed by researchers, including of two parts: first part was an interview form: a list of (10) items covered nurses/midwives' socio-demographic and working related data (age, levels of education, marital status, number of experience years in delivery rooms, interests in working at delivery room, number of training course in immediate newborn care, type of working shift, number of nurses/midwives' participated in the delivery of same newborn, number of delivery nurses/midwives' performed at each shift. second part was a checklist: for collection data about quality of immediate nursing care in delivery room, this part included the data about the nursing care of newborns after delivery, which consisted of eight domains (preparation to receive the baby, initiation of breathing, thermal regulation, cord clamping, assessment ,medication, documentation, initiation of breast feeding ). the ethical approval was obtained from the ethical committee of college of nursing after confirmation of confidentiality and anonymity of nurses / midwives. nine experts checked the validity of the instrument. methods 34 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.05 ejnm, vol. 1, no. (1), may, 2018 original article assessing quality of immediate nursing care provided to newborns at delivery room in according to nurses/midwives preparation for receiving the newborn table 2 shows that highest mean score (2.00) was allocated to the item (wears gloves), the lowest mean scores (1.00) was allocated to activities items like (washes hands with soap and water to receive the baby, wear disposable gown and checking oxygen supplementation. concerning quality of immediate nursing care for initiation of newborns breathing and thermoregulation table 3 all the items were at the same level and all nurses/ midwives do not perform these activities. changes and modifications were made in respect to the experts' suggestions and recommendations for the questionnaire and checklist format. a pilot study was conducted on a sample of 5 nurses/midwives for testing the equivalence of the instrument. reliability (stability) was determined and measured through computation of pearson product moment correlation as the correlation was (0.97). the checklist items of quality of immediate nursing care in delivery room were rated and scored according to the two points type scale are used for rating 40 items and scored as (2,1) for (yes, no) respectively. after obtaining the average of mean score of each item then the mean score of each domain calculated, followed by collection of mean score of eight domains and divided upon the number of domain for obtains quality of care, these levels were considered to be as a following: good (adequate) (1.47-1.50) fair (middle) (1.42-1.46) poor (in adequate) (1.38-1.41). test of significance chi-square and p-value were used to determine the level of significance. frequency and percentage mean, standard deviation, pearson coefficient correlation (r -test) and chi-square test were used in order to analyze and determine the significant association between nurses/midwives practices with demographic characteristics. in the current study results as revealed in table 1 the mean and standard deviation for the nurses/midwives age was 35.32± 8.330. concerning qualification of the nurses/midwives, the highest percentage (40%) was graduated from the preparatory midwifery school. majority (76%) of the nurses /midwives had experiences of working in delivery room from 1-10 years, and the highest percentage (64%) of the nurses/midwives had not attended any training courses. 35 results erbil journal of nursing & midwifery table 1: nurses/midwives sociodemographic and professional data socio-demographic and professional data n =25 f (%) age groups 24-34 11 (44) 35-45 11 (44) 46-56 3 (12) m ± sd 35.32± 8.330 qualification nursing college 2 (8) nursing institute 8 (32) preparatory midwifery 10 (40) preparatory nursing 2 (8) nursing school 3 (12) duration of working in delivery room 1-10yr 19 (76) 11-20yr 3 (12) 21-30yr 3 (12) training courses attendance 0 times 16 (64) 1-5 times 4 (16) 6-11 times 5 (20) https://doi.org/10.15218/ejnm.2018.05 ejnm, vol. 1, no. (1), may, 2018 original article caring for newborns cord in table 4 highest mean scores (2.00) were allocated to the following activities (place newborn on the mothers abdomen and first cord clamping) and the lowest mean scores (1.08) were allocated to the activity (second cord clamping). 36 table 2: quality of immediate nursing care at delivery room for preparation to receive the newborns by nurses/midwives erbil journal of nursing & midwifery preparation for receiving the baby n =25 yes no mean score f (%) f (%) hand washing 0 (0) 25 (100) 1.00* wear disposable gown 0 (0) 25 (100) 1.00 wears gloves 25 (100) 0 (0) 2.00** place the baby on clean surface 24 (96) 1 (4) 1.96 the warmer is put on 7 (28) 18 (72) 1.28 oxygen is checked 0 (0) 25 (100) 1.00 suction is in working condition 24 (96) 1 (4) 1.96 suction tube is kept ready 16 (64) 9 (36) 1.64 checking the resuscitation equipment 1 (4) 24 (96) 1.04 bassinette is ready 10 (40) 15 (60) 1.40 clean sheet is available 1 (4) 24 (96) 1.04 table 3: quality of immediate nursing care at delivery room for initiation of newborns breathing and thermoregulation by nurses/midwives * = lowest mean score (lowest quality of patient care) **= highest mean score (highest quality of patient care) items n=25 mean score yes no f (%) f (%) initiation of newborn breathing wipes the baby and wraps in clean cloth 0 (0) 25 (100) 1.00 ensure airway clearance 0 (0) 25 (100) 1.00 stimulate breathing by massaging 0 (0) 25 (100) 1.00 thermoregulation put newborn skin to skin contact with mother 0 (0) 25 (100) 1.00 put the newborn under warmer 0 (0) 25 (100) 1.00 dry the baby 0 (0) 25 (100) 1.00 clothing the baby 0 (0) 25 (100) 1.00 covering the head 0 (0) 25 (100) 1.00 https://doi.org/10.15218/ejnm.2018.05 ejnm, vol. 1, no. (1), may, 2018 original article in according to newborn assessment responsibility in table 5 it demonstrates that the highest mean scores (2.00) were allocated to the item (measures the weight) and the lowest mean scores (1.00) were allocated to the following activities (apgar score performed, apgar score recorded, measures the length, checks the body temperature, checks for congenital abnormality). table 6 indicates that all the items were at the same level and all nurses/midwives performed these activities of newborns documentation. furthermore in table 7 concerning initiation of breastfeeding all the items were at the same level and all nurses/midwives do not perform these activities. table 8 shows levels of overall quality of immediate nursing care for newborn baby. the highest percentage (68%) of the nursing care was at the poor level, while the lowest percentage (32 %) of nursing care was at fair level. table 5: quality of immediate nursing care at delivery room for newborns assessment 37 table 4: quality of immediate nursing care at delivery room for newborns cord clamping and mediation administration erbil journal of nursing & midwifery items n =25 mean score yes no f (%) f (%) cord clamping place newborn on the mothers abdomen 25 (100) 0 (0) 2.00 first cord clamping 25 (100) 0 (0) 2.00 second cord clamping 2 (8) 23 (92) 1.08 clamp the cord with sterile clamp 23 (92) 2 (8) 1.92 cut the cord with sterile scissors 17 (68) 8 (32) 1.68 mediation administration administrating eye ointment 0 (0) 25 (100) 1.00 vitamin k is given i.m 0 (0) 25 (100) 1.00 assessment n =25 mean score yes no f (%) f (%) apgar score performed 0 (0) 25 (100) 1.00 apgar score recorded 0 (0) 25 (100) 1.00 measures the length 0 (0) 25 (100) 1.00 measures the weight 25 (100) 0 (0) 2.00 checks the body temperature 0 (0) 25 (100) 1.00 checks for congenital abnormality 0 (0) 25 (100) 1.00 https://doi.org/10.15218/ejnm.2018.05 ejnm, vol. 1, no. (1), may, 2018 original article regarding nurses/midwives qualification and workload it shows that the highest percentages of the nurses/midwives graduated from the preparatory midwifery school. this finding is consistent with a study conducted *5+ in india on nurse/ midwives working at delivery room and found that 32.2% of them had above secondary education. more than two third of the nurses/midwives had experiences of working in delivery room from 1-10 years. in regards to the nurses attending training course about caring for newborn, the highest percentage of the nurses/midwives had no training course. this finding is in contrast to *5+ study which found that twothird of the nurses/midwives had attended refresher or training courses related to care of baby birth and resuscitation. the highest percentage of nurses/ midwives who participated in the study was working at the night shift in the delivery room as most of deliveries happened at night time which needed more nurses/ midwives caring for mother and neonates. majority of the nurses/midwives performed the delivery alone without help of other nurse. however, this result disagrees with american academy of pediatrics and american college of obstetricians and gynecologists guideline *6+ which recommends, two nurses attending every birth, one for the mother and one for the baby. concerning the quality of immediate nursing care provided to newborns at delivery room of mth in regarded to preparation to receive the newborn it revealed that the 38 erbil journal of nursing & midwifery table 6: quality of immediate nursing care at delivery room for newborns documentation table 7: quality of immediate nursing care at delivery room for newborns initiation of breastfeeding table 8: overall quality of immediate nursing care at delivery room documentation n=25 mean score yes no f (%) f (%) identification of sex 25 (100) 0 (0) 2.00 address of parents according to the local policy 25 (100) 0 (0) 2.00 nurses/midwives records all information documentation 25 (100) 0 (0) 2.00 initiation of breastfeeding n =25 mean score yes no f (%) f (%) asking for initiate breastfeeding within first hour after delivery 0 (0) 25 (100) 1.00 placing the baby on the breast in comfortable position 0 (0) 25 (100) 1.00 ensuring the baby has sucked for 5 – 10 minutes in each breast 0 (0) 25 (100) 1.00 assessing the baby for positioning of the breast feeding 0 (0) 25 (100) 1.00 overall quality of care f (%) poor 17 (68) fair 8 (32) total 25 (100) discussion https://doi.org/10.15218/ejnm.2018.05 ejnm, vol. 1, no. (1), may, 2018 original article of the mother after delivery. immediately after birth the newborn should be protected by smooth towel but actually in delivery unit unskilled workers who take care of the baby usually perform this activity. regarding immediate care for the cord clamp at delivery room the researcher found that all the nurses/midwives practiced cord clamping appropriately. concerning the medication care for newborn care at delivery room all nurses/ midwives did not perform these activities. the result of the present study was supported by a comparative cross-sectional study done by *9+ who found that eye care was zero percent. while a study *12+ carried out in canada contraries current studies finding and clarified that newborns routinely would receive two medications at birth: an intramuscular injection of vitamin k and an antibiotic agent for eye prophylaxis. according to routine policy in the delivery room of mth the nurse/ midwives were not responsible for prescribing or giving vitamink and eye ointment to newborns. concerning the assessment of the newborn by nurses/midwives the highest mean scores were allocated to the item of measuring the weight, and the lowest mean scores were allocated to the following activities: apgar score performed, apgar score recording, measuring the length, checking the body temperature, checking for congenital abnormality. the result of the present study is consistent with the study *7+ findings, which revealed that more than 90% of infants were weighed. while it is in disagree with a purposive study *5+ conducted in india and found that only one-third of the newborns were weighed at birth, although weighing at birth was considered an essential activity to determine high risk newborn and determination of extra care accordingly. furthermore, according to the guidelines of highest mean score was allocated to nurses/midwives gloves wearing while the lowest mean score was allocated to the other activities such as hand washing , disposable gown wearing and supplementary oxygen checking .this finding is in agreement with cross sectional study *1+ carried out in dharan hospital of nepal at labor room on 814 normal deliveries and found that the highest percentage of the staff (99.9%) were wearing the gloves while only 24% of staff were wearing gown before receiving the newborn babies. the efficacy of gloves in preventing contamination of health-care workers’ hands and helping to reduce transmission of pathogens to health care providers during the process of delivery and this clarifies that gloves are unlimitedly provided to delivery room at mth. concerning the immediate nursing care of newborns breathing initiation the present study found that all nurses / midwives did not perform these activities. this result disagrees with *7+ study, which found that nurses dried more than 90% of infants. and with another study *1+ which found that majority (100%) of nurses initiated newborns breathing. regarding immediate nursing care for newborns thermoregulation the result indicated that all nurses did not perform these activities. this finding is in agreement with *7+ study results that less than 10% only were allowed skin toskin contact. this finding is in contrast with guidelines *8+ stating that the baby should be kept warm, by skin-to skin contact with the mother for avoiding hypothermia. while it is in disagreement with comparative cross-sectional study *9+ conducted in pakistan on 30 delivery cases, which showed that the highest percentage of the thermal protection was 83.3%. according to *10+*11+ for thermal regulation they recommend that all neonates after birth should be placed over abdomen 39 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.05 ejnm, vol. 1, no. (1), may, 2018 original article percentage of the nurses/midwives levels of the nursing care was 68.0 % which indicated poor (inadequate) level, and the lowest percentage 32.0 % was at good (adequate) level. the findings of current study are in agreement with *14+ who explained that poor quality of newborn care immediately after birth in many hospitals was widely reported. nurses/midwives were not informed on universal guideline of immediate newborn care that could help them to participate actively in providing immediate care for the newborn. application of the universal guideline during the process of labor increases the level of care in the delivery room for the newborn and mother. regarding quality of nursing care at delivery room (preparation to receive the baby) the researcher found that all the nurse /midwives not washed their hands before and after performing each procedure at delivery room, concerning the initiation of breathing majority of nurse/ midwives they did not performed any activity like ensuring airway clearance and stimulating breathing by massage, regarding thermoregulation of the newborn by nurse /midwives don’t perform it. furthermore regarding newborn assessment only newborns body weight was assessed by the nurse/midwives while they never assessed apgar score, body temperature and congenital abnormality. moreover they don’t encourage mother to initiate breastfeeding within first hour after delivery. majority of nurse/midwives overall quality of immediate nursing care for newborn at delivery room was poor. the authors reported no conflicts of interest. american academy of pediatrics and american college of obstetricians and gynecologists *6+ it is recommended to check apgar score at 1 minute and 5 minutes after birth. regarding the documentation by nurses/ midwives all the documentation items were at the same level and all nurses performed these activities. this is in agreement with *13+ who explained that birth date, time, sex, etc. in the delivery room should be recorded. documentation of newborn baby is a crucial skill for nurses/ midwives at delivery room. complete, detailed records are important for clinical decision-making, for the coordination of ongoing care among providers, and as a source of quality improvement and research data. at delivery department in each delivery room the documentation was done completely for all newborns. however, the sense of urgency surrounding many resuscitations can make accurate, thorough documentation challenging. preparation can make this essential task easier. the present study showed that all the items about initiation of breast-feeding by the nurses/midwives were at the same level and all nurses did not perform these activities. this finding is in disagreement with *1+ study that found breastfeeding initiation soon after delivery was 76.9%. the benefits of breastfeeding for the health and wellbeing of the mother and baby are well documented. world health organization and american academy of pediatrics and american college of obstetricians and gynecologists *6+ recommend that breastfeeding should be initiated within 1 hour of birth. early initiation of breastfeeding within 1 hour provides benefits for both the baby and the mother. but this practice was neglected in the delivery room of mth by all nurses/midwives. concerning levels of overall quality of immediate nursing care for newborn the highest 40 erbil journal of nursing & midwifery conclusion conflicts of interest https://doi.org/10.15218/ejnm.2018.05 ejnm, vol. 1, no. (1), may, 2018 original article *13+ dattap. pediatricnursing.2ndedition. jaypee brothers medical ltd, new delhi ,india. 2009; 73-74. *14+ mike e., stephen n., john w., patrick m., newton o., philip a., et al, an intervention to improve pediatric and newborn care in kenyan district hospitals. understanding the context, implementation science journal english; licensee bmc ltd. 2009; 4(42). available from: http://www.implementationscience.com/ *accessed: 10th february 2014+. *1+ shrestha m, singh r, upreti d. quality of care provided to newborns by nursing personnel at bp koirala institute of health sciences. kathmandu university medical journal 2009; 7. 3(27): 231-232. available from: http://www.ncbi.nlm.nih.gov/ pubmed/20071868. *accessed: 9th april 2014+. *2+ beck d, ganges f, goldman s , long p., care of the newborn reference manual . washington, dc 20036. 2004; save the children federation.p24-32.available from: www.healthynewborns.com *accessed: 10th june 2013+. *3+ baral o, new born care practice of through mothers. a multidisciplinary journal. 2012; 2.1.p. 38-39. *4+ ministry of planning kurdistan regional government krg. regional development strategy for kurdistan region 2013-2017. 2012; p. 139. available from: http://www.mop.krg.org/resources *accessed: 1st august 2013+. *5+ sarin j, jeeva s, geetanjli, sheoran p. practices of auxiliary nurse midwives re garding care of baby at birth. nursing and midwifery research journal. 2011; 7, (3) .available from: http://medind.nic.in/nad/t11/i2/ nadt11i2p64.pdf *accessed: 15th january 2014+. *6+ american academy of pediatrics and american college of obstetricians and gynecologists. guidelines for prenatal care. 2007; available from: https:// www.awhonn.org/awhonn/binary.content *accessed: 10th february 2014+. *7+ sobel h , silvestre m , mantaring j, oliveros y, nyunt-u s. immediate newborn care practices delay thermoregulation and breastfeeding initiation. pubmed acta pædiatrica. 2011; 0803–5253.available from: http://www.ncbi.nlm.nih.gov/pubmed/21375583 *accessed: 10th february 2014+. *8+ iradakuna c., lambert b., moreiras j. resuscitation of the newborn anesthesia tutorial of the week 167. 2010; 3-11.available from : http://www.frca.co.uk *accessed: 8th february 2014+. *9+ khan m, h., khan f., r., noman n., hashmi g., gul s., ali a., et al.. essential newborn care practice in hospital versus home deliveries. gomal journal of medical sciences. 2006; 4, 1. available from: http:// www.gjms.com.pk/files *accessed: 10th february 2014+. *10+ world health organization. basic newborn resuscitation: practical guide. safe motherhood. 1999; 16. available from: http://whqlibdoc.who.int/hq *accessed: 4th february 2014+. *11+ chawla o., neonatal resuscitation: research issues. journal of neonatology. 2009; 23,4,p281. available from: http://www.donnageczi.com/pdfs/ios-pressjournal-library/support-files/jn.pdf *accessed: 10th february 2014+. *12+ champlain maternal newborn regional program (cmnrp). newborn adaptation to extrauterine life and newborn assessment. champlain maternal newborn regional program. 2013; p.3-11. available from: http://www.cmnrp.ca/download *accessed: 5th april 2014+. 41 erbil journal of nursing & midwifery references https://doi.org/10.15218/ejnm.2019.09 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article role of nurses in health needs of refugees and internally displaced peoples abstract introduction there has been a dramatic increase in the number of internally displaced peoples (idps) in recent years in iraq. therefore, nurses working in the residential areas of these people face a high health need in corresponded health settings. displaced people and refugees are involuntary migrants forced by extraordinary situations to leave their homes and/or countries of residence to find safe places *1+. the united nations defines a “refugee” as “any person who, owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership or particular social group, or political opinion, is outside the country of his nationality, and unable to or, owing to such fear, is unwilling to avail himself of the protection of that country” *2+. refugees face severe public health deficiencies as a result of poor sanitation of potable water which serves as one of the primarily responsible factors for mortality and morbidity *3+. the united nations high commissioner for refugees (unhcr) reported that 59.5 million persons were forcibly displaced across the world due to persecution, conflict, violence, or human rights violations by the end of 2014 *4+. infectious diseases are very common background and objectives: nurses working in refugee camps face to high basic health needs of these populations requiring a nursing role in this situation. the aim of this study was to explore the role of nurses in addressing the basic health needs of refugees and internally displaced peoples. methods: in this cross-sectional study, 120 nurses from 26 camps in duhok governorate/ iraqi kurdistan were invited to participate in the study between september 15th and november 25th, 2017. data was collected through the direct interview (investigatoradministered self-reported technique) with the participants. the findings of the study were presented in descriptive statistics. results: the mean age of nurses was 29.10 years old. the nurses participated in activities such as infection control activities (78.3%), health education campaigns (92.5%), breastfeeding education (84.2%), and nursing health care services (94.2%). board of relief and humanitarian affairs is a governmental body within the structure of duhok governorate and is a key agent of basic needs of refugees. conclusions: the study documented that a considerable percentage of nurses have participated in the nursing-based activities in refugee camps. keywords: refugee, internally displaced people, nurse, role, health needs hawar abdulrazaq mohammedsadiq; department of nursing, college of nursing, university of duhok, duhok, iraq. (correspondence: hawar.abdulrazaq@gmail.com ) sana thannon ahmed; department of nursing, college of nursing, university of duhok, duhok, iraq. saadia kadhim muhammedhassan; duhok general directorate of health, duhok, iraq. 70 erbil journal of nursing & midwifery received: 30/10/2018 accepted: 25/2/2019 published: 30/5/2019 mailto:hawar.abdulrazaq@gmail.com https://doi.org/10.15218/ejnm.2019.09 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article among refugees and idps. however, many of these diseases are preventable by establishing safe water practices such as sewage waste management and improved personal and water health practices as reflected in the world health organization (who) task force *5+. the kurdistan region is a federal state inside iraq that has faced a growing number of internally displaced peoples (idps) and syrian refugees for the past four years. in 2012, there was an unprecedented rise in the number of idps and refugees which has overburdened the local health-care system. as a result, it seems that numbers are not going to be reduced considerably. according to the board of relief and humanitarian affairs (brha), 144,181 families consisted of 738,494 individuals lived in 27 camps in duhok geographic areas until the end of october 2017 *6+. nurses can play an important role in identifying and addressing early basic health needs in refugees. refugees present unique opportunities and challenges for the nursing profession *7+. there is limited research on infectious disease and the lack of basic health needs among idps and refugees in this region. the nurses provided health services to 75,274 patients including idps and host communities in local health facilities from august 9th, 2014 through june 2015, according to the brha *6+. however, to the authors’ knowledge, the role of nurses in addressing the basic health needs of refugees has not been explored in this region. refugees and displaced people have a mortality rate of over 60-fold during the acute phase of forced migration and settlement in the camps. the spread of communicable diseases is responsible for over threequarters of these deaths *8+. nurses as a part of the health care team can play a key role in infection control in these emergency situations. the aim of this study was to explore and examine the role of nurses in addressing basic health needs of refugees and idps, specifically focusing on infection control, health education, and breastfeeding education in duhok governorate in kurdistan region-iraq in 2017. study design and sampling methods this cross-sectional study was based on a purposive sample including 120 nurses in 26 of 27 idps/refugee camps across duhok governorate in september 2017. only one camp was not recruited in this study due to its distance from the city center. the available and accessible nurses in the selected camps were invited to partake in the current study regardless of their gender, age, and other socio-demographic characteristics following taking official permission from their corresponding administrative and executive organizations. participation in the study was completely voluntary. the internally displaced peoples are people displaced from ninewa governorate, including mosul city, neinewa plain, zummar, and sinjar areas since august 2014 due to the conflict, violence, and atrocities applied by the islamic state in iraq and syria (isis) in the occupied areas. the majority of displaced persons live in urban areas, including cities, towns and residential complexes in duhok provinces and enjoy available health and social infrastructure such as water, electricity, housing, fuel, security, traffic, waste collection services, shopping centers just as province citizens do. data required for the present study included socio-demographic information and nursing-related practices were collected via interview. this study required information regarding gender, education level, methods 71 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.09 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article infrastructure and basic services to the syrian refugees in and outside camps such as water, shelter, health sanitation, and education. until 2016, 514,499 refugees lived in duhok governorate inside camps and host communities *6+. demographic composition in duhok camps the idps consist of majority muslim populations, including kurds, turkmen, and arabs with a few christian families and a considerable percentage of yezidi kurds (82.3% of camps inhabitants) displaced from sinjar, zumar, and ninewa plain following isis invasion. as of 2016, of the total 23 idps camps in duhok, the medical services to idps camps were provided by 78 physicians, 119 nurses, 32 pharmacists, 12 dentists, 25 phcs, 15 ambulances, 19 pharmacies, 2 delivery rooms, 7 dental clinics, and 12 medical laboratories. on average, 3,000 patients visit these health centers. common causes of patients’ consultation are respiratory infections, skin infections, and urinary tract infections *6+.verbal consent was taken from all nurses before data collection guaranteeing the confidentiality of all personal information. the scientific research division/department of planning/duhok general directorate of health in duhok/iraqi kurdistan approved the study protocol. the descriptive purposes of the study were addressed through the frequency percentage or mean standard deviation. the spss version 23 was used for statistical calculations. 120 nurses participated in the present study, with more than half of them identifying as female (53.3%) and most nurses graduated high school (41.7%) and nursing institute (40.8%) with a median experience of 56.50 months and mean age of 20.10 years old (table 1). age, experience in nursing by month, and nursing-related practices measured in binary responses. these responses were collected through the direct interview with nurses over the course of fifteen field trips from september through november 2017. in addition, information on brha activities and its services were obtained through visiting their main office in duhok and their website. the brha is a governmental body within the structure of duhok governorate established in 2015. it is the main operational counterpart of united nations (un) agencies, humanitarian organizations, health and non-health service providers to those persons who have left their hometowns from other regions of iraq and syria since 2014 following isis’ invasion. brha’s main concern is to provide the humanitarian assistance to idps, refugees, returnees and host communities by establishing cooperation with un agencies, non-governmental humanitarian organizations, governmental partners, camp management strategies, and community mobilization *6+. brha as the main governmental entity of the humanitarian department in duhok takes into consideration: on camp management; basic services, including water, sanitation, shelter, health, education, and municipal services; social and community services; and capacity building. basic health infrastructure in idps/refugee camps of the total 248,000 refugees registered in iraq, close to 97% of them were settled temporarily in kurdistan. duhok, being a governorate in close to syria, has accepted a significant percentage of syrian refugees thus creating a heavy burden for the local government and non-governmental organization (ngos) in the camps for their basic health services. duhok governorate and kurdistan regional government (krg) have allocated a budget annually for 72 results erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.09 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article the study showed that majority of the nurses had an active participation in infection control activities, including oral polio vaccine (opv) administration to the refugee/idps (85.8%), hbv vaccination during the first hours of the refugee arrival to camp (34.2%), tetanus vaccination administration to women (52.5%), and participation in infection control campaigns inside the camps (78.3%) (table 2). regarding refugee/idp health education in these camps, the results showed that the majority of them have participated in health education programs with activities such as personal hygiene, disease prevention, hand washing, and women’s health (92.5%). similarly, more than two-thirds of the nurses have visited the refugee/idps tents for the health education purposes (68.3%) and most the nurses (84.2%) have educated women on breastfeeding education (table 3). nursing care, including wound dressing, injection, and fracture maintenance, and general first aid services were presented by 94.2% and 95.8% of nurses, respectively. however, a small percentage of the nurses have participated in providing obstetric services to women in the camps (26.7%) (table 4). 73 table 1: demographic characteristics of nurses working in refugee and idp camps erbil journal of nursing & midwifery table 2: nursing role in infection control among refugee and idps in duhok nurses’ characteristics (n=120) frequency distribution f % gender male female 56 64 46.7 53.3 education high school graduate institute graduate bachelor 50 49 21 41.7 40.8 17.5 nurses’ experience (month); median/ interquartile range 46.50 78.75 age (year); mean/sd 29.10 12.90 infection control activities of nurses in camps (n=120) frequency distribution f (%) yes no giving opv vaccination upon refugee registration in camp 103 (85.8) 17 (14.2) hbv vaccination during the first hours of arrival to camp 41 (34.2) 79 (65.8) administrating tetanus vaccination to women in camp 63 (52.5) 57 (47.5) participating in campaigns of communicable disease control 94 (78.3) 26 (21.7) table 3: role of nurses in health education to refugees/idps in camps health education of nurses to refugee/idps in camps (n=120) frequency distribution* yes no health education, including personal hygiene, disease prevention, hand washing, women’s’ health 111 (92.5) 9 (7.5) home visit strategies for health education purposes 82 (68.3) 38 (31.7) breastfeeding education to women 101 (84.2) 19 (15.8) https://doi.org/10.15218/ejnm.2019.09 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article the present study showed that nurses working in refugees/idps camps in duhok governorate have participated actively in a variety of nursing roles, including providing vaccinations, health education in the form of home visits, breastfeeding education, and general first aid services to the camp residents. the practice of these health services is highly significant as it has been confirmed that those individuals who applied proper water and personal hygiene practices faced a lower level of diarrheal illnesses than those who did not as refugees/idps spend a greater part of their lives in camps before repatriation process *9+. the practices include drinking clean potable water sources piped into the home, hand washing, and sufficient soap availability. the risk factors for the transmission of communicable diseases such as moving mass populations, resettling in temporary geographic locations, overcrowding housing, degrading economy and environment, safe potable water scarcity, poor sanitation and waste management, impoverishment, non-existent shelter, poor nutritional status, and poor access to health care interact synergistically in these complexes *10+. the present study showed high participation of the nurses in vaccinating clients in primary health centers or through home visits in accordance with national vaccination campaigns against infectious diseases. these health services are available in all primary health centers inside the camps and infants are vaccinated upon birth in the delivery room in camps or hospitals in urban areas. those living in host communities have access to health centers in urban areas freely five days a week. it is expected that all nurses in health centers readily offer all types of vaccines as the refugees/ idps arrive the camps at different times. the study showed an acceptable percentage of participation of nurses in health education activities including personal hygiene, hand washing, and women’s health as reflected in the study findings. health education was also significantly associated with health improvement. in this regard, a review study showed that hand washing is associated with a 48% reduction in diarrheal diseases *11+. in the camps, water is supplied through piped networks connected to tap stands locations. it has been documented that access to convenient water in camps is associated with hand washing activities by the camp residents *12+. a home visit is a widespread earlyintervention strategy in most developed and developing countries. the present study showed that corresponding health departments have not perceived it as a novel strategy in health status improvement as the majority of the nurses reported participating in home visits and only a minority of them have never performed home visits inside and outside the camps. the role of home-visitation programs on improving health outcome in children and families has been well documented in the literature *13-15+. 74 table 4: role of nurses in providing nursing care to refugees/idps in camps erbil journal of nursing & midwifery nursing care provision to refugee/idps in camps (n=120) frequency distribution f (%) yes no wound dressing, injection, and fracture maintenance 113 (94.2%) 7 (5.8) assisting pregnant women in the delivery room in camps 32 (26.7) 88 (73.3) first aid services 115 (95.8) 5 (4.2) discussion https://doi.org/10.15218/ejnm.2019.09 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article in this study, a high percentage of nurses participated in breastfeeding education in refugee/idps camps. however, the remaining minority of these nurses never participated in breastfeeding education programs for pregnant women in the camps. this may be due to the fact that the majority of the nurses working in the camps simply graduated high school (41.7%) and the institute of nursing (40.8%). breastfeeding advice is significant as the world health organization (who) has recommended breastfeeding as the optimal form of nutrition for infants’ development and provides an important psychological and physiological advantage for both the mother and infant *4+. the united nation international children’s emergency fund (unicef) has estimated that 1.5 million infant deaths can be prevented annually if the infants are breastfed exclusively from birth to at least six months *16, 17+ and lower mortality rates have been seen among those children breastfed during emergency conditions *18, 19+. previous evidence has shown that breastfeeding is highest among women receiving breastfeeding education *20+ from these nurses*21+. the study showed that only 26.7% of nurses participated in delivery services to pregnant women. this may be due to the lack of delivery facilities in this region precluding them to have this opportunity in their nursing practice. in addition, there were only three delivery rooms in all 27 refugee/ idps camps. health promotion and education activities are achievable through interpersonal communication, group activities, and peer education and can result in positive social changes as nursing practitioners have opportunities to meet these issues through dynamic community-based approaches *22+. commitment must be made by humanitarian agencies *23+ and involved in healthcare decision making, in particular, to improve women’s health. *24+ this can be achieved through the establishment of partnerships with community members through hiring the available refugee nurses in the camps for health improvement purposes *23+ as suggested in the brha report as well *6+. despite widespread health services provided to refugees and idps inside and outside of the camps, the brha reported that the majority of the health centers work part-time with few medical specialists and the centers may lack certain medications for chronic diseases. strengths and limitations of the study the findings reported in the current study must be interpreted in the light of study design and reporting techniques, as the self-reporting technique does not guarantee the complete activities conducted by the nurses in the camp settings. however, to the authors’ knowledge, this is the first study conducted on the nurses’ role in addressing the basic health needs of refugees/idps in this region. the study is noteworthy as the majority of the nurses working in 26 camps of 27 available camps in duhok governorate were included in the present study. the results of the current study show that most of the nurses working in refugees/ idps camps in duhok governorate have participated in infection control activities, health education campaigns, and breastfeeding education. further studies are required to examine the effectiveness of the nurses’ activities on the overall improvement of refugees/idps’ health. the authors suggest the related local departments and their international counterparts take advantage of the refugee nurses’ skills in meeting the displaced 75 erbil journal of nursing & midwifery conclusions https://doi.org/10.15218/ejnm.2019.09 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *10+ connolly, ma, m gayer, mj ryan, p salama, p spiegel, and dl heymann, communicable diseases in complex emergencies: impact and challenges. the lancet, 2004. 364 (9449): 1974-1983. *11+ cairncross, s, c hunt, s boisson, k bostoen, v curtis, ic fung, et al., water, sanitation and hygiene for the prevention of diarrhoea. international journal of epidemiology, 2010. 39(suppl_1): i193-i205. *12+ biran, a, wp schmidt, r wright, t jones, m seshadri, p isaac, et al., the effect of a soap promotion and hygiene education campaign on handwashing behaviour in rural india: a cluster randomised trial. tropical medicine & international health, 2009. 14(10): 13031314. *13+ chapman, j, e siegel, and a cross, home visitors and child health: analysis of selected programs. pediatrics, 1990. 85(6): 10591068. *14+ weiss, hb, home visits: necessary but not sufficient. the future of children, 1993: 113128. *15+ schonberg, s, s anderson, j bays, p duncan, m felice, j frader, et al., the role of homevisitation programs in improving health outcomes for children and families. pediatrics, 1998. 101(3 i): 486-489. *16+ scariati, pd, lm grummer-strawn, and sb fein, a longitudinal analysis of infant morbidity and the extent of breastfeeding in the united states. obstetrical & gynecological survey, 1998. 53(2): 73-74. *17+ raisler, j, c alexander, and p o'campo, breast-feeding and infant illness: a doseresponse relationship? american journal of public health, 1999. 89(1): 25-30. *18+ molbak, k, a gottschau, p aaby, n hojlyng, l ingholt, and apj da silva, prolonged breast feeding, diarrhoeal disease, and survival of children in guinea-bissau. bmj clinical research, 1994. 308(6941): 1403-1406. *19+ jakobsen, m, m sodemann, g nylén, c balé, j nielsen, i lisse, et al., breastfeeding status as a predictor of mortality among refugee children in an emergency situation in guinea -bissau. tropical medicine & international health, 2003. 8(11): 992-996. *20+ raine, p, promoting breast-feeding in a deprived area: the influence of a peer support initiative. health & social care in the community, 2003. 11(6): 463-469. individuals’ health needs. in addition, nurses are the main point of contact with ill individuals in camps. therefore, it is vital that nurses working with refugees are well equipped with sufficient knowledge, skills, and resources to deliver efficient health care of acceptable quality. the authors report no conflict of interests. *1+ ozaras, r, h leblebicioglu, m sunbul, f tabak, ii balkan, m yemisen, et al., the syrian conflict and infectious diseases. expert review of anti-infective therapy, 2016. 14 (6): 547-555. *2+ zimmermann, a, j dörschner, and f machts, the 1951 convention relating to the status of refugees and its 1967 protocol: a commentary. 2011: oxford university press. *3+ spiegel, p, m sheik, c gotway-crawford, and p salama, health programmes and policies associated with decreased mortality in displaced people in postemergency phase camps: a retrospective study. the lancet, 2002. 360(9349): 1927-1934. *4+ trends unhcr global, forced displacement in 2014. unhcr: geneva, switzerland, 2016. *5+ prüss-üstün, a and c corvalán, preventing disease through healthy environments. towards an estimate of the environmental burden of disease. geneva: world health organization, 2006. *6+ brha, idps and refugees in duhok governorate, profile and general information. 2016, board of relief and humanitarian affair governorate of duhok. *7+ squires, a, nursing's opportunity within the global refugee crisis. international journal of nursing studies, 2016. 55: 1-3. *8+ paquet, c and g hanquet, control of infectious diseases in refugee and displaced populations in developing countries. bulletin de l'institut pasteur, 1998. 96(1): 3-14. *9+ morris, md, st popper, tc rodwell, sk brodine, and kc brouwer, healthcare barriers of refugees post-resettlement. journal of community health, 2009. 34(6): 529. 76 erbil journal of nursing & midwifery conflicts of interest references https://doi.org/10.15218/ejnm.2019.09 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *21+ madanat, h, h farrell, r merrill, and e cox, breastfeeding education, support, and barriers among iraqi refugee women in jordan. international electronic journal of health education, 2007. 10: 138-149. *22+ kimunai, e, health promotion and education among refugee women: a literature review. journal of social change, 2014. 6(1): 2. *23+ solheim, k, patterns of community relationship: nurses, non-governmental organizations and internally displaced persons. international nursing review, 2005. 52(1): 60-67. *24+ palinkas, la, sm pickwell, k brandstein, tj clark, ll hill, rj moser, et al., the journey to wellness: stages of refugee health promotion and disease prevention. journal of immigrant health, 2003. 5(1): 19-28. 77 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article knowledge of pharmacy staff regarding over the counter medications in erbil city abstract over the counter (otc) medications are defined as the medications available, and obtained without a physician prescription. over the counter medications can be used with appropriate caution and proper dosages. however many do not know the dangers of misuse and continue to use otc medications [1]. before the food and drug administration (fda) existed in the united states, all medications were allowed to be self-medicated; alcohol, cocaine, marijuana, and opium were included in some otc products without notification to users. for example, in the united states of america, products containing over 80 active ingredients of different therapeutic groups were switched from prescription-only to otc background and objectives: use of over the counter (otc) medications is an important area for research within different health care systems. it is also associated with increased risk of abuse and medication addiction. the need to avoid unnecessary exposure to medication is a concern among the health-care community, in which pharmacy staff plays first line of response and their knowledge is critical. in kurdistan region of iraq, other medical and to some extend non-medical staff also works in pharmacies which may affect their scientific understanding of medication. the current study aims to determine the knowledge of pharmacies staff regarding otc medication use in erbil city. methods: across-sectional study was conducted from 15thoctober 2018 to 15th october 2019. a sample of 187 pharmacies in erbil city centre was recruited through a systematic random sampling technique. data were collected through direct interview with participants, a questionnaire was used for interviewing the pharmacy staff about sociodemographic characteristics and knowledge regarding otc medications. the validity and reliability of the instrument was checked. data were analyzed by using the software system of statistical package for social science (spss version 23). results: the total number of the studied sample was 187 medical and para-medical staff working in erbil pharmacies. their mean age + sd were 28.56 + 5.33 years, ranging from 18 to 45 years. generally only quarter (25%) of the whole sample had good level of knowledge. less than one third (29.4%) of the sample knew the correct definition of the otc. only 28.3% of the sample thinks that the otc medications mostly cause side effects. good level of knowledge was significantly associated with being female, and being a graduate and with being a specialized pharmacist. conclusion: there is a limited knowledge about otc medications among staff working in pharmacies. however among other specialties (nurses and paramedic) specialist pharmacist had higher level of knowledge regarding otc. key words: self-medication, otc, knowledge, pharmacy araz abdulmajid aziz; department of community nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: araz.abdulmajed@gmail.com) salih ahmed abdulla; department of community nursing, college of nursing, hawler medical university, erbil, iraq. 144 erbil journal of nursing & midwifery received: 19/8/2019 accepted: 13/10/2019 published: 30/11/2019 introduction https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 mailto:araz.abdulmajed@gmail.com https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article status between 1976 and 2000. in 2007, a new law in united states of america became effective that required companies to report serious adverse events associated with otc medications, from there the law and regulation of otc medications was issued [2].in a study conducted by knapp, (1998), found that, in the early 1970s analgesics, cold remedies, and laxatives were frequently and commonly found in american homes, [7]. referring to the study conducted in malaysia in 2015, almost 60% respondents believed that otc medications are safe [6].people mostly reach for self-care products to help themselves their common health problems which include fever, body pains, diarrhea, vomiting, cough, indigestion and upper respiratory tract infections. this is because it is considered easier, more cost-effective, timesaving, or the problem may seem too unimportant to require making an appointment with a healthcare profession, and in other cases, they may have few or no other options[8].several studies on the subject indicate that there are risks such as misdiagnosis, drug resistance, and use of medications in excessive amounts, use of expired medications, prolonged duration of use, and medication interactions[3].otc medications are consumed by adults almost in everyday life, referring to a study conducted in maldives, in 2016; 76.6% of the 192respondents took otc medications. in another study conducted in jordan in 2011, the results revealed that 49.0% used left-over self-medication without physician’s consultation, while 51.8% use selfmedication based on a relative's advice [4].according to the fda, as with prescribed medication there are many health risks related to the use of otc medications such as: gastrointestinal problems, effect on kidney function, liver problem and risk of cardio vascular events[5].while people know the risks of otc medications they use otc medications for various reasons including because it is cheaper than the prescribed medication. knowing the knowledge of people regarding otc medications will help in exploring ways of awareness rising and conducting actions to reduce this phenomenon in our community. the study aims to determine the knowledge of pharmacy staffregarding over the counter medication use in erbil city. while the specific objectives were to find out the most common medications and indications used as otc drugs among users and to find out the association between socio-demographic characteristics of pharmacy staff and knowledge regarding otc medications. a quantitative descriptive cross-sectional study was used to assess the knowledge of the pharmacy staff on over the counter medications in from october 2018 to october 2019 in different locations in erbil city. the study sample consisted of 187 pharmacy staff (pharmacist, nurse, paramedical staff) in erbil city center, who were selected using systematic random sampling, according to the study’s inclusion and exclusion criteria. the study targeted pharmacy staff selling medication in pharmacies in erbil city center and staff working during evening shifts upon providing their informed consent. the sample size was estimated based on the formula of. in which is standard normal variety at 5% type one error when proportion with a 95% level of confidence and a margin of error of 5%, = 1.96. pvalue <0.05. the d is the absolute error and it’s equal to 0.05. and the p stands for the expected portion of population based pharmacy syndicate, there is 373 pharmacies in erbil city center, which is 86.4% of all pharmacies in erbil (432), thus the p= 0.86%. and based 145 erbil journal of nursing & midwifery methods https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article agreed upon the items of the study instrument. the changing of the instrument was mostly in the knowledge part where the experts added and modified some questions which were general to be more knowledge directed. prior of data collection, ethical approval was obtained from ethical and scientific committee of college of nursing / hawler medical university. furthermore, the informed oral consent was taken from the candidates who participated in the study, after confirmation of confidentiality, anonymity and participants self-determination by the researcher. also formal approval was obtained from kurdistan pharmacists syndicate (no:561, 20/12/2018) and erbil pharmacists syndicate (no: 1828, 26/12/2018). the statistical package for social science (spss, version 23) was used for data processing and statistical analysis. the statistical analysis included descriptive statistical analysis such as frequency and percentage to describe the basic features of the data in a study and provide simple summaries about the sample and the measures, inferential statistical analyses as chi-square and fisher exact test were implemented to make judgment about inferences from our data to more general conditions. the confidence interval was 95%. the p-value of each test ≤ 0.05 considered statistically significant. the sample consist of 187 medical and para-medical staff working in erbil pharmacies (one staff was selected per each pharmacy according to the availability of the staff). their mean age + sd was 28.56 + 5.33 years, ranging from 18 to 45 years. the highest proportion of the sample (33.7%) was aged 25 to 29 years, and only 11.2% were aged greater than or equal to ≥35years. the majority (73.3%) of the sample were males. around two thirds on this formula the study sample will be 187 pharmacies in erbil city center, which had been selected using systematic random sampling, 373/187=2 each second pharmacy will be recruited. a pilot study was conducted on 10 pharmacies. internal consistency of the study was obtained through applying pearson correlation (r) which was (0.74); it indicates that there was a medium positive correlation. direct face to face interview through questionnaire was conducted by researcher and separately with each of participated candidate for at least 25 to 30minutes; the interview took place in a private pharmacy. the questionnaire consisted of two parts. the first part was on socio-demographic characteristics of study sample. this part composed of questions about the age of the participants, the occupation, and level of education, residential area, income, and years of working experience. the second part assessed the knowledge of the pharmacy staff regarding otc medications, which was consisted of 8items which are concerned with issue of the knowledge of the pharmacy staff regarding otc. the questions included; knowledge about the side effects, consumption, use, prescription, indications, and other information regarding otcs. multiple and best answer choice were designed to obtain the participants response to the specific questions. each correct answer was equal to one score and total result were from 23 scores with the segregation of poor knowledge (≤7 scores), fair knowledge,(8-15 scores), and good knowledge (16-23 scores). the questionnaire was validated through a panel of ten experts in different fields to investigate the content of questionnaire for its clarity, relevancy, and adequacy. the expert’s responses were evaluated based on their agreements or disagreements. results had indicated that the majority of the experts 146 erbil journal of nursing & midwifery results https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article (62%) of the sample were college graduates, and only two personnel (1.1%) were graduates of primary school. table (1) shows that 27.8% of the sample was pharmacists, and the rest were paramedical staff of different qualifications, except for 10.2% of the sample who were not related to the medical field. it is evident in the mentioned table that 62% of the sample were originally from urban settings, and 24.1% of the sample mentioned that their income was not sufficient for daily needs. regarding the otc medications and their side effects, table 2 shows that; less than one third (29.4%) of the sample knew the correct definition of the otc medications 147 erbil journal of nursing & midwifery which is ‘any medication that people can purchase without prescription’ as presented in, as for the probable side effects, only 28.3% of the sample think that the otc medications may cause side effects while (71.1%) thought that these medications sometimes cause side effects. the following side effects of the otc medications had been mentioned by the pharmacy staff: allergy (82.4%), tremor (12.8%), swelling of the face and limbs (15%), abdominal pain (58.3%), insomnia (15%), sweating (15%), liver damage (24.1%), nausea and vomiting (64.2%), and difficult breathing (18.7%). table 1:basic characteristics of the studied sample no. (%) age <25 49 (26.2) 25-29 63 (33.7) 30-34 54 (28.9) ≥ 35 21 (11.2) gender male 137 (73.3) female 50 (26.7) educational level primary school 2 (1.1) intermediate school 6 (3.2) secondary school 3 (1.6) institute 60 (32.1) college 116 (62) occupation (title) pharmacist 52 (27.8) assistant pharmacist (institute) 36 (19.3) nurse (college) 53 (28.3) paramedical staff (institute) 27 (14.4) others (not related to medical field) 19 (10.2) residency urban 116 (62) rural 71 (38) income not sufficient 45 (24.1) sufficient 111 (59.4) exceeds needs 31 (16.6) https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article 148 erbil journal of nursing & midwifery table 2: definition of otc medications and their side effects no. (%) otc medications definition any medication prescribed by medical professional 35 (18.7) any medication sold by a pharmacist with or without prescription 97 (51.9) any medication that people can buy without prescription 55 (29.4) probable side effects sometimes cause side effect 133 (71.1) mostly cause side effect 53 (28.3) never cause side effect 1 (0.5) allergy yes 154 (82.4) no 33 (17.6) tremor yes 24 (12.8) no 163 (87.2) swelling of face and limbs yes 28 (15) no 159 (85) abdominal pain yes 109 (58.3) no 78 (41.7) insomnia yes 28 (15) no 159 (85) sweating yes 28 (15) no 159 (85) liver damage yes 45 (24.1) no 142 (75.9) nausea and vomiting yes 120 (64.2) no 67 (35.8) difficult breathing yes 35 (18.7) no 152 (81.3) https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article meanwhile; when the study sample were asked about otc indicator, their answers as it demonstrated in table 3 show that, the highest proportion (46.5%) of the staff thought that minor illnesses were the main indication for the otc medications, and 27.3% of the staff thought that infections were the main indication for the otc medications. meanwhile as showed in table 4, the majority (73.8%) of the staff believed that headache was the most common first indication for the otc medications, and 36.9% had chosen cold, cough, and sore throat as the second indication, while 23.1% and 22% of the staff had chosen body pain and fever, respectively, as the third indication of the otc medications. 149 erbil journal of nursing & midwifery table 3: general otc medications indications no. (%) otc indications hereditary disease 11 (5.9) minor illness 87 (46.5) heart diseases 3 (1.6) gi diseases 35 (18.7) infections 51 (27.3) table 4: top three most common otc medications indications no. (%) first most common indication headache 138 (73.8) fever 15 (8) cold, cough 25 (13.4) body pain 1 (0.5) joint pain 3 (1.6) htn 1 (0.5) gi problem 4 (2.1) second most common indication headache 23 (12.3) fever 24 (12.8) cold, cough, and sore throat 69 (36.9) body pain 34 (18.2) menses’ symptoms 6 (3.2) joint pain 9 (4.8) gi problems 22 (11.8) third most common indication headache 6 (3.3) fever 40 (22) cold, cough, sore throat 25 (13.7) body pain 42 (23.1) menses’ symptoms 9 (4.9) joint pain 28 (15.4) dm 2 (1.1) htn 4 (2.2) gi problems 26 (14.3) https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article regarding the knowledge of study sample about the proper person to decide on otc medication consuming, table 5 revealed that, 36.4% of the pharmacy staff think that the consumer is the person who decide to use the otc medications (which is the correct response), while 42.8% thought that the pharmacist is the person who chose the medications. knowledge about otc medications that are considered as otc was as follows: antacids (69%), cough syrups (58.3%), vitamins and food supplements (46%), decongestants (42.2%), and herbal products (26.2%). 150 erbil journal of nursing & midwifery the other groups of drugs are not considered as otc medications but in spite of that 70.6% and 66.3% of the staff considered the analgesics and antibiotics, respectively, as otc medications (table 5). considerable proportions of the pharmacy personnel considered the anti-diabetics and the antihypertensive medications as otc medications (14.4% and 12.3% respectively). figure 1 shows that 43.6% of the study sample had poor knowledge about the otc medications, and only 25% of the whole sample had good level of knowledge. table 5:the otc list group of medications considered as otc by the pharmacy staff (n = 187) no (%) analgesics 132 (70.6) antacids* 129 (69) antibiotics 124 (66.3) cough syrups* 109 (58.3) vitamins and food supplements* 86 (46) decongestants* 79 (42.2) laxatives 75 (40.1) antidiarrheal 74 (39.6) antihistamines 56 (29.9) antiemetic medications 53 (28.3) herbal products* 49 (26.2) anti-diabetics 27 (14.4) oral contraceptives 25 (13.4) antihypertensive medications 23 (12.3) figure 1: general knowledge of the study sample about the otc *included in the list of the otc medications https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article it is worth to mention that 29.6% of those aged 30-34 years had good level of knowledge (table 6) which is more than the other age categories. the same table shows that 32% of females had a good level of knowledge compared with 13.1% of males (p = 0.003). it is clear that none of those with low levels of education had good level of knowledge, while 25% of the college graduates had good level of knowledge (p = 0.046). 151 erbil journal of nursing & midwifery the same can be applied for occupation, where 46.2% of the pharmacists who are college graduates had good level of knowledge (p < 0.001). a non-significant association was detected between age and the knowledge level (p = 0.063), also a non-significant association was detected between the level of knowledge with participation in medical courses (p = 0.096), residency (p = 0.110), and income (p = 0.347). table6: the relationship between the demographic characteristic and the overall level of knowledge poor and fair knowledge good knowledge age no. (%) no. (%) p-volue < 25 44 (89.8) 5 (10.2) 25-29 53 (84.1) 10 (15.9) 30-34 38 (70.4) 16 (29.6) ≥ 35 18 (85.7) 3 (14.3) 0.063 gender male 119 (86.9) 18 (13.1) female 34 (68) 16 (32) 0.003 education primary 2 (100) 0 (0) intermediate 6 (100) 0 (0) secondary 3 (100) 0 (0) institute 55 (91.7) 5 (8.3) college and above 87 (75) 29 (25) 0.046 occupation pharmacist 28 (53.8) 24 (46.2) assistant pharmacist 33 (91.7) 3 (8.3) nurse 51 (96.2) 2 (3.8) paramedic 24 (88.9) 3 (11.1) other 17 (89.5) 2 (10.5) < 0.001 medical course yes 41 (74.5) 14 (25.5) no 112 (84.8) 20 (15.2) 0.096 residential area urban 99 (85.3) 17 (14.7) rural 54 (76.1) 17 (23.9) 0.11 *fisher’s exact test https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article self-medication is the practice where individuals treat their illnesses with medications which are approved and available without prescription, and which are safe and effective when used as per direction [9]. however they may result in unwanted effects if inappropriately used. pharmacy staff comes across many consumers who request medication without prescription, some which are allowed and some which are forbidden; thus pharmacy staff knowledge plays the most important role in consumers' safety regarding medication consumption. the current study aimed at assessing the knowledge of pharmacy staff regarding the otc. result indicated that only one quarter of the sample had a good level of knowledge while the rest had poor to fair knowledge level, where in a study conducted in india by ravichandran and basavareddy, (2016)their result showed higher rate of knowledge regarding the otc definition, where among the pharmacists holding bachelor degree, 69% were able to define otc correctly whereas only 31% of d. pharmacy degree holders could define otc [10]. however according to the researcher such differences is that the study conducted in india targeted only the pharmacist, while the current study also included other specialist as in erbil not only pharmacist works in the pharmacies. no significant association was detected between age and the knowledge level, but it is worth to mention that those in third decay of their age had more advanced level of knowledge that the other age groups. this result was similar to a study conducted in iran about the pharmacy staff knowledge of sport supplement (a type of otc) where their result also showed that lower age associated with lesser knowledge level [11]. meanwhile the result of current study was different from a study conducted in india where knowledge of 152 erbil journal of nursing & midwifery pharmacist were assessed specifically regarding otc side effects, in which bj et al., (2012) found that knowledge association is more in the age group 21 to 30 years (mean ± sd 5.16±2.89) and least was found in the age group of 51 to 60 years with mean score of (mean ± 3.33 ± 4.16 years) [12].while age has a direct relationship with years of experience, age was not associated with good knowledge level or practice skill of the pharmacy staff in this study. it was assumed that age association is different per studies as each study have selected different age group, and also number of study sample plays role in the differences. this study also revealed that regarding the sex of participants, females were more knowledgeable of the otc, than the males, and the results were statistically very significant. this result was similar to a study conducted by ali et al (2012) in malaysia. which showed that males had lower level of knowledge than females [13]. however, the results contradict with findings observed by boateng (2009), which indicated that females were more susceptible to self-medication due to strenuous job requirement[14].females might be keener on continuous updating of the knowledge, and are more capable of memorizing and focusing on contentious education which resulted in having more knowledge than the males. as for the probable side effects, less than onethird of the sample knew that, the otc medications mostly cause side effects. the majority of the sample study indicated allergies as one of the most common side effects of the otc medications, while half of them included abdominal pain as major side effect, and around two-thirds of the study sample indicated that nausea and vomiting are also one of the most common side effects of the otc. this study's results were similar to those found in a cross sectional study conducted discussion https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article in india medications which revealed that the staff working in pharmacies are very aware (68.5%) about the adverse effect or side effect of medication [15]. no participants with low levels of education had good level of knowledge, while only quarter of the college graduates had good level of knowledge. the same can be applied for occupation, where less than half of the pharmacists who are college graduates had good level of knowledge. according to the researcher it’s linked to the advanced and different education type which were received by different pharmacy workers. and also this difference among the pharmacy staff maybe it’s due to the fact that there were workers with no medical or health background. no significant association was detected between the level of knowledge with participation in medical courses, residency, and income. however no similar studies were available to compare the current results with previous work; in the time that the researcher highlights this as a study limitation, yet it's necessary to mention that during literature review almost all previous studies conducted by other researchers were about knowledge of community, or medical students about otc, rather than the pharmacy staff, assuming that in most of the countries there is strong system for the pharmacy expending of otc, thus the focus of researches is less on the performance of pharmacy staff but more on the students and the community group. overall knowledge about otc medications was low among the pharmacy staff, with slight differences in the knowledge level of the specialized pharmacists. especially on otc side effects, dosage, and reason for uses, which in term, increases the risk of otc adverse effect on the consumers. the current study also concluded that, 153 erbil journal of nursing & midwifery the years of working in pharmacy did not contribute to increasing their knowledge level about otc, which is probably due to using same system during all working years and no improvements were noted even with attending multiple courses on otc. the researchers reported no conflict of interest. [1] helal rm, abou-elwafa hs. self-medication in university students from the city of mansoura, egypt. journal of environmental and public health. 2017;2017: 9145193. [accessed 25.7.2019]available from:https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc5396441/ [2] le vt, norris turner a, mcdaniel a, hale km, athas c, kwiek nc. nonmedical use of over-the-counter medications is significantly associated with nonmedical use of prescription drugs among university students. journal of americans college health. 2018;66(1):1–8.[ accessed 7.5.2019] available from: https://www.ncbi.nlm.nih.gov/ pubmed/28812451 [3] khandeparkar a, rataboli pv. a study of harmful drug-drug interactions due to polypharmacy in hospitalized patients in goa medical college. perspectives in clinical research. 2017 dec;8(4):180–6. [accessed 5.6.2019] available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc5654218/ [4] shehadeh m, suaifan g, darwish rm, wazaify m, zaru l, alja’fari s. knowledge, attitudes and behavior regarding antibiotics use and misuse among adults in the community of jordan. a pilot study. saudi pharmaceutical journal. 2012 apr;20(2):125–33. [accessed27.6.2019] available from:https:// www.ncbi.nlm.nih.gov/pubmed/23960783 [5] imani f, motavaf m, safari s, alavian sm. the therapeutic use of analgesics in patients with liver cirrhosis: a literature review and evidence-based recommendations. hepat mon. 2014 oct; 14(10): e23539 [accessed11.7.2019];14(10).available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc4250965/ conclusion conflict of interest references https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article [6] ahmad a, khan mu, srikanth ab, kumar b, singh nk, trivedi n, et al. evaluation of knowledge, attitude and practice about selfmedication among rural and urban north indian population. national journal of community medicine 2015;7(5):7. [accessed 21.7.2019]availablefrom:http:njcmindia.org/ uploads/njcm_7-10_825-828.pdf [7] hamid sa. consumer socialisation of over-the -counter medicines: a study of adolescents in new zealand and malaysia.2011;. [accessed 18.7.2019]availablefrom:https:// pdfs.semanticscholar.org/05b2/538c2bce98 dffd428f39ea3eda20fe3d5a29.pdf [8] kuku k, odusanya o. self medication: knowledge , attitude and practices in the ikeja local govt. area of lagos nigeria. 2011. [accessed 12.6.2019]available from:https:// www.researchgate.netpublication/21646859 8_self_medication_knowledge_attitude_and _praties_in_the_ikeja_local_govt_area_of_ lagos_nigeria [9] susheela f, goruntla n, bhupalam pk, veerabhadrappa kv, sahithi b, ishrar smg. assessment of knowledge, attitude, and practice toward responsible self-medication among students of pharmacy colleges located in anantapur district, andhra pradesh, india. journal of education and health promotion. 2018 aug 2;7.[accessed 17.6.2019] availablefrom:https:/www.ncbi.nlm.nih.gov/ pmc/articles/pmc6088819/ [10] ravichandran, a., basavareddy, a. perception of pharmacists regarding over-thecounter medication: a survey. indian journal ofpharmacology.2016.48,729–732.[accessed 20.8.2019]availablefrom:https:// doi.org/10.4103/0253-7613.194857 [11] bastani p, nia aa, shabanpoor m, mehravar s, kashefian s. knowledge, attitude and practice of iranian pharmacists, body builders, and their coaches regarding sports supplements. journal of research of pharmacy practice. 2017;6(3):166–72.[accessed 12.7.2019] availablefrom: https:/ www.ncbi.nlm.nih.gov/pubmed/29026842 [12] bj mk, a s, m s. a survey on assessing the knowledge, attitude and behavior of community pharmacists to adverse drug reaction related aspects. saudi pharmaceutical journal. 2012;5(4):5.[accessed 22.6.2019] availablefrom:https:www.sciencedirect.com/ science/article/pii/s1319016413000868 [13] ali a, kai j, keat cc, dhanaraj s. selfmedication practices among health care 154 erbil journal of nursing & midwifery professionals in a private university, malaysia.international current pharmaceutical journal.2012, 1(10): 302-310.[accessed 15.7.2019]available from: http:// www.icpjonline.com/documents/ vol1issue10/01.pdf [14] boateng dp. self-medication among doctors and pharmacists at the korle bu teaching hospital. 2009. [accessed 12.6.2019] available from: https:// pdfs.semanticscholar.orgcde7/893bc37440 007e1dadae48ce544d410dfd93.pdf [15] shroti, r., nayak, n., rajput, m.s. a study on over the counter drugs in retail pharmacies in indore city.der pharmacia lettre, 2011, 3(3):133-138 [accessed 17.9.2019] available from: https:// www.scholarsresearchlibrary.com/articles/ a-study-on-over-the-counter-drugs-in-retail -pharmacies-in-indore-city.pdf https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/105 https://doi.org/10.15218/ejnm.2020.17 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article the consequence of teenage pregnancy on the primigravida health outcome delivers at sulaymaniyah maternity teaching hospital-kurdistan region-iraq. abstract introduction teenage pregnancy is a terminology to define a teenage girl, usually within the ages of 13-19, becoming pregnant [1]. globally, there are 16 million births a year to young married and unmarried women aged 15-19 years, representing 11% of all births worldwide [2]. around 95% of these births arise in developing countries, as 49% of girls in these countries get married before the age of 18. first pregnancy at an early age is considered high risk for both the mother and infant [3]. around the world, the rate of childbearing adolescent women shifts broadly, depending on cultural, religious, political, economic and other factors [4].teenage pregnancy is present in all societies; however, the level of teenage pregnancy background and objectives: teenage first pregnancy is a significant public health problem as it often occurs in the context of poor social support and maternal wellbeing. it is considered high risk for both the mother and infant. this study aimed to find out the effect of teenage pregnancy on neonatal health outcomes. methods: a descriptive, cross-sectional, prospective study was conducted in sulaymaniyah in the kurdistan region of iraq and involved all pregnant teenage mothers admitted to sulaymaniyah maternity teaching hospital from january 1, 2019, to june 30, 2019. results: 332 of mothers aged ≤19 years and their newborns were studied. a higher proportion of teenage mothers were from rural areas than the urban areas (59.3% vs 40.7%). the percentage of teenage mothers who did not attend antenatal care was 11.14%, and irregular attendees represented 9.94 %. compared with teenage mothers aged 14–16 years, teenage mothers aged 17–19 years had higher risks of anaemia, systemic infections, coincidental condition, low birth weight, preterm delivery and low apgar score. the risk of aspiration of meconium and stillbirth among infants born to teenage mothers was statistically not significant after adjustment for gestational age and birth weight, in addition to maternal characteristics and mode of delivery. teenage pregnancy was associated with higher risks of adverse pregnancy outcomes. conclusion: prevention strategies and the improvement of healthcare are essential to reduce the consequences of teenage pregnancy on maternal and neonatal health outcomes. teenage women were less likely to receive antenatal care services. use of community and health facility-based education programs are necessary to prevent teenage pregnancy and thus reduce adverse maternal and neonatal outcomes. keywords: primigravida, outcomes, pregnancy, teenage, health, consequences kochar ezat abdulla; department of nursing, college of nursing, university of sulaimani, sulaimani, iraq. )correspondence: kocheezat@gmail.com) pary muhammad azize; department of nursing, sulaimani technical institute sulaimani polytechnic university sulaimani, iraq. 143 received: 18/03/2020 accepted:27/07/2020 published: 30/11/2020 https://doi.org/10.15218/ejnm.2020.17 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article and childbearing varies from country to country [5]. in particular, unstable biological and social environments have an impact on the tendency, prevalence and the results of teenage pregnancies. additionally, the existing trends of teenage marriage in different parts of the globe also contribute to the problem persisting at various levels. therefore, adverse pregnancy outcomes are significantly higher in teenagers than in adults. babies of teen mothers are more likely to be premature and experience infant mortality [6]. the infants of teenage mothers often endure more risks to health and social wellbeing than do children of older mothers [7]. among the young women aged 15-19, the negative consequences of pregnancy and childbirth are the leading cause of death in developing countries. it is estimated that 90,000 adolescent mothers are not physically ready for parenthood [8]. study of maternal and perinatal outcomes in teenagers by dutta and joshi (2013) in west bengal, india, concluded that the rate of low birth weight (lbw) in teenage pregnancy was relatively high in the teenage mothers (29.2%) compared to the adult mothers (16.6%) [9]. also, birth asphyxia was found in 29.2% of the newborns of teenage mothers and 7.3% of the newborns of the adult mothers [10]. these adverse outcomes may be the result of the high rate of preterm delivery in the teenage group. some researchers found that good quality prenatal and natal care reduce adverse pregnancy outcomes in teenagers [2].the fact established in many studies about the negative consequences of teenage pregnancies is that it is still challenging to know how much the biological factors related to age contribute to the physical outcomes such as birth weight, prematurity and other perinatal complications [11]. therefore, this study was conducted to describe the consequences of teenage pregnancy on maternal and the first newborn health outcomes at sulaymaniyah maternity teaching hospital in sulaymaniyah, kurdistan region of iraq. the descriptive, cross-sectional, prospective study was conducted. the questionnaire was given to each teenage mother after her verbal consent. the questionnaire was included in the postpartum patient file to be completed after the delivery. teenagers were asked to complete the 23 questions and place the questionnaire in a sealed envelope provided by the researcher. the study was conducted in the maternity teaching hospital in sulaymaniyah in the kurdistan region of iraq from january 1 to june 30, 2019.a purposive nonprobability sample of 332 teenage mothers who delivered in the sulaymaniyah maternity teaching hospital and agreed to participate in the study was recruited to the study. during the study period, 6243 deliveries were registered and conducted at the sulaymaniyah maternity teaching hospital. among this group, 332 out of 6243 were teenagers. among the 332-teenager mothers, 273 had a normal vaginal delivery, and 59 had a caesarian section (sulaymaniyah maternity hospital statistical department, 2019).the study was conducted after obtaining agreement from the sulimaniyah university and the sulaymaniyah maternity hospital in sulymaniyah. the questionnaire included 23 questions approved by the human subjects committee of the university of sulaymaniyah. the study questionnaire consisted of three parts, as follows: part one: maternal socio-demographic information (such as age, education level, occupation, residency, nationality, socioeconomic status, body mass index (bmi), antenatal care (anc) visit, medical condition and mode of delivery). 144 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2020.17 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article data were collected through direct structured interview of teenage pregnant women using questionnaire form, which was designed for the study purpose. the researchers clearly explained the purpose of the study to all pregnant women, and their verbal consent was obtained before filling the questionnaire. for mothers, the interview took approximately 15 minutes, but for some neonates, it took longer because of checking neonatal outcomes or rechecking the condition. pregnant mothers aged 19 years and less and pregnant for the first time were included in the study. teenage mothers with the second or third pregnancies were excluded. the university approved the study for the advanced nursing research and training by sulaymaniyah maternity hospital. all information collected during the study will remain strictly confidential. no identifying information (i.e. name, address and telephone number) was requested so that the participants would not be recognized. participation was voluntary, and an informed consent document was included with the questionnaire. informed consent was obtained from the study participants before the data collection. the collected information during the period of the research was stored with the utmost confidentiality. all statistical computation was enhanced using the statistical package for social sciences (spss 21). the data were coded, tabulated, and presented in a descriptive form. the statistical procedure that was applied to determine the results of the present study included: alpha-cronbach for testing the reliability of the questionnaire, descriptive statistical data analysis (maternal demography, neonate demography and neonate outcomes) and chi-square, a simple regression model for inferential data analysis. part two: neonatal demography and medical history including seven items such as gender, gestational age (weeks), birth weight (grams), apgar score, fetal distress, aspiration meconium and shoulder dystocia). part three: neonatal outcomes, consisting of six items such as small for gestational age (sga), large for gestational age (lga), medical condition, type of deformity, neonate death and neonatal diagnosis. also, it included information about bmi measurement, height and weight. bmi grading as per who [12]: underweight <18.5 normal 18.5-24.99 overweight 25-30 obese >30 newborn birth weight [13]: extremely low birth weight (elbw) <1000 very low birth weight (vlbw) 1000-1500 low birth weight (lbw) 1500-2500 normal weight 2500-4500 over weight >4500 apgar score interpretation [14]: 0-3 severely depressed 4-6 moderately depressed 7-10 normal the council of the college of nursing accepted the research protocol, and the ethical committee approved the study of the college of medicine university of sulaymaniyah on february 7, 2019. accordingly, an official letter from the college of nursing of the university of sulaymaniyah was sent to the sulaymaniyah maternity hospital city to request facilitation and cooperation during data collection of this study. 145 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.17 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article score, 57.8% had a normal apgar score, 25% were moderately depressed, and only 3.3% were severely depressed. furthermore, 22.6% of the newborns had fetal distress, and 14.8% were stillborn with meconium aspiration. 1.5% of babies developed shoulder dystocia. table 4 demonstrates that 14.8% of newborns were stillborn, 17.8% was small for gestational age (sga), and 2.7% were large for gestational age (lga), the majority of the newborns were healthy (75%), while 9% of the baby had intrauterine growth retardation (iugr), and 1.2% of them had congenital anomalies. most of the babies (56.9%) had no deformity, while 22% had a physiological type of the deformity and 0.6% had a neurological deformity. among the study participants, 17.2% (57/332) of neonates died (stillbirth and intrauterine death iud), out of which 85.96% (49/57) of the newborns had a stillbirth, and 14.04 % (8/57) was iud. in terms of the clinical diagnosis, 54.5% of the newborn were healthy, follow by neonatal respiratory distress (28.9%) and 3.3% of newborns suffered from respiratory distress + asphyxia. the lowest percentage among all neonatal diagnoses types was death because of respiratory distress + sepsis (0.6%).ho: there is not a relationship between teenage mothers’ age and newborns’ gestational timeh1: there is a relationship between teenage mothers’ age and newborns’ gestational time ho: there is not the effect of the teenage mothers’ age on the newborns’ gestational timeh1: there is the effect of the teenage mothers’ age on the newborns’ gestational time according to the model summary of regression analysis in table 5, there is a significant positive statistical correlation between teenage mothers’ age and gestational age, which is 0.709 and that the p-value = < 0.001. this indicates acceptance of the alternative hypothesis, a positive correlation between 146 erbil journal of nursing & midwifery table 1 demonstrates that alpha-cronbach was used to get the result of the reliability of the questionnaire. as a result, the value of alpha-cronbach equaled to 0.895, and the validity was 0.801. the result of alphacronbach and validity shows the high reliability of the questionnaire. table 2 shows that out of 332 teenager mothers, 15.1 % were 14-16 years old, and 84.9% were 17-19 years old. the majority of mothers had a secondary level of education. most of the participants(83.4%) were unemployed, and 59.3% were from rural areas. the majority of participants were kurdish (65.1%), 61.7% were within the overweight bmi range, and 23.5% were obese. most of the participants (78.92%) regularly visited anc throughout pregnancy, while 9.94 visited the anc irregularly, and only 11.14% of participants did not attend the anc. some of the participants (26.5%) were healthy, and 24.4% of participants had an infectious disease during pregnancy. 79.2% of participants had a normal vaginal delivery, while 18.1% had a cesarean section. table 3 demonstrates that the majority of the newborns were male (53.6), more than half of the newborn were full-term in gestation age (59.9%), followed by extremely preterm (13.9%), and 11.1% were moderately and late preterm. however, only 6.6% of newborns were very preterm. most of the newborns (63.6%) had normal birth weight, while 12% of newborns had low birth weight and only 3% of them were overweight. regarding apgar results table 1:reliability and validity methods result alpha-cronbach 0.895 validity 0.801 https://doi.org/10.15218/ejnm.2020.17 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 147 erbil journal of nursing & midwifery the extent of teenage mothers’ age and gestational age. on the other hand, r square for this study is 0.5026. this indicates that 50.26% of the variance of gestational age has been explored in teenage mothers ’age. in other words, this illustrates that only 50.26% of factors affect gestational age in teenage mothers’ age. moreover, there was statistical significance by using the anova table (ftest). this means that the method is possible to be used to analyze this data. variables frequency (percent) age at first birth/years 14-16 50 (15.1) 17-19 282 (84.9) education level illiterate 14 (4.2) primary school 77 (23.2) secondary school 195 (58.7) undergraduate 46 (13.9) occupation employed 3 (0.9) unemployed 277 (83.4) student 52 (15.7) residency rural 197 (59.3) urban 135 (40.7) nationality kurd 216 (65.1) arab 90 (27.1) other 26 (7.8) mother bmi normal weight 49 (14.8) over weight 205 (61.7) obese 78 (23.5) antenatal care visit (anc) not attendant 37 (11.14) regular 262 (78.92) irregular 33 (9.94) medical condition anaemia 42 (12.7) infectious disease 81 (24.4) coincidental condition 16 (4.8) other condition 52 (15.7) anaemia + infectious disease 32 (9.6) anemia + infectious disease+ coincidental condition 3 (0.9) anemia+ other condition 5 (1.5) infectious disease + other condition 13 (3.9) normal 88 (26.5) mode of delivery vaginal delivery 263 (79.2) instrument vaginal delivery 9 (2.7) cesarean section 60 (18.1) total 332 (100) table 2: teenage mothers’ socio-demographic and clinical data https://doi.org/10.15218/ejnm.2020.17 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 148 erbil journal of nursing & midwifery table 3: newborns’ socio-demographic and clinical data variables frequency (percent) gender male 178 (53.6) female 154 (46.4) gestational age /week less than 28 extremely premature 46 (13.9) 28 to 32 very preterm 22 (6.6) 32 to 37 moderate to late preterm 37 (11.1) 37 to 40 full-term 199 (59.9) <42 weeks post mature 28 (8.4) birth weight (grams) extremely low birth weight (elbw) 56 (16.9) very low birth weight (vlbw) 15 (4.5) low birth weight (lbw) 40 (12) normal weight 211 (63.6) over weight 10 (3) apgar score not recorded 46 (13.9) severely depressed 11 (3.3) moderately depressed 83 (25) normal 192 (57.8) fetal distress yes 75 (22.6) no 208 (62.7) stillbirth 49 (14.8) aspiration of meconium yes 27 (8.1) no 256 (77.1) stillbirth 49 (14.8) shoulder dystocia yes 5 (1.5) no 278 (83.7) stillbirth 49 (14.8) total 332 (100) https://doi.org/10.15218/ejnm.2020.17 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 149 erbil journal of nursing & midwifery table 4: neonatal outcomes variables frequency (percent) sga yes 59 (17.8) no 224 (67.5) stillbirth 49 (14.8) lga yes 9 (2.7) no 274 (82.5) stillbirth 49 (14.8) medical condition normal 249 (75) iugr 30 (9) stillbirth 49 (14.8) congenital anomalies 4 (1.2) types of deformity physical 2 (0.6) physiological 73 (22) neurological deformity 2 (0.6) physical+ physiological 6 (1.8) physiological+ neurological deformity 14 (4.2) physical + neurological deformity 46 (13.9) normal 189 (56.9) neonate death yes 57 (17.2) no 275 (82.8) type of neonate death (yes ) stillbirth 49 (85.96) iud 8 (14.04) neonatal diagnoses normal 181 (54.5) respiratory distress 96 (28.9) asphyxia 33 (10) other 9 (2.7) respiratory distress + sepsis 2 (0.6) respiratory distress + asphyxia 11 (3.3) total 332 (100) table 5: regression analysis of a dependent variable (gestational age) effect of teenage mothers’ on the newborn’s gestational age model coefficients model summary anova table unstandardized coefficients tvalue pvalue r p-value r2 adjust r2 f-value p-value b std. error constant 50.76 4.745 10.697 < 0.001 0.709 < 0.001 0.5026 0.507 322.57 < 0.001 teenage pregnancy 4.737 0.264 17.96 < 0.001 https://doi.org/10.15218/ejnm.2020.17 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 150 erbil journal of nursing & midwifery table 6 represents the association between 14-16 years old and 17-19 years old related to birth weight characteristics. there was a highly statistically significant association between groups of 14-16 years old and 17-19 years old mothers and birth weight (p-value= < 0.001) because the result of p-value was less than the common alpha 0.05. most, (89.57%, 189/211) of the normal birth weight newborns was recorded in a 17-19 years old group, and only 10.43%, 22/211) of the newborns were from 14-16 years old teenage mothers group. ho: there is not a relationship between teenage mothers’ age and newborn's birth weighth1: there is a relationship between teenage mothers’ age and newborn’s birth weight ho: there is not the effect of the teenage mothers’ age on the newborn's birth weight h1: there is the effect of the teenage mothers’ age on the newborn’s birth weight according to the model summary table 7 of regression analysis above, there is a significant positive statistical correlation between teenage mothers’ age and newborns’ birth weight, which is 0.732 and that the pvalue is = < 0.001. this indicates acceptance of the alternative hypothesis, a positive correlation between the extent of teenage mothers’ age and neonatal birth weight. on the other hand, r square for this study is 0.534. this indicates that 53.4% of the variance of birth weight has been explored in teenage mothers’ age. in other words, this illustrates that only 53.4% of factors affect birth weight and teenage mothers’ age. moreover, there was statistical significance by using the anova table (f-test). this means that the method is possible to be used to analyze this data. table 8 shows the association between teenage mothers’ age (14-16 years old) and (17-19 years old) and the newborn‘s health outcomes. the result of the study shows that there were highly significant associations between both groups of the teenage mothers’ age and apgar score at p= <0.001, fetal distress p= <0.001, aspiration of meconium p= <0.001, shoulder dystocia p= <0.001, sga p= <0.001, lga p= <0.001, medical condition p= <0.00, and a significant association of neonatal diagnoses at p=0.046 because the p-value was less than the common alpha 0.05. however, there was no statistically significant association between the maternal age and neonatal death (p = 0.56), which was more than the common alpha 0.05. table 6: association between teenage mothers’ age and newborns’ birth weight variables items 14-16 years old 17-19 years old total significance test n % n % birth weight (elbw) 18 32.14 38 67.86 56 χ2 =20.907 p= < 0.001 (vlbw) 0 0 15 100 15 (lbw) 7 17.5 33 82.5 40 normal weight 22 10.43 189 89.57 211 over weight 3 30 7 70 10 https://doi.org/10.15218/ejnm.2020.17 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 151 erbil journal of nursing & midwifery table 7: regression analysis of a dependent variable (birth weight) effect of teenage mothers’ age on the newborn’s birth weight model coefficients model summary anova table unstandardized coefficients t-value p-value r p-value r2 adjust r2 f-value p-value b std. error constant 9528.91 68159 13.98 < 0.001 0.732 < 0.001 0.534 00.513 338.66 < 0.001 teenage pregnancy 702.346 38.165 18.403 < 0.001 table 8: association between teenage mothers’ age and newborns’ health outcomes variables items 14-16years old 17-19 years old total significance test n (%) n (%) apgar score not recorded 17 (37.0) 29 (63) 46 χ2 =21.928 p= < 0.001 severely depressed 2 (18.2) 9 (81.8) 11 moderately depressed 6 (7.2) 77 (92.8) 83 normal 25 (13) 167 (87) 192 fetal distress yes 5 (6.7) 70 (93.3) 75 χ2 =22.829 p= < 0.001 no 27 (13) 181 (87) 208 stillbirth 18 (36.7) 31 (63.3) 49 aspiration of meconium yes 1 (3.7) 26 (96.3) 27 χ2 =22.46 p= < 0.001 no 31 (12.1) 225 (87.9) 256 stillbirth 18 (36.7) 31 (63.3) 49 shoulder dystocia yes 1 (20) 4 (80) 5 χ2 =21.411 p= < 0.001 no 31 (11.2) 247 (88.8) 278 stillbirth 18 (36.7) 31 (63.3) 49 sga yes 6 (10.2) 53 (89.8) 59 χ2 =21.186 no 26 (11.6) 198 (88.4) 224 stillbirth 18 (36.7) 31 (63.3) 49 lga yes 2 (22.2) 7 (77.8) 9 χ2 =21.976 no 30 (10.9) 244 (89.1) 274 stillbirth 18 (36.7) 31 (63.3) 49 medical condition normal 27 (10.8) 222 (89.2) 249 χ2 =21.835 p= < 0.001 iugr 4 (13.3) 26 (86.7) 30 stillbirth 18 (36.7) 31 (63.3) 49 congenital anomalies 1 (25) 3 (75) 4 types of deformity physical 0 (0) 2 (100) 2 χ2 =26.159 p= < 0.001 physiological 5 (6.8) 68 (93.2) 73 neurological deformity 1 (50) 1 (50) 2 physical+ physiological 2 (33.3) 4 (66.7) 6 physiological+ neurological deformity 2 (14.3) 12 (85.7) 14 physical + neurological deformity 17 (37) 29 (63) 46 normal 23 (12.2) 166 (87.8) 189 neonatal death yes (stillbirth=49, iud=7) 10 (17.5) 47 (82.5) 57 χ2 =0.33 p= no 40 (14.5) 235 (85.5) 275 neonatal diagnoses normal 26 (14.4) 155 (85.6) 181 χ2 =11.28 p= 0.046 respiratory distress 18 (18.8) 78 (81.3) 96 asphyxia 0 (0) 33 (100) 33 other 3 (33.3) 6 (66.7) 9 respiratory distress + sepsis 1 (50) 1 (50) 2 respiratory distress + asphyxia 2 (18.2) 9 (81.8) 11 https://doi.org/10.15218/ejnm.2020.17 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 152 erbil journal of nursing & midwifery this study was conducted to provide information about the consequences of teenage pregnancy on maternal and neonatal outcomes at sulaymaniyah maternity teaching hospital in sulaymaniyah, kurdistan region of iraq. totally 332 teenager mothers participated in this study. among them, around one-seventh were between 14-16 years old, and the majority were 1719 years old. the majority of participants had a secondary level of education, and the minority was illiterate. among the study participants, more than half were from rural areas. in 2019, in a study about the predictors of teenage pregnancy among mothers aged 13–19 years in uganda, the results showed that age of the respondents and place of residence of respondents were not significantly associated with teenage pregnancy after adjusting for all independent factors [15]. teenage mothers, who reside in rural areas were twice more likely to become pregnant. these findings are inconsistent with the previous study in nepal [16]. the use of anc is essential and widely recommended for all pregnant women to reduce pregnancy-related morbidity and mortality. this study found that more than threequarters of pregnant mothers attended anc; however, some attended irregularly, and more than one-tenth did not attend at all. moreover, in this study, the minority were illiterate. previous studies which were done in slovenia [17] and thailand [18], also showed significantly lower antenatal care use among teenage mothers compared to others. this could be because of the difference in educational status between teenage mothers and adult women. these findings indicate an urgent need to improve female health education. the high rate of neonatal complications can be reduced through health education and properly organized antenatal checkup [11]. therefore, improvement of healthcare is essential to reduce adverse pregnancy outcomes among teenage women in iraq. teenage women who are less likely to receive anc service, and follow-ups, have a lower mean age at first pregnancy and are less likely to receive food supplements during their first pregnancy [19]. as a consequence, the lack of knowledge, early pregnancy, and absent or insufficient antenatal checkup have contributed to the infant in in-utero growth, resulting in lbw [20].regarding teenage mother’s bmi, nearly two-third were overweight and almost a quarter was obese. the majority had an infectious disease during pregnancy, while only a quarter was healthy. out of the total number, threequarter of teenage mothers had a normal vaginal delivery, the minority had a cesarean section, and only 9 has instrumental vaginal delivery. some studies report that the risk of caesarean section is increased in teenage pregnancy [21]. this result agrees with other study done in italy, which reported that two-third of teenage pregnant women had a normal vaginal delivery compared to less than half in the control group [17]. in comparison, some have the opposite finding stating that the chance of the infant’s lower birth weight can lead to a higher rate of success in normal vaginal delivery [22]. in the current study, 332 newborns were delivered. the majority of the newborns were male. more than half of the newborns had a gestational age between 37 and 40 weeks, which is the highest rate among all levels of gestational age, and 31.6% of all newborns were premature. this finding is in contrast with the previous study done in babylon, which reported a higher proportion of preterm deliveries in teenage discussion https://doi.org/10.15218/ejnm.2020.17 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 153 erbil journal of nursing & midwifery mothers compared to only 6% in the adult mothers [23]. the mechanisms associated with preterm labour are not well known and evoke much discussion. it is suggested that it could be due to immaturity of the reproductive organ of young women, poor nutrition, inadequate anc, urinary tract infection, anaemia and low level of education [24].according to the current study, about one-fifth of the newborns had sga, almost one-seventh were stillborn, while very few had lga. more than a quarter of the newborns suffered from respiratory distress, one-tenth had asphyxia as a medical diagnosis, and few had respiratory distress with asphyxia. a previous study from the united states found that the first teenage birth was independently associated with an increased risk of intrauterine growth restriction and premature delivery [25].regarding the association between both teenage mothers’ age groups and gestational age, there was a highly statistically significant association between 14-16 years old mothers and 1719 years old mothers and newborns, gestational age at p-value = 0.000. some studies agree with the present study results and found that low birth weight occurred significantly more often among infants of young mothers than among infants of older mothers (27,28). however, one of the studies from a high-income country did not show a significant association [26].there was a statistically significant association between both groups of the teenage mothers with the apgar score, fetal distress, aspiration of meconium, shoulder dystocia, sga, lga, medical condition, types of deformity and neonatal diagnoses. however, there was no statistically significant association between both groups and neonatal death. in another study that agrees with the present study regarding the association between early maternal age and newborn death, there was no statistically significant association between the teenage pregnancy groups and neonatal death (p=0.56). katz et al. also found no association between young maternal age and stillbirth in nepal [27]. in comparison, de vienne et al. found a significant relationship between the two [28]. a study in the city of sakarya in turkey determined that postnatal infant death rate is 2.5% in adolescent pregnancies and 0.1% adult pregnancies [29].regarding neonatal outcomes, this study showed a significantly higher risk of sga (p=0.000, χ2 =21.186) than lga. however, lga (p=0.000, χ2 =21.976) is less among newborn babies of teenage mothers. socolov et al. (2017) in romania who conducted a study among 3891 women aged < 19,9 and 9479 women aged 20-24, found the higher rate of sga infants in the first group than in the second group (13.77% vs 10.40%, p < 0.001) [30]. the results correspond with previous results of other authors ( 31,32) who found that the rate of sga infants is higher in adolescents compared to adult women (3.5% vs.2.3%), while the rate of lga infants is higher in adult mothers (3.2% vs 1.8%) [31]. other study did not find a significant difference between both groups [32].a highly significant difference in the apgar score of newborn babies at birth and at five minutes after birth was observed in the current study. analysis of the association between teenage pregnancy and adverse birth outcomes demonstrated that infants born to teenage mothers aged 17 or younger had a higher risk for low apgar score at five minutes [33].this could be attributed to the difference in the socio-demographic, obstetric, nutritional factors of the mother [34]. according to the model regression analysis, there is a significant positive statistical correlation between https://doi.org/10.15218/ejnm.2020.17 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 154 erbil journal of nursing & midwifery teenage mothers’ age and birth weight. r square for this study is 0.534. this indicates that more than half of the variance of birth weight has been explored in teenage mothers’ age. a local study was done in basrah, which reported that one-fifth of the cases had lbw babies as compared to (6.8%) of the control group (19). fetomaternal competition for nutrition is a common explanation for the higher risk of delivering low birth weight infant in adolescent mothers [35]. one-sixth of all births globally are lbw, with an increased risk of neonatal morbidity and mortality. as a result, the who during the sixty-fifth world health assembly in may 2012 planned to reduce lbw by 30% by the end of 2025 [36]. in this study, there was a statistically significant association between both age groups and newborns’ gestational time. in other words, there was a highly statistically significant difference between 14-16 years old and 17-19 years old in the birth weight of their infants. the lbw is less likely in teenage mother aged 14-16 than in the teenage mothers who are 1719 years old. therefore, strategies, which aim to reduce teenage pregnancy and adverse neonatal outcomes of adolescent pregnancy are necessary. immediate and effective measures to reduce the teenage pregnancy need to be developed and implemented, to achieve such target. in this study, the number of teenage pregnancies was 332 out of 6243, which is high alert to this region as well as to other countries. the who recommends prevention of teenage pregnancy as the primary strategy to reduce neonatal mortality, especially in developing countries. preventive measures such as prevention of early marriage and the use of contraceptive methods are effective in reducing teenage pregnancy and related complications. therefore, the programs in the prevention of teenage pregnancy should be developed and delivered. the use of such steps can reduce unwanted pregnancy among adolescents; lbw and preterm birth complications, and can decrease overall child morbidity and mortality in the country [37]. teenage pregnancy was associated with higher risks of adverse pregnancy outcomes. it has been demonstrated that pregnant teenagers have more significant health problems during pregnancy, labour and after labour. teenage pregnancy age significantly reduces the risk of gestational age as they were less likely to receive antenatal care service. the authors wish to thank the staff of sulaymaniyah maternity teaching hospital and the hospital administration for their cooperation and say thank to all teenage mothers who accepted to participate in this study. the authors report no conflict of interests [1] ochen am, chi pc, lawoko s. predictors of teenage pregnancy among girls aged 13-19 years in uganda: a community based case-control study. bmc pregnancy childbirth. 2019;19(1):1–14. [2] ayele b, tesfay g, hailu tesfay t, assefa, belete a. determinants of teenage pregnancy in degua tembien district, tigray, northern ethiopia: a community-based case-control study. plos one. 2018;13 (7):1–15. [3] kost k, henshaw s. u.s. teenage pregnancies, births and abortions, 2011: national trends by age, race and ethnicity. guttmacher institute. 2016;(april):1–28. available from: https:// www.guttmacher.org/pubs/ ustptrends10.pdf conclusion acknowledgement conflict of interest references https://doi.org/10.15218/ejnm.2020.17 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 155 erbil journal of nursing & midwifery [4] mersal fa, esmat om, khalil gm. effect of prenatal counselling on compliance and outcomes of teenage pregnancy. east mediterranean health journal. 2013;19(1):10–7. [5] kirchengast s. teenage pregnancies: a worldwide social and medical problem. intech. 2017;(april). available from: https://www.researchgate.net/ publication/309517576 teenage [6] mukhopadhyay p, chaudhuri rn, paul b. hospital-based perinatal outcomes and complications in teenage pregnancy in india. journal of health, population and nutrition. 2010;28(5):494–500. available from: https://www.researchgate.net/ publication/309517576 teenage [7] campbell b, martinelli-hackathon s, wong s. motherhood in childhood. in the state of world population. 2013. p. ii–116. available from: http://www.unfpa.org/sites/default/ files/pub-pdf/en-swop2013-final.pdf [8] mangeli m, rayyani m, cheraghi ma, tirgari b. exploring the challenges of adolescent mothers from their life experiences in the transition to motherhood: a qualitative study. journal of family& reproductive health. 2017;11(3):165–73. [9] dutta i, joshi p. maternal and perinatal outcome in teenage vs. vicenarian primigravidae a clinical study. journal of clinical and diagnostic research.2013;7(12):2881–2884. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc3919298/ [10] goonewardene imr, waduge rpkd. adverse effects of teenage pregnancy. ceylon medical journal. 2005;50(3):116–20. [11] ali n, sultana m, sheikh n, akram r, mahumud ra, asaduzzaman m. predictors of optimal antenatal care service utilization among adolescents and adult women in bangladesh. health services research and managerial epidemiology volume .2018;5:1 –8. [12] world health organization, cut-off for bmi according to who standards. available from: https://gateway.euro.who.int/en/ indicators/mn_survey_19-cut-off-for-bmiaccording-to-who-standards/.[ accessed from 2019]. [13] vincent i. baby birth weight statistics. retrieved from https:// www.verywellfamily.com/baby-birth-weight -statistics-2633630. updated on june 29,2020. [14] holton t. "what are apgar scores, and why are they important? " www.holtonlaw.com.2020. [15] bureau of statistics, uganda demographic and health survey uganda bureau of statistics kampala, uganda ; (2011), (p. 461). retrieved from https:// dhsprogram.com/pubs/pdf/fr264/ fr264.pdf [16] choe mk, thapa s, mishra v. early marriage and early motherhood in nepal. journal of biosocial science. 2005;37 (2):143–62. [17] korenčan s, pinter1 b, grebenc m, verdenik i. the outcomes of pregnancy and childbirth in adolescents in slovenia. national institute of public health. 2017;56(4):268–75. available from: file:///c:/users/cfvgf/ downloads/marriagejbspaper-choethapavinod.pdf [18] kassa gm, arowojolu ao, odukogbe aa, yalew aw. adverse neonatal outcomes of adolescent pregnancy in northwest ethiopia. plos one .2019;14(6):1–20. available from: file:///c:/users/cfvgf/videos/ journal.pone.0218259.pdf [19] mahomood naa. impact of teenage pregnancy on maternal and neonatal outcomes in baghdad city. world journal of pharmaceutical research. 2017;6 (7):197–208. available from: file:///c:/ users/cfvgf/desktop/ article_wjpr_1498892145 (3).pdf [20] bimerew a, teshome m, kassa gm. prevalence of timely breastfeeding initiation and associated factors in dembecha district, north west ethiopia: a crosssectional study. international breastfeed journal. 2016;11(1):1–8. available from: http://dx.doi.org/10.1186/s13006-0160087-4 [21] kovavisarach e, chairaj s, tosang k, asavapiriyanont s, chotigeat u. outcome of teenage pregnancy in rajavithi hospital. journal of the medical association of thailand. 2014;93(1). available from: https://www.researchgate.net/ publication/41668227_outcome_of_teenage_pr egnancy_in_rajavithi_hospital [22] lao, tt, ho, lf. the obstetric implications of teenage pregnancy. human reproduction hum reprod. 1997;12(10):2303–5. available from: file:///c:/users/cfvgf/ https://doi.org/10.15218/ejnm.2020.17 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 156 erbil journal of nursing & midwifery downloads/ the_obstetric_implications_of_teenage_pre gnancy.pdf [23] witwit sj. teenage motherhood: maternal & fetal complications. journal of babylon university/pure and applied sciences. 2015;11(2):828–42. available from: https:// www.iasj.net/iasj? func=fulltext&aid=103428 [24] morikawa m, cho k, yamada t, yamada t, sato s, minakami h. risk factors for eclampsia in japan between 2005 and 2009. international journal of gynaecology obstetrics. 2012;117(1):66–8. available from: https:// pubmed.ncbi.nlm.nih.gov/22257769/ [25] smith gcs, pell jp. population-based retrospective cohort study. bmj. 2001;323:1–5. available from: https://www.bmj.com/ content/bmj/323/7311/476.full.pdf [26] reichman ne, pagnini dl. maternal age and birth outcomes: data from new jersey. family planning perspectives. 1997;29 (6):268–95. [27] katz j, khatry sk, leclerq sc, shrestha sr, west kp, christian p. miscarriage but not stillbirth rates are higher among younger nulliparas in rural southern nepal. journal of adolescent health. 2008;42(6):587–95. [28] gibbs cm, wendt a, peters s, hogue cj. the impact of early age at first childbirth on maternal and infant health. paediatric and perinatal epidemiology. 2012;26 (suppl,1):259–84. available from: http:// www.ncbi.nlm.nih.gov/ pubmed/22742615%0ahttp:// www.pubmedcentral.nih.gov/ articlerender.fcgi?artid=pmc4562289 [29] cinar n, menekse d. effects of adolescent pregnancy on health of baby. open journal of pediatrics& neonatal care. 2017;3(1):12– 6. available from: www.scireslit.com [30] socolov dg, iorga m, carauleanu a, ilea c, blidaru i, boiculese l, et al. pregnancy during adolescence and associated risks: an 8year hospital-based cohort study (20072014) in romania, the country with the highest rate of teenage pregnancy in europe. biomed research international. 2017:1–8. available from: www.scireslit.com [31] harper lm, chang jj, macones ga. adolescent pregnancy and gestational weight gain: do the institute of medicine recommendations apply? american journal of obstetrics and gynecology. 2011;205(2):2–15. [32] iacobelli s, robillard p-y, gouyon j-b, hulsey tc, bonsante gb &francesco. obstetric and neonatal outcomes of adolescent primiparous singleton pregnancies: a cohort study in the south of reunion island, indian ocean. journal matern neonatal medicine. 2012;25(12):2591–6. available from: https:// www.tandfonline.com/doi/ full/10.3109/14767058.2012.718003? scroll=top&needaccess=true [33] chen xk, wen sw, fleming n, demissie k, rhoads gg, walker m. teenage pregnancy and adverse birth outcomes: a large population-based retrospective cohort study. international journal of epidemiology. 2007;36(2):368–73. [34] world health organization. global nutrition target 2025. breastfeeding policy brief. available from: file:///c:/users/ cfvgf/downloads/ who_nmh_nhd_14.7_eng%20(2).pdf. [accessed 2012] [35] ganchimeg t, ota e, morisaki n, et al. pregnancy and childbirth outcomes among adolescent mothers: a world health organization multicountry study. bjog: an international journal of obstetrics and gynaecology. 2014 mar;121 suppl 1:40-48. doi: 10.1111/14710528.12630. [36] world health organization. wha global nutrition targets 2025: low birth weight policy brief. available from: https:// www.who.int/nutrition/topics/ globaltargets_lowbirthweight_policybrief.pdf. [accessed 2014] [37] world health organization. preventing early pregnancy and poor reproductive outcomes. available from: https:// www.who.int/immunization/hpv/target/ preventing_early_pregnancy_and_poor_repr oductive_outcomes_who_2006.pdf? ua=1. [accessed 2011] https://doi.org/10.15218/ejnm.2018.06 ejnm, vol. 1, no. (1), may, 2018 original article prevalence and risk factors of work-related musculoskeletal disorders among nurses in erbil teaching hospitals abstract introduction work-related musculoskeletal disorders (wmsds) are isolated or shared problems in the muscles, tendons, synovial membranes (joint tissue) nerves, fascia (connective tissue) and ligaments, with or without tissue degeneration. they are diagnosed by the occurrence of symptoms, along with or not, like: pain, numbness, feeling of heaviness and fatigue *1+. these injuries generally affect the superior limbs, scapular region around the shoulder and cervical region, but can also affect the inferior limbs and are frequent causes of temporary or permanent occupational disabilities. injury caused by work-related musculoskeletal disorders arise from the extreme use of the musculoskeletal system and its inadequate recovery, and comprises clinical conditions. workers are victims when they are submitted to poor work conditions *2+. the risk of work-related musculoskeletal disorders is high among different healthcare professionals *3+. wmsds happen in some careers, including nursing, background and objective: the term musculoskeletal disorders includes a gamut of inflammatory and degenerative conditions that affect the muscles, tendons, ligaments, joints, peripheral nerves, and supporting blood vessels with consequent ache, pain or discomfort. the risk of musculoskeletal disorders is high among various healthcare professionals. this study investigated the prevalence of work-related musculoskeletal disorders and risk factors among nurses in erbil teaching hospitals. methods: this cross-sectional study was conducted in erbil city teaching hospitals in the kurdistan region of iraq. a total number of 256 nurses were selected as study samples through the use of non-probability convenience sampling method. the data were collected by a standardized questionnaire through the use of the interview (face to face) technique. results: the previous 12-month prevalence of work-related musculoskeletal disorders among nurses was 67%. lower back disorder was the most prevalent disorder compared to other body regions at 75% followed by 52% reported in one or both knees, and the lowest percentages (9%) reported in the upper back region. conclusion: work-related musculoskeletal disorders are high among nurses. there was an association between the prevalence of musculoskeletal disorders, genders, and training program on preventing work-related musculoskeletal disorders. it is recommended that training programmes on prevent work-related musculoskeletal disorders be implemented for all nurses. keywords: musculoskeletal disorders; work-related musculoskeletal disorders; erbil; low back disorder. salih ahmed abdulla; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: salih.ahmed@nur.hmu.edu.krd) 42 erbil journal of nursing & midwifery received: 15/9/2017 accepted: 14/11/2017 published: 5/5/2018 https://doi.org/10.15218/ejnm.2018.06 ejnm, vol. 1, no. (1), may, 2018 original article three or four times more often than in the general population *4+.nurses are at risk of wmsds due to their employment. hospital nursing tasks are generally composite and involve many physical activities that can lead to acute and chronic work related musculoskeletal disorders*5+.the main risk factors related to wmsds among nurses are extended hours of standing in the operation theatre; carrying and transporting patients; awkward posture; working without adequate breaks; numerous forward bending for dressing patients, i.v line insertions, and giving injections; and carrying heavy weights*4,6+. demographic characteristics and psychosocial factors such as age, gender, physical status, smoking, and workplace stress are also known to be important predictive variables*7+.decreasing risk factors is an important component of both treatment and prevention. however, the effects of rest time and physical activities on musculoskeletal symptoms and disability in worker populations have showed inconsistent results *8+. this study investigated the prevalence and risk factors of work-related musculoskeletal disorders (wmsds) among nurses in erbil teaching hospitals. the design of the study was quantitative cross sectional. it was conducted in the erbil city teaching hospitals in the kurdistan region of iraq. the hospitals included: hawler teaching hospital, rizgary teaching hospital, maternity and delivery teaching hospital, raparin paediatric teaching hospital, and the surgical specialty teaching hospital/cardiac centre. all of the nurses of the teaching hospitals who met the inclusion and exclusion criteria were the population of this study. two hundred and fifty six nurses were selected as samples from different units and wards and from different work shifts in the five hospitals. non-probability convenience sampling technique (also called accidental sampling) was used according to the following inclusion criteria: nurses who worked on all shifts according to the policy of the hospitals, nurses who work on different units and wards, both genders, and all categories of nurses (e.g. nursing school graduate, preparatory nursing graduate, institutional graduates and post graduates). data were collected through interviews by using a standardized questionnaire called the standardized nordic questionnaire for musculoskeletal symptoms *9+. the data gathered from the nurses at their work places did not affecting on their duties during the interview time. each nurse's interview took 10-15 minutes. the researcher gave examples when needed but did not assist in answering the questionnaire. the nurses’ agreement for participation in the study was obtained and the interview was carried out individually. the reliability of the standardized nordic questionnaire for musculoskeletal symptoms has been confirmed in various studies. dawson et al. (2009) reported that the questionnaire had demonstrated reliability results kappa values ranging from 0.88 to 1, and this questionnaire has been internationally validated. the data were analyzed with statistical package for social sciences (spss) version 21. frequencies, chi square test and fisher exact test were used for interpretation of the data. the probability values greater than 0.05 were considered statistically insignificant throughout the analysis. figure 1 shows the prevalence of work related musculoskeletal disorders among nurses in erbil teaching hospitals. the highest number of nurses who demonstrated wmsds was 175 (66.8%). table 1 shows the work-related musculoskeletal disorders (wmsds) experienced per each body methods 43 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2018.06 ejnm, vol. 1, no. (1), may, 2018 original article quarter (28.6%) had bmi between 25-29.9 (overweight); and 45% did not do regular physical exercise in comparison to the nurses who had wmsds were performed regular physical exercise (21.8%). the table also show that there is significant association between the prevalence of wmsds among nurses and gender (p-value = 0.05). the results show that there is no significant relationship between marital status and prevalence of wmsds. data analysis also shows that there is no significant association between the prevalence of wmsds among participant nurses and variables of smoking, exercise and bmi (p-value= 0.05). table 3 shows that 31.7% of the nurses who had wmsds had between 1-10 years’ experience in nursing, near to one fifth (19.8%) of them work in surgical ward, near to half (49.2%) were not having additional job, and 55.3% were not participated in any training toward preventing wmsds. the data finding shown in figure (1) identifies that during the last twelve months, the prevalence of work-related musculoskeletal disorders (wmsds) among nurses in erbil teaching hospitals in this study was 66.8%. this finding is in line region in the past twelve months. lower back disorder was reported by three quarters (75%) of the study sample, followed by 52% disorders reported in one or both knees. the lowest percentage (9%) of disorders was reported in the upper back region. table 2 shows that 29% of the nurses who had wmsds were between 30 to 39 years, 40.1% of the female nurses had wmsds in comparison to male nurses (26.7%). more than half (56.5%) of the study sample who had wmsds were married in comparison to 10.3% who were single. the highest percentage (37.4%) of the nurses who had wmsds had graduated from the institute of nursing of the nurses, who had wmsds 60.3% were non-smoker; more than a 44 erbil journal of nursing & midwifery figure 1: prevalence of the musculoskeletal disorders (msds) among nurses table 1: prevalence of the wmsds by the body regions body regions yes no total f (%) f (%) f (%) neck 80 (46) 95 (54) 175 (100) shoulders 69 (39) 106 (61) 175 (100) elbows 22 (13) 153 (87) 175 (100) wrists/ hands 63 (36) 112 (64) 175 (100) upper back 16 (9) 159 (91) 175 (100) lower back 131 (75) 44 (25) 175 (100) one or both hips/thighs 52 (30) 123 (70) 175 (100) one or both knees 91 (52) 84 (48) 175 (100) one or both ankles/ feet 20 (11) 155 (89) 175 (100) discussion https://doi.org/10.15218/ejnm.2018.06 ejnm, vol. 1, no. (1), may, 2018 original article with the results of a study done in ethekwini/south africa, when the researchers reported that the twelve months prevalence of wmsds among the nurses was also 67%,*10+, and also similar to one done in zambia (68.9%),*11+. however, the current study’s result is higher than those observed in canada (61%) *12+, and the united states (60%) *13+. the rate was lower than that in what was reported among nurses in brazil which was 93%*14+, among turkish nurses 90%*15+, and among iranian nurses was 89.9%*16+. the reason behind the different prevalence rate of wmsds in different countries/hospitals might be the differences in psychological and physical 45 table 2: association between socio-demographic characteristics of the nurses and wmsds erbil journal of nursing & midwifery variable wmsds p-value yes no total f (%) f (%) f (%) age groups 20-29 41 (15.6) 28(10.7) 69 (26.3) 0.13 30-39 76 (29) 34 (13) 110 (42) 40-49 34 (13) 20 (7.6) 54 (20.6) 50-59 24 (9.2) 5 (1.9) 29 (11.1) gender male 70 (26.7) 60 (22.9) 130 (49.6) < 0.001 female 105 (40.1) 27 (10.3) 132 (50.4) marital status single 27 (10.3) 22 (8.4) 49 (18.7) 0.05 married 148 (56.5) 65 (24.8) 213 (81.3) educational level school nursing 13 (5) 1 (0.4) 14 (5.4) 0.23 preparatory nursing 41(15.6) 18 (6.9) 59 (22.5) institutional nursing 98 (37.4) 53 (20.2) 151 (57.6) college of nursing 22 (8.4) 14 (5.3) 36 (13.7) post graduate nursing 1 (0.4) 1 (0.4) 2 (0.8) smoking status yes 17 (6.5) 12 (4.6) 29 (11.1) 0.32 no 158 (60.3) 75 (28.6) 233 (88.9) bmi (weight status) <18.5 (underweight) 52 (19.9) 27 (10.3) 79 (30.2) 0.21 18.5-24.9 (normal) 43 (16.4) 12 (4.6) 55 (21) 25-29.9 (overweight) 75 (28.6) 44 (16.8) 119 (45.4) 30-39.9 (obesity) 5 (1.9) 4 (1.5) 9 (3.4) physical exercise yes 57 (21.8) 29 (11) 86 (32.8) 0.90 no 118 (45) 58 (22.2) 176 (67.2) total 175 (66.8) 87 (33.2) 262 (100) https://doi.org/10.15218/ejnm.2018.06 ejnm, vol. 1, no. (1), may, 2018 original article environments. firstly, some hospitals have implemented the policy of “minimal manual lift” and use of devices to change the position of patients which helped to reduce the risk of musculoskeletal disorders *17+. secondly, the difference in the results may be related to sociodemographic characteristics, the range of disease conditions, work characteristics, job factors, practice settings, number of study participants, the availability of basic equipment, and the regular participation of the nurses in strategic training programs programs toward preventing of wmsds. many previous studies focused on several body regions due to the tendency of wmsds affecting more than two body parts. the current study sought to compare the prevalence of wmsds in all nine body regions, identified by the nordic questionnaire for musculoskeletal symptoms *9+. the current study revealed that the lower back disorder at 75% was the most prevalent region compared to other body regions followed by one or both knees at 52%, low back pain was the more prevalent on all units and across all nurse ranks, which was agreed with the several 46 erbil journal of nursing & midwifery discussion table 3: association between work-related factors with msds among nurses variable wmsds yes no total p-value f (%) f (%) f (%) years of experience 1 -10 83 (31.7) 45 (17.2) 128 (48.9) 0.02 11-20 43 (16.4) 31 (11.8) 74 (28.2) 21-30 36 (13.7) 11 (4.2) 47 (17.9) 31-40 10 (3.8) 0 (0) 10 (3.8) 41-50 3 (1.1) 0 (0) 3 (1.1) unit/ ward catheterization 3 (1.1) 2 (0.8) 5 (1.9) 0.7 consultation 12 (4.6) 8 (3.1) 20 (7.6) delivery unit 11 (4.2) 2 (0.8) 13 (5) emergency 16 (6.1) 7 (2.7) 23 (8.8) icu 29 (11.1) 15 (5.7) 44 (16.8) medical 24 (9.2) 7 (2.7) 31 (11.8) nicu 6 (2.3) 3 (1.1) 9 (3.4) surgical 52 (19.8) 27 (10.3) 79 (30.2) theatre 22 (8.4) 16 (6.1) 38 (14.5) dual employment yes 46 (17.6) 42 (16) 88 (33.6) < 0.001 no 129 (49.2) 45 (17.2) 174 (66.4) participation in training yes 30 (11.5) 25 (9.5) 55 (21) 0.03 no 145 (55.3) 62 (23.7) 207 (79) total 175 (66.8) 87 (33.2) 262 (100) https://doi.org/10.15218/ejnm.2018.06 ejnm, vol. 1, no. (1), may, 2018 original article prevalence of wmsds and training. the authors reported no conflicts of interest. *1+ national institute for occupational safety and health. musculoskeletal disorders and workplace factors: a critical review of epidemiologic evidence for workrelated musculoskeletal disorders of the neck, upper extremity, and low back. cincinnati (oh). (dhhs (niosh) publication no.(97b141) 1997 *2+ ministry of health, repetitive strain injury (rsi), work -related musculoskeletal disorders (msds), pain related to work. protocols of comprehensive health care of different complexity worker, brasilia: ministry of health, 2006. *3+ harcombe h, herbison gp, mcbride d, derrett s. musculoskeletal disorders among nurses compared with two other occupational groups. occup med; 2014, 64: 601–7. *4+ punnett l, wegman dh. work-related musculoskeletal disorders: the epidemiologic evidence and the debate. j electromyogrkinesiol,2004, 14:13-23. *5+ ando s, ono y, shimaoka m, hiruta s, hattovi y, hori f, et al. association of selfestimated workloads with musculoskeletal symptoms hospital nurses. occup environ med, 2000, 57: 211. *6+ da costa br, vieira er. risk factors for work-related musculoskeletal disorders: a systematic review of recent longitudinalstudies. am j. ind med. 2010;53 (3):285–323. *7+ lorusso a, bruno s, l’abbate n. musculoskeletal complaints among italian x-ray technologists,ind health, 2007,45, 705–8 *8+ hildebrandt vh, bongers pm,dul j, dijk fjhv, kemper hcg, the relationship between leisure time, physical activities and musculoskeletal symptoms and disability in worker populations. int arch occup environ health, 2000, 73:507–18. *9+ kuorinka, l., jonsson, b., kilbom, a., vinterberg, h., biering-sorensen, f., anderson, g. et al. standardised nordic questionnaires for the analysis of musculoskeletal symptoms,applergon, 1987, 18 (3): 233-7. *10+ babusisiwethandi evan kumalo, the relationship between work-related musculoskeletal disorders, absenteeism and visits to the staff clinic by nurses in an ethekwini district hospital, durban university of technology,2014,available:http://ir.dut.ac.za/ handle/10321/1255?show=full. *11+ loveness a. nkhata1, tonya m. esterhuizen1, seter siziya, peter d. c. phiri, esther munalula-nkandu, hastings shula. the prevalence and perceived contributing factors for work-related musculoskeletal disorders among nurses at the university teaching hospital in lusaka, zambia. sjph, 2015, 3(4): 508-513. available: http://www.sciencepublishinggroup.com/ journal/paperinfo.aspx?journalid previous studies. in addition, low back pain was the most prevalent body region in most of the previous studies. *18+. the present study shows that the most nurses with wmsds were those in their third decade of age, and there was no significant association between age categories and prevalence of wmsds (p-value = 0.130). the current study is in agreement with the findings of *19+, that there is no significant relationship between age and prevalence of wmsds within this population at (p-value 0.05) and it is also agreed with the reports of a study done among nurses in zambia *20+. the current study shows that 55.3% of the nurses who had wmsds were not participated in any training toward preventing injuries in comparison to only 11.5% of the nurses who also had wmsds but they were participated in training programs. this finding indicates that participation in training programs toward preventing wmsds by nurses may be a factor to decrease wmsds.the table also shows that there is a significant relationship between the prevalence of wmsds among participant nurses and their participation in training toward prevent wmsds at (pvalue = 0.03). the twelve months time period of wmsds in this study was 67%. lower back disorder demographic factors such as age, marital status, educational level, body mass index, smoking, and physical exercise performance did not predispose to an increase in the prevalence of wmsds. but some demographic factors such as gender were found have a strong relationship with the prevalence of wmsds.the prevalence of wmsds is higher among nurses who were not participated in any training strategies to prevent work-related musculoskeletal disorders (70%), and it found that there was a strong relationship between 47 erbil journal of nursing & midwifery conclusion conflicts of interest references https://doi.org/10.15218/ejnm.2018.06 ejnm, vol. 1, no. (1), may, 2018 original article *12+ yassi a, gilbert m, cvitkovich y. trends in injuries, illnesses, and policies in canadian healthcare workplaces, can j public health, 2005, 96:333–9. available:http://www.ncbi.nlm.nih.gov/ pubmed/16238148. *13+ trinkoff, a. m., lipscomb, j. a., geiger-brown, j., & brady, b. musculoskeletal problems of the neck, shoulder and back and functional consequences in nurses,am j ind med, 2002, 41, 170–8 available:http://www.ncbi.nlm.nih.gov/ pubmed/11920961. *14+ gurgueira gp, alexandre nm, corrêafilho hr: selfreported musculoskeletal symptoms among nursing personnel. rev lat am enfermagem 2003, 11:608– 613.avaiilable:http://bmcresnotes.biomedcentral. com /arti les/10.1186/1756-0500-7-61. *15+ tezel a. musculoskeletal complaints among a group of turkish nurses, int j neurosc,2005, 115:871–80 available:http://www.ncbi.nlm.nih.gov/ pubmed/16019580. *16+ barzideh m, choobineha,and tabatabaeis. job stress dimensions and their relationship to msds among iranian nurses. j. health system research, 2012, volume 8, number 7,1365-75.available:http://en. journals.sid.ir/viewpaper.aspx?id=348732. *17+ lusted mj, carrasco cl, mandryk ja and healey s. self-reported symptoms in the neck and upper limbs in nurses. applied ergonomics, 1996, 27(6):381–7 *18+ sheikhzadeh a, gore c, zuckerman jd, nordin m. 2009. perioperating nurses and technicians' perceptions of ergonomic risk factors in the surgical environment, appl ergon. 40:833-9. available: http:// www.ncbi.nlm.nih.gov/pubmed/19027099. *19+ altman, j.r. 2010. neck and shoulder pain in nurses working in seven wards of tygerberg hospital: quantifying the problem and exploring the risks (online). m. science, stellenbosch university. available: http://www.scholar.sun.ac.za/bitstream/ handle/10019. *20+ loveness a. nkhata1, tonya m. esterhuizen1, seter siziya, peter d. c. phiri, esther munalula-nkandu, hastings shula. 2015. the prevalence and perceived contributing factors for work-related musculoskeletal disorders among nurses at the university teaching hospital in lusaka, zambia. science journal of public health. 3(4): 508-13. available: http:// www.sciencepublishinggroup.com/journal/ paperinfo.aspx?journalid=. 48 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.10 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article effectiveness of distraction therapy on children’s pain perceptions during peripheral venous cannulation at pediatric teaching hospital in erbil city abstract introduction pain is a common experience for people in all societies around the world, and it is a necessary part of routine clinical care. today, pain is known as the fifth vital sign, and health professionals are recommended to monitor and manage it when caring for patients [1]. peripheral venous cannulation is the insertion of a vascular access device into a peripheral vein. it is a procedure in which the patient’s skin is wounded with a needle to allow insertion of a temporary plastic tube into a vein [2]. peripheral venous cannulation in pediatrics is one of background and objective: relief of pain is a basic need and right of all children; effective pain management requires health professionals to be able to apply a number of interventions to achieve optimal results. the current study aimed to discover the effects of distraction therapy on children’s pain perception during peripheral venous cannulation. methods: a quasi-experimental study was carried out at emergency unit of raparin paediatric teaching hospital in erbil city, iraq. data collection occurred from feb 22, 2016 to may 25, 2016. a non-probability purposive sample of 120 children who were undergoing peripheral venous cannulation are recruited for the study. data was collected through a questionnaire format and a standard observational checklist assessments of the face, legs, activity cry, and the console ability scale were used to assess the pain perception of child. a cartoon and animation video films were used by the researcher, as distraction therapy for the intervention group, while the control group received traditional routine care by the nurses. the statistical package for social science version 22 was used for data processing and statistical analysis such as frequency, percentage, mean, sd, f-test, paired t-test, chi-square and fisher exact test. results: the study found that the majority of children in the intervention group experienced mild discomfort and pain while the majority of children in the control group experienced severe pain or discomfort or both. the results revealed that there were very highly significant differences in the levels of pain perception between intervention and control groups. conclusion: application of distraction therapy could have a positive effectiveness for relieving pain among preschool age children during peripheral venous cannulation. keywords: cannulation, carton , pain perception , preschool, nurse. ari ahmed taha; cardiac center, erbil directorate of health, ministry of health, erbil, iraq. (correspondence: ariahmedtaha@gmail.com) norhan zeki shaker; department of nursing, college of nursing, hawler medical university, erbil, iraq. 75 erbil journal of nursing & midwifery received: 6/3/2018 accepted: 22/10/2018 published: 30/11/2018 https://doi.org/10.15218/ejnm.2018.10 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article the most distressing events and the most usually performed invasive procedures that the child may expose during his/her hospitalization or illness [3]. relief of pain is an essential need and right of all children, and in order to meet the pain management needs, health professionals must be willing to try a number of interventions to achieve optimal results [4]. to confirm adequate pain relief and to give the children a feeling of control over the situation, non-pharmacological techniques are broadly accepted as additional strategies that may be used independently or in addition to pharmacological methods [3]. distraction is one of the non-pharmacological and psychological strategies usually used for needle-related procedural pain in children [5]. pain is a stressful experience that is considered to be a global health problem, and children are vulnerable and under-served population. the emergency department itself is a very stressful place for children. it is essential to focus on the child rather than the procedure. untreated pain causes stress and can sensitize a child pain pathways making the feeling of pain worse. assessment of healthcare professionals, especially nurses, in this setting is necessary in order to reduce pain as much as possible, and also using appropriate methods for relieving pain to ensure a comfortable environment for intervention. this study aimed to find out the effect of distraction therapy on children’s pain perceptions during peripheral venous cannulation at emergency unit of raparin pediatric teaching hospital (rpth). unit in erbil city, kurdistan region, iraq. the present study was carried out at emergency unit of rpth. this hospital is located on the main street of shaqlawa and was established in 2005. the hospital consists of outpatient and inpatient departments. the inpatient department includes the emergency, surgery, and medical units. emergency department is consists of 80 beds. there were 14 nurses who were working in this unit; and divided into three shifts, morning, evening and night shift, there were seven nurses working in morning shift, three nurses in the evening shift and four nurses working in the night shift and each day more than 90 children from different developmental stages, accompanied with their parents attended this unit for peripheral venous cannulation. the target populations included children whose aged between two to six years old undergoing peripheral venous cannulation. 120 children were involved in this study including both genders. it was divided into two equal groups, with 60 participants in the intervention and 60 in the control group. children who were admitted to hospital and need peripheral venous cannulation. a verbal agreement was taken from the parents. the children with mental disabilities, cerebral palsy, autism, down syndrome, audibly handicapped (blindness deaf and dumb) or seriously ill were excluded from the study. the instrument of data collection consisted of the three parts: the first part was socio-demographic characteristic. a list of 16 items that covered demographical characteristics of children and parents including date of birth, gender, ethnicity, address, child attending a child care institution, history of previous cannulation, reason for admission, site of current cannulation, child’s order in the family, methods 76 erbil journal of nursing & midwifery a quasi-experimental design was used for conducting this study between the periods from november 2015 to november 2016. the study was carried out at emergency https://doi.org/10.15218/ejnm.2018.10 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article children in the intervention group were male and half of them were female, while 31 (51.7%) of children in the control group were female and 29 (48.3%) of them male. the majority of children 49 (81.7%) were kurd in both groups respectively. regarding the daycare centers attending, most children (90%) in intervention group and 52 (86.7%) in control group did not attend daycare centers and the highest percentage of children 44 (73.3%) and 52 (86.7%) had a previous history of cannulation in both intervention and control groups respectively. table 2 shows that the comparison between intervention and control groups regarding levels of pain. in the intervention group the highest percentage of children 33 (55%) had mild discomfort while in the control group, the highest percentage of children 34 (56.7%) had severe pain and/or discomfort. analysis detected the presence of very highly significant < 0.001 difference in the levels of pain perceptions between two groups. a comparison between intervention and control group in regard to pulse rate and oxygen saturation before and after cannulation in table 3. current result clarified that the mean and sd before cannulation were 114.62 ± 10.98 for pulse rate and 97.5 ± 1.31 for oxygen saturation in the intervention group while regarding control group it was found that 117.92 ± 15.89 for pulse rate 97.32 ± 1.38 for oxygen saturation. pulse rate 97.32 ± 1.38 for oxygen saturation. this result also indicates that the mean and sd after using cartoon or animation films and movies were 127.98 ± 16.62 for pulse rate and 97.02 ± 1.31 for oxygen saturation, whereas concerning to control group it was found that the mean and sd 148.83 ± 21.78 for pulse rate and 95.77 ± 2.3 for oxygen saturation. statistical significance difference was found considering pulse rate and oxygen saturation before and after distraction therapy (using cartoon or occupation of the mother and father, father’s and mother’s level of education, name of the cartoon or animation films or movies child chosen, cannulation completed with how many attempts. the second part was assessment of children’s pain by face, legs, activity cry, and the console ability (flacc) scale. and the third part was physiologic measurement (puls rate and oxygen saturation). the flacc scale is used for children who are two months to seven years of age and includes five categories of behavior face, legs, activity, cry, and console ability. the (flacc) pain scale presents a pain assessment scale between 0 and 10. in order to use the flacc scale, the researcher has to observe a child for one to five minutes [6]. each category the behavioral score (flacc) is scored on the 0–2 scale, which results in a total score of 0–10. zero means relaxed and comfortable, from 1–3 means mild discomfort from 4–6 means moderate pain, and from 7–10 means severe discomfort or pain or both [6]. the questionnaire has been validated by panel of eight experts in different fields. internal consistency of the study was obtained through applying of pearson correlation (r), it was 0.87. inter-rater reliability test were used to determine the reliability of the scale and questionnaire. frequency and percentage, mean and standard deviation, chi square, f-test, paired t-test, fisher exact test were used for analyze and determine the significant differences and association between control and intervention group and demographic characteristics. in the current study results, as revealed in table 1, the highest percentage (36.7%) of children in the intervention group were aged between 24 – 35 months, whereas 19 (31.7%) of children in the control group aged between 36 – 47 months. half of 77 results erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.10 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article 78 erbil journal of nursing & midwifery animation films and movies) p= < 0.001 respectively. the association between child’s socio-demographic characteristics and level of pain in intervention group is displayed in table 4. there was a significant association between age group and level of pain. regarding gender, it was found that there was a non -significant association between gender and level of pain. concerning ethnicity of the child and history of the previous cannulation, socio-demographic characteristics study groups (n= 120) intervention (n= 60) control (n= 60) no. % no. % age group / month 24-35 22 36.7 18 30 36-47 16 26.7 19 31.7 48-59 9 15 9 15 60-71 11 18.3 12 20 over 72 2 3.3 2 3.3 gender male 30 50 29 48.3 female 30 50 31 51.7 ethnicity kurd 49 81.7 49 81.7 arab 6 10 7 11.7 turekman 5 8.3 4 6.6 type of day care attended not attending day care centers 54 90 52 86.7 nursery 0 0 2 3.3 kindergarten 6 10 6 10 history of the previous cannulation no 16 26.7 8 13.3 yes 44 73.3 52 86.7 pain level groups p-value / f-test intervention control no. % no. % relaxed and comfortable 17 28.3 0 0 < 0.001 vhs mild discomfort 33 55 12 20 moderate pain 10 16.7 14 23.3 severe pain or discomfort or both 0 0 34 56.7 it was found that there was not any significant association between ethnicity and history of previous cannulation with level of pain in the intervention group. there were no significant associations between levels of pain and child’s socio-demographic characteristics such as age group, gender, ethnicity, and history of the previous cannulation respectively (table 5). table 1: children’s socio-demographic characteristics. table 2: comparison between intervention and control groups regarding levels of pain perception https://doi.org/10.15218/ejnm.2018.10 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article 79 table 3: comparison between physiologic measurement before and after cannulation for both intervention and control groups. erbil journal of nursing & midwifery groups pulse rate p-value / paired / t-test before cannulation mean ± sd after cannulation mean ± sd intervention 114.62 ± 10.98 127.98 ± 16.62 < 0.001 vhs control 117.92 ± 15.89 148.83 ± 21.78 < 0.001 vhs groups spo2 p-value / paired / t-test before cannulation after cannulation mean ± sd mean ± sd intervention 97.5 ± 1.31 97.02 ± 1.31 < 0.001 vhs control 97.32 ± 1.38 95.77 ± 2.3 < 0.001 vhs table 4: association between socio-demographic characteristics and level of pain in intervention group socio-demographic characteristics level of pain fisher’s exact test relaxed and comfortable mild discomfort moderate pain no. % no. % no. % age group / months 24-35 2 3.3 13 21.7 7 11.7 0.034 s 36-47 5 8.3 11 18.3 0 0 48-59 3 5 5 8.3 1 1.7 60-71 6 10 3 5 2 3.3 over 72 1 1.7 1 1.7 0 0 gender male 11 18.3 15 25 4 6.7 0.342* ns female 6 10 18 30 6 10 ethnicity kurd 16 26.7 27 45 6 10 0.259 ns arab 1 1.7 3 5 2 3.3 turkmen 0 0 3 5 2 3.3 history of the previous cannulation no 4 6.7 10 16.7 2 3.3 0.765 ns yes 13 21.7 23 38.3 8 13.3 https://doi.org/10.15218/ejnm.2018.10 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article *fisher’s exact test was used. 80 erbil journal of nursing & midwifery table 5: association between child’s socio-demographic characteristics and level of pain in control group socio-demographic characteristics control group mild pain moderate discomfort severe pain or discomfort or both p_ value no. % no. % no. % age group 24-35 2 3.3 5 8.3 11 18.4 0.066*ns 36-47 2 3.3 3 5 14 23.4 48-59 3 5 1 1.7 5 8.3 60-71 5 8.3 3 5 4 6.7 over 72 0 0 2 3.3 0 0 gender male 4 6.7 6 10 19 31.7 0.363 ns female 8 13.3 8 13.3 15 25 ethnicity kurd 11 18.3 10 16.7 28 46.7 0.631*ns arab 1 1.7 2 3.3 4 6.7 turekman 0 0 2 3.3 2 3.3 history of the prevous cannulation no 2 3.3 3 5 3 5 0.471*ns yes 10 16.7 11 18.3 31 51.7 results show that the highest percentage of children were between the age 24 35 months in the intervention group and 36 -45 months in control group. this finding was in contrast with a study of gupta et al 2014 who carried out a quasi-experimental study for 70 children admitted to pediatric ward of guru go bind singh medical hospital, faridkot, india, which assessed and compared the analgesic effect of holding the child by a family member versus holding the child by a family member along with an animation distraction intervention on the level of pain perception during venipuncture in children up to seven years of age, and found that 37.14% were from age 60 – 71 months and over [7]. concerning the gender of children, the findings of the present study shows that children who admitted for cannulation have equal number for both male and female in both groups. this result are supported by a study in china which found that most children admitted for cannulation were female [8 ]. but, discussion https://doi.org/10.15218/ejnm.2018.10 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article venepuncture. this study found that there was significantly less pain score at pre, during and post venipuncture with the animated cartoon as distraction strategy as compared to the routine group [12]. the current study also corresponds with wang et al. (2008), which reported that there was a significant difference between the intervention and control group [13]. these results are contradicted with another study that showed that audio music distraction did not result in a reduction of pain, anxiety or uncooperative behavior during dental procedure on young children [14]. the study results revealed that there was a very highly significant association between the physiologic measurement of pulse rate and oxygen saturation before and after cannulation in both intervention and control groups. this is indicated that the painful stimuli had special effects on the child physiologically, especially on the heart rate and oxygen saturation, even they assigned to cartoon or animation films and movies. the results from a study conducted in china are in disagreement with the current study. in the china study, participants in the virtual reality distraction group had lower pulse rate during medical procedures compared to the control group. however, the difference in oxygen saturation between the two groups was not significant [8]. furthermore, another study also disagrees with the results of the current study, and that study identified no differences between groups for pre-procedural or procedural mean of pulse rate or oxygen saturation (p > 0.05) [15]. most of children had mild discomfort in the age group of 24 – 35 months with a significant association between level of pain and child’s age in the intervention group. children in this age group had better interaction with the cartoon films. this contradicts with a study carried out by canbulat et al. (2015) which found that the majority of children were male in both groups [9]. the results of the current study is in contrast with the study carried out in india by gandhar et al 2015 and stated that the majority of children were male in both groups [10]. according to the history of the previous cannulation, the current study revealed that the majority of children had a history of the previous cannulation. the present study is in agreement with the study from 2015, which found that most of the children had exposure to same painful procedures [4]. the current study revealed that more than half of children have mild discomfort in the intervention group, while more than half of the children have severe pain or discomfort or both in control group. there were statistically very highly significant differences in the level of pain between intervention and control group. that’s to say, most of children in intervention group focused on the tv and they were inattentive from the procedure during cannulation and the distraction were effective in relieving pain and making children inattentive. this result is supported by a research from 2016, which indicated the efficacy of distraction with videos in reducing anxiety and pain in children subjected to venipuncture in pediatric emergency and found a presence of a significant difference between the video distraction group and the control group. it also showed that moderate and severe pain was more frequent in the control group than in the video distraction group [11]. another study conducted in india assessed the effectiveness of animated cartoons as a distraction strategy to reduce behavior response to perception of pain among children of three to six years old who were undergoing 81 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.10 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article pain. results are compatible with one study that found that gender was not significantly association with the level of pain [18]. more than half of children in this study had a history of the previous cannulation with no significant association between the history of previous cannulation and child’s level of pain in control group. this result is in agreement with other research finding which showed that there was no significant association between the level of pain and history of previous venipuncture [16]. whereas it is in contrast with the study which revealed that children who had a history of the previous hospitalization had an increased perception of pain and distress during the current hospitalization [3]. there is no conflict of interest. the author expresses gratitude for the raparin pediatric teaching hospital staff for their support through data collection, especially mr. fadhil h. abdulla. [1] sadeghi t, mohammadi n, shamshiri m, bagherzadeh r, hossinkhani n. effect of distraction on children's pain during intravenous catheter insertion. journal for specialists pediatric nursing . 013; 18(2): 109-10. available from: doi: https:// doi.org/10.1111/jspn.12018. [2] jackson a. reflecting on the nursing contribution to vascular access. british journal of nursing. 2003; 12 (11): 657. available from: doi: the result of the present study is supported by a quasi-experimental study by james et al. (2012), which found that the age increases the perception of pain decreases suggesting that there is an inverse relationship of pain responses with the age [12]. other research disputes the current study’s findings including one that used cartoon distraction to reduce venipuncture pain among preschoolers and found no significant association between level of pain and child’s age [16]. researchers recommended further studies about the differences between kurdi and children from another cultures. regarding the gender of the child in the intervention group, the majority of children had mild discomfort, and it showed no significant association between level of pain and child’s gender. researchers thinks this is related to the child raring patterns in the family which encourage children for bearing of pain. the current study is in agreement with other study findings which revealed that gender was not influenced the perception of pain [3, 17]. concerning the history of the previous cannulation in the intervention group, the majority of children had mild discomfort in the intervention group with no significant association between the child’s previous cannulation and level of pain. the result is in agreement with the quasi-experimental study that found that there was no significant association between the level of pain and previous venipuncture [16]. the majority of children who had severe pain and/or discomfort with no significant association between the age and their level of pain. these results are in agreement with prior research [10] and are in disagreement with other research [3]. concerning the control group, the highest percentage had severe pain and/or discomfort and there was no significant association between gender and level of 82 erbil journal of nursing & midwifery conflicts of interest acknowledgment: references: https://doi.org/10.15218/ejnm.2018.10 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article [9] canbulat n, ayhan f, inal s. effectiveness of external cold and vibration for procedural pain relief during peripheral intravenous cannulation in pediatric patients. pain managment nursing. 2015; 16 (1): 33-7. [10] gandhar s s, deshpande j, borude s. effectiveness of cartoon movies as distracter on pain among children undergoing venipuncture. international journal of science and research. 2016; 5(6): 2241-2242. [11] miguez-navarro c, guerreromarquez g. video-distraction system to reduce anxiety and pain in children subjected to venipuncture in pediatric emergencies. pediatric emergency care med open access. 2016; 1(1): 1-4. [12] james j, ghai s, rao k, sharma n. effectiveness of” animated cartoons” as a distraction strategy on behavioural response to pain perception among children undergoing venipuncture. nursing and midwifery research journal. 2012; 8(3): 20007. [13] wang z-x, sun l-h, chen a-p. the efficacy of non-pharmacological methods of pain management in school-age children receiving venepuncture in a paediatric department: a randomized controlled trial of audiovisual distraction and routine psychological intervention. swiss medical weekly. 2008; 138(3940): 579-84. [14] aitken j c, wilson s, coury d, moursi a m. the effect of music distraction on pain, anxiety and behavior in pediatric dental patients. pediatric dentistry. 2002; 24(2): 114-17. [15] miller k, rodger s, bucolo s, greer r, kimble r m. multi-modal distraction. using technology to combat https://doi.org/10.12968/ bjon.2003.12.11.11315 [accessed: 30th december 2015]. [3] kaur b, sarin j, kumar y. effectiveness of cartoon distraction on pain perception and distress in children during intravenous injection. journal of nursing and health science. 2014; 3(3): 8-9, 13. [4] abd el-gawad s m e-k, elsayed l a. effect of interactive distraction versus cutaneous stimulation for venipuncture pain relief in school age children. journal of nursing education and practice. 2015; 5(4): 32-38. available from: https:// doi.org/10.5430/jnep.v5n4p32 . [5] bagheriyan s, borhani f, abbaszade a, tehrani h. non-pharmacological interventions for needle-related procedural anxiety in children with thalassemia. iranian journal of blood and cancer. 2013; 5(4): 124. [6] voepel-lewis t, malviya s, merkel s, tait a r (2003). behavioral pain assessment and the face, legs, activity, cry and consolability instrument. expert review of pharmacoeconomics & outcomes research; 3(3): 317-20. [7] gupta h v, gupta v v, kaur a, singla r, chitkara n, bajaj k v, et al. comparison between the analgesic effect of two techniques on the level of pain perception during venipuncture in children up to 7 years of age: a quasi-experimental study. journal of clinical & diagnostic research . 2014; 8(8): 1-4. [8] hua y, qiu r, yao w-y, zhang q, chen x-l. the effect of virtual reality distraction on pain relief during dressing changes in children with chronic wounds on lower limbs. pain managment nursing . 2015; 16 (5): 685-90.[28th september 2015]. 83 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.10 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article pain in young children with burn injuries. burns. 2010; 36(5): 647-8. [16] labo m r, umarani j (2013). cartoon distraction reduces venipuncture pain among preschoolers – a quasi experimental study. international journal of scientific research ; 2(6): 454 55. [17] cerne d, sannino l, petean m. a randomised controlled trial examining the effectiveness of cartoons as a distraction technique. nursing children and young people. 2015; 27(3): 28-33. [18] windich-biermeier a, sjoberg i, dale j c, eshelman d, guzzetta c e. effects of distraction on pain, fear, and distress during venous port access and venipuncture in children and adolescents with cancer. journal of pediatric oncology nursing . 2007; 24(1): 8-19. 84 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.08 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article immediately postpartum care among nurses/midwives in rania city abstract introduction during first hours after delivery many physiological changes occur that require close observation and monitoring to prevent unwanted complications to the mother as well as neonates. therefore, the quality of care during immediately postpartum is a vital key to prevent complications and any life-threating consequences. lasting up to four hours, it is clear that in the last stage, the uterus makes its initial process to readjustment to non-pregnant state. actions undertaken by the health care staff are crucial to maintain of the quality of the woman’s physical and psychological well-being post-delivery [1]. interventions by nurses and midwives to prevent maternal and neonatal morbidity and mortality are essential for optimum quality of health services.[2] background and objective: the first hours after childbirth are considered risky for mother and newborn, with many deaths occurring during or immediately after childbirth. quality of care provided to mother and newborn after birth is important for the prevention of postpartum complications as well as neonatal and maternal morbidity and mortality. this study aimed to determine the knowledge and practice of nurses-midwives regarding care immediately after birth and to explore the relationship between nurses/midwives’ socio demographic characteristics with overall their level of knowledge and practice. methods: a descriptive study was conducted with all nurses and midwives (n=22) who worked in delivery room of maternity teaching hospital in rania city, from july 15, 2016 to december 20, 2017. a questionnaire and a checklist was designed to capture quality of care immediately after birth. the data were collected through interview and observation. frequency, percentage and chi-square test were used for analyzing the data. results: the results of the study revealed that the overall nurses/midwives ’ knowledge and practice regarding immediately post-delivery was good. in addition, the study results showed that there was no significant relationship with socio-demographic characteristics of nurse/midwives with the quality of immediately postpartum care. conclusion: the overall knowledge and practice of the nurses/midwives regarding some basic immediate postpartum care where acceptable. a comprehensive training courses regarding standard immediately postpartum care is recommended. keywords: quality of care, nurses, midwives. renas mohammed khdir; department of maternity nursing, college of nursing, raparin university. (correspondence: renas.mohamed@gmail.com sanaa hassan abdul-sahib; department of community nursing, college of nursing, raparin university. 57 erbil journal of nursing & midwifery received: 2/1/2018 accepted: 22/10/2018 published: 30/11/2018 https://doi.org/10.15218/ejnm.2018.08 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article all health care staff should be actively involved to provide appropriate quality of care. all must have adequate knowledge and clinical care expertise because the needs of mothers are need different based on their ethnicity, cultural background, and their living environment. the immediately postpartum period starts roughly one hour after the delivery of the placenta and includes the following 24 hours. postpartum care should respond to the special needs of the mother and baby include: the prevention and early detection and treatment of complications and disease, and the provision of advice and services on breastfeeding, birth spacing, and maternal nutrition. during the first hours after the birth, the care-giver must ensure that the uterus remains well contracted and that there is no heavy loss of blood.[3] nurses/midwives have an important enabling role to assist the woman during childbirth. as a result, they require high knowledge and interpersonal skills to deliver care to the mother and her newborn baby immediately postpartum. in addition, it is known that nursing services are the backbone for health care system in almost of the countries in the world. this study aimed to assess the knowledge and practice of nurses/midwives working in the delivery room at maternity teaching hospital in rania city regarding immediate postpartum care. a descriptive study was carried out from july 15, 2016 to december 20, 2017 with 22 nurses and midwives of delivery room in maternity teaching hospital, which has 50 beds. this hospital services four towns and 40 villages. all of nurses and midwives who work in delivery room were involved in the study. two study tools was used for data collection. the first questionire format which included socio-demographic data and knowledge of nurses and midwives regarding immediately postpartum care. the second tool included an observation check list of practice of nurses and midwives regarding immediately postpartum care. four experts in the field reviewed the questionnaire are and checklist who suggested changes in some items in order to improve internal validity of the tool. a pilot study was carried out to acquire the reliability of the questionnaire was determined through the use of split-half approach of the computation of cronbach's alpha correlation coefficients, on ten midwivesnurses and they were excluded from the original sample. the result of correlation was (r=0.81) for the entire questionnaire. all nurses and midwives were observed by researcher during immediate postpartum care and their knowledge were assessed through 30 minutes interviews. knowledge was assessed through a questionnaire with 24 items in which there were two responses: yes (correct answer) and no (incorrect answer). each correct answer counted for two points and incorrect answers were worth one point. knowledge level was divided to three groups: good (40-48 points), fair (32-39 points), and poor (2431 points). practice of the nurses/midwives was collected through observation of 21 items on a checklist, in which items were either observed to be accomplished or not. each item that was practiced by the nurses/midwives counted for two points and each item that was not practiced was worth one point. the practice levels were divided to three groups: good (35-42 points), fair (28-34 points) and poor (21-27 points). the proposal of the study was approved by scientific committee of college of nursing/raparin university. the formal permission methods 58 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.08 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article was given by administration of the hospital. informed consent was taken from nurses/midwives for participation in the study after explaining the purpose of the study. data were inserted into and analyzed by statistical package for the social sciences (spss) version 21. statistical analyses included frequency, percentage, correlation coefficient, and chi-square test. 59 results erbil journal of nursing & midwifery practice, generally they were good in all care which they had had knowledge about that except following care: checking the perineum for any laceration and tear, assessing maternal comfort and maternal intake and encourage intake (table 4). twenty-two nurses/midwives were involved in this study. half of the study sample aged between 25-34 years old (35.68±8.63). most (45.4%) had 6 to 14 years of experience working. half of the graduates graduated from a nursing institute. the majority of them were married. sixty-eight percent had not ever received training regarding postpartum care (table 1). nearly all nurses/midwives had correct knowledge regarding following immediate postpartum care: uterus massage after delivery, giving oxytocin to mother to prevent bleeding, containing of vaginal blood from clots, empting bladder, putting identification band for newborn immediately before cutting the cord, newborn mouth suction, drying the baby, covering head, encourage mother to breastfeeding and importance of skin to skin contact. however, they had no any information regarding following: mothers’ needs to nutritional and intake fluid support, individualized care is necessary for mother's care, checking vital signs, checking vaginal discharge every 15 minutes, or the 4th stage of labor as the most risky time for postpartum hemorrhage (table 2). only seven nurse/midwives had good overall knowledge and rest had fair knowledge regarding immediate postpartum care (table 3). regarding nurses/midwives characteristics f % age group 25-34 11 50 35-44 6 27.3 45-54 5 22.7 m ± sd = 35.68 ± 8.63 years of experience ≤ 5 8 36.4 6-14 10 45.4 ≥ 15 4 18.2 level of education primary school of nursing graduates 1 4.5 secondary school of nursing graduate 7 31.8 nursing institute graduate. 11 50 college of nursing graduates 3 13.7 marital status single 4 18.2 married 18 81.8 separated 0 0 divorced 0 0 widow/widower children 0 0 have you training course for immediate postpartu m care yes 15 68.2 no 7 31.8 table1: sociodemographic characteristics of the study sample https://doi.org/10.15218/ejnm.2018.08 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article 60 erbil journal of nursing & midwifery table 2: nurses/midwives’ knowledge regarding immediate postpartum care items yes no f % f % 1-4th stage of labor begins after delivery of placenta 7 31.8 15 68.2 2-4th stage of labor is the most risky time for postpartum hemorrhage 0 0 22 100 3-4th stage lasts for 48hours after delivery. 12 54.5 10 45.5 4-checking vital signs 0 0 22 100 5-uterus massages after delivery of placenta help the uterus to well contract 22 100 0 0 6-fundal height of uterus it above the umbilical cord after birth 17 77.3 5 22.7 7-oxytocin is given to mother to prevent bleeding 20 90.9 2 9.1 8-vaginal blood contains small clot and mucus after birth 22 100 0 0 9-bladder empty after birth decrease of bleeding occurrence 22 100 0 0 10-breast feeding initiate after two hours of birth. 14 63.6 8 36.4 11-all mother encouraged to breast feed after birth. 21 95.5 1 4.5 12-breast feeding increase immunity of newborn baby 22 100 0 0 13-breastfeeding s the best way to maintain newborn body temperature 22 100 0 0 14-skin to skin contact between mother and newborn baby occur after one hour 21 95.5 1 4.5 15-skin contact skin is important for breast feeding 22 100 0 0 16-skin to skin contact is important for prevention of newborn heat loss 22 100 0 0 17-checking vaginal discharge every 15 minutes 0 0 22 100 18-each newborn baby needs suction with bulb syringe 17 77.3 5 22.7 19-the newborn babies dried immediately after birth to prevent heat loss 22 100 0 0 20-is important to cover the head of newborn after birth 21 95.5 1 4.5 21-mothers need to nutritional and intake fluid support 0 0 22 100 22-individualized care is necessary for mother's care 0 0 22 100 23-identification band put immediately before cutting the cord 20 90.9 2 9.1 24-the band should include mother name only 18 81.8 4 18.2 overall knowledge f % good 7 31.8 fair 15 68.2 poor 0 0 total 22 100 table 3: overall nurses/midwives’ knowledge regarding immediate postpartum care https://doi.org/10.15218/ejnm.2018.08 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article table 5: overall practice of nurses/midwives regarding immediate postpartum care 61 table 4: nurses/midwives’ practice regarding immediate postpartum care erbil journal of nursing & midwifery items not done done f % f % 1-wash hands during contact with mother. 4 18.2 18 81.8 2-wearing gloves, cup, gown. 2 9.1 20 90.9 3-inspect placental membrane 2 9.1 20 90.9 4-uterus massage after delivery of placenta. 2 9.1 20 90.9 5-observe vaginal discharge. 3 13.6 19 86.4 6-check perineum for any laceration and tear. 22 100 0 0 7-monitore mother vital signs. 2 9.1 20 90.9 8-encourage the mother to empty bladder. 2 9.1 20 90.9 9-encourage the mother to initiate breast feeding 30 min. after birth 2 9.1 20 90.9 10-put the newborn skin to skin contact. 2 9.1 20 90.9 11-hand washing during contact with newborn baby. 2 9.1 20 90.9 12-using sterile instrument with newborn baby 2 9.1 20 90.9 13-cleaning air way. 7 31.8 15 68.2 14-suction the secretion from the mouth and nose. 5 22.7 17 77.3 15-dry and covering the baby with clean towel. 2 9.1 20 90.9 16-assess for maternal comfort 22 100 0 0 17-assess maternal intake and encourage intake 22 100 0 0 18-weighting of newborn. 6 27.3 16 72.7 19-taking newborn temperature. 7 31.8 15 68.2 20-put tag on the baby's hand. 8 36.4 14 63.6 21-record mother name, sex of baby, date on the tag 5 22.7 17 77.3 overall practice f % good 13 59.1 fair 7 31.8 poor 2 9.1 total 22 100 https://doi.org/10.15218/ejnm.2018.08 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article 62 erbil journal of nursing & midwifery table 6: association between nurse/midwives’ knowledge with their socio characteristics knowledge sociodemographic attributes fair good p-value fisher’s exact test f % f % age group 25-34 3 27.3 8 72.7 0.511 ns 35-44 3 50 3 50 45-54 1 20 4 80 years of experience ≤ 5 3 37.5 5 62.5 0.896 ns 6-14 3 30 7 70 ≥ 15 1 25 3 75 level of education primary school of nursing graduates 0 0 1 100 0.323 ns secondary school of nursing graduate 3 42.9 4 57.1 nursing institute graduate 2 18.2 9 81.8 college of nursing graduates 2 66.7 1 33.3 marital status single 0 0 4 100 0.131 ns married 7 38.9 11 61.1 training course regarding postpartum care yes 3 20 12 80 0.081 ns no 4 57.1 3 42.9 knowledge and practice of 22 nurses/ midwives were assessed regarding immediate postpartum care. the results of the present study show that nurses/ midwives generally had fair knowledge and practice regarding those immediate postpartum care which are essential but not standard care. the fourth stage of labor arbitrarily lasted approximately two hours after delivery of the placenta. this is the period of immediate recovery when homeostasis is re-established and it serves as an important period of observation for complications such as abnormal bleeding [4]. according to the results of the present study nurses/ midwives did not check vital signs, status of perineal area, and comfort level. in fact, this is perfomed by physicians.. during the first hour after birth, vital signs are taken every 15 minutes then every 30 minutes for the next hour if needed [5-8]. assessment of vaginal discharge (lochia) occurs every 15 minutes for the first hour and every 30 minutes for next hour, with palpating the fundus at the same time, to ascertain its firmness and help to estimate the amount of vaginal discharge [9]. these results agree with results of nuriy and ahmed (year) [10] who conducted a study on 15 nurses/midwives in the erbil maternity teaching hospital to assess quality of nursing care during labor. they found that necessary practices and intervention for postpartum mother were not completed by all nurses/ midwives. the findings of the present study are almost similar with the result of previous study conducted in discussion https://doi.org/10.15218/ejnm.2018.08 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article employed to increase awareness. providing regular training courses, especially outside the country, on the importance of nursing care and quality of nursing care is important. improving the knowledge of midwives and nurses will improve the quality of care in the hospital. the ministry of health should increase the number of midwives and nurses that are working in delivery and recovery room to provide the best quality of care. khartoum, to assess midwifery and nursing care for patient with episiotomy, which concluded that no midwives gave the mother advice about pain relief, they did not give advice about hygiene or food intake, and they did not observe for complications after episiotomies in the first two hours [11]. the results also agree with results of nuriy and ahmed because there is no significant association between practice of nurses/midwives and their level of education and taking training course [10]. good practices by nurses/midwives should beare routine care for all mothers and newborn. incomplete and substandard immediate postpartum care by nurses/ midwives in this study may be due to an abscene of hospital policies, guidelines, and protocol for care in the delivery room regarding postpartum care. it may also be due to not having proper, up-to-date, and continuous training courses on postpartum care. it may also be due to lack of clear job descriptions and poor commitment of health care providers in the delivery, as well as a lack of follow-up policies by administrative of the hospital in cases of substandard care. limitation of the present study include the fact that is it a one-time observation of the nurses/midwives during immediate postpartum care. 63 erbil journal of nursing & midwifery conclusions the overall knowledge and practice of the nurses/midwives regarding some basic immediate postpartum care were acceptable. a comprehensive training course regarding standards for immediate postpartum care is recommended for all nurses and midwives in the delivery room. it is recommended that continuous training through regular educational program for those nurses in delivery room in maternal child health hospital be conflict of interest the authors report no conflict of interests. references [1] abdelkareem, s., factor affecting the quality of nursing care in intensive care unit: perception of physicians and nurses versus health care consumers. (master thesis). cairo: ain shams university; 2008. [2] hoda, m. saving lives of mother and babies (an assessment on nurse's midwives knowledge in bangladesh) an assessment skilled birth attendant's knowledge in bangladesh, university of gothenburg. (2012). [3] steven ed, jennifer ed. niebyl, joe ed. simpson. obstetrics: normal and problem pregnancies. 4th ed. newyork: churchill living stone; 2002. [4] basavanthappa, b.t. textbook of midwifery and reproductive health nursing. 2nd ed. new delhi: jaypee brothers medical publishers;2006. [5] hacker n., moore j., gambone j. essential of obstetrics and gynecology. 4th ed. china: elsevier;2015. [6] london m, ladewig p, ball j, & bindler r. maternal and child nursing care. 2nd ed. new jersey: pearson;2007. [7] cunningham fg, leveno k, bloom s, hauth j, gilstrap l, & wenstrom k. williams obstetrics. 23rd ed. usa: mcgraw-hill companies;2009. https://doi.org/10.15218/ejnm.2018.08 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article [8] world health organazation. pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. 3rd edition. 2015 [9] ladewig pw, london ml, davidson mr. contemporary maternal – newborn nursing care. 6th ed. new jersey:pearson education; 2006. [10] nuri la, ahmed hm. nurse/midwives’ practices during labor and delivery in maternity teaching hospital in erbil city. erbil journal nursing midwifery.2018;1 (1):23-30. [11] khaier mgm. assessment of midwifery and nursing care for patients with episiotomy in albanjadeed teaching hospital. thesis , univerisity of medical sciences and technology,2006. 64 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.07 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article body fat percentage and body mass index for students and staff of the college of nursing/ hawler medical university abstract introduction health status depends much on body composition status therefore its frequent measurement is necessary for the health and fitness of all including general population, athletes, and children [1]. studies have found that there is direct correlation between body composition and health continuum in all levels ranging from mortality and morbidity, to immunity status, longevity, and athletic performance for both genders and for all ages. body composition is the ratio of fat and fat free mass (ffm). in human body fat percentage can be determined by dividing fat mass per kilo gram (kg) or deciliter (dl) by the whole body mass weight per kg or dl [2-4]. body mass index (bmi) is simple method for defining body weight and obesity and it's widely used for all age categories and for both genders [5]. bmi is calculated by dividing weight in kilogram by height in meter square (the unit is kg/m2)[6,7]. although the bmi method has some benefits because it's easy, safe, inexpensive, and able to gather data from a large number of respondents through screening, bmi measurements can be considered scientifically deficient because the method cannot measure fat percentage, which is the opposite of other methods including bioelectrical impedance background and objectives: the finding of an association between health and body composition mandated the necessity for frequent testing of body composition for all. these studies aimed to analyses body fat percentage and body mass index and identify the relationship between results of both tests for nursing students and staff working in the college of nursing, hawler medical university. methods: in this study two samples were recruited: 158 students (111 females and 47 males) and 112 staff (51 females and 61 males). body weight was measured and body mass index was determined. body fat percentage was measured by omron hbf 306 cn. the data were analyzed by social package for social sciences version 22, t-test and correlation coefficients were used (p value≤ 0.05 was considered significant). results: mean body mass index of students in both genders were within normal range (23.4 for male and 22.9for female), while that of the staff in both genders was in the overweight range (27.2 for male and 28.4 for female). the mean body fat percentage in students was normal in both genders, while that of the staff was high. there is proportion of low body fat percentage and absence of very high body fat percentage in students against considered proportion of very high body fat percentages in staff; also the levels of body mass index were inconsistent with the levels of body fat percentage in both samples. there was statistically significant moderate positive correlation between body mass index and body fat percentage in both samples. conclusion: body mass index could not indicate the same body fat percentage. keywords: body mass index, adipose tissue, association, iraq ibrahim hasan mustafa ; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: ibrahimzmar@yahoo.com ) 50 erbil journal of nursing & midwifery received: 11/3/2018 accepted: 9/9/2018 published: 30/11/2018 mailto:ibrahimzmar@yahoo.com https://doi.org/10.15218/ejnm.2018.07 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article analysis (bia)[8-10]. there are several methods for measuring body fat percentage like skin fold method, anthropometric measurement, dual energy x-ray, bioelectrical impedance analysis (bia), among others [11]. bia is widely used by researchers and clinicians to estimate fat percentage for all age categories [5]. bia depends on special scale or device. the process measures body resistance for electrical current through sending small un harmful amount of electrical current (50hz) through the body either from hand to hand or leg to leg, depending on the type of device [1,12]. bia device can measure body resistance for electrical current which help to estimate body water, fat free mass, and body fat ratio [13]. the method has several advantages because it is easy, fast, painless, safe, inexpensive, requires minimal skill scan be used for healthy individuals and for some chronic conditions such as mild to moderate obesity, diabetes mellitus, and for other health problems which have not water distribution problems in body [12,14]. the bia method is used to identify body composition not for identifying therapy or treatment regimens [12]. the process depends on entering data related to body resistance, reactance, age, height, weight, and sex of participant's in the reputation (or device) [15]. there are many types of bia devices: hand to hand, finger to finger, knee to knee, and foot to foot and others [16,17]. according to the author’s knowledge, there have been no previous studies conducted in erbil to analyze body fat percentage. as a result, this study aimed to analyze body fat percentage and body mass index, and identifying relationships between the results of both measurements for students and staff of the college of nursing, hawler medical university. a cross-sectional study was conducted at the college of nursing, hawler medical university, erbil/ iraq from february 4 to may 4, 2017. in this study, the convenient sampling method was used to recruited 158 students (111 females and 47 males) and 112 staff (51 females and 61 males). students aged ≥ 20 years, from second, third and fourth years in nursing college, and from both departments, nursing and midwifery. all staff who worked during study period and gave consent for participating in study were included. those who had pacemaker or were using hydrocortisone drugs and pregnant women were excluded. the ages of participants were categorized in accordance with the recommended body fat percentage guidelines of the national institutes of health /world health organization (nih/who). which showed in methods 51 erbil journal of nursing & midwifery table1: interpreting the body fat percentage result* very high high normal low age gender 39.0≥ 33.0-38.9 21.0-32.9 <21.0 20-39 female 40.0≥ 34.0-39.9 23.0-33.9 <23.0 40-59 42.0≥ 36.0-41.9 24.0-35.9 <24.0 60-79 very high high normal low age 25.0≥ 20.0-24.9 8.0-19.9 <8.0 20-39 male 28.0≥ 22.0-27.9 11.0-21.9 <11.0 40-59 30.0≥ 25.0-29.9 13.0-24.9 <13.0 60-79 * according to the recommended body fat percentage guidelines of the national institutes of health / world health organization (nih/who). https://doi.org/10.15218/ejnm.2018.07 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article samples (students and staff p. values were 0.40 and 0.14 respectively) (table 2). *not applicable because body fat percentage natural is higher in women than men **age categories according to recommended body fat percentage for age and gender *** only one participant in male groups and one in female group were 60 year therefore there was no result of mean in this age group results show that the highest percentage (67.7) % of students had normal bmi, followed by 20.9% of them who were overweight. regarding bmi in staff in table 3 shows that the majority (55.4%) of the sample were overweight, followed by 22.3% who were obese, and 21.4% were of normal weight. the table shows that more tools and methods of data collection where through: i) anthropometric measurement: weight, height and bmi. the height was taken barefoot using tape measure in centimeters; it was recorded in to nearest millimeter. the weight was measured in kilograms, without shoes and wearing clothing, by a digital weighing scale. one kg was the estimated weight of the clothing and it was subtracted from whole body weight of each participant. checks on the scale were conducted routinely before recording the weight of each subject. the body weights were recorded when the display of body weight became stabilized. the bmi calculated was weight in kilogram /height in meter² and was used to assess the nutritional status of subjects. a bmi score lower than 18.5 indicated low body weight, a score between 18.5 and 24.9 was considered normal, a score between 25 and 29.9 was considered overweight, and a score of 30 or more was considered obese [18]. ii) bio-electrical impedance was used to determine body fat percentage and it was measured by omron hbf 306cn.the adopted recommendations for body fat percentages range are shown in table 1 [18]. the study was approved by the ethical committee of college of nursing, hawler medical university. all participants gave verbal consent after explaining the purpose of the study and anonymous were emphasized before participating in the study. the data were analyzed by social package for social sciences (spss version 22). frequency, percentage, means, t-tests, and correlation coefficients were used. a p value≤ 0.05 was considered significant. results show that there were no statistically significant difference between 52 results erbil journal of nursing & midwifery students t-test female (n=111) male (n=47) variables mean± s.d mean ±s.d 0.079 21.0±1.06 21.4±1.4 age 0.0001 57.8±9.8 69.8±9.7 weight 0.001 159.2±5.9 173.0±5.5 height 0.403 22.9±3.5 23.4±3. 2 bmi n/a* 24.4±5.9 13.57±5.7 body fat percentage staff t-test female (n=51) male (n=61) variables mean± s.d mean ±s.d 0.646 40.04±9.9 40.8±9.2 age 0.001 72.02±15.2 82.3±11.3 weight 0.001 159.1±5.9 173.6±6.2 height 0.141 28.4±5.4 27.2±2.9 bmi n/a* 34.5±6.4 24.9±5.0 body fat percentage mean ±s.d mean ±s.d age categories ** n/a* 31.7±7.1 37.7±3.6 46.6*** 22.7±5.3 26.7±3.9 30.7*** (20-39) (40-59) ≥ 60 table 2: study samples by gender, age, and body composition https://doi.org/10.15218/ejnm.2018.07 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article than half (54.4%) of students had a high body fat percentage followed by 38.6% who were of normal weight, and 7 % who had a low body fat percentage. regarding staff, those having normal body fat percentage constituted 25.9% of the sample, compared to 38.4% who had high and 33.9% who had very high body fat percentage (table 3). results shows that there was positive statistically significant correlation between bmi and body fat percentage in both samples students r=0.58, (p. value <0.0001), and staff r=0.59, (p_value<0.0001)(figure 1 and figure 2). figure 1: scatter plot between body mass index and body fat percentage for students figure 2: scatter plot between body mass index and body fat percentage for staff the mean bmi measurements of males and females in the student sample were normal according to who adult standards [19]. a study of carpenter et al. (2013), which involved 1029 students found that the mean of bmi of males and females were normal (24.4 kg/m2) (22.0 kg/m2) respectively and it's similar to american's bmi population [20]. among staff, the mean bmi in females was higher than that 53 table 3: study samples by body mass index and body fat percentage of nurses and team-leaders erbil journal of nursing & midwifery staff no. (%) students no. (%) bmi levels 1(0.9) 9(5.7) under weight 24(21.4) 107(67.7) normal (18.5-24.9) 62(55.4) 33(20.9) overweight (2529.9) 25 (22.3)* 9(5.7) obesity (30+) staff no. (%) students no. (%) body fat percentage levels 2(1.8) 11(7) low 29(25.9) 61(38.6) normal 43(38.4) 86(54.4) high 38(33.9) 112(100) 0(0.0) 158(100) very high total discussion https://doi.org/10.15218/ejnm.2018.07 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article of males, but results were not statistically significant. both means of males and females were overweight according to who standards [19].a study in nigeria, which sought to identify prevalence and overweight of staff working in university usmanu danfodiyo showed that the highest percentage (50%) of sample was top normal bmi (25± 4) according to who standards[21]. a study of kawamoto et al indicated that frequency of overweight and obesity were higher in elderly people [22]. the present study shows that the means of body fat percentage among students were normal in both genders, according to the recommended body fat percentage range for age and sex [18] table 1. carpenter et al. (2013) found that, in males, the mean of body fat percentage was normal among asian and white groups, while it was high among the hispanic group and other groups. in females, carpenter et al. (2013) found that the mean body fat percentage was normal in all groups [20]. our study findings are comparable. furthermore, weaver et al. (2009) ,sampled healthy adults aged18 to 32 years old and found that the mean body fat percentage was17.2 in males and 25.4 in females [23]. both of these measurements are normal according to the recommended body fat percentage for their age [18] table 1. this study shows that among staff, the mean body fat percentage was high in both groups of males, while for the females, it was above normal for one group and was high in the second group, according to recommended body fat percentage [18].pongchaiyakul et al. (2004) found that among436 participants in thailand, the mean body fat percentage was normal in males and females [24]. the present study shows that there was inconsistency between the bmi measurement and levels body fat percentage in both groups of people (students and staff). in students, those with normal bmi constituted the majority of the sample, while the majority of the sample had high body fat percentage. also7% of students had low body fat percentage, and absence of very high body fat percentage. in the staff group, the majority of people were overweight and obese according to their bmi measurements and they had high and very high in body fat percentage. there were differences between the proportions of levels in both tests. a study conducted at bowen university which involved a sample of 300 students showed that the highest ratio (73%) of bmi test was normal, followed by 12% was overweight. regarding body fat percentage, the highest percentage of people (41.3%) had normal body fat percentage, followed by 37.7% which had low body fat percentage [25]. a study carried out by akindele et al. in nigeria involved 1571 subjects (>18 years) from different ethnic groups residing in an urban setting results, and this study showed that there was consistencies between bmi levels and body fat percentages levels[26].result shows that there were moderate positive correlations between bmi and body fat percentage in both samples (students and staff). the study by akindele and his colleagues mentioned that there was strong positive correlation between body fat percentage and bmi, and age and sex are predictors of this association [26]. this present study demonstrated that there were no significant differences between females and males regarding bmi in both samples (students and staff). there were inconsistencies among levels of bmi and body fat percentages in both samples. there was a moderate significant positive correlation between bmi and body fat percentage in both samples. 54 erbil journal of nursing & midwifery conclusions https://doi.org/10.15218/ejnm.2018.07 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article the author report no conflict of interests. [1] ortansa io., ileana ga. the importance of body composition measurement at athletes and nonathletes.sports medicine j. 2006; 6(2). available from: http:// www.medicinasportiva.ro/sroms/ english/journal/no.6/the% 20importance%20of%20body% 20composition%20measurement%20at% 20athletes%20and%20non%20athletes% 20full.html. [accessed: in feb. 6, 2018]. [2] abdelaal m., le roux cw., docherty ng. morbidity and mortality associated with obesity. annales of translational medicine . 2017 apr; 5(7): 161. [3] biodynamics. clinical desk reference for bioelectrical impedance analysis testing. 2017available from:https:// www.biodyncorp.com/pdf/ clinician_desk_reference_bio.pdf. [accessed:in feb. 6, 2018]. [4] scott jr. body composition and body fat percentage. how to measure and interpret your body fat percentage. nov. 22, 2017. available from: https:// www.verywellfit.com/what-is-bodycomposition-3495614.[accessed:feb. 6, 2018]. [5] bhurosy t., jeewon r. pitfalls of using body mass index in assessment of obesity risk. current research in nutrition and food science journal., 2013;.1(1), 71-76. [6] tyrrell j., jones se., beaumont r., astley cm., lovell r.,yaghootkar h., et al. height, body mass index, and socioeconomic status: mendelian randomisation study in uk biobank. british medical journal. 2016; 352. available from: doi: https:// doi.org/10.1136/bmj.i582. [7] kuczmarski rj, flegal km. criteria for definition of overweight in transition: background and recommendations for the united states. american journal of clinical nutrition. 2000; 72(5): 1075– 1081. [8] tremblay s. body mass index advantages and disadvantages. livestrong.com. last update jul. 18, 2017. available from: http:// www.livestong.com/articale/93472problems-bmi.[accessed: feb. 7, 2018]. [9] han ts. sattar n., lean m. assessment of obesity and clinical implications british medical journal. sep. 28, 2006; 333. available from:http:// doi.org/10.1136bmi.333. 7570.695. [accessed: feb. 7, 2018]. [10] rothman kj. body mass index –related error in measurement of obesity. international journal of obesity. 2008; 32 (3):56-9. [11] guedes dp. clinical procedures used for analysis of the body composition. revista brasileira de clineantropometria e desempenlo human journal . 2013; 15 (1): 113-129. [12] mylott e., kutschera e., widenhorn r. bioelectrical impedance analysis as a laboratory activity: at the interface of physics and the body. american journal of physics. 2014; 82 (5): 520-29. [13] rani gs. different measuring techniques for body fat analysis. international research journal of science and engineering, 2015; 3(3): 98106. [14] roubenoff r. applications of bioelectrical impedance analysis for body composition to epidemiologic studies. american journal of clinical nutrition. 1996; 64(3suppl):459-62. [15] us national library of medicine. bioelectrical impedance analysis in body composition measurement: national institutes of health technology assessment conferences statement. american journal of clinical nutrition. 1996; 64 (3 supply): 524-532. 55 erbil journal of nursing & midwifery references conflict of interest https://doi.org/10.15218/ejnm.2018.07 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article [24] pongchaiyakul c., kosulwat v., rojroongwasinkul n., charoenkiatkul s., thepsuthammarat k., laopaiboon m., et al prediction of percentage body fat in rural thai population using simple anthropometric measurements. obesity research journal. 2005;13 (4):729-38. [25] ojo g., adetola o. the relationship between skin fold thickness and body mass index in estimation body fat percentage on bowen university students. international biological and biomedical journal. 2017; 3(3): 138-144. [26] akindele mo., phillipsjs.,igumbor eu. the relationship between body fat percentage and body mass index in overweight and obese individuals in an urban african setting. journal of public health in africa. 2016; 7(1) 15-19. [16] peterson jt., repovich es., parascand cr. smartphone-based bioelectrical impedance analysis devices for obesity management. british medical journal. 2015; 333(7570):695-8. [17] national institution of health technology assessment conferences statement. bioelectrical impedance analysis in body composition measurement. nutrition journal. december 12-14, 1994. [18] gallagher d., heymsfield sb., heo m. healthy percentage body fat ranges: an approach for developing guidelines based on body mass index. american journal of clinical nutrition. 2000; 72(3): 694-701. [19] james pt, leach r, kalamara e, shayeghi m: the worldwide obesity epidemic. obesity research journal. 2001; 9 (4):s2228–s0033. [20] carpenter cl., yan e., chen s., hong k., arechiga a., kim w., et al. body fat and body mass index among multiethnic sample of college-age men and women. journal of obesity. 2013. available from: file:///c:/users/kawa%20it/downloads/ jobes2013-7906541%20(1).pdf. [accessed in february, 21, 2018] [21] nkwoka i.j., egua m.o., abdullahi m., sabi’u a., mohammed a.i. (2014).overweight and obesity among staff of usmanudanfodiyo university, sokoto, nigeria. international research journals. 2014; 5(8): 290-295. [22] kawamoto, r., ohtsuka, n., ninomiya, d. and naka-mura, s. (2008) association of obesity and visceral fat distribution with intima-media thickness of carotid arteries in middle-aged and older persons. internal medicine journal. 2008; 47(3): 143-9. doi:10.2169/ internalmedicine.47.0478. [23] weaver a m., hill ac., andreacci jl., dixon cb. evaluation of hand to hand bioelectrical impedance analysis for estimating percentage body fat in young adults. international journal of exercise science. 2009; 2(4): 25463. available from: http://www.intjexersci.com [accessed february 21, 2018]. 56 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.01 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article dialysis-related factors affecting activities of daily living among hemodialysis patients in erbil city abstract introduction dialysis is the best technique to remove excess fluid and waste products from the body if the kidneys cannot perform this function. it can also balance acid-base and regulate fluid and electrolytes [1].the hemodialysis machine (hd) filters and cleans the blood of the patients, usually three times per week, four to six hours at a time [2]. daily activities like self-care of an individual at home and other individual activities outdoors are called activities of daily living (adls). ability and inability of doing adls is an essential measure of the functional status of individual patients [3].main types of adls are self-care activities such as eating, personal hygiene, background and objectives: hemodialysis procedure is one of the important replacement therapies for patients with renal failure. maintenance hemodialysis is associated with many complications that play a significant role in the activities of daily living. the present study aimed to find out the factors affecting activities of daily living among patients with maintenance hemodialysis in erbil city in the kurdistan region of iraq. methods: the cross-sectional study was conducted on 268 patients undergoing maintenance hemodialysis for more than two months, and at least two times per a week at two dialysis centres in erbil city from december 2019 to april 2020. the activities of daily living and complications from the hemodialysis procedure questionnaire to collect research data. the data analysis was conducted using descriptive statistical approach including frequency, percentages, and inferential statistical analysis consisting chi-square test. results: according to the findings of the study, the majority of participants were above 51 years of age, able to read and write, with middle income, and from an urban area. almost half of the study sample were males, and most were on hemodialysis between one and three years. the majority of them had hypertension and complications associated with hemodialysis such as headache and hypotension, and more than half had back pain. a highly significant association was found between dependency in activities of daily living and some socio-economic and clinical variables. furthermore, a significant association was found between dependency in activities of daily living and some hemodialysis complications with p<0.001. conclusion: according to the result of the study, the researchers concluded that participants suffered from chronic diseases, hemodialysis complications and low level of activities of daily living. the complications of hemodialysis treatment were significantly affecting the activities of daily living. haemodialysis patients need more education and nursing care to reduce treatment complications and to increase their activities. keywords: activities; daily living; hemodialysis patient; complication; independency; dependency. sideeq sadir ali; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: sideeq.ali@hmu.edu.krd) vian afan naqshbandi; department of nursing, college of nursing, hawler medical university, erbil, iraq. shihab ahmed sedeeq ; department of nursing, college of nursing, hawler medical university, erbil, iraq. 1 erbil journal of nursing & midwifery received: 27/05/2020 accepted: 08/11/2020 published: 30/05/2021 mailto:sideeq.ali@hmu.edu.krd https://doi.org/10.15218/ejnm.2021.01 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article shopping and mobility [4].treatment by hd always needs to be done at an hd centre or a hospital because the patients may develop many complications [5]. a study by kopple et al. (2018) reported that patients with maintenance hd had reduced performance of physical mobility and daily physical activity [6]. another study that was conducted on physical activity of hd patients revealed that their physical activity was lower than other patients, because of many problems, complications and stressful factors related to the condition and treatment [7]. it is essential to assess and monitor the level of physical activities of all hd patients, especially during the day of hd procedure because they often deal with several problems related to their sedentary lifestyle [8]. the patients should improve their daily activity and self-care to prevent hd complications and to continue the life of health and well-being [9].the researchers assessed the patients' level of adls and determined the main complications and problems that occurred during and after hd. they also identified the main related factors that affected those problems and inactivity. the cross-sectional study design was conducted at both dialysis centers of hawler teaching hospital in erbil city in the kurdistan region of iraq. the study sample included all patients with maintenance hemodialysis treatment in both centers. from 318 hd patients treated in the centres, 268 patients were selected according to the inclusion criteria of the present study. the inclusion criteria encompassed all male and female patients above the age of 18 with chronic renal failure and maintenance hd at least twice a week. fifty cases were excluded; 12 were under 18 years old, 10 were on hd less than two months, 13 had hd treatment less than one time a week, and 15 refused to participate in the study. the study was conducted during the period of 1st december 2019 to 15th april 2020. the data were collected during one month after approval of the proposal. the researchers collected the data by face to face interviews using a questionnaire, which consisted of three parts based on the proposed research objectives. part 1 included sociodemographic datasheet; part 2 contained clinical information, and part 3 recorded hd complications that the researchers identified through the literature review. part 4 was used to assess the adls. the concept of the adls was first described by sheldon in the journal of health and physical education in 1935, as reported by feinstein et al.[10]. in 1969, lawton and brody were the first authors to describe two levels of adls as basic and instrumental adls, and they considered it to be a valid and reliable scale for health surveys [11]. the adls tool was used in many studies such as singh et al., in 2007, watanabe et al., in 2018 and kutsuna et al., in 2019 [12,13,14]. the researchers modified the adls tool to achieve the research objectives and included 16 items divided into two domains subscales; basic adls (10 items), instrumental adls (6 items) and 3 levels of adls dependency (independent, requires assistance and dependent). the study was approved by the scientific and ethical committees at the college of nursing of hawler medical university in erbil. the verbal consent was obtained from each patient with hd before the interview. the data were analysed using the statistical package for social sciences (spss, version 25), and used two statistical approaches. the descriptive data analysis included frequency and percentage, and inferential data analysis calculated chisquare test. p-value of ≤ 0.05 was considered statistically significant to find out 2 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2021.01 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article most of the patients (89.6%) had other chronic diseases ( 73.9% hypertension, 49.3% diabetes mellitus, 14.6% anaemia, 14.2% heart disease and 3.7% hepatitis). regarding the duration of hd treatment, more than half of the participants (55.2%) received treatment for 1-3 years. a high percentage of them (94.8%) had information about the importance of adls. table 3 demonstrates the overall activities of daily living divided into two main domains, basic and instrumental activities. the maximum percentage of basic adls (42.9%) was within the level of independence. however, more than half (52.6%) of the participants were dependent in the instrumental adls. in general, the largest proportion of participants (36.6%) was within the level of dependency in both types of adls (basic and instrumental). factors that affected daily adls among hd patients. regarding the scoring, 0 was used for 'dependent', 1 for 'requires assistance' and 2 for 'independent' responses. an overall level of adls was also determined as ‘independent’, ‘requires assistance’ and ‘dependent’. table 1 shows the socio-economic characteristics of hd patients. most participants were more than 51 years old (68.3%), male (51.5%) and illiterate (61.2%). moreover, the majority of the patients were married (70.2%), and 45.9% were housewives, had middle income (76.9%) and lived in urban areas (89.2%).table 2 shows the clinical characteristics of the participants. almost half of the patients (47.8%) who took part in the study had a normal weight. 3 erbil journal of nursing & midwifery results table 1: socio-economic data of patients with maintenance hemodialysis n= 268 f (%) age group (years) 18-35 28 (10.4) 36-50 57 (21.3) 51 and above 183 (68.3) sex male 138 (51.5) female 130 (48.5) formal years of education read and/write 164 (61.2) primary school 71 (26.4) secondary 9 (3.4) higher educa24 (9) marital status single 18 (6.7) married 188 (70.2) widower 62 (23.1) current occupation employment 25 (9.3) jobless 120 (44.8) housewife 123 (45.9) economic status low income 33 (12.3) middle income 206 (76.9) high income 29 (10.8) residential urban 239 (89.2) rural 29 (10.8) table 2: clinical characteristic of the patients with maintenance hemodialysis variables n= 268 f (%) body max index (bmi) underweight 10 (3.7) normal weight 128 (47.8) overweight 88 (32.8) obese 42 (15.7) associated disease with chronic renal failure yes 240 (89.6) no 28 (10.4) type of chronic disease (n= 240) hypertension 198 (73.9) diabetes mellitus 132 (49.3) anaemia 39 (14.6) heart disease 38 (14.2) hepatitis 10 (3.7) duration of hd treatment <1 year 56 (20.9) 1–3 years 148 (55.2) >3 year 64 (23.9) information about adl yes 254 (94.8) no 14 (5.2) https://doi.org/10.15218/ejnm.2021.01 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article table 4 exhibits the common complications and problems that occurred during and after the hd procedure. the most common complications identified through the questionnaire included headache (81.7%) after hd procedure (39.9%), hypotension (72%) during hd procedure (59.3%) and back pain (58.2%) during hd procedure (43.3%). the least common problems and complications that occurred among hd patients included infiltration (4 cases, 1.5%) during hd procedure in all 4 patients (100%), air embolism (4 cases, 1.5%), 3 cases occurred during hd procedure (1.1%), and the least common complication was coma in 5 patients (1.7%), 4 (1.5%) of which occurred during hd procedure. table 5 demonstrates the association between the adls and socioeconomic characteristics of the patients. there was a highly significant association between the 'dependent' level of the adls and four variables; age group of the participants (46.1% for 56 years and above and 14% for 36 55 years vs 10.7% for 18 35 years, p-value <0.001), marital status (61.3% for a widower and 23.9% for married vs 16.7% for single, p-value <0.001), formal years of education (41.5% for illiterate and can read/ write and 19.7% for primary school graduates vs 16.7% for higher-level education, p-value <0.001), and current occupation (39.8% for housewife and 29.2% for unemployment vs 8% for employment, p-value <0.001). dependency was more significant among low income and middle-income participants than in high-income respondents (36.4% and 34%, 13.8% respectively, p = 0.025). finally, there was no significant association between the adls and gender (p = 0.057) and residential area (p = 0.221). table 6 shows the association between clinical characteristics and adls. dependency of adls was significantly associated with the bmi (50% for underweight, 35.2% for normal weight, 27.3% overweight and 28.6% for obese, p-value = 0.020) and duration of hd treatment (33.9 % for <1 year and 31.8% for 1–3 years vs 31.3% for >3 year, p-value =0.037). also, dependency was significantly associated with another chronic disease; hypertension (35.4% hypertension and 22.9% for no hypertension, p-value = 0.004), diabetes mellitus (41.7% diabetes mellitus and 22.8% for no diabetes mellitus, p-value = 0.002), hepatitis (32.9% for no hepatitis and 29.1%, for hepatitis, p-value = 0.029) and heart disease (50% heart disease and 29.1% for no heart disease, p-value = 0.003). finally, dependency was significantly associated with not being informed about adls (35.7%) and 31.9% and being informed about adls (31.9%) (p-value = 0.006). there was no statistically significant association between adls and anemia (p-value = 0.062).final results of the study are demonstrated in table 7. they illustrate an association between some complications and problems of the hd procedure and overall level of adls. from all of 19 complications/ problems, only nine had a statistically significant association with adls. the dependent level of the adls was significantly higher in patients with nausea (44.4% nausea vs. 29% no nausea, p = 0.004), vomiting (42.3% vomiting vs. 28.4% no vomiting, p = 0.021), restlessness (37.3% no restlessness vs. 29.2% restlessness, p = 0.041),tightness 4 erbil journal of nursing & midwifery table 3: overall activities of daily living items activities of daily living dependent requires assistance independent f (%) f (%) f (%) basic activity 82 (30.6) 71 (26.5) 115 (42.9) instrumental activity 141 (52.6) 90 (33.6) 37 (13.8) overall adls 98 (36.6) 86 (32.1) 84 (31.3) https://doi.org/10.15218/ejnm.2021.01 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article 28.7% no clotting, p = 0.043), blood line obstruction (80% blood line obstruction vs. 30.2% no blood line obstruction, p = 0.004) and hematoma (33.1% no hematoma vs. 0% hematoma, p = 0.003). 5 erbil journal of nursing & midwifery in the chest (37.2% no tightness in the chest vs. 27.8% tightness in the chest, p = 0.003), chills (32.9% no chills vs. 29.1% chills, p = 0.049), fever (38.2% no fever vs. 27.9% fever, p = 0.026), clotting (38.1% clotting vs. table 4: health problems associated with hemodialysis among the study sample complication or problem no yes yes during procedure after procedure remaining by hours f (%) f (%) f (%) f (%) f (%) nausea 214 (79.9) 54 (20.1) 48 (17.9) 5 (1.9) 1 (0.4) vomiting 197 (73.5) 71 (26.5) 63 (23.5) 7 (2.6) 1 (0.4) restlessness 244 (91) 24 (9) 19 (7.1) 4 (1.5) 1 (0.4) headache 49 (18.3) 219 (81.7) 95 (35.4) 107 (39.9) 17 (6.3) seizure 258 (96.3) 10 (3.7) 5 (1.9) 5 (1.9) 0 (0) coma 263 (98.1) 5 (1.9) 4 (1.5) 1 (0.4) 0 (0) hypotension 75 (28) 193 (72) 159 (59.3) 29 (10.8) 5 (1.9) back pain 112 (41.8) 156 (58.2) 116 (43.3) 26 (9.7) 14 (5.2) tightness in the chest 250 (93.3) 18 (6.7) 11 (4.1) 5 (1.9) 2 (0.7) shortness of breath 215 (80.2) 53 (19.8) 44 (16.4) 8 (3) 1 (0.4) chill 213 (79.5) 55 (20.5) 46 (17.2) 6 (2.2) 3 (1.1) fever 225 (84) 43 (16) 34 (12.7) 8 (3) 1 (0.4) air embolism 264 (98.5) 4 (1.5) 3 (1.1) 1 (0.4) 0 (0) clotting 171 (63.8) 97 (36.2) 92 (34.3) 4 (1.5) 1 (0.4) blood line obstruction 258 (96.3) 10 (3.7) 10 (3.7) 0 (0) 0 (0) bleeding 249 (92.9) 19 (7.1) 14 (5.2) 5 (1.9) 0 (0) pain 231 (86.2) 37 (13.8) 31 (11.6) 4 (1.5) 2 (0.7) infiltration 264 (98.5) 4 (1.5) 4 (100) 0 (0) 0 (0) hematoma 260 (97) 8 (3) 3 (37.5) 5 (62.5) 0 (0) https://doi.org/10.15218/ejnm.2021.01 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article 6 erbil journal of nursing & midwifery table 5: association between socio-economic data and overall adls variables dependent requires assistance independent p-value f (%) f (%) f (%) age group (year) 18 35 (young adult) 3 (10.7) 3 (10.7) 22 (78.6) <0.001 36 55 (middle-aged adults) 12 (14) 18 (20.9) 56 (65.1) 56 years old and above (older adult) 71 (46.1) 62 (40.3) 21 (13.6) sex male 36 (26.1) 47 (34.1) 55 (39.9) 0.057 female 50 (38.5) 36 (27.7) 44 (33.8) marital status single 3 (16.7) 3 (16.7) 12 (66.7) <0.001 married 45 (23.9) 60 (31.9) 83 (44.1) widower 38 (61.3) 20 (32.3) 4 (6.5) formal years of education illiterate and can read /write 68 (41.5) 58 (35.4) 38 (23.2) <0.001 primary school 14 (19.7) 21 (29.6) 36 (50.7) secondary school 0 (0) 3 (33.3) 6 (66.7) higher education 4 (16.7) 1 (4.2) 19 (79.2) current occupation employment 2 (8) 2 (8) 21 (84) <0.001 jobless 35 (29.2) 45 (37.5) 40 (33.3) housewife 49 (39.8) 36 (29.3) 38 (30.9) economic status low income 12 (36.4) 13 (39.4) 8 (24.2) 0.025 middle income 70 (34) 63 (30.6) 73 (35.4) high income 4 (13.8) 7 (24.1) 18 (62.1) residential area urban 74 (31) 73 (30.5) 92 (38.5) 0.221 rural 12 (41.4) 10 (34.5) 7 (24.1) https://doi.org/10.15218/ejnm.2021.01 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article 7 erbil journal of nursing & midwifery table 6: association between clinical data and the overall level of adls variables dependent f (%) requires assistance f (%) independent f (%) p-value classification of bmi underweight 5 (50) 0 (0) 5 (50) 0.020 normal weight 45 (35.2) 31 (24.2) 52 (40.6) overweight 24 (27.3) 39 (44.3) 25 (28.4) obese 12 (28.6) 13 (31) 17 (40.5) duration of hd treatment <1 year 19 (33.9) 16 (28.6) 21 (37.5) 0.037 1–3 years 47 (31.8) 38 (25.7) 63 (42.6) >3 year 20 (31.3) 29 (45.3) 15 (23.4) do you have hypertension? yes 70 (35.4) 66 (33.3) 62 (31.3) 0.006 no 16 (22.9) 17 (24.3) 37 (52.9) do you have diabetes mellitus? yes 55 (41.7) 39 (29.5) 38 (28.8) 0.002 no 31 (22.8) 44 (32.4) 61 (44.9) do you have anaemia yes 17 (43.6) 14 (35.9) 8 (20.5) 0.062 no 69 (30.1) 69 (30.1) 91 (39.7) do you have hepatitis? yes 1 (10) 5 (50) 4 (40) 0.029 no 85 (32.9) 78 (30.2) 95 (36.8) do you have heart disease? yes 19 (50) 12 (31.6) 7 (18.4) 0.003 no 67 (29.1) 71 (30.9) 92 (40) do you have information about adls yes 81 (31.9) 80 (31.5) 93 (36.6) 0.006 no 5 (35.7) 3 (21.4) 6 (42.9) https://doi.org/10.15218/ejnm.2021.01 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article 8 erbil journal of nursing & midwifery table 7: association between overall adls and complications/ problems complications/ problems overall adl levels p-value dependent requires assistance independent f (%) f (%) f (%) nausea (*yes =54) (*no =214) yes 24 (44.4) 10 (18.5) 20 (37) 0.004 no 62 (29) 73 (34.1) 79 (36.9) vomiting (*yes =71) (*no=197) yes 30 (42.3) 20 (28.2) 21 (29.6) 0.021 no 56 (28.4) 63 (32) 78 (39.6) restlessness (*yes = 219) (*no= 49) yes 7 (29.2) 13 (54.2) 4 (16.7) 0.041 no 91 (37.3) 73 (29.9) 80 (32.8) headache (*yes = 219) (*no= 49) yes 21 (42.9) 9 (18.4) 19 (38.8) 0.071 no 65 (29.7) 74 (33.8) 80 (36.5) hypotension (*yes = 193) (*no= 75) yes 62 (32.1) 58 (30.1) 73 (37.8) 0.215 no 24 (32) 25 (33.3) 26 (34.7) back pain (*yes = 156) (*no= 112) yes 55 (35.3) 50 (32.1) 51 (32.7) 0.101 no 31 (27.7) 33 (29.5) 48 (42.9) tightness in the chest (*yes = 18) (*no= 250) yes 5 (27.8) 12 (66.7) 1 (5.6) 0.003 no 93 (37.2) 74 (29.6) 83 (33.2) chill (*yes = 55) (*no= 213) yes 16 (29.1) 15 (27.3) 24 (43.6) 0.049 no 70 (32.9) 68 (31.9) 75 (35.2) fever (*yes = 43) (*no= 225) yes 12 (27.9) 10 (23.3) 21 (48.8) 0.026 no 86 (38.2) 76 (33.8) 63 (28) clotting (*yes = 97) (*no = 171) yes 37 (38.1) 34 (35.1) 26 (26.8) 0.043 no 49 (28.7) 49 (28.7) 73 (42.7) blood line obstruction (*yes =10) (*no= 258) yes 8 (80) 0 (0) 2 (20) 0.004 no 78 (30.2) 83 (32.2) 97 (37.6) hematoma (*yes = 8) (*no= 260) yes 0 (0) 6 (75) 2 (25) 0.003 no 86 (33.1) 77 (29.6) 97 (37.3) https://doi.org/10.15218/ejnm.2021.01 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article only 30% of participants were independent in adls, while post-intervention, 50% were independent, demonstrating an increased by two-thirds. 66.7% of patients in the study were independent after the followup period [21].the treatment by hd procedure among patients in this study was associated with many complications and problems. the majority of patients had headache, hypotension and back pain. at the same time, the least common complication was a coma, and the least common problems were infiltration and air embolism that occurred during the hd procedure. those complications or problems were expected as the majority of the study participants had other chronic diseases, and those complications could be due to those conditions. moreover, the hd procedure is the major invasive procedure that transports the blood from the body of the patients into the dialyser machine through the hollow fibres, and after the filtration returns into the body, which takes 4 to 6 hours. therefore the hd procedure carries the risk of many complications [22]. the hd patients experience multiple problems and health complications in the community and their daily lives because they have daily treatment as well as the treatment by hemodialysis procedure [23, 24]. the results of this study were supported by the caplin et al., study that studied 550 hd patients in london, uk. after analysis, they identified the hypotension, headache, backache, pruritus, dizziness and cramps as the main complications of hd [25]. another retrospective study in the uttar pradesh, india; during 11 years assessed 2325 renal failure hd patients and found that the most common intradialytic complications were hypotension, nausea, vomiting, fever and chills [26]. the cross-sectional survey study by gela and mengistu conducted in ethiopia showed that the majority of the participants on hd treatment this study explored the common complications and problems associated with hd during or after the procedure and factors that affected patients' adls. the results revealed that almost half of the participants were dependent in performing instrumental adls. in contrast, the maximum percentage of participants were independent in their basic adls. the overall level of patients' independence in adls was inadequate. according to extensive research data, the activity during the day is essential for all people and especially for patients with chronic kidney disease. in contrast, inactivity is one of the main problems associated with many diseases, complications and mortality as well as the quality of life [15, 16, 17]. the results of low activity in our study could be due to the age of the study participants as the majority of them were more than 51 years old. low level of education could also contribute, as the activity in the older age group usually declines in the society. this result is supported by the study of julius et al., which reported the highest dependency in adls among older patients, female and less educated [18]. painter and marcus found that, generally, participants with renal failure usually had low levels of physical activity [19]. the study of cook and jassal also supported this result; the majority of their study group was dependent in most items of basic and instrumental adls [20]. self-care activities can increase if they are designed by educational program and improve patients' knowledge, as found in the quasi-experimental study of mohamed et al., which was conducted in egypt. it used nottingham scale of adls and studied the effect of the interventional program on the hd patients and their ability of self-care. the results showed that before the intervention, 9 erbil journal of nursing & midwifery discussions https://doi.org/10.15218/ejnm.2021.01 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article of studied patients was over one year, which may lead to unemployment and inadequate income. all of the above challenges also affected the psychology of the patients and their adls [32,33]. this result was supported by aucella et al. in italy, whose research concluded that unemployment and age of hd patients affected their activity, and education, duration of dialysis and presence of anaemia were also associated with a low level of energy [34]. this research also agrees with many other studies that showed that occupational status of hd patients was significantly associated with daily activity [35, 36, 37]. the effect of the duration of hd treatment on adls in the present study was different from a descriptive study on 138 hd patients in sivas, turkey, which found no significant association between the duration of hd and patients' activity [38]. in the present study, the adls were positively associated with the income as in the study of kamble and shinde in india, in which the monthly income of the family was associated with physical activity [39]. the current study identified a highly significant association between marital status and adls as in the study by julius et al.; in which dependency in adls was associated with the marital status and educational level [18]. furthermore, the dependency in adls was significantly associated with the presence of another chronic disease. thomas et al. in their study demonstrated that some of the chronic kidney diseases were significantly associated with many health complications like anaemia and cardiovascular disease [40]. the dependency in adls was significantly associated with some chronic disease like hypertension, diabetes mellitus, hepatitis and heart disease in research by algarni, in 2014, who stated that the diabetes mellitus and hypertension were the leading causes of renal failure and affected adls[41]. had anaemia as acomplication [27]. hemodialysis patients often complain about many complications before, during and after hd treatment. by improving nursing interventions, nurses can reduce the risk of complications [28]. the present study identified infiltration and air embolism as problems related to vascular access. the longitudinal cohort study that was conducted in north america observing vascular hd access during 90 days and second time end of the first year revealed many problems [29]. the adls of patients were significantly associated with many variables of socio-economic and clinical characteristic. there was a highly statistically significant association with age group, level of education and bmi of the participants, which could be because the majority of the study groups were older adults, and their level of education was low. furthermore, almost half of the participants had a normal weight, however, the daily accumulation of waste products and excessive fluid led to an increase in their weight affecting their activity. these results are similar to the findings of a study by johansen et al. in the california, usa, which showed age, level of education, and bmi were significantly associated with physical activity [30]. however, there was a difference with the study by stack and murthy, who found that severe limitations in the adls among hd patients were negatively related to the age and heart failure [31]. the current occupation and economic status, as well as the duration of hd treatment of the patients in the current study also affected the adls. this could be due to the high percentage of housewives and unemployed people in the study sample. also, a majority of participants had middle income and were dependent on other people for daily income. additionally, the duration of dialysis in the majority 10 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.01 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article with the dependency in adls. this result agrees with a study by davenport, in 2006, which explored low functional activity among hd patients related to complications of hd procedure such as chest tightness, angioedema with throat and laryngeal oedema fever, tachycardia, flushing, headache, chest pain, dyspnea, pruritus, anxiety, laryngeal oedema, numbness of the fingers toes and lips, hypotension and hypertension [50]. moreover, this study was supported by mehmood et al., who, in 2016, observed an association between complications during hemodialysis and activity like; hypotension, cramps, itching, vomiting and dialysis reaction [51]. this study found that the adls of hemodialysis patients were low, which could be due to the ageing process, low level of education and the presence of other chronic diseases. the results of the study showed that there was a highly significant statistical association between adls and the majority of the socio-economic and clinical characteristics. most patients suffered from complications and problems of hd during and after treatment, which increased their dependency in adls. nursing care and patient education are essential for hemodialysis patients and can increase functional daily living activity and decrease in hd related complications and problems. the authors report no conflicts of interest. [1] smeltzer so, bare bg. brunner and suddarth's textbook of medical-surgical nursing. 10th ed. philadelphia: jb lippincott; 2003. p. 1289. [2] rhoades, ra, tanner, ga. medical physiology. 2nd ed. lippincott-raven. part vi renal physiology and body fluids, chapter 23, kidney function; 2003. p.378. this result agrees with many studies that explored diabetes mellitus as the main factors of renal disease which also significantly affected daily activity [42, 43]. concerning the association of adls with heart disease, this study is supported by a cross-sectional study by cheung et al., in which the majority of hd patients had other cardiovascular diseases, and there was a positive association between activity and all disease categories and age [44]. another study similar to this research was by mousa et al., in which the majority of study participants had a chronic disease, and activity of the patients was significantly associated with age, educational level, income, living status, occupation, and hd duration [45].further results of the current study illustrated that some of the hd complications or/and problems occurred during or after hd procedure or continued for some time after. the hd procedure is invasive, difficult for the patient to cope with, and carries the risk for myocardial infarction, heart failure, fluid overload and stroke that can also affect adls[46]. furthermore, there could be some hidden problem such as coronary artery disease, aplastic bone disease, high turnover renal bone disease, bleeding diathesis (uremic platelets), and osteomalacia, which can be directly associated with decreased daily activity [47]. this is in agreement with the study of alhajim, in 2017, found that hd patients often experience many complications such as cardiovascular disease that directly affect their adls [48]. this study is also supported by a descriptive and analytical study done in iran by asgari et al., which revealed that patients undergoing hd faced severe nausea and vomiting [49]. another complication was restlessness and tightness in the chest, which were also significantly associated 11 erbil journal of nursing & midwifery conclusion conflicts of interest references https://doi.org/10.15218/ejnm.2021.01 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article [13] watanabe t, kutsuna t, yoneki k, harada m, shimoda t, matsunaga y, et al. determinants of difficulty in activities of daily living in ambulatory patients undergoing hemodialysis. renal replacement therapy. 2018 dec 1; 4 (1): 1-8. available from: doi 10.1186/ s41100-018-0146-y. [14] kutsuna t, isobe y, watanabe t, matsunaga y, kusaka s, kusumoto y, et al. comparison of difficulty with activities of daily living in elderly adults undergoing hemodialysis and community-dwelling individuals: a crosssectional study. renal replacement therapy. 2019 dec 1; 5 (1):50. available from: https://doi.org/10.1186/s4110-019-0250-7. [15] jagannathan r, ziolkowski sl, weber mb, cobb j, pham n, long j, et al. physical activity promotion for patients transitioning to dialysis using the “exercise is medicine” framework: a multi-centre randomised pragmatic trial (eim-ckd trial) protocol. bmc nephrology. 2018 dec 1; 19 (1): 230. available from: https://doi.org/10.1186/s12882018-1032-0. [16] anding k, bär t, trojniak-hennig j, kuchinke s, krause r, rost jm, et al. a structured exercise programme during haemodialysis for patients with chronic kidney disease: clinical benefit and long-term adherence. bmj open. 2015 aug 1; 5 (8):e008709. available from: doi:10.1136/bmjopen-2015-008709. [17] kutner ng, zhang r, allman rm, bowling cb. correlates of adl difficulty in a large hemodialysis cohort. hemodialysis international. 2014 jan; 18 (1):70-7. available from: doi:10.1111/hdi.12098. [18] julius m, hawthorne vm, carpentier-alting p, kneisley j, wolfe ra, port fk. independence in activities of daily living for end-stage renal disease patients: biomedical and demographic correlates. american journal of kidney diseases. 1989 jan 1; 13 (1):61-9. [19] painter p, marcus rl. assessing physical function and physical activity in patients with ckd. clinical journal of the american society of nephrology. 2013 may 7; 8 (5):861 -72. available from: doi: 10.2215/ cjn.06590712. [20] cook wl, jassal sv. functional dependencies among the elderly on hemodialysis. kidney international. 2008 jun 1; 73 (11):1289-95. available from: doi:10.1038/ki.2008.62. [21] mohamed sk, el-fouly ya, el-deeb ma. impact of a designed self-care program on selected outcomes among patients undergoing [3] shabila np, alhagbaker jm, ali ss. daily living activities among geriatric residents at geriatric homes in erbil and sulaimaniyah cities, kurdistan region. zanco journal of medical sciences. 2017; 21(1):161928. available from: https:// doi.org/10.15218/zjms.2017.012. [4] mlinaca me, fengb mc. assessment of activities of daily living, self-care, and independence. archives of clinical neuropsychology. 2016;506–516. available from: doi:10.1093/arclin/acw049. [5] williams ls, hopper pd. understanding medical-surgical nursing. 2nd ed. usa, philadelphia: f.a. davis company publishing; 2003. p. 645-7. [6] kopple jd, kim jc, shapiro bb, zhang m, li y, porszasz j et al. factors affecting daily physical activity and physical performance in maintenance dialysis patients. journal of renal nutrition. 2018; 25(2): 217–22. available from: doi:10.1053/ j.jrn.2014.10.017. [7] atashpeikar s, jalilazar t, heidarzadeh m. self-care ability in hemodialysis patients. journal of caring sciences. 2012 may; 1(1): 31-5. [8] johansen kl, chertow gm, ng av, mulligan k, carey s, schoenfeld py, et al. physical activity levels in patients on hemodialysis and healthy sedentary controls. kidney international. 2000 1st june; 57(6):256470. available from: doi: 10.1046/j.15231755.2000.00116.x. [9] shukla b, kaur a. study to assess knowledge and attitude regarding selfcare among patients undergoing hemodialysis in selected hospital of punjab, india. jars international research journal. 2012; 2 (1): 3-4. [10] feinstein ar, josephy br, wells ck. scientific and clinical problems in indexes of functional disability. annals of internal medicine. 1986 sep 1; 105 (3):413-20. [11] lawton mp, brody em. assessment of older people: self-maintaining and instrumental activities of daily living. the gerontologist. 1969 1st october; 9 (3): 179-86. [12] singh s, multani nk, verma sk. development and validation of geriatric assessment tools: a preliminary report from indian population. journal of exercise science and physiotherapy. 2007 dec; 3 (2):103. 12 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.01 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article kidney international. 2010 dec 1; 78 (11):1164-70. available from: doi:10.1038/ ki.2010.312. [31] stack ag, murthy b. exercise and limitations in physical activity levels among new dialysis patients in the united states: an epidemiologic study. annals of epidemiology. 2008 dec 1; 18 (12):880-8. [32] na l, streim je. psychosocial well-being associated with activity of daily living stages among community-dwelling older adults. gerontology and geriatric medicine. 2017 mar 21; 3 (1): 1-13. available from: doi.10.1177/23337214177000. [33] yu f, chen y, mathiason ma, wan q, lin fv. cognitive and physical factors affecting daily function in alzheimer's disease: a crosssectional analysis. nursing & health sciences. 2019 mar; 21(1):14-20. available from: doi: 10.1111/nhs.12426. [34] aucella f, battaglia y, bellizzi v, bolignano d, capitanini a, cupisti a. physical exercise programs in ckd: lights, shades and perspectives: a position paper of the “physical exercise in ckd study group” of the italian society of nephrology. journal of nephrology. 2015 apr 1;28 (2):143-50. available from: doi 10.1007/s40620-014-0169-6. [35] mollaoglu m. fatigue in people undergoing hemodialysis. dialysis & transplantation. 2009 jun; 38 (6):216-20. [36] muehrer rj, schatell d, witten b, gangnon r, becker bn, hofmann rm. factors affecting employment at initiation of dialysis. clinical journal of the american society of nephrology. 2011 mar 1; 6 (3):489-96. available from: doi: 10.2215/cjn.02550310. [37] hallab a, wish jb. employment among patients on dialysis: an unfulfilled promise. clinical journal of the american society of nephrology. 2018 january 18; 13 (1): 1-2. available from: doi: 10.2215/cjn.13491217. [38] bağ e, mollaoğlu m. the evaluation of selfcare and self-efficacy in patients undergoing hemodialysis. journal of evaluation in clinical practice. 2010 jun; 16 (3):605-10. availablefrom:doi:10.1111/j.13652753.2009.01214.x. [39] kamble ds, shinde mb. factors affecting quality of life among hemodialysis patients. international journal of science andresearch. 2015; 6(1):572-6. hemodialysis. international journal of research in applied. 2016; 4 (5):73-90. [22] timby bk, smith ne. introductory medicalsurgical nursing. 10th ed. lippincott williams & wilkins: 2010; p. 931. [23] rahimi f, oskouie f, naser o, sanandji me, gharib a. the effect of self-care on patients undergoing hemodialysis in the sanandaj hospitals affiliated to kurdistan university of medical sciences in 2016. bali medical journal. 2017 jan 1; 6 (3):6849. available from: doi:10.15562/bmj. [24] mccaleb a, cull vv. sociocultural influences and self-care practices of middle adolescents. journal of pediatric nursing. 2000 feb 1; 15(1):30-5. [25] caplin b, kumar s, davenport a. patients' perspective of haemodialysis-associated symptoms. nephrology dialysis transplantation. 2011 1st august;26(8):2656-63. available from: doi: 10.1093/ndt/gfq763. [26] singh rg, singh s, rathore ss, choudhary ta. spectrum of intradialytic complications during hemodialysis and its management: a single-center experience. saudi journal of kidney diseases and transplantation. 2015 jan 1; 26 (1):168. [27] gela d, mengistu d. self-management and associated factors among patients with end-stage renal disease undergoing hemodialysis at health facilities in addis ababa, ethiopia. international journal of nephrology and renovascular disease. 2018; 11:329. available from: http:// dx.doi.org/10.2147/ijnrd.s184671. [28] minn ww. enhancing patient safety in hemodialysis nursing care practice among nurses in the renal unit at the defence services general hospital: a best practice implementation project. jbi database of systematic reviews and implementation reports. 2014 sep 1; 12 (9):467-88. available from: doi: 10.11124/jbisrir-2014-1368. [29] xue h, ix jh, wang w, brunelli sm, lazarus m, hakim r, et al. hemodialysis access usage patterns in the incident dialysis year and associated catheter-related complications. american journal of kidney diseases. 2013 jan 1; 61(1):123-30. available from: http://dx.doi.org/10.1053/ j.ajkd.2012.09.006. [30] johansen kl, chertow gm, kutner ng, dalrymple ls, grimes ba, kaysen ga. low level of self-reported physical activity in ambulatory patients new to dialysis 13 erbil journal of nursing & midwifery http://dx.doi.org/10.2147/ijnrd.s184671 http://dx.doi.org/10.2147/ijnrd.s184671 https://doi.org/10.15218/ejnm.2021.01 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article available from: https:// doi.org/10.26719/2017.23.12.815 [49] davenport a. intradialytic complications during hemodialysis. hemodialysis international. 2006 apr; 10 (2):162-7. [50] asgari mr, asghari f, ghods aa, ghorbani r, motlagh nh, rahaei f. incidence and severity of nausea and vomiting in a group of maintenance hemodialysis patients. journal of renal injury prevention. 2017; 6 (1):49. available from: doi: 10.15171/jrip.2017.09. [51] mehmood y, ghafoor s, ashraf mi, riaz h, atif sr, saeed m. intradialytic complications found in patients at a tertiary care hospital. austin journal of pharmacology and therapeutics. 2016; 4 (1):107. [40] thomas r, kanso a, sedor jr. chronic kidney disease and its complications. primary care: clinics in office practice. 2008 jun 1; 35 (2):329-44. available from: doi:10.1016/j.pop.2008.01.008. [41] algarni rs. exploring the concept of health -related quality of life for patients with end-stage renal disease on haemodialysis in the eastern region of saudi arabia. (doctoral dissertation). the university of manchester (united kingdom)). 2014. accessed: 10th february 2020. available from: https://www.semanticscholar.org/ paper/exploring-the-concept-of-healthrelated-quality-of-algarni/ ef304884f6e87594bf6c00509c3b10d5d3b 1e4a2 [42] gutman, ra, stead, ww, robinson, rr. physical activity and employment status of patients on maintenance dialysis. new england journal of medicine. 1981 feb 5; 304 (6):309-13. [43] anees m, hameed f, mumtaz a, ibrahim m, saeed km. dialysis-related factors affecting quality of life in patients on hemodialysis. iranian journal of kidney diseases. 2011 jun; 5 (1):329-44. [44] cheung ak, sarnak mj, yan g, dwyer jt, heyka rj, rocco mv, et al. atherosclerotic cardiovascular disease risks in chronic hemodialysis patients. kidney international. 2000 jul 1; 58 (1):353-62. [45] mousa i, ataba r, al-ali k, alkaiyat a, sa’ed hz. dialysis-related factors affecting self-efficacy and quality of life in patients on haemodialysis: a cross-sectional study from palestine. renal replacement therapy. 2018 dec; 4 (1):21. available from: https://doi.org/10.1186/s41100-018-0162 -y. [46] morfin ja, fluck rj, weinhandl ed, kansal s, mccullough pa, komenda p. intensive hemodialysis and treatment complications and tolerability. american journal of kidney diseases. 2016 nov 1; 68 (5):s43-50. available from: http://dx.doi.org/10.1053/ j.ajkd.2016.05.021. [47] schrier rw. diseases of the kidney & urinary tract. 8th ed. volume 1. lippincott williams & wilkins; 2007. chapter 100. p. 2649-69. [48] alhajim sa. assessment of the quality of life in patients on haemodialysis in iraq. eastern mediterranean health journal. 2017 jan 1; 23 (12):815-20. 14 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.06 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article prevalence and risk factors of episiotomy and perineal tear in the maternity teaching hospital of erbil city, iraq abstract introduction during child birth, tearing to the perineum can occur naturally or by the surgical process of an incision known as episiotomy. both natural tearing and episiotomy are found to be traumatic to the genitalia *1+. reported rates of episiotomies vary from as low as 9.7% in sweden to as high as 100% in taiwan considering both nulliparous and multiparous women *2,3+. more than 85% of women having a vaginal birth experience some form of perineal trauma, and 60–70% of women receive sutures post-delivery to repair the perineum. approximately one-third of the women in the united states and the united kingdom background and objectives: during childbirth, women are at risk for experiencing perineal trauma to the genitalia resulting in a tear of the perineum or the surgical process of an episiotomy. knowing the prevalence and the risk factors associated with perineal trauma may help in the reduction of episiotomy and prevention of occurrence of tear. the aim of the study was to find out the prevalence and risk factors associated with perineal trauma among women ages 15-48. methods: a cross sectional study was conducted in the maternity teaching hospital of erbil, kurdistan region, iraq. all records of mothers (n = 1500) who had been admitted to the delivery room for vaginal delivery during the month of may (2015) were reviewed. chisquare test of association and binary logistic regression were used to interpret the data. results: the overall rates of episiotomy, tear, their combined presence, and an intact perineum were: 47.8%, 7.2%, 26.1% and 18.9%, respectively. incidence of having an episiotomy, tear, or combination of both, were significantly associated with women of young ages and women who were primigravida parity. there was a statistically significant association between high birth weight and the occurrence of perineal trauma. there was no association between perineal trauma and residency (urban/rural), occupation, gender of baby and time of delivery. binary logistic regression analysis showed that having an episiotomy increased the risk of a tear by more than 30%. conclusions: the prevalence of episiotomy was found to be 73.9% which is much higher compared to the world health organization recommendation which is 10%. perineal trauma were associated with factors such as age, parity, and birth weight. episiotomy is a risk factor for a vaginal tear. we recommend further research to inform the development and implementation of restrictive episiotomy policies to reduce and prevent occurrences of perineal trauma. key words: perineal trauma, episiotomy, tear, prevalence, risk factors hamdia mirkhan ahmed; department of midwifery , college of nursing, hawler medical university, erbil, iraq. warda hasan abdollah; department of midwifery , college of nursing, hawler medical university, erbil, iraq. (correspondence: hamdia.mirkhan@nur.hmu.edu.krd) namir ghanim al-tawil; department of community medicine , college of medicine, hawler medical university, erbil, iraq. 44 erbil journal of nursing & midwifery received: 28/9/2018 accepted: 25/2/2019 published: 30/5/2019 mailto:hamdia.mirkhan@nur.hmu.edu.krd https://doi.org/10.15218/ejnm.2019.06 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article experience spontaneous tears to the perineum during delivery *2+. women are affected by perineal trauma in the intermediate postnatal period and can extend beyond this period. the impact of perineal trauma to women’s physical, psychological, and social wellbeing may lead to negative effects on family life, disruption of breastfeeding, and sexual relations. a study done in the uk showed that a considerable proportion of women continue to experience short-term complications such as pain, discomfort, dyspareunia, fecal incontinence, and urinary problems during the postpartum period. depending on the severity of perineal trauma, some women may experience continued pain as a longterm effect due an expected complication. in addition, whether of not trauma management was effective plays a role in the continued experience of long-term pain. *3+. a 2009 systematic review of eight randomized trials found that women who gave birth in sites with restricted episiotomy policies experienced less severe perineal trauma, less requirement for suturing, and fewer complications, compared to women who gave birth in sites with routine episiotomy policies. in addition, women who gave birth in sites with restricted episiotomy policies presented no difference in pain, urinary incontinence or dyspareunia, however they had a higher risk of anterior perineal damage *4+. according to two previous studies conducted in kurdistan, most of the midwives reported that the rate of episiotomy was high in their hospitals. they attributed this to the common practices of midwives and obstetricians and policies of the hospitals in their health system *5+. another study showed that most of the reasons given by the midwives for performing episiotomies were not evidence-based *6+. no study was done for determining the rate of episiotomy and perineal tear in kurdistan's maternity hospitals. the authors believe that knowing the prevalence and risk factors of perineal trauma during delivery may lead to a decrease in the incidence of vaginal tear. the aims of this study are to determine the prevalence and risk factors associated with perineal trauma in the maternity teaching hospital in erbil city. owing to the lack of research in this field in erbil city, the results of this study will provide valuable information leading to better practices in the delivery room. in addition, the results of this study may be used to inform and develop new evidence-based guidelines to help decrease the rate of episiotomies and prevent the occurrence of vaginal tears during childbirth. a retrospective cross-sectional study was conducted in the postpartum unit of the maternity teaching hospital located in erbil city in the kurdistan region of iraq. this hospital is a public site hosting 300 patient beds. records of mothers who had been admitted to the delivery room for vaginal delivery (n=1500) during the month of may (2015) were reviewed. as per hospital policy, the decision for performing episiotomy are made by midwives during the second stage of delivery. it is important to note the difference in educational (graduated from a school, institute or college of nursing/midwifery) and experience levels among midwives within the hospital. a tool was developed for the purpose of data collection and included demographic and obstetrical characteristics of mothers who had an episiotomy, vaginal tear or both. prior to data collection, permission to conduct the study was obtained from the scientific and ethics committee of college of nursing/hawler medical university and the erbil general directorate of methods 45 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.06 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article (29.4%) of the same age experienced vaginal tearing in spite of doing an episiotomy. this percentage is much higher compared to women ages 4049, who experienced both an episiotomy and vaginal tearing (p < 0.001). a considerable proportion of primiparous women (28.9%) who experienced an episiotomy also developed a vaginal tear, compared to 17.8% of the grandmultiparous women (p < 0.001). among the women who delivered a big baby, approximately one-third (32.4%) of women experienced tearing in spite of episiotomy compared to 22.7% of the women women who delivered a small baby developed tearing in spite of episiotomy (p = 0.013). there were no significant associations between post-delivery perineum status and residency (p = 0.402), occupation (p = 0.223), time of delivery (p = 0.493), and gender of baby (p = 0.663). table 2 shows that among all the women, the incidence of a vaginal tear was 33.3% regardless of whether or not an episiotomy was done. among these women who experienced an episiotomy, the incidence of a tear was significantly high (35.3%), compared to the women (27.6%) without episiotomy (p = 0.006). binary logistic regression analysis showed that an episiotomy may increase the risk of a tear by more than 30% (or = 1.37; 95% ci 1.045 to 1.798).no significant association was found between the development of a tear with age, parity, and baby weight (table 3). this study reviewed and analyzed the records of 1500 women who experienced a vaginal delivery during a month period. according to who, the prevalence rate of episiotomy vary widely from country to country*1+. compared to the who *7,8+ recommended rate of episiotomy (10%), health. data were analyzed using the statistical package for social sciences (spss, version 22). chi-square test of association was used to compare proportions. fisher’s exact test was used when more than 20% of the cells of the table have expected count less than 5. binary logistic regression was used where the dependent variable was the tear, and the independent variables (included in the regression model) were the factors found to be significantly associated (according to chi square test) with the development of tear. a p value of ≤ 0.05 was considered as statistically significant. the files of 1500 women admitted to the maternity teaching hospital for a vaginal delivery in may 2015 were reviewed. the mean age + sd of the women was 25.89 + 6.19 years, ranging from 15 to 48 years. the median was 25 years. the mean + sd of parity was 2.5 + 1.62. the mean baby weight was 3580.9 + 520 grams, ranging from 1800 to 6000 grams. the median was 3500 grams. of the 1500 women, more than two-thirds of the women (1109) experienced an episiotomy during childbirth. nearly half (47.8%) of the women who experienced an episiotomy during childbirth did not develop a vaginal tear and only 391 (26.1%) women who had episiotomy also experienced vaginal. the results also show that 108 (7.2%) women developed vaginal with knowledge of no episiotomy done and there were 283 (18.9%) women who experienced no episiotomy or vaginal tearing (table 1). there was a significant association between age and perineum status. women less than 20 years of age who had an episiotomy done (57.2%) did not develop vaginal tearing. approximately one-third of the women 46 results erbil journal of nursing & midwifery discussion https://doi.org/10.15218/ejnm.2019.06 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *by fisher’s exact test 47 table 1: risk factors of episiotomy and tears among study sample erbil journal of nursing & midwifery variables episiotomy (no tear) tear (no episiotomy) both none p-value n no. % no. % no. % no. % age group <20 201 115 (57.2) 7 (3.5) 59 (29.4) 20 (10.0) <0.001 20-29 867 421 (48.6) 66 (7.6) 243 (28) 137 (15.8) 30-39 374 159 (42.5) 30 (8) 82 (21.9) 103 (27.5) 40-49 58 23 (39.7) 5 (8.6) 7 (12.1) 23 (39.7) residency urban 672 330 (49.1) 43 (6.4) 181 (26.9) 118 (17.6) 0.402 rural 828 388 (46.9) 65 (7.9) 210 (25.4) 165 (19.9) occupation housewife 1398 665 (47.6) 103 (7.4) 358 (25.6) 272 (19.5) 0.223 employed 79 41 (51.9) 5 (6.3) 24 (304) 9 (11.4) student 23 12 (52.2) 0 (0) 9 (39.1) 2 (8.7) parity primipara 484 311 (64.3) 15 (3.1) 140 (28.9) 18 (3.7) <0.001 multipara 847 367 (43.3) 83 (9.8) 221 (26.1) 176 (20.8) grandmulti 169 40 (23.7) 10 (5.9) 30 (17.8) 89 (52.7) time of delivery morning 374 187 (50) 31 (8.3) 84 (22.5) 72 (19.3) 0.493 evening 394 191 (48.5) 27 (6.9) 110 (27.9) 66 (16.8) night 732 340 (46.4) 50 (6.8) 197 (26.9) 145 (19.8) birth weight low birth weight 22 9 (40.9) 1 (4.5 ) 5 (22.7) 7 (31.8) 0.013 normal 1077 540 (50.1) 83 (7.7) 256 (23.8) 198 (18.4) big baby 401 169 (42.1) 24 (6) 130 (32.4) 78 (19.5) sex of baby male 786 387 (49.2) 53 (6.7) 202 (25.7) 144 (18.3) female 707 329 (46.5) 54 (7.6) 186 (26.3) 138 (19.5) 0.663* twin 7 2 (28.6) 1 (14.3) 3 (42.9) 1 (14.3) total 1500 718 (47.8) 108 (7.2) 391 (26.1) 283 (18.9) table 2: incidence of tear by episiotomy no tear tear total episiotomy no. % no. % no. % p-value no 283 72.4 108 27.6 391 100 0.006 yes 718 64.7 391 35.3 1109 100 total 1001 66.7 499 33.3 1500 100 https://doi.org/10.15218/ejnm.2019.06 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article the rate of episiotomy was significantly higher (73.9%) in this study. a study in turkey (karacam et al., 2013) , of 396 prim parous women found that among the women 56.35% experienced an episiotomy, 40.2% experienced vaginal tearing, 11.6% experienced both and 3.5% had an intact perineum. these results are not in agreement with the results of this present study *9+. the reported rates of episiotomy, tear and intact perineum in a study done in iran (rasouli et al., 2016) were 41.5%, 34.7% and 23.8% respectively, in which the rate of tear is higher than the results of the present study *10+. the overall rate of episiotomies in a study done in saudi arabia was 51.2%, which is lower compared to the overall rate of episiotomies in this study *11+. the rates of episiotomies and tears in this study are lower when compared to the results obtained from studies done in italy, and the united states, *12,13+ but are higher when compared to results obtained from studies done in the united kingdom and nigeria *5,14-17+. findings from this current study indicate a significant association between age (p=0.187), parity (p=0.049), and birth weight (p=0.033) with perineum status, which agree with the results of other studies done in turkey, the united kingdom, the united states and singapore *9,15,18,19+. one study (howden et al., 20014) found that high educational status, marriage, multiparty, and a history of cesarean delivery among women 30 years of age and older are independent are independent risk factors for an episiotomy *13+. another study (enyindah et al., 2007) found the rate of episiotomy decreased with high parity while the rate of perineal tears slightly increased with parity. 48 table 3: spss output for logistic regression analysis between tear as a dependent variable with several covariates. erbil journal of nursing & midwifery covariates b p or 95% c.i. for or lower upper age (years) 0.187 < 20 0.553 0.140 1.739 0.834 3.626 20-29 0.614 0.074 1.849 0.941 3.631 30-39 0.398 0.255 1.488 0.750 2.953 40-49 (reference) parity 0.049 primi 0.174 0.455 1.190 0.754 1.880 multi 0.401 0.053 1.494 0.994 2.245 grand-multi (reference) baby weight 0.033 low birth weight (reference) normal birth weight 0.189 0.699 1.208 0.463 3.154 big baby 0.509 0.306 1.663 0.628 4.405 episiotomy 0.315 0.023 1.370 1.045 1.798 constant -2.028 0.001 0.132 https://doi.org/10.15218/ejnm.2019.06 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article nulliparity, vaginal breech deliveries, and instrumental deliveries were identified as risk factors for an episiotomy *16+. in the present study, the incidence of a tear was significantly higher among those who had an episiotomy, compared with those without one. also, the results show that having an episiotomy will increase the risk of a tear by more than 30%. it is noteworthy that all cases had a mediolateral episiotomy. the increasing risk of a tear in case of episiotomy may be due to the small size of the episiotomy, timing of the episiotomy or the incorrect technique of delivery of the baby by the midwives. a routine practice among midwives of the maternity teaching hospital is ‘hand on’. midwives in this hospital start lubrication and dilatation of the vaginal opening once the 1st stage of labor has been completed. ritgen maneuver applies for all vaginal deliveries at the time of head crowning, as well. midwives are allowed to do the episiotomy but not to suture it, which is the responsibility of the obstetricians according to the hospital policy. we observed that midwives perform as small an episiotomy as possible to decrease the surgical trauma to the perineum. these results are supported by results of the review of six randomized trials which showed no differences in vaginal or perineal trauma between patients with and without an episiotomy *20+. restrictive use of episiotomy policies helps women experience less severe perineal trauma, although overall, women experienced more anterior perineal damage with restrictive episiotomy *17,21+. the limitations of the present study were the variations in recording types and severity of tears, indication of an episiotomy, mother position during the second stage of labor, midwifery technique in perineal support and baby head circumference. in addition, the relationship between oxytocin therapy with the mother's perineal status was not studied. maternal age, parity, and birth weight are associated risk factors for perineal trauma resulting in vaginal tearing or an episiotomy. it was found that there is a correlation between having an episiotomy and increased risk factor for vaginal tears. the prevalence of episiotomies in this study is significantly higher than the who recommendation. the results from this study suggests that further research is necessary to inform, develop, and implement policies regarding restrictive use of episiotomy. there is no conflict of interest. *1+ kettle c, tohill s. perineal care. bmj clinical evidence 2008; 09:1401 *2+ graham id, carroli g, davies c, medves jm. episiotomy rates around the world: an update. birth 2005; 32(3):219-23. doi: 10.1111/ j.0730-7659.2005.00373.x *3+ alnakash ah, jafar s, abdul-raheem y. whether selective or routine episiotomy is more useful to protect anal sphincter in primiparous women. iraqi journal of medical science 2012; 11(1):26-32 [4] carroli g, mignini l. episiotomy for vaginal birth (review). cochrane database of systematic reviews 2009, issue 1. doi: 10.1002/14651858.cd000081.pub2. *5+ piro ss, ahmed hm. midwives' perspectives regarding episiotomy practice in kurdistan region/iraq. zanco journal of medical science 2016; 20 (1): 1233-43. doi: http:// dx.doi.org/10.15218/zjms.2016.001. *6+ ahmed hm. midwives’ clinical reasons for performing episiotomies in the kurdistan region: are they evidence-based? sultan qaboos university medical journal 2014 aug; 14 (3): e369–74. 49 erbil journal of nursing & midwifery counclusions conflict of interest references https://www.ncbi.nlm.nih.gov/pubmed/19445799 https://www.ncbi.nlm.nih.gov/pubmed/19445799 https://doi.org/10.1111/j.0730-7659.2005.00373.x https://doi.org/10.1111/j.0730-7659.2005.00373.x http://dx.doi.org/10.15218/zjms.2016.001 http://dx.doi.org/10.15218/zjms.2016.001 https://doi.org/10.15218/ejnm.2019.06 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *18+ gossett dr, dunsmoor su. episiotomy practice in a community hospital setting. journal of reproductive medicine 2008; 53(10):8038. *19+ wu lc, malhotra r, allen jc, lie d, tan tc, ostbye t. risk factors and midwife-reported reasons for episiotomy in women undergoing normal vaginal delivery. arch gynecology and obstetrics 2013; 288:1249-56. doi: 10.1007/s00404-013-2897-6. epub 2013 may 26. *20+ repke j. when is episiotomy warranted? what the evidence shows. obg management 2003;15(10):46-54 *21+ klein mc, gauthier rj, robbins jm, kaczorowski j, jorgensen sh, franco ed, et al. episiotomy should be used only for specified fetal-maternal indications. american journal of obstetrics and gynecology 1994; 171:591-8 *7+ world health organization division of family health maternal health and safe motherhood. care in normal birth: a practical guide. report of a technical working group. geneva: world health organization; 1996. *8+ holmes d, baker pn ed. midwifery by ten teachers. london, uk: crc press; 2006. pp. 239–41 *9+ karacam z, ekmen h, calisir h, seker s. prevalence of episiotomy in primiparas, related conditions, and effects of episiotomy on suture materials used, perineal pain, wound healing 3 weeks postpartum, in turkey: a prospective follow-up study. iran journal of nursing and midwifery research 2013; 18 (3): 237-45. *10+ rasouli m, keramat a, khosravi a, mohabatpour z. prevalence and factors associated with episiotomy in shahroud city, northeast of iran. international journal of women’s health and reproduction sciences 2016; 4 (3): 125–9. doi: 10.15296/ijwhr.2016.29 *11+ saadia z. rates and indicators for episiotomy in modern obstetrics – a study from saudi arabia. mater sociomed 2014 jun; 26(3): 188 -190. doi: 10.5455/msm.2014.26.188-190 *12+ bertozzi s, londero a, fruscalzo a, driul l, delneri c, calcagno a, etal. impact of episiotomy on pelvic floor disorders and their influence on women's wellness after the sixth month postpartum: a retrospective study. bmc women's health 2011; 11(12). doi:10.1186/1472-6874-11-12 *13+ howden nl, weber am, meyn la. episiotomy use among residents and faculty compared with private practitioners. obstetrics and gynecology 2004; 103(1): 114-8. *14+ inyang-etoh ec, umoiyoho aj. the practice of episiotomy in a university teaching hospital in nigeria: how satisfactory? international journal of medicine and biomedicl research 2012; 1(1):68-72 *15+ robinson j, norwitz e, cohen a, lieberman e. predictors of episiotomy use at first spontaneous vaginal delivery. obstetrics and gynecology 2000; 96(2): 214-18 *16+ enyindah ce, fiebai po, se anya, okpani ao. episiotomy and perineal trauma prevalence and obstetric risk factors in port harcourt, nigeria. nigerian journal of medicine 2007; 16(3):242-5 *17+ chigbu b, onwere s, aluka c, kamanu c, adibe e. factors influencing the use of episiotomy during vaginal delivery in south eastern nigeria. east african medical journal 2008; 85(5): 240-3 50 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.01 ejnm, vol. 1, no. (1), may, 2018 original article impact of nurse’s satisfaction on work performance abstract introduction employees are the most important resources of all organizations. how they feel about the work and the outcomes from it have a direct impact on the organization’s performance and stability. a job is a paid position of regular employment and employment is required to be financially independent and have control over life *1+. hulin and judge (2003) noted that job satisfaction includes multidimensional psychological responses to one's job and that such responses have cognitive (evaluative), affective (emotional), and behavioral components *2+. job satisfaction is defined as, “the level of contentment a person feels regarding their job while work performance is the work related activities expected from an employee and how well those activities are executed by them” *3+. to measure work performance, the quality of the job has traditionally understood as being represented by the wage level, while in some sociological or industrial relations studies, it was related to working conditions. recent developments in economics and socio-economic approaches propose additional dimensions to the definition of job quality *4+. the recent framework suggested by green(2006) integrates these ideas and recognizes the multidimensional character of job quality through the evolution of different dimensions that including background and objective: a high satisfaction of nurses implies an improvement in effectiveness and performance in doing work or health care service. this study aimed to find out the relationship between nurse’s job satisfaction and their work performance in the hospital while providing health care. methods: a descriptive cross-sectional study was carried out at both hawler and rizgary teaching hospitals in erbil city of the kurdistan region of iraq. a randomized-clustered sampling technique was used for enrolling 89 nurses and 27 their team-leaders through a direct interview by a questionnaire to assess nurse’s job satisfaction by researcher and evaluate work performance by their team-leaders. the outcome focused on the correlation coefficient to find out the correlation between job satisfaction and work performance of nurses. results: the majority of the study sample was between 20 and 32 years old, institute graduated, had fewer than five years of experience, and single among nurses with 33 and 45 years old, college graduated, more than five years, and married among team-leaders, from urban areas of both groups. most of the nurses had fairly job satisfaction and team-leaders think that the nurses need some improvement in their work performance. conclusion: there was a strong positive correlation between nurse’s job satisfaction and their work performance in the hospital during providing health care. keywords: nurse; team-leader; job satisfaction; health work performance; correlation. dara abdulla al-banna; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: daraaq@nur.hmu.edu.krd) 2 erbil journal of nursing & midwifery received: 30/8/2017 accepted: 19/10/2017 published: 5/5/2018 https://doi.org/10.15218/ejnm.2018.01 ejnm, vol. 1, no. (1), may, 2018 original article skills; work effort and intensification’ workers’ discretion; wages’ risk and job insecurity’ and workers’ well-being and thus takes into account the multidimensional nature of job quality in work performance *5+. a nurse with a high level of job satisfaction holds positive attitudes towards his or her job in health care, while a nurse who is dissatisfied with his or her job may hold negative attitudes about the job. therefore, job satisfaction is a key issue for health care professionals around the world and investigations reveal first of all that the organizational features of a structure usually a hospital can greatly influence the job satisfaction of nurses *6+. however, the total organizational performance depends on the efficient and effective performance of individual employees of the organization. therefore, every organization places a considerable reliance on their individual employee performance to gain high productivity in the organization *7+. a large empirical literature exists that explores the determinants of organizational performance including the determinants of financial performance and the determinants of labor productivity. many studies are based on firm-level data. one might argue, however, that, in order to understand the determinants of firm performance, it is important to analyze employee level of job satisfaction given that the behavior of employees and the decisions they make may influence workplace performance *8+. from the above definitions, it is clear that nurse’s job satisfaction is an unobservable variable. job satisfaction can be affected by the work performance of nursing care and can directly impact the productivity of each organization or hospital. in examining in outcomes of job satisfaction, it is important to breakdown the analysis into a series of specific set of variables regarding nurse’s satisfaction and evaluating form of work performance. the main objective of this study was to find out the correlation between nurse’s job satisfaction and their work performance, evaluated by their team-leaders. a cross-sectional study design was conducted among nurses and their teamleaders to find out the relationship between job satisfaction and their work performance, from april to july 2017 at two hospitals of rizgary and hawler teaching hospitals in erbil city in the kurdistan region of iraq. one hundred sixteen nurses enrolled in this study. they were divided in to two groups: the first group consisted of 89 nurses in different wards and units; the second group included 27 team-leaders of the nurses. the participants are working in the two hospitals of rizgary and hawler teaching hospitals in erbil city in the kurdistan region of iraq. non-randomized clustered sampling technique was used to establish a representative sample of the target population, according to the study’s inclusion and exclusion criteria. both men and women were included. agreed to be subject in this study with good personal communication. administrative nurses (nurses working in offices without direct contact with patients) and who was in vacation and night shift was excluded. nurses group were asked about their job satisfaction, while team-leaders group were asked to evaluate these nurses who participated in the study. the sample size estimated based on the following parameters through the g-power software version 3.1 in two tails: alpha i error/ level of significance = 0.05 in 95% confidence interval power (1-beta ii error) = 80% = 0.8, effect size (0.257) of correlation (0.0663) of the previous study. the data were collected through a direct interview by the researcher in the kurdish language after translating from english versions and vice versus. methods 3 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.01 ejnm, vol. 1, no. (1), may, 2018 original article ethical and scientific committees in the college of nursing/ hawler medical university. informal oral consent was obtained from each participant, and all patients’ information was kept confidential. in addition, the researcher told each participant that their participation was voluntary work, and that they were free to leave at any time, even the interview process was not finished. after data collection, the variables and data were entered to statistical application (statistical package for social science -spss version 23). the data were analyzed through using spss software that included descriptive statistical analysis (frequency, percentage, mean, and standard deviation) and inferential statistical analysis (spearman correlation coefficient). the confidence interval was 95%. the p-value of each test ≤ 0.05 considered as statistically significant, power 0.80, and correlation between ± 1. table 1 shows the sociodemographic characteristics of the 89 nurses and 27 their team-leaders. regarding age group, the highest percentage of the study sample was between ages 20-32 years old among nurses (76.5%) while it was between ages 33-45 years old among teamleaders (70.4%). more than half of the study sample were female among nurses; but most of the team-leaders were male (92.6%). concerning the level of education, among the nurses the majority had graduated from a medical institute (75.3%), while half of the team-leaders had graduated from a medical institute and others from nursing college. half of the nurses had fewer than five years of experience, but among team-leaders, the majority had more than five years of experience (89%). half of the nurses were unmarried, while most of team-leaders were married (85.2%). the data collection tool was prepared by the researcher based on literature review, prior studies, and expert recommendations from the field. the questionnaire consisted of two different forms. the first questionnaire designed for nurses included 17 sociodemographic characteristics of the nurse and questions regarding job satisfaction, which that contained 17 questions distributed on five main domains “general working conditions, pay and promotion potential, work relationships, use of skills and abilities, and work activities”. job satisfaction questions allowed for three levels of satisfaction (unsatisfied, moderately satisfied, and satisfied), scored from one to three. the second questionnaire for teamleaders who leading above described nurses that included 14 questions related to sociodemographic characteristics of the team-leaders and 14 questions regarding evaluation of nurse’s work performance of health care by their team-leader with responds of five level of work performance (major improvement needed, some improvement needed, meets expectations, often exceeds expectations, and consistently exceeds expectations) scored from one to five. the validity of the questionnaire was checked initially by experts from different related of nursing and administrative specialties. the expert responses were based on agreement or disagreement with items of questionnaire. the results indicated that all experts agreed the content of the questionnaire with some modifications. the researcher took into consideration their responses and prepared the final version of the questionnaire. a pilot study was carried out in two wards of each hospital (11 nurses and 2 team-leaders) to determine the reliability of the questionnaire (internal consistency by split-half). the alpha correlation coefficient was 0.842, which is statistically adequate. the formal permission obtained from both of the 4 results erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.01 ejnm, vol. 1, no. (1), may, 2018 original article finally, most of the study participants were from urban areas including 86.5% of nurses and 100% of team-leaders. table 2 shows nurses’ job satisfaction about their work. the majority of nurses responded saying they were fairly satisfied regarding general working conditions and work relationships (46.1% and 43.8% respectively). however, the majority of the participants responded saying they were dissatisfied regarding pay and promotion potential, use of skills and abilities, and work activities (52.8%, 48.3%, and 46.1% respectively). the overall level of nurse’s satisfaction was fairly satisfied which present 69.7%, but 21.3% and 9% for each of dissatisfied and satisfied respectively. regarding overall evaluation of nurse’s work performance by their team-leaders, results in table 3 show that most the majority of the team-leaders indicated that the nurses required some improvements (85.2%), while 14.8% of the team-leaders suggested the nurses required major improvements unfortunately, there no nurses met the expectations of their work performance of providing care. table 4 describes the correlation between the job satisfactions of nurses with their evaluation of work performance by their team-leaders which there is a nearly matching mean scores between the above two variables (m ± sd = 1.88 ± 0.540 and 2.04 ± 0.366 respectively). there is a very highly statistical significant correlation between nurse’s job satisfaction and their work performance (p-value = < 0.001). the correlation between the two described variables is strong (r = 0.712) with positive direction of the correlation. 5 table 1: sociodemographic characteristics of nurses and team-leaders sociodemographic characteristics nurse (n=89) teamleader (n=27) f (%) f (%) age group (years) 20-32 68 (76.5) 4 (14.8) 33-45 19 (21.3) 19 (70.4) 46-58 2 (2.2) 4 (14.8) gender male 43 (48.3) 25 (92.6) female 46 (51.7) 2 (7.4) education level institute graduated 67 (75.3) 13 (48.1) college graduated 22 (24.7) 14 (51.9) years of experience ≤ 5 49 (55.1) 3 (11.1) 6-10 26 (29.2) 11 (40.7) 11-15 8 (9) 10 (37.1) > 15 6 (6.7) 3 (11.1) marital status single 48 (53.9) 4 (14.8) married 39 (43.9) 23 (85.2) divorced 2 (2.2) 0 (0) residency area urban 77 (86.5) 27 (100) rural 12 (13.5) 0 (0) total 89 (100) 27 (100) table 2: level of job satisfaction among nurses questions regarding nurse’s job satisfaction dissatisfied moderately satisfied satisfied f (%) f (%) f (%) general working conditions 15 (16.9) 41 (46.1) 33 (37.1) pay and promotion potential 47 (52.8) 39 (43.8) 3 (3.4) work relationships 13 (14.6) 39 (43.8) 37 (41.6) use of skills and abilities 43 (48.3) 30 (33.7) 16 (18) work activities 41 (46.1) 39 (43.8) 9 (10.1) overall nurse satisfaction 19 (21.3) 62 (69.7) 8 (9) erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.01 ejnm, vol. 1, no. (1), may, 2018 original article the aim of the current study was to find out the relationship between nurse’s job satisfaction and their work performance which was evaluated by their team leaders. regarding the sociodemographic characteristics of both nurses and team-leaders, the highest percentage of the study sample was between ages 20 to 32 years old among nurses, while it was between ages 33 to 45 years old among team-leaders. because all of the nurses graduated from medical institute and college of nursing and these institutions are newer than preparatory of nursing, the majority of the nurses are in the twenties of age. more than half of the study sample was female among nurses; but most of the teamleaders were male. traditionally most of leaders are male. concerning the level of education, among the nurses, most had graduated from a medical institute, while half of the team-leaders were graduates from the medical institute and others from the college of nursing. half of the nurses are single, while most of team-leaders were married. these results supported by a study done in kingdom saudi arabia by almaliki et al in 2012 they found that the highest percentage of their study sample of nurses were aged between 20 and 29 years old, female, had a diploma, and were not married *9,10+. half the nurses had fewer than five years of experience, but most team-leaders had more than five years’ experience. this result is supported by the study which was done in public hospitals-libya by ali et al in 2014, which showed that nearly half of the staff has fewer than five years with regards to working experience in hospitals *2+. concerning the level of job satisfaction among nurses, the highest percentage of the nurses answered fairly satisfied regarding general working conditions and work relationships, while the highest percentage of the participants answered that they were dissatisfied table 4: association between nurse’s job satisfaction and their work performance 6 discussion association between nurse’s job satisfaction and their work performance mean standard deviation p-value correlation coefficient strength direction nurse’s job satisfaction 1.88 0.540 < 0.001 vhs 0.712 strong positive nurse’s work performance 2.04 0.366 table 3: overall evaluation of nurse’s work performance by their team-leaders overall evaluation of nurse’s work performance by their team-leaders f (%) major improvement needed 4 (14.8) some improvement needed 23 (85.2) meets expectations 0 (0) often exceeds expectations 0 (0) consistently exceeds expectations 0 (0) total 27 (100) erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.01 ejnm, vol. 1, no. (1), may, 2018 original article regarding pay and promotion potential, use of skills and abilities, and work activities. the overall level of nurses’ satisfaction was fairly satisfied and others were dissatisfied with less satisfied nurses. the political instability, financial crises, lack of salary and payment, wars, food insecurity, unclarity of future and missing of basic human needs affected employees’ satisfaction particularly among nurses. the present findings agreed with other studied done in different areas and countries as following: in a study done in libya in 2014 under the title of “job satisfaction, organizational behavior, and training to improve employees performance” about the relationship between hospital staff and human resource managers, the relationship between hospital staff and managers is sometimes breakable. the nurses and staff may feel uncomfortable giving unfavorable opinions about managers because of worries about job security, while managers and supervisors wonders if nurses and staff are working to the best of their ability. the absence of incentives and low salaries were two main reasons for reported poor job satisfaction, and according to the job satisfaction factor in medical sector had a negative effect on staff’s performance. they also measured the incentives that employees received during their past period working in public hospitals. because incentives and salary are of the main factors that increase and improve performance at any organization. the result showed that 38 out of 56 respondents were disagreed and strongly disagreed. the incentive systems to medical and staff in libyan public hospitals was approximately the major percentage of hospital staff revealed no incentives and less salary have been given to them in the past, which shows the lack of real incentives and salary giving to hospital staff in order to give them higher motivation and push them to work better and give their best output to their organization. the findings of the present study regarding the nurses job satisfaction supported findings from other studies conducted in bangalore, iran, and turkey by ramesh et al, saraji and dargahi, and sirin in 2013, 2006, and 2015. the findings revealed that respondents were dissatisfied with their work life and these findings are consistent with findings of a number of previous studies where nurses were not satisfied with their work life *2,11 -13+. regarding the overall evaluation of nurse work performance by their team-leaders, most of the team-leaders suggested that nurses required some improvement, while fewer team-leaders suggested that the nurses required of needing the major improvement by nurses. unfortunately, there are no nurses meet the expectations in their work performance of providing health care. this is because of that most of the nurses were fairly or not satisfied with their job. the study results agreed with the study done by becton and matthews in the usa during the years 2011 to 2012, they found that the nursing quality has a significant impact on patient outcomes. research has shown that the job performance of nurses is the single largest predictor of patients’ satisfaction and significantly affects patients’ health outcomes during and after hospitalization. therefore, the consequences of poor nurse performance are significant to improve the job performance of nurses *14+. the present study found that there is an association between nurse’s job satisfaction and their work performance which was evaluated by their team-leader. there was a very high statistically significant correlation between nurse’s job satisfaction and their work performance. the correlation between the two described variables is strong with the positive direction of the correlation. this association is important for health care 7 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.01 ejnm, vol. 1, no. (1), may, 2018 original article work performance in hospital in providing health care. the implications of this study are helpful for planning and increasing the level of nurse job satisfaction. this could be done through improving working hours, flexibility in scheduling, area of work, and offering adequate amount of paid vacation time or sick leave; in security and potential promotion like pay of salary in its time and amount, assurance, and job security; also in elevating work relationships for increasing relationships with coworkers, team-leaders, supervisors, and head of departments; improving skills and abilities through participating nurses in training courses, opportunity to learn new skills then utilizing their skills and talents. furthermore, it is important to increase work activities including improving the variety of job responsibilities, increasing the degree of independence, delegating authorities, and adequate opportunity for periodic changes in duties. study limitations although the present study described important findings, no study is without limitations, first, this study was conducted within two large hospitals within the same erbil city. while the study focused on the prediction of the job performance of nurses, it is possible that the present study findings may be a performance and outcome of some locally or regionally specific factors which could not be controlled. second, this study focused on nurses who are working in these two big hospitals. it should be noted that nurses are working in other types of healthcare organizations in addition to hospitals, such as nursing homes, health clinics, medical practices, and other outside places of the hospital. as a result, the study design may limit the generalizability of the results to other settings. future studies could include nurses from a variety of healthcare organizations in a variety of locations. and hospital outcomes. this expected result supported by many studies. authors platis et al presented a study under the title “relation between job satisfaction and job performance in healthcare services”, they showed that self-satisfaction of quantity of work versus self-satisfaction of productivity has a significant, strong, and positive correlation (r=0.76). in this work investigation of the performance for the quality of job satisfaction and self-job satisfaction for nurses is taking place. for the job satisfaction, two factors have been introduced which are manager administration and job productivity, explaining the 68.7% of the total information. furthermore, the ability of nursing managers to communicate with the employees and respect their opinions in considered of high importance for the nursing staff satisfaction *9+. in a study which was done in pakistan by khan et al, in 2011 entitled “impact of job satisfaction on employee performance: an empirical study of autonomous medical institutions of pakistan” they found that the relationship between productivity (often under the form of personal achievements) and satisfaction in job is also considered strong *15+. in a study about employee motivation and organizational performance, employee attitude and job performance are essential to the success of the organization, regardless big or small. in the modern workplace, human resources are valued above all other values, so motivated, happy personal feelings, opinions, attitudes of nurses and committed employees are the productive employees and play a critical role in their performance *16+. creating and maintaining a healthy work life for nurses is very important to improve their work satisfaction, which lead to improves nursing care outcomes *10+. the present study concluded that there was a strong positive association between nurse job satisfaction and their 8 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.01 ejnm, vol. 1, no. (1), may, 2018 original article *14+ becton jb, matthews mc, hartley dl, whitaker ld. using biodata as a predictor of errors, tardiness, policy violations, overall job performance, and turnover among nurses. journal of management & organization. 2012 sep;18(5):714-27. *15+ khan ah, ahmad i, aleem m, hamed w. impact of job satisfaction on employee performance: an empirical study of autonomous medical institutions of pakistan. international journal of management and innovation. 2011 jul 1;3(2):1. *16+ dobre oi. employee motivation and organizational performance. review of applied socio-economic research. 2013;5(1):53-60. references my warmest thanks and wish of health go to the sample who participated in this study. i express my much appreciation to everyone who helped directly or indirectly with the accomplishment of this study particularly during data collection. the author reported no conflict of interests. *1+ munisamy s. identifying factors that influence job performance amongst employees in oil palm plantation-fass final project (psychology). 2013. *2+ ali ae, kertahadi mc, nayati h. job satisfaction, organizational behavior, and training to improve employees performance acase: public hospitals–libya. journal of business and management. 2014;16(8):7582. *3+ wright be, davis bs. job satisfaction in the public sector: the role of the work environment. the american review of public administration. 2003 mar;33(1):7090. *4+ gallie d, editor. employment regimes and the quality of work. oxford university press; 2009. *5+ davoine l, erhel c, guergoat-larivière m. a taxonomy of european labour markets using quality indicators. 2008. *6+ bhatnagar k, srivastava k. job satisfaction in healthcare organizations. industrial psychiatry journal. 2012 jan;21(1):75. *7+ pushpakumari md. the impact of job satisfaction on job performance: an empirical analysis. in city forum 2008 jan 1 (vol. 9, no. 1, pp. 89-105). *8+ brown s, mchardy j, mcnabb r, taylor k. workplace performance, worker commitment, and loyalty. journal of economics & management strategy. 2011 sep 1;20(3):925-55. *9+ platis c, reklitis p, zimeras s. relation between job satisfaction and job performance in healthcare services. procedia-social and behavioral sciences. 2015 feb 12;175:480-7. *10+ almalki mj, fitzgerald g, clark m. the relationship between quality of work life and turnover intention of primary health care nurses in saudi arabia. bmc health services research. 2012 sep 12;12(1):314. *11+ sirin m, sokmen sm. quality of nursing work life scale: the psychometric evaluation of the turkish version. international journal of caring sciences. 2015 sep 1;8(3):543. *12+ ramesh n, nisha c, josephine am, thomas s, joseph b. a study on quality of work life among nurses in a medical college hospital in bangalore. national journal of community medicine.2013;4(3): 471-74 9 acknowledgement conflicts of interest erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.12 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article association of rhesus blood group (rhd) and toxoplasmosis in women with miscarriage in erbil abstract introduction toxoplasmosis is a cosmopolitan zoonosis caused by the obligate intracellular coccidian parasite toxoplasma gondii (t. gondii) toxoplasmosis has worldwide distribution and the incidence of the disease varies around the world [1-,3]. major routes of t. gondii infection include ingestion of food or water that contaminated with oocysts shed by cats or by eating under cooked or raw meat containing tissue cysts [4]. the prevalence of infection depends on age, geographical situation, food habits as well as many epidemiological factors. the clinical spectrum of t. gondii infection varies from background and objective: toxoplasmosis has worldwide distribution and the incidence of the disease varies around the world. human blood is categorized within two main systems: abo and rhesus factor blood group systems. the rhesus factor protein which is the rhesus factor gene product and a major component in the rh blood group system carries the strongest blood group immunogen, this study aimed to estimate the sero-prevalence of toxoplasmosis and to investigate the distribution of abo and rhesus factor blood groups among women with toxoplasma infection. methods: this cross-sectional study was carried out in erbil from september 2017 to april 2018, in which 200 women with history of abortion were enrolled. blood samples were collected and tested for anti-toxoplasma igm antibody using direct agglutination and enzyme linked immunosorbent assay techniques. results: the percentages of anti-toxoplasma igm was 33.5% .and 65 (97%) of the seropositive women were rhd negative. significant relationship between rhd blood group and toxoplasma seropositive was observed while no significant relationship was found between toxoplasmosis and each abo phenotype and demographic characteristics. comparably, high sero-prevalence rate of anti-toxoplasma antibody was found among age group 21-40 years old (73.1%), however, it was statistically nonsignificant. conclusion: anti toxoplasma igm antibodies was relatively high among women with history of abortion in erbil and rhesus factor positive was significant. keywords: toxoplasmosis, rh factor, abo blood group banaz sadik smael; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: banaz.sadiq@nur.hmu.edu.krd) sadiya abdulla palpitany; department of nursing, college of nursing, hawler medical university, erbil, iraq. kazhal hassan hamarahim; department of nursing, college of nursing, hawler medical university, erbil, iraq. 94 erbil journal of nursing & midwifery received: 10/9/2018 accepted: 27/10/2018 published: 30/11/2018 https://doi.org/10.15218/ejnm.2018.12 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article an asymptomatic state to sever illness [5,6]. human blood is categorized within two main systems: abo blood group and rhd blood group systems. the rhd protein which is the rhd gene product and a major component in the rh blood group system carries the strongest blood group immunogen, the d antigen. [7,8]. this antigen is absent in a significant minority (about 16%) of the population (rh-negatives) due to rhd deletion or alternation. the structure homology data suggest that the rhd protein acts as an ion pump of uncertain specificity and unknown physiological role [9,10]. except for the well-known but artificial role of the rhd protein in hemolytic disease of newborns, no phenotypic expression of the absence or presence of rhd on the surface of erythrocytes of a subject was known for more than sixty years. recently, two studies on two populations of blood donors, one of conscripts [11], and the other of university students have shown that rh-positive subjects and rhd positive heterozygotes in particular, are protected against latent toxoplasmosis-induced impairment of reaction times. a prospective cohort study performed on nearly four thousand military drivers has found that rh-negative toxoplasma-infected subjects have about three times higher probability of a traffic accident than rh-negative toxoplasma-free subjects or than rh-positive (toxoplasma free or toxoplasma-infected) subjects [12] . the importance of this study is due to high prevalence of this infection in our population especially in slaughtered houses for animals in which the sero prevalence of anti toxoplasma antibodies were high in erbil city among animals which directly affect human [13].. the seropositive percentages of toxoplasma among pregnant women in 2002 were showed the highest frequency (72.4%) in erbil city [14]. during 2015 high percentages of igg and igm antibodies of t were found among depressive pregnant woman [15]. this study aimed to determine the seroprevalence of anti t.gondii antibodies and to explore whether rh-positive subjects are protected against the toxoplasma infection. a cross-sectional study was conducted during september 2017 until april 2018, in which 200 pregnant women who had a history of abortion and attended maternity teaching hospital in erbil city were invited to be enrolled in the study. a verbal consent was obtained from each participant through a direct interview, a structured questionnaire was completed that included demographic data (age, residency, and education). approximately 10 ml of venous blood was drawn at the same time and divided into two parts, first for detecting t. gondii antibodies and the second was used for blood group testing. sera were separated after centrifugation at 3000 rpm for 10 minutes. diagnosis of toxoplasmosis was determined by two methods enzyme linked immune absorbent (elisa) and direct agglutination test, first direct latex agglutination test was done by utilizing toxocell (toxocell latex, barcelona, spain); this technique was used for direct detection of t.gondii antibodies according to the manufacturer’s instructions. the detection of igm anti-t. gondii was done by elisa biokit, toxo igm (biomieux, spain) with cut-off value ≥ 0.65. the abo phenotypes then identified by the standard test tube hemagglutination using commercial monoclonal anti-sera anti-a, anti-b and anti-a,b for direct typing and standard red blood cells a1 and b for reverse typing (fresenius kabi, brazil). methods 95 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.12 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article the frequencies of the four abo blood group phenotypes were 20.5% for group a, 25% for group b, 9% for group ab, and 45.5% for group o, and 66.5% of the cases were rh positive and 33.5% of them were rh negative. of the participants, 33.5% presented positive anti toxoplasma antibody and 66.5% had negative serological results for anti-t. gondii antibodies as shown in table 2. table 2: frequencies of the abo blood group phenotypes in pregnant women with positive and negative serology for anti-toxoplasma gondii antibodies table (3), reveals the association of sociodemographic data and maternal toxoplasmosis. demographic characteristics those were not significantly associated with toxoplasmosis (p > 0.05) in this group were: age group, residence area and educational level with (p-value= 0.261, 0.644 and 0.958) respectively. however, while not significant, a high sero prevalence rate of toxoplasmosis was among the age group of 21 to 40 years old (73.1%), with the majority of them being from rural area (55.2%) and being educated (47.8%). the lowest percentage of infection was among age group 41 and over (11.9%). the overall seropositive prevalence rate is (33.5%). research proposal was approved by scientific committee of college of nursing at hawler medical university. informed consent was taken from participants of the study after explaining the purposes of the study. the data was analyzed by using percentages and frequency also the x² test for significance differences. the probability level of ≤ 0.05 is accepted as statistically significant. statistical analyses are carried out by spss software (version 20; spss, inc., usa). table 1 shows the demographic characteristics of the 200 women with a history of abortion. according to age, which was divided into three groups, a higher percentage of age in this study sample was found among age group 21-40 years old (79%), while lower percentage was among 41 and over (16%). most lived in a rural area (57.5%). regarding educational level, most were non-educated (52.5%), and the remaining were educated (47.5%). table 1: demographic characteristics of the study sample: 96 results erbil journal of nursing & midwifery demographic characteristics f (%) age group 20 & under 26(13) 21-40 158(79) 41&over 16(8) residence urban 85(42.5) rural 115(57.5) educational status educated 95(47.5) noneducated 105(52.5) blood group f (%) a 41 (20.5) b 50(25) ab 18(9) o 91(45.5) rh factor positive 133(66.5) negative 67(33.5) toxoplasmosis positive 67(33.5) negative 133(66.5) https://doi.org/10.15218/ejnm.2018.12 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article 97 erbil journal of nursing & midwifery table 3: distribution of age, residence, educational status and anti-toxoplasma igm antibody among pregnant women demographic data positive toxoplasmosis f (%) negative toxoplasmosis f (%) total f (%) p_value age group ≤20 10(14.9) 16(12.1) 26(13) 0.2617 2140 49(73.1) 109(84.9) 158(79) ≥41 8(11.9) 8(6.01) 16(8) total 67(33.5) 133(66.5) 200(100) residence urban 30(44.8) 55(41.4) 85(42.5) 0.6440 rural 37(55.2) 78(58.6) 115(57.5) educational status educated 32(47.8) 63(47.4) 95(47.5) 0.9581 non educated 35(47.4) 70(52.6) 105(52.5) total 67(33.5) 133(66.5) 200(100) positive toxoplasmosis f (%) negative toxoplasmosis f (%) total f (%) p_value abo blood group a 20(29.9) 21(15.8) 41(20.5) 0.134 b 14(20.9) 36(27.1) 50(25) ab 6(9) 12(9) 18(9) o 27(40.3) 64(48.1) 91(45.5) total 67(33.5) 133(66.5) 200(100) rh factor positive 2(3) 131(98.5) 133(66.5) 0.0001 negative 65(97) 3(1.5) 67(33.5) total 67(33.5) 133(66.5) 200(100) the frequencies of abo blood group phenotypes, in respect to results of the serological test (positive and negative) for anti-t. gondii antibodies as listed in table (4) do not demonstrate statistically significant differences (p-value = 0.134) while there was highly significant relationship between rhd blood group and toxoplasma infection (p-value 0.0001). table 4: association of abo blood group, rh factor and toxoplasma infection. https://doi.org/10.15218/ejnm.2018.12 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article the aim of this study was to determine the sero prevalence of anti-toxoplasma gondii antibodies and to explore whether rhpositive subjects are protected against the toxoplasma infection. our result reveals overall sero prevalence rate toxoplasmosis igm antibodies among aborted women (33.5%), elisa result is similar to those studies done in alhawiji and albaiji districts in iraq by aljebouri et al in 2013and those done in qadisyiyah province in iraq by hadi et al in 2016, they found high sero prevalence rate of toxoplasmosis among aborted women [20, 21]. these similarities in high sero prevalence rate of toxoplasmosis in different women in different area depend on several factors like: environmental effects, traditional habits, economic status, and hygiene condition in these areas. also high rate of infection was found among age group 20-40 years old which is in accordance to those reported by hung et al (2007), this might be due to the fact that this rang of age is child bearing age and usually women became more susceptible and symptoms more obviously appear during pregnancy [22]. no significant relation was found between age group and sero prevalence of toxoplasmosis, this result compatible with those reported in united states by jones et al in 2001 [23]., but it's different from those done in iran by ahmed et al in 2014 who found a significant linear trend of increasing overall sero prevalence of toxoplasmosis by age [24]. the present results do not demonstrate any association between evidence of infection by t. gondii and the abo blood group system and, thus, does not agree with those studies that proposed that the b antigen, expressed in b and ab blood groups, acts as a potential receptor for this parasite in the gastrointestinal tract [16-17]. on the other hand, the results agreed with investigations of blood donors in tanzania and of pregnant french women, which did not report any association between this system and infection by t. gondii [8, 19]. the disagreement among these results and other studies may result from several factors. it is possible that the b antigen exerts a small influence on the adherence of t. gondii to the gastrointestinal mucosa and its contribution is obscured by the high prevalence of infection by these parasites in our population. moreover, the use of only female patients in this study might not be sufficient to reveal possible influences of gender in the association of the abo blood group system with infection by t. gondii [19]. the present results was also indicated that rhd phenotype modulates the responses of the body to anti toxoplasma antibody this result agree with those reported by fleeger et al in 2009 [12] but its differ from those done in america by parnell in 2014 [25] however, the results of previous studies and current knowledge about localization and probable function of rh proteins suggest that rhd proteins that act as ion pumps, coded for at the rh locus and localized on the erythrocyte membrane, are involved in the regulation of ion balance in some critical compartment of nerve or muscle tissue. such regulation could be important especially in the subjects handicapped by the presence of toxoplasma cysts in nerve and muscle tissues [10, 11]. anti-toxoplasma igm antibodies were relatively high among women with a history of abortion in erbil. abo blood groups distribution was not significantly 98 erbil journal of nursing & midwifery discussion conclusions https://doi.org/10.15218/ejnm.2018.12 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article associated with toxoplasmosis, however significant sero-prevalence rate of toxoplasmosis was observed among women who were negative for rhd antigen screening for toxoplasmosis in women prior to pregnancy is an insisted demand in order to prevent abnormal pregnancy termination. the authors report no conflict of interest the author would like to thank all participants who participated in conducting the study. [1] dubey jp, lindsay ds, speer ca . structures of toxoplasma gondii tachyzoites, bradyzoites and sporozoites and biology and development of. tissue cysts. clinical microbiology review 1998.( 11):267-299. [2] hill de, chirukandoth s and dubey jp . biology and epidemiology of toxoplasma gondii in man and animals. animal health research review, 2005 (6):41-61. [3] dubey jp . toxoplasmosis of animals and humans. second edition .boca .raton, florida crc press. [4] dawson d . foodborne protozoan parasites. internal journal of food microbiology. 2005 (103):207 227. [5] walker m and zunt jr .parasitic central nervous system infections in immunocompromised hosts. clinical iinfectious disease. 2005. (40):1005-1015. [6] balasundaram mb, andavar r, palaniswamy m , venkatapathy n. outbreak of acquired ocular toxoplasmosis involving 248 patients. archive of ophthalmology, 2010(128):28-32. [7] flegel w.a. molecular genetics of rh and its clinical application. transfusion clinical biology 2006 (13): 4–12. [8] carritt b., kemp t.j., poulter m. evolution of the human rh (rhesus) blood group genes: a 50 year old prediction (partially) fulfilled. human molecular genetic. 1997 (6): 843–850. [9] biver s., scohy s., szpirer j., szpirer c., andre b., marini a.m. physiological role of the putative ammonium transporter rhcg in the mouse. transfusion clinical biology. 2006 ,(13): 167–168. [10] kustu s., inwood w. biological gas channels for nh3 and co2: evidence that rh (rhesus) proteins are co2 channels. transfusion clinical biology. 2006, (13): 103–110. [11] novotná m., havlíček j., smith a.p., kolbeková p., skallová a., klose j.et al toxoplasma and reaction time: role of toxoplasmosis in the origin, preservation and geographical distribution of rh blood group polymorphism. parasitology. 2008, (135): 1253–1261. [12] flegr j., klose j., novotná m., berenreitterová m., havlíče j. increased incidence of traffic accidents in toxoplasma infected military drivers and protective effect rhd molecule revealed by a large-scale prospective cohort study. bmc infectious disease. 2009. (9): e72. [13] kader jm, seroprevalence of toxoplasma gondi in some meat producing animals in erbil city. msc thesis. college of medicine. hawler medical university. 2010. [14] bakre hm, evaluation of immunocapture elisa and other testes for diagnosing toxoplasmosis. msc thesis. college of medicine. hawler medical university. 2002. [15] mohammed ak, possible role of toxoplasma gondi infection, cytokines and inflammatory markers in patients with major depressive disorders. msc thesis. college of medicine. hawler medical university. 2015. 99 erbil journal of nursing & midwifery acknowledgement references conflict of interest https://doi.org/10.15218/ejnm.2018.12 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article [24] ahmed d, shahabeddin s, mohsen a, azadeh m, ehsan a, azar s, et al seroprevalence of toxoplasma gondii in the iranian general population: a systematic review and meta-analysis ,acta tropica. 2014; (137):185-194 . [25] parnell l l. examination of possible protective effect of rhesus d positive blood factor on toxoplasma-related depressive symptoms in pregnancy. phd. college of nursing university of south florida. 2014. [16] kolbekova p, kourbatova e, novotna m, kodym p, flegr j. new and old riskfactors for toxoplasma gondii infection: prospective cross-sectional study among military personnel in the czech republic. clinical microbiology infection. 2007;13 (10):12-7. [17] midtvedt t, vaage l. relationship between toxoplasma gondii antibodies and blood group. european journal of clinical microbiology infectious disease. 1989;8 (6):575-6. [18] gill hs. occurrence of toxoplasma gondii antibodies in tanzanian blood donors. east african medical journal. 1985;62 (8):585-8. [19] lecolier b, grynberg h, freund m. absence of relationship between toxoplasma gondii antibodies and blood group in pregnant women in france. european journal of clinical microbiology infectious disease. 1990;9(2):152-3. [20] al-jebouri m, al-janabi m, ismail h. the prevalence of toxoplasmosis among female patient in al-hawija and albaiji districts in iraq. open journal of epidemiology.2013;3(38):85-88. [21] hadi hs, kadhim ra, al-mammori rt. seroepidemiological aspects for toxoplasma gondii infection in women of qadisyiyah province, iraq. international journal of pharmacology and technelogy research.2016;9(11):252-59. [22] hung cc, fan ck, su ke, sung fc, chiou ay, gil v, et al. serological screening and toxoplasmosis exposure factors among pregnant women in the democratis republic of sao tome and principe. journal of transactions of the royal society tropical medical hygiene. 2007; 101 (2):97-103. [23] jones jl, kruszan md, wilson m, mcquillan g, navin t, mcauley jb. toxoplasma gondii infection in the united states: seroprevalence and risk factors. american journal of epidemiology. 2001 154 (4):357-65. 100 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.07 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article nurses job satisfaction in health care institutions in duhok city abstract introduction job satisfaction can be defined as the emotional responses of employees to their employment status. employees are generally focused on their job satisfaction which explains why it has been defined as "a pleasant or positive emotional state resulting from the evaluation of employee's a job or career experience". therefore, there is a wide variation in what people expect from their jobs and how they interact with one another in the workplace *1+. background and objectives: nurses are one of the most important human resources working in health care institutions as they range in different levels and disciplines. they are the mainstay of modern health care institutions and a vital component in these institutions achieving their goals. therefore, nurses' job satisfaction is an important aspect in providing quality health care. this study was conducted to determine nurses' job satisfaction in health care institutions in duhok city. methods: a descriptive study design was carried out to assess the nurses' job satisfaction in health care institutions of duhok city. this study involved nurses who worked the morning shift in both primary health care centers and public hospitals in duhok city. a total of 137 nurses were selected from 946 nurses through utilizing a non-probability (purposive) sampling method and agreed to be subject of present study. a questionnaire designed by researchers was used for data collection through review of previous related studies and the data were gathered through self-report method. this questionnaire consisted of two aspects; the first one used for gathering nurses' socio-demographic data and the second one consisted of 30 likert scale questions with responses ranging from strongly disagree, disagree, agree, strongly agree, and scored one to four respectively. these questions were divided into 5 categories as follow: job promotion, nature of work, work policy, communication and interaction, and supervision satisfaction. data was analyzed using descriptive and inferential statistics (frequency, percentage, mean, standard deviation, t-test, and pearson correlation) and levels of job satisfaction were calculated through using cut off points. results: the present study shows general dissatisfaction of nurses in regards to their job promotion, nature of work, work policy, work supervision, and communication and interaction. conclusions: the present study concludes that nurses working in health care institutions in duhok city were dissatisfied in regards to the categories included in this study. key words: nurses, job satisfaction, health care institution. salim saeed azzez ; department of nursing, college of nursing, university of duhok , duhok , iraq. alaa noori sarkees ; department of nursing, college of nursing, university of duhok , duhok , iraq. (correspondence: alaa.sarkees@uod.ac ) 51 erbil journal of nursing & midwifery received: 30/9/2018 accepted: 15/1/2019 published: 30/5/2019 mailto:alaa.sarkees@uod.ac https://doi.org/10.15218/ejnm.2019.07 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article job satisfaction is considered an important segment of both organizational psychology and behavior. therefore, it has been argued and usually examined because it examines the physical and mental well-being of individuals and work from both a psychological and human resources perspective *2+. due to the nature of these nurses' jobs deal with all aspects of health and illness, they experience high levels of occupational stress. therefore, job satisfaction is affected by this stressful nursing occupation *3+. the hierarchy of needs theory was developed by abraham maslow. in 1954, he suggested five basic needs that human beings need to be satisfied. these needs are physiological, safety, belongingness, selfesteem, and self-actualization. he ranked them into higher and lower needs. according to his theory, the human starts to meet the unsatisfied needs that motivate behavior, lowest-level needs, like physiological and safety then struggles to achieve the highest-level needs such as belongingness, esteem, and self-actualization *4+. one of the top issues in health care sectors is the nursing shortage. in fact, this worldwide phenomenon continues as demand for nursing increases yet the current supply is unable to meet the needs of society. furthermore, there is a high resignation rate among nurses as more than 13% of new nurses decide to leave their profession within first year *5+. though many factors affect job satisfaction, they can be summarized in two domains, intrinsic and extrinsic factors. intrinsic factors include payment, autonomy, task requirements, policies, interaction, and professional status. while extrinsic factors can include hygiene or care factors which if absent, can reflect job dissatisfaction *6+. nurses are vital to modern health care institutions to achieving their goals. therefore nurses' job satisfaction is an important aspect in providing quality health care. this study aims to determine job satisfaction among nurses those working in health care institutions in duhok city, the association of nurses' job satisfaction with their socio-demographic characteristics, and compare between job satisfactions levels according to health care institutions. a descriptive study design was carried out to assess nurses' job satisfaction in health care institutions in duhok city. the study included all nurses working in 13 primary health care centers directed by physicians morning shift of six public hospitals. a total of 137 nurses were selected from 946 nurses through utilizing a non-probability (purposive) sampling method. the researchers recruited the nurses who agreed to be subject in this present study and worked during the day shift of hospitals and others were excluded from the current study. a questionnaire was used as a tool for data collection. this questionnaire was constructed through review of previous related studies and the data was gathered through self-report method. the questionnaire consisted of two parts. the first part was used for gathering socio-demographic data (age, gender, level of educational, english language, marital status, monthly income, residential area, type of family) in addition to employment data (years of services, number of training courses, place of work) and the second one consisted of 30 likert scale questions with responses ranging from strongly disagree, disagree, agree, strongly agree, and scored one to four respectively. these questions were divided into 5 main domains as job promotion, nature of work, work policy, communication and interaction and finally supervision satisfaction. data was analyzed through using (frequency, percentage, mean, standard deviation, t-test, and pearson methods 52 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.07 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article finally, 73% of the nurses show dissatisfaction towards work supervision and 37.0% show discrepancy (table 3). correlation). levels of job satisfaction were calculated through using cut off points as follows: for the first and fifth domains, dissatisfied (5-9), discrepancy (10-14) and satisfied (15-20), for second and third domains, dissatisfied (7-13), discrepancy (1420) and satisfied (21-28). finally, for the fourth domain, dissatisfied (6-11), discrepancy (12-17) and satisfied (18-24). socioeconomic status of the nurses was calculated through collecting data related to nurse's education, family crowding index, household asset and monthly income. this data was scored and distributed to poor, average, and high by use of the cut off point method. results showed that the largest percentage of nurses in the study 38% were between 30-39years of age, 59.9% of them were female, 40.1% attended secondary school, 44.5% of the sample has less than seven years of experience, 42.3% knew moderate amounts of the english language, most of the sample 74.5% took training courses, and 83.9% worked in a hospital setting (table 1). results of the present study show that two thirds of nurses are married and live within a nuclear family 65%, the majority of which, 84.7%, also receive an insufficient monthly income, and are residents of urban areas, 85.4%. in addition, more than half of them, 51.1%, stated average level of socio-economic status (table 2). results show that 80.3% of the nurses were dissatisfied regarding job promotion, 67.9% were dissatisfied towards the nature of their work, nearly one third of the sample, 31.4%, showed discrepancy and 62.8% were dissatisfied with work policy and others show discrepancy, 54.7% of them were dissatisfied with communication and interaction, while 45.3% show discrepancy. 53 results erbil journal of nursing & midwifery table 1: nurses' distribution by their demographic characteristics demographic characteristics f (%) m (±sd) age 20-29 30-39 40-49 50 and more gender male female level of education intermediate school secondary school institute university years of services less 1-7 8-14 15-21 22-28 29-36 number of training courses 0-2 3-5 6-8 9-11 english language excellent very good good moderate poor institution hospital primary health care center 44 (32.1) 52 (38) 35 (25.5) 6 (4.4) 55 (40.1) 82 (59.9) 15 (10.9) 55 (40.1) 45 (32.8) 22 (16.1) 61 (44.5) 28 (20.4) 23 (16.8) 14 (10.2) 11 (8) 102 (74.5) 25 (18.2) 6 (4.4) 4 (2.9) 4 (2.9) 8 (5.8) 20 (14.6) 58 (42.3) 47 (34.3) 115 (83.9) 22 (16.1) 34.53 (7.908) 1.6 (0.492) 2.54 (0.891) 11.768 (9.612) 1.88 (2.244) 3.99 (0.996) 1.16 (0.368) https://doi.org/10.15218/ejnm.2019.07 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article table 4 demonstrates a significant positive relationship (p= 0.023) between nature of work and health care institution at level 0.05. moreover, there is a significant negative relationship(p=0.011) between work supervision and number of training courses at level 0.05, while job promotion, work policy, and communication and interaction satisfaction-related domains did not reveal any relationship with nurses' demographic characteristics. table 5 shows a highly significant negative relationship (p = 0.004) between nurses' monthly income with their satisfaction to work supervision domain and at (0.01) level only. table 6 and 7 indicate a significant difference among nurses related to their satisfaction toward nature of work domain according to their work place in health care institutions. the main purpose of this research was to determine nurses' job satisfaction in governmental hospitals and primary health 54 erbil journal of nursing & midwifery table 2: nurses' distribution by their social characteristics social characteristics f (%) m (±sd) marital status single married divorced widow 40 (29.2) 89 (65) 7 (5.1) 1 (0.7) 1.77 (0.569) monthly income sufficient insufficient 21 (15.3) 116 (84.7) 1.85 (0.362) residency rural urban 20 (14.6) 117 (85.4) 1.85 (0.354) family type nuclear family extended family single parent family 89 (65) 46 (33.6) 2 (1.5) 1.36 (0.513) socioeconomic status poor average high 5 (3.6) 70 (51.1) 62 (45.3) 55.96 (9.511) table 3: distribution of nurses’ job satisfaction level according domains job satisfaction level f (%) m (±sd) job promotion dissatisfied discrepancy satisfied 110 (80.3) 25 (18.2) 2 (1.5) 7.75 (2.192) nature of work dissatisfied discrepancy satisfied 93 (67.9) 43 (31.4) 1 (0.7) 12.23 (3.494) work policy dissatisfied discrepancy satisfied 86 (62.8) 51 (37.2) 0 (0) 12.64 (2.935) communication and interaction dissatisfied discrepancy satisfied 75 (54.7) 62 (45.3) 0 (0) 10.69 (2.427) work supervision dissatisfied discrepancy satisfied 100 (73.0) 37 (27.0) 0 (0) 7.95 (2.073) discussion https://doi.org/10.15218/ejnm.2019.07 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *correlation is significant at the 0.05 level (2-tailed). pearson. co = pearson correlation, sig. = significant, n. = number 55 erbil journal of nursing & midwifery table 4: relationship of nurses' job satisfaction domains with their demographic characteristics age gender level of education year of services number of training courses english language institution job promotion pearson. co sig.(2-tailed) n. 0.23 .787 137 -.059.494 137 .107 .214 137 .050 .563 137 .000 .997 137 -.098 .252 137 .086 .317 137 nature of work pearson. co sig.(2-tailed) n. .147 .086 137 -.109 .204 137 -.018 .832 137 .146 .089 137 -.050 .563 137 .011 .898 137 .194* .023 137 work policy pearson. co sig.(2-tailed) n. .065 .452 137 -.046 .592 137 -.081 .344 137 .116 .177 137 -.013 .885 137 .064 .454 137 .055 .526 137 communication and interaction pearson. co sig.(2-tailed) n. .049 .569 137 .019 .823 137 -.021 .803 137 .010 .911 137 -.045 .603 137 .008 .924 137 -.010 .905 137 work supervision pearson. co sig.(2-tailed) n. .141 .100 137 -.121 .158 137 -.084 .327 137 .154 .072 137 -.218* .011 137 .021 .806 137 .049 .567 137 care centers of duhok city. concerning to nurses' demographic characteristics, the present study shows most of the participants are between 30-49 years of age and female. regarding nurses level of education, most of the participants completed secondary nursing schools because college level nursing was just established at 2007. the number of nursing graduates is small compared to the number of secondary nursing school graduates. most worked between one to seven years in the field. this was determined as most of the nurses with more experience were engaged in management duties and as a result have no time to participate in current study. in addition, due to the shortage of nursing staff in duhok health institutions, the nurses do not have much opportunity to participate in many training courses. as mentioned before, the majority of the nurses who participated in current study graduated from secondary nursing schools and therefore have a moderate understanding https://doi.org/10.15218/ejnm.2019.07 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article of the english language. finally, the majority of nurses who participated in current study work in hospitals. a study conducted on nurse’s job stress in duhok governmental hospital found that most of the participants were female, 59.3% and 53.4% received an education of less than a high school diploma. regarding years of experience, the study showed that more than half of the nurses had less than three to six years of experience 51.6% *7+. concerning job satisfaction and burnout among palestinian nurses, findings show that the majority of nurses were female between 25-34 years of age. also, they found that most nurses had certification to practice nursing and most of them have between four to six years of experience *1+. according to world health organization (who) and ministry of health (moh) as of 2003-2008 in iraq, the majority of the nursing workforce, 6499 nurses out of 17743, were secondary nurses who graduated three years after intermediate school *8+. respecting to nurses' marital status, more than half of nurses were married and life in a nuclear family. this is due to the large number of the study population being above 25 years of age. the majority of them live in a nuclear family because of kurdistan population growth and their socio-cultural development over the last several years. extended families tend to be independent from the immediate family. most participants have an insufficient monthly income, due to the last kurdistan economic crisis and most of them have only a few years of work service. the majority of participants reside urban areas as a result of conducting this current study in health care institutions in urbanized areas of duhok city. it was interesting to find out that the majority of study subjects' socioeconomic status ranged between average to high because most nurses have private jobs rather than government jobs to compensate for the shortage in monthly payment due to compulsory saving measures. a research paper found that most of the nurses who participated in the study were married *9+. musa in (2012) also found that the majority of the nurses who participated in the study were married (59.6%) *7+. a study on nurses who worked in selective private hospitals in england found that (67.53%) of the participants showed dissatisfaction toward salary and they would leave their current hospitals *10+.regarding nurses' job satisfaction levels, the present study shows dissatisfaction of nurses towards job promotion, nature of work, work policy, work supervision, communication, and interaction. a recent study indicated that receiving a job promotion increased job satisfaction by nearly 0.12 units on average *11+. results in a study done by farsi indicated that nurses were less satisfied in work comfortable and neglecting aspects related to respect part of the study while also being secure by having sufficient promotional opportunities and salaries *13+. a research study conducted by lephalala et.al, related to the nature of nursing work stated that the majority of nurses show dissatisfaction toward social disruptions and working overtime *10+. a study conducted at muhimbili national hospital shows nearly half of the nurses who worked there displayed feelings of dissatisfaction toward hospital policy, environment, and technical supervision. on the other hand, they were satisfied with their co-worker relationships and improved working conditions *14+. results of other studies showed low nurses' satisfaction regarding supervision, training issues (opportunities, time, funding for courses and perceptions of adequate training), and moderate level of satisfaction related to contact with 56 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.07 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article their nature of work which lead them to feel insecure. a study conducted on job satisfaction of nurses in ministry of health hospitals in riyadh, saudi arabia by alahmadi revealed that a combination of several aspects(recognition, technical aspects of supervision, work conditions, applying skill, job advancement, and payment) have strong influence on overall job satisfaction. the combination of these aspects clarify the difference in overall nursing job satisfaction *19+. another study was done in order to find out the factors affecting job satisfaction of registered nurses in mashhad, iran. this study indicated positive correlation of overall nurses' job satisfaction with supportive nursing management, efforts undertaken to improve working conditions, professional development, improved professional status, and increased salaries *20+. finally, study findings related to their place of work found significant differences between the nurses' satisfaction towards their nature of work on the basis of their work place and no relationship between other variables. the nurses who worked in primary health care centers are partially more satisfied with their job than those in hospitals because the nature of nursing duties in primary health care centers requires less efforts and stress. regarding personal job promotion, a recent study’s results show that 59.1% of nurses expressed dissatisfaction towards having ample opportunities for professional personal growth and development through the course of their education and training while 41.3% of them were satisfied with such level of promotion. particularly, out of those dissatisfied 68% work in healthcare centers while the rest of the nurses (31.7%) work in hospitals *21+. a recent study conducted to explore the job satisfaction among professional workers in primary healthcare centers in an area colleagues and feeling part of a team *15+. a recent study conducted on professional nurses who worked at public hospitals in johannesburg city, south africa indicated inadequate communication between professional nurses and their managers. furthermore, they showed dissatisfaction toward the recognition of their work efforts and lack of acknowledgment that they received for their efforts *16+. respecting the relationship between nurses' job satisfaction and their demographic characteristics, the present study showed a significant positive relationship between nature of work and health care institution because the nurses who worked in primary health care centers were more satisfied toward their work nature and they did not have much work stress compared to those working in hospitals. in addition, the findings show a significant negative relationship between work supervision roles and number of training courses. because of these roles, nurses' opportunities have been limited to participating in training courses to enhance and develop their skills and knowledge. a research study by vermeir et al related to job satisfaction and its relation to communication among nurses concluded that a relationship exists between job satisfaction and communication among nurses *17+. furthermore, a study in ekiti state in nigeria on nurses working in primary healthcare centers showed strong positive correlation between overall work environment of these primary healthcare centers and the general job satisfaction of the nurses *18+. concerning the relation between nurses' job satisfaction and their social characteristics, the current study found a highly significant relationship between nurses' satisfaction to work supervision roles and their monthly income. this due to financial negative rules and regulations of health care institutions toward nursing comparing to 57 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.07 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article the authors report no conflict of interests. *1+ jayasuriya r, whittaker m, halim g and matineau t. rural health workers and their work environment: the role of interpersonal factors on job satisfaction of nurses in rural papua new guinea. british medical center for health services research. 2012; 12:156. available from: https:// doi.org/10.1186/1472-6963-12-156 *2+ haijuan w, yongpin n, and bibo x. main factors influencing nurse job satisfaction. a cross-country study. msc. thesis. international business department of business administration & economics. 2006. *3+ abushaikha l and saca-hazboun h. job satisfaction and burnout among palestinian nurses. eastern mediterranean health journal.2009; 15(1):190-197. available from: http://applications.emro.who.int/dsaf/ dsa971.pdf *4+ younes mr. job satisfaction and work performance, a case study of the american university in cairo. msc. thesis. american university in cairo, school of global affairs and public policy department of public policy and administration. 2012. available form: http://dar.aucegypt.edu/ handle/10526/3129 *5+ kalisch bj, lee h and rochman m. nursing staff teamwork and job satisfaction. journal of nursing management. 2010; 18(8):93847. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc2994317/ *6+ poh lc. nurses’ job satisfaction in the malaysian private hospitals. msc. thesis. business administration department. 2008. available from: http:// eprints.usm.my/25387/1/nurses%e2%80% 99_job_satisfaction.pdf *7+ musa m. job stress source among nurses working in duhok governmental hospitals. journal of university of duhok (pure and eng. sciences). 2012; 15(2):94-101. available at: web.uod.ac/documents/190/ final.pdf of asturias found that the nursing staff was most satisfied with their jobs compared to other occupations who work in these centers *22+. other recent study at rzgary teaching hospital of erbil city shows that the nurses working in these hospitals were satisfied with their job *23+. in conclusion, this study demonstrates that nurses working in health care institutions in duhok city were generally dissatisfied toward job promotion, nature of work, work policy, communication and interaction, and work supervision. moreover, there was a significant relationship between the nurses' satisfaction toward the nature of work and their place of work and work supervision roles with the number of training courses. in addition, there was significant relationship between their satisfaction toward work supervision roles and their monthly income. furthermore, nurses working in primary health care centers were partially more satisfied with their nature of work than those working in hospitals. as a result, it is recommended that the director of health of duhok province needs to consider the domains of this study to increase nurses' satisfaction towards their job as well as improve the quality of nursing care through increasing nursing training courses, distributing them fairly, and creating a good work environment for communication. supervisors with higher levels of education and more work experience should be able to communicate with other nurses and facilitate discussions where nurses can discuss their problems, needs and share in developing the policies of their healthcare institutions. 58 erbil journal of nursing & midwifery conclusions conflicts of interest references https://doi.org/10.1186/1472-6963-12-156 https://doi.org/10.1186/1472-6963-12-156 https://doi.org/10.15218/ejnm.2019.07 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *17+ ayamolowo s j, irinoye o, oladoyin m a. job satisfaction and work environment of primary health care nurses in ekiti state, nigeria: an exploratory study. international journal of caring sciences. 2013; 6(3): 531542. available from: www.internationaljournalofcaringsciences.o rg *18+ al-ahmadi h a. job satisfaction of nurses in ministry of health hospitals in riyadh, saudi arabia. saudi medical journal. 2002; 23(6): 645-650. available from: https:// pdfs.semanticscholar.org/7370/9562b4766 311e7611deae93c95a5761ed04b.pdf *19+ atefi n, lim abdullah k, wong l p, mazlom r. factors influencing job satisfaction among registered nurses: a questionnaire survey in mashhad, iran. journal of nursing management. 2013; 23(4): 448-458. available from: https://doi.org/10.1111/ jonm.12151 *20+ asegid a, belachew t, yimam e. factors influencing job satisfaction and anticipated turnover among nurses in sidama zone public health facilities, south ethiopia. nursing research and practice. volume, 2014. 1-27. available from: http://dx.doi.org/10.1155/2014/909768 *21+ rodríguez-alonso a, gómez-fernández p, del-valle rd. study of job satisfaction in primary healthcare in an area of asturias. enfermeria global, 2017; 47: 384-399. available from: http://dx.doi.org/10.6018/ eglobal.16.3.256641 *22+ omer b o, karim m a, rafii f, mahmoudi f. job satisfaction among nurses in rzgary teaching hospital in erbil city. kufa journal for nursing sciences, 2016; 6(2): 1-7 available from: http://www.uokufa.edu.iq/ journals/index.php/kjns/article/view/5014 *8+ world health organization (who) and ministry of health (moh) in iraq. national strategy and plan of action for nursing and midwifery development in iraq 2003–2008. available from: http://applications.emro.who.int/ dsaf/libcat/emropd_104.pdf *9+ semachew a, belachew t, tesfaye t, and adinew ym. predictors of job satisfaction among nurses working in ethiopian public hospitals, 2014: institution-based crosssectional study. human resources for health. 2017; 15:31. available from: https://doi.org/10.1186/s12960-017-0204-5 *10+ lephalala rp, ehlers vj, oosthuizen mj. factors influencing nurses’ job satisfaction in selected private hospitals in england. curationis. 2008; 31(3): 60-69. available from: https://curationis.org.za/index.php/ curationis/article/view/1040/976 *11+ kosteas vd. job satisfaction and promotions. cleveland state university. 2011, pp.1-35. available from: http:// academic.csuohio.edu/kosteas_b/job% 20satisfaction%20and%20promotions.pdf *12+ farsi z, dehghan-nayeri n, negarandeh r, broomand s. nursing profession in iran: an overview of opportunities and challenges. japan journal of nursing sciences. 2010; 7 (1): 9-18. available from: doi: 10.1111/j.1742 -7924.2010.00137.x. *13+ rashid ss. determinants of job satisfaction among nurses at the muhimbili national hospital. msc. thesis of business. 2013. available from: http:// repository.out.ac.tz/836/1/ abdallah_mwaduga.pdf *14+ hennessy e. job satisfaction of nurses in a public hospital with a high number of hiv and aids patients. msc. theses in nursing. university of the witwatersrand, johannesburg, 2009. *15+ wagner j d, bezuidenhout m c, roos j h. communication satisfaction of professional nurses working in public hospitals. journal of nursing management. 2015; 23(8):97482. available from: https://doi.org/10.1111/ jonm.12243 *16+ vermeir p, degroote s, vandijck d, mariman a, deveugele m, peleman r, et al,. job satisfaction in relation to communication in health care among nurses: a narrative review and practical recommendations. sage journal. 2017. pp. 1-11. available from: doi/ full/10.1177/2158244017711486 59 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article scope of mothers’ knowledge regarding child fever management in ranya city, iraq kurdistan region abstract introduction fever is a common problem in children and one of the most common reasons parents seek medical attention for their children. it accounts for 20–30% of all practical visiting, and in most of the cases, nothing harmful is diagnosed [1, 2].fever is one of the most common symptoms of childhood disease, which in turn causes several concerns among families. almost every child has a fever of 37.8 40.8°c at least once during childhood [3-5].while fever is well recognized to be a natural defence mechanism, it is a significant source of family fear. even a slight increase in body temperature will trigger attempts to reduce the temperature and cause background and objective: children’s caregivers around the world are often unaware of the level of body temperature that indicates a fever. the way that they deal with a feverish child is sometimes incorrect or inappropriate. this study aimed to assess the mothers’ knowledge regarding fever management of a child under the age of five. methods: a quantitative descriptive study was carried out in ranya in the kurdistan region of iraq in 2018-2019. a purposive sample of 120 participants was initially selected from the mothers who attended two primary healthcare centers (kewarash and paparin) in ranya. the questionnaire was utilized as a tool for data collection, and both descriptive and inferential statistical methods were used to analyze the data. descriptive statistical data analysis included frequencies, percentages, and mean scores and the inferential statistical data analysis provided mean scores and chi-square. results: a total of 110 mothers participated in the study after the exclusion of 10 women. the findings showed that 76% of participants did not know which measurement is the best to measure child temperature, 82% were not sure about the best place to take child’s temperature, and 63% did not have knowledge about what temperature is considered to be a fever. according to the results, 72% of mothers believed that a cold sponge or ice pack is suitable for lowering body temperature, while 87% of mothers knew the most common complication of high fever. there was a positive association between level of education and mothers' knowledge regarding child fever management. conclusions: while mothers have some knowledge about fever and its management, they are unable to utilize this knowledge correctly. an educational program should be developed for mothers who attend primary healthcare centres to teach them about child fever management. keywords: child, mothers, fever management, knowledge, primary health care blend barzan ameen; department of nursing, college of nursing, university of raparin, sulaymaniyah, iraq. correspondence: (blend.ameen@uor.edu.krd) 157 erbil journal of nursing & midwifery received: 22/04/2020 accepted: 27/07/2020 published: 30/11/2020 https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article panic among family members [6].fever causes a high level of anxiety and fear in a child’s caregiver regarding its possible complications [7]. fever is generally harmless and usually manifests that the body is fighting an illness or infection. it can be considered a good sign that the child’s immune system is working, and the body is trying to heal itself. at the same time, it is essential to look at the cause of fever [8]. most mothers quickly administer an antipyretic (paracetamol or ibuprofen) to their children if they feel that the child has a fever. paracetamol is a safe medicine if it is given correctly, but giving too much can be dangerous and causes death in rare cases. overdose is the leading cause of liver failure in children. ibuprofen can cause gut problems and kidney damage in some children, even when it is given at the recommended dose [9]. fever is one of the most common problems in paediatrics for which parents seek health care. nurses can provide parents with correct information regarding the fever and the appropriate management for it. the study was carried out from august 2, 2018, to january 14, 2019, at kewarash and raparin primary health care centres (phc) in ranya in the kurdistan region of iraq. the researcher obtained ethical approval for the study from the research ethics committee of the college of the nursing, university of raparin, the research centre department, university of raparin, the raparin directorate of health, and the two involved primary health care centres. the study used a quantitative descriptive design. the researcher recruited a nonprobability, convenient sample of 120 mothers and excluded 10 women. criteria for selection included: mothers who attend phcs with children under the age of five with fever. a questionnaire was constructed after a review of the literature to achieve the objectives of the study and consisted of two parts. the first part included the socio-demographic characteristics of mothers, and part two included 12 items related to the mothers’ knowledge regarding child fever management. the data were collected using a face to face interview approach. items were measured by using three levels of likert scales and rated as the: a correct answer 3, not sure 2, and an incorrect answer 1 [10]. the mean of the score from 1 1.66 was considered insufficient knowledge, 1.67 2.33 was considered moderate knowledge, and 2.34 3 was considered high knowledge. statistical package for social sciences (spss) version 20 was used for data analysis. descriptive statistical data analysis included frequencies, percentages, and mean scores and inferential statistical data analysis calculated mean scores and chisquare. out of 110 mothers who participated in this study, 25.0 % were 23-27 years old. concerning the level of education, 42% of the study sample was illiterate, and 18% of participants graduated from college. more than 68% of mothers were housewives, 30% were governmental employees, and less than 2% were self-employed. furthermore, 27.5% of subjects had one child, 25% had two children, and 47.5% had three or more children. finally, more than 94% of mothers lived in suburban areas, and 5.5% of participants lived in a rural setting (table 1).table 2 shows that the mothers had a low level of knowledge regarding the best method to measure temperature, when they should give unwell child paracetamol rectally, and when to use a cold sponge or ice pack. also, mothers had limited knowledge regarding normal body temperature and fever, sites 158 erbil journal of nursing & midwifery methods results https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article for treating children with fever, when to give children paracetamol, and which tool is accurate in determining the right dose of paracetamol syrup. for temperature measurement, indications for treatment, and visiting a health facility. in contrast, mothers had adequate knowledge regarding the most common complication of high fever in children, which medication is effective and safe 159 erbil journal of nursing & midwifery table 1: socio-demographic characteristics of mothers participating in the study. age (years) f (%) 18 – 22 7 (6) 23 27 28 (25) 28 32 26 (24) 33 – 37 23 (21) 38 – 42 26 (24) 110 (100) level of education f (%) illiterate 23 (21) able to read and write 23 (21) primary school graduate 10 ( 9) secondary school graduate 21 (19) institute graduate 13 (12) college graduate 20 (18) 110 (100) occupational status f (%) governmental employment 33 (30) self-employed 2 (1.8) housewife 75 (68.2) 110 (100) number of children f (%) one child 30 (27.5) two children 28 (25) ≥ three children 52 (47.5) residential area f (%) suburban 104 (94.5) rural 6 (5.5) total 110 (100) f= frequency %= percentage https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article 160 erbil journal of nursing & midwifery table 2: mothers’ knowledge regarding child fever management. no items correct incorrect not sure ms k.l f (%) f (%) f (%) 1 the best place to take the temperature of a child under five years is: a. rectal b. mouth. c. axilla. d. not sure 14 (12) 8 (6) 88 (82.3) 2.06 m.k 2 the normal body temperature of a child: a. 36°c b. 37°c c. 38°c d. ≥ 39°c f. not sure 34 (33) 10 (9) 66 (58) 2.21 m.k 3 above what temperature would you consider child have a fever: a. 36.5°c b. 37°c.5 c. 38°.5c d. ≥39.5°c e. not sure 35 (33) 5 (4) 70 (63) 2.27 m.k 4 above what temperature would you give child treatment: a. 37.5°c b. 38.5°c c. ≥39°c e. not sure 39 (36) 2 (1) 69 (63) 2.33 m.k 5 if a child has a fever, how high temperature you call the doctor or go to the hospital or consulting health care worker: a. 37.5 b. 38°c c, 39.5°c d. ≥40°c 5.e. not sure 24 (24) 6 (6) 80 (70) 2.16 m.k 6 the most common complication of high fever in children if don’t treat it: a. febrile seizure b. death c. brain damage d. coma e. nothing will happen f. not sure 96 (87) 5 (5) 9 (8) 2.82 g.k 7 which measurement is the best way to measure unwell child temperature: a. your hand b. glass thermometer c. electronic thermometer d. not sure 7 (7) 84 (76) 19 (17) 1.30 l.k 8 which drug is best to give to your unwell child for fever: a. acetaminophen b. aspirin c. ibuprofen (prufen) d. antibiotic e. not sure 81 (77) 13 (7) 16 (16) 2.61 g.k 9 which instrument is best accurate to determine the right dose of paracetamol syrup: a. tablespoon b. teaspoon c. specific measures spoon/syringe drugs d. not sure 70 (66) 25 (19) 15 (15) 2.40 g.k 10 mothers should give unwell child paracetamol rectally if: a. she wants more useful b. she wants to become a more practical c. unable to give him orally because of vomiting or child refusal. d. not sure 25 (25) 61 (52) 24 (23) 1.67 l.k 11 how do you decide the right fever lowering drugs to give to your child: a. according to label instructions or consulting health care worker b. according to information gathered previously c. i decide by myself what i think is right d. not sure 81 (72) 10 (9) 19 (19) 2.64 g.k 12 cold sponge or ice pack is good for lowering body temperature in addition to drugs that reduce fever in children: a. correct b. incorrect c. not sure 29 (29) 72 (62) 9 (9) 1.60 l.k g.k= good knowledge m.k= moderate knowledge l.k= low knowledge m.s= mean of score k.l= knowledge level . https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article mothers and their knowledge regarding child fever management (p-value < 0.05). table 5 shows that there is no significant correlation between the number of children in the family and mothers’ knowledge regarding child fever management (p-value > 0.05). 161 erbil journal of nursing & midwifery table 3 shows there is no significant association between the age of the mothers who participated in the study and their knowledge regarding child fever management (p-value >0.05). table 4 indicates that there is a significant association between the level of education of table 3: the association between mothers’ knowledge regarding child fever management and the age of mothers. mothers respond to answer age groups (years) correct incorrect not sure f (%) f ( %) f (%) total 18-22 23-27 28-32 33-37 38 (7.1) 15 (4.94) 31 (6.44) 84 153 (28.6) 64 (21.05) 107 (22.25) 324 129 (24.12) 80 (26.31) 115 (23.9) 324 105 (19.62) 71 (23.35) 100 (20.7) 276 110 (20.56) 74 (24.35) 128 (26.61) 312 total 535 (100) 304 (100) 481 (100) 1320 χ² obs= 13.4 df=8 χ² crit= 15.5 p>0.05 f=numbers of (correct, incorrect and not sure answers that had been answered by the sample regarding each question related to infant fever and its management in table 2 table 4:the association between mothers’ knowledge regarding child fever management and mothers’ level of education. mothers respond to answer level of education correct incorrect not sure f (%) f (%) f (%) total illiterate primary school graduate secondary school graduate institution graduate college graduate 161 (30.09) 133 (43.75) 263 (54.68) 557 47 (8.78) 24 (7.90) 49 (10.19) 120 120 (22.46) 59 (19.41) 73 (15.17) 252 82 (15.33) 35 (11.51) 38 (7.91) 155 125 (23.36) 53 (17.43) 58 (12.05) 236 535 (100) 304 (100) 481 (100) 1320 χ² obs=74.7 df=8 χ² crit=15.51 p<0.05 f=numbers of (correct, incorrect and not sure answers that had been answered by the sample regarding each question related to infant fever and its management in table 2 https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article 162 erbil journal of nursing & midwifery available research studies report that parents have false beliefs, limited knowledge and misconception regarding fever management, complications and its role in illness [11,12]. mothers know the most common complications of high fever. children with fever are not at increased risk of seizures, dehydration, brain damage, or death, except in high fever when the child may develop febrile seizures [13]. in the current study, 82.3% of mothers were not sure about which body site is the best for taking the temperature. this finding supports the conclusion of desnous et al. (2011), who indicated that most of the mothers measured the body temperature of the children using a rectal route [14]. this means mothers often do not know the best place for checking the child’s temperature as rectal or oral measurements of body temperature should be avoided [15]. parents should be encouraged to measure the axillary temperature. in this study, only 34% of the sample knew that normal body temperature is 37.0°c. e yavuz et al. in their study found that more than 80% of the parents did not know the correct temperature for fever for the measured site. there are similar previous reports in turkey and culturally diverse populations in different countries [1620]. concerning when to give a child treatment, 36% of the participants would give treatment at 37 °c. world health organization (who) recommends using treatment when the temperature is above 38.5°c [21].additionally, mothers in this study had a lack of knowledge about when to call the doctor, go to the hospital, or consult a health care worker if the child has a fever. this is probably because most of the mothers did not know what the normal body temperature was. in contrast, mothers knew the correct medication to use to decrease fever. this finding is consistent with a study by saed et al., 2013.using antipyretics was the most commonly used treatment of fever [10]. in a study in denmark, jansen et al. indicated that acetaminophen is used by parents for treatment of fever [22]. acetaminophen and ibuprofen are the only antipyretic drugs recommended for use [23].in the current study, mothers had insufficient knowledge about the best way to measure temperature, and 76% answered that using a hand is the best method. parmar et al. (2001) reported that only 15% table 5:the association between mothers’ knowledge regarding child fever management and mothers’ number of children. mothers respond to answer number of children among sample correct incorrect not sure f (%) f (%) f (%) total mothers with one child mothers with two children mothers with ≥ three children total 162 (30.29) 75 (24.68) 123 (25.57) 360 131 (24.48) 76 (25) 129 (26.82) 336 242 (45.23) 153 (50.32) 229 (47.61) 624 535 304 481 1320 χ² obs= 4.7 df= 4 χ² crit= 9.5 p>0.05 f=numbers of (correct, incorrect and not sure answers that had been answered by the sample regarding each question related to infant fever and its management in table 2 discussion https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article and the age of children were found to be significantly associated with mothers' knowledge of fever. however, the study also shows that there is a highly significant positive association between the mothers' knowledge and the level of education. many studies have revealed that mothers’ education has a positive impact on their knowledge and practice in child health matters [29-30]. also, sharabanou t et al. (2016) indicated a significant correlation between fever management and educational level [31]. this is significant when identifying strategies to help mothers better understand how to treat fever. furthermore, the result of a study by talebian et al. (2009) shows that with a high educational level, knowledge and attitudes of parents improved significantly [32]. finally, the findings of the current study show that there is no significant association between the mothers' knowledge and a number of children in the family. although 70% of mothers in the study had more than one child, they did not have the right knowledge in treating children with fever. however, anokye r et al. (2018) indicated that the number of children and the level of education was found to be significantly associated with mothers' knowledge of fever [33]. mothers in this study had some knowledge about fever and its management. however, they had insufficient information about which method of measurement is best for their children with fever; they did not know the reason and appropriate use of rectal paracetamol. a small number of mothers knew that the physical method (cold sponge or ice pack) is suitable for lowering body temperature only in the cases of hyperthermia. finally, the findings of the study also show that there was a highly significant positive association between of parents had a thermometer at home [24], which is in line with the findings in this study. 66.0% of participants in the current study used the specific measuring spoon/syringe drug to determine the right dose of paracetamol syrup. it is recommended that mothers should never use kitchen spoons to give a child medication as they can vary in size [25]. nearly half of the mothers in this study thought it was more useful and practical to give the unwell child paracetamol rectally. it has been recommended to use oral administration of acetaminophen rather than rectal administration, except in the presence of any conditions that prevent oral administration, such as vomiting or refusal [21]. this study's results show that most of the mothers gave paracetamol according to label instructions, or they consulted the dosage with a health care provider. in terms of cold sponge or ice pack being effective for lowering body temperature, only 29.0% answered correctly. studies have found that physical methods used to reduce fever such as bathing, cold sponging, application of ice bags, and rubbing the body with alcohol might have adverse effects. these methods may paradoxically increase fever, shaking, shiver, severe hypoglycemia, or lead to coma [26]. consequently, physical methods to reduce fever are not recommended except in cases of hyperthermia [27]. there is a necessity to provide parents with appropriate fever management strategies, such as giving their febrile children more fluids and rest and keeping them comfortable, as well as guidelines on when to use medications and seek medical advice, to reduce fever phobias and the probability of overdosing [28].the results of the current study showed no significant correlation between mothers' knowledge regarding child fever management and their age. in contrast, reindolf anokye et al. (2018) indicated that the age of mothers 163 erbil journal of nursing & midwifery conclusion https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article [6] arica sg, arica v, onur h, gülbayzar s, dağ h, obut ö. knowledge, attitude and response of mothers about fever in their children. emergency medicine journal. 2012 dec 1;29(12):e4 [7] jalil ha, jumah na, al-baghli aa. mothers' knowledge, fears and self-management of fever: a cross-sectional study from the capital governorate in kuwait. kuwait medical journal. 2007;39(4):349. [8] fever and your child. american academy of pediatrics. 2007. updated 21/11/2015). available on: https:// www.healthychildren.org/english/healthissues/conditions/fever/pages/signs-andsymptoms-of-fever.aspx#:~:text=a20fever% 20is%20usually%20a,is%20trying%20to% 20heal%20itself. [9] star k, and choonara i. how safe is paracetamol? (2015): 73-74 [10] polit fb., & hungler pb. nursing research principles and methods. 6th edition. lippincott williams & wilkins; january 1, 1999. [11] crocetti m, moghbeli n, serwint j. fever phobia revisited: have parental misconceptions about fever changed in 20 years?. pediatrics. 2001 june 1;107(6):1241-6 [12] demir f, sekreter o. knowledge, attitudes and misconceptions of primary care physicians regarding fever in children: a crosssectional study. italian journal of pediatrics. 2012 dec 1;38(1):40 [13] green r, jeena p, kotze s, lewis h, webb d, wells m. management of acute fever in children: guideline for community healthcare providers and pharmacists. south african medical journal. 2013 december 9;103 (12):948-54. [14] desnous b, goujon e, bellavoine v, merdariu d, auvin s. perceptions of fever and fever management practices in parents of children with dravet syndrome. epilepsy & behavior. 2011 august 1;21(4):446-8. [15] richardson m, lakhanpaul m. assessment and initial management of feverish illness in children younger than 5 years: summary of nice guidance. bmj. 2007 may 31;334 (7604):1163-4. [16] yavuz e, yayla e, cebeci se, kırımlı e, gümüştakım rş, çakır l, doğan s. parental beliefs and practices regarding childhood fever in turkish primary care. nigerian journal of clinical practice. 2017;20(1):93-8 [17] kilmon ca. parents' knowledge and practices related to fever management. journal of mothers’ knowledge regarding child fever management and level of education and a number of children that the mother has. an educational program should be developed for mothers who attend primary health care centres for all issues related to child fever management. health care providers such as nurses, health visitors or vaccinators can increase mothers' awareness and level of knowledge regarding fever management at home. the author reports no conflict of interest. i would like to express my thanks to all mothers who participated in this study for their valuable time and responses. my gratitude goes to the phcs in ranya for their generosity in allowing this research to be carried out and cooperation during the period of study. [1] armon k, stephenson t, gabriel v, macfaul r, eccleston p, werneke u, et al. determining the common medical presenting problems to an accident and emergency department. archives of disease in childhood. 2001 may 1;84(5):390-2 [2] finkelstein ja, christiansen cl, platt r. fever in pediatric primary care: occurrence, management, and outcomes. pediatrics. 2000 january1.260-6 [3] casey r, mcmahon f, mccormick mc, pasquariello ps, zavod w, king fh. fever therapy: an educational intervention for parents. pediatrics. 1984 may 1;73(5):600-3. [4] stuijvenberg mv, vos sd, tjiang gc, steyerberg ew, derksen‐lubsen g, moll ha. parents’ fear regarding fever and febrile seizures. acta paediatrica. 1999 jun;88(6):61822. [5] o’neill-murphy ka, liebman m, barnsteiner jh. fever education: does it reduce parent fever anxiety?. pediatric emergency care. 2001 feb 1;17(1):47-51 164 erbil journal of nursing & midwifery recommendations conflict of interest acknowledgements references https://doi.org/10.15218/ejnm.2019.18 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article [28] walsh a, edwards h, fraser j. over‐the‐ counter medication use for childhood fever: a cross‐sectional study of australian parents. journal of paediatrics and child health. 2007 sep;43(9):601-6. [29] akpabio a, klausner cp, inglehart mr. mothers'/guardians' knowledge about promoting children's oral health. american dental hygienists' association. 2008 january 1;82 (1):12 [30] saeed aa, bani ia. prevalence and correlates of acute respiratory infections in children less than two years of age. saudi medical journal. 2000 dec;21(12):1152-6. [31] talebi s, shahrabadi h, vahidi sa, talebi s, siyavoshi m. mothers’ management of fever of children in sabzevar. journal of nursing and midwifery sciences, 2016, 3(2), 32-39. [32] talebian a, honarpisheh a, barekatain b, taghadosi m, mousavi sg. evaluating of knowledge, attitude, practice and related factors in mothers of children with febrile convulsion at kashan during 2006-2007. kaums journal (feyz). 2009 apr 10;13(1):43 -7 [33] anokye r, amihere r, abbiaw p, acheampong e, gyamfi n, budu-ainooson a. childhood fever knowledge and management: a case of mothers with children under five years. int j pediatr res. 2018;4:044. pediatric health care. 1987 july 1;1(4):173-9. [18] sa’ed hz, al-jabi sw, sweileh wm, nabulsi mm, tubaila mf, awang r, sawalha af. beliefs and practices regarding childhood fever among parents: a cross-sectional study from palestine. bmc pediatrics. 2013 dec 1;13 (1):66. [19] erkek n, senel s, sahin m, ozgur o, karacan c. parents' perspectives to childhood fever: comparison of culturally diverse populations. journal of paediatrics and child health. 2010 oct;46(10):583-7. [20] halıcıoğlu o, koç f, akman sa, teyin a. in feverish children, mothers' knowledge and home management about fever and its relationship with socio-demographic characteristics. i̇zmir dr. behçet uz çocuk hastanesi dergisi. 2011;1(1):13-9. [21] world health organization world health organization. department of child, adolescent health, world health organization, unicef. handbook imci: integrated management of childhood illness. world health organization; 2005 [22] jensen jf, tønnesen ll, söderström m, thorsen h, siersma v. paracetamol for feverish children: parental motives and experiences. scandinavian journal of primary health care. 2010 jan 1;28(2):115-20. [23] chiappini e, principi n, longhi r, tovo pa, becherucci p, bonsignori f, esposito s, festini f, galli l, lucchesi b, mugelli a. management of fever in children: summary of the italian pediatric society guidelines. clinical therapeutics. 2009 aug 1;31(8):1826-43. [24] parmar rc, sahu dr, bavdekar sb. knowledge, attitude and practices of parents of children with febrile convulsion. journal of postgraduate medicine. 2001 january 1;47 (1):19. [25] webmd. safely treat children's fever and pain: only use the dosing tool that comes with the medication. 2005 2019 webmd llc. all rights reserved available on https:// https://www.webmd.com/painmanagement/pain-relievers-for-children#2 [26] meremikwu mm, oyo‐ita a. physical methods versus drug placebo or no treatment for managing fever in children. cochrane database of systematic reviews. 2003(2). [27] national collaborating centre for women's and children's health (uk. feverish illness in children: assessment and initial management in children younger than 5 years. 165 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.13 erbil j. nurs. midwifery, vol. 2, no. (2), may, 2019 original article perception of undergraduate nursing students regarding humor’s using as a teaching strategy in the classroom at college of nursing in erbil city abstract introduction humor is an characteristic that can motivate an individual to accomplish significant goals in his or her life.[2] examples background and objectives: humor is a necessary teaching strategy tool in nursing education programs. nursing students may feel a sense of boredom in class and therefore, it is important for faculty and instructors to incorporate humor in both the class and clinical setting to improve the overall learning environment. the purpose of this study was to explore students’ experiences regarding the use of humor in the classroom. methods: a qualitative study using a hermeneutic-phenomenological approach was taken as a framework for the study. a volunteer sample of 9 undergraduate nursing students from the fourth stage of college of nursing at hawler medical university participated in the study. the data was analyzed using the content analysis method. this method included four stages; interview transcript, open coding, axial coding, and core category. data was collected using a semi-structured interview utilizing four open-ended interview questions: (a) did humor improve your relationship with teachers? how? (b) did humor help you to pay attention to the class? how? (c) did humor increase your interest in the topic? how? (d) did you have experiences with humor in the classroom? how? results: most of the participants reported and emphasized that using humor in the classroom by nurse educators was helpful in making the learning environment fun. also, participants mentioned that using humor was helpful in that they were able to ask their teachers questions in class without fear. students reported that utilizing humor in the classroom encouraged them to enjoy the course content and the teachers. there were two main themes used in this study; a) encourage students for discussion in the classroom with the following sub-themes: enhance the learning process, improve students critical thinking and communication skills, and decrease the students’ stress, fear and anxiety and b) attract students’ attention in the classroom with the following sub-themes: improve students’ course grade, encourage group discussion, increase students’ attendance in the classroom, and pay attention to the class . conclusion: the use of humor in the classroom enhances the learning process. all of the students confirmed that using humor in the classroom improved student-teacher’s communication skills. also, students indicated that using humor in the classroom influenced them to pay attention to the class, retain the information, and digest the information very well. keywords: humor, classroom, nurse educator, nursing students, nursing education dlzar sedeeq anwer; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: dlzar.anwer@hmu.edu.krd) norhan zeki shaker; department of nursing, college of nursing, hawler medical university, erbil, iraq. adnan rasheed aziz; department of nursing, college of nursing, hawler medical university, erbil, iraq. 101 erbil journal of nursing & midwifery received: 19/11/2018 accepted: 22/8/2019 published: 30/11/2019 https://doi.org/10.15218/ejnm.2019.13 erbil j. nurs. midwifery, vol. 2, no. (2), may, 2019 original article of humor include jokes, cartoons, comedy, laughter, etc. [1] it carries a message of caring, warmth, love, and compassion and enhances positive communication in the learning environment. [3] humor can assist students in remembering topics and course content particularly if the humor supports the class material. [3] humor creates a relaxed environment where both teaching and learning can be interesting and improved upon. humor is used to develop the learning process and enhances nursing students’ desire to learn and diminishes the “boring” classroom setting. humor is a concept that can help nursing students feel relaxed throughout lecture. when nursing students are comfortable, thinking becomes productive and important. an anxious atmosphere impedes thinking. [2-4] humor can be an effective, multi-purpose teaching tool for nurse educators to teach course content, keep students’ attention, relieve anxiety, establish relationships, and make learning fun. [5] humor appropriately used has the potential to humanize, explain, soothe, encourage, reduce anxiety, and keep people thinking. [6] humor has been said to facilitate the retention of original information as well. [7] the effective use of humor in the classroom produces loyalty, supports self-esteem, lessens stress, lessens criticism, and increases effective leadership. as college classrooms become more diverse both in student population and delivery methods, it becomes increasingly imperative for nurse educators to link with their students on a variety of levels that students perceive as beneficial to their learning process. nurse educators should be role models for students. nurse educators who are well-informed about humor and utilize humor in their classrooms can help students identify their own sense of humor and how it affects others around them, including their patients. [8] humor is understood to diminish anxiety and worry, build self-confidence, develop productivity, increase interest, reduce boredom and encourage different thinking. [9] it is an ideal teaching aid for creating a classroom atmosphere helpful to learning. when used in the correct way, humor can motivate creative thinking, improve memory of the learners, stimulate learners to learn, gain information, and build a positive learner-teacher relationship. [10] positive humor, particularly when related to the topic, encourages learning because it establishes a conducive environment for adult learning, memory, unification of organizers and learners, and adopted cohesiveness. [11] humor is recognized as a teaching method for increasing a positive learning environment. when a teacher creates a helpful social environment, learners are more likely to be receptive to learning. [12] learners stated that humor makes teachers more likeable, makes the material easier to learn, decreases stress, and increases self-esteem and attention. humor can also bridge the gap between the teacher and the students by putting students at ease. [13] humor has been mentioned as one of the important characteristics of a good instructor and it is a valuable teaching method with many benefits for teachers, as it could enhance learning by helping comprehension. [14] nurse educators should use humor effectively in facilitating learning so as to develop the learners’ sense of humor, which is also expected in clinical practice, where a climate of acceptance, support, trust and freedom of expression should be created. [15] it is crucial to the nurse educator to use humor as a teaching strategy in the classroom to promote the learning outcome of the nursing students. this study was conducted because there were limited qualitative research studies about humor in 102 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.13 erbil j. nurs. midwifery, vol. 2, no. (2), may, 2019 original article the criteria for sample selection includes: fourth stage nursing students, either male or female, self-reports of being present when humor is being used in the classroom. the criteria for sample exclusion includes: first stage, second stage, and third stage undergraduate nursing students. instrument/measurement the instruments selected for collecting data in this study were: (a) semi-structured open-ended questions interview and (b) demographic data. demographic data consisted of age, gender, educational level, and the question: have you ever witnessed humor used in the classroom? the four semi-structured interview question was consisted of; (a) did humor improve your relationship with teachers? how? (b) did humor help you to pay attention to the class? how? (c) did humor increase your interest to the topic? how? (d) did you have experiences with humor in the classroom? how? data collection procedures prior to data collection, approval was obtained from the research ethical committee and scientific committee of college of nursing at hawler medical university. participants were recruited by explaining the purpose of the study and the qualifying eligibility criteria. the researcher contacted participants directly by visiting the classroom after students finished their lecture. prior to the start of the interview, each participant was informed of methods to ensure confidentiality and his/her right to refuse participation at any time. each participant was also asked to sign an informed consent form agreeing to participate in the study. each participant was asked the same four open-ended questions. the interview took place face-toface (recording voice) between researcher and participants. data was collected until data saturation was obtained. education and even fewer on humor in nursing education. the scope is further limited when examining studies reflecting how humor is perceived by students regarding their learning experience. the use of humor is a somewhat recent innovation in nursing education. therefore, how it is used and the reasoning for using it is unclear. while educators still remain doubtful to the use of humor in the educational setting, students voice their support and appreciation of humor as an adjunct to their education. the objective of this study was to explore the perceptions of undergraduate nursing students regarding the use of humor in the classroom as a teaching strategy to promote learning outcomes. research design a qualitative studyhermeneuticphenomenological approach used to explore undergraduate nursing students’ perception of humor in the classroom. the hermeneutic-phenomenological approach seeks to describe and analyze phenomena as they are experienced. the content analysis was used as a data analysis method in this study. the focus of this study was to examine undergraduate nursing students’ perception of humor in the classroom who are in their last year of the baccalaureate nursing program. population, sample, and setting the population involves undergraduate nursing students (fourth stage) attending college of nursing-hawler medical universityin erbil-kurdistan region-iraq. the sample for the study was a purposeful sample. this allowed for potential participants who have encountered humor in the classroom to come forward and identify themselves. once inclusion criteria were met, a random sample of 9 students from the learning institution were interviewed. 103 methods erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.13 erbil j. nurs. midwifery, vol. 2, no. (2), may, 2019 original article the data was analyzed by using content analysis method. this method included four stages; interview transcript, open coding, axial coding, and core category. in interview transcript, all students’ speech was put in one column. in open coding, all students’ speech details were summarized into short meaningful phrases. in axial coding, all those phrases were summarized into sub-themes. in core category, all those phrases were summarized into themes. 1– encourage students for discussion in the classroom a-enhance learning process student one: “in third stage, i had a psychology course. i love this course because the teacher made this course more interesting. the teacher always included funny jokes in the class. it encouraged me to love this course. i was able to love the teacher and be happy in his course. it encouraged me to create questions regarding course content.” student seven: “i had a teacher who was like a friend and he spoke to us so nicely in the class. he showed us many pictures on the slides. this teacher did not make me feel down in the classroom and his behavior encouraged me to easily understand the content of the course”. student four: i paid attention to the contents of the course due to the use of caricatures and emoji pictures that my teacher put on the slides of the powerpoint. this teacher instead of just giving the basic details of his lecture, he included so many pictures in the slides and it was helpful to understand the content of the course. for me, i was not doing well in this course, but when the teacher put all caricatures and emoji’s in the slides it helped me to understand the content very well and i got a good grade in this course; most other students also well in the course” . student eight: “the use of kind and funny language has influenced students’ course grades. it encourages us to love the teachers and pay attention to the class. it also influences our examination grades”. b-improve students critical thinking and communication skills student three: “during our second stage pharmacology course, there was a teacher that i loved because she had a good relationship with students. student seven: “i had many examples regarding using humor in the class. one thing that i remember and experienced was in my communication skill course when i was in second stage. one night i did not sleep very well as well as my classmate. during the class time, i slept in the class until the end of the class. the teacher knew that i slept in the class but he did not wake me up and he did not feel me down in front of the students. i instead, at the end of the class, the teacher put a picture on the slide that some students slept in the class. this picture on the slide made us laugh in the class and we were waking up with the students’ laughter. this teacher’s behavior made us love the teacher”. c-decrease the students stress, fear and anxiety student three: the teacher was always used nice words to decrease our anxiety and fear in the class. this teacher’s behaviors helped me to make questions regarding the content of the course and love the course and teacher. previously, i did not like the pharmacology course but this teacher made me love this course due to being so nice during the class. certainly, if there was no fear between the teachers and students, it would encourage the students to learn the topic”. 104 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2019.13 erbil j. nurs. midwifery, vol. 2, no. (2), may, 2019 original article that happened here. his lecture regarding the earthquake stated that people were praying in every home and the color of their faces changed once it happened. it was so nice that the teacher talked about these things because our psychological status was not good. we had fear regarding the earthquake and the teacher decreased this fear by with his jokes. also this joke helped me learn more about the earthquake which was nice. it also helped me to pay attention to the class and it was so good”. student six: “in second stage, i had a pharmacology course. that teacher used funny and nice language in the class and he was so open to us as he listened to the students. his nice speech in the class made us happy. we were able to pay attention to the class and loved to ask questions. the teacher always used pictures in the slides and it helped us to digest the topic very easily. the teacher was able to give more information in a short period of time. it was useful to the students to learn the content of the course”. cincrease students’ attendance rates in the classroom students eight: “i had teachers in both my ethics and psychology courses who used humor very nicely. these teachers were nice and used humor in a reasonable manner and in a short period of time. we loved both the teachers and going to class. we would be so worried if we missed the class of these two teachers who used humor. in these two courses, we learned the content of the course and paid attention to the class. we learned a lot while being respectful of one another and earned good grades in the course”. dpay attention to the class student nine: “i was in second stage in my microbiology course. i did not like this 105 erbil journal of nursing & midwifery 2attract students’ attention in the classroom aimprove students’ course grade student one: “in third stage, i had a psychology course. the teacher in this course had a great influence on us to pay attention to the class and to have a great grade in this course. when you understand the content in the class, it makes the examination very easy. this teacher frequently used funny language in the class and this was helpful in understanding the course”. student four: “in my second stage communications skill course, i had a teacher who filled all slides with caricatures and emoji from first lecture until the final lecture. we had a good grade in this course”. student five: “i remember last year i had a biostatistics and a research course both taught by one teacher. from the first lecture until now, we had fear regarding this teacher. the teacher was really serious, did not have smile, and did not use funny language in her class. the teacher did not use humor in the class to make us smile and happy. during the examination, i studied so much yet did not get a good grade. this was strange to me. at the same time, i had a psychology teacher and though it was really hard to understand the content of the course, the teacher made a funny joke in the class. it helped us to learn the content of the course. it encouraged us to pay attention to the class and create questions regarding the content of the course. if a teacher did not use humor like funny jokes and spoke nicely during class time, it will not encourage me to ask questions regarding the topic. it means that the teacher is not open to students”. bencourage group discussion student two: “last year in third stage, i had a psychology course. the teacher made a funny joke about an earthquake https://doi.org/10.15218/ejnm.2019.13 erbil j. nurs. midwifery, vol. 2, no. (2), may, 2019 original article course and though i studied so much, i was not able to get a good grade in this course. i was sitting in the last chair in the class and that day i was so sleepy, my teacher said to me ‘why you do not have voice today?’. all my classmates looked at me and all of them thought that i was a smart student in this class. for the remainder of the class, that teacher told me you have to sit in the front seat of the class. this teacher’s behavior made me to love this teacher and pay attention to the teacher. i was able to have increase my interest for studying in this course. this teacher’s behavior encouraged me to have a good grade in the microbiology course”. a quantitative study had been conducted in the united states with students who had taken a psychology course. the purpose of the study was to determine the outcome of using humor on students’ exam performance. the results showed that students who experienced humor in their courses had higher grades on the final exam. [4] a qualitative study had been conducted in iran which mentioned that understanding nurses’ perceptions and experiences of humor helps identify its contributing factors and provides valuable guidelines for enhancing nurses and patients’ mental, emotional and physical health. spreading a culture of humor through teaching methods can improve workplace cheerfulness and highlights the importance of humor in patient care in nurses and nursing students. [16] a qualitative study using the phenomenological approach was conducted in the united states. the focus of this study was to examine undergraduate nursing students’ experience with humor in the classroom. the results of the study support the principles that emotions can influences the learning process and that interpersonal relationships are a concern for nursing students. students expressed their desire to have classroom experiences that help them perceive, create, feel, and wonder and to have a classroom atmosphere where environmental conditions facilitate learning. [17] there are several potential limitations to the study: (a) small sample size, (b) geographical area consisting only of college of nursing-hawler medical university, (c) dependence on students’ recall of nurse educators’ uses of humor, and (d) the inexperience of the researcher could introduce researcher bias. interview technique and questions facilitated participant disclosure and the discovery of common experiences. the following conclusions are based on the results of this study: 1) nursing students in the college of nursing believed that humor in the classroom encourages students to pay attention to the class, retain the information, and digest the topic very well; 2) students believed that humor should be incorporated more often into the nursing curriculum; 3) students believed that humor improves student-teacher communication skills; 4) students indicated that using humor in the classroom influenced them to increase their interest in the content of the course. we declared that there is no conflict of interest with this study. [1] olsson h, kook m, sorenson s, koch m. nursing and humor: an exploratory study in sweden. vard i norden 2000; 1: 42-45. [2] chabeli m. humor: a pedagogical tool to promote learning. curationis september 2008. 106 erbil journal of nursing & midwifery counclusion discussion conflict of interest reference https://doi.org/10.15218/ejnm.2019.13 erbil j. nurs. midwifery, vol. 2, no. (2), may, 2019 original article [17] athern t. undergraduate nursing students’ experience of humor in the classroom. 2008 dissertation. [3] ron d. the use of humor as a teaching tool in the college classroom. nacta journal 2000. [4] ziv a. teaching and learning with humor: experiment and replication. journal of experimental education 1988; 57(1): 5–11. [5] ulloth j. the benefits of humor in nursing education. journal of nursing education 2002; 41, 476-481. [6] torok e, mcmorris f, lin c. is humor an appreciated teaching tool? perceptions of professors’ teaching styles and use of humor. journalcollege teaching .2004; 52, 14-20. [7] cornett e. why get serious about humor? in learning through laughter; humor in the classroom. bloomington, in; phi delta kappa educational foundation; 1986. [8] pierson p, bredeson v. it’s not just a laughing matter: school principals’ use of humor in interpersonal communications with teenagers. journal of school leadership 1993; 3, 522. [9] ziegler b. use of humour in medical teaching. medical teacher .1998; 20(4):341-348. [10] goudinho j, jacob m. .humor as a teaching strategy in medical education. european journal of pharmaceutical and medical research 2016; 3(7): 419-422. [11] baid h. lambert n. enjoyable learning: the role of humour, games, and fun activities in nursing and midwifery education. nurse education today .2010; 30, 548–552. [12] nadeem m. teaching with humor: a benevolent teaching technique for second language learners in teacher education. international journal of english and literature. 2012; 2(4): 89-96. [13] huss j, eastep s .the attitudes of university faculty toward humor as a pedagogical tool: can we take a joke?. journal of inquiry & action in education .2016; 8 (1):39-65. [14] nasiri f, mafakheri f. higher education lecturing and humor: from perspectives to strategies. higher education studies 2015; 5 (5): 26-31. [15] chabeli m, malesela j, rasepae m. humour to facilitate meaningful learning in nursing education as experienced by learner nurses. journal of education. 2014; 59, 90-113. [16] ghaffari1g, nayeri n, shali m. nurses’ experiences of humour in clinical settings. medical journal of the islamic republic of iran. 2015; 29 (182): 2-11. 107 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.09 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article knowledge and perspectives of postgraduate nurses regarding competency of advanced nursing practice in kurdistan region of iraq abstract introduction advanced nursing practice (anp) is a high degree of knowledge, skill and experience that is applied within the nurse-consumer relationship to achieve optimal outcomes through critical analysis, problem solving and accurate decision-making *1+. anp has always existed because nursing is continually evolving, and this might be reflecting on patients and community service needs *2+. besides, the role of the advanced nurse has grown continuously over the last centuries due to pressures related to reimbursement and managed care, a growing patient advocacy, and changing attitudes about role of nurses. background and objectives: advanced nursing practice (anp) involves integration role domains, which are related to clinical practice, education, research, professional development and organizational leadership. the objectives of this study were to assess the knowledge and perspective of graduated nurse regarding competency of advanced nursing practice and explain the domains of advanced nursing practice competency. methods: this cross-sectional study sought to determine knowledge and perspective of graduated nurses regarding advanced nursing practice in kurdistan region from 20th june 2014 to 20th december 2014. nurses who held degrees including master of science, and philosophy of doctorate or both were invited to participate. one hundred and fifty participants met the inclusion criteria, and 50 completely responded to the questionnaire. data were analyzed by using statistical package for the social sciences (spss) version (20). results: the total 50 of interviewed participants responded to the survey, with 24 (48%) considering that an anp should have autonomy in clinical practice. while 28 (56 %) and 35 (70 %) of participants mentioned that an anp should be able to manage complexity throughout clinical placement. conclusion: considerable number of participants in this study did not have adequate and satisfactory knowledge regarding advanced nursing practice. keywords: advanced nursing practice, knowledge, nurse. bootan hasan ahmed ; department of nursing, college of nursing, hawler medical university, erbil, iraq. ribwar arsalan mohammed; department of nursing, college of nursing, university of raparin, sulaimaniya , iraq. sanaa hassan abdulsahib ; department of nursing, college of nursing, university of raparin .sulaimaniya , iraq. vian afan naqshbandi; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: ribwar@uor.edu.krd) 64 erbil journal of nursing & midwifery received: 2/9/2017 accepted: 28/10/2017 published: 5/5/2018 https://doi.org/10.15218/ejnm.2018.09 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article as a result, these phenomena were helpful in developing role of nurse *3+. studies have demonstrated that many reasons and events that are helpful in emerging and developing role of anp but are not limited including the health care needs of the population, practice pattern and new models of care, education, workforce issues and the legacy and policy context *12+. similarly, another study introduces that socio-political environment, government policy and support, intra/ inter professional collaboration and developing nursing education shaped anp *4,5+. furthermore, health cares policy and culture of the health care settings where nurse work played a considerable role in shaping and defining role of anp *10+. the concept of advanced nursing practice (anp) and/or advanced practice nurse (apn) have been used interchangeably among the literature and studies; however, they represent the same meaning *4, 6, 12, 13+. there is no single definition of anp but there is a consensus agreement that it extends traditional scope of nursing, highly autonomous practice of nurse, increase the use of nursing knowledge and participating to the development of profession *14, 15+ apn has been defined in different forms in studies. for example, international council of nurses (icn) defines anp as a “registered nurse who has acquired the expert knowledge base, complex decision making skills and clinical competencies for expanded practice the characteristics for which are shaped by the context and / or country in which s/he credentialed to practice. a master’s degree is required for entry level” *7+. thus, there is lack of worldwide acceptance regarding the definition of anp and this led to inconsistency about competencies that are required for this level of practice *11, 18+. however, there are three features that distinguishes apn from basic nursing practice including specialization of care for a specific population of patient with complex health care needs, acquisition of recent knowledge and skills as well as autonomy extending in scope of nursing practice *14, 15+ competence and skills are required to achieve anp but describing these two terminologies is complex and dynamic *10, 13+. competency is a quality or characteristics of a person that is related to effective performance including combination of knowledge, skills, motives and traits *19+. on the other hand, icn defines competency as the level of performance demonstrating the effective application of knowledge, skills, judgment and personal attributes required to practice safely and ethically in a diagnosed role and setting *7+. distinguishing the role of apn is less difficult in countries including the united states, where legalization, regulatory mechanisms, protected titles for clinical nurse specialist, nurse midwives, nurse anesthetists and nurse practitioners exist *10+. because problems might arise when several roles are applied to the same title, such as nurse specialist, there is now an international agreement about the utilization of titles to distinguish the anp role. bryant-lukosius and dicenso (2004) stated that roles of anp would be clearly distinguished due to lack of regulation and protective title for nurses in clinical nurse specialist. the role is defined as the competences related to clinical practice, education, research, organizational leadership, and professional development *10+. in the kurdistan region (kr) of iraq, the college of nursing was created in three provinces including erbil, sulimani, dohuk and raparin in 2001 in order to develop the nurse workforce. increasing the number of undergraduate students, developing higher education 65 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.09 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article composed of knowledge regarding competencies of anp. the third section was the perspective of participants regarding developing anp in kr. the questionnaire was given to participants to complete individually. eligible criteria to participate in this study were nurses who were holding master of science in nursing (m.sc.), philosophy of doctorate (phd) or both; having a scientific degree that is not less than assistant lecturer and being able to speak and write in english. both diploma and m.sc. degree considered studying of graduate for 2 years separately, whereas phd degree was considered studying of graduate degree for three to four years. participants were attending schools of nursing in public universities including hawler medical university, university of raparin, duhok university, public and private hospitals. prior to commencement of the study, written confirmation was obtained from research committee in college of nursing in hawler medical university. a total 150 participants met the inclusion criteria. data collection was done by self-administered questionnaire, and given to the participants in the given areas, and only 50 completely responded questions in the questionnaire; the remaining rejected to participate in the study. data were analyzed by using statistical package for the social sciences (spss) version (20). in which mean and standard deviation of participants were taken in terms of age and their experience as a nurse. then, frequency and percentage of participants with respect to each question was introduced. degrees (master, and phd) in nursing fields, increasing workload on the physicians, and developing more subspecialties in clinical practice demonstrate anp in nursing education in the kr. this i because when health care delivery increases via consumer demands, anp may emerge *4+. surprisingly, in kr, there is no a scientific evidence regarding the perspective of graduated nurses on anp at nursing academic institutions. anp in academic settings are introduced to change pattern of practice, identification of skills and specialization in a relevant field *20+. as health-care is always evolving, innovative clinical practitioner is required in order to play a major role in health care settings *14+. the primary aim of this article is to assess the knowledge of graduate nurses regarding competence of anp and to examine their perspectives toward incorporation of anp in kurdistan region health care facilities. a quantitative cross-sectional study was carried out to assess knowledge and perspective of graduated nurses regarding competency of anp in kurdistan region of iraq from june 20, 2014 to december 20, 2014. following an extensive reading of anp literature, and specifically advanced nursing practice toolkit *21+ a constructed questionnaire was developed to meet the purpose of the study. it was reviewed by two expertise's in order to improve internal validity and internal consistency reliability of the questionnaire. the questionnaire was composed of three sections. the first section was demographical characteristics of participants. the second section was 66 erbil journal of nursing & midwifery methods results regarding demographical data, mean and standard deviation of the participant age https://doi.org/10.15218/ejnm.2018.09 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article and years of experience in nursing were 40.08 ±9.52 and 6.58 ±4.46 respectively. the majority of participants were studying inside of iraqi universities (78%), whereas 22% of them were finished the postgraduate degree abroad. most held a masters degree (68 %). the academic titles of the participants were mainly assistant lecturer (48 %), while lecturer, assistant professor and professor were 28%, 12% and 2% respectively as revealed in the table 1. table 1: participant characteristics table 2: knowledge of participants regarding, pre-requisites qualification and roles of advanced nursing practice table 3 reveals that almost all participants (86%) posited that decision-making, clinical judgment and problem solving are the main competencies that an advanced clinical practitioner must have, during their clinical practice. on the other hand, 24 (48 %) and 21 (42 %) considered that an anp should have autonomy in clinical practice and managing risk respectively. while 28 (56 %) and 35 (70 %) of participants mentioned that an anp should be able to manage complexity and have a good communication skill with colleagues throughout clinical placement respectively. table 4 shows number of participants believed that an anp should develop their ability to access research 17 (34 %) and implement research findings 17 (34 %) in clinical placement. however, low number of participants suggested that anp need to 67 erbil journal of nursing & midwifery participant characteristics frequency % roles educator and researcher 40 80 leader 5 10 clinical practitioner 5 10 total 50 100 academic title assistant lecturer 24 48 lecturer 14 28 assistant professor 6 12 professor 1 2 no academic title 5 10 total 50 100 qualification msc 34 68 phd 16 32 total 50 100 regarding the prerequisite qualification to take anp role, 22% of participants thought that holding a diploma was a minimum requirement, compared to 20% who believed that holding a masters degree was required. the majority believed that anp must be an advanced clinical practitioner (76%), whereas only 4% of them highlighted that an anp should play all roles. (table 2). prerequisite qualification of anp frequency % cbtc 10 20 diploma 11 22 bsc 10 20 msc 10 20 phd 9 18 total 50 100 anp roles clinical/ professional leadership 4 8.0 facilitating learning 5 10.0 research and development 1 2.0 advanced clinical practice 38 76.0 all above 2 4.0 total 50 100.0 https://doi.org/10.15218/ejnm.2018.09 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article develop their ability in terms of presenting seminar in conference 14 (28 %) and publication 12 (24 %) table 3: perspectives of participants regarding skill abilities and characteristics of advanced clinical practice table 4: perspective of participants regarding research, and development competency domains of advanced nursing practice table 5 reveals that participants supposed that being able to learn and improve nurse’s capability and building capacity 17 (34 %). however, 10 (20 %) and 14 (28 %) of participants demonstrated that an anp should be able to provide information and develop principles of teaching respectively. table 6 shows that 19 (38 %) participants believed developing the team in working place was the main skill of this type of nurse’s role. a small number of responders highlighted that equality and diversity 10 (20%) are the main clinical leadership skills of an anp. regarding perspectives of an anp, table 7 shows that majority of participants 40 (80 %) suggested that anp should be incorporate into context of health care including primary health care centers and hospitals in kr. besides, 23 (46 %) participants thought that anp can meet health care needs of society, while 3(6 %) 68 erbil journal of nursing & midwifery advanced clinical practice frequency % decision making / clinical judgment and problem solving 43 86 critical thinking and analytical skills incorporating critical reflection 35 70 managing complexity 28 56 assessment, diagnosis referral, discharge 34 68 developing higher levels of autonomy 24 48 assessing and managing risk 21 42 prescribing 25 50 developing confidence 29 58 developing therapeutic nursing to improve patient outcomes 33 66 higher level communication skills 35 70 patient focus / public involvement 31 62 research and development frequency percent % ability to access research/ use information 17 34 critical appraisal / evaluation skills 14 28 involvement in research / audit 13 26 ability to implement research findings into practiceincluding use of and development of policies / protocols and guidelines. 17 34 conference presentations 14 28 publications 12 24 https://doi.org/10.15218/ejnm.2018.09 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article participants mentioned that governmental health policy is helpful to introduce anp into health care sectors of kurdistan region. in other words, as is clarified in the table 7, most participants thought developing of anp in kurdistan region may be difficult due to deficiencies of job descriptions in the health care system (46 %) and lack of inter and intra professional cooperation 6 (12 %) among health care staff at the hospitals. in addition, 4 (8%) considered that socio-political environment of hospitals is another difficulty in front of introducing anp in kurdistan region. 69 erbil journal of nursing & midwifery table 5: perspective of participants regarding facilitating-learning anp competency domain. table 6: perspective of participants about clinical leadership basic skills. facilitating learning frequency % principles of teaching and learning 17 34 supporting others to develop knowledge and skills 15 30 promotion of learning / creation of learning environment 16 32 service user/ career teaching and information giving 10 20 developing service user/ career education materials 14 28 mentorship and coaching 15 30 building capability and capacity 17 34 clinical /professional leadership frequency % identifying need for change, developing case for change including service development. 16 32 clinical governance 11 22 equality & diversity 10 20 ethical decision-making 16 32 developing case for change 13 26 negotiation and influencing skills 13 26 incorporate values-based care into practice 12 24 networking 13 26 team development 19 38 https://doi.org/10.15218/ejnm.2018.09 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article 70 erbil journal of nursing & midwifery table 7: participant perspectives regarding incorporation of the anps in health care sectors and obstacles of introducing anp into health care settings in kr incorporation of the anp into health settings frequency % yes 40 80 no 10 20 total 50 100 incorporate anps to meet the health needs of society 23 46 health care work loads 5 10 governmental policy and support 3 6 development of nursing education 15 30 no answered 4 8 total 50 100 obstacles of introducing of anp frequency (%) lack of job description in the health care system 23 46 absence of the high qualified nurses 5 10 socio-political environment of the health agencies 4 8 lack of inter-intra professional cooperation’s 6 12 no answered 2 4 total 50 100 the present study found that most of the participants believed that holding a diploma certificate in nursing (those who graduate in technical institute) (22%) is required to be appointed as an anp, whereas (20%) and (18 %) of participants highlighted that m.sc. and phd are required for being an anp respectively. as indicated in the literature, nurses working at advanced level during extensive clinical practice experience of a specific field and following completion of master’s level or above can work as anps. various studies support having a masters degree as the minimum to appointed as anp *2, 5, 7+. this study has found that few participants had acceptable knowledge about the roles of anp. it might be due to this role is not delineated in iraq, and kurdistan region. most participants are not studying abroad specifically in united kingdom (uk) and the united states or other countries where nurses have this role. in contrast to this study, for the first time in the uk a study found that an anp must be an expert practitioner, educator, researcher and consultant in clinical practice *13+. moreover, three studies have suggested that role of the anp should not be introduced as a homogeneous category, however; it needs to be introduced as heterogeneous sub-roles *5, 10+. with respect to characteristics and skills of anp discussion https://doi.org/10.15218/ejnm.2018.09 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article that the responsibility of apns should be clarified for nurses at hospitals and other health care settings. finally, it is recommended that a module of anp have to in corporate into postgraduate curriculum in nursing faculties. inadequate knowledge regarding sub roles, competences of anp, and required qualify cation to enter the level of anp were identified. participant attitudes toward developing anps in kr were positive. the role of anp need to be more clearly defined to all postgraduate nurses in order to improve and meet health care needs in this region. there is no conflict of interest to declare regrading this study. this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector *1+ mantzoukas s, watkinson s. review of advanced nursing practice: the international literature and developing the generic features. j clin nurs. 2007;16(1):28-37 *2+ department of health. advanced level nursing: a position statement. leeds: uk government; 2010 *3+ keane a, becker d. emerging roles of the advanced practice nurse. in: joel al (eds) advanced practice nursing essentials for role development. nursing, joanne patzek dacunh. the domains as shown in the table (2), participants of this study did not provide insight regarding competencies of anp in terms of clinical performance, characteristics of clinical leadership and conducting research. this is might be due to two factors: there is no such kind of nursing roles in the iraq and kurdistan region and advanced nursing has not been incorporated into postgraduate curriculums. numerous studies regarding anp have stated that it must play the key roles in competencies of advanced nurse practitioner, being educator in clinical practice, researcher, leader and manger in clinical practice *18+. most participants have diverse views regarding anp sub-role competencies; this might be referred to lack of inadequate knowledge regarding this role. incorporating anps into the health care system in the kurdistan region is seen as essential by the participants in which 40 (80%) supported that anp should be introduced in health care system of kr. this is because all felt that role of nurses has to be expanded to improve the health care services and to meet patients’ needs. implementation of new roles might be confronted variety of challenges and problems. a total 46% expected that developing such kind roles in kr is likely to face a number of challenges including a lack of job description, supporting of professional bodies, and role recognition by authorities. most participants supposed that lack of job description and lack of inter and intra-professional cooperation were the main obstacles *22+. additional study with more participants, including all nurses who hold b.sc. or high and diploma in nursing, and medical doctors, and other stakeholders, should be conducted. the concept anp need to be explained for nurses who hold m.sc., phd or both of them in order to provide an insight regarding anp. additionally,, it is important 71 erbil journal of nursing & midwifery conclusion conflict of interest: funding sources: references: https://doi.org/10.15218/ejnm.2018.09 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article *13+ manley k. a conceptual framework for advanced practice: an action research project operationalizing an advanced practitioner/consultant nurse role. journal of clinical nursing. 1997:6(3):179-190. *14+ canadian nurse association, advanced nurse practice: a national framework *internet+. 2008.. available from: https://www.cna-aiic.ca/-/media/ cna/page-content/pdf-en/ anp_national_framework_e.pdf *accessed june, 2018+ *15+ american nurses association. nursing’s social policy statement *internet+. washington, dc : united states of america. 1995. available from: https:// essentialguidetonursingpractice.files.wordpress.com/2012/07/ pages-from-essential-guide-tonursing-practice-chapter-1.pdf *accessed june, 2018+ *16+ pieper, b., & colwell, j. doctoral education for woc nurses considering advanced practice nursing. journal of wound ostomy & continence nursing, 2012. 39(3): 249 -255. *17+ mejza b. will the woc, nurse of the future also be a dnp. journal of wound, ostomy and continence nursing. 2009:36(3):271-274. *18+ davies b, hughes a. clarification of advanced nursing practice: characteristics and competencies. clinical nurse specialist. 2002:16 (3):147-152. *19+ national prescribing center. a single competency framework for all prescribers *internet+. united kingdom: national institute for health and clinical excellence *reviewed may 2014+. available from: https:// www.associationforprescribers.org.u k united states of america. 2009. 23-45 *4+ ketefian s, redman r, hanucharurnkul s, masterson a, neves e. the development of advanced practice roles: implications in the international nursing community. int nurs rev. 2001;48 (3):152-163 *5+ hamric a, spross j, hanson c, hamric a. advanced practice nursing. st. louis: elsevier saunders; 2009. *6+ schober m, affara f. international council of nurses. oxford, uk: blackwell pub; 2006. *7+ international council of nurses: the scope of practice, standards, and competencies of the advanced practice nurse. international council of nurses, switzerland: icn regulation series; 2008. *8+ pearson a, peels s. 1: nursing a global perspective. international journal of nursing practice. 2001:7 (1): s1-s4. *9+ dunn l. a literature review of advanced clinical nursing practice in the united states of america. journal of advanced nursing. 1997:25(4):814 -819. *10+ bryant-lukosius d, dicenso a. a framework for the introduction and evaluation of advanced practice nursing roles. journal of advanced nursing. 2004: 8(5):530-540. *11+ daly w, carnwell r. nursing roles and levels of practice: a framework for differentiating between elementary, specialist and advancing nursing practice. journal of clinical nursing. 2003:12(2):158-167. *12+ geest dm, moons p, callens p, gut c, lindpaintner l, spirig r, introducing advanced practice/nurse practitioners in health care systems / a framework for reflection and analysis. swiss med wkly. 2008; 138 (43-44): 621-628 72 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.09 erbil j. nurs. midwifery, vol. 1, no. (2), nov, 2018 original article /images/ single_competency_framework.pdf *accessed june, 2018+ *20+ joel l. advanced practice nursing. philadelphia: f.a. davis; 2009. *21+ advanced nursing practice toolkit *internet+. 2015 *cited 31 october 2015+. available from: http:// www.advancedpractice.scot.nhs.uk *22+ kleinpell r. evolving role descriptions of the acute care nurse practitioner. critical care nursing quarterly. 1999:21(4):9-15. 73 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.15 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article quality of life of patients with heart failure at teaching hospitals in erbil city abstract introduction heart failure (hf) is an imprecise term used to describe the state that develops when the heart cannot maintain an adequate cardiac output or can do so only at the expense of an elevated filling pressure. . cardiac output is adequate at rest and becomes inadequate only when the metabolic demand increases during exercise or some other form of stress [1,2]. some cases of hf are reversible, depending on the cause. most often, hf is a progressive, lifelong condition that is managed with lifestyle changes and medications to prevent episodes of acute decompensate heart failure. these episodes are characterized by an increase in symptoms but decreased in cardiac output, and low perfusion [3]. world health organization quality of life (whoqol) group defined quality of life as an “individual's perception” of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. it is a broad ranging concept affected in a complex way by the person's physical health, background and objectives: heart failure is a common and significant health problem, with an increasing incidence and a gloomy prognosis that is often accompanied by a negative impact on the length and quality of life of patients. this study aimed to assess quality of life among patients with heart failure in erbil city and to find the association of quality of life domains (physical, level of independence and social relationship) with some sociodemographic data (age, gender, level of education, and marital status) methods: a quantitative design / a descriptive cross-sectional study was conducted at hawler and rizgary teaching hospitals in erbil city kurdistan region. this study was carried out from november 17th 2014 to november 17th 2015 on non-probability (purposive) samples was selected among 140 heart failure patients who were admitted to coronary care unit and medical ward of both teaching hospitals. their quality of life was measured by standardized questionnaire of world health organization with some modification. results: the findings of the study indicated that most patients were female and illiterate, their mean age was 68.75. moreover, significant associations exist between levels of education with physical ability, level of independence, social domains, and marital state with physical domain. conclusion: the study concluded that the majority of the study sample had moderate level of quality of life while less than one-fourth of them had poor level. keywords: heart failure, quality of life, coronary care unit, world health organization berivan star hammad ameen; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: berivan.hamadameen@hmu.edu.krd) yousif mohammed younis; department of nursing, college of nursing, hawler medical university, erbil, iraq. 116 erbil journal of nursing & midwifery received: 5/1/2019 accepted: 22/9/2019 published: 30/11/2019 mailto:berivan.hamadameen@hmu.edu.krd https://doi.org/10.15218/ejnm.2019.15 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article psychological state, personal belief, social relationships, and their relationship to salient features of their environment [4]. heart failure is a major public health problem in industrialized nations. it seems to be the only common cardiovascular condition, which is increasing in prevalence and incidence in north america and europe. in the united states, hf is responsible for 1 million hospital admissions and 50,000 deaths annually [5]. the incidence of hf increases with age. american heart association estimate more than 5 million people in the united states have hf, and 550,000 new cases are diagnosed each year [3,6]. heart failure is a serious and chronic condition whose prevalence (0.2-0.4% in the general population and up to 17% in people over 70 years of age) continues to increase its incidence is calculated to be around 0.20.3% per year. the estimated prevalence of hf in india is 1.3–4.6 million with an annual incidence of 0.5–1.8 million, in china, the hf prevalence rate among the general population was 0.9% [7,8]. there were (509) cases of heart failure in erbil city in (2013) according to the statistics of directorate of health in erbil. coronary artery diseases and advancing age are the primary risk factors for chf, other factors including hypertension, diabetes, cigarette smoking, obesity, and high cholesterol level can contribute the factors to the development of heart failure [9].causes of heart failure include coronary artery disease, myocardial infarction, cardiomyopathy, heart valve problems, and hypertension [10,11]. heart failure is a most frequent cause of hospitalization for people aged 65 and older. currently, hf continues to have a poor prognosis and is likely to remain a major clinical and health care problem [9]. a measure of qol requires a definition of the concept. qol theoretically encompasses the individual’s physical health, psychosocial wellbeing and functioning, independence, control over life material circumstances, and external environment. health related to quality of life health related quality of life (hrql) "the functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient [12]. heart failure is one of the chronic diseases that mainly affect quality of life. the physical condition of patients is compromised be dyspnea, fatigue and loss of muscular mass, and commonly by symptoms of the underlying cause of their condition (e.g. angina). in addition, dietary restrictions, difficulties in executing occupational and family responsibilities, progressive loss of self-reliance and self-control, the side effects of medication, and recurrent hospitalizations are also taken into consideration, and it is easy to understand how the quality of life of these patients can deteriorate [13].decreased functional capacity and psychological deterioration in end-stage hf patients may have a negative impact on the quality of life. functional inability to perform activities is one of the most common problems in patients with hf. functional impairment has a stronger association with quality of life in hf patients than cardiac function does [14]. heart failure is one of the chronic diseases that mainly affects quality of life, which is leading to compromised physical activities of daily living of patient, thus to preventing and to controlling of heart failure take much attention in kurdistan to reduce mortality and morbidity of heart failure. this study aimed to assess the quality of life in patients with heart failure in erbil city and to find out the association of quality of life domains (physical, level of independence and social relationship) with some socio-demographic data (age, gender, level of education, and marital status). 117 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.15 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article the data were analyzed using of (spss windows software version 20). data analysis approach for this study included two approaches: descriptive data analysis approach includes (frequency and percentage) and inferential statistical data analysis approach includes (chi-square and fisher’s exact test). table 1 shows the distribution of the sociodemographic characteristics of 140 adult heart failure patients. the age of the patients ranged from 25≥65 years. the highest percentage 68.7% of the samples were in the age group≥65 years. 60.7% of them were female. it was shown that the highest percentage 72.8% were illiterate. the majority 58.6% of the samples were married for 61.5%, in regard to residential area, the highest percentage of the samples were from urban. moreover, the highest percentage 54.4 % were reported housewife. in addition, 60% were out of work, the rest 40% returned to work after diagnosis of their disease. table 2 shows overall level of quality of life of hf patients among 140 hf patients. the highest percentage (75.7%) of patients had fair level of qol and (13.6%) of patients had poor level of qol while (10.7%) had good level of qol. table 3 shows the association between age group and quality of life domains, the highest percentage (68.7%) of the patient's age was age group ≥ 65 years and the lowest percentage (0.7%) was inage group 25-34 years. the finding of the study showed that there was no significant relationship between patients’ age group and the rest of other quality of life domains including physical p=0.56, level of independence p=0.31, and social p=0.76 domains. descriptive cross-sectional study design was conducted to assess the quality of life of patients with heart failure in erbil city. among non-probability (purposive) samples of 140 adult patients with heart failure who were admitted to the coronary care unit and medical wards in both hawler and rizgary teaching hospitals. the study started from november 17th 2014 to november 17th 2015. approval was obtained from ethical committee in nursing college / hawler medical university. the study was carried out after providing approval by general director of health in erbil (doh), hawler and rizgary teaching hospitals, oral consent was taken from research participants. inclusion criteria for selecting the samples of the study included patients who agrees to participate in the study. patients aged more than 18 years, diagnosed with heart failure, conscious patient, both gender and patients who had psychiatric disorders and patient’s diagnosis before 3 month of heart failure were excluded. the data was collected through the interview method questionnaire. it was developed by researcher and adopted with revised from who regarding quality of life, data were gathered through the using of questionnaire which consisted of following parts: part one,demographic data: it was concerned with demographic characteristics of the patients such as age, gender, marital status, level of education, residential area occupation before and after diagnosis disease. part two: overall of qol and associations between patients age group and qol domains, patients’ gender and qol domains, patients’ level of education qol domains, patient’s marital status qol domains. the calculation of overall quality of life was categorized to three groups of good quality of life, fair quality of life, and poor quality of life. 118 methods erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2019.15 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article 119 erbil journal of nursing & midwifery socio-demographic characteristics f age group / years 25-34 1 35-44 3 45-54 16 55-64 24 ≥ 65 96 total 140 gender male 55 female 85 total 140 educational level illiterate 102 able to read and write 21 primary school graduate 11 secondary school graduate 4 college graduate 2 total 140 marital status single 2 married 86 divorced 3 widowed 48 separated 1 total 140 residential area rural 58 urban 82 total 140 occupation before employed 17 disease unemployed 31 housewife 76 retired 16 total 140 occupation after returned to work 56 lower case out of work 84 total 140 table 1. socio-demographic characteristics of heart failure patients https://doi.org/10.15218/ejnm.2019.15 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article 120 erbil journal of nursing & midwifery table 2: overall levels of quality of life domains of heart failure patients 35-44 45-54 ≥65 age group/ years total qol domains f f f f f f physical never domain some times always total independence never domain some times always total social domain never some times always table 3. association between patients’ age group and quality of life domains of heart failure patients ns: non significant dc: decimal overall quality of life f good 15 fair 106 poor 19 total 140 table 4 illustrates the associations between gender and quality of life domains of hf patients. concerning gender, the highest percentage (60.7%) of patients was female. this table shows there was no significant relationship between gender and quality of life domains, physical p=0.92, level of independence p= 0.26, and social p=0.99. table 5 shows the association between levels of education and quality of life domains of hf patients. regarding levels of education, the majority of patients (72.8%) were illiterate. the results found that there was a highly significant relationship between patients’ levels of education and levels of independence p=0.009, significant relationship with physical p=0.012 and social domain p=0.05. table 6. association between patients ’marital status and quality of life domains. table 6 shows the association between marital statues and qol domains. it has indicated that the highest numbers of the sample (61.5%) were https://doi.org/10.15218/ejnm.2019.15 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article married. the results have also shown that there was significant relationship between the marital status and physical 0.01. while there was no significant relationship between patients’ marital status and qol in level of independence, and social domain 0.24, 0.7 respectively. 121 erbil journal of nursing & midwifery table.4 association between patients’ gender and quality of life domains of heart failure patients gender female total chi-square qol domains f physical domain never some times always total independence never domain some times always total social domain never some times always total ns: non-significant dec.: decision educational level illiterate able to primary secondary college total chi-square read and school school graduate write graduate graduate & dec. qol domains f f f f f f physical never domain some times always 15 total independence never domain some times always total social never domain some times always total table .5 associations between patients’ level of education and qol domains of heart failure patients s: significant vhs: very highly significant dec.: decision https://doi.org/10.15218/ejnm.2019.15 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article domains of hf patients, there was no significant association between gender and quality of life domains as shown in table 4, the result of study consistent with the study done by erceg et al (2013) who found that there were no significant differences between male and female patients regarding health-related quality of life. table 5, shows that there was significant relationship between levels of education and physical domain, level of independence domain and social domain.the highest percentage of patients was illiterate. the study results were supported by erceg et al (2013) who reported that the education level of the patients correlated positively with the physical dimension of healthrelated quality of life but not with emotional dimension[20]. the findings of the present study in table 6 shows there was a significant association between marital status and physical domain. while there was no significant association with level of independence and social domain. this is similar with the study carried out by luttik et al (2006) who revealed that patients living with a partner had (12%) less events the result shows that most of the patients were in age group of ≥ 65 years. this is similar to the cross-sectional study which carried out on 103 patients with heart failure in brazil [15] and the majority of the patients in this study were females. this result is similar to the results of study which carried out in tehran by hatmi et al (2015) who found that most of the heart failure patients were female [16].regarding levels of education, the present study revealed that majority of the patients (72.8%) were illiterate. about the marital status, the majority of the patients were married, which was consistent with the result of study done by dunlay et al (2015) on 1128 . the result of the study indicates that the highest percentage (68.7%) of the patients’ age was 65 years and more. it is in line with study done by yaghoubi et al (2012) by increasing age significant decrease occur in patient’s quality of life [19].regarding association between gender and quality of life 122 erbil journal of nursing & midwifery marital status single married divorced separated total chi-square qol domains f f f f physical domain never sometimes 0 63 2 35 1 101 0.01 always s total 140 independence never domain sometimes always total social never domain sometimes always total table 6. association between patients’marital status and quality of life domains of heart failure patients ns: non-significant s: significant dc: decision discussion https://doi.org/10.15218/ejnm.2019.15 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article [7] evangelista, l.s., moser, d.k., westlake, ch., pike,n., ter-galstanyan, a. and dracup, k. correlates of fatigue in patients with heart failure. progress in cardiovascular nursing banner.2008;23(1):12-17. [8] lee, sh. khurana,r, gerard leong, k.t. heart failure: epidemiology and prevention in india. national medical journal india.2010;23 (5):283-288. [9] lewis, s.l., heitkemper, m.m.,and dirksen,s.r.medical surgical nursing assessment and management of clinical problem.7thed.(2007). philadelphia: mosby elsevier. p.p821-822. [10] lemon, p.,and burke, k.medical surgical nursing critical thinking in client care. 4thed. usa:(2008) person education. p .1030. [11] timby, b.k., and smith, n.e .introductory medical surgical nnursing.10th ed.china: (2010) lippincott williams and wilkins. p .392. [12] coelho,r., ramos,s., prata,j., bettencourt,p.,ferreira,a.,and gomes,m.,c. heart failure and health related quality of life. clinical practice and epidemiology in mental health.2005;1(19). [13] papadopoulou, e. f., mavrogeni, s. i., dritsas, a., and cokkinos d. v. assessment of quality of life using three activity questionnaires in heart failure patients after monthly, intermittent administration of levosimendan during a six-month period. hellenic journal cardiology.2009;50(4):269-274. [14] karapolat, h., eyigor, s., zoghi, m., nalbantgil,s., yagdi, t., durmaz, b. et al. health related quality of life in patients awaiting heart transplantation. the tohoku journal of experimental medicine.2008;214(1):17-25. [15] pena, f.m., soares, j.s., paiva, b.t.c.,piraciaba, m.c.t., marins, r.m., barcellos,a.f et al. sociodemographic factors and depressive symptoms in hospitalized patients with heart failure. experimental and clinical cardiology. 2010; 15(2) : e29-e32. [16] hatmi, z.n., shaterian, m. and kazemi, m.a. quality of life in patiens hospitalized with heart failure:anovel two questionnaire study .acta medica iranica.(2007) .45(6): 493 -500;2007 [17] dunlay, sh.m. manemann, sh.m., chamberlain,a.m., cheville,a.l., jiang, r., weston,s.a., et al. activities of daily living and outcomes in heart failure. circulation heart failure.2015;8:261-267 compared with patients living alone [21]. present study concluded that patients’ quality of life was moderate level. the study recommends that further study to establish health educational program for patients and caregivers, designed to help heart failure patients live better or life longer. integration quality of life in care plans and focusing on providing holistic care in heart failure patients in order to improve quality of life in long term. the authors reported no conflict of interes [1] boon, n.a., colledge, n.r., walker, b.r., and hunter, a.j.a., editors (2006).davidsons principles & practice of medicine.20th ed. philadelphia: elsevier. p. 542. [2] carpenter, c.c., griggs, r.c., and benjamin, i.j., (2007). andreoli and carpenters cecil essential of medicine.7th ed. canada: saunders and elsevier. p.830 [3] smeltzer, s.c., bare, b.g., hinkle, j.l., and cheever, k.h., editors (2010). brunner& suddarths text book of medical – surgical nursing. 12th ed. philadelphia: lippincott williams and wilkins. p. 825-830. [4] hoekstra,t. jaarsma,t., veldhuisen, d.j.,hillege, h.l, sanderma,r. and leegte, i.l.quality of life and survival in patients with heartfail ure . european journal of heart fail ure.2013;15(1):94-102. [5] braunwald, e., kasper, d.l., fauci, a.s., hauser, s.l., long, d.l., and jameson, j.l., editors (2015). harrison’s principle of internal medicine. 16th ed. new york: mcgraw-hill. p. 1367. [6] mozaffarian d, go as, roger vl, benjamin ej, and berry jd.heart disease and stroke statistics—2013 update: a report from the american heart association.circulation.2013;127 (1):e6-e245. 123 erbil journal of nursing & midwifery conclusion conflict of interest references https://doi.org/10.15218/ejnm.2019.15 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article [18] wu, j.r., moser, d.k., rayens, m.k., jong, m.j.d., chung, m.l., riegel, b., et al. rurality and event-free survival in patients with heart failure. heart lung.2010;39(6):5125200. [19] yaghoubi, a., tabrizi, j.s., mirinazhad, m.m., azami, s., m.n.,behzad, ghojazadeh, m. quality of life in cardiovascular patients in iran and factors affecting it: a systematic review. journal of cardiovascular and thoracic research.2012;4(4):95-101. [20] erceg, p., despotovic, n., milosevic, p. d., soldatovic, i., zdravkovic, s., tomic, s., et al. health-related quality of life in elderly patients hospitalized with chronic heart failure. clinical interventions in aging.2013;8:153946. [21] luttik, m.l., jaarsma, t., veeger, n. and veldhuisen, d.j. marital status, quality of life, and clinical outcome in patients with heart failure. heart lung.2006;35(1):3-8. 124 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.08 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article prevalence of post-traumatic stress disorder and potentially traumatic events among adolescents in erbil city abstract introduction children and teenagers are vulnerable for experiencing many forms of stressful events due to the rapid physiological and psychological changes happening during adolescent years. this vulnerability can increase among adolescents living in countries facing crisis continuously. trauma creates a loss of faith that there may be any safety in this world, and it smashes a person’s innocence *1+.. wars, political and religious violence, forced displacement and migration, human right abuses, background and objectives: many children and teenagers throughout lifetime maybe expose to extraordinary forms of stressful and traumatic events, particularly individuals who live in countries experiencing continuous conflicts such as iraq. approximately one-third of traumatized adolescents might develop symptoms of post-traumatic stress disorder. the current study aimed to evaluate the types of potentially traumatic events and prevalence of post-traumatic stress disorder among adolescents in erbil city. methods: a descriptive cross-sectional study was carried out at eleven public and private schools in erbil city. the samples of the study were selected in three stages; the schools' selection, the class selection in the schools, and involvement of 300 students within the study. data were collected from face-to-face interview of participants from 1st of march to 15th may 2018. screening for post-traumatic stress disorder was done by using the posttraumatic stress disorder screening tool. the validity and reliability have been verified. frequency, percentage, mean, standard deviation, chi-square, t-tests, and fisher exact test was used for data analysis. results: majority of participants were kurdish, from the host community; more than half of them were males and middle in the rank within their families while the most prevalent potentially traumatic events were identified to be emotional abuse and physical abuse. such events include betrayal and disappointment, witnessing parents fighting with each other, witnessing direct physical torturing, and physical torture. among traumatized adolescents it is predicted that about 41.7% have post-traumatic stress disorder. conclusions: post-traumatic stress disorder is prevalent among adolescent students and it differs in terms of gender and type of schools. post-traumatic stress disorder was found to be the highest percentage among females compared to males, and within public schools compared to private schools. the most prevalent potentially traumatic events among adolescents were emotional and physical trauma. key words: adolescent, child maltreatment, post-traumatic stress disorders, students, schools. raveen ismael abdullah; department of nursing, college of nursing, university of duhok , duhok , iraq. (correspondence: raveenmayi@yahoo.com ) norhan zeki shaker; department of nursing, college of nursing, hawler medical university, erbil, iraq. 60 erbil journal of nursing & midwifery received: 7/12/2018 accepted: 15/1/2019 published: 30/5/2019 mailto:raveenmayi@rocketmail.com https://doi.org/10.15218/ejnm.2019.08 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article unemployment, and poverty have damaged iraqi society, creating major public mental health crises *2+. .post-traumatic stress disorder (ptsd) can result from exposure to shocking trauma and is characterized by continual re-experiencing, avoidance/numbing, and hyper arousal, present for more than one month and associated with significant distress and/or functional impairment *3+.. trauma during the childhood period has been called as “the hidden epidemic’’ *1+. many recover from traumatic events and others may develop symptoms of post-traumatic stress disorder *4+, especially after exposure to a range of traumatic events *5+, such as sexual and physical abuse, domestic and school violence, medical trauma, car accidents, war and terrorism, suicides, and other traumatic events *6+. other individuals may develop ptsd after being exposed to potentially traumatic events (ptes) *7+. ptsd is a disabling disorder, in both the developed and the developing countries *8+ which can lead to chronic psychiatric morbidity and loss of normal daily life *9+. it has a lifelong impact on multiple aspects of functioning, including adaptive and interpersonal functioning, emotion regulation, cognition and memory, and neuroendocrine function *4+.the risk for ptsd among children relies upon on the nature of the trauma; the child's age and gender; and personal, family, and community factors *4+. traumatic experiences may result from conflicts *10+ as supported by literature that shows that the rate of ptsd among youth in iraq has multiplied. adolescents in iraq have been exposed to different kinds of traumatic events during the last decade especially after the conflict of 2003*11+, but the fact is even ordinary people who experience common stressful events may develop ptsd *12+. people in iraq have been more or less continually exposed to war for more than three decades *13+. iraq and the kurdistan region of iraq have faced more difficulties and challenges since the influx of syrian refugees which began in 2012 and iraqi civil war against the islamic state of iraq and al-sham (isis) in 2014 which resulted in thousands of internally displaced people *14+. this humanitarian crisis has created financial and political instabilities in the country *15+. furthermore, the political violence as a factor for developing psychological distresses among community individuals has been taken in consideration *10+. it expected that adolescents in kurdistan region of iraq along the isis war have been exposed to a variety of potentially traumatic events and violence such as physical violence ,emotional violence, and domestic violence which resulted from different types of crisis and insecurities. increase in the number of traumatic events result in increase in ptsd prevalence *16+. therefore, it is important to identify teenager’s psychological challenges for forming a more healthy generation of future adults. the current study aims to find the types of potentially traumatic events, prevalence of post-traumatic stress disorder and ptsd association with adolescent’s sociodemographic characteristics in erbil city. a descriptive cross-sectional study was carried out in a period from january to november 2018 among adolescent students in erbil city. the study samples were recruited through multiple stage of random sampling from the list of 260 mixed schools which have grade level of six to eleven (basic, high, and secondary schools) in erbil city of the iraqi kurdistan region. eleven schools were selected after dividing schools into two strata: private schools and public schools. two private schools and nine public schools were randomly selected from each stratum using a methods 61 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.08 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article tortured physically, witnessing parents fight with each other, being betrayed or disappointed, witness of physical torture, being affected by horror movies and indirect violence through television, experience of unexpected death of someone close, witnessing suicide or homicide and experience of car accidents. the last part of questionnaire has been adopted from the primary care of post-traumatic stress disorder screening tool (pc-ptsd-5) for screening probable ptsd. a score of three or more out of a total of five questions about how traumatic event(s) has affected him/ her over the past month is considered positive *18+. pc-ptsd-5 is based on the fifth edition of the diagnostic and statistical manual of mental disorders (dsm5) which was published in the may 2013 *19+. data collection has been done throughout face-to-face interview by researcher and it took place in an isolated room inside the school building to create a safe, supportive, and non-threatening environment for the participant. the validity of instruments has been verified for its accuracy, relevance, and clarity via a panel of experts. after conducting a pilot study on a sample of 30 adolescent students at one of the mixed basic schools the internal consistency and reliability was determined and measured via computation of pearson product moment correlation and the r value was (r = 0.8294). the collected data have been analyzed through using the statistical package for social science (spss, version 23). the socio-demographic characters described by frequency, percentage, mean, and standard deviation tests. while chi-square, fisher exact test, and independent t-tests used for identifying the significance of association. the p value of ≤ less 0.05 used for determination of significance level. proportionate stratified random sampling where the total number of private mixed schools were 45 (17.3 %) and the total number of public mixed schools were 215 (82.6%) out of 260 schools. as researcher proportioned choosing sample fraction of 4% for both strata. the selected participants from the eleven schools (high, secondary, or basic schools) ranged from ages 11 to 17 years old (both sexes) from grades six to eleven. using simple random sampling, 52 students were from private schools and 248 students were from public schools. adolescent students from twelfth school grade level and those whose age less than 11 years or more than 17 years old were excluded from the study. estimation of sample size in the current study was 303 adolescent students but unfortunately three of them have dropped out from the study. the study sample size has been calculated through using n=z 2p (1−p)/d formula *17+. prior to data collection ethical approval was obtained from ethical committee at the college of nursing, hawler medical university, erbil general directorate of education, and the consent of participated schools. furthermore, the oral consent was taken from adolescent students for the participation in the study after confirmation of confidentiality, anonymity and participants self-determination by the researcher. withdrawal from study was permitted whenever the person lost desire to answer questions or disclose. a reliable questionnaire format which consisted of three parts was used to collect data. the first part covered sociodemographic characteristics of adolescents such as school type, school grade level, age, gender, ordinal position in the family, nationality, type of residency, source of financial support, child labor. the second part assessed the potentially traumatic life events among adolescent students which included physical torture, threat to be 62 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.08 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article tables 1 shows that the mean± sd of the participant’s age was 14.02 ± 1.62, it also illustrates that the 92.7% of participants (278) were from the host community, 91.3% were kurds (274). 140 (46.7%) were females and 160 (53.3%) were males. the highest percentage,76.7% of students were financially depended on their parents, and only 14.7% of adolescents were working for earning money. it also shows that 18.3% of adolescents who participated in the study were from grades eight and nine. *f: frequency, **%: percentage figure 1 shows that the highest percentage, 54.7% of participants were the middle children in their families. figure 1: ordinal position of adolescents in the family figure 2 shows that the prevalence of ptsd among adolescents was estimated to be 41.7% of whom probably had ptsd. figure 2: prevalence of ptsd among adolescents’ students in erbil city table 2 illustrates the highest percentage, 56% of ptsd symptoms among adolescents was for “tried hard not to think about the event(s) or went out of the way to avoid situations that reminded them of the event”, and the least prevalent symptom, 27.7%, was “felt numb or detached from people, activities, or their surroundings”. 63 erbil journal of nursing & midwifery results table 1: socio-demographic characteristics of adolescents. characteristics n= 300 *f **% age mean± sd school grade level six seventh eighth ninth tenth eleventh 56 52 54 57 28 53 14.02±1.62 18.7 17.3 18.0 19.0 9.3 17.7 gender female male 140 160 46.7 53.3 ethnicity kurdish arabic turkmen 274 25 1 91.33 8.33 0.33 residency type host community internally displaced person 278 22 92.7 7.3 financial support parents siblings financially independent others such as: grandfather, uncle ,and other1st degree relatives 230 13 44 13 76.7 4.3 14.7 4.3 working yes no 44 256 14.7 85.3 https://doi.org/10.15218/ejnm.2019.08 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article table3 shows that most prevalent potentially traumatic events among adolescents were: betrayal and disappointment (58%), witnessing parents fighting with each other (53.3%), and witnessing physical torturing directly (46.3%). table 3: prevalence of potentially traumatic events among study sample . 64 erbil journal of nursing & midwifery n=300 ptes no f % yes f % physical torture 173 57.7 127 42.3 threatens to be tortured physically 176 58.7 124 41.3 witnessing parents fights with each other 140 46.7 160 53.3 being betrayed or disappointed 126 42.0 174 58 witness of physical torture 161 53.7 139 46.3 forced migration or displacement 275 91.7 25 8.3 experience car accident 240 80.0 60 20 long-term illnesses and hospitalizations 271 90.3 29 9.7 being affected by horror movies and indirect violence through tv 212 70.7 88 29.3 been in war zone 257 85.7 43 14.3 witnessing suicide or homicide 274 91.3 26 8.7 experience of unexpected death of someone close 216 72.0 84 28 witness of car accidents 256 85.3 44 14.7 table 2: post-traumatic stress disorder symptoms among adolescents n=300 in the past month have you.. yes f (%) no f (%) had a nightmare about the event(s) or thought about event(s) when you did not want to? 99(33) 201(67) tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event? 168(56) 132(44) been constantly on guard, watchful, or easily startled? 138(46) 162(54) felt numb or detached from people, activities, or your surroundings? 83(27.7) 217(72.3) felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? 122 (40.7) 178(59.3) https://doi.org/10.15218/ejnm.2019.08 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article according to table 4 shows that, the mean age of those who had ptsd was 14 and there was no significant association found between ptsd and age,while a very highly significance in association between type of school and ptsd 119 (48%) of participants from public schools and 6 (11.5%) of participants from private schools have the likelihood of having ptsd. results indicate there is a highly significant association between gender and ptsd (p-value is less than 0.0001). ptsd prevalence among females 80 (64%) is higher than in males 45 (36%). the likelihood of having ptsd was 111 ( 88.8%) among host community adolescents; 78 (62.4%) among adolescents who receive their financial support from parents; 59 (47.2%) among the middle children in families; and 93(74.4%) among those adolescents who work for gaining their daily life income. 65 erbil journal of nursing & midwifery table 4: association between ptsd and socio-demographic characteristics of adolescent students’ socio-demographic characteristics ptsd positive f (%) negative f (%) p-value age mean± sd type of school private school public schools school grade level six seventh eighth ninth tenth eleventh 14.13±1.598 6 (11.5) 119 (48) 17 (14.2) 20 (16.7) 22 (18.3) 27 (22.5) 13 (10.8) 21 (17.5) 13.95±1.639 46 (88.5) 129 (52) 11 (7.2) 34 (22.2) 33 (21.6) 28 (18.3) 15 (9.8) 32 (20.9) 0.498 ns <0.0001* vhs 0.341 ns gender female male 80 (64) 45 (36) 60 (34.3) 115 (65.7) <0.0001 vhs ordinal position in family first born child middle child youngest child only child 28 (22.4) 59 (47.2) 35 (28) 3 (2.4) 40 (22.9) 105 (60) 25 (14.3) 5 (2.9) 0.028 s residency type host community internally displaced person 111 (88.8) 14 (11.2) 167 (95.4) 8 (4.6) 0.030 s financial support parents siblings financially independent others 78 (62.4) 10 (8) 32 (25.6) 5 (4) 152 (86.9) 3 (1.7) 12 (6.9) 8 (4.6) <0.0001 vhs working yes no 93 (74.4) 32 (25.6) 163 (93.1) 12 (6.9) <0.0001 vhs *the chi-squared test was performed for all statistical analyses. ns: non-significant, vhs: very high significant, s: significant https://doi.org/10.15218/ejnm.2019.08 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article other. exposure to child physical abuse and parents’ domestic violence lead to ptsd *23+. it is difficult to sort out the research conducted on child maltreatment because various forms of maltreatment do not occur in isolation for example, physical maltreatment and emotional maltreatment often happened together *25+. regarding sociodemographic characteristics and ptsd prevalence, a very significant association was found between type of school and gender. almost half of participants from public schools present the likelihood of having ptsd, , in previous studies researchers have emphasized that adolescents attending private schools not only utilize more effective strategies to cope with problems, they also utilized emotionoriented strategies that were based on their relationships with others such as seeking out support from spiritual groups, talking with friends or identifying professional help *26+. public schools adolescents are mostly from families with low economic status and from poor sectors of the community. adolescent public school population size is relatively larger compared to private schools, thus creating a barrier for receiving adequate support and attention from school officials and family members. children who have greater social support are less likely to develop ptsd than those without such support *25+. the highest percentages of those who have the likelihood of ptsd in current study were females. findings from literature review supported the current study results which emphasized that girls are two to three times are likely to develop ptsd compared with boys *25+, but the results disagreed with a study conducted in a sample of school children of 122 girls and 165 boys in kabul, afghanistan which found 26% prevalence of probable ptsd in boys compare to 14% in girls *28+. all human beings starting from childhood might go through many different shockable life events, and difficulties until reaching to adulthood. exposure to such events might increase internal fears and create insecurities and if the impacts of traumatic events remain with person for long durations without support to cope with the aftermath of traumatic events, it may ultimately lead to psychological problems. the current descriptive crosssectional study which was carried out at eleven public and private schools in erbil city and has demonstrated that the majority of adolescents in this study may have probable ptsd. the majority of adolescents expressed avoidance symptoms, and the least prevalent symptom was numbness and detachment from people, activities, or their surroundings. the current results were consistent to a 2017 study of 251 children from 3 summer camps ages 6 to 16 years in palestine regarding ptsd symptoms which presented an intrusion mean of 8.98 and an avoidance symptoms subscale mean of 9.49 *20+. the results of another study prioritized social avoidance as one of the most common symptoms *21+. the current study also indicated that ptsd is prevalent and the results were very close to a study in erbil during 2016 which showed the prevalence of ptsd among 570 participants aged between 15 and 64 years was 39.6% *22+. it’s also consistent to ptsd prevalence of several other studies including studies in mosul which suggested that, 37% of children have mental disorders, and 10.5% have ptsd; in baghdad which revealed that, 47% of primary school children reported exposure to a major traumatic event, 14% had ptsd *2+ and the most potentially traumatic lifetime event among adolescents are betrayal/disappointment and witnessing parents fighting with each 66 erbil journal of nursing & midwifery discussion https://doi.org/10.15218/ejnm.2019.08 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article events were emotional and physical trauma. besides exposure and/or witness of traumatic events, there are many factors that interfere with probability of ptsd. it was concluded that there is an association with increased ptsd prevalence with factors such as the type of school, gender, ordinal position, residency type, source of financial support, and child labor. the authors have no conflict of interest. *1+ margolies l, read pd~ 3 min. understanding the effects of trauma: post-traumatic stress disorder (ptsd) *online+. psych central. 2016 .available from: https:// psychcentral.com/lib/understanding-theeffects-of-trauma-post-traumatic-stressdisorder-ptsd/ *2+ alobaidi a. psychological trauma: experience from iraq. journal of trauma and treatment. 2013 nov 20;2(1):1–2. *3+ suliman s, kaminer d, seedat s, stein d. assessing post-traumatic stress disorder in south african adolescents: using the child and adolescent trauma survey (cats) as a screening tool. annals of general psychiatry. 2005 jan 31;4(1):2. *4+ gerson r, rappaport n. traumatic stress and posttraumatic stress disorder in youth: recent research findings on clinical impact, assessment, and treatment. journal adolescent health. 2013 feb 1;52(2):137–43. *5+ calitz fjw, jongh d, j n, horn a, nel ml, joubert g. children and adolescents treated for post-traumatic stress disorder at the free state psychiatric complex. south african journal of psychiatry. 2014 mar;20(1):15 –20. *6+ american psychological association. children and trauma: update for mental health professionals *online+. http://www.apa.org. 2008 *cited 2018 jul 26+. available from: http://www.apa.org/pi/families/resources/ children-trauma-update.aspx a significant association was found between ptsd and types of residency as the majority of those who have ptsd were from host community. this implies that despite of not being in war zone directly ptsd is prevalent among vulnerable groups silently *25+. current study also concluded that almost half of those adolescents who receive money from parents they have ptsd and there is very highly significant association between ptsd and financial source. those who work to earn money have a greater likelihood of having ptsd as environment of work for such age furthers the pressure on the adolescent population. this study also demonstrated that more than half of adolescents who receive their financial support from parents have likelihood of having ptsd. this may be a result of the recent economic crisis in iraq which has created conflicts within families; no similar studies were found to support this. more than half of the adolescents who work for gaining their daily life income are likely to have ptsd which is supported from literature review findings that the there was a statistically significant association between ptsd and working during school and association between age and ptsd was also statistically significant. almost half of the adolescents who are the middle child in current study probably have ptsd which is contrary with a finding of another study which revealed that 49.2% of the ptsd children were the first-born in their families *27+. the current study concluded that ptsd is prevalent among adolescent students in erbil city despite of not going through war directly. each of participants had a lifetime exposure to at least one of the types of potentially traumatic events assessed, and the most prevalent potentially traumatic 67 erbil journal of nursing & midwifery conclusions references conflicts of interest https://doi.org/10.15218/ejnm.2019.08 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *17+ lancaster cl, teeters jb, gros df, back se. posttraumatic stress disorder: overview of evidence-based assessment and treatment. journal of clinical medicine*internet+. 2016 nov 22 *cited 2018 aug 28+;5(11). available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc5126802/ *18+ charan j, biswas t. how to calculate sample size for different study designs in medical research? indian journal of psychological medicine. 2013;35(2):121–6. *19+ prins a, bovin mj, smolenski dj, marx bp, kimerling r, jenkins-guarnieri ma, et al. the primary care ptsd screen for dsm-5 (pcptsd-5): development and evaluation within a veteran primary care sample. journal of general internal medicine. 2016 oct 1;31 (10):1206–11. *20+ regier da, kuhl ea, kupfer dj. the dsm-5: classification and criteria changes. official journal of the world psychiatric association. 2013 jun;12(2):92. *21+ thabet am, thabet ss. stress, trauma and post-traumatic stress disorder among adolescents in the gaza strip. journal of trauma and critical care *internet+. 2017 *cited 2018 nov 5+;1(2). available from: http:// www.alliedacademies.org/abstract/stresstrauma-and-posttraumatic-stress-disorderamong-adolescents-in-the-gaza-strip8249.html *22+ gökçen c, sahingöz m, annagür b. does a non-destructive earthquake cause posttraumatic stress disorder? a cross-sectional study. european child & adolescent psychiatry. 2012 nov 26;22. *23+ karim b, al-salihy z, karim d, laugharne r. prevalence of posttraumatic stress disorder in erbil kurdistan .arab journal of psychiatry. 2016 may;44(0):1–18. *24+ margolin g, vickerman ka. post-traumatic stress in children and adolescents exposed to family violence: i. overview and issues. professional psychology research and practice. 2007 dec 1;38(6):613–9. *25+ mohr wk. johnson’s psychiatric mental health nursing: 5 edition. lippincott williams & wilkins; 2003. 832 p. *7+ cisler jm, amstadter ab, begle am, resnick hs, danielson ck, saunders be, et al. ptsd symptoms, potentially traumatic event exposure, and binge drinking: a prospective study with a national sample of adolescents.journal of anxiety disorders. 2011 oct; 25(7):978–87. *8+ kaminer d, seedat s, stein dj. post-traumatic stress disorder in children. official journal of the world psychiatric association. 2005 jun;4 (2):121–5. *9+ mouthaan j, sijbrandij m, reitsma jb, gersons bpr, olff m. comparing screening instruments to predict posttraumatic stress disorder. plos one *internet+. 2014 may 9 *cited 2018 jun 24+;9(5). available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc4016271/ *10+ ibrahim h, hassan cq. post-traumatic stress disorder symptoms resulting from torture and other traumatic events among syrian kurdish refugees in kurdistan region, iraq. frontier in psychology. *internet+. 2017 feb 20 *cited 2018 jul 28+;8. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc5316552/ *11+ alshawi a. posttraumatic stress disorder among youth in iraq, short systemic review. journal of community medicine and health care.2017 feb 9;2(2). *12+ kato n, kawata m, pitman rk, editors. ptsd: brain mechanisms and clinical implications. 2006 edition. tokyo: springer; 2006. 304 p. *13+ al-hadethe a, hunt n, thomas s, al-qaysi a. prevalence of traumatic events and ptsd symptoms among secondary school students in baghdad. european journal of psychotraumatology. 2014 dec;5(1):23928. *14+ un ocha. humanitarian response plan *internet+. un ocha; 2017 *cited 2018 jan 10+. available from: https:// www.humanitarianresponse.info/en/ operations/iraq/document/2017-iraqhumanitarian-response-plan *15+ rudaw. poverty rate in kurdistan region quadrupled to 15 percent, official *internet+. rudaw. 2016 *cited 2018 may 27+. available from: http://www.rudaw.net/english/ kurdistan/281220162 *16+ nils womer. , nils; lamberty, idp and refugee crises in the kurdistan region of iraq.lebanon: konrad-adenauer-foundation (kas) *assessed on: 5th feb, 2018+. 2016. available from: http://www.kas.de/syrienirak/en/publications/47238/ 68 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.08 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *26+ mclaughlin k. posttraumatic stress disorder in children and adolescents: epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis *internet+. uptodate. 2018 *cited 2018 nov 6+. available from: https://www.uptodate.com/contents/ posttraumatic-stress-disorder-in-childrenand-adolescents-epidemiology-pathogenesis -clinical-manifestations-course-assessmentand-diagnosis#h802051063 *27+ chavis s. adolescents in private schools cope better *internet+. 2010 *cited 2018 nov 6+. available from: https://psychcentral.com/ news/2010/10/30/adolescents-in-privateschools-cope-better/20174.html *28+ lafta rk, aziz zs, alobaidi a. posttraumatic stress disorder (ptsd) among male adolescents in baghdad. journal of psychological abnormalities. 2014 jun 14;3(3):1–5. 69 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.01 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article physical activity and fat-related eating behavior among patients with cholelithiasis in erbil city: a case-control study abstract introduction cholelithiasis is the medical term of gallstone disease; cholelithiasis denotes stones inside the gallbladder. gallstone formation represents the most common abnormality of the biliary system *1+. they are divided into two major types. first pure cholesterol (10%). often single stone, larger than 2.5cm, and round in shape. second pure pigment (bile salts 10%). pigment stones are black or brown in color. the most common type is mixed stone which is more than three-quarters of all type of cholelithiasis *2+.the roles of physical background and objective: the effect of physical activity and diet is an essential modifiable or environmental factor. evidence from epidemiological studies suggests that assessing associations between diet and general health is important. the aim of the study was to assess the level of physical activity and fat-related eating behaviour of patients with cholelithiasis. methods: a matched case-control study was done on 100 participants; 50 were patients with gallstone disease and 50 were patients without gallstone disease. the study was conducted from december 2017 to june 2018. the constructed questionnaire used and designed based on the literature review. it consisted of four parts: demographic data, physical activity, fat-related eating behaviour, and investigations. ultrasounds were done on all study participants to confirm whether patients had gallstone disease or not. reliability of the questionnaire was determined through a pilot study and the validity through a panel of experts from medicine and nursing fields. frequency, percentage, mean and standard deviation, and the chi-square test was used for analyzing data. results: in total, 70 female and 30 male patients were investigated. most (52%) were 28 to 47 years old. most (72%) were physically inactive. regarding fat-related eating behaviour most (73%) had unhealthy behavior. there was a significant association between physical activity and the risk of getting cholelithiasis. risk of disease the development was about 2.8 times higher in patients who were physically inactive (odds ratio = 2.79, 95% ci; 1.1– 7.0) in comparison to patients were physically active. there was no significant difference between development of cholelithiasis and unhealthy fat-related eating behaviour (odds ratio = 0.886, 95% ci; 0.338–2.323). conclusion: there is a significant relationship between cholelithiasis and engaging in physical activity. keywords: gallstone, diet, activity, case-control study. ali taher mohammed-ameen; department of nursing, college of nursing, hawler medical university, erbil, iraq. yousif mohammed younis; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: ali.taher@nur.hmu.edu.krd) 1 erbil journal of nursing & midwifery received: 16/7/2018 accepted: 17/12/2018 published: 30/5/2019 mailto:ali.taher@nur.hmu.edu.krd https://doi.org/10.15218/ejnm.2019.01 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article activity in protecting patients to develop cholelithiasis disease are underestimated. they are thought that the mechanisms of physical activity in inhibiting the formation of cholelithiasis include facilitating weight control *3+. a recent cohort study in the united kingdom, after 5 years of follow-up, reveals that by 70% decreased the risk of symptomatic gallstones at the maximum level of physical activity *4+. however, from several observational studies findings, independent of body weight have been varying among several studies *5+. a cohort study in the united stated of america noted that an inverse relationship between physical activity and the risk of developing cholelithiasis disease of women *6+. furthermore, the influence of gender differences on the association between physical activity and cholelithiasis still unidentified *7+. regarding diet as an essential modifiable factor, mounting evidence in nutritional epidemiology recommends that the way of analysis is the most realistic approach to investigating or assessing associations between diet as a general and health or disease, in place of focusing on the single dietary component *8+. a study on public health nutrition shows that a relationship between dietary patterns and the risk of formation of cholelithiasis *9+. it seems the number of patients with cholecystectomy has increased. there is a lack of published articles in kurdistan on this subject, and epidemiological researches could substantiate the prevailing evidence and provide new valuable information. this study aimed to assess and identify physical activity and fat-related eating behavior among patients with cholelithiasis in erbil city. a descriptive, matched case-control study was conducted at hawler teaching rizgary hospitals and kurdistan region. the settings of the study were both inpatient and outpatient radiological and ultrasonography departments and surgical unit (male and female sides) for both case and control group. for the case group, the investigator selected those patients who had cholelithiasis and diagnosed by sonography. while for the control group, those patients without cholelithiasis in both departments which confirmed by ultrasound. ultrasound was performed by radiologists working in the radiological department. the study occurred from december 2017 to june 2018. selection of case and control group were according to the following inclusion and exclusion criteria: inclusion criteria for both groups were 18 years and older, both genders, and good verbal communication. exclusion criteria for study and control group previous cholecystectomy for gallbladder stone and positive history of cholelithiasis treated by medications. the matching criteria were age and gender between both the study and control group. frequency matched principles we used in this study. direct face to face interview method was used for data collection. the total sample size was 98 (49 cases and 49 controls). through the gpower software v.3.1 *10+, was used for sample size estimation based on proportion of exposure among case= 0.27, proportion of exposure among control= 0.63, level of significance= 0.05 in 95% ci, power (1-β err probability)= 0.95, and allocation ratio= 1; from the previous case-control study in iran *11+. we took 100 patients; 50 patients f0000or the case group and 50 patients for the control group. a questionnaire was generated by the researcher as a result of a literature review about risk factors of gallstone in the several textbooks and updated article. it was reviewed by several experts in the medical and nursing field for the validity of the methods 2 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.01 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article obtained from erbil directorate of health, then the researcher brought it to hawler teaching and rizgary teaching hospitals. written informed consent was received prior to each participant’s participation. a pilot study was carried out from the same setting on ten patients in the case group and ten patients in the control group to determine the reliability of the questionnaire. data were analyzed through the application statistical package for science service (spss) version 25 for windows. descriptive statistical analyses were used to describe the samples such as frequency (f) and percentage (%) also mean and standard deviation. chi-square test and odds ratio were used for assessing the association between the outcome, disease, and categorical predictors. p-value ≤ 0.05 was considered as significant. table 1 shows that 30 patients were male and 70 patients were females. in each group, 15 were males and 35 of them were females. regarding the age group, we categorized age into six groups; the same number of participants for each age group between cases and controls (due to matched case-control). more than half (50%) of patients were within the age group 28-47 years. in addition, the youngest age group (18-27 years) were 12 percent. while the oldest age group (68 years and older) were only 4 percent. the current study shows that most were married (77%), more than half (58%) had less than 6 children, less than two-thirds (61%) lived in the urban area, and 34% were unable to read and write text. most (74%) were non-smokers, and all smokers were cigarette smokers; 69% smoked less than 20 cigarettes per day (table 2). questionnaire. the questionnaire consisted of the following part: 1) socio-demographic data, which included age, gender, number of children, level of education, marital status, occupational status, and residential area. 2) international physical activity questionnaires (ipaq), short form (4 generic items). the purpose of the question forms is to deliver common mechanisms that can be used to obtain internationally comparable data on health-related physical activity. it is available in public, no agreements are essentially required to practice it, and it is open access *12+. ipaq was extensively tested for reliability and validity, which was undertaken across 12 countries *13+. also, recently assessed by several studies in europa and asia *14, 15+. in addition, used in the various field and used by several authors *16, 17+. for scoring and analysis by using an excel spreadsheet; then automatically gives the result of physical activity into three levels as inactivity, minimally active, and health-enhancing physical activity *18+. 3) fat-related diet behavior questionnaire *19+. this questionnaire has been used in recent studies *20, 21+. individuals participated in the case group were asked to describe their fat-related eating behaviour, before the happening of cholelithiasis for symptomatic or before knowing cholelithiasis for asymptomatic. this technique was done because symptomatic cholelithiasis is the leading cause of dietary changes and modification of diet habits, not for medical purposes, but because of the occurrence of acute gastric pain, nausea, and vomiting. 4) sonography report: all participants assessed by a trained physician specialist in radiologist. all study samples were in the fasting status at least 6 hours before doing an ultrasound. the researcher obtained an approval letter from the ethical committee at the college of nursing at hawler medical university. before collecting the data, the official permission was 3 results erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.01 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article 4 table 1: matching criteria between study and control group erbil journal of nursing & midwifery table 2: sociodemographic data of the study sample matching criteria f (%) case f (%) control f (%) gender male 30 (30) 15 (30) 15 (30) female 70 (70) 35 (70) 35 (70) total 100 (100) 50 (100) 50 (100) age groups 18 27 years 12 (12) 6 (12) 6 (12) 28 37 years old 30 (30) 15 (30) 15 (30) 38 -47 years old 22 (22) 11 (22) 11 (22) 48 57 years old 16 (16) 8 (16) 8 (16) 58 67 years old 16 (16) 8 (16) 8 (16) 68 and older 4 (4) 2 (4) 2 (4) total 100 50 (100) 50 (100) mean ± sd 42.59±13.5 42.68±13.8 42.5±13.2 sociodemographic data f (%) case f (%) control f (%) marital status single 13 (13) 5 (10) 8 (16) married 77 (77) 38 (76) 39 (78) widowed 8 (8) 5 (10) 3 (6) divorced 2 (2) 2 (4) - number(s) of children 0 to 5 children 51 (58) 28 (62) 23 (55) 6 to 10 children 30 (35) 13 (29) 17 (40) 11 to 15 children 6 (7) 4 (9) 2 (5) residency urban 61 (61) 28 (56) 33 (66) rural 1 (1) 1 (2) - sub-urban 38 (38) 21 (42) 17 (34) educational level illiterate 34 (34) 18 (36) 16 (32) able to read & write 14 (14) 6 (12) 8 (16) primary school 22 (22) 13 (4) 9 (18) secondary school 12 (12) 4 (4) 8 (16) high school 6 (6) 2 (4) 4 (8) diploma 6 (6) 2 (4) 4 (8) bachelor degree 5 (5) 4 (8) 1 (2) master degree 1 (1) 1 (2) - occupation state housewife 63 (63) 32 (64) 31 (62) retired 2 (2) 2 (4) - student 5 (5) 1 (2) 4 (8) work in public sector 16 (16) 8 (16) 8 (16) work in private sector 14 (14) 7 (14) 7 (14) habit of smoking non-smoker 74 (74) 35 (70) 39 (78) ex-smoker 5 (5) 3 (6) 2 (4) smoker 21 (21) 12 (24) 9 (18) current alcohol drinker yes 0 (0) 0 (0) 0 (0) no 100 (100) 50 (100) 50 (100) https://doi.org/10.15218/ejnm.2019.01 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article table 3 shows that 72% of the participants were physically inactive. among cases, 82% of them were inactive, while 62% of controls were inactive. there were more minimally active participants among controls (38%), compared to cases (18%). there was a statistically significant association between physical activity and cholelithiasis (p=0.044). this study aimed to assess the effect of physical activity and eating fatty food on the formation of gallbladder stones in order to understand the association between these two lifestyle factors with cholelithiasis. in this study, physical activity appears to be associated with cholelithiasis. in china, several authors found that physical activity may reduce the risk of cholelithiasis formation *22+. likewise, several recent studies described the protective effect of physical activity on gallstones *23, 24+. while some earlier regarding fat-related eating behavior (table 4), the highest percentage (60%) of patients were unhealthy and 21% had good fat-related eating behaviour. roughly double (24%) the cases had poor diet behaviour when compared to controls (14%). there was no significant association between fat behaviour and cholelithiasis. studies have not given a decision about the effect of activity on the disease *25, 26+. a recent study reveals that there is an association for the male gender but not for female gender *27+. one suggested a mechanism behind the protective effect of physical activity is a reduced colonic transit time associated with increased gallbladder motility and a reduced intestinal bile salt dihydroxylation *28+. generally, these findings topic to likely usefulness of lifestyle modification as effective actions for the prevention of cholelithiasis. findings for physical activity are inconsistent with the previous studies done in ns=non-significant; *= chi-square test 5 erbil journal of nursing & midwifery table 3: physical activity and its association with cholelithiasis physical activity total f (%) case f (%) control f (%) p-value* inactive 72 (72) 41 (82) 31 (62) 0.044 s minimally active 28 (28) 9 (18) 19 (38) hepa active --- total 100 (100) 50 (100) 50 (100) hepa= health enhancement physical activity; s=significant; *= chi-square test; table 4: fat-related eating behavior and its association with cholelithiasis fat-related eating behavior categories total f (%) case f(%) control f (%) p-value* best fat-related eating behavior --- 0.066 ns good fat-related eating behavior 21 (21) 11 (22) 10 (20) bad fat-related eating behavior 72 (72) 32 (64) 28 (56) worst fat-related eating behavior 28 (28) 7 (14) 12 (24) total 100 (100) 50 (100) 50 (100) discussion https://doi.org/10.15218/ejnm.2019.01 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article united kingdom; which found that there was a statistically non-significant association between physical activity and cholelithiasis *29+. in mexico, a study done about women found that no differences in the frequencies of persons that performed some form of moderate physical exercise with the women who have a sedentary lifestyle and cholelithiasis formation *30+. in current study showed that there is no relation between fat-related eating behaviour and cholelithiasis. the role of lipids in the cholesterol gallstones formation of currently remains uncertain *31+. fatty acid classes naturally occurring such as saturated, monounsaturated and polyunsaturated; none of the fatty acids were associated with gallstone disease in men and women *29+. another case-control study showed that non-association in used of more than 600 ml of oil among men and women with cholelithiasis and without cholelithiasis participants *32+. inconsistency with other case-control studies found that there is an association between the consumption of total fat in the group of cases was significantly higher as compared to controls; the study sample was including women participant only *30, 33+. similarly, earlier french research presented a positive link between gallstone disease and total fat intake *34+. in prospective follow-up studies; a higher intake of saturated and trans-fatty acids were associated with a heightened risk of gallstones *35, 36+. cuevas et, al in chile found that a higher intake of monoand polyunsaturated fatty acids, which were correlated with reduced risk of cholelithiasis *37+. in an epidemiological study detected a negative association between cholesterol consumption and gallstone disease *38+. this study concluded that cholelithiasis more frequently in the female, young adult, married, less than 5 children, illiterate, housewife, non-smoker, and overweight to obese class i. there was a significant association between physical activity and having cholelithiasis, but not significant association between eating fatty food with cholelithiasis. there is no actual or potential conflict of interest in relation to this study. there is no financial support for this study. *1+ timby bk, smith ne. introductory medicalsurgical nursing. 10th ed. philadelphia: lippincott william & wilkin; 2010. p.720. *2+ mclatchie g, borley n, chikwe j, (ed.). oxford handbook of clinical surgery. 4th ed. united kingdom: oxford university press; 2013. *3+ dietz wh, baur la, hall k, puhl rm, taveras em, uauy r, et al. management of obesity: improvement of health-care training and systems for prevention and care. the lancet. 2015;385(9986):2521-2533, https:// doi.org/10.1016/s0140-6736(14)61748-7. *4+ banim pj, luben rn, wareham nj, sharp sj, khaw k-t, hart ar. physical activity reduces the risk of symptomatic gallstones: a prospective cohort study. european journal of gastroenterology & hepatology. 2010;22 (8):983-988, *5+ misciagna g, centonze s, leoci c, guerra v, cisternino am, ceo r, et al. diet, physical activity, and gallstones—a population-based, case-control study in southern italy. the american journal of clinical nutrition. 1999;69(1):120-126,https:// doi.org/10.1093/ajcn/69.1.120. *6+ storti kl, brach js, fitzgerald sj, zmuda jm, cauley ja, kriska am. physical activity and decreased risk of clinical gallstone disease among post-menopausal women. preventive medicine.2005;41(3-4):772-777, https:// doi.org/10.1016/j.ypmed.2005.04.002. 6 erbil journal of nursing & midwifery conclusion conflict of interest financial support references https://doi.org/10.15218/ejnm.2019.01 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *17+ hirvensalo m, magnussen cg, yang x, telama r, heinonen i, hutri-kähönen n, et al. convergent validity of a physical activity questionnaire against objectively measured physical activity in adults: the cardiovascular risk in young finns study. advances in physical education. 2017;7(04):457-472, https://doi.org/10.4236/ape.2017.74038. *18+ blasio ad, donato fd, mazzocco c. ipaq automatic report english version online: ipaq; 2016 *updated 30 jul 2016; cited 2017 november+. available from: https://docs.google.com/viewer? a=v&pid=sites&srcid=zgvmyxvsdgrvbwfp bnx0agvpcgfxfgd4ojuxnja1mzu5zdi3njvi nmq. *19+ shannon j, kristal ar, curry sj, beresford s. application of a behavioral approach to measuring dietary change: the fat-and fiberrelated diet behavior questionnaire. cancer epidemiology and prevention biomarkers. 1997;6(5):355-361, retrieved from: http:// www.scopus.com/inward/record.url? scp=0030987393&partnerid=8yflogxk. [20] hendrychova t, vytrisalova m, vlcek j, smahelova a, kubena aa. an analysis of fatrelated and fiber-related behavior in men and women with type 2 diabetes mellitus: key findings for clinical practice. patient preference and adherence. 2013;7:877-884, https://doi.org/10.2147/ppa.s47497. *21+ hendrychova t, vytrisalova m, alwarafi a, tebbens jd, vankatova h, leal s, et al. fatand fiber-related diet behavior among type 2 diabetes patients from distinct regions. patient preference and adherence. 2015;9:319-325, https://doi.org/10.2147/ ppa.s71373. *22+ hou l, shu x-o, gao y-t, ji b-t, weiss jm, yang g, et al. anthropometric measurements, physical activity, and the risk of symptomatic gallstone disease in chinese women. annals of epidemiology. 2009;19 (5):344-350, https://doi.org/10.1016/ j.annepidem.2008.12.002. *23+ de oliveira ep, burini rc. the impact of physical exercise on the gastrointestinal tract. current opinion in clinical nutrition & metabolic care. 2009;12(5):533-538, https://doi.org/10.1097/ mco.0b013e32832e6776. *7+ lindseth g, bird-baker my. risk factors for cholelithiasis in pregnancy. research in nursing & health. 2004;27(6):382-391, https:// doi.org/10.1002/nur.20041. *8+ hu fb. dietary pattern analysis: a new direction in nutritional epidemiology. current opinion in lipidology. 2002;13(1):3-9, https:// doi.org/10.1097/00041433-20020200000002. [9] tseng m, everhart je, sandler rs. dietary intake and gallbladder disease: a review. public health nutrition. 1999;2(2):161172,https://doi.org/10.1017/ s136898009900021x. *10+ faul f, erdfelder e, buchner a, lang a-g. statistical power analyses using g*power 3.1: tests for correlation and regression analyses. behavior research methods. 2009;41:11491160, *11+ jessri m, rashidkhani b. dietary patterns and risk of gallbladder disease: a hospital-based case-control study in adult women. journal of health, population, and nutrition. 2015;33 (1):39, [12] ipaq. international physical activity questionnaire online: ipaq; 2002 *updated 12 jan 2012; cited 2017 november+. available from: https://sites.google.com/site/theipaq/. [13] dai s. validity of the international physical activity questionnaire short form (ipaq-sf) in adults: a systematic review: the university of hong kong; 2015, thesis, retrieved from: https://doi.org/10.5353/th_b5662548. [14] macfarlane dj, lee cc, ho ey, chan kl, chan dt. reliability and validity of the chinese version of ipaq (short, last 7 days). journal of science and medicine in sport. 2007;10 (1):45-51, https://doi.org/10.1016/ j.jsams.2006.05.003. [15] boon rm, hamlin mj, steel gd, ross jj. validation of the new zealand physical activity questionnaire (nzpaq-lf) and the international physical activity questionnaire (ipaqlf) with accelerometry. british journal of sports medicine. 2010;44(10):741-746, https://doi.org/10.1136/bjsm.2008.052167. [16] duncan mj, arbour-nicitopoulos k, subramanieapillai m, remington g, faulkner g. revisiting the international physical activity questionnaire (ipaq): assessing physical activity among individuals with schizophrenia. schizophrenia research. 2017;179:2-7, https:// doi.org/10.1016/j.schres.2016.09.010. 7 erbil journal of nursing & midwifery https://doi.org/10.4236/ape.2017.74038 https://docs.google.com/viewer?a=v&pid=sites&srcid=zgvmyxvsdgrvbwfpbnx0agvpcgfxfgd4ojuxnja1mzu5zdi3njvinmq https://docs.google.com/viewer?a=v&pid=sites&srcid=zgvmyxvsdgrvbwfpbnx0agvpcgfxfgd4ojuxnja1mzu5zdi3njvinmq https://docs.google.com/viewer?a=v&pid=sites&srcid=zgvmyxvsdgrvbwfpbnx0agvpcgfxfgd4ojuxnja1mzu5zdi3njvinmq https://docs.google.com/viewer?a=v&pid=sites&srcid=zgvmyxvsdgrvbwfpbnx0agvpcgfxfgd4ojuxnja1mzu5zdi3njvinmq http://www.scopus.com/inward/record.url?scp=0030987393&partnerid=8yflogxk http://www.scopus.com/inward/record.url?scp=0030987393&partnerid=8yflogxk http://www.scopus.com/inward/record.url?scp=0030987393&partnerid=8yflogxk https://doi.org/10.2147/ppa.s47497 https://doi.org/10.2147/ppa.s71373 https://doi.org/10.2147/ppa.s71373 https://doi.org/10.1016/j.annepidem.2008.12.002 https://doi.org/10.1016/j.annepidem.2008.12.002 https://sites.google.com/site/theipaq/ https://doi.org/10.5353/th_b5662548 https://doi.org/10.1016/j.jsams.2006.05.003 https://doi.org/10.1016/j.jsams.2006.05.003 https://doi.org/10.1136/bjsm.2008.052167 https://doi.org/10.15218/ejnm.2019.01 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *33+ pixley f, mann j. dietary factors in the aetiology of gall stones: a case control study. gutbmj. 1988;29(11):1511-1515, https:// doi.org/10.1136/gut.29.11.1511. *34+ caroli-bosc f-x, deveau c, peten ep, delabre b, zanaldi h, hebuterne x, et al. cholelithiasis and dietary risk factors (an epidemiologic investigation in vidauban, southeast france). digestive diseases and sciences. 1998;43(9):2131-2137, https:// doi.org/10.1023/a:1018879819301. *35+ tsai c-j, leitzmann mf, willett wc, giovannucci el. long-term intake of trans-fatty acids and risk of gallstone disease in men. archives of internal medicine. 2005;165 (9):1011-1015, https://doi.org/10.1001/ archinte.165.9.1011. *36+ tsai c-j, leitzmann mf, willett wc, giovannucci el. long-chain saturated fatty acids consumption and risk of gallstone disease among men. annals of surgery. 2008;247 (1):95-103, https://doi.org/10.1097/ sla.0b013e31815792c2. *37+ cuevas a, miquel jf, reyes ms, zanlungo s, nervi f. diet as a risk factor for cholesterol gallstone disease. journal of the american college of nutrition. 2004;23(3):187-196, http:// dx.doi.org/10.1080/07315724.2004.107193 60. *38+ marchesini g, forlani g. nash: from liver diseases to metabolic disorders and back to clinical hepatology. hepatology. 2002;35 (2):497-499, https://doi.org/10.1053/ jhep.2002.31551. *24+ av a, kg k. diabetes mellitus and other lifestyle risk factors for cholelithiasis: a case control study. international journal of preventive and therapeutic medicine. 2015;3(1), retrived from: http://ijptm.com/index.php/ ijptm/article/view/270. *25+ jørgensen t, kay l, schultz-larsen k. the epidemiology of gallstones in a 70-year-old danish population. scandinavian journal of gastroenterology. 1990;25(4):335-340, https:// doi.org/10.3109/00365529009095495. *26+ basso l, mccollum p, darling m, tocchi w, tanner w. a descriptive study of pregnant women with gallstones. relation to dietary and social habits, education, physical activity, height, and weight. european journal of epidemiology. 1992;8(5):629-633, https:// doi.org/10.1007/bf00145375. *27+ liu t, wang w, ji y, wang y, liu x, cao l, et al. association between different combination of measures for obesity and new-onset gallstone disease. plos one. 2018;13 (5):e0196457, https://doi.org/10.1371/ journal.pone.0196457. *28+ lammert f, sauerbruch t. mechanisms of disease: the genetic epidemiology of gallbladder stones. nature reviews gastroenterology and hepatology. 2005;2(9):423, https://doi.org/10.1038/ncpgasthep0257. [29] banim pj. aetiological and clinical aspects of symptomatic gallstone disease and pancreatic cancer. norwich: university of east anglia; 2011, thesis, retrieved from: https:// ueaeprints.uea.ac.uk/id/eprint/49763. *30+ ruvalcaba cb, hita mg, sanchez-enriquez s. diet and nutritional factors related to symptomatic gallstone disease in women. journal of clinical case rep. 2014;4(12), https://doi.org/10.4172/21657920.1000458. *31+ stokes cs, krawczyk m, lammert f. gallstones: environment, lifestyle and genes. digestive diseases. 2011;29(2):191-201, https://doi.org/10.1159/000323885. *32+ jayanthi v, anand l, ashok l, srinivasan v. dietary factors in pathogenesis of gallstone disease in southern india a hospital-based case-control study. indian journal of gastroenterology. 2005;24(3):97-99, retrieved from: https://www.ncbi.nlm.nih.gov/ pubmed/16041099. 8 erbil journal of nursing & midwifery https://doi.org/10.1136/gut.29.11.1511 https://doi.org/10.1136/gut.29.11.1511 https://doi.org/10.1023/a:1018879819301 https://doi.org/10.1023/a:1018879819301 https://doi.org/10.1001/archinte.165.9.1011 https://doi.org/10.1001/archinte.165.9.1011 https://doi.org/10.1097/sla.0b013e31815792c2 https://doi.org/10.1097/sla.0b013e31815792c2 http://dx.doi.org/10.1080/07315724.2004.10719360 http://dx.doi.org/10.1080/07315724.2004.10719360 http://dx.doi.org/10.1080/07315724.2004.10719360 https://doi.org/10.1053/jhep.2002.31551 https://doi.org/10.1053/jhep.2002.31551 http://ijptm.com/index.php/ijptm/article/view/270 http://ijptm.com/index.php/ijptm/article/view/270 https://doi.org/10.3109/00365529009095495 https://doi.org/10.3109/00365529009095495 https://doi.org/10.1007/bf00145375 https://doi.org/10.1007/bf00145375 https://doi.org/10.1371/journal.pone.0196457 https://doi.org/10.1371/journal.pone.0196457 https://doi.org/10.1038/ncpgasthep0257 https://ueaeprints.uea.ac.uk/id/eprint/49763 https://ueaeprints.uea.ac.uk/id/eprint/49763 https://doi.org/10.4172/2165-7920.1000458 https://doi.org/10.4172/2165-7920.1000458 https://doi.org/10.1159/000323885 https://www.ncbi.nlm.nih.gov/pubmed/16041099 https://www.ncbi.nlm.nih.gov/pubmed/16041099 https://doi.org/10.15218/ejnm.2019.17 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article barriers to adherence to post-stroke exercise program: a qualitative study into the experiences of patients with stroke abstract according to the definition proposed by the world health organization, stroke is “the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot. this cuts off the supply of oxygen and nutrients, causing damage to the brain tissue”, which includes both main types of ischemic and hemorrhagic strokes [1]. approximately one-third of stroke patients remain disabled; therefore, there is a dire need for post-stroke exercise rehabilitation programs [2] which is a dynamic process with the overall purpose of reducing disabilities from stroke complications in which collaboration between medical specialties and financial background and objective: approximately one-third of stroke patients remain disabled and post-stroke rehabilitation is required. adherence to an exercise rehabilitation program is considered an important area of interest in the wake of optimizing long-term participation in physical activities after stroke. this study aims to explore the barriers to adherence to exercise program among post-stroke patients. methods: a qualitative study was conducted in the physiotherapy units of hawler and rizgary teaching hospitals, erbil, the kurdistan region of iraq including twelve post-stroke participants with limited/ inadequate adherence to a post-stroke exercise program schedule from march to december 2018. data was collected through face-to-face interviews. all of the interviews were conducted at a time and place that was the most convenient for the participants. within two months, the categories emerging from the analysis of the interviews began to repeat, and no new categories emerged, leading to an enrollment of 14 participants. one month after the first interview, the second interview was conducted which included 12 participants. this was done to confirm their previous answers and ensuring that there were no new concepts about this limited adherence. software for qualitative data analysis was used for managing the data. results: more than half of the participants were over 70 years old, male, illiterate, married, and housekeepers from urban areas. most of the participants had an ischemic stroke for more than four weeks. the barriers to adherence to post-stroke exercise program were categorized into the four main categories of the barriers related to environment and facility, personal (physical and psychological) factors, organizational policies, and contents of exercise program. conclusion: barriers to adherence are different in nature. environmental barriers and lack of facilities show that a well-organized rehabilitation program in health care system at directorate of health-erbil is very important to improve and facilitate adherence to the poststroke exercise program. keywords: adherence; barriers; post-stroke patients; qualitative research. dara abdulla al-banna; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: : dara.albanna@hmu.edu.krd ) sadea ahmed khuder; department of nursing, college of nursing, hawler medical university, erbil, iraq. 132 erbil journal of nursing & midwifery received: 1/7/2019 accepted: 22/9/2019 published: 30/11/2019 introduction mailto:dara.albanna@hmu.edu.krd https://doi.org/10.15218/ejnm.2019.17 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article and administrative systems in terms of establishing team working to provide poststroke care can be required [3]. stroke patients are vulnerable to the effects of a sedentary lifestyle and would benefit from increasing the amount of exercise they regularly obtain [4,5]. the significantly lower rate of adherence to and participation in regular exercise among disabled people is related to a variety of environmental and personal barriers which include architectural barriers, organizational policies and practices, discrimination, and social attitudes. these barriers effectively reduce personal options, inhibit participation in healthy and active lifestyles, and prevent people with stroke and other disabilities from full participation [6]. general examinations of personal and environmental barriers and facility mediators of physical activity in individuals with stroke require a better understanding of the contextual factors such as personal, environmental, and facility factors that are associated with the target population’s participation in physical activity. also, health conditions associated with stroke are barriers to these individuals’ opportunities to engage in exercise programs. without understanding the critical person-environment barriers associated with participation in exercise programs, it is difficult to establish effective programs that have sustainable outcomes [7]. in order to come up with better understanding of why post-stroke patients do not adhere to exercise programs designed specifically for them according to their needs, the researchers in the present study conducted this qualitative study on post-stroke patients that did not adhere to the randomized controlled trial of exercise program. therefore, the purpose of the present study was to explore barriers to adherence to the randomized controlled trial of exercise rehabilitation program among poststroke patients. design the present qualitative study used a conventional content analysis described by graneheim and lundman[8]. qualitative content analysis allows for the subjective interpretation of data and helps better understand human emotions and the meaning underlying everyday experiences[9]. conventional content analysis is generally used with a study design whose aim is to describe a phenomenon. this type of design is appropriate when the existing theory or research on a phenomenon is limited. researchers avoid using preconceived categories [10]. this form of analysis was selected because the aim of the study was to explore the phenomenon of perceptions of post-stroke patients from barriers to adherence to the exercise program without using predetermined categories. study setting and participant the study was conducted at the physiotherapy units in both hawler and rizgary teaching hospitals located in erbil, the kurdistan region of iraq. these units provide rehabilitation for patients with neuromuscular problems through physiotherapy and exercise programs. in a qualitative research study, researchers try to make sense of phenomena and interpret them in terms of semantics provided by people in their natural position[11]. according to the nature of qualitative research, the target participants were selected through the purposive sampling method. the inclusion criteria were ability to do exercise, no contraindications for physical exercise, agreement to participate in the study, age of 18 years or more, ability to establish verbal communication, and limited adherence to poststroke exercise as determined by failure to regularly attend all sessions of the 133 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2019.17 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article what did you find concerning the organizational services in facilitating your exercise program? i’d like to hear from you about your experience of participating in the exercise program? what interested or disinterested you when you were involved in the exercise program? what do you think about the positive and negative aspects of the exercise program? can you tell me more about the barriers that made you withdrew from the exercise program? how do you feel that the exercise program is affecting your activity limitations? how do you think exercise is managing and maintaining you? how did the exercise make you feel better? how did you solve the problems with the exercise program? what was your opinion about the content of the exercise program? interview procedure data were collected by face-to-face interviews. all of the interviews were carried out at a time and place that were the most convenient for the participants. two months after the initiation of the study, the categories emerging from analyzing the interviews began to repeat, and no new categories emerged. a total of 14 participants were recruited for the study. after one month of the first interview, the second interview was done on 12 (missing two) participants. each interview lasted from 40 to 70 minutes, which was taken to indicate that most of the codes had been identified; therefore, sampling was discontinued. field notes were written during and after interviews. exercise program. the formal approvals were obtained from both ethical and scientific committees (code no.58 in 2018.03.10) in the college of nursing, hawler medical university. the patients were made sure about the confidentiality of their information and that the collected data would be used for this study only. afterwards, they were provided with explanation about the purpose of the study. in addition, each participant was informed that their participation in the study was voluntary and they could leave any time even without completing the exercise program. finally, written informed consent was obtained from each patient, including their signature on the informed consent form. data collection interviews are among the most familiar strategies for collecting qualitative data and much qualitative research is interview based. this study data was collected through semi-structured in-depth interviews. in-depth interviews can provide rich and in-depth information about the experiences of individuals[12]. the researchers developed the interview guide specifically for the purposes of this study. it was a questionnaire that consisted of two main parts. the first part was related to socio-demographic and some clinical information which was aimed at collecting data on the participants’ age, sex, education level, marital status, occupation, residency area, duration of stroke (since the diagnosis), and type of stroke. the other part contained open-ended questions regarding the barriers to adherence to poststroke exercise program. interview questions were asked about the participants’ perception of the post-stroke exercise program and the barriers to adherence to the regular schedule as follows. 134 erbil journal of nursing & midwifery ethical considerations https://doi.org/10.15218/ejnm.2019.17 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article trustworthiness based on the lincoln and guba’s criteria [9], the credibility of the data was established through prolonged engagement in the research site for two years, learning and understanding all about the context, culture, social setting, and the phenomenon of interest, persistent observation for exploring all characteristics in the situation that are most relevant to the exercise adherence, individual interviews, choosing participants from various experiences with 5 younger participants for member checking, and maximum variation of age, sex, level of education, occupation, and place of living. the dependability of the data was established through constant comparative analysis of the data, clarifying the data analysis process, and peer review. to ensure the conformability of the data, there were experts in qualitative research from the school of nursing, tehran university of medical science who were asked to assess the congruence between the data and the findings. to facilitate transferability, a clear description of the characteristics of culture and context, the participants’ characteristics, data collection, the analysis process, and provision of enough meaning units were used to ensure that the findings fitted the quotes. qualitative data analysis to analyze the collected data, a qualitative conventional content analysis, guided by graneheim and lundman[8], was used; which was based on the following steps: 1. transcription of the interviews verbatim and several revisions to understand the concept as a whole, 2. breaking down the text into rational units that will be condensed, 3. conceptualization of the compressed significant units and cataloging them with codes, 4. categorization of the codes into subcategories and categories, depending on their similarities and differences, and 5.devising themes based on the 135 erbil journal of nursing & midwifery latent content of the text[8]. the process of data collection and data analysis was conducted concurrently. all of the interviews were audiotaped, transcribed verbatim, read, and reread in order to understand the meaning within the context of significant words or phrases then analyzed using content analysis. the texts were read through several times to obtain a sense of the whole meaning units, and those that corresponded to the purpose were highlighted, condensed, and coded. the codes and meaning units were compared to the context. the codes were grouped together to form categories and subcategories. the final four categories were examined by the researchers, and in order to ensure a clear difference between them, the meaning units within all subcategories were checked for accuracy. the maxqda version 2018 was used to manage the data. participants’ sociodemographic characteristics fourteen participants were recruited, but only 12 of them agreed to participate in the study. more than half of the participants were over 70 years old, male, illiterate, married, housekeepers, and from urban areas. regarding the duration of stroke since the diagnosis, most of the participants had ischemic stroke for more than four weeks. the participants’ characteristics are presented in table 2. barriers to exercise program adherence analyzing the collected data led to identification of four major categories, namely of the barriers related to environment and facility, personal (physical and psychological) factors, organizational policies, and contents of exercise program. the main first two categories were established after the first three interviews, others were identified by the tenth interview. by then, results https://doi.org/10.15218/ejnm.2019.17 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article quotes are shown in italic.participants are identified with pt. code number, age per years, and sex inside double brackets. 136 erbil journal of nursing & midwifery no new codes were added and the main categories were ensured during the last two interviews and existing categories were supported. table 1: steps of the content analysis process steps actions 1 identifying excerpts which are related to the research questions 2 descriptive categories of excerpts to describe the collected data 3 examination of descriptive categories to determine relationships between them, developing main categories formed by groupings of sub-categories 4 confirming of the transcripts for other relevant data, with continuing adjustment and finalizing the sorting of the major and minor categories table 2: socio-demographic characteristics of the 12 participants in the experimental group sn age sex level of education marital status occupational status residency area duration / weeks type of stroke 1 61 male secondary school married keeping house/ homemaker urban 4 ischemic 2 71 male cannot read and write married retired urban 5 ischemic 3 69 male can read and write married retired urban 4 ischemic 4 70 female cannot read and write widowed unemployed (other reason) rural 3 ischemic 5 72 male cannot read and write married retired urban 2 ischemic 6 70 female cannot read and write married keeping house/ homemaker rural 4 ischemic 7 63 male secondary school married self employed urban 4 hemorrhagic 8 63 female cannot read and write widowed keeping house/ homemaker rural 3 hemorrhagic 9 78 male can read and write married keeping house/ homemaker rural 5 ischemic 10 72 female cannot read and write married keeping house/ homemaker rural 4 ischemic 11 74 female can read and write married keeping house/ homemaker urban 4 ischemic 12 68 male cannot read and write married self employed urban 4 hemorrhagic https://doi.org/10.15218/ejnm.2019.17 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article category of the environment and facility barriers the category “environmental and facilityrelated barriers” derived from the participants’ description of some barriers related to this category. participant 1 said “i think there needs to be a new building with enough space for doing all types of exercise”, participant 3 mentioned “the hospital is so far from my home, i need to take a taxi”. most of the participants had a problem with the transportation and their financial shortage as participant 8 explained “such daily prolonged exercises need more money to spend on transportation”. some of the participating women explained that they had to take care of their children every day and that is why they could not attend all sessions of the exercise program every day. participant 10 described “i’m married with children, and most of my time during the day is devoted to them”. the emergence of this category is shown in table 3. 137 erbil journal of nursing & midwifery table 3: categories associated with environment and facility barriers sn exercise barriers and evidence (n=12) no. of excerpts code/ age/ sex of participant environment and facility barriers 1 “i think there needs to be a new building with enough space for doing all types of exercise” 4 pt.1 (61, male) 2 “the lack of equipment made me attend less every day” 8 pt.1 (61, male) 4 “there was no one among my family, friends, and relatives supporting me to complete all exercises” 5 pt.1 (61, male) 5 “you know, the weather is so cold, so it’s not good for me to go out of home” 9 pt.1 (61, male) 3 “the hospital is so far from my home, i need to take a taxi” 6 pt.3 (69, male) 6 “prolonged waiting for my turn made me follow up less and more bored” 6 pt.5 (72, male) 7 “such daily prolonged exercises need more money to spend on transportation” 5 pt.8 (78, male) 8 “i’m married with children, and most of my time during the day is devoted to them” 3 pt.10 (72, female) https://doi.org/10.15218/ejnm.2019.17 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article category of physical and psychologicalpersonal barriers according to the findings in presented in table 4, the personal barriers are the most frequent barriers that were mentioned by the participants. these barriers were mostly related to the physical and psychological barriers to exercise adherence, such that they feared and had negative feelings about adaptation, suitability, and outcomes of the exercises. some evidence in this regard includes “ you know , i have heart problems and the exercise is not 138 erbil journal of nursing & midwifery good for me” (p. 2), participant 4 said “i feel fatigue and pain during the exercise”, participant 4 explained “my age is not helpful for daily exercise, and i don’t have enough energy and power compared to when i was young”, participant 5 described “i feel that the exercise will not be beneficial for my paralysis”, participant 4 said “i have many problems in my joints, and the exercise makes me worse”, and participant 6 mentioned “i don’t have enough time because of my family and guests”. table 4: categories associated with personal barriers (physical and psychological barriers) sn exercise barriers and evidence (n=12) no. of excerpts code/ age/ sex of participant personal barriers 1 “i am not adapted to do exercise every day” 7 pt.1 (61, male) 2 “you know, i have heart problems and the exercise is not good for me” 7 pt.2 (71, male) 3 “i am so worried about my medical status and the future of my work” 4 pt.3 (69, male) 4 “because i am better than before, i try to do my daily activities and it’s like the exercise” 6 pt.3 (69, male) 5 “i am female and i cannot attend the exercise every day as males” 3 pt.4 (70 ,male) 6 “i feel fatigue and pain during the exercise” 5 pt.4 (70 ,male) 7 “my age is not helpful for daily exercise and i don’t have enough energy and power compared to when i was young” 4 pt.4 (70 ,male) 8 “i have many problems in my joints and the exercise makes me worse” 7 pt.4 (70 ,male) 9 “i cannot control all my body during the exercise” 3 pt.5 (72, male) 10 “i need someone to hold me and help me to do exercise” 6 pt.5 (72, male) 11 “i feel that the exercise will not be beneficial for my paralysis” 4 pt.5 (72, male) 12 “i think that i cannot complete all sessions of the exercise” 4 pt.6 (70, female) 13 “i don’t have enough time because of my family and guests” 4 pt.6 (70, female) 14 “my obesity makes me lazier to do daily activities” 3 pt.7 (63, male) 15 “i did not feel any good progress with my paralysis and you know, i did 2 weeks still my weakness has not been solved” 4 pt.9 (78, male) https://doi.org/10.15218/ejnm.2019.17 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article category of organizational policies barriers some of the participants noted wanting to make the modifications in some of the organizational policies, regulations, and job descriptions which they stated made it more difficult to access some important services. this category can be seen in some evidence including “the policeman at the gate of the hospital doesn’t allow us to use our car inside the hospital. you know, the distance between the gate and the exercise hall is so far, and there are not enough wheelchairs and they do not work well” (p. 10).some of the participants blamed about the health care service outcomes inside the hospital , participant 2 explained “this is the second time that this hospital has tried to treat me with exercise, it was simple 139 erbil journal of nursing & midwifery and did not made me better until i visited a private center outside of the hospital”. table 5 describes this category. category of the content of exercise program barriers some of the participants explained that they could not adapt to and cope with such an exercise program easily, because of their expectations and experiences regarding the content, sessions, and outcomes of the exercise program as in “the duration of all exercises is very long, and you need several months to complete it” and “a huge amount of content is included inside a small exercise book” (p. 4), participant 10 explained “what is presented for exercise in this small book is so difficult that you cannot follow all sessions correctly”. the data related to the emergence of this category are shown in table 6. sn exercise barriers and evidence (n=12) no. of excerpts code/ age/ sex of participant organizational policies barriers 1 “this is the second time that this hospital has tried to treat me with exercise, it was simple and did not made me better until i visited a private center outside of the hospital” 7 pt.2 (71, male) 2 “the hospital doesn’t allow me to bring all my 3 sons with me” 2 pt.10 (72, female) 3 “the policeman at the gate of the hospital doesn’t allow us to use our car inside the hospital. you know, the distance between the gate and the exercise hall is so far, and there are not enough wheelchairs and they do not work well” 1 pt.10 (72, female) table 5: categories associated with organizational policies barriers table 6: categories associated with the content of the exercise program barriers sn exercise barriers and evidence (n=12) no. of excerpts code/ age/ sex of participant exercise program barriers 1 “the duration of all exercises is very long, and you need several months to complete it” 6 pt.4 (70 ,male) 2 “a huge content is included inside a small exercise book” 4 pt.4 (70 ,male) 3 “the exercises were not comfortable or enjoyable, they were so boring” 3 pt.5 (72, male) 4 “from the first week i felt that this exercise would make worse and 4 pt.6 (70, female) 5 “what is presented for exercise in this small book is so difficult that you cannot follow all sessions correctly” 3 pt.10 (72, female) https://doi.org/10.15218/ejnm.2019.17 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article summary of the findings and comparison with other studies this study aimed to explore the barriers to adherence to exercise program among post -stroke patients. for this purpose, semistructured interviews, which is an efficient way to investigate an under-researched topic, allowed interviewees to explain their opinions accurately in their own terms, and gain direct information from study participants without imposing preconceived categories or theoretical perspectives. these interviews were conducted to collect required data which were later analyzed by content analysis method based on the participants’ unique perspectives and their actual data. there are limited theories and studies focusing on adherence to exercise program among post-stroke patients which is why the researchers selected conventional content analysis to derive the barriers directly from the post-stroke patients’ own words as row data. through qualitative interviews with post-stroke patients regarding their adherence to the randomized controlled trial of exercise program, it was found that there were many barriers that affected the post-stroke patients’ efficient adherence to the exercise program until the end of the schedule that was planned according to their needs. the participants reported multiple barriers to attend all sessions of the exercise program that were interpreted as four main barriers of environment, personal (physical and psychological barriers), organizational policies, and some barriers regarding the content of the exercise program itself. in environment and facility barriers, the majority of the participants explained that cold weather, lack of equipment, lack of time, and problems with the transportation were the main barriers regarding the facilities to participate in such exercise programs . in the study carried out by jack et al. 140 erbil journal of nursing & midwifery (2010), about 70% of the participants referred to the lack of transportation as a major barrier [7]. the findings of the present study were consistent with previously out by jack et al. (2010), about 70% of the published studies that involved poststroke patients. some of the interviewees wished to avoid the hassle of organizing another appointment or finding additional time out to attend, while others expressed anxiety about the potential for new tests to reveal more health problems. also, time constraints were frequently cited as barriers to participation, generally construed as resulting carried from external forces beyond individual control [16]. rimmer et al. reported several different categories of environmental or facility barriers related to participation in physical activity among people with physical disabilities; these barriers included the built environment, cost of services or programs, equipment, policies, information, and education and training of fitness facility staff [5]. the authors recommend that more facilities and organizational services should be provided in order to access the exercise programs easily. regarding the personal barriers of physical and psychological aspects: health status problems, coping strategies and adaptation to exercise program, feeling undesirable symptoms, negative ideas, lack of energy, low confidence, low self-efficacy, feel of unsafely and injurious outcomes, lack of selfmotivation, and dependency were the main barriers to adherence to an exercise program. the results of a study showed that one-fourth (26%) of the participants felt uncomfortable exercising in the facilities, and (39%) of them felt lack of energy [7]. in another study, five significant barriers were mentioned to exercise among older adults, including fear of injury/ falling, inertia, time constraints, negative effects, and physical ailments, the discussion https://doi.org/10.15218/ejnm.2019.17 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article frequencies of responses were also noted. inertia, characterized by being “too tired” or “too lazy” or finding exercise to be “boring” was the most frequently mentioned barrier to the exercisers [15]. some of the participants believed that the exercise program was too long and too difficult for post-stroke patients. they also expressed that the exercise program made their health status worse and caused injuries. others confirmed that the program was not enjoyable or exciting. considering that an estimated 80% of stroke patients are discharged home and most will be cared for by a family member following discharge from inpatient rehabilitation[17], families need to be involved in all aspects of care as early as possible. stroke patients and their family caregivers would benefit from a collaborative, dynamic treatment process that includes an understanding of the social and environmental context of the family[18]. including family as the central part of the rehabilitation process would ensure that all patients and families are given the opportunity to participate in and contribute to rehabilitation programs. in the study, some of the participants explained that they could not adapt to and cope with such an exercise program easily. a qualitative study showed that key factors such as lack of awareness about stroke recovery and exercises, hopelessness, and lack of emphasis on exercises by healthcare professionals led to non-adherence while commitment, continued supervision, and having a supportive family and society facilitated adherence[18]. this is needed to develop effective interventions for promoting exercise adherence among stroke survivors in low and middle income countries. limitations of the study the study had several limitations. most of the participants in this study consisted of elderly patients with stroke; therefore, it is 141 erbil journal of nursing & midwifery not clear whether young people with stroke have similar or different barriers to adherence. in this study, although we attempted to gain participants’ trust during data collection, some might have had some reservations during interviews and hence, might have decided not to share some aspects of their experiences. the findings of this study may not be generalizable to countries with advanced transportation systems. implications for increasing adherence rates the findings of this study may be useful for and applied by nurses, physiotherapists, and clinicians to identify these key barriers to exercise adherence in the development of exercise rehabilitation programs and deepen their understanding of the context of the strategies for overcoming all possible barriers among all diverse samples of post-stroke patients, which can in turn, increase exercise adherence. another advantage of determining the barriers in this study is to improve performance in activities of daily living, and the overall quality of life might increase exercise adherence. exploration of the barriers to adherence to exercise program among post-stroke patients helps researchers, nurses, physiotherapists, and clinicians, and other health care providers to prepare an applicable exercise program and overcome the barriers that are mostly related to the content of the program, environment, organizational policies, and physical-psychological aspects. the authors recommend that most of the barriers be controlled through organizational regulation and policies, family support, health education on taking care of stroke patients, financial support, and provision of special facilities according to individualized needs. conclusion https://doi.org/10.15218/ejnm.2019.17 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article these strategies may affect the perception, beliefs, expectation, and experience toward the positive direction and maximize the rate of exercise adherence among post -stroke patients. further studies should focus on the content of the exercise programs with regard to the duration and frequency of each exercise and determine the impact of them on the exercise program adherence among different groups of poststroke patients. warmest thanks and wishes for better health go to all participants in this study. also, much appreciation goes to the administration of the study setting who directly or indirectly helped with the accomplishment of this study particularly during data collection. grateful thanks are extended to the academic staff experts in school of nursing of tehran university of medical science (dr. nikbakht a., dr. seylani kh., and dr. hajbabaee) who commented on earlier drafts of this study. there is no conflict of interest. a.d. devised the project, proposed the main conceptual ideas and proof outline, conducted the interviews, carried out data collection and data clarification, worked out almost all of the technical details, performed the statistical analysis for the gathered data, and wrote the manuscript. kh. s. supervised the whole process from the proposal to the end and reviewed the manuscript. the authors reported no conflict of interes [1] attwood s, morton k, mitchell j, van emmenis m, sutton s, vbi programme team. reasons for non-participation in a primary care-based physical activity trial: a qualitative study. british medical journal open.2016;23;6(5):e011577. doi: 10.1136/ bmjopen-2016-011577.[pubmed: 27217288]. 142 erbil journal of nursing & midwifery [2] bengtsson m. how to plan and perform a qualitative study using content analysis. nursing plus open. 2016;2. doi: 10.1016/ j.npls.2016.01.001. [3] dobkin b, dorsch a. new evidence for therapies in stroke rehabilitation. current atherosclerosis reports. 2013; 15(6): 331. doi: 10.1007/s11883-013-0331-y. [4] frich jc, russell d. stroke-a new epoch. tidsskr nor laegeforen. 2007;127(6):719. [pubmed: 17363980]. [5] graneheim uh, lundmanb. qualitative content analysis in nursing research: concepts, procedures and measure to achieve trustworthiness nurse education today. nurse education today. 2004 feb;24(2):105-12. doi: 10.1016/j.nedt.2003.10.001. [pubmed: 14769454]. [6] ivey fm, hafer-macko ce, macko rf. exercise rehabilitation after stroke. neuro therapeutics (neurorx). 2006;3(4):439–50. doi: 10.1016/j.nurx.2006.07.011. [pubmed: 17012057]. [7] lees fd, clarkr pg, nigg cr, newman p. barriers to exercise behavior among older adults: a focus-group study. journal of aging and physical activity. 2005 jan;13(1):2333. [pubmed: 15677833]. [8] lincoln ys, guba eg. naturalistic inquiry. newbury park, ca: sage publications. 1985. isbn-13: 978-0803924314. isbn-10: 0803924313. [9] polit df, beck ct. essentials of nursing research: appraising evidence for nursing practice. lippincott williams & wilkins 2009. [10] rimmer jh, rubin ss, braddock d. barriers to exercise in african american women with physical disabilities. archives of physical medicine and rehabilitation. 2000;81 (2):182–88. [pubmed: 10668772]. [11] elo s, kyngas h. the qualitative content analysis process. journal advance nursing. 2008;62:107–15. [12] barbara dicicco, bloom-benjamin f crabtree.the qualitative research interview.medical education 2006;40: 314–321. [13] rimmer jh, wang e, smith d. barriers associated with exercise and community access for individuals with stroke. journal of rehabilitation research & development. 2008;45 (2):315-22. [pubmed: 18566948]. [14] rimmer jh, wang e. aerobic exercise training in stroke survivors. topics stroke rehabilitation journal. 2005;12(1):17–30. doi: 10.1310/l6hg-8x8n-qc9q-hhm acknowledgments references conflict of interest https://doi.org/10.15218/ejnm.2019.17 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article [pubmed: 15735998]. [15] shaughnessy m, resnick bm, macko rf. testing a model of post-stroke exercise behavior. rehabilitation nursing journal. 2006;31(1):15–21. [pubmed: 16422040]. [16] world health organizations. global status report on noncommunicable diseases. stroke, cerebrovascular accident. 2014. isbn: 978 92 4 156485 4. [17] eldred c, sykes c. psychosocial interventions for carers of survivors of stroke: a systematic review of interventions based on psychological principles and theoretical frameworks. british journal of health psychology. 2008; 13(3):565–581. [18] creasy kr, lutz bj, young me, ford a, martz c. the impact of interactions with providers on stroke caregivers’ needs. rehabilitation nursing. 2013; 38(2):88–98. [pubmed: 23529947]. [19] amreen mahmood, pradeepa nayak, gerjo kok, coralie english, natarajan manikandan. factors influencing adherence to homebased exercises among community-dwelling stroke survivors in india: a qualitative study. european journal of physiotherapy. 2019; 1 (7). doi: 10.1080/21679169.2019.1635641. 143 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.04 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article patients' satisfaction about health services in out-patients clinics of teaching hospitals in erbil city abstract introduction clients satisfaction refers to the levels of satisfaction that the clients experience having used a medical service in all levels and all domains. satisfaction is the reflects the gap between the target or desired services and experiences of services provided by health care professionals, from the clients' view *1,2+. out-patients department (opd) is a department that provides the main linkage of the hospital with the public, its primary objective to provide medical services for the clients in minimal costs, and its scope of services are different from background and objectives: outpatients' satisfaction is important aspect to evaluation levels of quality and quantity services provided in outpatients departments. the study aimed to assess patients' satisfaction toward health care provided in out-patients clinics of rizgary and hawler teaching hospitals and find out the factors that are associated with levels of satisfaction. methods: a cross–sectional study was conducted in hawler and rizgary teaching hospitals in erbil city. the study started from april 1st, 2017 to july 1st, 2017. a convenience method of sampling was used to recruit 500 participants who attended in out-patients clinics 238 (47.6%) from rizgary hospital, and 262 (52.4%) from hawler hospital. the questionnaire format was designed by researches for data collection. the questionnaire consisted of two parts: part one socio-demographic and hospitalization data and part two included 59 questions about health care services. five points likert scale was used to assess patients' satisfaction. the statistical package for the social sciences, version 22 was used data enter and analysis. a chi-square test of association was used to compare proportion. results: the study found 27.8% of patients were satisfied, with respect to all health services (including physicians, nurses, pharmacies, and laboratories) and in health aspects (including communication, maintain for privacy of patients and respect them, counseling and advising roles, and time spend with patients) . there was an association between patients' satisfaction and age categories, levels of income, and the number of visits to outpatient departments. conclusions: the majorities of outpatients have no idea regarding satisfaction or not satisfied with health services in outpatients departments of major hospitals in erbil city. there were significant association between the level of satisfaction with age, level of income and hospital. keywords: patients' satisfaction, outpatients departments. ako ramadan satar; daub health centre, kirkuk directorate of health, ministry of health, kirkuk, iraq. ibrahim hassan mustafa; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: ako.ramadan@yahoo.com ) 26 erbil journal of nursing & midwifery received: 23/9/2018 accepted: 15/1/2019 published: 30/5/2019 mailto:ako.ramadan@yahoo.com. https://doi.org/10.15218/ejnm.2019.04 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article area to area, mostly opd's the services are curative (including diagnosis and treatment), follow up of chronic diseases and referring, in addition rehabilitation, and some time immunizing *3+. many studies indicated that increased level of quality of health services has relationship with increased level of clients' satisfaction *4+. studies aimed to find methods to increase clients' satisfaction the results indicated that the hospitals' administrations should create new methods to decrease waiting time in clinics, improve good dialogues skills between healthcare professionals and patients, and maintain privacy of patients. in addition, tudies recommended it's necessary to do training courses for physicians and other health care professionals to improve their abilities and skills to counseling and guiding the patients *5,6+. a study by nabbuye-sekandl and his collogues carried in mulago hospital, uganda in year 2011. results indicated that health services provided in hospital should devise innovative ways to reach high satisfaction scores for outpatients clinic care. adequate facilities should provide for patients and services should be more patients-centered in outpatients clinics to achieve all clients' needs *7+. for the purpose of assessing levels of clients' satisfaction, hospitals' administrators periodically need to gather and analysis related data to identify quality of healthcare services in actually and using the results for improving the quality of healthcare service for better levels *8-10+. health services are different from country to country but in well-functioning health systems the health services should have number of characteristics including comprehensive, accessibility, caregiver, continuity, quality, person-centeredness, coordination and accountable and efficiency *11+ . few studies concerned on outpatient’s satisfaction toward health services provided in public hospital in erbil city. this study aimed to assess patients' satisfaction with health care services provided in out-patients clinics of rizgary and hawler teaching hospitals and find out the factors that are associated with levels of satisfaction . a cross–sectional study was conducted in out-patients departments of hawler and rizgary teaching hospitals in erbil city. during april 1st, 2017 to july 1st, 2017. a convenience method of sampling was used to recruit 500 participants who attended in out-patients clinics 238 (47.6%) from rizgary hospital, and 262 (52.4%) from hawler hospital. the sample size was determined by yamance statistical formula (n=n/1+n(e)2) *12+, after estimating the rate of patients visited in the both opds in the month from the medical record. (the small n letter in formula indicated to sample size, the capital n letter indicated to population size, and e small letter indicated to level of precision of sampling error which equals to 0.05). by process of entering the known data in formula and as (3858)/1+ (3858)*(0.05)2=362 sample size, researchers selected 500 patients as a study sample to reach more representative sample size and for purpose strengthening study. patients' age ≥18 years, both genders, have ≥ 2 times visiting during one year were included. patients with mental or psychological problems were excluded. data was gathered by the self-report method by using the questionnaire format that was designed by researchers. the validity of the questionnaire was assessed by fifteen experts from different medical and nursing fields. the questionnaire consists of two parts; part one related to socio-demographic characteristics of patients and hospitalization data (such as age, gender, marital status, levels of family income in the month, the methods 27 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.04 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article the mean of patients' satisfaction score (m±sd) was 180.7 ±29.4 (table 1). the proportion of male and female were rough to equal. the highest percentage of the sample was 42.8% among age category 19 to 29 years, followed by 38.6% was age category 30 to 40 years. results show that more than half (51.2%) of the study sample has enough income for daily life, followed by 46.2% of the sample mentioned there income level is not enough for daily life. results show that 58% of the sample has 2-3 times visiting outpatients' clinics during one year (table 2). results showed that the highest scores more than half in majority in all out-patients departments were recorded in neutral (among them the highest score 63.4%was recorded in facilities services, and lowest score 46.8was recorded in laboratory services), only 16.0% of the sample was high satisfied toward nursing services, and 31.6% of the sample was dissatisfied toward laboratory services (table 3). results showed the satisfaction of out-patients toward health care aspects were scored in majorly neutral for all aspects more than half of the sample 54.6% and 53.8% respectively were scored neutral satisfaction for the time which spends with patients and maintains patient privacy and respects respectively. regarding communication highest score 45.4% was scored in neutral satisfied the rest was rough to equal distribute between satisfied and dissatisfied. regarding health professionals' advice and counseling more than one third (38%) of the patients were neutral, and more than a quarter of them (25.8%) were dissatisfied (table 4). results show more than half 257 (51.4%) of the sample was neutral satisfied about health services, and 139 (27.8%) was satisfied, the rest 104 (20.8%) was dissatisfied. results also show that there was no number of visiting outpatients' clinics, and hospitals). part two includes a number of questions about health care services. a five-point likert scale was used to assess patients' satisfaction, were score five indicated the highest level of satisfaction and score one indicated the lowest level of satisfaction. patients were asked 59 questions to assess their satisfaction with health care services. the equation accrued by subtracting lower score (59) from upper score (295) then the result divided by three. dissatisfied (59-137) neutral (138216) and satisfied (217-295). to identify out-patients satisfaction about health professionals including physicians, nurses, pharmacies, laboratories and facilities (included number and type of seats, adequately car parking, cleanness status, directional follow inside clinics, heating, cooling, lighting and ventilation system) and to identify patients satisfaction for the aspects of the healthcare services that provided by the healthcare professionals (including communication skills, respects and maintain the privacy of patients, advises and counseling role for patients, and amount of time spent with patients) each one of these items in separates scores. the researchers calculated all scores related to each one of them, then presented it into three levels: dissatisfied (for the low score), neutral (for the medium score) and satisfied (for the high score). the research was approved by the ethical committee of the college of nursing, hawler medical university and permission from general directorate of health in erbil city. the statistical package for the social sciences (spss, version 22) was used data enter and analysis. the descriptive statistical analysis which involved frequency, percentage, mean and standard division were used. chi -square test of association was used to compare proportion. a pthe value of ≤ 0.05 was considered as statically significant. 28 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2019.04 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article differences between male and female regarding levels of satisfaction (dissatisfied, neutral, and satisfied) (p. value=0.144). results show more than half (54.8%) of dissatisfied were patients in the age group 2029, and 38.1% of the satisfied were patients in the age group 40 and more. highly significant statistically differences (p. value <0.001). results also show that only 13 (2.6%) of the whole sample has exceeded enough income for daily life among them 0.0% were recorded in dissatisfied, the others were distributed between neutral and satisfied respectively. patients who have enough income for daily life harvested 70.5% in the satisfied group. highly significant statistically differences (p. value <0.001). regarding differences of levels of satisfaction between the clients of both hospitals (rizgary and hawler) results show 75.5% of satisfied patients were clients of hawler hospital, against only 24.5% of them were clients of rizgary hospital highly significant statistically differences (p. value <0.001) (table 5). 29 erbil journal of nursing & midwifery table2: socio-demographic characteristics of the study sample % no. variables 49.8 50.2 249 251 sex male female 42.8 38.6 18.6 214 193 93 age 19-29 30-40 41-51 46.2 51.2 2.6 231 256 13 levels of income not enough for daily life enough for daily life exceeds enough for daily life 58.0 42.0 290 210 number of visiting outpatients clinic 2-3 visits 4-5 visits 100 500 total stander deviation range maximum minimum mean 29.4 128.0 240.0 112.0 180.7 table1: describe satisfaction status of study sample table 3: patients' satisfaction toward health services total (%) satisfaction levels health care aspects satisfied no. (%) neutral no. (%) dissatisfied no. (%) 500(100) 102 (20.4) 263 (52.6) 135 (27.0) physicians 500(100) 80 (16.0) 284 (56.8) 136 (27.2) nursing 500(100) 181 (36.2) 278 (55.6) 41 (8.2) pharmacy 500(100) 108 (21.6) 234 (46.8) 158 (31.6) laboratory 500(100) 97 (19.4) 317 (63.4) 86 (17.2) facilities https://doi.org/10.15218/ejnm.2019.04 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article the results of this study showed that the average of patients' satisfaction has stayed in 180.7 which is in the second the highest half of the total score (table 1). present study show the highest scores in all type of health services were harvested in the neutral, very limited percentage of sample was dissatisfied toward pharmacy services and less than twenty percentage of sample was satisfied toward nursing care (table 3). results of a study carried in malaysia by abd munaf indicated that the overall health satisfaction was high in outpatients of public and private hospitals. the study also finds there was a relationship between satisfaction of patients and waiting time in the outpatient's clinic *16+. study of amini and amiri indicated the most of the patients scored satisfaction with health services; the highest score was recorded for physicians, while the lowest score went 30 erbil journal of nursing & midwifery table 4: satisfaction level of sample according to outpatients' services satisfaction levels health care aspects satisfied no. (%) neutral no. (%) dissatisfied no. (%) 137(27.4) 227(45.4) 136(27.2) health professionals' communication 84(16.8) 269(53.8) 147(29.4) patients' privacy maintain and respect 181(36.2) 190(38.0) 129(25.8) health professional advice and counseling 147(29.4) 273(54.6) 80(16.0) time spends with patients table 5: association between levels of satisfaction and socio-demographic variables levels of satisfaction p value variables dissatisfied 104(20.8) no.(%) neutral 257(51.4) no.(%) satisfied 139(27.8) no.(%) sex male female 57 (54.8) 47 (45.2) 117 (45.5) 140 (54.5) 75 (54.0) 64 (46.0) 0.144 age categories 20-29 30-39 40+ 57 (54.8) 44 (42.3) 3 (2.9) 110 (42.8) 110 (42.8) 37 (14.4) 47 (33.8) 39 (28.1) 53 (38.1) ≤0.001 levels of income not enough for daily life enough for daily life exceeds enough for daily life 46 (44.2) 58 (55.8) 0 (0.0) 150 (58.4) 100 (38.9) 7 (2.7) 35 (25.2) 98 (70.5) 6 (4.3) ≤0.001 hospitals rizgary 63 (60.6) 141 (54.9) 34 (24.5) hawler 41 (39.4) 116 (45.1) 105 (75.5) ≤0.001 *the satisfied level consisted27.8% of whole sample discussion https://doi.org/10.15218/ejnm.2019.04 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article to time waiting. the inconsistencies among studies maybe related to differences between facilities, and services of hospitals *6+.table 4 in the present study also shows that the highest scores of health professionals about services aspects were distributed majority (more than half and sometimes near to half) for neutral in most behavioral activities which involved times dedicated with patients, maintains privacy of patients and respect them, and communication skills of health professionals with the patients. the results of table 4 verify the results of table 3in the present study about most of the scores were went to neutral. these results are predictable because the services are available in outpatients clinics but it's not enough in quality and quantity, and our patients have courtesies in there speaking when they evaluate services. in addition patients in erbil want the service in out-patients whatever type with regardless of its quality. therefore the results gone to neutral level studies indicated that training health professional principles of communication skills and counseling is necessary to increase patients' satisfaction *1719+. this study shows that 27.8% of the whole study sample was satisfied toward health services which provided in outpatients clinics of both rizgary and hawler hospitals (table 5). in a study carried by asefa and his colleagues in hawassa university teaching hospital, in the year 2014 results indicated that 80.1% of patients were satisfied towered health services provided in outpatients clinics of the hospital and association between patients' satisfaction and good communication with patients, length of staying in outpatients' clinics to take the healthcare, and available main health services *5+.the inconsistencies between the results of the two studies maybe related to differences between qualities of health services in hospitals. the present study shows that there were no differences between male and female regarding satisfaction levels. the study carried of nabbuye-sekandl and his colleagues indicated that there were no significant differences between males and females regarding satisfaction *7+. regarding age the present study showed satisfaction of outpatients increased in patients age 40 and more the association between age groups and levels of satisfaction were significant. nabbuyesekandl et al indicates that there were no significant differences between age groups and levels of satisfaction *7+. the present study also shows that there was an association between levels of income and satisfaction of patients towered health services in out-patient clinics. highest scores of satisfied were recorded with those who have enough income for daily life. the results of a study carried by net in year 2007 indicated that there was no association between levels of income and levels of out -patients satisfaction *13+. while pascoe (1983), found that increases income among patients is a factor for decrease satisfaction toward nursing *14+. al-tawil et al in the year 2015 indicated that income is subjective and participants could be erroneously classified into different levels of income groups *15+. the association between socio-demographic characteristics of clients and their levels of satisfaction were divers from study to other *4+. present study found that the satisfaction of outpatients in hawler hospital is better than the satisfaction of the outpatients clinic at rizgary hospital. present study concluded that only 27.8% of the whole sample was satisfied with health services, the majority of scores were recorded neutral satisfaction in all health services. there was a significant association between patients' satisfaction 31 erbil journal of nursing & midwifery conclusions https://doi.org/10.15218/ejnm.2019.04 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *8+ aldebasi yh, ahmed mi. patients’ satisfaction with medical services in the qassim area. journal of clinical and diagnosis research. 2011; res. 5(4):813-817. *9+ donabedian a. the quality of care: how can it be assessed? journal of the american medical association 1988;260(12):1743–8. available from doi: jama.1988.03410120089033.https:// jamanetwork.com/journals/jama/articleabstract/374139. *10+ cleary pd, mcneil bj. patient satisfaction as an indicator of quality care.journal of medical care organization. 1988;25:25–36. available pubmed/2966123. *access in may 20, 2018+. *11+ who. health service delivery. 2010. available from:www.who.int/healthinfo/systems/ who_mbhss_2010_section1_web.pdf *access in march 12, 2018+. *12+ ajays ss., micah bm. sampling techniques and determination of sample size in applied statistics research: an overview. international journal of economics commerce and management, uk; 2014; 2(11)1-22. *13+ net n. patients' satisfaction towards health services at the out-patient department clinic of wangnumyen community hospital sakaeo province, sakaeo province: mahidol university thailand. *thesis+. 2007. *14+ pascoe gc. patient satisfaction in primary health care: a literature review and analysis: evalprog plan 1983; 6(3-4):185-210. available from: https://www.ncbi.nlm.nih.gov/ pubmed/10299618. *access in march 17, 2018+. *15+ al-tawilng., mustafa ih., ismahil za. inpatients satisfaction toward nursing services in medical and surgical wards of rizgary teaching hospital, erbil, iraq.zanco journal of medical science; 2016;20(2):1349-55. *16+ abdmanaf nh, nooi ps. patients' satisfaction of services quality in malaysian public hospital. the asian journal of quality. 2016; 10(1): 77-87. available from: https:// doi.org/10.1108/15982688200700028 *17+ azizam n a, shamsuddin k. health care providerpatient communication: a satisfaction study in the outpatients clinic at hospital kuala lumpur. malays journal of medical science. 2015; 22(3)56-64. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc4681722/. *access in apr 10, 2018+. and age categories, levels of income, and number of visits to outpatients' clinics, and there was a difference between patients of rizgary hospital and hawler hospital regarding outpatients' satisfaction. the authors report no conflict of interests. *1+ prakash b. patients satisfaction. journal of cutaneous and aesthetic surgery sep. 2010; 3(3):151-5. available from: doi: 10.4103/0974-2077.74491/.https:// www.researchgate.net/ *2+ aragon sj, gesell sb. a patient satisfaction theory and its robustness across gender in emergency departments.american journal of medical science.2003; 18: 229-41. *3+ singh bedi s. impact of healthcare services on outpatient satisfaction in public and private hospitals: a study of hospitals in mumbai. *thesis+. mumbai: d.y.patil, university, navi mumbai; 2014. *4+ batbaatar e., dorjdagva j., luvsannyam a., savion mm., amenta p. determinants of patient satisfaction: a systematic review. respect public health journal. mar. 2017; 137(2):89-101. available from: doi: 10.1177/1757913916634136. http:// www.ncbi.nlm.nih. *5+ asefa a., kassa a., dessalegn m. patient satisfaction with outpatient health services in hawassa university teaching hospital, southern ethiopia. journal of public health epidemiology. feb. 2014; 6(2): 101-10. available from: doi: 10.5897/jphe2013.061. www.academicjournals.org *6+ amerion a., amini h., meskarpour m., ebrahimnia m., sanaienasab h. assessment of patient satisfaction and its related factors with outpatient services of military hospital clinic in iran. wulfenia journal. decmb.2014; 19(5):74-83. *7+ nabbuyesekandl j., makumbl f., kasangaki a., kizza i., tugumisirize j., nshimye e., et al, patients satisfaction with services in outpatient clinics at mulago hospital, uganda. international journal of quality health care. 2011; 23(5):516-23. available from: doi: 10.1093/intqhc/mzr040.https:// www.ncbi.nlm.nih.gov/pubmed/21775313. 32 erbil journal of nursing & midwifery conflict of interest references https://doi.org/10.15218/ejnm.2019.04 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *18+ king ma., hoppe rb. "best practice" for patients-centered communication: a narrative review. journal of graduate medical education. sept. 2013; 5(3):385-93. available from: doi: 10.4300/jgme-d-1300072.1..https://www.ncbi.nlm.nih.gov/ pubmed/24404300, *19+ kamhawi s, underwood c., murad h., jaber b. clients-center counseling improves client satisfaction with family planning visits: evidence from irbid, jordan. global health science and practice journal. aug. 2013; 1(2): 18092. available from: http:// www.chwcentral.org/client-centeredcounseling-improves-client-satisfactionfamily-planning-visits-evidence-irbid-jordan. *access in march 17, 2018+. 33 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.14 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article knowledge and attitude of pregnant women towards antenatal exercise in erbil city abstract introduction exercise is essential for pregnant women’s health and wellbeing.it is a safe and effective way to gain many physical and mental health benefits,pregnancy is a good time to develop healthy lifestyle habits including regular exercise and good nutrition [1,2,3,4,5]. improving the quantity and quality of information related to physical exercise has the potential to correct background and objective: antenatal exercises provide many health benefits not only to pregnant mothers, but also to the fetuses. in the absence of medical or obstetrical complications, pregnant women are encouraged to continue and maintain active lifestyles during their pregnancies. the objective of this study is to assess knowledge and attitude of pregnant women towards antenatal exercises. methods: a descriptive cross -sectional study was conducted to assess mother's knowledge and attitudes regarding exercise during pregnancy. the convenience sample of the study included 100 pregnant women. the study was conducted in najdi heydari health care center in erbil city / kurdistan region / iraq from december 2016 to feb, 2017. data were collected by interview with the pregnant women. a questionnaire was constructed to collect the data by researchers. a statistical package for social science (spss, version20) was used for data analysis the data. all statistical procedures were tested on a probability of p-value was ≤ 0.05 significant. results: the majority of the study sample had poor overall knowledge regarding antenatal exercises (93%), interest in attending antenatal exercise classes 80%, the barrier to attend antenatal exercise 79% during pregnancy. there was very highly significant relationship between the pregnant women’s educational level and overall knowledge regarding exercise during pregnancy. conclusion: the knowledge of women about exercise during pregnancy was less than average and women do not believe in the positive effect of exercises during pregnancy. the main reason for poor knowledge was inadequate antenatal exercise education. it is recommended that the apply antenatal exercise education teaching program is important to increase pregnant women’s knowledge regarding to exercise during pregnancy and change their believe regarding antenatal exercises. key words: pregnancy, antenatal exercises, knowledge, attitude, assessment warda hassan abdullah; department of midwifery, college of nursing, hawler medical university, erbil, iraq. (correspondence: warda.abdullah@hmu.edu.krd) badia mohammed najib; department of midwifery, college of nursing, hawler medical university, erbil, iraq. 108 erbil journal of nursing & midwifery received: 30/11/2018 accepted: 27/8/2019 published: 30/11/2019 mailto:mailtowarda.abdullah@hmu.edu.krd https://doi.org/10.15218/ejnm.2019.14 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article inaccurate perceptions and confer several benefits on maternal and fetal health. effective intervention strategies should focus not only on the pregnant woman but also extend to her family, friends and exercise provider [3,4]. the american college of obstetricians and gynecologists [6] and the american college of sports medicine (acsm) [7] recommend low-impact, moderate-intensity and regular exercises for pregnant women irrespective of their physical fitness level for approximately 30 minutes on most days of the week its necessary to the mother and fetus. knowledge regarding benefits and contraindications to antenatal exercise significantly influenced the attitude of the women towards exercise in pregnancy. there is sample and consistent evidence that promoting physical activity in women of reproductive age may be a promising approach for the prevention of excessive weight gain, gestational diabetes mellitus and subsequent complications suffered by children born from pregnancies [8]. therefore, providing the essential training and an emphasis on the benefits of exercise, decreases the worry of pregnant women about probable adverse effects on the fetus and also with emphasis on this fact that specific exercise during pregnancy with the preparation of the pelvic floor muscles and the abdominal, prepares the mother for the easier vaginal delivery and without damage to the fetus, also improve mothers' performance for having physical activity [8.9]. and there is some evidence showed that physical activity during pregnancy is linked with a shorten length of labor and reduce delivery complications during delivery, including a diminished need for cesarean section delivery [10,11] exercises throughout pregnancy it can shorten the duration of labor and reduce delivery complications [12, 13]. now, information shows that for many communities, activity levels are inadequate and many people have adopted a sedentary lifestyle. likewise, there is a low level of awareness about exercise during pregnancy. many previous studies indicated that information about antenatal exercise is inadequate among pregnant women [14,15,16,17]. this preliminary study assessed the pregnant women’s knowledge and attitude regarding exercise during pregnancy. for a purpose of developing a prenatal exercises program to be implemented in a group of pregnant women to find out the effect of such program on pregnancy outcome. across-sectional, descriptive study was carried out in erbil city, kurdistan region, iraq from december 1, 2016 to february 30, 2017 with a convenient sample of 100 pregnant women who attended najdi heydari health care center, kurdistan region, iraq and agreed to participate in the research. women with major psychological diseases excluded from the study. the study was approved by the ethical committee in the college of nursing, hawler medical university, registration no:8, 16/ 3/2016 and directorate of health no 13203, 25/10/2016, erbil city. the purpose of the study was explained to all subjects in the study,then informed verbal consents were taken during a researcher interview with the pregnant women.,. data were collected through interview with pregnant women. a questionnaire was constructed to collect the data by researchers, based on the recommendations of antenatal exercises by american college of obstetrics and gynecologists,2015 [6] and other literature review, which included the following variables: pregnant women demographic data, pregnant obstetrical history, knowledge of exercise during pregnancy 109 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2019.14 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article percentage (48%) of the study sample their age ranged between 20-25 years and x ± sd 28.79±5.818 and the majority (39%) of them had primary school education. in addition, the highest percentage (77%) of them were housewives and 93% of the study sample was multigravida figure 1 shows the highest percentage (93%) of the study sample had poor overall knowledge regarding antenatal exercises during pregnancy. and the last part is the pregnant women’s attitude about the possibility of the antenatal exercise class during pregnancy period. the response of the knowledge items included two answers 0 = incorrect and 1 = correct. there were 38 questions related to knowledge about exercise (7 items for types of exercise,12 items for benefits,11 items for contraindication, and finally 8 items for discontinuing of exercise during pregnancy). to measure the content validity of the tool, the questionnaire was presented through a panel of 16 experts. the split-half reliability was determined, measured through computation of pearson correlation coefficient. the correlation coefficient was (r = 0.779). data were prepared, organized and entered into the computer file; a statistical package for social science (spss, version 20) was used for data analysis the data.data were analyzed through the application of two approaches, which included: descriptive data analysis approach (mean, standard deviation, frequencies and percentage), and inferential statistical analysis. fisher exact test was used when more than 20% of the cells of the table have expected count less than 5. all statistical procedures were tested on a probability of p-value was ≤ 0.001 very highly significant (vhs), ≤ 0.01 highly significant (hs), ≤ 0.05 significant (s) >0.05 non-significant (ns). the results of the study showed that 72% of mothers attended primary health care center in the second trimester and 28% in the third trimester of pregnancy. none attended antenatal exercise class during the last pregnancy and 100% of them their activity was at level one activity (only daily activities). table 1 shows sociodemographic characteristics of 100 pregnant women. regarding age group, the highest 110 erbil journal of nursing & midwifery results table 1: demographic data of the study sample n= 100 variables f (%) age (years) ≤20 21 – 25 26 – 30 31 – 35 m ± sd (28.79±5.818) education level illiterate primary secondary institute college occupation formal employment privet employment housewife student gravida 1 2-4 ≥ 5 12 48 34 6 18 39 26 8 9 11 9 77 3 3 93 4 (12) (48) (34) (6) (18) (39) (26) (8) (9) (11) (9) (77) (3) (3) (93) (4) https://doi.org/10.15218/ejnm.2019.14 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article figure 1: distribution of the study participants by the level of knowledge regarding antenatal exercises n=100 table 2 shows that the highest percentage (94%), (94%), (94%), (93%) the respectively of the study sample had poor knowledge regarding the types, benefits, contraindications, discontinuity of exercise during pregnancy . table 3 shows that 79%, 80% of the study sample stated that the barrier to attending antenatal exercise is lack of time and family barriers respectively. table 4 indicates the relationship between the age group of the study sample with their overall knowledge regarding antenatal exercise classes during pregnancy, the results of this table show the following: there was no statistically significant relationship between the pregnant women’s age with their overall knowledge regarding exercise during pregnancy. (p< 0.557). table 5 indicates the relationship between the educational level of the study sample with pregnant women overall knowledge regarding antenatal exercise classes during pregnancy, the results of this table show the following: there was a very highly statistically significant relationship between the pregnant women’s educational level and overall knowledge regarding exercise during pregnancy, (p <0.000). 111 erbil journal of nursing & midwifery 0 20 40 60 80 100 overall knowledge of exercise during pregnancy poor fair good table 2: pregnant women’s knowledge regarding antenatal exercise among study sample n=100 variables good fair poor total f (%) f (% ) f (% ) f (%) types of exercise 3 (3) 3 (3) 94 (94) 100 (100) benefits of exercise 0 (0) 6 (6) 94 (94) 100 (100) contraindication of exercise 5 (5) 2 (2) 93 (93) 100 (100) discontinuity of exercise 3 (3) 3 (3) 94 (94) 100 (100) table 3: attitude of pregnant women towards antenatal exercises variables yes no total 100 f (%) f (%) f (%) lack of time 79 (79) 21 (21) 100 (100) harmful the mother 14 (14) 86 (86) 100 (100) harmful the fetus 14 (14) 86 (86) 100 (100) lack of money for transport 8 (8) 92 (92) 100 (100) family barriers: 80 (80) 20 (200) 100 (100) lack health services 28 (28) 72 (72) 100 (100) feels uncomfortable 2 (2) 98 (98) 100 (100) https://doi.org/10.15218/ejnm.2019.14 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article muhammad (2014) reported that 81.2% of the study sample had inadequate knowledge regarding the effect of exercise during pregnancy [17] and wijesiriwardana & gunawardena (2015) showed the majority of their study sample had poor knowledge concerning antenatal exercise [16]. pregnant women that involved in this study had poor knowledge about types of antenatal exercises such as walking, leg raising, pelvic floor, and yoga, these results are inconsistent with a study carried out by chidozie et al. (2014), reported that most of the women had knowledge of pelvic floor exercise, muscle strengthening exercise, and relaxation and breathing exercise as types of antenatal exercises [19]. knowledge was inadequate concerning benefits of exercise among the study sample as (6%) of them stated it reduces the risk of back pain, prevents excessive weight gain. this shows that pregnant 112 erbil journal of nursing & midwifery *fisher-exact test was applied antenatal exercises improve maternal and fetal health and enhance normal delivery. prenatal exercise is neglected in the kurdistan region community. the antenatal exercise program is not conducted in primary health care centers. the results of the present study showed that the activity level of all study samples is at level one activity which means only daily activity. and that might due to the attitudes of a community about exercise in general and during pregnancy specifically. the study showed that knowledge of study sample was very poor as the majority of them had poor overall knowledge and information concerning antenatal exercise, as such services are not available for pregnant women in the government agencies. these results are consistent with the findings of another study table 4: relationship between age groups of the study sample with pregnant women’s overall knowledge regarding antenatal exercises classes n=100 table 5: relationship between the educational level of the study sample with pregnant women’s knowledge regarding antenatal exercise class n=100 variables illiterate f (%) primary f (%) secondary f (%) institute & college f (%) total f (%) p-value good fair poor 0 (0) 0 (0) 18(18) 0 (0) 1(1) 31(31) 0 (0) 0 (0) 26 (26) 0 (0) 6 (6) 11(11) 0(0) 7(7) 93(93) .0..0> total 18 (18) 32(32) 26(26) 17(17) 100(100) discussion variables <20 20 – 25 26 30 31 – 35 total p-value f (%) f (%) f (%) f (%) f (%) good fair poor 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 3 (3) 1 (1) 7 (7) 0. 577 12 (12) 45 (45) 31 (31) 5 (5) 93 (93) total 12 (12) 45 (45) 3 4 (34) 6 (6) 100 (100) https://doi.org/10.15218/ejnm.2019.14 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article knowledge about antenatal exercises. these results supported by a study done by chidozie et al (2014) stated most of the women believe that antenatal exercise reduces the risk of back pain and prevents excessive weight gain [19]. regarding contraindication to antenatal exercise, women in this study had poor knowledge as only (5%) of them stated that vaginal bleeding, uterine contractions, difficulty in breathing, and presence of back pain during pregnancy are contraindications to exercise during pregnancy. these results are in agreement with the recommendations of the american college of obstetrician and gynecologists (2015) and sujindra et al (2015) [6, 20].another appealing finding in this study is that they had poor knowledge also regarding discontinuity of exercise the small percentage of them mentioned the following factors for discontinuity exercise during pregnancy: vaginal bleeding, regular painful contraction, and amniotic fluid leakage, these factors are reported as well by american college of obstetrician and gynecologists as a guideline to discontinue exercises during pregnancy [6]. the majority of study participants mentioned that exercise is possible during pregnancy. this emphasizes that women are interested to be involved in the antenatal exercise, therefore, it needs to incorporate exercise in prenatal care by health care providers. this result agrees with a study conducted by watson et al. (2015) and lovenson et al. (2015), that mentioned 78% of women agreed that most women can continue their regular exercise during pregnancy [18, 21].women were asked about their interest of involvements in antenatal exercise classes. in this study, 80% of pregnant women agreed to attend antenatal exercise classes these results are encouraging to include antenatal exercise in the education program of pregnant women. the majority of study sample stated the following limitations for attending prenatal exercises lack time 79%, family barriers and childcare activities 80%. these results are consistent with a study conducted by khatri et al. (2014), mentioned that most of the study sample they can attend an antenatal education program once weekly for half an hour [22]. regarding the association between the age of pregnant women and overall knowledge related to exercise during pregnancy was not statistically significant, these results are consistent with findings of other studies, which showed that no statistically significant association between age of pregnant women’s and overall knowledge [15,16,17]. there was a significant relationship between the level of education and pregnant women’s overall exercises knowledge during pregnancy this results is agree with the findings of loveness et al (in 2014), which reported that were significant associations between adequate knowledge of physical exercise during pregnancy and their education level [21] and also is in agreement with study conducted by atiya & muhammad in 2014 , who showed that level of knowledge about exercise increase with increasing level of education [22]. chidozie et al. (2015) reported that there was a statistically significant relationship between the level of education and women overall knowledge exercises during pregnancy [1]. women’s knowledge about exercise during pregnancy was less than average and women’s responses indicate that they do not believe in the positive effect of exercises during pregnancy. the main reason for poor knowledge was inadequate antenatal exercise education. it is recommended that the antenatal exercise educationteaching program is important to increase pregnant women’s knowledge regarding to 113 erbil journal of nursing & midwifery conclusion https://doi.org/10.15218/ejnm.2019.14 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article exercise during pregnancy and to change their beliefs regarding antenatal exercise. the authors are thankful for the staff at najdi heydari health care center. maternity and rizgary teaching hospitals, erbil city, iraq. my warmest thanks and wish for health go to the sample who participated in this study. there is no conflict of interest and sources of financial support for any of the authors. [1] chidozie em, olubukayomi ea, taofeek oa, funmilola af, monisola oo, abiola oo, et al. practice and pattern of antenatal and postnatal exercise among nigerian women. international journal of women’s health and reproduction sciences.2015;3(2): 93–98. [2] clarke pe, gross h. women’s behaviour, beliefs and information sources about physical exercise in pregnancy. journal. midwifery. 2004; (20):133–141 [3] connolly ch p, feltz dl, pivarnik jm. overcoming barriers to physical activity during pregnancy and the postpartum period. the potential impact of social support: national academy of kinesiology. 2014; 3: 135-148. http://dx.doi.org/10.1123/kr.2013-0009 [4] katy k, natasha l, hezelgrave b, andrew h sh. exercise in pregnancy. royal college of obstetricians and gynaecologists. 2015 doi: 10.1111/tog. 12228 [5] moyer c, jeffrey l, xiangming f, linda e. influence of exercise mode on pregnancy outcomes: enhanced by mom project. bmc pregnancy and childbirth. 2015; 15:133 [6] physical activity and exercise during pregnancy and the postpartum period. the american college of obstetricians and gynecologists-women's health care physician. obstet gynecology .2015;126: 135-42 114 erbil journal of nursing & midwifery acknowledgements conflict of interests references [7] american college of sports medicine. guidelines for exercise testing and prescription.7th edit. lippincott williams & wilkins., 2006, philadelphia, pp.(194-226). [8] maryam r, habibeh m, parichehr k, maryam m. effects of education on exercise (physical activity) performance of pregnant women. international journal of medical research & health sciences. 2015; 12:142146. [9] prather h, spitznagle t, hunt d. benefits of exercise during pregnancy. pm&rj. 2012; vol.4, 11, source: pubmed [10] marit l. b, anna m s-riz. exercise during pregnancy and cesarean delivery. pmc. 2012; 36 (3): 200–207. [11] moyer c, may l. influence of exercise mode of maternal, fetal, and neonatal health outcomes cite. medical journal obstetrics gynecology. 2014;2 (2): 1036. [12] price b. b, amini s, kappeler k. exercise in pregnancy: effect on fitness and obstetric outcomes-a randomized trial. medicine & science in sports & exercise. 2012; 44 (12): 2263-2269. [13] haakstad, la., bo k. exercise in pregnant women and birth weight: a randomized controlled trial. bmc pregnancy and childbirth. 2011; 11:66 [14] rachana n, lizanne p, vijaya kk, amitesh n, suchitra th, prasanna m p. knowledge, perception, and attitude of pregnant women towards the role of physical therapy in antenatal care: journal of health and allied sciences. 2015; vol 14, 4 [15] rachana n, simeen v, chetna g, vijaya k, amitsh n, suchitra th. awareness of antenatal exercise among pregnant woman in tertiary care center, mangalore, india. jamscr. 2015; 3 (2): 243-247 [16] wijesiriwardana ws, gunawardena ns. knowledge, attitudes and practices regarding antenatal exercises among pregnant mothers attending de soyza maternity hospital colombo. journal of obstetrics and gynaecology. 2015;37(4): 65–71 [17] atiya km, muhammad ra. assessment of knowledge and belief of pregnant women attending maternal and child care unit in primary health center of sulaimani city regarding exercise during pregnancy. kirkuk university journal /scientific studies (kujss). 2014; 10; 1: 158-172 https://doi.org/10.15218/ejnm.2019.14 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article [18] watson e d, oddie b, constantinou d. exercise during pregnancy: knowledge and beliefs of medical practitioners in south africa: a survey study. bmc pregnancy and childbirth. 2015; doi 10.1186/s12884-015-0690-1 [19] chidozie em, olubukayomi ea, adebanjo ba, olujide oa, olumide od, olabisi aa. knowledge and attitude of nigerian pregnant women towards antenatal exercise: a crosssectional survey. isrn obstetrics and gynecology. volume, 2014, article id 260539,8pages,http:// dx.doi.org/10.1155/2014/260539 [20] sujindra e, bupathy a, suganya a, praveena r. knowledge, attitude, and practice of exercise during pregnancy among antenatal mothers. international journal of educational and psychological researches. 2015; vol 1; issue 3 [21] loveness an, esther mn, hastings s. exercise practice among women attending antenatal care at the university teaching hospital in lusaka, zambia. science journal of public health. 2015; 3(3): 361-365 [22] khatri ak, sirohi s, dixit s, rai s, pandey d, effect of antenatal exercise on outcome of labor. national journal of community medicine. 2014; vol 5, iss 3 115 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2018.02 ejnm, vol. 1, no. (1), may, 2018 original article lifestyle behaviors among nursing students in hawler medical university abstract introduction the importance of proper nutrition and physical activity in reducing rates of disease and death from chronic diseases has been well established. poor diet and physical inactivity cause deaths per year and are major contributors to disabilities that result from diabetes, obesity, and stroke. drug abuse is a more intense and often misuse of drugs may cause addiction. the focus of health promotion and lifestyle are on changing patterns of behavior to promote health rather than simply to avoid illness. health promotion involves focusing on persons and populations as a whole and diseases. many factors affect health and these factors are integrated into an individual's lifestyle *1+. tobacco smoking, diet, and physical exercise are key aspects of lifestyle that influence the risk for the major diseases of rich societies such as cancer and coronary heart disease. lifestyles and health beliefs appear to be established early in life, setting the pattern for later years *2+. the major determinants of health are socioeconomic factors, lifestyle factors and the physical environment. lifestyle-related risk factors that were acknowledged in health report of the who included unhealthy nutrition, physical background and objective: the importance of proper nutrition and physical activity in reducing rates of disease and death from chronic diseases has been well established. poor diet and physical inactivity cause deaths and are major contributors to disabilities that result from diabetes, obesity, and stroke. drug abuse is a more intense and misuse of drugs can result in addiction. the objectives of this study were to identify lifestyle behaviors among students and to find out association between their lifestyles and some variables (sex, stage, and body mass index) in the college of nursing in erbil city. methods: a descriptive, cross sectional study was conducted on 100 students from four stages in the college of nursing (25 students from each stage) during the period december 2016 to april 2017. a questionnaire was composed of two parts, socio-demographic characteristics and questions related to lifestyle behaviors (three domains) among students in the college. frequency, percentage and chi-square test was used for interpretation of data. results: most of the study sample was aged between 18 and 24 years old from urban areas. near half of them was female and the highest percentage had normal weight based on body mass index assessment tool. there is a non-significant association between lifestyle behaviors and sex among the study sample (p-value 0.312, 0.346 and 0.385 respectively) and with body mass index in activity and nutrition (p-value 0.885 and 0.060 respectively). conclusion: most of the students sometimes practicing the different types of physical activities and exercises, while never abused of substances with sometimes eating more than usual of red meat, salt, and fatty foods. . keywords: lifestyle behaviors; activity domain; habit. kareem fattah azeez; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: kareem.fattah@nur.hmu.edu.krd) 10 erbil journal of nursing & midwifery received: 2/9/2017 accepted: 25/10/2017 published: 5/5/2018 https://doi.org/10.15218/ejnm.2018.02 ejnm, vol. 1, no. (1), may, 2018 original article inactivity, tobacco use and the use of alcohol and illicit drugs *3+. health-related behavior in early life influences later risks for lifestyle-related disorders. it is therefore important to investigate health behaviors among young people. university students represent a major segment of the young adult population *3+. the promotion of general health and wellbeing *4+. a healthy lifestyle consists of accepting personal responsibility for one’s own health, selffulfillment, health screenings, stress management, healthy diet and regular exercise *5+. previous studies have suggested that lifestyle choices may account for as much as 50% of preventable deaths; lifestyle factors during childhood, adolescence, and adulthood are major factors in human disease *6+. behavior patterns are typically established during adolescence instruction of children and adolescents in health consciousness is more effective than alteration of adult behavior patterns. the extent to which, living conditions, and harmful occupational environments affect the establishment of a healthy lifestyle remains unknown *7+. the objective of the study was to identify lifestyle behaviors among students and identify association between their lifestyles and some variables (sex and of the students) in the college of nursing in erbil city. a descriptive cross sectional study was conducted on 100 students in different years at the college of nursing/hawler medical university from 25 december 2016 to 1 april 2017, in erbil city. data were collected through direct interviews with students. a questionnaire format was used for data collection which composed of two parts: part one included demographic characteristics and part two included questions related to three main categories lifestyle behaviors of the activities (walking, swimming, cycling, and running with regular weekly exercise), substance abuse (smoking, alcohol drinking, and illegal drugs), and nutrition (red meat, salt, and fatty foods). the students responded to the part two through three response options: never, sometimes, and always. regarding ethical consideration the permission was taken from ethical committee of the college before beginning the research process. informed consent was obtained from students and they were free to accept or reject the participation. the data were analyzed using spss program version 23. frequency, percentage, chi-square, and fisher’s exact tests were used. table 1 shows the demographic characteristics of the study participants. most of the study sample was aged between 18 and 24 years old (95%), were from urban areas (64%). nearly half of them were female (51%) and the majority were of normal weight (72%), while only 23% of the participants were overweight and obese based on body mass index assessment tool. regarding the life style behaviors of study sample, which are presented in table 2, the researcher assessed the three main domains of activity, substance abuse, and nutrition. most of the study sample sometimes practicing the different types of physical activities and exercises like walking, swimming, cycling, and running with regular weekly exercise (80%) while most had never abused of substances such as cigarettes, alcohol, and illegal drugs (98%). more than half of the study sample indicated that they sometimes ate more than a usual amount of red meat, salt, and fatty foods (62%). methods 11 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2018.02 ejnm, vol. 1, no. (1), may, 2018 original article female, while most of them had normal bmi. these results agreed with results of the study done by sauter who found that most of study sample had normal bmi *8+. majority of the students practiced physical activities so this was agreed with results findings of spear and kulbok, which found that majority of study sample practice healthy lifestyles *7+. regarding the domain of drug abuse, most of the students reported never practicing this habit, which agreed with results of the study of mamand and aldosky who found that the number of drug abusers in kurdistan region were less than other country, and that this was related to cultures, social factors and other traditional habits in the kurdistan region. culture is one factor may affect the habit or behaviors *9+. regarding nutrition domain most of the students responded by sometimes that means majority of them practiced nutrition habit not properly and these findings agreed were with the study of bryan et al who found that college students not practiced proper habit regarding nutrition domain *10+. the other results of the study indicate that there was no significant association between sex and three domains of lifestyles, and this finding disagreed with the study of li et al, which revealed that there was significant association between sex and lifestyles behaviors *11+. the findings of the study indicate that there was a significant association between student's year in school and activity domain while there was significant association between bmi and abuse domain so this finding was table 1: demographic characteristics of the study sample table 3 presented the non-significant association between lifestyle behaviors and sex among the study sample (p-value 0.312, 0.346 and 0.385 respectively). in association between body mass index and lifestyle behavior domains in table 4, there is only substance abuse has a significant association with body mass index (bmi) (p-value 0.013) while activity and nutrition had a non-significant association (p-value 0.885 and 0.060 respectively). the study revealed that the majority of the cohort were from a city center and 12 discussion erbil journal of nursing & midwifery lifestyle behaviors never sometimes always total f (%) f (%) f (%) f (%) activity domain 19 (19) 80 (80) 1 (1) 100 (100) abuse domain 98 (98) 1 (1) 1 (1) 100 (100) nutrition domain 13 (13) 62 (62) 25 (25) 100 (100) table 2: lifestyle behaviors (three domains) demographic characteristics f (%) age group (years) 18-24 95 (95) 25-31 5 (5) living location urban 64 (64) rural 17 (17) suburban 19 (19) sex male 49 (49) female 51 (51) body mass index (kg/m²) underweight < 18.5 5 (5) normal weight 18.5-24.9 72 (72) overweight 25 -29.9 17 (17) obesity ≥ 30 6 (6) https://doi.org/10.15218/ejnm.2018.02 ejnm, vol. 1, no. (1), may, 2018 original article agreed with study of barry and petry who revealed that there was a significant association between bmi and abuse domain *12+. the majority of students reported sometimes practicing physical activities and exercises, they never abused substances, and sometimes reported eating more than usual amount of red meat, salt, and fatty foods. the author reports no conflicts of interest. 13 table 3: association between lifestyle behaviors and sex table 4: association between bmi and lifestyle behaviors erbil journal of nursing & midwifery sex lifestyle behaviors male female p-value f (%) f (%) activity domain never 7 (36.8) 12 (63.2) 0.312 ns sometimes 41 (51.2) 39 (48.8) always 1 (100) 0 (0) abuse domain never 47 (48) 51 (52) 0.346 ns sometimes 1 (100) 0 (0) always 1 (100) 0 (0) nutrition domain never 5 (38.5) 8 (61.5) 0.385 ns sometimes 29 (46.8) 33 (53.2) always 15 (60) 10 (40) bmi life style behaviors underweight normal overweight obesity p-value f (%) f (%) f (%) f (%) activity domain never 0 (0) 13 (68.4) 4 (21.1) 2 (10.5) 0.855 ns sometimes 5 (6.3) 58 (72.5) 13 (16.3) 4 (5) always 0 (0) 1 (100) 0 (0) 0 (0) abuse domain never 5 (5.1) 71 (72.4) 17 (17.3) 5 (5.1) 0.013 s sometimes 0 (0) 1 (100) 0 (0) 0 (0) always 0 (0) 1 (100) 0 (0) 0 (0) nutrition domain never 0 (0) 12 (92.3) 1 (7.7) 0 (0) 0.060 ns sometimes 2 (3.2) 45 (72.6) 13 (21) 2 (3.2) always 3 (12) 15 (60) 3 (12) 4 (16) conclussion conflicts of interest https://doi.org/10.15218/ejnm.2018.02 ejnm, vol. 1, no. (1), may, 2018 original article references the author would like to thank all participants and all staff and students who participated in conducting the study. *1+ smith c, maurer f. community health nursing; theory and practice. 2nd ed. w.b. saunders company: philadelphia; 2010. *2+ steptoe a, wardle j, cui w, bellisle f, zotti am, baranyai r et al. trends in smoking, diet, physical exercise, and attitudes toward health in european university students from 13 countries. 2010; 35 (2): 97–104. *3+ the european health report 2010. copenhagen, who regional office for europe, 2010 (european series, no. 97). *4+ paredes-lópez o, cervantes-ceja ml, vigna-pérez m, hernández-pérez t. berries: improving human health and healthy aging, and promoting quality life—a review. plant foods for human nutrition. 2010 sep 1;65 (3):299-308. *5+ buranatrevedh s, sweatsriskul p. model development for health promotion and control of agricultural occupational health hazards and accidents in pathumthani, thailand. industrial health. 2005;43(4):669-76. *6+fish c. health promotion needs of students in a college environment. public health nursing. 1996 apr 1;13 (2):104-11. *7+ spear hj, kulbok pa. adolescent health behaviors and related factors: a review. public health nursing. 2001 jan 1;18(2):82-93. *8+ sauter sl. integrative approaches to safeguarding the health and safety of workers. industrial health. 2013;51(6):559-61. *9+ who. regional office for europe fact shit report. alcohol: why .pay attention to this issue during adolescence 2012. available from http// www.euro.who.int/en/home. *10+ bryan s, parasher r, cahil t, zipp pg. yoga, mindful eating, and weight management. journal of nutritional therapeutics. 2013 dec 30;2(4):173-81. *11+ li s, huang h, cai y, xu g, huang f, shen x. characteristics and determinants of sexual behavior among adolescents of migrant workers in shangai (china). bmc public health. 2009 jun 19;9(1):195. *12+ barry d, petry nm. associations between body mass index and substance use disorders differ by gender: results from the national epidemiologic survey on alcohol and related conditions. addictive behaviors. 2009 jan 31;34(1):51-60. 14 acknowledgement erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.01 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article risk factors associated with early and late-onset of neonatal sepsis in duhok city abstract introduction neonatal sepsis refers to bacterial, fungal, protozoan infections or any viral pathogen instantly after the delivery[1]. neonatal inflammation indicates to the infections of newborns through the first-month of existence, surrounding infections in the eyes, mouth, skin, and the umbilicus.. the mostly ways of newborn infections are during the broken skin in the umbilical cord [1,2]. early neonatal period refers to the first seven days of newborn’s life, while the late neonatal period means the period from after seven days to 28 days of life. [2]. maternal sepsis is the main factor leading to death of newborns with prevalence one from ten deaths. for more than 95% of maternal deaths are associated to maternal infections which happens in the societies where incomes are low. [3]. one million newborn deaths are related with backgrounds and objectives: neonatal sepsis refers to bacterial, fungal, protozoan infections or any viral agents or pathogens which inter to the newborns blood stream after the birth. neonatal sepsis is the main reason of deaths in non-developed countries. there is an overall prevalence of 54.67% in iraq. the present study intends to explore the demographic and clinical affecting factors of early and late onset of neonatal sepsis of a sample population in duhok city. the predictors of neonatal sepsis diagnosis were determined accordingly. methods: this cross-sectional study shows 110 neonates who were diagnosed with early or late onset of neonatal sepsis. a pediatrician diagnosed the patients through physical and clinical assessment. results: the prevalence of early and late onset of neonatal sepsis was 52.73% and 47.7%, respectively. the apgar scores of less than seven and more than seven were risk factors for early and late-onset of neonatal sepsis, prolonged rupture of the membranes greater than18 hours and multiple gestations are common in patients with early onset of neonatal sepsis. conclusions: the study showed that the early onset of neonatal sepsis or late-onset of neonatal sepsis was associated with apgar score and prolonged rupture of the membranes. keywords: early onset of neonatal sepsis; late-onset of neonatal sepsis; risk factors delshad abdallah mohamed; department of nursing, college of nursing, university of duhok, duhok, iraq. )correspondence: dilshad_msc14@yahoo.com) salah abdulkareem ibrahim; department of pediatric, college of medicine, university of duhok, duhok, iraq. sherzad khudeida suleman; community health and pediatric unit, college of nursing, university of duhok, duhok, iraq. 1 erbil journal of nursing & midwifery received: 25/3/2019 accepted: 17/9/2019 published: 30/5/2020 mailto:dilshad_msc14@yahoo.com https://doi.org/10.15218/ejnm.2020.01 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article maternal infection every year [4].reduction in the neonate and child mortality is a significant world goal to achieve health for all. during the last quarter of the century, the emphasis has paid to the reduction in under-five childhood mortality largely through vaccination, oral rehydration therapy (ors), and control of respiratory tract infections. while, this changes did not have marked influence among neonates leading to converting of infant mortality at an any age [5].in developing countries newborn infection is considered a common reason of neonatal morbidity and mortality [6]. insufficient care and inappropriate pregnancy treatment, including a lack of hygiene during the obstetric and delivery, contributes to the poor care of neonates. [5-6].it’s evaluated that three million newborns and 1.2 million children complain from sepsis globally. [7]. neonatal sepsis in kurdistan and iraq a study conducted in three hospitals in baghdad to identify the leading microorganism of bacteria and viruses, as well the qualification factors studied 150 weakened and sensitive newborns, among sensitive newborns, the incidence of newborn infection it was 54.67% [8]. immature newborn, weakness, inflammation of urinary and reproductive system of mothers, and cesarean section delivery, leads to predispose, newborns neonatal sepsis [8-9]. in early and late onset of neonatal sepsis, staphylococci were the predominant pathogen in both eos and los sepsis. while a large rate of this pathogen was coagulasenegative in lons. generally gram-positive bacteria have the most frequent level rather than positive bacteria, whereas fungi and toxoplasma showed no significant effect or fewer roles in neonatal sepsis among newborns in iraqi community. to avoid increasing the percentage of deaths among neonates we should taking in account the early detection and diagnosis of the microbes as soon as possible. [9-11] a study conducted in duhok reported that 25.39% of the neonates diagnosed with neonatal sepsis, including 61.9% in patients their age less than7 days [9].in another study conducted in erbil city, 425 newborn patients were diagnosed with neonatal infections, including 53% in ages less than seven days and 47% in patients between seven and 28 days. [10] the purpose of this study was to discover the demographic and clinical risk factors of early and late neonatal sepsis in a sample population in duhok city. also, the predictors of early and late-onset of neonatal sepsis diagnosis were considered in this study. this cross-sectional study targeted patients attending the out-patient clinic of a pediatric hospital were consecutively screened for diagnostic criteria of different types of neonatal sepsis. the patients who were recruited in a purposive way from the neonatal intensive care unit (nicu) of heevi pediatric hospital in duhok between 1st february 2018 and 27th december 2018. the newborns who were involved in this study were the neonates diagnosed with clinical futures of newborn infections in early or late stage of neonatal infection in duhok city. the investigators attempted to include all cases who attended the hospital between the mentioned time periods. the following patients were included in the study: male or female, aged from birth to 28 days, diagnosed with early or late onset of neonatal sepsis, admitted to the hospital. the patients whose parents did not accepted to participation were excluded from the study. also, the patients who had other medical conditions were not included in the study. 2 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2020.01 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article the program that which used to calculate our data were performed in spss (statistical package for social sciences) version 25. the ethical approval of the present investigation was obtained from the scientific research davison of duhok general directorate of health on 20/06/2017. the verbal consent was taken from all mothers before data collection, and the guarantee was given for the confidentiality of their personal i information. of the total 110 patients diagnosed with neonatal sepsis and included in the study, the prevalence of eons and lons were 52.73% and 47.7%, respectively. the research did not discovered an important difference in gender distribution (p= 0.345), maternal age (38.5% between 31 and 40 years in eons and 43.1% between 21 and 30 years in lons; p=0.387), education level of mothers (p=0.407) between mother of neonates infected by enos and lnos. moreover, the study doesn’t shows large differences in gestational age of the mother between two groups of the study (55.8% between 37 and 42 weeks in eons and 53.4% in lons; p=0.367), see table 1. the multiple gestations in eons and lons were 59.6% and 48.3%, respectively, with no significant difference (p=0.234). also, the study did not report the considerable difference in the mode of delivery (44.2% by cesarean section in enos and 55.2% in lnos; p=0.252) and twin gestation (p=0.938), see table 1. baseline information was collected through self-reported by mothers and included information of newborn and parents such as age, gender, education, gestational age, and mode of delivery. the discovering of newborn infection or sepsis was established by the pediatrician, and according to the following clinical criteria, temperature instability; account of heart-bit (180 bit/ minute, or 100 bit/minute; the rate of respiration more than 60 breaths/min, desaturations; lethargy/altered mental status; glucose intolerance (plasma glucose >10 mmol/liter); feed intolerance. [11]. leukocytosis (wbc count >34000×109/l); leukopenia (wbc count <5000×109/l); immature neutrophils >10%; premature: the rate of total neutrophil >0.2; thrombocytopenia <100000× 109/l; crp (c reactive protein) >10 mg/l or 2 sd (sta. deviation) above normal value; procalcitonin >8.1 mg/dl or 2 sd above normal value; il-6 or il-8 >70 g/ml. [11,13] the apgar score is a method of newborn health assessment against infant mortality. which is calculated based on score of where 1 to 10 scores. where high point indicate the baby’s health status is good. appearance (skin color); pulse (heart rate), grimace response (reflexes), activity (muscle tone), respiration are included as indicators [12]. preterm premature rupture of membranes is defined as occurring prior to 37 week’s gestation when the amniotic fluid is leaking prior to exit the baby out of the mother’s vagina due to tearing of the membrane in more than 24 hours [13]. the difference between general and clinical characteristics of the patients diagnosed with early neonatal sepsis was examined through chi-square and fishers’ exact test. besides, the predictors of neonatal sepsis (early and late) were examined through univariate analysis of variance. the null hypothesis was rejected in a p-value of equal or less than 0.05. 3 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2020.01 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 4 erbil journal of nursing & midwifery table 1: general characteristics between patients in early and late onset of neonatal sepsis general characteristics (n=110) early onset (n=52, 47.27%) late onset (n=58, 52.73%) p-value (two-sided) gender of infant male female 28 (53.8) 24 (46.2) 26 (44.8) 32 (55.2) 0.345* maternal age of mother < 20 year 21-30 years old 31-40 years old > 40 year 13 (25) 18 (34.6) 20 (38.5) 1 (1.9) 9 (15.5) 25 (43.1) 24 (41.4) 0 (0) 0.387** educational status of mother none primary secondary tertiary 15 (28.8) 14 (26.9) 12 (23.1) 11 (21.2) 12 (20.7) 13 (22.4) 22 (37.9) 11 (19) 0.407* gestational age of mother <37 weeks 37-42 w >42 weeks 21 (40.4) 29 (55.8) 2 (3.8) 27 (46.6) 31 (53.4) 0 (0) 0.367** multiple gestations yes no 31 (59.6) 21 (40.4) 28 (48.3) 30 (51.7) 0.234* mode of delivery vaginal delivery cesarean section 29 (55.8) 23 (44.2) 26 (44.8) 32 (55.2) 0.252* twin gestation yes no 14 (26.9) 38 (73.1) 16 (27.6) 42 (72.4) 0.938* *chi-square and **fishers’ exact tests were performed for statistical analyses. the numbers are in frequency (percentage). https://doi.org/10.15218/ejnm.2020.01 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 5 erbil journal of nursing & midwifery table 2 showed that there is no relationship between enos and lnos study groups in maternal fever (p=0.763), maternal group b streptococcal colonization, uti (p=0.792), prematurity rupture of membrane before the onset of labor (p=0.488), foul-smelling liquor (p=0.103), birth weight (p=0.170), resuscitation at birth (p=0.603), fetal tachycardia (p=0.365), fetal abnormalities (p=0.314), invasive procedures (p=0.899), hand washing (p=0.994) and prom (p=0.047), see table 2. whereas the majority of the patients with eons had apgar score less than 7 (71.2%) compared to the majority with apgar, score of more than 7 (63.8%) in lons (p=<0.0001). meconium-stained amniotic fluid was more prevalent in enos; 75.0% compared to 56.9%, respectively (p=0.046), see table 2. table 2: comparison of clinical characteristics between patients with early and lateonset of neonatal sepsis general characteristics early-onset (n=52) late-onset (n=58) p-value (two-sided) prolonged rupture of the membranes* (4.56)46 (6454)72 05062 maternal fever (..55)72 (.554)46 05244 maternal group b streptococcal colonization, uti** (.254)43 (4753)44 05227 prematurity rupture of membrane before the onset of labor. (435.)7 (..57)47 05655 foul smelling liquor (5.56)46 (.0)72 05304 apgar score (1min) <than7 >than 7 (2357)42 (7555)3. (4457)73 (4455)42 <050003 birth weight <than 2.5 kg ≥than 2.5 kg (2357)42 (7555)3. (.554)46 (6356)76 05320 resuscitation at birth (445.)44 (.554)46 05404 meconium-stained amniotic fluid (2.50)42 (.452)44 05064 fetal tachycardia (.0)74 (.554)46 0544. fetal abnormalities (7453)37 (3.5.)2 05436 inadequate hand washing (4254)4. (4257)42 05226 invasive procedures (2056)62 (5252).7 05522 chi-square was performed for all statistical analyses. the numbers are in frequency (percentage). *prom: the prolonged rupture of the membranes > 18 hrs. **uti: urinary tract infection https://doi.org/10.15218/ejnm.2020.01 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 6 erbil journal of nursing & midwifery the predictors of enos and lnos were examined in univariate analysis model in table 3. the study showed that having multiple gestations is a predictor of enos (p=0.013). also, the lower apgar score predicts enos, and higher apgar score predicts lnos. table 3: univariate analysis of variance of early and late neonatal sepsis dependent variable: early and late neonatal onset risk factors mean square f score p-value effect size gender 05324 05220 05422 05002 maternal age 05333 05.04 05422 05035 mother education 05767 35306 054.7 05045 gestational age 05706 05243 05425 05077 prolonged rupture of the membranes 05.4. 75662 05377 05075 maternal fever 05705 052.7 05447 05033 urinary tract infections 050.7 05744 05475 05004 multiple gestation 35637 456.. 05034 05023 premature rupture of membrane* 05002 05040 05544 05000 mode of delivery 05035 05053 05222 05003 foul smelling liquor 05454 35265 05320 05070 inadequate hand washing 05006 05070 05552 05000 apgar score 45754 3.500. 05000 053.7 birth weight 05043 05363 05202 05007 resuscitation at birth 05063 05355 05444 05007 meconium-stained amniotic fluid 05706 05240 05445 05033 twin gestation 05023 05636 05.77 0500. fetal tachycardia 05046 05723 05.23 05004 fetal abnormalities 0504. 05724 05.55 05006 invasive procedures 05342 05227 05457 05002 *prm: prematurity rupture of membrane before the onset of labor. https://doi.org/10.15218/ejnm.2020.01 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 7 erbil journal of nursing & midwifery in the present study the general and clinical risk factors of neonatal sepsis in a sample population of neonates were determined. in the study, gender of neonate was not determined to be a predictor of neonatal sepsis. there are contradictory reports about the dangerous of gender for neonatal sepsis [14]. sexual dimorphism from the human immune response is quite clear; female babies produce the more active of cellular immune reaction so that they are more resistant to the infection. [15]. the differences with the present study could be due to the sample size or study design. mother’s maternal age and level of education was not significantly associated with neonatal sepsis [16, 17], possibly due to the lack of mother information and experience about newborn care. prolong rapture of membrane (≥18 hours) was shown to not be associated with neonatal sepsis; other researches in other communities shows the same results to the results of our study[18, 19]. one of the most common reason of upgrade of pathogens to rise from vagina and cervical canal in to the amniotic fluid and fetal sac are easy and late tearing of the membrane as asphyxia which leading to sepsis [19, 20]. in the present study, intrapartum fever was not shown a significant influence in the newborn infection and sepsis. the newborns were delivered from mothers with high body temperature during delivery have six times higher odds of developing sepsis compared to newborns that delivered from mothers their body temperature were normal during the labor. [19, 21]. intra partum fever is an indicator of maternal infections that are frequently transmitted to the baby inside the uterus or through the delivery canal when the newborn pass through this canal, which always leading to early-onset sepsis [22, 19]. the study determined that those infants with apgar score less than seven usually are affected by eons and the infants with apgar score greater than seven affect by lnos (p<0.0001). the previous study have shown that apgar score less than seven in the first minute have a risk of 14.05 times (95% ci 5.487-35.987) to the eons occurrence. a study considered that the eons happens in newborns with apgar score less than seven in the early minutes rises 11.1 times with a significant ratio p-value 0.001 [14]. also there were a same results and it was very closed to the previous study which shows a high significant rate in neonates with apgar less than seven with p value 0.002 [23, 24]. generally there were a relationship between the apgar score in the moment of first life span of the newborn and the hydrogen potential (ph) cord blood and during delivery depression, but there was no relationship with the consequences, while the apgar score refers to the changes which happen in the infant’s health condition and the performance of resuscitation applied. [25]. several factors can cause perinatal hypoxia-ischemia, while in the consistent consequences which performed from the previous study, explained that low apgar score in the first minute may be due to the infants infection factors which happens from the perinatal period, usually a number of weeks, immediately before and after birth [24, 25].birth weight, resuscitation at birth, meconium-stained amniotic fluid, twin gestation, fetal tachycardia, fetal abnormalities, poor feeding were not found to be predisposing factors of newborn infection or sepsis in this study in disagreement with some studies in the literature review [26]. this study shows that adequate hand washing before and after clinical procedures is not discussion https://doi.org/10.15218/ejnm.2020.01 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 8 erbil journal of nursing & midwifery a significant predictor of late onset of neonatal sepsis. more than quarter of neonatal mortality is related to sepsis or infections. caregivers, mothers and nurses hygiene and hand washing with soap and detergents usually decrease neonatal sepsis and infections. a study examined the effect of plenty handwashing advancing the hand washing style and behavior of mothers. in nepal there was a significant difference between mothers who wash their hands several times rather than mothers who did not wash their hands or has washing their hand few times, and the first group were at 44% lower risk of neonatal infection and death rather than the second group [27]. in a study conducted between two groups of mothers, which shows that good handwashing with detergents and antiseptic agents were significantly increased before and after breastfeeding, feces contact among case mothers than among controls. [28] therefore, the hygiene of mothers and hand washing with detergents before and after fecal attaches were less frequent rather than the spread of this style marked among mothers of small children in developing communities, which confirms the large barriers to hand washing progressed by mothers of newborns [28].lastly, the study showed that invasive clonal procedure is not a predictor for neonatal sepsis types. in another study shows that the lumbar puncture (lp) meningitis can be the main indicator of neonatal sepsis in approximately 3% sample size; subsequently cerebrospinal fluid aspiration analysis ought to be considered in the majority of newborns with late-onset of neonatal sepsis prior using of antibiotics. [20]. when septicemia or blood infection, are shows in the positive blood culture and clinical picture, this refers to presence of eons, lp, so lp should be delayed in that cases [29] there are several blood investigations other than culture used to detect sepsis. i: t ratio, micro esr (erythrocyte sedimentation rate) [30]. strength and limitation the strong point of the present investigation must be searched in the study design as the mostly of the previous studies focused on cross-sectional design rather than a comparative design. the study was performed in one clinical setting, precluding us from generalizing the findings to other settings across the country. there was evidence in the analyzing statistics which obvious that apgar score is only a predictable factor of early and late onset of newborn sepsis. the majority of the subjects who were infected by enos had long term tearing down of the membranes longer than 18 hours, and their mothers had multiple gestations. the authors of the study would like to present their deepest thanks to the clinical staff of pediatric heevi hospital. this study was not supported financially. the authors announced that there were no conflicts of interest. the corresponding author claims that all authors of the present study had sufficient contribution to study design, review, concept, assessment, diagnosis, and analysis. conclusion acknowledgments funding conflicts of interest authorship https://doi.org/10.15218/ejnm.2020.01 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 9 erbil journal of nursing & midwifery [1] rosdahl cb, kowalski mt. textbook of basic nursing: lippincott williams & wilkins; 2008. [2] thacker n. improving status of neonatal health in india. indian acad pediatrics maulana azad medical college, dept pediatrics, new delhi, 110 002, india; 2007. [4] say l, chou d, gemmill a, tunçalp ö, moller a-b, daniels j, et al. global causes of maternal death: a who systematic analysis. the lancet global health. 2014;2(6):p: e323e33. . [6] black re, laxminarayan r, temmerman m, walker n. reproductive maternal newborn and child health: disease control priorities, third edition (volume 2).2016. [.] yoon hs, shin yj, ki m. risk factors for neonatal infections in full-term babies in south korea. yonsei medical journal.2008; 49(4):p: 530-6. [4] kulkarni m. manual of neonatology. jaypee brothers. 2000. [2] fleischmann-struzek c, goldfarb dm, schlattmann p, schlapbach lj, reinhart k, kissoon n. the global burden of paediatric and neonatal sepsis: a systematic review. the lancet respiratory medicine.2018; 6 (3):p: 223-30. [5] al-mayah qs, chalob fa, jawad ti. incidence of neonatal sepsis in a sample of iraqi newborns. pakistan journal biotechnology.2017; 14(4):p: 797-802. [2] atrushi am. the profile of neonatal sepsis in duhok city and predictors of mortality: a prospective case series study. duhok medical journal. 2018;12(2):p: 10-20. [30] shaker nz. disease patterns and outcomes of neonatal admissions at raparin pediatric teaching hospital in erbil city. nursing national iraqi specility. 2015;28(2):p: 39-46. [33] haque kn. definitions of bloodstream infection in the newborn. pediatric critical care medicine. 6(3):p: s45-s9. 2005. [37] finster m, wood m. the apgar score has survived the test of time. the journal of the american society of anesthesiologists.2005; 102(4):p: 855-7. 2005. [34] de waal k, kluckow m. prolonged rupture of membranes and pulmonary hypoplasia in very preterm infants: pathophysiology and guided treatment. the journal of pediatrics.2015; 166(5):p: 1113-20. [14] chacko b, sohi i. early onset neonatal sepsis. the indian journal of pediatrics. 2005;72(1):p: 23. [15] network n. national neonatal-perinatal database (report 2002–2003). new delhi, india: department of pediatrics, all india institute of medical sciences. 2005. [16] siakwa m, kpikpitse d, mupepi sc, semuatu m. neonatal sepsis in rural ghana: a case control study of risk factors in a birth cohort. 2014. [17] adatara p, afaya a, salia sm, afaya ra, konlan kd, agyabeng-fandoh e, et al. risk factors associated with neonatal sepsis: a case study at a specialist hospital in ghana. the scientific world journal. 2019. [35] park k. innate immunity in allergeninduced airway inflammation role of macrophage migration inhibitory factor (mif) and cholesterol 25-hydroxylase (ch25h) in alveolar macrophages: the johns hopkins university; 2011. [32] hasan m, mahmood c. predictive values of risk factors in neonatal sepsis. journal of bangladesh college of physicians and surgeons. 29(4):p: 187-95. 2012. [70] siakwa m, kpikpitse md, mohamed s. neonatal sepsis in rural ghana: a case control study of risk factors in a birth cohort. international journal of research in medical and health sciences.2014; 4(5):p: 77-88. [73] freeman mc, stocks me, cumming o, jeandron a, higgins jp, wolf j, et al. systematic review: hygiene and health: systematic review of handwashing practices worldwide and update of health effects. tropical medicine & international health.2014; 19(8):p: 906-16. [77] nili f, nayeri f, shariat m. risk factors in early onset neonatal sepsis. 2006. [74] shah g, budhathoki s, das b, mandal r. risk factors in early neonatal sepsis. kathmandu university medical journal.2006; 4 (2):p: 187-91. [76] soman m, green b, daling j. risk factors for early neonatal sepsis. american journal of epidemiology.1985; 121(5):p:712-9. [7.] cloherty jp, eichenwald ec, stark ar. manual of neonatal care: lippincott williams & wilkins; 2008. [74] bouman a, schipper m, heineman mj, faas mm. gender difference in the nonspecific and specific immune response in humans. american journal of reproductive immunology.2004;52(1):19-26. references https://doi.org/10.15218/ejnm.2020.01 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 10 erbil journal of nursing & midwifery [27] marshall je, raynor md. myles' textbook for midwives e-book: elsevier health sciences; 2014. [28] alam mm, saleem af, shaikh as, munir o, qadir m. neonatal sepsis following prolonged rupture of membranes in a tertiary care hospital in karachi, pakistan. the journal of infection in developing countries.2014; 8(01):p: 067-73. [29] kayange n, kamugisha e, mwizamholya dl, jeremiah s, mshana se. predictors of positive blood culture and deaths among neonates with suspected neonatal sepsis in a tertiary hospital, mwanza-tanzania. bmc pediatrics.2010; 10(1):p: 39. [30] polinski c. the value of the white blood cell count and differential in the prediction of neonatal sepsis. neonatal network.1996; 15(7):p: 13-23. https://doi.org/10.15218/ejnm.2019.10 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article effectiveness of health teaching on women’s knowledge and skills regarding breast self-examination in primary health centers in erbil city/iraq abstract introduction the main causes of mortality and morbidity among women in developed and developing countries are breast cancer *1+.in malaysia, there is the most common cancer among women regardless of ethnic groups and begin from age 15 onwards *2+. clinical breast examination, mammography and breast self-examination bse may help detection of breast cancer in early time. *3+. bse alone is not enough for early detection of breast cancer, but it is still an important screening tool for early detection of breast cancer in most developing countries, because it is cheap, widely available, and does not need difficult technical training *4+. practicing bse help a woman to be familiar with her normal breast structure, helps her to learn and see any abnormal changes in her breast tissue, size or shape of her breast. *5+ most studies indicated that the majority of malaysian women have not enough knowledge about breast cancer, and other research demonstrated that breast self-examination practices have a significant association with breast cancer knowledge *6+ breast cancer is the main causes of morbidity and mortality among background and objectives: breast cancer is a general term used for different types of cancers that develop from breast tissue cells. breast self-examination may help detection of breast cancer in early time. the aim of the study is to identify women’s knowledge and skills about breast self-examination. the objectives of the study was to identify the overall effectiveness of health teaching on knowledge and skills of women about breast selfexamination. methods: a quasi-experimental study was conducted on 100 women who attended to three main primary health care centers in erbil city during november 2017 to april 2018. data collection was done two times, one before teaching session and second after that through direct interview and a questionnaire format. chi-square test was used for comparing pre and post –test results of the study sample. results: regarding level of knowledge about breast self-examination the results revealed that there were three levels as: poor 28%, fair 49% and good 23%. regarding their skills about breast self-examination, the results indicated that there were three categories as poor 78%, fair 6% and good 16 %. there was significant difference between overall knowledge and skills of participants before and after teaching session. conclusion: teaching session was effective on breast self-examination knowledge and skills. public education can be developed by health policy in the region in order to breast cancer prevention and early detection. keywords: breast self-examination, knowledge, skills. kareem fattah aziz; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: kareem.fattah@nur.hmu.edu.krd) shayma sameer maqsud; department of nursing, college of nursing, hawler medical university, erbil, iraq. 78 erbil journal of nursing & midwifery received: 25/7/2018 accepted: 15/1/2019 published: 30/5/2019 mailto:kareem.fattah@nur.hmu.edu.krd https://doi.org/10.15218/ejnm.2019.10 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article women and with a high rate especially the malignancy cancer every year, nearly one million new cases of breast cancer are diagnosed worldwide. there were about 519,000 women who die from breast cancer annually and about one millions of women develop breast cancer each year and information by who, 2010 *7+. breast cancer is the second cause of death among women in the eastern mediterranean region and it is a general term used for different types of cancers that develop from breast tissue cells and also it is an uncontrolled growth of malignant tissue (uncontrolled and causes death) that arises in the breast *8+. breast self-examination is necessary for women to know any abnormality in their breast. but early breast cancer is often found on a mammogram (for women 45 years and older) before a lump can be felt. *9+. the woman’s chances of developing breast cancer increase with age, i.e. as a woman ages, her likelihood of developing breast cancer also increases. close to 80 percent of breast cancers occur in women age 45 or older. the rates of breast cancer in young women actually quite low, but they increase rapidly with advancing age state that, many patients do not realize the impact of age on risk. they often 10 overestimate or underestimate their risk of breast cancer. although breast cancer can strike both men and women, the majority of breast cancer occurs in women. less than 1% of all cases are diagnosed in men. in fact, being female is the single greatest risk factor for breast cancer. *10+ high dose radiation exposure is associated with increased breast cancer risk. *11+. clinical breast examination cbe is performed by advanced practice nurses and other healthcare providers. *12+.the first and common sign of breast cancer is often a painless lump or thickening in the breast *13+. agars and mcmurray reported that breast cancer continues to have no exact known cause or primary prevention. *14+. the rates of breast cancer in young women actually quite low, but they increase rapidly with advancing age *15+. this study aimed to assess women’s knowledge and skills about bse and to identify the overall effectiveness of health teaching contents on knowledge and skills of women about breast self-examination bse. the design of the study included a quasiexperimental study and it was conducted to evaluate the effect of teaching on knowledge and skills of women regarding bse. the sample size was included 100 women who attended to three primary health care centers in erbil city (mala fandi, nazdar bamarni and kurdistan) according to geographical area of erbil city, depending on a non-probability convenient sampling method. the study was begun from 1-nov-2017 to 1-april -2018. a questionnaire format was used for data collection which developed according massive review literature. the questionnaire was reviewed by panel of experts in nursing field for validity and according their comments the questionnaire was revised and it included three parts: part one sociodemographic data and part two questions related to knowledge on bse and part three related to skills of women about bse. data collected in two different days: first day pre-test and conducting teaching session and second day posttest done on theoretical and skills of bse. regarding ethical consideration, the approval was taken from ethical committee/college of nursing. agreement was taken from general directorate of health in erbil city. the informed consent was taken from all study sample after explaining the purpose and knowing right of withdraw during study. regarding the contents of health teaching it was focused on the importance of bse methods 79 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.10 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article percentage of the sample study was between the age of (16-30) years, the highest percentage of them graduated from secondary school, majority of them were housewife, which represented 93%, most of them were married which represented 78%, while majority of them were from urban which represented 82%, and most of them were having no history of breast cancer, half of them had more than two children while majority of them had more than two years of marriage. and breast cancer prevention and early detection as general and specifically focused on knowledge of bse and skills of performing bse. there was no any exclusion criteria just refusing to participation. the data entered in statistical package of social science (spss) version 23 and analyzed with descriptive and inferential statistics (frequency, percentage, chi-square). table 1 indicated that the highest 80 results erbil journal of nursing & midwifery table 1: socio-demographic characteristics of the sample study socio-demographic categories f % age group/ level of education occupational status. history of breast cancer. marital status years of marriage number of children residential area 16-30 47(47) 47(47) 31-45 38(38) 38(38) 46-60 15(15) 15(15) illiterate 26(26) 26(26) primary 31(31) 31(31) secondary 36(36) 36(36) bachelor 7(7) 7(7) house wife employee unskilled present not present marriage single widowed not marriage one year two years more than 2 none one two more than 2 urban suburbs rural 93(93) 5(5) 2(2) 93(93) 5(5) 2(2) 11(11) 89(89) 78(78) 19(19) 3(3) 19(19) 4(4) 14(14) 63(63) 19(19) 15(15) 14(14) 52(52) 82(82) 10 (10) 8(8) 11(11) 89(89) 78(78) 19(19) 3(3) 19(19) 4(4) 14(14) 63(63) 19(19) 15(15) 14(14) 52(52) 82(82) 10 (10) 8(8) https://doi.org/10.15218/ejnm.2019.10 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article table 2 revealed that overall knowledge of sample study was classified in to three levels as following poor level 28%, fair level 49% and good level 23% in pre-test while the capacity of knowledge for all women had improved properly to 100% in posttest, because of effectiveness of application health teaching . table 3 indicated that the skills of women about bse were classified into three levels poor 78%, fair 6% and good 16% in pretest, while in post-test the skills were improved properly to 100% because of the effectiveness of health teaching. table 4 indicated overall knowledge and skills of sample about bse. there were highly significant differences between pretest and post-test (13.9 ± 5.89, 24.9 ± 0.17) this was interpreted that teaching that was applied for them was effective on their knowledge and skills about bse. 81 table 2: overall knowledge level on bse erbil journal of nursing & midwifery table 3: overall skill level of breast self-examination bse overall knowledge pre-test post test -test f % f % poor fair good 28(28) 28(28) 0(0) 0(0) 49(49) 49(49) 0(0) 0(0) 23(23) 23(23) 100(100) 100(100) (100) (100) (100) (100) total overall practice pre-test post-test f % f % poor 78(78) 78(78) 0(0) 0(0) fair 6(6) 6(6) 0(0) 0(0) good 16 (16) 16 (16) 100(100) 100(100) total 100 100 100 100 table 4: overall knowledge and skills of bse overall knowledge ,skills pre-test post-test p-value paired t-test m ± sd m ± sd overall knowledge 13.9 ± 5.89 24.9 ± 0.17 < 0.001 vhs overall practice 2.3 ± 4.21 12.0 ± 0.001 < 0.001 vhs https://doi.org/10.15218/ejnm.2019.10 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article the results of the study indicated that sample study was classified in to three levels for each of their knowledge and skills about breast self-examination bse these findings were agreed with a study done by milat who found that mothers in jeddah had little knowledge about bse *16+. regarding overall knowledge and skills about bse , the study revealed that there were highly significant differences between pretest and post-test 13.9±5.89 pre-test , 24.9 ± 0.17post-test about their knowledge and skills, regarding breast self-examination bse the interpretation for that due to effectiveness of teaching contents that had been implemented upon women who attending to main primary health care centers in erbil city, this results were agreed with the study done by elfituri a. etal,who found that it was necessary to apply the teaching process upon women to increase their knowledge and skills about bse *17+.the results of the study was also similar to the study done by al-tawil and abdul ameer who found that lack of knowledge and skills about bse due to lack of implementation of teaching for women *18+.the findings of the study revealed that teaching program was effective to change their knowledge and skills about bse and was agreed with the study done by abdel-hadi who said that in arab countries mother’s knowledge and skills toward bse was low because of lack of teaching process *19+. the limitation of the study was sample size and refusing to participate in the teaching session. the results of the study revealed that women have poor knowledge and skills regarding bse and health teaching can improve their level of knowledge and practice. the study recommended establishing bse centers in main primary health care centers in kurdistan region for early detection and prevention from breast cancer among women as breast cancer awareness program (bcap). the authors report no conflicts of interest. the author would like to thank all women who participated in the study and thank all staff in dfprimary health care centers who helped to complete this study. *1+ loh sy, chew sl. awareness and practice of breast selfexamination among malaysian women with breast cancer. asian pacific journal of cancer prevention, vol 12(1): 2011, 199-202. *2+ national cancer registry, malaysia cancer incidence in peninsular malaysia 2003-2005. ministry of health malaysia. 2008. *3+ giridhara rb, goleen s, sharon pc, breast cancer screening among females in iran and recommendations for improved practice: a review. asian pacific journal of cancer prevention: apjcp · january 2011.no. 12(6): 1647-55. *4+ akhtari-zavare m1, juni mh, said sm, ismail i.z ,beliefs and behavior of malaysia undergraduate female students in a public university toward breast self-examination practice. asian pacific journal cancer prevention. 2013;14(1):57-61. available from: https:// www.ncbi.nlm.nih.gov/pubmed/23534796. *5+ fotedar v, seam rk, gupta mk, knowledge of risk factors and early detection methods and practices towards breast cancer among nurses in indira gandhi medical college, shimla, himachal pradesh, india. asian pacific journal of cancer prevention. 2013; 14 (1): 117-20. *6+ world health organization. breast cancer: prevention and control. available from: http://www.who.int/cancer/ detection/ breastcancer/en/index3.html. accessed 12th may 2014. 82 erbil journal of nursing & midwifery discussion conclusions conflicts of interest acknowledgements references https://doi.org/10.15218/ejnm.2019.10 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *7+ chong cc, jeya dc, balakrishnan s. perception of breast health amongst malaysian female adolescents. asian pacific journal of cancer prevention. 2014; 15(17) 75-80. *8+ world health organization cancer. retrieved on 20th april accessed in: ,http:// www.who.int/ mediacentre/factsheets/ fs297/en/, 2010. *9+ lewis, j. your guide to breast cancer. london: hodden arnold,2005. *10+ american cancer society. . cancer facts and figures. atlanta, georgia, american cancer society. accessed in: american cancer society. breast cancer facts and figures atlanta: georgia: american cancer society 2003. *11+ colditz, g. a. & stein, c. j. handbook of cancer risk assessment and prevention. sudbury, 22. massachusetts: jones and bartlett publishers. 10colditz, g. a. & stein, c. j. handbook of cancer risk assessment and prevention. sudbury, massachusetts: jones and bartlett publishers; 2004. *12+ american cancer society. cancer facts and figures 2008. atlanta, georgia: american cancer society.mason, t. e. & white, k. m. (2008). applying an extended model of the theory of planned behaviour to breast selfexamination. journal of health psychology, 2008, 13, 946-955. *13+ lewis, j. you’re guide to breast cancer. london: hodden arnold,2005. *14+ lisasummerscnm, drphmarionmccartneycnm, bsn. liability concerns: a view from the american college of nursemidwives. journal of midwifery & women's health november–december 2005, pages 531-535. *15+ colditz, g. a. & stein, c. j. handbook of cancer risk assessment and prevention. sudbury, massachusetts: jones and bartlett publishers. 2004. *16+ milaat, knowledge of female secondary school students on breast cancer and bse in jeddah, saudi arabia 2000 /6(2/3):338343.available from:http://2/32000.who.int. (accessed on 2 november 2008). *17+ elfituri,aa, elmahaish ms, and macdonquid th. role of the health education program within the libyan community . east mediterranean health journal1999. 5(2):268-72. *18+ al-tawil ng, abdul ameer aj. al-tawil wg.knowledge and practices of bse among a group of women attending some medical clinic in baghdad .iraqi postgraduate medical journal 1:279-285. 2002 *19+ abdel-hadi ms,.breast cancer awareness among health professionals. us national library of medicine national institutes of health: ann saudi medicine, 2000, 20(2):135 -6. 83 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.03 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article a comparative study of nurses knowledge, attitudes, and practices concerning fluid therapy in children in public versus private hospitals in erbil city abstract introduction in fluid therapy, circulation is restored by increasing extracellular fluid. proper functioning of cells depends greatly on water because it plays an essential role in chemical and metabolic reactions inside cells, transports nutrients to cells, removes waste from cells, and regulates body temperature. the balance between the input and output of fluids in the body is called fluid balance which helps metabolic processes function correctly[1]. acute diarrhea remains a leading cause of death among children in developing countries [2]. globally, in 2015, estimated that diarrhea was a leading cause of death among all ages (1·31 million deaths), and diarrhea was a common cause of death among children under 5 years old [3]. nurses are in charge of initiating, monitoring, and terminating fluid therapy. they also need to know and prevent complications caused by catheter inserted through a vein or resulted from background and objectives: dehydration caused by diarrhea is considered as a significant cause of morbidity and mortality among children all over the world, fluid therapy remain the most effective methods to treat dehydration. nurses are responsible for initiating, monitoring, terminating, knowing preventing and complications of intravenous fluid therapy. the main aim of the study was to compare nurses’ knowledge, attitude, and practice concerning fluid therapy in children in public versus private hospitals. methods: a comparative study design was conducted in children hospitals in erbil city. a randomized sampling technique was used for enrolling 98 nurses from three pediatric hospitals ; from three pediatric hospitals; 70 from rapareen public hospital other 28 nurses from lala and consultant medical city private hospitals. the data were collected through direct interview and analyzed through descriptive and inferential statistics (paired samples t-test) using spss 22.0. results: the results revealed that highest percentage of nurses age group were 22-28 years, 67.1% %were female in public hospital , about 34.3% and 64.3% graduated from institutes in both hospitals. there was no significant difference between the nurses sociodemographic characteristics from public hospital and private hospitals. there was a significant difference between the nurses from public hospital and private hospitals regarding their kap. the nurses from private hospital have better kap than public hospital . conclusion: knowledge, attitude, and practice of fluid therapy among nurses of rapareen public hospital were poor, while the nurses from private hospitals had an acceptable level of knowledge, attitude, and practice of fluid therapy. keywords: nurses; kap; fluid; public; private; hospital nazar ramadhan othman; department of nursing, college of nursing, hawler medical university, erbil, iraq. )correspondence: nazar.ramathan@nur.hmu.edu.krd ) abbas abdulqader ahmed; department of nursing, college of nursing, hawler medical university, erbil, iraq. 22 erbil journal of nursing & midwifery received: 22/8/2019 accepted: 13/11/2019 published: 30/5/2020 mailto:%20nazar.ramathan@nur.hmu.edu.krd https://doi.org/10.15218/ejnm.2020.03 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article intravenous fluid therapy[4.5.6].i nurses are needed to increase their knowledge and performance regarding intravenous (iv) fluid therapy to manage its possible complications and improve patient safety [7]. in this regard, errors have been reported to be made by about 39% of nurses and 36% jointly by nurses and emergency physicians. incorrect medication dose (35%), incorrect medication (30%), and fluid overload (35%) are among the most common errors[8].there has been a general tendency in the last decade toward establishing private systems in the health service; however, health services must be provided equally to all humans. research has shown how patient satisfaction with health services can be affected by a tangible realm, and that this issue needs to be paid more attention to by the public sector [9]. it is argued that in low and middle income countries more efficient, accountable, and sustainable healthcare services are provided by private sector than the public sector which tends to deliver more equitable and evidence-based care[10].according to the results of a review of 17 studies including over 5,500 hospitals across europe, public hospitals are reported to have a better economic performance than private not-forprofit (pnfp) and private for-profit (pfp) hospitals. the results of that review also showed that pnfp hospitals are better than pfp hospitals regarding their economic performance[11].research has shown that nurses in private hospitals have higher and better skills and competence than those working in public hospitals[12].the results of another study indicate that private healthcare centers deliver better care and pay more attention to patients[13].the present study was aimed at comparing knowledge, attitude, and practice needed for fluid therapy in children among nurses working in public and private hospitals in erbil city. a comparative study was carried out from january to august 2018 order to investigate and compare knowledge, attitude, and practice (kap) required for fluid therapy in children among public hospital and private hospitals in erbil, kurdistan region of iraq. researchers selected 98 nurses randomly to the study from selected hospitals with 70 nurses randomly chosen from rapareen public hospital, 14 from lala and other 14 from consultant medical city (cmc) private hospital. the study inclusion criteria were providing care to sick children admitted hospitals, both genders, having experience in caring for children of at least one year, and graduating from primary nursing schools, intermediate nursing schools, preparatory nursing schools, nursing institutes, or nursing colleges. the study exclusion criteria included nurses working in operation room and who held msc or phd in nursing. the required data were collected through observation during practice by the researcher and direct (faceto-face) interview using a questionnaire which was designed and developed by the researcher according to the international guideline of pediatric fluid therapy. it consisted of two sections: (1) the sociodemographic characteristics including personal data (age, sex, address, marital status, and years of experience) and socioeconomic data (occupation, education, and crowding index) and (2) the nurses knowledge (30 items), attitude (15 items), and practice (25 items). the content and structural validity of the questionnaire was determined initially by a panel of 15 experts from different related specialties. and its reliability was examined through the spearman -brown coefficient reliability of 10 cases which was obtained as 83.9 which is statistically adequate. moreover, a checklist for fluid therapy in children was prepared which included assessment of dehydration, 23 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2020.03 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article working in private hospital have had poor knowledge. about 47.1% and 7.1% of nurses were poor attitude in public and private hospitals respectively, 51.4% and 57.1% were fair in practice in both hospital respectively. table 3. according to the present study, there was a significant association between the nurses’ age, level of education and their knowledge on fluid therapy in both public and private hospitals 0.013, 0.041 and 0.022, 0.036 respectively. there was non significant association between nurses’ gender with their knowledge, attitude, and practice in public hospital and attitude and practice in private hospitals , moreover, there was a highly significant association between the nurses’ years of experience toward fluid therapy and their knowledge and practice and significant with their attitude in public and private hospitals. in addition, a non significant association was observed between the nurses’ type of employment and their kap regarding fluid therapy (p>0.05). status of dehydration, oral rehydration therapy, intravenous solution, method of administration (bolus), deficit, maintenance, and ongoing loss. the nurses’ knowledge consisted of 30 multiple choice questions (mcq) with 0 incorrect and 1 correct answer. the nurses’ attitude was scored using a 5-point likert scale (strongly disagree=1,disagree=2,neutral=3,agree=4, and strongly agree=5). higher scores in this section indicated higher attitude. the practice checklist was obtained from the college of nursing, hawler medical university. to score the checklist, each achieved step was given 1 and each non-achieved step 0. the nurses’ kap was rated as poor ≤50%, fair=50-75 %, good≥75%. data analysis was carried out through frequency and percentage and inferential statistics (chi square and paired samples t-test) using spss 22.0. formal permission was take from an ethical committee of the college of nursing, hawler medical university, participants and hospitals(no.86in 26/1/2017). table 1. the present study reveal 54.3% of nurses from public and 60.7% from private hospital aged 22 to 28 years old. it was observed that most of them 67.1% from public and 60.7% from private hospital were female. as for their education, 41.4% from colleges from public, while 64.3% of them graduated from institutes in private hospitals. 54.3% of the nurses had 1 to 5 years of experience in public and 67.9% of nurses from private hospital. in respect of their socioeconomic status (ses), the highest percentage 53% of nurses were from low socioeconomic class. there was non significant association between nurses socio demographical characteristics in both hospital p-value ≥0.05. table 2. this table clarifies that majority 87.1 % of nurse in public hospital have had poor knowledge while 67.9% of nurses 24 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2020.03 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 25 erbil journal of nursing & midwifery table 1: sociodemographic characteristics of the nurses sociodemographic characteristics category public hospital n=70 private hospitals n=28 p-value f (%) f (%) age group/years 22-28 38 (54.3) 17 (60.7) 0.643 ns 29-35 8 (11.4) 4 (14.3) 36-42 10 (14.3) 2 (7.1) 43-49 14 (20) 5 (17.9) gender male 23 (32.9) 11 (39.3) 0.225 ns female 47 (67.1) 17 (60.7) level of education intermediate 6 (8.6) 0 (0) 0.827 ns secondary 11 (15.7) 1 (3.6) institute 24 (34.3) 18 (64.3) college 29 (41.4) 9 (32.1) marital status married 41 (58.6) 16 (57.1) 0.702 ns single 27 (38.6) 12 (42.9) widow 2 (2.9) 0 (0) type of employments formal 55 (78.6) 0 (0) 0.080 ns contract 3 (4.3) 28 (100) volunteer 12 (17.1) 0 (0) years of experience 1-5 38 (54.3) 19 (67.9) 0.918 ns 6-10 11 (15.7) 2 (7.1) 11-15 9 (12.9) 2 (7.1) >15 12 (17.1) 5 (17.9) unit of work medical 17 (24.3) 13 (46.4) 0.078 ns surgical 18 (25.7) 0 (0) nicu 22 (31.4) 7 (25) emergency 13 (18.6) 8 (28.6) training course yes 0 (0) 0 (0) a* no 70 (100) 28 (100) residency urban 46 (65.7 20 (71.4) 0.901 ns sub urban 10 (14.3 6 (21.4) rural 14 (20) 2 (7.1) socio-economical status high 10 (14.3) 3 (10.7) 0.881 ns middle 32 (45.7) 10 (35.7) low 28 (40) 15 (53.6) *no statics because the participation was constant https://doi.org/10.15218/ejnm.2020.03 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 26 erbil journal of nursing & midwifery table 2: nurse kap in public and private hospitals. kap category public hospital (n=70) private hospitals (n=28) f (%) f (%) knowledge poor 61 (87.1) 19 (67.9) fair 5 (7.1) 2 (7.1) good 4 (5.7) 7 (25) attitude poor 33 (47.1) 2 (7.1) fair 33 (47.1) 19 (67.9) good 4 (5.7) 7 (25) practice poor 32 (45.7) 11 (39.3) fair 36 (51.4) 16 (57.1) good 2 (2.9) 1 (3.6) table 3: the association between the nurses’ kap and their socio demographic characteristics sociodemographic characteristics public hospital private hospital knowledge attitude practice knowledge attitude practice age 0.013 0.216 0.016 0.041 0.494 0.218 gender 0.261 0.666 0.132 0.049 0.416 0.963 level of education 0.022 0.098 0.003 0.036 0.278 0.117 type of employments 0.678 0.068 0.976 0.515 0.396 0.788 years of experience 0.004 0.047 0.002 0.008 0.016 0.006 socio-economical status 0.045 0.177 0.035 0.539 0.411 0.956 https://doi.org/10.15218/ejnm.2020.03 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 27 erbil journal of nursing & midwifery the current study revealed that that most of the nurses from public and private hospitals were aged between 22 and 28 years. this finding agrees with findings from elshamy et al (2015) who reported that 60% of the nurses aged from 21 to 32 years[14]. similarly, mohammed (2015) showed that most of the nurses aged under 30 years[15]. it was also concluded that about most of nurse from public and private hospital were female, which is in line with deshmukh and shind (2012) whose study consisted of 83.3% women [16]. regarding the nurses’ level of education, the current study revealed that more than half of the nurses public and private hospital graduated from institutes, which is in line with the studies carried out by elshamy et al (2015) and deshmukh and shind (2012) who reported that most of the nurses held diploma[14, 16] .on contrary, the majority of the nurses (76.4%) in the study of shaymaa et al (2013) graduated from nursing schools[17]. concerning the nurses’ clinical experience, most from public and private hospitals had 1 to 5 years of experience. this finding is in high agreement with the results reported by deshmukh and shind (2012) who reported that 71.67% of the nurses had worked 0 to 5 years in clinics[16]. similarly, ahmed (2007) concluded that 70.3% of the nurses had less than 5 years of experience[18]. concerning the nurses’ ses, about 40.0% and 53.6% of the participants were from both hospitals respectively belonged to the low socioeconomic class, which can be attributed to the current financial problems in the kurdistan region since 2014. there was no significant association between nurses socio-demographical characteristics in both hospital p-value ≥0.05.this finding is strongly with ghorbani et al (2014) also demonstrated that in their there was no significant association between nurses gender and educational level between public and private hospital while a significant association was seen with nurses age group and years of experience p-value <0.05[19] . our results agree with javadi et al (2011), which found no significant association between nurses view point score of response based on gender and educational level and type of hospital p-value <0.05 [20]. similarly founded by haukedal et al (2018) found there was no significant association between nurses age group, gender, and experience in health care in both control and intervention group pvalue ≥0.05[21]. likewise keleekai et al (2016) reported no significant association between nurses socio demographical characteristics in both control and intervention group p-value ≥0.05[22]. with respect to knowledge about fluid therapy, results showed that the nurses from both hospitals had poor knowledge, nurses in the private hospital had better knowledge than public hospital. this finding aligns with deshmukh and shind (2012) and mohammed and taha (2016), which showed that nurses had poor knowledge [16,23]. higher level of knowledge in the private hospitals could be due to attention to educational program and financial support than private one, while disagree with alrubaee et al (2017) who found that most nurses (87%) had a fair level of knowledge[24]. concerning nurse attitudes, our study revealed that 47.1% of nurses had a fair attitude about public hospitals while 67.9% had fair attitudes about private hospitals. this finding is completely agree with the study done by kwateng et al (2017) in their study that indicate there was a higher level of care and attention at private healthcare facilities than the public[25]. but disagree with moonaghi et al; (2012) discussion https://doi.org/10.15218/ejnm.2020.03 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 28 erbil journal of nursing & midwifery and feng et al ;(2014) they concluded that the nurses’ poor perception regarding toward fluid administration [26,27]. unfortunately, regarding nurse practice, 51.4% of nurse demonstrated only fair practice in public hospital while 57.1% demonstrate fair practice in private hospitals. camilleri et al (1998) also found that private hospitals are expected to offer a higher quality service[28] . the higher level of practice in the private hospitals of the present study can be due to greater financial support and adequate equipment supply in the private hospitals, and lower level of practice in rapareen hospital was because there is no infusion pump and they do not use flow meter despite its availability. the present study revealed a significant association between nurse age , level of education, and their knowledge about fluid therapy in children . this is agreement with feng etal (2014) and mogileeswari and ruth grace (2016), which demonstrated a significant association between the nurse knowledge about fluid and electrolyte replacement therapy and age and level of education[27,29]. however, this finding not in line with deshmukh and shind (2012) and vijayan (2011) they concluded that there was no significant association between the nurse age and their knowledge[16, 30]. the present study also showed that there was a highly significant association between nurse years of experience and knowledge and practice in public and private hospitals p value 0.004, 0.008 and 0.002, 0.006 respectively . this finding is in strong agreement with the studies by mohammed and taha (2016) and mogileeswari and ruth grace (2016) they reported in theirs studies a highly significant association between the nurses’ knowledge and experience[23,29]. the results demonstrated a significant association between nurses socioeconomic status knowledge nurses’ and practice in public hospitals, p value 0.046 ,0.035 respectively, while nonsignificant association in private hospitals. this finding is in agreement with mogileeswari and ruth grace (2016), which reported a significant correlation between the nurses’ income and their knowledge and practice[29]. regarding the nurses’ attitude, there was a significant association between the type of hospital and the attitude in public hospital p.value 0.011, which may be due to greater accountability and administrating supervisor and better finance support in private hospitals. the majority of nurses were between 22 and 28 years old, female, married, graduates of institutes, and formally employed. nurses had less than five years of experience, and had low socioeconomic status , nurse knowledge, attitudes, and practices were better in the private hospitals than public hospital. researchers recommended supporting public hospitals financially and ,administratively to improve services at public hospitals. [1] welch, k. “fluid balance”. learning disability practice.2010; 13: 6, 33-38. [2] walker cl, aryee mj, boschi-pinto c, black re.estimating diarrhea mortality among young children in low and middle income countries.plos one.2012; 7(1):e29151 [3] troeger c, forouzanfar m, rao pc, khalil i, brown a, reiner rc jr, fullman n etal; global burden of diseases, .estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: a systematic analysis for the global burden of disease study. lancet infectious disease. 2017;17(9):909-948 [4] ulusoy, mf. and görgülü, rs.. principles of nursing basic theory, concept principles and methods: (3rd ed). tdfo ltd. şti: ankara, turkey, 1996; 233-276. [5] karadağ, a. intravenous fluid therapy: conclusion references https://doi.org/10.15218/ejnm.2020.03 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 29 erbil journal of nursing & midwifery complications and nursing care. cu journal of school of nursing, 1999;3: 39-47. [6] karadeniz, g., baykal, d. and özbakkaloğlu, b. nurses' knowledge about the development of phlebitis in a patient with intravenous catheter applications to patients with phlebitis. ege journal of school of nursing,. 1999; 15: 103-113.. [7] nice ,national institute of health and care excellence guidance on giving intravenous fluids, nursing times, 2014;110 (6), 12-13. [8] selbst, m., fein, a.medication and intravenous fluid errors in a paediatric emergency department; pediatric emergency care journal;1999;15(1); 1-4. [9] mehran a., seyed, m., roya, r,, seyed, m., fard, a., mahnaz, j, etal; comparison quality of health services between public and private providers: the iranian people’s perspective. electron physician. 2016; 8(9): 2935–2941. [01] sanjay, b., andrews, j., kishore, s., panjabi, r., and stuckler, d.comparative performance of private and public healthcare systems in lowand middle-income countries: a systematic review. plos medicine.2012; 9 (6): e1001244. doi: 10.1371 [00] liina-k, t. and karsten ,v. comparing public and private providers: a scoping review of hospital services in europe. bmc health services research. 2018;18;141 [01] mehdi, r., mohammad, k. bahadori, r., ramin, r. and seyed, m. comparing the quality of nursing services between two public and private hospitals. international journal of healthcare management. 2017; 10(4):252-258. [01] kwame, r, and florence, a. service quality in public and private hospitals: a comparative study on patient satisfaction. international journal of healthcare management. 2017; 12(4). 251-258 [01] elshamy, f ,mohammed, a., and mohammed, a. effect of implementing intravenous infusion therapy protocol on nurses’ knowledge and performance at specialized medical hospital. journal of american science.2015;11(11) [01] mohameda. salwa and weheida m soheir .effects of implementing educational program about pressure ulcer control successfully complete a test of basic knowledge on nurses’ knowledge and safety of immobilized and performance before assuming independent patients, journal of nursing education and practice. 2015;5 (3). 1-10. [16] deshmukh, m. and shind, m. impact of structured education on knowledge and practice regarding venous access device care among nurses”. international journal of science and research (ijsr).2012; 3.358 1 2 [07] shaymaa s. khalil, zienab a. mohammad, manal e. ez el-deen, nagwa m. ahmed, impact of implementing a designed nursing intervention protocol on nurses' knowledge and practice regarding patients undergoing blood transfusion. medical. journal of cairo university . 2013;81(2), 163-171 [08] ahmed abd.sherein. study of nurse’s performance regarding infection control for patients with central venous catheter. master thesis. faculty of nursing, zagazig university,2007 p. 95.publications.zu.edu.eg. [09] ghorbani a.ali , hesamzadeh a , khademloo m, khalili s, hesamzadeh sh and berger v.public and private hospital nurses’ perceptions of the ethical climate in their work settings, sari city, nursing midwifery study. 2014; 3(1): e12867. [11] haukedal a.thor,reierson a. inger, hedeman h and bjørk t. ida. the impact of a new pedagogical intervention on nursing students’ knowledge acquisition in simulation-based learning: a quasi-experimental study. hindawi. nursing research and practice. 2018; id 7437386, 10 pages.doi.org/10.1155/2018/7437386 [10] keleekai l. nowai, schuster l. catherine, murray l. connie , king a. mary, stahl r. brian, labrozzi j. laura , et al. improving nurses' peripheral intravenous catheter insertion knowledge,confidence, and skills using a simulation-based blended learning program a randomized trial. simulation healthcare 2016; 11(6): 376–384. [11] javadi m.,karimis.,raiesia.,yaghoubim., kaveh k.comparison of patients’ and nurses’viewpoints about responsiveness among a sample from public and private hospitals of isfahan. iranian journal of nursing and midwifery research. 2011; 16(4): 273–277. [11] mohammed, k., and taha, s., critical care nurses’ knowledge and practice regarding administration of total parenteral nutrition at critical care areas in egypt. journal of biology, agriculture and healthcare. 2014;4 (13):10-22 https://doi.org/10.15218/ejnm.2020.03 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 30 erbil journal of nursing & midwifery [24] alrubaiee, g., baharom, a., shahar, k., daud, m. and basaleem, o. knowledge and practices of nurses regarding nosocomial infection control measures in private hospitals in sana’a city, yemen. safety in health. 2017; 3(16):2-6 [25] kwateng o. kwame, lumor r. and acheampong o. florence. service quality in public and private hospitals: a comparative study on patient satisfaction. international journal of healthcare management 2017;12(4). 251 -258 [26] moonaghi k., hasanzadeh f,, shamsoddini s,., emamimoghadam, z. and ebrahimzadeh, s. a comparison of face to face and video-based education on attitude related to diet and fluids: adherence in hemodialysis patientsiran. journal of nursing and midwifery reseach. 2012;17(5): 360–364. [27] feng x. li., liu, a. and qin, y. nurses' perception of risk factors for infusion phlebitis: a cross-sectional survey. chinese nursing research .2016;3(1). pp37-40 [28] camilleri d, mark o’callaghan . comparing public and private hospital care service quality. international journal of health care quality assurance. 1998;11(4-5)127-33 [29] mogileeswari p, ruth m., knowledge and practice regarding fluid and electrolyte replacement therapy for patient with burns. international journal of multidisciplinary research and development. 2016; 3( 4).217220. [30] vijayan, a. “a study to assess the knowledge and practices of staff nurses regarding fluid and electrolyte administration in postoperative cardiac surgical patients admitted in cardiac surgical icu and cardiac surgical ward, free chitra tirunal institute for medical sciences and technology. 2011;p1-27. https://doi.org/10.15218/ejnm.2020.11 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article health professional’s knowledge and attitude regarding adolescent pregnancy care in primary health care centers in erbil city abstract introduction adolescence (meaning "to grow up") is a transitional phase of physical and psychological human development that usually occurs for the duration of the time starting puberty to legal adulthood [1], a time of serious social, emotional, economic, and biological alteration [2].the world health organization (who) explained adolescence as the change from childhood to adulthood which may be referred to as ‘adolescence’ or ‘teenage’, which is a time between 10-19 years. this is the period when structural, functional, and psychosocial developments occur in an adolescent to organize her for assuming the responsibility of motherhood [3]. also, defines adolescent pregnancy as the pregnancy in which the mother is below the age of 20 at the time the pregnancy completes [4]. who stated that around 16 million adolescents aging between 15 and 19 years and approximately one million adolescents younger background and objectives: the world health organization defines adolescent pregnancy as pregnancy in which the mother is under the age of 20 at the time the pregnancy ends. about 16 million girls aging between 15 and 19 years give birth every year. the study aimed to assess the level of knowledge and attitude among nurses and physicians in erbil primary health care centers regarding adolescent pregnancy care and comparing them. methods: a quantitative; descriptive cross-sectional study was conducted in maternal and child health care units at twenty three primary health care centers in erbil city, between november 15th , 2018 and november 15th , 2019. non-probability, convenience sampling technique was used for selecting sample which includes 95 from the total of 100 health professionals. data was collected through interview (face to face) by using questionnaire form which was designed by the investigator. data were analyzed using the chi square test, fisher’s exact test. results: health professionals mean age + sd was 41.95 + 8.40 years, ranging from 27 to 62 years. the median was 42 years. less than half (42.1%) of the sample were nurses, and the rest were physicians of different specialties. the highest percentage of the nurse’s knowledge and attitude were in medium level (42.5% and 47.5%, respectively). the highest percentage of physician’s knowledge and attitude were in high level (58.3% and 65.5% respectively). there were significant difference between them regarding their knowledge (p = 0.32) and attitude (p = 0.006). conclusions: health professionals working in maternal and child health care units need improving their knowledge and attitude regarding adolescent pregnancy care. nurses need more information and training sessions regarding that. key words: adolescent pregnancy; health professional; knowledge; attitude. srwa abdulrahman mustafa; department of nursing, college of nursing, hawler medical university, erbil, iraq. )correspondence: srwa.mustafa@hmu.edu.krd) hamdia ahmad mirkhan; department of health sciences, college of health sciences , hawler medical university,erbil, iraq. 91 erbil journal of nursing & midwifery received: 20/11/2019 accepted:22/12/2019 published: 30/11/2020 https://doi.org/10.15218/ejnm.2020.11 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article than 15 years present birth each year [5].the central bureau of iraqi statistics (2011) showed that 5% of iraqi adolescents were married prior to the age of 15 years while about 22% of iraqi adolescents were married before they turned 18. the problem of adolescent childbearing in the kurdistan regioniraq is currently to be sufficiently researched and recognized in order to be successfully addressed through encouragement and policy recommendations [6]. the majority were between 15 and 19 years. the directorate of health in erbil/ iraq registered approximately 770 per 25330 adolescent pregnancies in 2018 [7]. adolescent pregnancy is allied with progression of maternal and fetal complications. anemia, pre-eclampsia, eclampsia, preterm delivery, instrumental delivery, and increased lower segment caesarian section (lscs) rate due to cephalopelvic disproportion (cpd) are strongly associated maternal complications in adolescent pregnancy. fetal complications being prematurity, low birth weight, still birth, asphyxia, respiratory distress, birth trauma. immature pelvis in adolescents makes them prone to have cpd and end up in caesarean delivery [8]. while the amount of adolescent pregnancies has already declined, there is still vast need for maintaining [9]. physicians and nurses have responsibility for caring of a pregnant adolescent with distinctive characteristics of the adult pregnant. they require to be aware of the physical, emotional and social changes experienced by adolescents, the property that they have and what their ways of coping with these situations [10].the study aimed to assess the level of knowledge and attitude among physicians and nurses in erbil primary health care centers regarding adolescent pregnancy care and comparing them. a quantitative, descriptive cross-sectional study was conducted between november 15, 2018 and november 15th, 2019. all eligible sample was involved which include 95 from total of 100 health professionals (55 physicians and 40 nurses) working in maternal and child health care units five of them drop out samples (one of them was take sick leave, two of them were take study leave and the rests were take maternity leave and they were excluded in the study) at twenty three primary health care centers in erbil city. according to the study’s inclusion and exclusion criteria; all of those health professionals (nurses and physicians) that work in maternal and child health care departments at primary health care centers in erbil city regardless of educational level were included and those of health professionals that they were not available at the time of data collection were excluded. data was collected through interview (face to face) by using questionnaire format which was designed by the investigator through massive review of the literature and it was included three parts (first part an interviewing questionnaire which included socio-demographic characteristics of study sample. second part was structured knowledge questionnaire consists of 33 questions related to knowledge regarding adolescent pregnancy care. there were three responses for items as following: i don’t know 0 score, no 1 score and yes 2 score. the maximum score on knowledge items was 66. the levels of knowledge were categorized as following: low knowledge level ≤ 50%;medium knowledge level = 51-75%;high knowledge level ≥ 75%. the third part was structured attitude questionnaire consists of 11 questions related to attitude towards of health professionals regarding adolescent pregnancy care. there were three responses for items as the following: disagree 92 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2020.11 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article for the following knowledge statements: pregnant adolescents need advice by nutritionist, pregnant adolescents should have a nutritional assessment, pregnant adolescents should have vitamin and food, untreated maternal depression in adolescent pregnant women is associated with adverse maternal, neonatal, and childhood outcomes, and taking information from pregnant adolescents about her location, family, financial, and her level education are very important. the other knowledge statements are presented in table 2. score 1, neutral score 2 and agree score 3 from the item 1 to 9, for the items 10 and 11 responses were agree score 1, neutral score 2 and disagree score 3 . the different levels of attitude are categorized as: low attitude level ≤ 50%;medium attitude level = 51% 75%;high attitude level ≥ 75%. [sapkota, 2017] ethical approval was obtained from ethical committee at the college of nursing. hawler medical university (hmu) with serial number 73 at 23/6/2019. the informed oral consent was taken from the health professionals to participate in the study, after confirmation of confidentiality, anonymity and participants selfdetermination by the researcher. formal permission was also obtained from erbil directorate of health and primary health care centers (phcc) in erbil city. data were analyzed by using the statistical package for social sciences (spss, version 22) through frequency, percentage, chi square test of association was used to compare proportions, and fisher’s exact test was used when the expected count of more than 20% of the cells of the table was less than five. a p value of ≤ 0.05 was considered statistically significant. ninety five health professionals (40 nurses and 55 physicians) had been included in the study. their mean age + sd were 41.95 + 8.40 years, ranging from 27 to 62 years. the median was 42 years. less than half (42.1%) of the sample were nurses, and the rest were physicians of different specialties like (obstetrician and gynecologist, family medicine, general practitioner, and nurses) those are working in (mch). regarding the educational level, more than one third (35.7%) of the sample were holding the bachelor of medicine, bachelor of surgery/ chirurgery degree, and 28.4% were graduates of the nursing institute. more than 90% of the studied samples answered ‘yes’ 93 erbil journal of nursing & midwifery results table 1:socio-demographic characteritics of the study sample age no. (%) < 40 34 (35.8) 40-49 42 (44.2) ≥ 50 19 (20.0) mean (+ sd) 41.96 (+ 8.40) title nurse 40 (42.1) obstetrician/gynecologist 23 (24.2) general practitioner (gp) 13 (13.7) family physician 11 (11.6) gp (gynecology) 8 (8.4) years of experience in mch 14 25 (26.3) 5-9 24 (25.3) 10-14 22 (23.2) ≥ 15 24 (25.3) educational level bachelor of medicine, bachelor of surgery/chirurgery degree 34 (35.7) higher diploma 8 (8.4) master 10 (10.5) board 3 (3.2) secondary nursing school 13 (13.7) nursing institute 27 (28.4) total 95 (100) https://doi.org/10.15218/ejnm.2020.11 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 94 erbil journal of nursing & midwifery table 2: knowledge about adolescents’ pregnancy care i don’t know no yes questions related to knowledge no. (%) no. (%) no. (%) adolescent pregnancy is a pregnancy in a women aged of 10-19 years. 11 (11.6) 12 (12.6) 72 (75.8) adolescent mothers face higher risk of abortion 6 (6.3) 12 (12.6) 77 (81.1) adolescent mothers face higher risk of still birth 13 (13.7) 23 (24.2) 59 (62.1) adolescent mothers face higher risk of cesarean section 10 (10.5) 22 (23.2) 63 (66.3) adolescent pregnancy has higher risk for gestational diabetes than adult pregnant women 11 (11.6) 57 (60.0)* 27 (28.4) adolescent mothers face lower risks of eclampsia than women aged 20 to 24 years 10 (10.5) 37 (38.9)* 48 (50.5) adolescent mothers face lower risks of puerperal endometritis than women aged 20 to 24 years 18 (18.9) 44 (46.3)* 33 (34.7) adolescent mothers face lower risks of systemic infections than women aged 20 to 24 years 12 (12.6) 52 (54.7)* 31 (32.6) adolescent pregnancy has higher risk for placenta previa than adult pregnant women 21 (22.1) 38 (40.0)* 36 (37.9) adolescent pregnancy has higher risk for abruption of placenta than adult pregnant women 21 (22.1) 30 (31.6)* 44 (46.3) adolescent pregnancy has higher risk for oligohydraminos than adult pregnant women 19 (20.0) 34 (35.8) 42 (44.2) adolescent pregnancy populations has higher risk of intrauterine growth restriction (iugr) than adult pregnant populations 10 (10.5) 17 (17.9) 68 (71.6) in adolescent pregnancy iodine deficiency can cause brain damage of the fetus 27 28.4) 18 (18.9) 50 (52.6) adverse fetal outcomes of adolescent mothers is low birth weight 14 (14.7) 15 (15.8) 66 (69.5) adverse fetal outcomes of adolescent mothers is preterm delivery 10 10.5) 18 (18.9) 67 (70.5) adverse fetal outcomes of adolescent mothers is birth trauma and injury 21 (22.1) 20 (21.1) 54 (56.8) complications during pregnancy and delivery are the leading causes of death for women aged 15 to 19 13 (26) 56 (13.7) 27.4 (58.9) complications during pregnancy and delivery are the leading causes of death for adolescents than women in their 20s. 14 (14.7) 26 (27.4) 55 (57.9) gentle prenatal exercise helps strengthen the body and increase stamina to prepare for labor and delivery 7 (7.4) 8 (8.4) 80 (84.2) pregnant adolescents need advice by nutritionist on healthy eating during pregnancy 0 (0) 0 (0) 95 (100) anemia (hemoglobin < 105 g/l) is a very common complication in pregnant adolescents 3 (3.2) 15 (15.8) 77 (81.1) pregnant adolescents should have a nutritional assessment 0 (0) 3 (3.2) 92 (96.8) pregnant adolescents should have vitamin and food 0 (0) 4 (4.2) 91 (95.8) adolescent pregnancy visits to primary health care centers in the second or third trimester should be more frequently 2 (2.1) 12 (12.6) 81 (85.3) psychological distress is associated with adolescent pregnancy 9 (9.5) 14 (14.7) 72 (75.8) adolescent pregnancy are more likely to have mood disorders (depression) than adult pregnant women or non-pregnant adolescent 10 (10.5) 15 (15.8) 70 (73.7) untreated maternal depression in adolescent pregnant women is associated with adverse maternal, neonatal, and childhood outcomes 4 (4.2) 5 (5.3) 86 (90.5) untreated maternal depression in adolescent pregnant women is also associated with post partum depression 10 (10.5) 5 (5.3) 80 (84.2) the psychological needs of pregnant adolescent women can be greater than of other women 3 (3.2) 9 (9.5) 83 (87.4) adolescent pregnancies are more likely to experience violence within marriage 11 (11.6) 6 (6.3) 78 (82.1) the social needs of pregnant adolescent women can be greater than of other women 8 (8.4) 11 (11.6) 76 (80) taking information from pregnant adolescents about her location, family, financial, and her level education are very important. 4 (4.2) 5 (5.3) 86 (90.5) adolescent parents should be included as much as possible in adolescent pregnancy care prenatal/infant care 7 (7.4) 4 (4.2) 84 (88.4) *the correct response is ‘no’. for the other questions, the correct response is ‘yes’. https://doi.org/10.15218/ejnm.2020.11 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 95 erbil journal of nursing & midwifery it is evident in table 3 that 91.6% of health care providers believe that the adolescent pregnant need special care, 83.2% believe that adolescent pregnancy is more predominant (95%) in less educated populations, 84.2% believe that adolescent pregnancy is more predominant (95%) in societies that accept and encourage childhood marriage. the other responses are presented in table 3.table 4: shows that 58.2% of the physicians had high knowledge scores compared with 35.0% of the nurses (p = 0.032). around two thirds (65.5%) of the physicians had high attitude scores which was significantly higher than the rate (32.5%) among nurses (p = 0.006). table 3: attitudes towards adolescents’ pregnancy disagree neutral agree attitudes no. (%) no. (%) no. (%) it is better that adolescent to postpone pregnancy. 6 (6.3) 16 (16.8) 73 (76.8) adolescent pregnancy is more predominant (95%) in less educated populations. 5 (5.3) 11 (11.6) 79 (83.2) adolescent pregnancy is more predominant (95%) with low to middle income populations. 7 (7.4) 21 (22.1) 67 (70.5) adolescent pregnancy is more predominant (95%) in societies that accept and encourage childhood marriage 5 (5.3) 10 (10.5) 80 (84.2) medical risks are associated with adolescent pregnancy. 6 (6.3) 17 (17.9) 72 (75.8) knowledge of adolescent pregnancy about sex increases with age. 8 (8.4) 14 (14.7) 73 (76.8) parents should be responsible for teaching their children about sex. 14 (14.7) 12 (12.6) 69 (72.6) adolescent pregnant need help for decision from her parents regarding the pregnancy. 21 (22.1) 16 (16.8) 58 (61.1) adolescent pregnant need special care. 2 (2.1) 6 (6.3) 87 (91.6) adolescent pregnancy is normal as in adult. 67 (70.5)* 16 (16.8)) 12 (12.6) adolescents can adapt with pregnancy and contract with problems easily. 51 (53.7)* 23 (24.2) 21 (22.1) *disagree is the correct response. for all the other statements, ‘agree’ is the correct response. table 4: knowledge and attitudes’ scores of physicians and nurses nurses physicians total knowledge score no. (%) no. (%) no. (%) p low 9 (22.5) 4 (7.3) 13 (13.7) medium 17 (42.5) 19 (34.5) 36 (37.9) high 14 (35) 32 (58.2) 46 (48.4) 0.032 attitude score low 8 (20) 5 (9.1) 13 (13.7) medium 19 (47.5) 14 (25.5) 33 (34.7) high 13 (32.5) 36 (65.5) 49 (51.6) 0.006 total 40 (100) 55 (100) 95 (100) *by fisher’s exact test. https://doi.org/10.15218/ejnm.2020.11 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 96 erbil journal of nursing & midwifery the present study explored knowledge and attitude of nurses and physicians regarding adolescent pregnancy care. the study shows that the highest percentages of health professionals (physicians and nurses) have knowledge regarding adolescent pregnancy care. this result agree with a study reported by tshitenge et al (2018) in mahalapye, botswana and mentioned that the majority (91.2%) of respondents have knowledge regarding adolescent pregnancy care [11].the overall attitude of health professionals (nurses and physicians) in current study revealed that 91.6% of them believed that the adolescent pregnant need special care. it is similar to the findings of agu et al., (2017) which revealed that general attitude of the midwives towards teenage pregnancy and motherhood were more positive (44.4%) [12].this study shows that 76.8% of health professionals believe it is better that adolescent to postpone their pregnancy. this is in consistent with study done by carter et al, (2002) to find out birth control that 82.35 % of participants were agreed to the statement of both the men and women are responsible for using birth control [13]. it’s evident in the present study that 72.6% of health professionals believe that parents should be responsible for teaching their children about sex. this is in contrast to the results of the study by carter et al, (2002) that 82.35 % of the respondents were strongly disagreed of these statements [13].result of our study showed that 61.1 % of health professionals agreed with the statement of adolescent pregnant need help for decision from her parents regarding the pregnancy. it’s disagreed to finding of the study done by carter et al, (2002) that 60 % of participants were strongly disagreed with this statement [13].the result of present study showed that most participants were agreed for statements of adolescent pregnancy is more predominant (95%) in less educated populations, adolescent pregnancy is more predominant (95%) with low to middle income populations and adolescent pregnancy is more predominant (95%) in societies that accept and encourage childhood marriage by (83.2 % , 70.5 %, and 84.2 %). this consistent to the results of study that done by mangeli et al, (2017) on iranian adolescent mothers to determine the challenges that facing them during the transition to motherhood; they reported in their study that one of the main challenges that adolescent mothers faced was ineffectiveness they were not able to take care from insufficient education of their family [14]. the other study was done by papri 2016 reported that there were some factors that increase pregnancy among adolescents; teenage pregnancy is often occurs in a family with lower socioeconomic status, low educational attainment [15]. the result of our study revealed that 75.6 % of health professionals were agreed to the statement on medical risks is associated with adolescent pregnancy. is consistent with the results of the study that done by azevedo et al, (2015) they were studied systemic literature review to determine complications related to adolescent pregnancy in the finding of the study they were reported that the abortion, hypertensive pregnancy disorders, lower urinary tract infections, premature rupture of membranes and placenta previa occurred more frequently in adolescent pregnancy [16]. according to professionals’ attitudes toward the statement of adolescents can adapt with pregnancy and contract with problems easily; more than half 53.7 % of health professionals were disagreed with this statement. discussion https://doi.org/10.15218/ejnm.2020.11 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 97 erbil journal of nursing & midwifery this agreed to the finding of the study that done by yahya, (2016); he pointed that most of the teenage mothers had less preparation to cope and adapt to the roles of parent. their ability to cope with the stresses of teen parenthood and their limited knowledge of appropriate child rearing skills affected their psychological wellbeing. this is because stress is assumed to place individuals at increased risk for depression, anxiety, and other emotional problems [17].the present study reveals that 58.2% of the physicians had high knowledge scores compared with 35.0% of the nurses (p = 0.032). this agreed to the finding of the study that done bymasonbrink et al, (2019) reported that most respondents had insufficient knowledge regarding adolescent’s reproductive health care (59%) [18]. this study is also consistent with the other study was done on adolescent mothers and health centers staff by sychareun et al. (2018) they were reported that adolescent mothers reported in their study, low utilization of sexual and maternal health services was common, and adolescent specific services were unavailable. this was also corroborated by the healthcare workers, who reported low uptake off sexual and reproductive health services [19]. the present study also agreed with the other study that done by hellerstedit et al. (2019) revealed that knowledge of nurses regarding adolescent pregnancy were 39 % [20].the current study shows that around two thirds (65.5%) of the physicians had high attitude scores which was significantly higher than the rate (32.5%) among nurses (p = 0.006). this agreed to the finding of study that done by govender et al, (2018) exposed that nurses had poor attitude toward adolescent pregnancy care [21]. this also agreed with the study done by sychareun et al., (2018) revealed that providers themselves recognized that they were often uncertain of how to deal with pregnant adolescents and said they sometimes found them very frustrating to deal with [19]. the results of the study indicated that physician’s knowledge and attitude regarding adolescent pregnancy care were more than nurse’s knowledge and attitude regarding adolescent pregnancy care. health professionals working in maternal and child health care units must improve their knowledge and attitude regarding adolescent pregnancy care. nurses need more information and training sessions regarding this topic. there is no actual or potential conflict of interest. [1] taghizadeh m. h, bahreini a, ajilian abbasi m, fazli f, saeidi m. adolescence health: the needs, problems and attention. international journal of pediatrics. 2016; 4 (2):1423-38.available from:http:ijp.mums.ac.irarticle_6569_7305 11251d3e060fdd0318cecf61c984.pdf [2] lansford je, banati p, ed. handbook of adolescent development research and its impact on global policy. oxford university press; 2018. available from: https:// www.unicef-irc.org/publications/987handbook-of-adolescent-developmentresearch-and-its-impact-on-globalpolicy.html [3] al-bassam an. maternal risk in teenage pregnancies. al-qadisiah medical journal. 2014; 10(17):214-23. available from: https://www.iasj.net/iasj? func=fulltext&aid=93880 [4] socolov dg, iorga m, carauleanu a, ilea c, blidaru i, boiculese l et al. pregnancy during adolescence and associated risks: an 8year hospital-based cohort study (2007– 2014) in romania, the country with the highest rate of teenage pregnancy in europe. biomed research international. 2017; (2): 1-8. available from: https:// conclusion conflict of interest references https://doi.org/10.15218/ejnm.2020.11 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 98 erbil journal of nursing & midwifery www.hindawi.com/journals/ bmri/2017/9205016/ [5] kirchengast s. teenage pregnancies: a worldwide social and medical problem. an analysis of contemporary social welfare issues. austria: vienna publishing; 2016. available from: https:// www.intechopen.com/books/an-analysis-of -contemporary-social-welfare-issues/ [6] unfpa (united nation’s population fund). child marriage in kurdistan regioniraq (overview) 2014: available from: https:// iraq.unfpa.org/sites/default/files/pub-pdf/ child%20marriage%20broucher% 20english%20final%20covers%206.pdf [7] directorate of health statistic department, erbil/ iraq. 2018. [8] thaker rv, panchal mv, vyas rc, shah sr, shah pt, deliwala kj. study of feto-maternal outcome of teenage pregnancy at tertiary care hospital. gujrat medical journal. 2013; 68 (2):45-8. available from: https:// www.ijrcog.org/index.php/ijrcog/article/ viewfile/3053/2495 [9] sarreira de oliveira p, néné m. nursing care needs in the postpartum period of adolescent mothers: systematic review. journal of nursing ufpe on line.2014;8:395361.available from: https:// www.researchgate.net/ publication/313129654 [10] de sousa vm, rodrigues dp, queiroz mv, fé mc, de olivindo dd. prenatal of pregnant adolescents performed by nurses in primary health care. open journal of nursing. 2016; 6(10): 833. available from: https:// www.scirp.org/journalpaperabs.aspx? paperid=71138 [11] tshitenge st, nlisi k, setlhare v, ogundipe r. knowledge, attitudes and practice of healthcare providers regarding contraceptive use in adolescence in mahalapye, botswana. south african family practice journal. 2018; 60(6): 181-6. available from: https:doi.org/10.1080/20786190.2018.1501 239 [12] agu, c., rae, t. & pitter, c. attitudes of midwives towards teenage pregnancy and motherhood in an urban specialist hospital in jamaica. international journal of nursing. 2017; 4(2): 29-39. available from: : https:// www.researchgate.netpublication/3237454 13 [13] carter kf, spear hj. knowledge, attitudes, and behavior related to pregnancy in a rural teenage population. journal of community health nursing. 2002; 19(2): 65-75. available from: https://www.jstor.org/ stable/pdf/3427663.pdf [14] mangeli m, rayyani m, cheraghi ma, tirgari b. exploring the challenges of adolescent mothers from their life experiences in the transition to motherhood: a qualitative study. journal of family & reproductive health. 2017; 11(3): 165. available from: https://www.researchgate.net/ publication/326491060 [11] papri fs, khanam z, ara s, panna mb. adolescent pregnancy: risk factors, outcome and prevention. chattagram maa-o-shishu hospital medical college journal. 2016; 15 (1): 53-6. available from: https:// www.researchgate.netpublication/3053932 38 [16] azevedo wf, diniz mb, fonseca es, azevedo lm, evangelista cb. complications in adolescent pregnancy: systematic review of the literature. einstein (são paulo). 2015; 13(4): 618-26. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc4878642/ [17] bah ym. teenage pregnancy: teenage mothers’ experiences and perspectives: a qualitative study. journal of health, medicine and nursing. 2016; 29. available from: https://pdfs.semanticscholar.org/417d/ e35cfd1cd7731916765c3c828b99cbea697e .pdf [18] masonbrink ar, stancil s, reid kj, goggin k, hunt ja, mermelstein sj et al. adolescent reproductive health care: views and practices of pediatric hospitalists. hospital pediatrics. 2019; 9(2): 100-6. available from: https://www.ncbi.nlm.nih.gov/ pubmed/30622112 [19] sychareun v, vongxay v, houaboun s, thammavongsa v, phummavongsa p, chaleunvong k et al. determinants of adolescent pregnancy and access to reproductive and sexual health services for married and unmarried adolescents in rural lao pdr: a qualitative study. bmc pregnancy and childbirth. 2018; 18(1): 219. available from: https:// bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/ s12884-018-1859-1 [22] hellerstedt wl, smith ae, shew ml, resnick md. perceived knowledge and training needs in adolescent pregnancy prevention: https://doi.org/10.15218/ejnm.2020.11 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 99 erbil journal of nursing & midwifery results from a multidisciplinary survey. archives of pediatrics & adolescent medicine. 2000; 154(7): 679-84. available from: https://jamanetwork.com/journals/ jamapediatrics/fullarticle/350078 [21] govender d, naidoo s, taylor m. nurses' perception of the multidisciplinary team approach of care for adolescent mothers and their children in ugu, kwazulu-natal. african journal of primary health care & family medicine. 2019; 11(1): 1936. available from: https://www.ncbi.nlm.nih.gov/ pubmed/ 31038339 [22] sapkota sd. a study to evaluate the effectiveness of structured teaching program on knowledge and attitude regarding the teenage pregnancy among early adolescent girls in selected school at bangalore, karnataka. journal of nursing and health science. 2017; 6(2). available from: https:// www.iosrjournals.org/iosr-jnhs/papers/vol6 -issue2/version-6/j0602067787.pdf https://doi.org/10.15218/ejnm.2019.19 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article coping strategies among caregivers of children with acute leukemia at nanakali hospital in erbil city abstract childhood cancer is an increasing and prevalent type of chronic disease worldwide. leukemia represents 25% of all cancers in children under the age of 15 years and is the most common type of cancer in this age group [1]. acute leukemia is the most common malignancy that affects children. in 2018, leukemia accounted for 6.6% of 25,320 new cases of cancers in the iraqi population [2]. in erbil, during 2016-2018, there were more than 120 cases of children with leukemia registered at the nanakali hospital for blood diseases and cancer. like other chronic diseases, the situation causes many physical and psychosocial problems for a person who gives care for the children having cancer. background and objective: childhood with leukemia is one of the developing global health issues, which has negative psychological, social, and physical consequences on caregivers, and affects the quality of long-term care of leukemic children. the current study aimed to assess coping strategies among caregivers of children with acute leukemia in erbil city in the kurdistan region of iraq. methods: a descriptive study was carried out at the nanakali hospital for blood diseases and cancer in erbil city from 10th october 2018 to 10th june 2019. the research sample involved 54 caregivers of leukemic children undergoing chemotherapy that were purposively recruited for the study. the researchers used a standard tool of “coping health inventory for parents” after verifying its validity and reliability. the data were collected by interviewing the participants and analyzed using frequency, percentage, mean, chi-square, and fisher's exact test. results: more than half, 28 (52%) of the children were female and the majority, 48 (88.9%) of them were diagnosed with acute lymphoblastic leukemia. the mean age of caregivers was 36.53± 7.53 years, and the majority of chief caregivers (87%) were mothers, mainly illiterate and secondary school graduates. regarding the overall levels of coping patterns scores among caregivers, the highest percentage (61.1%) of them were at the medium level. concerning each of the three levels of coping patterns score; for 87% of caregivers, maintaining family integration was within the medium level, while social support and selfesteem and an understanding medical situation, had lower percentages of 59.3% and 63% retrospectively. the results of the study revealed that there is a significant relationship between levels of coping and caregiver’s education. conclusion: according to the findings of the study, the majority of caregivers of children with leukemia undergoing chemotherapy treatment had a low level of coping in most of the coping patterns domains. keywords: caregivers, leukemia sinur askander hamad; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: snur.askandar@gmail.com ) norhan zeki shaker; department of nursing, college of nursing, hawler medical university, erbil, iraq. 155 erbil journal of nursing & midwifery received: 5/9/2019 accepted: 13/10/2019 published: 30/11/2019 introduction https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/106 mailto:snur.askandar@gmail.com https://doi.org/10.15218/ejnm.2019.19 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article caregivers, who are mainly parents, during the early stages of their child’s diagnosis show various levels of psychological problems [1]. families of the children with cancer face significant stress as they conform to demanding treatment regimens, potential side effects of medical treatment, daily activities changes, interruption in roles, and the threat of death [4]. a caregiver is an individual who helps a person during physical and psychosocial care in need. usually, most of the caregivers are family members that support the patient to do daily living activities without remuneration [5]. coping is defined as cognitive and behavioral effort to manage demands perceived as taxing or exceeding the resources of an individual. coping is classified into two types including problem-focused coping and emotion-focused coping. the first one is oriented toward resolving challenges, while the second type is connected to managing emotions [6]. coping can be difficult for all family members especially caregivers of children with the physical and emotional challenges of a cancer diagnosis and its treatment. this is especially true of pediatric cancer patients, with extensive research documenting the psychosocial consequences experienced by the parents and siblings of patients [7]. leukemic children can affect social well-being of caregivers, especially changing the family roles and can also affect the physical well-being of a parent during the care for the patient. although the health status of caregiver is initially similar to that of the normal population, caregivers often report more problems with fatigue, sleep disturbances, and impaired cognitive function than noncaregivers. nurses are in a unique position to identify stress and the psychological burden of caregivers [8]. furthermore, they can identify the possible negative effects of cancer such as decreased familial coping and adaptation, increasing hospitalization, abilities, and increased family stress levels. nurses who understand the characteristics of caregivers’ coping responses and how different coping strategies affect their adjustment can plan appropriate interventions. this study aimed to assess coping strategies among caregivers of children with acute leukemia in erbil city and identify an association between some of the socio-demographic characteristics with the overall level of coping patterns. to the best of the researchers’ knowledge, this is one of the first studies on the coping patterns among the caregivers of children with leukemia in erbil city. a descriptive study was conducted among the caregivers having leukemic children undergoing chemotherapy treatment in erbil city from 10th october in 2018 to10thjune in 2019. the sample of the study was chosen from the outpatient department of the pediatric unit at the nanakali hospital for blood diseases and cancer in erbil city and included 54 caregivers of children, medically diagnosed with acute leukemia and undergoing chemotherapeutic treatment. the caregivers had to able to communicate clearly in kurdish language to be included. the caregivers having a chronic disability such as inability to speak or difficulty of listening, psychologically not comfortable, and the caregivers who refused to participate in the study were excluded. the researchers obtained official permission for conducting the study from both the erbil general directorate of health and the nanakali hospital for blood diseases and cancer. the informed consent was obtained from all the study participants and the ethical approval was obtained from the research ethics committee at the college of nursing of hawler medical 156 erbil journal of nursing & midwifery methods https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/106 https://doi.org/10.15218/ejnm.2019.19 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article follows: never used (0), sometimes used (1), and always used (2). the total of scores gained by the caregivers was arranged as the following grades: a low coping level (0-28), a medium coping level (29 -55), and a high coping level (56-84).the pilot study was carried out in february 2018 on ten caregivers who were excluded from the study and the results were analyzed to find out the reliability by calculating cronbach's coefficient correlation, which was 0.78. the data were collected through direct interviews with caregivers by researchers and lasted approximately 20-25 minutes. data were organized and coded using statistical package for social sciences (spss) version 25, in addition to using excel program for graphic descriptive statistical analysis (frequency, percentage, mean and standard deviation). the inferential statistical analysis (chi-square test or fisher’s exact test) for categorical variables was used to measure the significant association between different variables p-value measured form ≤ 0.05. fifty-four caregivers participated in the study. their mean age and standard deviation were 36.53 ± 7.53 years old. the result of the study shows that the majority (87%) of caregivers were mothers and 29.6% of them were between 31-35 years old. approximately half of the caregivers were either illiterate or secondary school graduates. the highest proportion of the respondents were unemployed (77.8%), and 48.1% of them were living in urban areas (table 1). the results of the study showed that more than half (51.9%) of children were females, 31.5% of children’s age was between 1-4 years old and 31.5% of children were the second-order child in the family. the majority (88.9%) of children had acute lymphoblastic leukemia, university, dated 25th june 2019 with serial number 76. in order to achieve the aim of the study, the researchers prepared a questionnaire consisting two parts. the first part was divided in to two sections, the first section was to assess the socio-demographic data of the caregivers (main caregiver, age, level of education, occupation and place of residence), and the second section was to gather the socio-demographic data of the leukemic child (age, gender, order of the child, medical diagnosis and family history of cancer). the second part of the questionnaire contained the coping health inventory for parents (chip) to assess the caregiver’s coping strategies, which was developed by mccubbin et al, in 1981 [9]. the chip consisted of a checklist of 42 specific behaviors divided into three domains that represented different positive coping patterns. the pattern i was identified as maintaining family integration, cooperation and an optimistic view of the situation, the pattern ii was identified as maintaining social support, self-esteem and psychological stability, and the pattern iii was identified as understanding the medical situation through communication with other parents and consultation with medical staff. this validated instrument was designed to assess parents’ or caregivers’ appraisal of behaviors currently in use to manage family life when they have chronically ill children. the tool was previously modified by el-malky in 2016 [10]. the tool was submitted to a panel of eleven experts in different fields of nursing and medicine to assess the content of the questionnaire for its clarity, relevance, and adequacy. after the approval, the researchers translated the instrument into the kurdish language. a total score ranging from 0 to 84, was used, and the scoring was modified to the 3-point likert scale instead of 5-point likert scale as 157 erbil journal of nursing & midwifery results https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/106 https://doi.org/10.15218/ejnm.2019.19 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article and 79.6% of children had no family history of cancer (table 2). the study illustrated that the caregivers had a low level of coping related to the understanding the medical situation, maintaining social support and self-esteem (63%, and 59.3% respectively), and the majority (87%) of caregivers had a medium level of coping regarding maintaining family integration (figure 1). 158 erbil journal of nursing & midwifery table 1: demographic characteristics of caregivers of children with leukemia demographic characteristics f (%) mean age ± standard deviation 36.54 ± 7.53 the person responsible for caring father 6 (11.1) mother 47 (87) grandparent 1 (1.9) caregiver age (years) 21-25 2 (3.7) 26-30 11 (20.4) 31-35 16 (29.6) 36-40 11 (20.4) 41 and above 14(25.9) level of education illiterate 14 (25.9) read and write 10 (18.5) primary school graduate 12 (22.2) secondary school graduate 14 (25.9) graduated institute and college 4 (7.5) occupation employed 12 (22.2) unemployed 42 (77.8) place of residence rural 11 (20.4) suburban 17 (31.5) urban 26 (48.1) total 54 (100) table 2: demographic characteristics of children with leukemia demographic characteristics f (%) sex male 26 (48.1) female 28 (51.9) age groups (years) 14 17 (31.5) 4.1-8 14 (25.9) 8.1-12 15 (27.8) 12.1-16 8 (14.8) child’s order in the family 1st 12 (22.2) 2nd 17 (31.5) 3rd 9 (16.72) 4th and above 16 (29.6) the medical diagnosis of children aml 6 (11.1) all 48 (88.9) family history of cancer yes 11 (20.4) no 43 (79.6) total 54 (100) figure 1: distribution of caregivers coping patterns levels (low, medium and high) among three coping patterns domains https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/106 https://doi.org/10.15218/ejnm.2019.19 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article results also reveal a statistically significant association with the caregiver’s occupation, the residency area and the child’s family history of cancer (p-value 0.012, pvalue 0.05, and p-value 0.024 respectively), while the association between the overall level of coping and the age of the caregivers was statistically non-significant (p-value = 0.348). 159 erbil journal of nursing & midwifery the study showed that the majority (61.1%) of caregivers’ overall level of coping was within the medium level, 37% of caregivers have had a low level, and only 9.1% were within a high level of coping (figure 2).table 3 shows the association between some of the socio-demographic and overall level of caregivers’ coping and indicates the presence of highly significant figure 2: distribution of caregivers of children with leukemia among overall levels of coping pattern table 3: association between socio-demographic characteristics of caregivers with an overall level of coping pattern demographic characteristics (n=54) low medium high total p-value* f (%) f (%) f (%) f (%) caregiver age (years) 0.348**** 20-25 1(50) 1(50) 0(0) 2(100) 26-30 3(27.3) 8(72.7) 0(0) 11(100) 31-35 6(37.5) 10(62.5) 0(0) 16(100) 36-40 2(18.2) 8(72.7) 1(9.1) 11(100) 41 and above 8(57.1) 6(42.9) 0(0) 14(100) level of education 0.001** illiterate 11(78.6) 3(21.4) 0(0) 14(100) read and write 4(40) 6(60) 0(0) 10(100) primary school graduate 3(25) 9(75) 0(0) 12(100) secondary school graduate 2(14.3) 12(85.7) 0(0) 14(100) graduated institute and college 0(0) 3(75) 1(20) 4(100) occupation 0.012*** employed 1(8.3) 10(83.3) 1(8.3) 12(100) unemployed 19(45.2) 23(54.8) 0(0) 42(100) residency area 0.050*** rural 3(27.3) 8(72.7) 0(0) 11(100) suburban 3(17.6) 14(82.4) 0(0) 17(100) urban 14(53.8) 11(42.3) 1(3.8) 26(100) (children) family history of cancer 0.024*** yes 1(9.1) 9(81.8) 1(9.1) 11(100) no 19(44.2) 24(55.8) 0(0) 43(100) total 54(100) * fisher’s exact test, ** highly significant, ***significant, **** non-significant. https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/106 https://doi.org/10.15218/ejnm.2019.19 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article acute leukemia in children like other chronic diseases has a significant physical and psychosocial effect on the family members and caregivers leading to poor coping with this condition. regarding the sociodemographic characteristics, the highest percentage of the study caregivers were in their thirties (the mean age of 36.53 ± 7.53 years), which agrees with the result of a previous, quasi-experimental study conducted in egypt with 80 caregivers’ of children with epilepsy that found the mean age score was 37.21±5.22 years [10]. the result of this study indicated that the highest percentage of caregivers caring for leukemic children were mothers, which is consistent with the result of a descriptive study conducted by hasan et al in erbil (2012), which assessed the caregivers’ home care for adolescent leukemia patients and found that most of the caregivers (71.3%) were the patients’ mothers [3].furthermore, the study found that the caregivers of leukemic children were mostly secondary school graduates or illiterate and the majority were living in urban areas. these results are similar to the findings of a quasi-experimental study conducted in egypt by el-abbassy et al in 2015 who studied the effectiveness of practical guides on burden's coping strategies among the 50 caregivers of children undergoing hemodialysis [11].the present study found that the majority of the children were diagnosed with acute lymphocytic leukemia. this result is congruent with the finding of a descriptive study conducted in erbil by hasan et al, among 80 adolescents from the period of 2010 to 2011, which aimed to assess the common physical problems among leukemic adolescent patients undergoing chemotherapy. they also found that 77.5% of cases had acute lymphoblastic leukemia and a lower percentage of cases had acute myelocytic leukemia (22.5%) [12]. concerning the age groups of children, the age range of 1-4 years had the highest percentage. this agrees with a longitudinal prospective study finding which was carried out in the netherlands among 115 parents and found that most of the children age were less than four years old [13].regarding the coping pattern i (maintaining family integration, cooperation and an optimistic of the situation), the majority of caregivers had a medium level of coping. the researchers believe that during the stress situations all the relatives and family members help and support each other following their muslim culture and recommendations, and therefore express a medium level of coping. concerning the coping pattern ii (maintaining social support, self-esteem and psychological stability) and iii (understanding the medical situation through communication with other parents and consultation with medical staff), the current study demonstrated that the majority of participants had low levels of coping compared to the coping pattern i (maintaining family integration, cooperation and an optimistic of the situation). this finding is supported by a study carried out among 200 korean mothers of children with cancer, which found that mothers had a low rate of coping behaviors of the support subscale (coping pattern ii) comparing with the other clusters of coping strategies measured by the chip [14]. the researchers believe that because most of available educating sources about leukemia are in english or other foreign languages and the caregivers have low educational level, they are not able to gain information from such sources or understand the medical staff explanation. consequently, caregivers demonstrate a low level of coping in the coping pattern iii (understanding the medical situation through communication with other parents and consultation with medical staff). 160 erbil journal of nursing & midwifery discussion https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/106 https://doi.org/10.15218/ejnm.2019.19 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article regarding the overall level of coping patterns of caregiver having children with acute leukemia in the present study, the majority of caregivers showed a medium level of coping. this finding is in concurrence with a quasi study conducted by hassan and ibrahim (2018) in egypt among 60 caregivers, which showed that most of the caregivers of cancer children had a moderate level of coping patterns [15].in addition, the results of the current study show that in terms of the relationship between the total scores of overall coping level and some chosen parameters, as shown in table 3, there was no statistically significant association between the age of caregivers and coping patterns level. this finding is consistent with the results of a study conducted by hassan and mohamed in 2011 for the assessment of burden and coping strategies in 100 caregivers of schizophrenic patients at assiut university hospital, egypt, which reported that there was a significant negative correlation between the mean score of coping strategies and age of caregivers [16].the current study revealed that there was a statistically significant association between the overall level of coping with caregivers’ education level, and residence. this is in line with the findings of the study conducted by el-abbassy et al in 2015, which found statistically significant differences between total scores of coping patterns with the father’s education and residence [11]. their study found no significant association between the total scores of coping strategies and the occupation of participants, which is in contrast with the present study that demonstrated a significant association between the overall score of coping patterns and the occupation of caregivers. researchers concluded that the highest percentage of the caregivers with leukemic 161 erbil journal of nursing & midwifery children had a low level of coping in two domains of coping (pattern ii; maintaining social support, self-esteem and psychological stability and pattern iii; understanding the medical situation through communication with other parents and consultation with medical staff). furthermore, a highly significant association was found between the levels of education and overall coping patterns level. finally, the researchers recommend further studies with a larger sample size. the authors reported no conflict of interest. [1] mahmoud s, abd elaziz na. effect of psycho -educational training program for parent’s having child with leukemia on their experience and psychological wellbeing. journal of education and practice. 2015;6(12): 13– 29. available from: https://eric.ed.gov/? id=ej1080628 [2] international agency for research on cancer. global cancer observatory. 2018; 1-2. available from: https://gco.iarc.fr/today/ data/factsheets/populations/368-iraq-factsheets.pdf [3] hasan ss, hussein ka, al-ani mh. assessment of home care management for caregiver’s having leukemic adolescent patient in erbil city. kufa journal for nursing sciences. 2012;2(1).available from: http:// www.uokufa.edu.iq/journals/index.php/ kjns/article/view/138 [4] bigalke k. coping, hardiness, and parental stress in parents of children diagnosed with cancer. dissertations. 2015;109. available from: dissertations/109 [5] sullivan ab, miller d. who is taking care of the caregiver? journal of patient experience.2015;2(1):7–12.availablefrom: https:// doi.org/10.1177/237437431500200103 [6] rodríguez-pérez m, abreu-sánchez a, rojas -ocaña mj, del-pino-casado r. coping strategies and quality of life in caregivers of dependent elderly relatives. health and quality of life outcomes. 2017;15(1): 71. available from: https://doi.org/10.1186/s12955conclusion conflicts of interest references https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/106 https://doi.org/10.15218/ejnm.2019.19 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article [7] hagedoorn m, kreicbergs u, appel c. coping with cancer: the perspective of patients’ relatives. acta oncologica.2011;50(2):205– 11.availablefrom:https:doi.org/10.3109/028 4186x.2010.536165 [8] northouse ll, katapodi m, song l, zhang l, mood dw. interventions with family caregivers of cancer patients: meta-analysis of randomized trials. ca cancer journal clinicians. 2010;60(5): 317–39. available from: https://doi.org/10.3322/caac.20081 [9] mccubbin hi, mccubbin ma, patterson jm, cauble ae, wilson lr, warwick w. chip. coping health inventory for parents: an assessment of parental coping patterns in the care of the chronically ill child. journal of marriage and family. 1983;45(2): 359–70. available from: https://www.jstor.org/ stable/351514 [10] el-malky m, mohsen m, amer h. the effectiveness of the nursing intervention program on the feeling of burden and coping among caregivers of children with epilepsy. international journal of advanced nursing studies. 2016;5(1): 87–95. available from: https:// www.sciencepubco.com/index.php/ijans/ article/view/5686 [11] el-abbassy aa, atia mm, alam fh. the effectiveness of practical guides on burden’s coping strategies among caregiver of children undergoing hemodialysis. international journal of nursing. 2015;2(2): 128-143. available from: http://dx.doi.org/. [12] hasan ss, hussein ka, al-ani mh. physical problems among leukemic adolescent patients undergoing chemotherapy in erbil city. zanco journal of medical sciences. 2013;17 (1):273-279. available from: 10.15218/ zjms.2013.0002 [13] hoekstra-weebers j, wijnberg-williams b, jaspers j, kamps w, wiel h. coping and its effect on psychological distress of parents of pediatric cancer patients: a longitudinal prospective study. psycho-oncology. 2012;21 (8):903-11.available from: 10.1002/pon.1987 [14] han h-r, cho ej, kim d, kim j. the report of coping strategies and psychosocial adjustment in korean mothers of children with cancer. psychooncology. 2009;18(9):956–64. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc3056775/ [15] hassan ga, ibrahim hs. the effect of supportive nursing intervention on the burden and coping strategies of caregivers 162 erbil journal of nursing & midwifery of children with cancer. journal of nursing edu cation and practice. 2018;8(7):125. available from: https://doi.org/10.5430/ jnep.v8n7p125 [16] hassan wa-n, mohamed ii. burden and coping strategies in caregivers of schizophrenic patients. journal of american science. 2011;7(5). available from: http:// www.americanscience.org https://ejnm.hmu.edu.krd/index.php/ejnm/article/view/106 https://doi.org/10.15218/ejnm.2020.04 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article sexual satisfaction among infertile spouses in erbil city abstract introduction infertility is defined as the inability to conceive after one year of regular, unprotected sexual intercourse. it is a common problem with an estimated 10-15% prevalence rate worldwide. this common problem might have an important effect on the sexual lives of couples. additionally, infertility work-up and treatment is a deeply stressing experience for many couples. approximately 15% of all couples experience difficulty to conceive after 1 year of unprotected sexual intercourse (1).world health organization (who) defines sex as a biopsychological drive that is gradually developed among human children and may continue across their life cycle associated with socio-cultural and environmental factors in which they born and live [2]. sexual satisfaction is an emotional state that occurs with the fulfillment of individual wishes in the area of sexual life [2]. healthy sexual relationships lead to achievement of affinity and affection in families in addition to proper satisfaction of sexual instincts [3]. lack of sexual satisfaction is considered one of the most important problems, impacting an individual’s personal and social lives and plays an important role in one's personality development [4]. sexual satisfaction is affected background and objectives: sexual satisfaction is an emotional state that occurs with the fulfillment of individual wishes in the area of sexual life. sexual satisfaction is mainly affected by the outcomes of infertility. the study aimed to assess sexual satisfaction among infertile spouses in erbil city and to determine associations between sexual satisfaction and their sociodemographic characteristics. methods: a cross sectional study was conducted on 150 infertile couples visiting maternity teaching hospital and three private infertile centers in erbil city. index of sexual satisfaction was used to assess sexual satisfaction. verbal informed consent was obtained from all participants. data was analyzed by using the frequency, percentage, chi-square test and fisher’s exact test from the statistical package for social sciences version 22. results: three hundred persons (150 infertile couples) participated in the study. their mean age was 31.82 + 6.60 years, ranging from 17 to 49 years old. more than half of participants were less satisfied, with wives being less satisfied than their husbands. no significant association was detected between sexual satisfaction scores and level of education, occupation income and residency. conclusion: the findings of the study indicated that more than half of participants were less satisfied, and wives were less satisfied than their husband. infertile spouses especially wives should be educated to increase their awareness regarding sexual issues. keywords: sexual satisfaction; infertility; spouses. nergz bayiz abdulrehman; department of nursing, college of nursing, hawler medical university, erbil, iraq. )correspondence: nergiz.bayz89@gmail.com ) tiran jamil piro; department of midwifery, college of nursing, hawler medical university, erbil, iraq. 31 erbil journal of nursing & midwifery received: 13/9/2019 accepted: 13/11/2019 published: 30/5/2020 mailto:nergiz.bayz89@gmail.com https://doi.org/10.15218/ejnm.2020.04 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article by different factors like job stress, couples’ struggles, education level, cultural influences, and economic problems, moral, sexual consistency, physical and mental diseases [5]. sexual dissatisfaction leads to negative mental and spiritual effects, like disappointment, depression, insecurity, unhappiness, as well as spiritual, mental and personality imbalance. these complications result in diminished ability and creative power, serious conflicts, as well as negative emotions as annoyance, jealousy, competition to suppress each other, lack of self-confidence and being ignored [6] the relationship between sexuality and infertility is bidirectional, as the latter can be either the cause or the consequence of possible sexual disturbances. it has been shown that infertility is the result of underlying sexual disorders in only a minority of cases, while involuntary childlessness itself impairs the individual sexual functioning and the couple ’ s sexual balance [7]. several studies have demonstrated that infertile couples have significantly higher rates of sexual satisfaction than fertile couple. similarly, it has been established that those with secondary infertility have more sexual satisfaction compared with those with primary infertility [8]. the study aimed to assess sexual satisfaction among infertile spouses in erbil city and to determine associations between the sexual satisfaction and their selected socio demographic characteristics (age, gender, level of education, occupation, income, and residency) a cross-sectional study was conducted between october, 8, 2018 and october, 8, 2019. a convenience sample of 150 infertile spouses was taken from maternity teaching hospital and three private infertile centers in erbil city. according to the study’s inclusion and exclusion criteria; those who were diagnosed with infertility by a gynecologist were included and infertile spouses with any chronic health condition and psychiatric diseases were excluded. ethical approval was obtained from ethical committee at the college of nursing, hawler medical university in 26, july 2019 (number 77). furthermore, informed oral consent was taken from the candidate’s participation in the study, after confirmation of confidentiality, anonymity and participants self-determination by the researcher. formal permission was also obtained from maternity teaching hospital and three private infertility centers. the index of sexual satisfaction (iss) was used to measure sexual satisfaction as a scale which was modified by the researchers. sensitive questions had been paraphrased in order to be acceptable by the participants, and the 6 points likert scale was made of 3 points either 0, none of the time, 1 sometimes, 2 most of the time. the total of the scores obtained from the 19 questions was calculated. the maximum total score for satisfaction was 38 scores. finally, the spouses were categorized into two groups, those with >29 were classified as more satisfied and those with ≤ 29 were classified as less satisfied data was analyzed using the statistical package through social sciences (spss, version 22). categorical variables were presented as proportions, and numerical variables were summarized as means and standard deviations. chi-square test of association was used to compare proportions. fisher’s exact test was used when the expected count of more than 20% of the cells of the table was less than 5. a p-value of ≤ 0.05 was considered statistically significant. table1 shows that three hundred persons (150 infertile couples) participated in the study. their mean age was 31.82 with a sd of 6.60 years and ages, ranging from 17-49 32 erbil journal of nursing & midwifery methods results https://doi.org/10.15218/ejnm.2020.04 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article the income of the majority (74%) was sufficient for daily living figure 1 showed more than half (57%) of participants were less satisfied. the same trend existed in the wives as the majority (69.3%) were employed and 30.7% were housewives. the majority (89.7%) of the sample in urban areas. the income of the majority (74%) was sufficient for daily living table 2 showed a significant association was detected within age group 3949 years and sexual satisfaction, with wives being less satisfied than their husbands. (p-value= 0.020 and p-value= 0.001 respectively). non-significant associations were detected between sexual satisfaction and level of education, occupation, income and residency. years old. table 1 also shows that the majority (47.0%) of them were between 28 -38 years old and only 14.7% were ages 3949 years old. the highest percentage (42.6%) of husbands graduated from institute and college, 19.3% were high school graduates, and only 2.7% of them were illiterate. regarding the wives education most of them (48%) graduated from college and institute, and 10% were high school graduates, and only 3.3% were illiterate. regarding occupation, the majority (67.3%) of husbands were employed and 32.7% of them were unemployed. the same trend existed in the wives as the majority (69.3%) were employed and 30.7% were housewives. the majority (89.7%) of the sample in urban areas, and 33 erbil journal of nursing & midwifery table 1: basic characteristics of study sample variables no. (%) age (years) 17-27 115 (38.3) 28-38 141 (47) 39-49 44 (14.7) 6.60 years +sd was 31.82 +mean age gender male 150 (50) female 150 (50) residency rural 31 (10.3) urban 269 (89.7) income sufficient for daily living 222 (74) insufficient 40 (13.3) exceed need 38 (12.7) education level husband --------------- no. (%) wife --------------- no. (%) illiterate 4 (2.7) 5 (3.3) read and write 0 (0) 3 (92) primary school 23 (15.3) 21 (14) secondary school 25 (16.7) 28 (18.7) high school 29 (19.3) 15 (10) institute and college graduate 64 (42.6) 27 (48) post-graduate 5 (3.3) 6 (4) total 150 (100) 150 (100) occupation employed 101 (67.3) 104 (69.3) unemployed 49 (32.7) 46 (30.7) total 150 (100) 150 (100) https://doi.org/10.15218/ejnm.2020.04 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 34 erbil journal of nursing & midwifery figure 1: determine the level of sexual satisfaction table 2: distribution of sample by feeling satisfied with each item of the index of sexual satisfaction most of the time sometimes none of the time index of sexual satisfaction (iss) )%( no. )%( no. )%( no. items 76)) 228 (20.7) 62 (3.3) 10 (1) i feel that my partner enjoys our sex life 2)) 6 27)) 81 (71) 213 2) sex is fun for my partner and m) 8)) 24 41.7)) 125 (50.3) 151 (3) our sex life is monotonous 14)) 42 64)) 192 (22) 66 (4) when we have sex it is too rushed and hurriedly completed 32)) 96 60.7)) 182 (7.3) 22 (5) i enjoy the sex techniques that my partner likes or uses 37.7)) 113 43)) 129 (19.3) 58 (6) i feel that my partner wants too much sex from me 46.3)) 139 38.3)) 115 (15.3) 46 (7) my partner dwells on sex too much 66.3)) 199 29)) 87 (4.7) 14 (8) i try to avoid sexual contact with my partner 68.3)) 205 28.3)) 85 (3.3) 10 (9) i feel that sex is a normal function of our relationship (58) 174 36.7)) 110 (5.3) 16 (10) my partner does not want sex when i do 75.3)) 226 20.3)) 61 (4.3) 13 (11) i feel that our sex life really adds a lot to our relationship 72)) 216 25.7)) 77 (2.3) 7 (12) my partner is very sensitive to my sexual needs and desires 35.7)) 107 55)) 165 (9.3) 28 (13) i speak about sexuality with my partner 3)) 9 28.3)) 85 (68.7) 206 (14) i would live better without sexuality 59)) 177 (33.7) 101 (7.3) 22 15 i reach orgasm during sex) 2)) 6 15.6)) 47 (82.3) 247 )16) sexuality scars me 37.3)) 112 51.3)) 154 (11.3) 34 ) feel that my sex life is boring11) 62.3)) 187 (34) 102 (3.6) 11 (18) i am satisfied with the frequency which i have sexual intercourse 62.6)) 188 34.6)) 104 (2.6) 8 (19) i am satisfied with the amount of time my partners) and i spend together immediately after intercourse https://doi.org/10.15218/ejnm.2020.04 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 35 erbil journal of nursing & midwifery table 3: association between socio-demographic characteristics and sexual satisfaction levels variables sexual satisfaction scores more satisfied less satisfied p value no. (%) no. (%) age( years) 17-27 57 (49.6) 58 (50.4) 28-38 61 (43.3) 80 (56.7) 39-49 11 (25) 33 (75) 0.020 s gender male 82 (54.7) 68 (45.3) female 47 (31.3) 103 (68.7) 0.001 vhs level of education illiterate 3 (33.3) 6 ( 66.7) read and write 0 0)) 3 (100) primary school 17 (38.6) 27 61.4)) secondary school 23 (43.4) 30 (56.6) high school 24 (54.5) 20 (45.5) institute graduate 17 (32.1) 36 (67.9) college graduate 39 (47) 44 (53) post graduated 6 (54.5) 5 (45.5) 0.269 ns occupation employed 92 (44.9) 113 55.1)) unemployed 37 (38.9) 58 61.1)) 0.334 ns residency rural 14 (45.2) 17 (54.8) urban 115 (42.8) 154 (57.2) 0.797 ns income sufficient for daily living 103 (46.4) 119 (53.6) insufficient 13 32.5)) 27 67.5)) exceed need 13 34.2)) 25 65.8)) 0.133 ns *by fisher’s exact test. https://doi.org/10.15218/ejnm.2020.04 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 36 erbil journal of nursing & midwifery this study was conducted among infertile spouses in maternity teaching hospital and three private infertile centers. the present study demonstrated that more than half of infertile spouses had less sexual satisfaction. a study conducted in iran found that low sexual satisfaction was less common among infertile couples compared to fertile which was inconsistent with present study [9]. another supported study also conducted in iran found that in 292 couples (63.4%) of them had high sexual satisfaction, and only a few of them (0.7%) were dissatisfied which was different from our findings [10]. regarding age, the current study results indicated that there was a significant association between older ages and sexual satisfaction as, wives were less satisfied compared to their husbands. results of the current study were in contrast to a study conducted in japan entitled sexual satisfaction of infertile couples, that they revealed sexual satisfaction of male partners was significantly lower than those of female partners between ages 30 or older [11]. another study conducted in iran comparison of quality of life, sexual satisfaction and marital satisfaction between fertile and infertile couples, found that when couple's age decreases the sexual satisfaction increases. conversely, when couple’s age increases, their sexual satisfaction decreases. considering the fact that increase in age is followed by psychological and social changes in the individuals and the society has a negative attitude toward sexual behaviors in higher ages, increase in age can be mentioned as one of the reasons for reduction of sexual satisfaction [10].the current study results found that no significant association was detected between sexual satisfaction and couple's educational level. a study conducted in nigeria on sexual dissatisfaction among female patients of reproductive age revealed that a higher educational attainment increases the chance that spouses can speak about their sexual problems [12]. regarding occupation, the present study's findings indicated that no significant association was found between sexual satisfaction and occupation. the results were consistent with a study's results carried out by khoei et al. who found no relationship between couples occupation, and sexual sat-isfaction [13]. regarding residency, the current study showed that sexual satisfaction was not associated with place of living. the present results were supported by a study conducted in turkey regarding sex. it was found that there was no relationship between place of living and sexual satisfaction [14]. regarding family income, no association was found between income and sexual satisfaction in this study. a study carried out by velten and margraf conducted in germany about how individual, partner, and relationship factors impact sexual satisfaction within partnerships, differed with the present study as it revealed that income was positively related to sexual satisfaction among spouses, and found that higher socioeconomic status is also associated with better mental and physical health which are correlated with higher sexual satisfaction [15]. the findings of the study indicated that more than half of participants were less satisfied. a significant association was detected between sexual satisfaction and age group (39-49 years), and also wives were less satisfied than their husbands. infertile spouses especially wives should be educated to increase their awareness regarding sexual issues. discussion conclusion https://doi.org/10.15218/ejnm.2020.04 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 37 erbil journal of nursing & midwifery there is no actual or potential conflict of interest in relation to this study. [1] gurunath s, pandian z, anderson ra, bhattacharya s. defining infertility—a systematic review of prevalence studies. human reproduction update. 2011 14;17 (5):575-88. available from: https:// www.ncbi.nlm.nih.gov/pubmed/21493634 [7] who. gender, women and health: what do we mean by “sex” and “gender”. geneva (ch): who. 2014. available from: http:// dx.doi.org/10.2471/blt.18.211607 [3] ziherl s, masten r. differences in predictors of sexual satisfaction and in sexual satisfaction between female and male university students in slovenia. psychiatria danubina. 2010 29; 22(3):425-9. available from: https://www.ncbi.nlm.nih.gov/ pubmed/20856186 [4] toorzani zm, zahraei rh, ehsanpour s, nasiri m, shahidi s, soleimani b. a study on the relationship of sexual satisfaction and common contraceptive methods employed by the couples. iranian journal of nursing and midwifery research. 2010; 15(3):115. available from: https://www.ncbi.nlm.nih.gov › pmc › articles › pmc3093165 [5] marvi n, golmakani n, esmaily h, shareh h. the relationship between sexual satisfaction and genital self-image in infertile women. journal of midwifery and reproductive health. 2018;6(4):1468-75. available from: https://www.civilica.com › printablejr_jmreh-6-4_01. [6] heidari ar, asskary p, azarkish m. relation of some demographic factors with marital commitment, sexual satisfaction and life satisfaction in women. journal of american science. 2012;8(2):194-9available from: http://ijfs.ir/library/upload/file/farzad.pdf [7] gheshlaghi f, dorvashi g, aran f, shafiei f, najafabadi gm. the study of sexual satisfaction in iranian women applying for divorce. international journal of fertility & sterility. 2014 ;8(3):281. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc4221515. [8] piva i, lo monte g, graziano a, marci r. a literature review on the relationship between infertility and sexual dysfunction: does fun end with baby making?. the european journal of contraception & reproductive health care. 2014 1; 19(4):231-7. available from: https:// www.ncbi.nlm.nih.gov/pubmed/24901746 [9] masoumi sz, garousian m, khani s, oliaei sr, shayan a. comparison of quality of life, sexual satisfaction and marital satisfaction between fertile and infertile couples. international journal of fertility & fterility. 2016 ;10(3):290. available from: from: https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc5023039/ [10] rahmani a, khoei em, gholi la. sexual satisfaction and its relation to marital happiness in iranians. iranian journal of public health. 2009:77-82. available from: http:// ijph.tums.ac.ir/index.php/ijph/article/ view/3153 [11] shoji m, hamatani t, ishikawa s, kuji n, ohta h, matsui h, et al. sexual satisfaction of infertile couples assessed using the golombok-rust inventory of sexual satisfaction (griss). scientific reports. 2014 6;4:5203. available from: https:// www.nature.com/articles/srep05203 [12] fajewonyomi ba, orji eo, adeyemo ao. sexual dysfunction among female patients of reproductive age in a hospital setting in nigeria. journal of health, population, and nutrition. 2007 ;25(1):101. available from: https://www.ncbi.nlm.nih.gov/ pubmed/17615910 [13] khoei em, maasoumi r, talebi s, hajimirzaie s, bayat a, rimaz s, et al. factors affecting sexual satisfaction in iranian women. women's health bulletin. 2015;2 (4). available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc4221515/ [14] dundon cm, rellini ah. more than sexual function: predictors of sexual satisfaction in a sample of women age 40–70. the journal of sexual medicine. 2010 1;7(2):896904. available from: https:// www.ncbi.nlm.nih.gov/pubmed/19889146 [51] velten j, margraf j. satisfaction guaranteed? how individual, partner, and relationship factors impact sexual satisfaction within partnerships. plos one. 2017 23;12 (2):e0172855. available from: https:// www.ncbi.nlm.nih.gov/pubmed/28231314. conflict of interest refernces https://doi.org/10.15218/ejnm.2020.12 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article physical activity and perceived barriers among type2 diabetic patients in erbil city abstract introduction diabetes is a serious, long-standing disease that develops either when the pancreas does not make adequate insulin (a hormone that regulates blood glucose), or when the body cannot definitely use the insulin it produces. diabetes has turn into one of the major causes of morbidity and mortality across the globe. it is combined with large varieties of complications like retinopathy, neuropathy and lower limb amputation [1].the rising prevalence of diabetes mellitus conceives medical and social leads to the diabetic complications. if comorbid diseases of diabetes which are hyperlipidemia, hypertension and obesity accordingly labeled, restriction of these complications is achievable. physical activity, dietary adjustment and counseling background and objectives: physical activity is necessary for providing a healthy lifestyle, improving quality of life, controlling diabetes mellitus and promoting glycemic control. the aim of the study was to assess physical activity and to determine barriers to physical activity among type 2 diabetic patients in erbil city. methods: a cross-sectional study was conducted among 400 type 2 diabetic patients, attending layla qasim center in erbil city during may 27 to 30 august 2019. data was collected using an interview based questionnaire to obtain socio-demographic data, clinical characteristics, physical activity assessed using global physical activity questionnaire (gpaq) and standardized questionnaire developed by the centers of diseases control and prevention for determining barriers of physical activity. data were analyzed using descriptive statistical approach. results: participant were 400 patients with mean age of 57.0 + 9.4 years, 64.3% of the sample were females. (72.3%) of the sample were illiterate, 77.5% were either unemployed or housewives. 83.8% of the sample were married, 80.25% of samples had first degree relative positive family of diabetes. 56.5% of samples take oral hypoglycemic mediactons.39.2% of samples were overweight and 83.7% of samples had poor glycemic control.57.8% of participants didn’t meet recommendations (< 600 minutes per week) of physical activity. the main barriers that keeps patients from being active were lack of energy (54.8%), lack of willpower (53%), and lack of skill (49.3%). conclusions: according to the finding of the study type 2 diabetic patients had insufficient physical activity to meet the recommended level necessary to achieve optimal glycaemic control, prevent or decrease diabetic complications. interventions should include guiding individuals to evolving recreational physical activity and overwhelming barriers to physical activity. keywords: physical activity, type 2 diabetes mellitus, glycemic control, overweight, lack of energy rezhna abdullah ahmed; department of nursing, college of nursing, hawler medical university, erbil, iraq. )correspondence: rejna92@gmail.com) ronak nihmatala hussain; department of nursing, college of nursing, hawler medical university, erbil, iraq. iraq. 100 erbil journal of nursing & midwifery received: 06/11/2019 accepted:15/1/2020 published: 30/11/2020 mailto:rejna92@gmail.com https://doi.org/10.15218/ejnm.2020.12 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article therapy are part of the overall treatment strategy in type 2 diabetic patients [2].world health organization (who) defines physical activity as any movement of the body that composed by skeletal muscles that requires energy consumptionincluding activities attempted while working, playing, carrying, travelling, and inviting in recreational pursuits. inadequate physical activity is one of prominent risk factors for global mortality and people who are insufficiently active have a 20% to 30% increased risk of death compared to whom are sufficiently active [3]. regular exercise can offer both general health benefits and diabetes-specific health benefits. it can reduce the cardiovascular risk by improving lipid profile, lowering the blood pressure and inducing weight loss [4]. appraisal and highlighting barriers are very necessary to develop and apply effective physical activity programs and guidelines to diabetic patients according to the barriers. western community has reported lack of time [5] [6], lack of knowledge, lack of willpower [7]. in arab countries data on barriers to physical activity in both public and type 2 diabetic patients are lack of time [8] and lack of resources [9]. no study in iraq even in kurdistan region on physical activity among type 2 diabetic patients, the aim of this study was to assess physical activities and determine barriers to physical activity among type 2 diabetic patients. a descriptive cross-sectional interviewbased study was conducted among 400 type 2 diabetic patients in layla qasim health center for diabetes in erbil city during may 27 to august 30, 2019. the sample size was determined by epi. info software (version 7) used for sample size estimation. the expected frequency (25%) based on the study done in united arab emirates [10] and confidence interval of 95%. the population size 2433 number of diabetic patients that visited layla qasm center from april 2018 to april 2019 accordingly the estimated sample size by epi. info was 380 but the researcher decided to select 400 cases as a sample size to be more accurate representative sample. researcher attained confirmation of the ethics committee at the college of nursing at 13, june 2019 (number 68), hawler medical university and the official approval from the ministry of health in erbil directorate of health was taken. a questionnaire prepared for collecting data based on global physical activity questionnaire [11] and the centers of diseases control and prevention questionnaire [12] for determining barriers of physical activity were used. the questionnaires are reliable and accessible in public, no arrangements are actually needed to practice it, and it its open entry and broadly tested for reliability and validity in nine [13] countries also in ireland [14], usa [15]and bangladesh [16].pilot study was conducted on 20 included type 2 diabetic patients were selected purposively from layla qasim health care center on april 2019 and re-tested after 15 days’ same patients were asked same questions. the pilot study was useful to determine the reliability, clarity, acceptability and time estimation for each participant to complete the interview which was 30-40 minutes. the results of two analyzing (test and re-test) were checked to determine the reliability by calculating cronbach’s coefficient correlation it was 0.87.sociodemographic data of diabetic patients included age, gender, marital status, educational level, occupation and family income, and medical data of samples included family history, duration of diabetes, types of treatment, body mass index and glycemic control. physical activity assessment physical activity level of patients with type 2 diabetes mellitus t2dm were 101 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2020.12 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article one barrier category. a scoring system was used to demonstrate how likely each statement/item was considered to be a barrier (very likely=3, somewhat likely=2, somewhat unlikely=1, very unlikely=0). scores of the three theme-related questions were added up to provide a total for each category of barriers. a score of ≥5 was considered as an important barrier to overcome. table 1 shows the socio-demographic characteristics of the study sample, the mean age + sd was 57.0 + 9.4 years and the highest percentage of the patients 38.8% were within the age groups 55-64 years. regarding to the gender, more than half of the sample 64.3% were female and the minority were male 35.8%. furthermore, 83.8% of the sample were married, most of them were illiterate 72.8%, and 77.5% were either unemployed or housewives and regarding the income was enough for 44.5% of the patients and only 13.8% were exceeded needs. table 2 shows the medical data of samples 72.75% had positive family of diabetes. in relation to the duration of diabetes mellitus by years, the highest percentage 56% of the sample in durations of diabetes mellitus was 1-8 years, while the lowest percentage 0.8% was ≥25, with the mean duration of 8.61 years. the majority of the patients take oral hypoglycemic drugs, either alone 56.5%, in combination with insulin 15.8%, or in combination with a dietary regimen 9.8%. about bmi 39.2% were overweight and majority of patients had poor glycemic control based on hba1c ≥ 7 83.8%. results shows that more than half 57.8% of the sample didn’t meet the recommended score for physical activity (table 2). results also shows (table 3) that the main barriers that keeps patients from being active were lack of energy 54.75%, lack of willpower 53%, and lack of skill 49.25%. determined by using global physical activity questionnaire (gpaq). it is comprised of 16 questions about physical activity in a typical week and determines physical activity in three domains, work, transportation and recreational activities. the ratio of a person's functioning metabolic rate relative to the resting metabolic rate is called metabolic equivalent (met). in the estimation of a person's overall energy consumption, 4 mets was given to the time used in moderate activities, and 8 mets to the time used in vigorous activities. the total time used on physical activity during a typical week, the number of days as well as the intensity of physical activity is taken into account to calculate for the categorical indicator, through a week, including activity work, during transport and leisure time, adults should do at least 150 minutes of moderateintensity physical activity, 75 minutes of vigorous-intensity physical activity and an equivalent combination of moderate-and vigorous – intensity physical activity achieving at least 600 metminutes. total physical activity metminutes/week (=the sum of the total met minutes of activity computed for each setting) equation: physical activity metminutes/week= [(p2*p3*8) + (p5*p6*4) + (p8*p9*4) + (p11*p12*8) + (p14*p15*4)] the two levels of physical activity suggested for classifying patients, not meeting recommendations (met<600 minutes per week) and meeting recommendations (met ≥ 600 minutes per week). center for disease control (cdc) questionnaire barriers to physical activity center for disease control questionnaire ‘barriers to being active’ was used in a study which is 21 questions on seven barriers (lack of time, lack of social support, lack of energy, lack of willpower, fear of injury, lack of skill and lack of resources). a set of three related questions (total of 21 questions) given in random order within the questionnaire 102 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2020.12 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 103 erbil journal of nursing & midwifery table 1: socio-demographic characteristics of study sample age (years) no. (%) < 45 32 (8.0) 45-54 130 (32.5) 55-64 155 (38.75) ≥ 65 83 (20.75) gender male 143 (35.75) female marital status single married divorced separated widow/er 257 7 335 2 6 50 (64.25) (1.75) (83.75) (0.5) (1.5) (12.5) educational level illiterate 289 (72.25) primary school graduate 47 (11.75) intermediate school graduate 23 (5.75) high school graduate 10 (2.5) diploma 18 (4.5) college and post gradate 13 (3.25) occupation high rank 12 (3.0) non manual 22 (5.5) skilled manual 25 (6.25) unskilled manual 31 (7.75) unemployed/housewife family income enough not enough exceeds needs 310 178 167 55 (77.5) (44.5) (41.75) (13.75) table 2: medical data of study participants no. (%) family history of dm no yes duration of dm / years 1 – 8 9-16 17-24 ≥25 types of treatment insulin 109 291 224 137 36 3 61 (27.25) (72.75) (56) (34.25) (9) (0.75) (15.25) oral hypoglycemic 226 (56.5) diet 4 (1.0) insulin & oral hypoglycemic 63 (15.75) oral hypoglycemic & diet 39 (9.75) none bmi <25 25-29 30-34 ≥35 glycemic control good hba1c (<7%) poor hba1c (≥7%) 7 100 157 118 25 65 335 (1.75) (25) (39.25) (29.5) (6.25) (16.25) (83.75) table 3:physical activity scores of study samples met-minutes/week* no. (%) not meeting recommend tions (< 600 minutes per week) 231 (57.75) meeting recommendations (≥600 minutes per week) 169 (42.25) mean + sd 870.1 + 1208.4 total 400 (100) table 4: barriers to being active barriers * no. n = 400 no. (%) lack of energy 219 (54.75) lack of willpower 212 (53) lack of skill 197 (49.25) fear of injury 180 (45.0) lack of time 179 (44.75) social influence 141 (35.25) lack of resources 64 (16) *more than one barrier is a possibility in the same patient. https://doi.org/10.15218/ejnm.2020.12 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 104 erbil journal of nursing & midwifery the mean age of current study is 56.9 ± 9.3 which agree with the result of previous study done on 320 type 2 diabetic patients who found that most of participants were between 45 -65-year-oldandthe mean age was 55 years old [17]. most of the patients in this study were female and married which is persistent with earlier studies that demonstrated similar results [17] [18]. majority of patients in this study were housewives as supported by study done in iran [19]. the present study findings show that the highest percentage (80.25%) of patients had positive family history of diabetes for a first degree relative similar to study results done in saudi arabia [20]. about the duration of diabetes higher percentage was between 1-8 years with the mean and standard deviation 8.61 ± 5.4. this result agrees with the study done in emirates [10]. in addition, majority of them were taking oral hypoglycemic medications, this concurs with a cross-sectional survey conducted on 305 type 2 diabetic patents in oman [21]. results show that high proportion of the study samples has poor glycemic control (≥7%) with the mean and standard deviation of 8.7 ± 1.6 finding come along with a cross-sectional study done in philippine which reported that the higher proportion (89.4%) pf patients had poor glycemic control (≥7%) [22]. the present study finding show poor glycemic control was associated with low or insufficient physical activity practices, being active physically aids in glycemic control by increasing insulin sensitivity thus maintaining good glycemic control. the majority of patients had inadequate physical activities in erbil city and more than half of patients didn’t meet recommended guidelines of physical activity, this finding is similar to a study done among type 2 diabetic patients in emirates [10], pakistan [23] and uk [24].insufficient physical activity could be related to many factors, in our study we found that high level of illiteracy, older age are main factors perhaps due to the matter that individuals aged older tend to prefer less intense activity. the level of physical activity has definitely declined in recent years due to changing in lifestyle and enhancing in wellbeing facilities. living in urban areas, applying elevators approximately in all buildings and the improvement of public transportation systems, expanding markets and shopping centers promote to a reduction in physical activity level. three barriers were derived through the determination of barriers to physical activity practice in patients with type 2 diabetes in this study. lack of energy towards physical activity was the main barrier. studies shown that type 2 diabetic patients often struggle with lack of energy and fatigue, which affects their self-care and quality of life, also fatigue has been related to physical inactivity, depression, high body mass index, sleep disturbance, and chronic lo-grade inflammation [25]. findings revealed that lack of willpower has been reported as second important barrier to physical activity practice in patients with diabetes. a previous study also indicated lack of willpower as the most influencing factor for low physical activity level among type 2 diabetes mellitus patients [21] [26]. the study stated that the majority of the type 2 diabetic patients in erbil didn’t meet recommended guidelines of physical activities mostly patients with poor glycemic control and older age. study also identified lack energy and lack of willpower as the most common barriers to achieving physical activities. we should provide arrangements toward establishing the programs on how to strengthen our patients discussion conclusion https://doi.org/10.15218/ejnm.2020.12 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 105 erbil journal of nursing & midwifery to have continued exercise that improve health and applying strategies to overwhelming these barriers and developing motivators are crucially needed.  health care providers have crucial role in explaining the effects of physical exercise on blood glucose control, health benefits of physical activity, and eventually on the quality of life also they play role in patients monitoring, weight reduction, counseling and appropriate management of diabetes.  regular physical activity should be improved among diabetic patients to achieve optimal glycaemic control and prevent complications of diabetes.  approaches that strengthen will power and strategies to enhancing energy include (maintaining healthy weight, eating healthy diet, regular exercise, adequate rest and sleep, stress restriction and meditation. the author reports no conflict of interests. [1] atlas, diabetes. "international diabetes federation." idf diabetes atlas, 7th edn. brussels, belgium: international diabetes federation. 2015. available from: https:// suckhoenoitiet.vn/download/atla-benh-daithao-duong-2-1511669800.pdf [accessed 18th dec 2019 . [2] laaksonen de, lindström j, lakka ta, eriksson jg, niskanen l, wikström k, et al. prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. new england journal of medicine, 2005.jan;54(1):15865.2005.availablefrom:https:www.ncbi.nlm. nih.gov/pubmed/15616024[accessed 10thsep 2019 . [3] world health organization. who physical activity. (2018). available from: http:// www.who.int/dietphysicalactivity/pa/en/ [accessed 9th nov 2019. [4] the look ahead research group. longterm effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus. archives of internal medicine. 2010;170 (17):1566. available from: https:// www.ncbi.nlm.nih.govepubmed/2087640 8 [accessed 10th sep 2019 . [5] egan am, mahmood wa, fenton r, redziniak n, kyawtun t, sreenan s,et al. barriers to exercise in obese patients with type 2 diabetes. the quarterly journal of medicine. 2013;10(6):635–8. available from: https://www.ncbi.nlm.nih.gov/ pubmed/23525164 [accessed 20th sep 2019 . [6] korkiakangas ee, alahuhta ma, laitinen jh. barriers to regular exercise among adults at high risk or diagnosed with type 2 diabetes: a systematic review. health promotion international.2009;2(4):416– 27.availablefrom:https:// www.semanticscholar.org/paper/barriers -to-regular-exercise-among-adults-athigh2koriakangasalhuhta/0df7115de8308 36731277012eae963e499ac8b02 [accessed 20th sep 2019 ] [7] booth, a.o., lowis, c., dean, m., hunter, s.j. and mckinley, m.c. diet and physical activity in the self-management of type 2 diabetes: barriers and facilitators identified by patients and health professionals. primary health care research & development.(2013) 14, (2)93-306.available from: https:www.ncbi.nlm.nih.govepubmed/23 739524 [accessed 13th oct 2019 ] [8] serour m, alqhenaei h, al-saqabi s, mustafa ar, ben-nakhi a. cultural factors and patients' adherence to lifestyle measures. british journal of general practice. 2007. 57(537):291-295.available from: https:// www.ncbi.nlm.nih.govepubmed/1739473 2 [accessed 10th oct 2019 ] [9] alquaiz am, tayel sa. barriers to a healthy lifestyle among patients attending primary care clinics at a university hospital in riyadh. annals of saudi medicine. 2009;29:30–5.available from: https:// www.ncbi.nlm.nih.gov/ pubmed/19139617 [accessed 13th oct 2019 ] recommandations conflict of intrest refrences https://doi.org/10.15218/ejnm.2020.12 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 106 erbil journal of nursing & midwifery [10] al-kaabi j, al-maskari f, saadi h, afandi b, parkar h, nagelkerke n. physical activity and reported barriers to activity among type 2 diabetic patients in the united arab emirates. the review of diabetics studies. 2009;6(4):271. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc2836198 / [accessed 10th sep 2019 ] [11] world health organization. global physical activity surveillance. in: chronic diseases and health promotion; 2016. http:// www.who.int/chp/steps/gpaq/en/ [accessed 20th august2019 ] [12] cdc. “overcoming barriers to physical activity”: centers for disease control and prevention, 2011. available from: https:// www.ucd.ie/issda/t4media/ barrierstobeingactivequestionnaire_section7_q4.pdf [accessed 19th dec 2019 ] [13] bull fc, maslin ts, armstrong t: global physical activity questionnaire (gpaq) nine country reliability and validity study. journal of physical activity health. 2009, 6:790–804. available from: https:// pdfs.semanticscholar.org/45fd/9a5df90a3b a5580428c3d3cc85e8c141a826.pdf [accessed 20th oct 2019 ] [14] cleland cl, hunter rf, kee f, cupples me, sallis jf, tully ma. validity of the global physical activity questionnaire (gpaq) in assessing levels and change in moderatevigorous physical activity and sedentary behavior. bmc public health. 2014;14:1255 –65. available from: https:// bmcpublichealth.biomedcentral.com/ articles/10.1186/1471-2458-14-1255 [accessed 17th oct 2019 ] [15] herrmann sd, heumann kj, der ananian ca, ainsworth be. validity and reliability of the global physical activity questionnaire (gpaq). measurement in physical education and exercise science. 2013;17:221–35. available from: https:// www.tandfonline.com/doi/ abs/10.1080/1091367x.2013.805139 [accessed 20th sep 2019 ] [16] shirin jm, liaquata , anthony b and dafna m. validity of the global physical activity questionnaire (gpaq) in bangladesh. bmc public health (2017) 17:650.available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc5553893/ [accessed 15th oct 2019 ] [17] fattahi a, barati m, bashirian s, moghadam rh. physical activity and its related factors among type 2 diabetic patients in hamadan. iranian journal of diabetes and obesity. 2014; 6(2), 85-92. ijdo.ssu.ac.ir [81] shazwani n, suzana s, hanis mastura y, lim cj, teh sc, mohd fauzee mz, et al assessment of physical activity level among individuals with type 2 diabetes mellitus at cheras health clinic, kuala lumpur. malaysian journal of nutrition. 2010; 16(1): 101 112. ncbi.nlm.nih.gov [81] naderimagham, s., niknami, s., abolhassani, f. 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(1), 103. available from: https:// bmcpublichealth.biomedcentral.com/ articles/10.1186/1471-2458-12-1035 [accessed 20th oct 2019 ] [02] mohamed ba ,almajwal am , saeed aa and bani ib. dietary practices among patients with type 2 diabetes in riyadh, saudi arabia. journal of food, agriculture & environment.2013;11(2):110-114. available from: https:// www.academia.edu/34494751/ dtary_practices_among_patients_with_typ e_2_diabetes_in_riyadh_saudi_arabia [accessed 18th dec 2019 ]. [08] alghafri t, alharthi sm, al farsi ym. perceived barriers to leisure time physical activity in adults with type 2 diabetes attending primary healthcare in oman: a cross-sectional survey. bmj open 2017;7:e016946. [00] palermo m, majorie; sandoval ma. assessment of physical activity level among patients with type 2 diabetes mellitus at the up – philippine general hospital diabetes clinic. journal of the asean federation of endocrine societies.2016; 31(2),144. available at: https:// asean-endocrinejournal.org/index.php/ jafes/article/view/336 [accessed 28th oct2019 ]. [02] arshad r, younis bb, masood j, tahira m, khurhsid s. pattern of physical activity among persons with type-2 diabetes with special consideration to daily routine. pakistan journal medical sciences. 2016;32 (1):234-238. https://doi.org/10.15218/ejnm.2020.12 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 107 erbil journal of nursing & midwifery [24] thomas n, alder e, leese gp. barriers to physical activity in patients with diabetes. postgraduate medical journal. 2004 may;80(943):287-91. available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc1742997/ [accessed 11th oct 2019 ] [25] fritschi c, fink ma. fatigue in adults with type 2 diabetes-an overview of current understanding and management approages.us endocrinology. 2012;8(2):8487. available from: https:// www.touchendocrinology.com/fatigue-inadults-with-type-2-diabetes-an-overviewof-current-understanding-andmanagement-approaches-2/ [accessed 12th oct 2019 ] [26] ghimires . barriers to diet and exercise among nepalese type 2 diabetic patients. hindawi international scholarly research notices volume 2017;2017 available from: https://www.researchgate.net/ publication/321062658_barriers_to_diet_and_ex ercise_among_nepalese_type_2_diabetic _patients [accessed 20th oct 2019 ] https://doi.org/10.15218/ejnm.2020.08 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article assessment of the levels of hopelessness among the patients with major depressive disorder in sulaimani city abstract introduction there is a growing belief that major depressive disorder (mdd) can be associated with increased feelings of powerlessness which leads to the cycle of loss. according to the cycle of loss, feelings of powerlessness leads to feelings of hopelessness, and can lead to a sense of despair which in turn leads into a deeper sense of loss . this cycle may continue overtime and perhaps leading to a suicidal behavior [1].research findings indicated an association between hopelessness with major depressive disorder [2, 3]. it can be the contributory factors to depression [4, 5]. in the view of tuck [6] hopelessness is a negative emotion characterized by a lack of hope, optimism and passion. hopelessness is both a cause and symptom of depression, and in the context of depression, it is a strong predictor of suicide according to previous studies [7]. lubow [8] noted that hopelessness can be a passing part of a depressive episode, or even a brief aspect of grief. hopelessness can be a long term pattern of thinking and feeling, and it is almost inevitably the result of trauma. living with feelings of hopelessness is very painful experience. other studies show that hopelessness also leads to low self-esteem [9] and may lead to ineffective problem solving in depressed background and objectives: major depressive disorder associated with greater morbidity and mortality. many researchers have sought complex association between depressions with hopelessness. the level of severity of such factors can play role in the causes, recovery and prediction of depression. the main objective of this study is to assess the levels of hopelessness among patients with major depressive disorder. methods: a quantitative descriptive study design was conducted at a psychiatric clinic in the ali kamal medical consultation center in sulaimaniya city. a non-probability, convenient sampling was recruited of 150 patients with major depressive disorder attending the psychiatric clinic. the data was collected from december, 21st, 2017 to april 1st, 2018 by the researcher of current study through the utilization of structured interview guided by the questionnaire. result: the results show that the patients with major depressive disorder experience moderate level to severe level of hopelessness. suicidal attempt is a highly significant factor affecting the levels of hopelessness. conclusions: the study concluded that hopelessness value on its own the strongest significant factor may represent emotional source and possibly used to handle or cope with depressed mood by the patients. keywords: major depressive disorder; depression; hopelessness; patients taha ahmad faraj; department of nursing, college of nursing, university of sulaimani, sulaimani, iraq. )correspondence: taha.faraj@univsul.edu.iq ) salwa shakir muhsin; department of nursing, college of nursing, university of sulaimani, sulaimani , iraq. 68 erbil journal of nursing & midwifery received: 19/8/2019 accepted: 27/11/2019 published: 30/5/2020 mailto:taha.faraj@univsul.edu.iq mailto:taha.faraj@univsul.edu.iq https://doi.org/10.15218/ejnm.2020.08 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article patients with suicidal ideation [10]. unfortunately, hopelessness condition is converted into specific symptom pattern of depression, and remains elusive [11]. huen [12] defined hopelessness as a powerful emotion that often contributes to low mood and may adversely affect the perception of oneself, others, circumstances and even the world. hopelessness can have a significant influence on human behavior as it may reflect an individual's negative view of the future. hopelessness in the depressed patient is extremely dangerous; not only is the depressed patient expressing depressed mood and behavior, they also perseverates on the pessimistic view that life is unbearable and positive change is unfathomable. various studies consistently reported that hopelessness is a key variable in linking depression to suicidal behavior [13]. britton [14] pointed that there is a significant correlation between hopelessness and suicidal ideation compared to depression and it is more precise in predicting eventual suicide. a person whose thoughts are hopeless and rigid may conclude that suicide is the only choice. the hopeless person may view death as a means to an end, an opportunity to escape the pain experienced in life. in addition, the impact of hopelessness leads to a lack of adequate coping skills. a person who is experiencing the conceptual feeling of hopelessness tends to think in extremely narrow term. some patients may deny feeling of hopelessness or depression and focus on identification of various somatic complaints as physical symptoms are more socially acceptable than those of psychological nature [15]. a quantitative-descriptive design was used. the study was carried out from december, 10th, 2017 to october, 1st, 2018. ethical approval for the use of the questionnaire of this study was issued by research ethical committee of the college of medicine/ university of sulaimani. verbal informed consent was taken from patients and relatives prior to participation and interviewing by the researcher for data collection. this study was carried out at a psychiatric clinic in ali kamal medical consultation center which is affiliated to the teaching hospital in sulaimani city. a nonprobability, convenient sample of 150 patients previously diagnosed with major depressive disorder who attended the psychiatric department were recruited. criteria for selection included: patients who have a diagnosis of major depressive disorder and are currently non-psychotic as assessed by the consulting psychiatrist; males and females ages 18 years and above and on regular treatment. patients who have a diagnosis of major depressive disorder with any co-morbid psychiatric or medical illness were excluded from the study. a questionnaire developed to achieve objectives of this study and beck hopelessness scale (bhs) used. this scale includes a list of 20 items with true/false keyed with total score ranging from 0-20 (0-3 minimal hopelessness, 4-8 mild hopelessness, 9-14 moderate hopelessness, and 15-20 severe hopelessness). statistical package for social science (spss) version 22 was used for data analysis. descriptive statistical data analysis was consist of frequencies, percentage, mean, and standard deviation. inferential statistical data analysis was consist of cronbach’s alpha , t-test, and analysis of variance (anova). table (1) shows that one-third of the sample (34.0%) are in the age group (28-37) years, and only (4.6%) of them are in age group more than 58 years. the mean of this age group 37.5 ± 11.3. more than half were male (66%) and married (58%). 69 erbil journal of nursing & midwifery methods results https://doi.org/10.15218/ejnm.2020.08 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article from uban area (78%) and only 6% of them were from rural area; in regard to religious status, the table shows that the majority of the participants (74%) engage in religious practice and the least of them (12%) do not engage in any religious practice. furthermore, 26% completed primary school education, while 20% graduated from a college or institution. two-thirds (66%) of the study sample are not employed, with barely sufficient economic status 52% and the majority of them were 70 erbil journal of nursing & midwifery table 1: distribution the socio-demographic characteristics of the sample sociodemographic characteristics frequency (percentage) age 18-27 year 28-37 year 38-47 year 48-57 year 58 year or more 31 51 40 21 7 (20.7) (34) (26.7) (14) (4.6) mean ± sd 37.5 ± 11.03 gender male female 99 51 (66) (34) marital status single married divorced widowed 33 87 24 6 (22) (58) (16) (4) educational level illiterate primary school intermediate school secondary school institute or university 36 39 24 21 30 (24) (26) (16) (14) (20) occupation employed unemployed 51 99 (34) (66) residential area urban sub urban rural 117 24 9 (78) (16) (6) economic status sufficient somehow sufficient insufficient 24 78 48 (16) (52) (32) religious-status practice partial practice non practice 111 21 18 (74) (14) (12) total 150 (100) https://doi.org/10.15218/ejnm.2020.08 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article while 32% of them have suicidal attempt and 12% of them attempted more than four attempts, then 8% of them attempted three attempts, also the same percentage (6%) of them attempted one or two attempts. around two-thirds of the study sample (68%) have no family history of mental illness, while 36% have family history of mental illness among them 24% related second degree of kinship while only 6% related to first and third degrees of kinship. 71 erbil journal of nursing & midwifery table (2) shows that more than half of the depressed patients their duration of illness ranged from 1-5 years (58%), and least percentage is from 16-20 years (4%). the majority of the study sample (74%) have no admission to mental hospital, only 10% of them have admitted once and 4% have their three times of hospitalizations and the same percentage (4%) have more than four times of hospitalizations. two third of the sample (68%) have no suicidal attempt table 2 :distribution of the sample according to their psychiatric history characteristics psychiatric history clinical characteristics frequency (percentage) duration of illness 1-5 years 6-10 years 11-15 years 16-20 years 21-25 years 87 36 12 6 9 (58) (24) (8) (4) (6) number of hospitalization non 1 time 2 times 3 times 4 times and more 111 15 12 6 6 (74) (10) (8) (4) (4) suicidal attempt no yes 102 48 (68) (32) number of suicidal attempt no attempt 1 attempt 2 attempt 3 attempt 4 attempt and more 102 9 9 12 18 (68) (6) (6) (8) (12) family history of mental illness no yes 96 54 (64) (36) family member with illness non first degree second degree third degree 96 9 36 9 (64) (6) (24) (6) total 150 (100) https://doi.org/10.15218/ejnm.2020.08 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 72 erbil journal of nursing & midwifery table(3)shows statistically non-significant difference between calculated mean ( =9.860) and theoretical mean (×=10) (test =0.367 sd ± 4.676) at ≤ 0.05 level. the results indicate that the level of hopelessness in general, was moderate among the patients with major depressive disorder. table (4) shows that the distribution of the patients according to the hopelessness scale index. the table shows that 40% of the total patients were having moderate level of hopelessness and the mean score ranged from 9-14, followed by 30% who experienced mild levels of hopelessness and the mean score ranged from 4-8, then 18% who experienced levels of severe hopelessness and the mean score ≥ 15, and 12% of the total sample were experiencing minimal level of hopelessness and the mean score ranged from 0-3.table (5) shows that there was statistically highly significant mean score of hopelessness (test =9.1204 at <0.001) in regard to patients attempted suicide. table 3 :the significant difference between calculated mean and theoretical mean in hopelessness measures for the sample using -test variable sample calculative mean standard deviation theoretical mean value level of significance hopelessness 150 9.860 4.676 10 0.367 non-significant table 4 :distribution of the sample according to the level of hopelessness statistical indicator level of hopelessness total minimal score 0-3 mild score 4-8 moderate score 9-14 sever score ≥15 frequency 18 45 60 27 150 percentage %12 %30 %40 %18 %100 table 5 :the differences of mean scores of hopelessness in regard to suicide attempt factor among patients variables suicide attempt number mean score standard deviation value level of significant hopelessness no 102 8.41 3.96 9.1204 0.001 yes 48 12.93 4.60 * sem = (0.3233 and 0.3756), df = 298 https://doi.org/10.15218/ejnm.2020.08 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 73 erbil journal of nursing & midwifery the findings showed that both the observed mean score 9.860 4.676 and theoretical mean score 10.0 4.676 have statistically non-significant differences (p>0.05) which means that high distribution of the study sample experiences moderate level of hopelessness (40%). findings are consistent with results of ribeiro[16] study in usa and vass [17] study in uk. hopelessness is the subjective appraisal of negative expectations about the occurrence of highly valued outcomes coupled with the sense that one lacks control over desired to event in the future [18].hopelessness has been related to the onset or development of depression [19]. in a systematic review study by soundy [20], hopelessness was identified as a major barrier to recovery from depression. a recent study noted that hopelessness is a powerful emotion that often contributes to low mood and can play a mediating role to effects symptoms and subjective recovery [12].although, the results of this study revealed a moderate (40%) to severe (18%) level of hopelessness among study patients, the mechanism of how hopelessness influences depression is not an objective of this study. however fortinash and worret [11] stated that unfortunately the specific mechanisms of hopelessness is converted into the specific symptom pattern of depression and hopelessness condition remains elusive. it is evident based on the results of present study that patients with major depressive disorder clearly experience a condition of hopelessness. in this study, suicidal attempts is a significant factor effecting hopelessness level (p <0.001). these results are consistent with the study by pomplim [19], kaviani [1] and ribeiro [16] which determined that hopelessness has been related to the onset or development of depression and is associated with suicidal ideation. it is also recognized as better predictor for suicidal intent than depression. these results are also in line with studies by fortinash and worret [11] which reported that suicide behaviors are symptoms of depressive episodes, other symptoms of depression relating to apathy, lack of motivation, and sadness. these symptoms as well as other symptoms of depression are all believed to flow from the condition of hopelessness. most of patients in this study were males with a mean age of 37.5 years, unemployed, living in urban areas, practicing religious activities and they were less likely to be admitted to hospital although duration of illness ranged from 1-25 years. the patients experience moderate level of hopelessness. suicidal attempt is a highly significant factor affecting the levels of hopelessness. importance of assessing hopelessness in patients with major depressive disorder and provide critical evidence of the need for nurses and clinicians to encourage patients to participate in social and recreational outpatient activities. the author report no conflict of interest. [1] kaviani h, rahimi m, rahimi-darabad p, naghavi hr. overgeneral memory retrieval and ineffective problem-solving in depressed patients with suicidal ideation: implications for therapy. international journal of psychology & psychological therapy. 2011;11(3). [2] avila fm. self-esteem, spirituality, and acculturation and the relationship with depression in latinos. 2014. discusion conclusion recommendation conflict of interest references https://doi.org/10.15218/ejnm.2020.08 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 74 erbil journal of nursing & midwifery [3] schneider ma, schneider md. recognizing post-stroke depression. 2012; 42(12):60-3. [4] lee a. does self-esteem mediate the effect of attachment of relationship quality. 2014.6420.https://scholarsarchive.byu.edu/ etd/6420. [5] yaacob sn, juhari r, talib ma, uba i. loneliness, stress, self-esteem, and depression among malaysian adolescents. journal kemanusiaan. 2009;7(2). [6] tuck i. a critical review of a spirituality intervention. western journal of nursing research. 2012;34(6):712-35. [7] mohammed t. m. effectiveness of psychoeducational program on negative selfconcept and suicidal ideation of patients with major depressive disorder in psychiatric department in general hospital in sulaimani city. unpublished phd dissertation, 2012. [8] hepp u, wittmann l, schnyder u, michel k. psychological and psychosocial interventions after attempted suicide. crisis. 2004 may;25(3):108-17. [9] lubow c. experiences of depression: hopelessness, good therapy. 2011. https:// www.goodtherapy.org. [10] ahmad a, altaf m & jank. loneliness, selfesteem and depression among people of kashmir. the international journal of indian psychology.2016.vol.3,issue4. dip:18.01.072120160304. [11] fortinash k. m. & worret p. a., (eds). psychiatric mental health nursing (5th ed.). 2012. st. louis, mo: elsevier/ mosby. [12] huen jm, ip by, ho sm, yip ps. hope and hopelessness: the role of hope in buffering the impact of hopelessness on suicidal ideation. plos one. 2015;10(6):e0130073. [13] barker , d. the who is suicidal. psychiatric mental health nursing: the craft of caring. london, uk: hodder arnold. 2009. [14] britton pc, duberstein pr, conner kr, heisel mj, hirsch jk, conwell y. reasons for living, hopelessness, and suicide ideation among depressed adults 50 years or older. the american journal of geriatric psychiatry. 2008;16(9):736-41. [15] hall mf, hall se. managing the psychological impact of medical trauma: a guide for mental health and health care professionals. usa, springer publishing company; 2016. [16] ribeiro jd, huang x, fox kr, franklin jc. depression and hopelessness as risk factors for suicide ideation, attempts and death: meta-analysis of longitudinal studies. the british journal of psychiatry. 2018; 212 (5):279-86. [17] vass v, morrison ap, law h, dudley j, taylor p, bennett km, et al. how stigma impacts on people with psychosis: the mediating effect of self-esteem and hopelessness on subjective recovery and psychotic experiences. psychiatry research. 2015; 230(2):487-95. [18] fraser l, burnell m, salter lc, fourkala eo, kalsi j, ryan a, et al. identifying hopelessness in population research: a validation study of two brief measures of hopelessness. bmj open. 2014; 4(5):e005093. [11] pompili m. exploring the phenomenology of suicide. suicide life threat behavior. 2010. 40:234–44. [20] soundy a, stubbs b, roskell c, williams se, fox a, vancampfort d. identifying the facilitators and processes which influence recovery in individuals with schizophrenia: a systematic review and thematic synthesis. journal of mental health. 2015 mar 4;24 (2):103-10. https://doi.org/10.15218/ejnm.2021.08 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article dietary habits among medical science students in duhok city abstract introduction background and objectives: students at the university level are more exposed to changes in physical and social status and lifestyle changes, which will affect students’ eating habits. this study aimed to assess dietary habits among medical science students in duhok city. methods: a descriptive cross-sectional study was conducted from 20th january 2019 to 28th april 2019. the cluster sampling procedure enrolled 359 medical science students aged 18-26 years from five medical science colleges in duhok city. dietary habits were obtained by direct interview. the questionnaire consists of three parts: socio-demographic characteristics, questions regarding main meals, and measuring dietary habits using a likert scale. data were analyzed using spss version 23. results: most of the study participants were males 56.8% with a mean age was 21 years. slightly more than half of the students 52% claimed they ate three main meals every day and about 11% skipped it. about 45% of the participants ate breakfast every day. the most frequently eaten meals and beverages among students were soft drinks 80%, rice 80%, snacks 72%, and sweats/chocolate 70%. decreased intake of fruits 60%, vegetables 50%, and dairy products 38% were observed. there were significant differences among males and females in food consumption and beverages namely, sports drinks, eggs, cheese, red meat, chips, and sweets/chocolate. conclusion: the current study indicated that skipping meals was typical among students. most students had unhealthy food habits and behaviors according to the standard recommendations for eating and drinking daily. the assessment of dietary habits as a part of the health component can serve as a screening tool to identify adult students to improve their well-being and dietary habits. keywords: dietary habits, medical students, nutrition, duhok city, kurdistan region, iraq dilkhosh shamal ramadhan; department of nursing, college of nursing, duhok university, duhok, iraq. (correspondence: dilkhosh.ramadhan@uod.ac) arazoo issa tahir;department of nursing, bardarash technical institute, duhok polytechnic university. rebar yahya abdullah; department of nursing, college of nursing, duhok university, duhok, iraq. 69 erbil journal of nursing & midwifery received: 13/07/2021 accepted: 26/09/2021 published: 30/11/2021 proper eating is one of the most effective methods to improve one's overall health. a well-balanced diet should include a variety of raw and fresh meals, plenty of fruits, vegetables, as well as vitaminand mineral-dense foods and beverages. a healthy lifestyle also includes regular physical activity and dietary choices suitable for both physical and mental wellbeing [1, 2, 3]. for various causes and obstacles, university populations are particularly vulnerable in terms of their dietary habits [4]. a variety of factors, such as a new environment, study stress, a lack mailto:arazoo.tahir@dpu.edu.krd) https://doi.org/10.15218/ejnm.2021.08 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article of adequate time management and hectic class schedules, and the cost of healthy food, can all contribute to a lack of interest in their well-being [3, 4]. most students engage in unhealthy eating and lifestyle habits throughout this stage of their lives, including meal skipping, snacking, fast-food intake, smoking, and excessive internet usage [5]. personal and environmental factors both influence and are influenced by one's eating habits. people are influenced by psychological and biological elements, whereas these same aspects influence the immediate social environment. aside from school lunches and fast-food restaurants, other aspects to consider are the community, which includes family members, friends, and peer networks. [6] another critical issue is the social framework, often known as the macro system, which comprises elements such as mass media, marketing, and advertising, in addition to society's social and cultural standards. a growing body of evidence and study indicates that some aspects of eating behaviors are critical in managing weight and overall health [7]. contextualizing advice and providing realistic counsel on appropriate meal consumption, including which meals should be consumed more frequently and in which combination, and at what times will aid in developing and translating dietary recommendations. the majority of students in the kurdistan region experiences challenges during their academic careers, prompting the current study to assess dietary habits and eating patterns of medical university students in duhok city. the objectives of the study are to assess dietary habits among medical science students, find out consumption of diets per week, determine patterns of eating according to main meal and to find out male and female behaviors regarding dietary habits. design and sampling procedure from the 20th of january 2019 to the 28th of april 2019, the present study was conducted at medical science/colleges in duhok, and it was designed as a descriptive crosssectional study. students ranging in age from 18 to 26 years old were chosen from a pool of 359 students 56.8 % males and 43.2% females. the sample size calculated from a total of 2147 students was 326. to decrease bias and increase representativeness, this number increased to 359 [8]. each of the five medical science colleges provided samples for this study from different disciplines, including nursing, medicine, pharmacy, dentistry, and health sciences. students were selected using a basic random sample technique after using the cluster sampling procedure. direct interviews were used to obtain information about students’ food habits and sociodemographic characteristics. the questionnaire consisted of two components: questions surrounding socio-demographic characteristics and questions assessing nutritional behaviors. dietary habits were measured using a likert scale (always (7 days per week), sometimes (3 days per week), and never (never at all/0 days per week). daily and weekly eating and drinking habits were assessed with questions about foods that were eaten including breakfast, the number of snacks and main meals throughout the day, intake of fruits, vegetables, and rice and dairy products. data were analyzed using spss version 23 for descriptive statistics such as frequency and percentages, along with t-tests and analysis of variance to examine various forms of eating behavior (dependent variable) and gender (two categories), as well as (years). 70 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2021.08 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article and vegetables and dairy products (38%) were the lesser consumed foods and beverages. gender seems to influence food and beverage consumption frequency, as shown in table 3. the most common foods influenced by gender were sport drinks with (mean difference -2.1, t-value-13.3, pvalue 0.0001), red meat (mean difference 0.44, t-value -5.43, p-value 0.0001), and chips (mean difference 0.59, t-value 4.03, p -value 0.003). other food items include sweets/chocolate (mean difference 0.40, tvalue 3.1, p-value -0.02), cheese (mean difference 0.07, t-value 49, p-value 0.017), and eggs (mean difference -0.24, t-value1.63, p-value 0.03). it is also important to highlight that breakfast meals were also influenced by gender (mean difference 0.44, t-value-2.8, p-value 0.001). there were no variations in how males and females consumed other foods. three hundred and fifty-nine medical students participated in this study, of which 204 (56.8%) were males. the age of students ranged from 18 to 26 years with a mean age of 21 years. most of the respondents were students at colleges of medicine 31.1% and pharmacy 23.5%. the higher percentage of students was in their first year (24.2%) and third year (24.5%) as shown in (table 1). approximately more than half (52%) of students had three main meals and 11% skipped them. of the students that had three main meals, 45% always eat breakfast, and 19% never have breakfast. as illustrated in (figure 1), the most consumed foods and beverages per week among medical science students were soft drinks (80%), rice (80%), snacks (72%), and sweets (70%). fruits (60%), eggs (58%), chips (54%), red meat (52%), fried foods (50%), 71 erbil journal of nursing & midwifery table 1: demographic characteristics of medical science students f (%) character age 115 (32) 18-20 177 (49.3) 21-23 67 (18.7) 24-26 sex 204 (56.8) male 155 (43.2) 57 (15.9) 112 (31.1) 50 (13.9) 84 (23.5) 56 (15.6) 87 (24.2) 66 (18.4) 88 (24.5) 67 (18.7) 38 (10.6) 13 (3.6) female colleges nursing medicine dentistry pharmacy health sciences classes 1st class 2nd classes 3rd classes 4th classes 5th classes 6th classes 359 (100) total results table 2: patterns of eating according to main meals servings per weak main meals (%) breakfast (%) always 188 (52) 163 (45) sometimes 134 (37) 130 (36) never 37 (11) 66 (19) total 100 100 figure 1: consumption of food items per. week https://doi.org/10.15218/ejnm.2021.08 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article medical students must have a positive outlook toward a balanced lifestyle and eating practices as they will be the future healthcare providers who will affect the public. the data indicate that medical students in duhok medical universities have negative attitudes and a lack of awareness and good practices selecting nutritious and safe foods and beverages. students' eating habits have never been addressed, and the need to track eating habits among students has grown in recent years as the number of students enrolled each year has increased. in this study, eating habits of medical science students revealed that slightly more than half of the students ate daily meals; this result was higher than those recorded in saudi arabia, such as the college of health sciences at rass, qassim university (36.7%) [9], and abha university (31.0%) [10]. meanwhile, this result was lower than those recorded for chinese (83.6%) [11], lebanese (61.4%) [12], iraq (56.7%) [13], and malaysian medical students (57.6%) [14]. breakfast was the most commonly skipped meal, with only around half of students eating breakfast every day. a similar propensity for missing breakfast 72 erbil journal of nursing & midwifery table 3: mean weekly consumption of food items of medical students according to genders. p-value t-value mean difference female (n=154) mean s.d. male (n=204) mean s.d. food items 0.77 0.40 0.055 1.23 3.20 1.27 3.26 fresh fruits 0.33 0.37 0.050 1.34 3.33 1.18 3.38 raw vegetables 0.0001 -13.3 -2.1 1.76 3.31 0.98 5.42 sport drinks 0.300 1.25 0.19 1.51 4.03 1.38 4.22 milk 0.786 -0.49 -0.07 1.47 3.65 1.43 3.58 fried food 0.017 0.49 0.07 1.50 3.84 1.23 3.91 cheese 0.295 0.96 0.14 1.49 3.95 1.38 4.10 yogurt 0.032 -1.63 -0.24 1.41 3.56 1.38 3.31 eggs 0.218 0.2 0.03 1.20 2.62 1.44 2.65 rice 0.243 1.67 0.23 1.23 2.20 1.36 2.44 soft drinks 0.021 3.1 0.40 1.41 2.65 1.36 3.11 sweets/ chocolate 0.0001 -5.43 -0.79 1.40 4.00 1.35 3.20 red meat 0.070 -1.62 -0.21 1.09 3.67 1.30 3.46 chicken meat 0.423 -1.5 -0.22 1.49 3.14 1.33 2.91 snacks 0.003 4.03 0.59 1.40 3.07 1.37 3.67 chips 0.109 2.3 0.30 1.22 4.24 1.25 4.55 macaroni/spaghetti 0.001 -2.8 -0.44 1.61 3.12 1.40 2.67 breakfast (s.d= standard deviation) *statistical significance set at p≤ 0.05 and calculated with t-test, t-value, mean difference and significant values are in bold. discussion https://doi.org/10.15218/ejnm.2021.08 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article conducted among school kids in the kore sub-district of erbil in iraq's kurdistan region, which found that milk and dairy products were consumed more frequently (83.8%) [13]. taking into account the gender differences in food consumption among medical students, the current study found that female students consume significantly more sports drinks, breakfast, energy drinks, red meat, cheese, eggs, sweets/chocolate, and chips than male students. in kuwait, similar findings were discovered: male students consume more sports drinks, cheese, and chips, whereas female students consume fast food, highfat foods, sweets, soft drinks, and chips [30]. another study conducted in iraq, which supports the current findings, found substantial variations in the intake of energy drinks, sugar-sweetened drinks, sweets/ chocolate consumption, and fast food consumption between males and females [19]. gender differences were observed in a study of teenage consumption of fast food, sweets, red meat, and sugary beverages in syria [31]. unhealthy eating patterns have become a significant concern worldwide resulting in a rise in the community's incidence of non-communicable diseases in the future. students are not immune to this phenomenon, as their eating patterns change while at university. in other contexts, it has already been mentioned how difficult it is for students to maintain healthy eating habits. food preferences are affected by several factors, including changes in lifestyle, the convenience of fast foods, taste, and the physical and social environment in which they live. according to the current study, skipping meals was common among students. the majority had unhealthy food habits and behaviors based on the standard food groups' daily eating and drinking 73 erbil journal of nursing & midwifery has been recorded among iraqi medical students [13], malaysia [15], turkish [16], and india [17]. meal skipping was prevalent, which may be attributed to students' changing life habits, time, study, and the fact that some students live far from family. educational initiatives in the kurdistan region aimed at improving healthy eating habits must be initiated. the current study's findings contradict those of studies conducted in saudi arabia (22%) [18], (20.4) [2], bahrain (26.3%) [19] and pakistan (20%) [20]. however, higher consumption (81.8%) was recorded by another study [14]. adults can consume a minimum of five servings (400 g) of vegetables and fruits each day, according to the world health organization (who) [21]. the majority of students eat fried food 50 % of the time; this may be attributed to fast food's low cost, good taste, and the fact that they did not have time to prepare meals. fried food consumption was found to be similar in both groups [14]. in the present study, rice, soft drinks, sweets/chocolates, and snacks were eaten by the vast majority of students more than any other form of food. this reveals that medical students have poor eating habits and that immediate action is required since soft drink use increases the risk of obesity and type 2 diabetes mellitus [22]. furthermore, frequent snacking and eating fried meals might be harm students' health due to the availability of energy-dense and high-fat elements found in these foods [23]. the result of the current study was in agreement with the results of other studies [24, 19, 25]. however, these findings were higher than other studies that reported lower intake in eastern india [26], and in sudan [27]. in addition, low consumption of milk and dairy products among students was common in this study, which was similar to other studies [28], [29]. however, this result was lower than that of a study conclusion https://doi.org/10.15218/ejnm.2021.08 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article recommendations. there were differences among males and females in consuming some .foods and beverages. the health component's assessment of dietary habits can be used as a screening tool to identify adult students who need to improve their well-being and healthy diets. include nutritional health education messages and the appropriateness of proper food choices in each health educational plan. emphasis should be placed on the importance of breakfast, the dangers of eating unhealthy fast food, high-calorie snacks regularly, and the importance of certain food products in obesity prevention. high-calorie items including chips, sweetened beverages, and other highcalorie foods can be avoided by consciously engaging with the media. there is no conflict of interest . the study was given ethical approval by the scientific committee of the university of duhok's college of nursing and duhok directorate general of health. each participant gave written informed consent at the beginning of the study. all participants' rights to privacy and policy were maintained. [1] hilger j, loerbroks a, diehl k. eating behaviour of university students in germany: dietary intake, barriers to healthy eating and changes in eating behaviour since the time of matriculation. appetite. 2017 1;109:100-7. [2] alzahrani sh, saeedi aa, baamer mk, shalabi af, alzahrani am. eating habits among medical students at king abdulaziz university, jeddah, saudi arabia. international journal of general medicine.2020;13:77-88. https:// doi.org/10.2147/ijgm.s246296 . [3] el-mani sf, mansour rm, abdessamad ae, al-abbar ea, shallouf n, amer r. factors influencing eating behavior of benghazi university students. asian journal of medical sciences. 2020;11(4):20-9. [4] hernandez kong, joany and bamwesigye, dastan and horák, miroslav. eating behaviors of university students. mendelnet 2016.thesis (unpublished), 106s., ankara. [5] ferreira-pêgo c, rodrigues j, costa a, sousa b. eating behavior: the influence of age, nutrition knowledge, and mediterranean diet. the journal of nutrition and health. 2020;26(4):303-9. [6] nelson mc, story m, larson ni, neumarksztainer d, lytle la. emerging adulthood and college-aged youth: an overlooked age for weight-related behavior change. obesity. 2008 1;16(10):2205. [7] st-onge mp, ard j, baskin ml, chiuve se, johnson hm, kris-etherton p, et al., frequency: implications for cardiovascular disease prevention: a scientific statement from the american heart association. circulation. 2017; 135:e96–e121. [8] the survey sysytems, 2012 availabe at https://www.surveysystem.com/sscalc.htm. [9] al-rethaiaa as, fahmy ae, al-shwaiyat nm. obesity and eating habits among college students in saudi arabia: a cross sectional study. the journal of nutrition. 2010;9(1):10. [10] alshahrani mm, chandramohan s. a crosssectional study on prevalence of obesity and its association with dietary habits among college students in abha, saudi arabia. the international journal of community medicine and public health. 2017;4(5):1406– 1412.doi:10.18203/23946040.ijcmph201717 47. [11] sakamaki r, toyama k, amamoto r, liu c-j, shinfuku n. nutritional knowledge, food habits and health attitude of chinese university students–a cross sectional study. bmc nutrition. 2005;4(1):4. [12] rizk s, yahia n, achkar a, abdallah a. eating habits and obesity among lebanese university students. the journal of nutrition. 2008;7:32. [13] al-asadi jn. perceived stress and eating habits among medical students. international journal of medical research and pharmaceutical sciences. 2014;4(3):81-90. [14] ganasegeran k, al-dubai sa, qureshi am, alabed a-aa, rizal a, aljunid sm. social and psychological factors affecting eating habits 74 erbil journal of nursing & midwifery conflict of interest ethical considerations recommendation references https://doi.org/10.15218/ejnm.2021.08 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article behaviors across seven semesters of college: living on or off campus matters. health education & behavior. 2013;40(4):435-41. [26] mohanty bb, pradhan s, nayak l, baisakh p, nayak g, chinara pk. food habits of medical students: a study among the students of a health university in eastern india. journal of the anatomical society of india. 2017;66:s66. [27] al-haj me, awooda ha, elnimeiri mk. eating habits among medical students in a sudanese medical faculty. international journal of research in medical sciences. 2015;3(3):649. [28] lupi s, bagordo f, stefanati a, grassi t, piccinni l, bergamini m, et al., assessment of lifestyle and eating habits among undergraduate students in northern italy. annali dell'istituto superiore di sanita. 2015;51:15461. [29] al-jawaldeh a, rayner m, julia c, elmadfa i, hammerich a, mccoll k. improving nutrition information in the eastern mediterranean region: implementation of front-of-pack nutrition labelling. nutrients. 2020;12 (2):330. [30] ahmed f, al-radhwan l, al-azmi gz, albeajan m. association between stress and dietary behaviours among undergraduate students in kuwait: gender differences. journal of nutrition and health sciences. 2014;1 (1):1-8 [31] musaiger ao, kalam f. dietary habits and lifestyle among adolescents in damascus, syria. annals of agricultural and environmental medicine. 2014;21(2). among university students in a malaysian medical school: a cross-sectional study. bmc nutrition. 2012;11(1):48. [15] chin ys, mohd n. eating behaviors among female adolescents in kuantan district, pahang, malaysia. pakistan journal of nutrition. 2009;8(4):425-32. [16] huang tt, harris kj, lee re, nazir n, born w, kaur h. assessing overweight, obesity, diet, and physical activity in college students. journal of american college health. 2003;52(2):83-6. [17] kerwani t, gupta s, epari v, sahoo j. association of skipping breakfast and different domains of cognitive function among undergraduate medical students: a crosssectional study. indian journal of physiology pharmacology. 2020:64(2):137-41. [18] al-otaibi hh. the pattern of fruit and vegetable consumption among saudi university students. global journal of health science. 2014;6(2):155. [19] musaiger ao, al-mufty ba, al-hazzaa hm. eating habits, inactivity, and sedentary behavior among adolescents in iraq: sex differences in the hidden risks of noncommunicable diseases. food and nutrition bulletin. 2014;35(1):12-9. [20] khalid u, nosheen f, raza ma, et al. a comparative study about the daily intake of fruits and vegetables among female students of two universities of faisalabad. pakistan journal of nutrition. 2011;10 (7):684–689.doi:10.3923pjn.2011.684.689. [21] world health organization and food and agriculture organization of the united nations. fruit and vegetables for health. report of a joint fao/who workshop, 1– 3, 2004, kobe, japan. philippines. available athttps://www.who.int/ dietphysicalactivity/fruit/en/. [22] malik vs, hu fb. sweeteners and risk of obesity and type 2 diabetes: the role of sugar-sweetened beverages. current diabetes reports. 2012;12(2):195-203. [23] yahia n, achkar a, abdallah a, rizk s. eating habits and obesity among lebanese university students. journal of nutrition. 2008;7(1):1-6. [24] adelina r. the trend of consumption pattern among college students in malang city. berita kedokteran masyarakat. 2018;34(5):8-6. [25] small m, bailey-davis l, morgan n, et al. changes in eating and physical activity 75 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.03 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article midwives’ views and perceptions of patient dignity in midwifery services abstract introduction human dignity has been defined as respecting human individuality. in this definition, each individual is regarded to be a unique human being *1+. it is highly recommended that human dignity must be respected in healthcare settings *2+. in the moral codes of midwifery profession, human dignity has been referred to as an obligation and a human right *3+. as a result of human dignity being maintained, a feeling of being valued develops in the individuals, leading to a rise in trust *4+. as defined by the world health organization, dignity is the inherent value and worth felt by individuals, and it is strongly linked to freedom of choice, self-worth, recognition, and respect *5+.the essence of midwifery is caring which has root in human trait and emotion *6+. the purpose of midwifery caring is to support and help women during childbearing; therefore, the nature of midwifery caring is different from caring in other health professions *7+.in midwifery, the quality of caring increases highly once dignity and respect are taken into account *8+. in this regard, it is highly significant for midwifery professionals to create effective interpersonal relationships with their clients *9+. however, it should be noted that there is much background and objective: human dignity which is defined as respect to human individuality is a highly recommended necessity to be taken into account in medical settings to deliver high-quality services and raise the patients’ satisfaction. due to a lack of well-defined provisions and instructions in midwifery practice in the kurdistan region of iraq, human dignity is threatened in this field. the present study was an attempt to figure out the meaning of patient dignity, what threatens patients’ dignity, and how to promote patients dignity in midwifery settings in maternity departments and clinics in erbil, in the kurdistan region-iraq. method: the present qualitative study was conducted on 10 kurdish registered midwives who were working delivery room of maternity teaching hospital and dyke private hospital located in erbil, iraqi kurdistan. in-depth semi-structured interviews were conducted with the midwives to collect required data. the interviews were recorded and then transcribed verbatim and analyzed using the six methodological activities proposed by van manen, and the themes and subthemes were extracted. results: analyzing the transcribed interviews resulted in emergence of one main theme, namely “need for holistic support” which had subthemes, namely “need for medical support”, “need for mental support”, and “need for sympathetic support”. conclusion: human dignity of pregnant and childbearing mothers in maternity departments and clinics is relatively low due to lack of sufficient equipment and facilities and insufficient number of midwives and maternity staff. therefore, appropriate measures need to be taken in these regards. keywords: human dignity, midwifery, maternity wards, pregnancy, childbearing women tiran jamil piro; department of midwifery , college of nursing, hawler medical university, erbil, iraq. (correspondence: tiran.piro@hmu.edu.krd ) 23 erbil journal of nursing & midwifery received: 25/08/2020 accepted: 14/12/2020 published: 30/05/2021 mailto:tiran.piro@hmu.edu.krd https://doi.org/10.15218/ejnm.2021.03 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article controversy on the elements of respectful care in midwifery practice *10+.childbirth is a scary and painful experience for most women, which can be relieved by promoting women’s emotional wellbeing through provision of quality midwifery care during pregnancy and at birth *11+. despite the significance of midwifery care, research has indicated that many women have described their encounters with midwives as uncaring *12+, and some women have reported that midwives do not usually behave with dignity and respect *13+. there are other reports by pregnant women showing midwifery care lacking emotional support, sympathy, and compassion. in justification of such behavior, some have referred to issues like administrative overload and the organization structure *14+. patient dignity in midwifery settings has been focused on very few studies. moreover, the effect of midwives’ behavior at workplace on patient dignity has rarely been studied via observation *15, 16+. according to the results of the studies carried out in the kurdistan region of iraq, maternity and midwifery services are negatively affected by professional unaccountability, lack of job description, and limited health resources which in turn have negative impact on the patient’s health and dignity *17+.give the significance of human dignity in delivery of quality maternity services and mothers’ overall wellbeing, and since human dignity is a complex human phenomenon and can be studied well through individuals’ lived experiences, the present study was carried out to investigate the meaning of patient dignity, how patients’ dignity is threatened, and how patients’ dignity is promoted in midwifery settings. the present qualitative phenomenological study was carried out by using van manen’s hermeneutic phenomenological method *18+. from december 2019 to february 2020 to achieve a deep understanding of human dignity of mothers according to midwives working in maternity departments and delivery rooms of erbil, iraqi kurdistan. phenomenological researchers seek to ask how persons experience their lived world. max van manen’s hermeneutic phenomenological approach is especially relevant to nursing research as it provides a way to understand how the persons experience their world. this approach also provides six steps of data analysis which encourages the nursing researchers to craft the texts in order to develop the structure of meaning of the texts or themes. then, the researchers would be able to understand the meaning of the experience of the participants as they lived in it and the knowledge would provide services or strategies to help them more effectively. the study sample consisted of 10 kurdish registered midwives who were working delivery room of maternity teaching hospital and dyke private hospital located in erbil, iraqi kurdistan. this number of participants based on data saturation because the goal of qualitative research is achieving data saturation or redundancy. saturation occurs when adding more participants to the study does not result in obtaining additional perspectives or information. they were selected from among registered midwives by using purposive sampling based on some inclusion criteria: work experience of more than 1 year, speaking and understanding kurdish, and willingness to participate in the study. semi-structured in-depth interviews are employed in order to collect required data in phenomenological studies *19+; therefore, the midwives in the present study were interviewed face-to-face. for this purpose and to elicit required information about the interviewees’ lived experiences regarding human dignity of mothers, they 24 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2021.03 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article which were recorded at the interviewees’ permission and then transcribed verbatim and translated into english for analysis *after obtaining permission from the interviewee+. each interview lasted between 30 and 60 minutes that was continued until data saturation occurred. transferability, conformability, dependability, and credibility which are lincoln and guba’s four-criterion gold standard were used to make sure about the rigor of the study *20+. also, memberand peerchecking techniques proposed by devadas (2016) *21+ were employed to make sure about the credibility of the findings, which was also ensured through the researcher’s prolonged engagement with the data and referral to maternity departments and clinics in erbil to communicate with the participants effectively and elicit reliable data from them. required approval on the research protocol was obtained from the ethics committee of hawler medical university/ college of nursing. moreover, the participants were provided with a thorough explanation about the study’s aims, method of data collection, their information confidentiality, and their right to withdraw from the study at any phase. in addition, informed participation consent was obtained from the participants. the midwives also permitted the researcher to record the interviews. furthermore, each midwife was given a unique code (midwife 1= m1midwife 2, =m2, etc.) in order to keep the collected data anonymous. were asked open-ended questions, such as “what do you think about aspects of human dignity according to your experience of working here?” to elicit more detailed information, exploratory questions like how and what questions were used. kurdish was the language of the interviews the transcripts of the interviews were analyzed following the six methodologicalactivities proposed by van manen *18+ (see table 1). 25 erbil journal of nursing & midwifery data analysis table 1: van manen’s six methodological activities *18+ van manen’s methodical activities the researchers’ activities approaching the nature of lived experience pregnancy and childbirth are among the most significant events in every woman’s life. without appropriate maternity and medical care and also psychological support from maternity team, human dignity of mothers can be negatively affected. investigating experience as it is lived selecting midwives with sufficient experience. thinking about the major themes as the characteristics of the phenomenon utilizing thematic analysis using the art of writing and rewriting to describe the phenomenon through creating a phenomenological text through writing and rewriting maintaining a strong and oriented relation to the phenomenon discussing the themes about phenomena balancing the research context by considering the parts and the whole moving between transcripts and themes trustworthiness ethical consideration https://doi.org/10.15218/ejnm.2021.03 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article according to study result the selected midwives’ age ranged from 25 to 56 years, and their work experience from 1 to 37 years. with regard to their education level, most of them were graduates of midwifery institutes (n=5), some studied midwifery school (n=4), and one of them graduated from university and had bachelor’s in midwifery. analyzing the interview scripts led to the emergence of one main theme which was labeled as “need for holistic support”, and it consisted of three subthemes, namely “need for medical support”, “need for mental support”, and “need for sympathetic support”. the midwives’ lived experiences regarding the aspects of human dignity and its status in the studied maternity departments and clinics were interpreted as pregnant women and mothers’ need for holistic support. the midwives believed that mothers’ human dignity can be raised and maintained if they are provided with comprehensive support which gives them the feeling that they are well-valued. in this regard, midwife 4 said: “human dignity can be achieved in many ways. as far as pregnant women are concerned, i guess if they are given sufficient support and help, their human dignity will be ensured. in our maternity department, we pay close attention to mothers’ needs and try to meet them. due to some shortages; however, we may fail to provide full support and meet every single need of the mothers.” comprehensive support was also mentioned by midwife 7 who stated: “being pregnant especially for those with their first experience can be quite worrying and apprehensive. however, if comprehensive support is provided, mothers can feel better, which also raises their human dignity by giving them a sense of being valued. unfortunately, due to various issues, such as huge workload in maternity departments and lack of sufficient maternity staff, comprehensive support and help are sometimes difficult to provide. ”first subtheme: need for medical support one of the most frequent types of support mentioned by almost all of the midwives was medical support. they stated that what mothers expect from them more than anything else is medical help and support. they linked medical support and human dignity by referring to the sense of value that mothers have after receiving a good deal of medical support. in this regard, midwife 2 said: “i’ve been working as a midwife for more than 15 years, and i know what makes mothers satisfied. they’d like to be provided with good medical care. i guess provision of good medical care also raises the level of human dignity among mothers.” 26 erbil journal of nursing & midwifery results table 2: below shows the participants’ demographic characteristics. demographic characteristics n(%) sex female 10(100.0) male 0(0.0) age (years) 25-30 2(20.0) 31-40 3(30.0) 41-50 3(30.0) 51-60 2(20.0) place of residence urban 10(100.0) rural 0(0.0) level of education midwife4(40.0) institute 5(50.0) bachelor 1(10.0) work experience (years) 1-10 2(20.0) 11-20 3(30.0) 21-30 3(30.0) 31-40 2(20.0) main theme: need for holistic support https://doi.org/10.15218/ejnm.2021.03 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article of human dignity.” in addition, midwife 10 stated: “respecting mothers along with sympathizing with them can give them the feeling that they are valued. although i don’t have enough time to spend with mothers and sympathize with them, i treat them with full respect and show my sympathy in my behavior. i know it may not be sufficient, but i guess it does the trick and raise the level of their human dignity.” third subtheme: need for mental support pregnancy can threaten women’s mental health if they are not provided with sufficient mental support. this is particularly true about those with their very first experience. therefore, one of the human responsibilities of maternity team and midwives is to help mothers and pregnant women psychologically. in this regard, midwife 3 said: “due to the special cultural structure of kurdish families, pregnant women in some families do not normally receive appropriate psychological support from their families particularly from their husbands. therefore, once they refer to us, they are usually in a poor mental state, so in addition to maternity services, we need to prepare them mentally to become a mother. because in primary health care centers they took just medical support without emotional support or advices. however, again due to the culture in the region, which encourages people to have many children, delivery rooms and maternal wards are always crowded, and midwives do not usually have sufficient time to spend with mothers and provide mental support fully for labor. that is why i suggest hospitals that they employ a psychologist to assist maternity wards and delivery rooms in this regard.” in the same regard, midwife 9 said: “being pregnant and becoming a mother can be an overwhelming experience. that is why such women need to be supported psychologically. midwives can provide mental support; however, our 27 erbil journal of nursing & midwifery despite the significance of medical care and support, the midwives revealed the fact that their departments were not wellequipped and facilitated, as a result, they sometimes fail to provide sufficient medical care. in this regard, midwife 5 said: “our department is undermanned. also, it is not well-equipped. so, it is quite common that mothers may not receive full medical care, which i’m quite sure has a negative effect on their personality and human dignity.” similarly, midwife 8 stated: “maternity wards are usually crowded, and the facilities and equipment are not enough to respond to every single mother’s need for medical support fully. in addition to equipment, we need more midwives and maternity staff to provide better maternity services and medical care which will raise our clients’ human dignity.” second subtheme: need for sympathetic support another important aspect of support mentioned by most of the midwives was the mothers’ need for sympathetic support. they referred to this kind of support as the most important factor in enhancing mothers’ human dignity and selfvalue. in this regard, midwife 1 related: “in addition to maternity care, one thing they need is sympathetic help. this is even more important for those women who are experiencing their first pregnancy. i usually listen to them and try to give them sympathetic support, too. however, given the crowdedness of department and shortage of time, sometimes i’m just able to give them maternity care and advice.” moreover, midwife 6 said: “there are just two midwives in our super-crowded delivery room, so we hardly have enough time to spend with the mothers. i know they need something more than maternity and medical care. we need to spend time with them and listen to their concerns and feelings. they sure need our sympathetic support which is helpful for their feeling https://doi.org/10.15218/ejnm.2021.03 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article number one concern is delivering maternity services, so i guess psychological support needs to be provided by someone who specializes in psychology specialty in labor or giving midwives the opportunity to support and advise women before pregnancy until birth not just in labor.” during pregnancy and at birth, mothers need to be treated with dignity and respect. such dignity should be associated with appropriate maternity care provided by midwives and maternity staff *22+. as a stressful job, midwifery can lead to quick job burnout which in turn can cause low levels of job satisfaction among midwives. job dissatisfaction can cause midwives to behave in a way that their clients feel they do not receive services and are not valued or respected fully *23, 24+. as shown by the results of the present study, some issues in maternity wards like high workload and lack of sufficient well-trained maternity staff cause midwives to fail to provide full support to pregnant women and mothers, which can have negative impacts on the level of mothers’ human dignity. research has indicated that promotion of partner involvement, facilitation of new social contacts, pedagogical creativity, emotional confirmation, and a listening and holistic approach by midwives are highly appreciated and welcomed by pregnant women during pregnancy and at childbirth *25+. moreover, it has been proved that it is highly helpful to provide women with antenatal sessions where they have the chance to have contact and get familiar with the midwives and maternity team. during such sessions, it is also vitally helpful to prepare pregnant women with explanations and feedback on their progress during their pregnancy and labor. the success of such sessions and feedback is highly dependent on the midwives’ competence and previous training *26+.that is why research has highlighted the need for more competent midwives, preand in-service training courses, improvement of working conditions, mental preparation of pregnant women, and appropriate health policies to deliver respectful maternity services and promote human dignity *27+. since there is not sufficient evidence-based practice in maternity care, a feeling of pressure is experienced by women while trying to receive such care *28+.successful childbirth requires management of the process by a wellexperienced midwife. this process consists of various specialized interventions which should be carried out by enough number of midwives and maternity nurses. in addition to the maternity team, collaboration from the childbearing woman is required, which can be obtained once her human dignity and respect are well attended to in an appropriate environment *29, 30+. in the present study, the midwives referred to issues like overcrowded maternity wards, lack of sufficient equipment and facilities, and lack enough maternity staff. mentioning these issues, they stated that full medical support and high-quality maternity services cannot be provided, which can have a negative effect on mothers’ human dignity and the sense of being valued. in line with this finding, hall et al. pointed out that the pregnant and childbearing women’s independence and dignity can be threatened by the lack of reasonable equipment in midwifery departments and clinics. as a result of such issues in maternity wards, they noticed the explicit statement by women expressing their feeling of being ignored or deprivation from personal choices, and ultimately their human dignity being threatened *31+. similar issues were referred to by the women in the study carried out by baranowska et al. who noticed pregnant and childbearing women complaining about maternity care as a result of 28 erbil journal of nursing & midwifery discussion https://doi.org/10.15218/ejnm.2021.03 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article dignity. however, midwives in this study stated that they did not have enough time to spend with mothers and give them mental help and support, and they suggested that hospitals should employ psychologists for this purpose. similar to this finding, research has shown that women are highly vulnerable during pregnancy because they usually lose their normal physical abilities and undergo some psychological and social pressures, anxiety, depression, and feeling of uncertainty in life *3638+. the human dignity of this group has not received sufficient attention in the kurdistan region of iraq, because very few relevant provisions and instructions are available *39+. limitation of the present study was just rejection to participate in the study from some midwives because of their individual reasons. it should be stated that some midwives were not willing to take part in the study and discuss their experiences, which could be related to their low trust of the researcher and also their limited time. the themes that emerged in the present study revealed that the status of human dignity among pregnant and childbearing women in the kurdistan region of iraq is not satisfactory due to a lack of sufficient equipment and facilities, barely enough number of well-trained maternity staff and midwives, and crowdedness of the maternity departments. there is no actual or potential conflict of interest in relation to this study. *1+ ebrahimi h, torabizadeh c, mohammadi e, valizadeh s. patients' perception of dignity in iranian healthcare settings: a qualitative content analysis. journal of medical ethics. 2012; 38:723-8. poor communication with and ignorance of their viewpoint by the maternity team *32+.research has proved the human dignity of mothers rises through constructive communication with the maternity staff. this type of communication is characterized by sympathetic relationships, the staff’s willingness and readiness to answer questions posed by mothers, and the allocation of sufficient time to discuss the mothers’ concerns *33+. in this regard, caseload care has been proposed to be a successful model in which a single midwife or small group of midwives are assigned to take care of pregnant or childbearing women *34+. in the present study, midwives stated that they do not have enough time to spend with mothers and provide them with sympathetic support because there is a high workload on them; however, some of them try to compensate that gap by respecting mothers and show their sympathy in their behavior. in a similar study carried out by hall et al., some participants also revealed that the maternity staff did not spend enough time to meet their needs, and no extra support was provided for women with a kind of disability *31+. similarly, kozhimannil et al. reported women’s complaints about the insufficient time spent by the maternity staff with them which increases their concerns and stress. they also complained about their failure to understand the medical terminology used by the maternity staff *35+. it shows that pregnant and childbearing women need more friendly and passionate relationships and communication within the maternity departments. the psychological stress of pregnant and childbearing women was emphasized by the midwives in the present study, and as they stated, this situation can be relieved by providing mothers with psychological and mental support, which in turn raises their human 29 erbil journal of nursing & midwifery conclusion conflict of interest references https://doi.org/10.15218/ejnm.2021.03 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article reproductive health. 2018; 15. 10.1186/ s12978-017-0447-6. *14+ mathibe jm, masitenyane ss. psychosocial antenatal care: a midwifery context. in: selected topics in midwifery care. 2018; london, united kingdom: intechopen . *15+ baillie l. patient dignity in an acute hospital setting: a case study. international journal of nursing studies. 2008; 46: 23–37. doi: 10.1016/j.ijnurstu. *16+ hall j, mitchell m. dignity and respect in midwifery education in the uk: a survey of lead midwives of education. nurse education in practice. 2016; volume 21, pages 915. available at: https://doi.org/10.1016/ j.nepr.2016.09.003. *17+ ghiyasvandian s, piro t. j, salsali m. iraqi nurses’ perspectives on safety issues in maternity services. nursing and midwifery studies. 2015; 4(3): e29529. doi: 10.17795/ nmsjournal29529. *18+ zahavi d. the practice of phenomenology: the case of max van manen: journal of nursing philosophy. 2019; volume 21,issu 2. *19+ jamshed s. qualitative research methodinterviewing and observation. journal of basic and clinical pharmacy. 2014; 5(4):87– 88. *20+ . shenton, a. k. strategies for ensuring trustworthiness in qualitative research projects. education for information. 2004; 22: 63-75. *21+ devadas, b. a critical review of qualitative research methods in evaluating nursing curriculum models: implication for nursing education in the arab world. journal of education and practice. 2016; 7(7): 2222-88. *22+ declercq e, sakala c, corry m, applebaum s, herrlich a. listening to mothers iii: pregnancy and birth. new york: childbirth connection; 2013. *23+ . valizadeh s, fallahi m, mohammadi e, ebrahimi h, arshadi m. dignity and respect are the missing link of nurses' empowerment. international journal of medical research & health sciences. 2016; 5, 3:110-15. *24+ parsa p, saeedzadeh n, masoumi s z, roshanaei g. the effectiveness of counseling in reducing anxiety among nulliparous pregnant women. journal of family and reproductive health. 2016; vol. 10, no. 4. *25+ mattern e, lohmann s, ayerle g m. experiences and wishes of women regarding systemic aspects of midwifery care in germany: a qualitative study with focus groups. bmc pregnancy childbirth. 2017; 17: 389. *2+ griffin l. an analysis of the concept dignity. accident and emergency nursing. 2005; 13:251-7. *3+ lam k. dignity, respect for dignity, and dignity conserving in palliative care. newsletter hong kong society of palliative medicine. 2007; 3:30-5. *4+ parandeh a, khaghanizade m, mohammadi e, mokhtari j. nurses' human dignity in education and practice: an integrated literature review. iran journal nursing midwifery research. 2016; 21(1):1-8. doi: 10.4103/1735-9066.174750. *5+ world health organization (who). world mental health day 2015: dignity and mental health. information sheet. retrieved on august 10, 2020 available at: http:// www.who.int/mental_health/worldmental-health-day/2015_infosheet/en/ *6+ mason e, mcintosh a, bryan a, mason t. key concepts in nursing. sage publications inc. 2008, thousand oaks, united states. *7+ . thelin i, lundgren i, hermansson e. midwives’ lived experience of caring during childbirth—a phenomenological study. sexual & reproductive healthcare. 2014; 5: 113-8 *8+ hall j. developing a culture of compassionate care-the midwives voice? midwifery. 2013; 29(4):269-71. *9+ halldorsdottir s, karlsdottir i. the primacy of the good midwife in midwifery services: an evolving theory of professionalism in midwifery. scandinavian journal caring science. 2011; 25: 806–17. *10+ vogel p, bohren m. a, tunçalp o, oladapo o t, gülmezoglu a m. promoting respect and preventing mistreatment during childbirth. international journal of obstetrics & gynaecology. 2016; 123(5):671-4. doi: 10.1111/1471-0528.13750. *11+ moberg k u. the roar behind the silence: why kindness, compassion and respect matter in maternity care 2015; london: pinter and martin ltd. *12+ bohren m a, vogel j, hunter e, lutsiv o. the mistreatment of women during childbirth in health facilities globally: a mixed methods systematic review. plos medicine. 2015; 12(6): e1001847. doi: 10.1371/ journal.pmed.1001847. *13+ kana s, shigeko h, sebalda l. yoko s. midwives' respect and disrespect of women during facility-based childbirth in urban tanzania: a qualitative study. 30 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.03 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article *35+ kozhimannil k. b, attanasio l. b., yang t, avery m, declercq e. midwifery care and patient-provider communication in maternity decisions. maternal&child health. 2015; j. 19(7): 1608–15. doi:10.1007/s10995-0151671-8. *36+ joolaee s, nikbakht a, parsa z. *iranian nurses, physicians and patients' lived experiences regarding patient’s rights practice (persian)+. iran journal of nursing. 2009; 22 (60), 28-41. *37+ toosi m, akbarzadeh m, zare n, sharif n. effect of attachment training on anxiety and attachment behaviors of first-time mothers. hayat. 2011; 17:69-79. *38+ talley l. stress management in pregnancy. international journal of childbirth education. 2013; 28: 43-5. *39+ piro t. j. research paper: kurdish maternity nurse’s perspectives about human dignity. journal of client-centered nursing care. 2016; 2(3), 161-168. available at: https:// doi.org/10.32598/jccnc.2.3.161. doi:10.1186/s12884-017-1552-9. *26+ hildingsson i, thomas j e. women’s perspectives on maternity services in sweden: processes, problems, and solutions. journal midwifery womens health. 2007; 52(2):126–33. *27+ shimoda k, horiuchi s, leshabari s, shimpuku y. midwives’ respect and disrespect of women during facility-based childbirth in urban tanzania: a qualitative study. reproductive health. 2018; 15, 8. available at: https://doi.org/10.1186/s12978-0170447-6. *28+ mattern, e, lohmann, s, ayerle, g m. experiences and wishes of women regarding systemic aspects of midwifery care in germany: a qualitative study with focus groups. bmc pregnancy and childbirth. 2017; 17(1), 389. https://doi.org/10.1186/ s12884-017-1552-9 . *29+ bohren m. a, vogel j p, hunter e c, lutsiv o, makh s k, souza j p, et al. the mistreatment of women during childbirth in health facilities globally: a mixed‑methods systematic review. plos medicine. 2015; 12: e1001847. *30+ baczek g, tataj-puzyna u, sys d, baranowska b. freestanding midwife‑led units: a narrative review. iranian journal of nursing midwifery research. april 2020; 25:181‑8. *31+ hall j, hundley v, collins b, ireland j. dignity and respect during pregnancy and childbirth: a survey of the experience of disabled women. hall. bmc pregnancy and childbirth. 2018; 18:328, available at: https://doi.org/10.1186/s12884-018-1950 -7. *32+ baranowska b, doroszewska a, kubicka u. is there respectful maternity care in poland? women’s views about care during labor and birth. bmc pregnancy childbirth. 2019; 19: 520. available at: https:// doi.org/10.1186/s12884-019-2675-y . *33+ raine r, cartwright m, richens y, mahamed z, smith d. a qualitative study of women’s experiences of communication in antenatal care: identifying areas for action. maternal and child health journal. 2010; 14(4):590–99. *34+ mccourt c. supporting choice and control? communication and interaction between midwives and women at the antenatal booking visit. social science and medicine. 2006; 62(6):1307–18. 31 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.02 erbil j. nurs. midwifery, vol. 4 no. (1), may, 2021 original article knowledge of shaken baby syndrome among hospital nurses in erbil city abstract introduction shaken baby syndrome (sbs) and pediatric abuse head trauma continue to be the leading causes of child abuse death and the most common causes of mortality and morbidity due to physical child abuse in the united states *1+. sbs is a severe form of child abuse caused by the violent shaking of an infant or child *2+. when significant rotational acceleration-deceleration forces are applied, the brain is susceptible to shearing of the bridging veins in the subdural space, diffuse axonal injury, contusion and oedema. shaking an infant or small child can cause bleeding into the back of the eyes *3+.and other injuries such as damage to the neck, spine, and eyes *4+. it is dangerous and can cause severe brain damage, blindness, cerebral palsy, mental retardation, behavioural disorders, and impaired motor and cognitive skills. factors that may increase the risk of inflicting shaken baby syndrome background and objectives: shaken baby syndrome and pediatric abuse head trauma are the most common causes of mortality and morbidity due to physical child abuse. nurses have a main role in parents’ education regarding child abuse prevention. this study aimed to assess nurses’ knowledge regarding shaken baby syndrome in erbil city. methods: a descriptive study was conducted at postpartum units, the delivery room and the ward at the maternity teaching hospital, and the inpatient and intensive care units at rapareen pediatric teaching hospital in 2017 in erbil city. a purposive sample of 50 nurses was recruited to the study. the data collection was performed using a questionnaire for interviewing the study participants, and the data were analyzed using descriptive and inferential statistical analysis. results: the study findings revealed that the majority of the study participants were 19-25 years old and most did not have enough knowledge regarding the signs and symptoms of the shaken baby syndrome (irritability, lethargy, poor feeding breathing problems, uncontrollable crying, vomiting, bluish skin, changes in sleeping pattern, convulsions or seizures and unresponsiveness). nurses also had insufficient knowledge about the risk factors of this condition. only a quarter of nurses knew that domestic violence is a risk factor and less than a quarter of them recognized depression and substance abuse of the caregiver as a risk factor. regarding knowledge of the complications, the study found that a quarter of nurses knew that brain damage, cerebral palsy and blindness are complications of the shaken baby syndrome. conclusions: majority of nurses had poor knowledge about causes, signs, symptoms, risk factors and complications of the shaken baby syndrome. keywords: shaken baby syndrome; nurse; knowledge. madiha abass muhammad; department of nursing, college of nursing, hawler medical university, erbil, iraq. )correspondence: madiha.abbas@hmu.edu.krd ) norhan zeki shaker; department of nursing, college of nursing, hawler medical university, erbil, iraq. gulala kream aziz; department of nursing, college of nursing, hawler medical university, erbil, iraq. 15 received: 24/08/2020 accepted: 02/11/2021 published: 30/05/2021 mailto:madiha.abbas@hmu.edu.krd?subject=madiha.abbas@hmu.edu.krd https://doi.org/10.15218/ejnm.2021.02 erbil j. nurs. midwifery, vol. 4 no. (1), may, 2021 original article include unrealistic expectations of babies, young or single parenthood, stress, domestic violence, alcohol or substance abuse, unstable family situations, depression, and a history of mistreatment as a child *5+. sbs leads to extreme irritability, lethargy, poor feeding, breathing problems, convulsions, vomiting, and pale or bluish skin. shaken baby injuries usually occur in children younger than 2 years old, but maybe seen in children up to the age of 5 *6+. the data indicate that 1,000 to 1,500 infants per year are shaken and sustain a head injury. according to the information from the center for disease control and prevention in the united states, of the nearly 2,000 children who die from abuse every year, pediatric abusive head trauma, or sbs is responsible for 10-12 percent of those fatalities. research also indicates that there is a strong relationship between poverty and child abuse *2+. nearly all victims of sbs have serious health consequences, such as brain injury, cerebral palsy, seizures and paralysis, and at least one of every four babies who are violently shaken dies. most adults who admit to shaking a baby say that they became frustrated and upset when the baby would not stop crying *7+. child welfare information *8+ suggests solving this problem by teaching parents and nurses about the dangers of shaking a baby, as well as ways to cope with the stresses of caring for a child. these educational programmes are very effective in reducing the incidence of sbs. a systematic review conducted in new york state recommends that all hospitals should offer new parents the option of viewing a video on sbs, including ways to cope with a crying child. furthermore, it is reported that in developing countries, sbs is one of the leading causes of death *9+. currently, there are no statistical data about sbs in iraq and erbil city, and no published studies about nurses’ knowledge of sbs, which is one of the reasons for conducting this study. the descriptive study design was used to assess nurses’ knowledge about shaken baby syndrome. this study was carried out from november 2016 to november 2017 at two public hospitals in erbil city. these hospitals included maternity and rapareen pediatric teaching hospitals. official permission to conduct the study was obtained from the erbil general directorate of health and the involved hospitals. a purposive research sample consisted of 50 nurses from postpartum units, the delivery room and the ward at the maternity teaching hospital, and the inpatient and intensive care units at rapareen pediatric teaching hospital in erbil city. nurses’ oral informed consent was obtained for participation in the study, after confirmation of confidentiality, anonymity, and participants’ self-determination by the researcher. the researcher constructed a questionnaire after an extensive review of relevant literature. the questionnaire included three parts. the first part contained sociodemographic information of nurses (age, gender, level of education, hospital setting, duration of experience in nursing and the current unit, participation in training courses and seminars). the second part assessed nurses’ knowledge regarding shaken baby syndrome and was divided into five domains (definition, carrying baby criteria, signs and symptoms, risk factors, complications). the third part was designed to assess the source of nurses’ knowledge about sbs (nursing school, tv, internet, journals, physicians, seminar, workshop and conference). the knowledge of sbs items was rated and scored according to the two points type scale for all items and scored as 2 and 1 for correct, incorrect answer respectively. after 16 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2021.02 erbil j. nurs. midwifery, vol. 4 no. (1), may, 2021 original article 7.17 ± 5.12 years. regarding nurses’ professional background, 8% of nurses participated in a training course related to sbs, and for the highest percentage of nurses’ (66%), the source of information was the internet. table 2 shows the nurses’ knowledge about the definition of sbs and the questions included the following: sbs is an injury caused by a sudden jerking of the head (1.24 ± 0.43), sbs is abusive head trauma (1.28 ± 0.45), sbs results in a subdural hematoma & retinal haemorrhage on the brain’s surface (1.22 ± 0.42). the mean score of nurses’ knowledge regarding the definition of sbs was 1.24. this table shows that most of the nurses answered the questions incorrectly. table 3 indicates that the mean score of nurses’ knowledge about crying baby was 1.18, showing that the majority of nurses did not know correct answers to the questions in this area. table 4 shows that the mean score of nurses’ knowledge about signs and symptoms of sbs was 1.22. this table also clarifies that the majority of nurses did not have sufficient knowledge of the signs and symptoms of sbs. table 5 shows that the mean scores of nurses’ knowledge about risk factors and complications of sbs were 1.2 and 1.1 respectively. this table shows that the majority of nurses answered the risk factors and complications of sbs questions incorrectly. table 6 indicates a statistically not significant association between nurses’ level of knowledge about sbs, nurses’ education, and participation in training courses, and a statistically significant association with duration of experience in nursing. obtaining the average of the mean score of each item, the mean score of each domain was calculated, followed by a collection of the mean scores of all knowledge items and divided to two levels (poor and fair) for obtaining levels of nurses knowledge about sbs. these levels were considered to be as a following: poor = 0.72 0.985, and fair = 0.99 1.25.content validity of the questionnaire was checked initially by a panel of five experts specialized in maternity and pediatric nursing and medicine, and all experts’ comments regarding the items of the questionnaire were taken into consideration. a pilot study was conducted on a purposive sample of ten nurses and midwives to determine the reliability of the questionnaire. after two weeks the same nurses were selected to assess the same items among nurses from involved hospitals. the participants of the pilot study were included in the main study sample. the reliability of the tool was computed, and the correlation of 0.86 was statistically adequate. the collected data were analyzed using the statistical package for social science (spss, version 20). the descriptive statistical analysis included frequency, percentage, mean, and standard deviation, while chi-square and fisher exact test were used for inferential analysis. the p-value of ≤ 0.05 was considered significant. table 1 shows that 44% of participants were within the age group of 19-25 years. the mean score and standard deviation (sd) of their age were 26.54 ± 5.64. the highest percentage (64%) of the sample were nursing institute graduates, and 64% of nurses were working at the maternity teaching hospital (post-partum unit 12%, delivery room 12%, inpatient ward 46%, icu 30%. the mean score and standard deviation of nurses’ experience were 17 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2021.02 erbil j. nurs. midwifery, vol. 4 no. (1), may, 2021 original article 18 erbil journal of nursing & midwifery table 1: demographic data of nurses, sample n=50 socio-demographic data n=50 *f **% age 19-25 22 44 26-32 20 40 33-39 8 16 *** ± sd 26.54 ± 5.64 education level nursing college graduates 13 26 nursing institute graduates 32 64 preparatory nursing school graduates 1 2 preparatory midwifery school graduates 1 2 nursing school graduates 3 6 hospital name maternity 32 64 rapareen 18 36 working unit postpartum 6 12 delivery room 6 12 ward 23 46 icu 15 30 experience years 2-9 38 76 10-17 9 18 18-25 3 6 ± sd 7.17 ± 5.12 participation in a training course yes 4 8 no 46 92 source of information internet 33 66 others 17 34 *frequency **percentage *** mean ± standard deviation table 2: assessment of nurse’s knowledge about the definition of the shaken baby syndrome. nurses’ knowledge about the definition of sbs n=50 correct f (%) incorrect f (%) ± sd sbs is an injury caused by a sudden jerking of the head. 12(24) 38(76) 1.24 ± 0.43 sbs is abusive head trauma. 14( 28) 36( 72) 1.28 ± 0.45 sbs results in a subdural hematomas &retinal haemorrhage on the brain’s surface. 11(22) 39(78) 1.22 ± 0.42 total mean score 1.24 https://doi.org/10.15218/ejnm.2021.02 erbil j. nurs. midwifery, vol. 4 no. (1), may, 2021 original article 19 erbil journal of nursing & midwifery table 3:assessment of nurses’ knowledge about crying baby criteria nurses’ knowledge about crying baby criteria n=50 correct f (%) incorrect f (%) ± sd infants cry more often in the late afternoon and evening. 11(22.0) 39(78) 1.22 ± 0.42 infant crying increases in the first few weeks of life and reaches a peak in the first 2 or 3 months before getting less. 9(18) 41(82) 1.18 ± 0.38 sometimes a healthy infant cries unexpectedly or without a clear reason. 7(14) 43(86) 1.14 ±0 .35 when an infant cries it is not always a sign that something is wrong. 6(12) 44(88) 1.12 ± 0.33 sometimes a crying infant can look like she/he is in pain even when they are not. 10(20) 40(80) 1.2 ± 0.40 sometimes healthy infants can cry for 5 or more hours a day. 10(20) 40(80) 1.2 ± 0.40 it is ok to walk away from a crying infant when his or her crying becomes very frustrating. 13(26) 37(74) 1.26 ± 0.44 sb is not a good way to help a baby stop crying. 6(12) 44(88) 1.12 ± 0.33 total mean score 1.18 table 4: assessment of nurses’ knowledge about signs and symptoms of the shaken baby syndrome. signs and symptoms of the shaken baby syndrome n=50 correct f (%) incorrect f (%) ± sd become extremely irritable. 11(22.0) 39(78) 1.22 ± 0.42 become lethargy. 12(24) 38(76) 1.24 ± 0.43 become poor feeding. 14( 28) 36( 72) 1.28 ± 0.45 will complain from breathing problems. 16(32) 34(68) 1.32 ± 0.47 will complain from uncontrollable crying. 15(30) 35(70) 1.30 ± 046 will complain from vomiting. 15(30) 35(70) 1.30 ± 046 become pale or bluish skin. 9(18) 41(82) 1.18 ± 0.38 will complain from significant changes in sleeping patterns. 9(18) 41(82) 1.18 ± 0.38 cannot be consoled. 9(18) 41(82) 1.18 ± 0.38 will complain from convulsions or seizures. 7(14) 43(86) 1.14 ± 0.35 in more severe cases of sbs, the babies may be unresponsive. 7(14) 43(86) 1.14 ± 0.35 total mean score 1.22 table 5: assessment of nurses’ knowledge about risk factors and complication of the shaken baby syndrome. risk factors of sbs n=50 correct f (%) incorrect f (%) ± sd unrealistic expectations of babies 10(20) 40(80) 1.2 ± 0.40 domestic violence 12(24) 38(76) 1.24 ± 0.43 depression, substance abuse 11(22.0) 39(78) 1.26 ± 0.44 family history of sbs. 11(22.0) 39(78) 1.22 ± 0.41 unstable family situations 8(16) 42(84) 1.16 ± 0.37 mother’s depression 10(20) 40(80) 1.2 ± 0.40 a history of mistreatment as a child 8(16) 42(84) 1.16 ± 0.37 total mean score 1.2 complications of sbs sbs causes severe brain damage 4(8) 46(92) 1.08 ± 0.27 sbs causes cerebral palsy 4(8) 46(92) 1.08 ± 0.27 sbs causes blindness 5(10) 45(90) 1.10 ±0.30 sbs causes behavioural disorders 4(8) 46(92) 1.08 ± 0.27 sbs causes impaired motor and cognitive skills 10(20) 40(80) 1.2 ± 0.40 sbs caused damage to the neck and spine 4(8) 46(92) 1.08 ± 0.27 total mean score 1.1 https://doi.org/10.15218/ejnm.2021.02 erbil j. nurs. midwifery, vol. 4 no. (1), may, 2021 original article 20 erbil journal of nursing & midwifery figure 1 represents the mean score of nurses’ knowledge about sbs in its fours domains was low. figure 2 indicates that sbs knowledge of the majority of nurses (88%) was poor and that 12% of study participants had a fair analysis of demographic characteristics revealed that the highest percentage of nurses were in the age group of 19-25 years and nursing institute graduates. this finding is in contrast to a study carried out brubaker in 2016, which evaluated nurses’ knowledge of shaken baby syndrome prevention after exposure to "period of purple crying" program, and found that lowest percentage of nurses had diploma certificate *10+. the current study indicates that few nurses participated in the training course and the internet was the main source of their information about sbs. as we know the nurse is a primary care provider to infants, and a parent educator before the child is discharged from the hospital or when they come for well-child visits and should therefore identify sbs and its consequences, risk factors, signs and symptoms. testing nurses’ knowledge in the current study was divided into four domains; the first domain evaluated nurses’ knowledge of the definition of sbs. this study reveals that more than two-thirds of nurses responded incorrectly to sbs definition items, which table 6: association between nurse levels of shaken baby syndrome knowledge and education, age. nurses criteria nurses knowledge levels (n=50) fair* f (%) poor** f (%) total f (%) p-value education level college 10 3 13 0.194 ns*** institute 29 3 32 preparatory nursing school 1 0 1 preparatory midwifery 1 0 1 school graduate 3 0 3 duration of experience years 2-9 35 3 38 0.00 hs**** 10-17 8 1 9 18-25 1 2 3 participation in trainyes 2 2 4 0.06 no 42 4 46 *poor= 0.72 0.98, ** fair = 0.99 1.25, ***ns= not significant, **** hs=high significant 1 1.1 1.2 1.3 1.24 1.22 1.2 1.18 1.1 definition signs & symptoms risk factors crying baby critera complications fig.1 distribution of nurses according to mean scores of 4 domains of the shaken baby syndrome knowledge. fig: 2 overall levels of nurses’ knowledge about the shaken baby syndrome. discussion https://doi.org/10.15218/ejnm.2021.02 erbil j. nurs. midwifery, vol. 4 no. (1), may, 2021 original article 21 erbil journal of nursing & midwifery reflects nurses’ poor knowledge about sbs. concerning nurses’ knowledge about crying baby criteria, the current study shows that majority of nurses replied incorrectly to most of crying baby criteria items, with highest percentages only in two items (infant cries is not always a sign that something is wrong, and shaking baby is not a good way to help a baby stop crying), confirming that nurses have knowledge deficit in this regard. bravo states that every infant who is discharged from a newborn nursery should be sent home with parents who are prepared for neonatal care. through educational programs, parents can receive positive guidelines to help them to cope with children who have special needs, need extra attention, or simply cry for long periods *11+, and nurses are responsible for educating of mothers before discharge. adding to that, sbs often occurs after shaking in response to crying attacks *12+. this implicates the importance of nurses’ knowledge about crying baby. regarding nurses knowledge about signs and symptoms of sbs, the finding of the present study reveals that majority of nurses did not know the signs and symptoms of sbs and gave incorrect answers to the questionnaire items (irritable, lethargy, poor feeding, breathing problems, uncontrollable crying, vomiting, bluish skin, changes in sleeping patterns, convulsions or seizures and unresponsive). this finding reveals nurses’ poor information about sbs symptoms when it is expected from the nurses to discover abused and maltreated children in addition to their responsibility in educating parents about sbs prevention and child safety. regarding nurses’ knowledge about risk factors of sbs, the current study found that about a quarter of nurses know that domestic violence is a risk factor for sbs. this is compatible with the study done in the united states by steven et al, which mentions that caretakers at risk of abusive behaviour generally have unrealistic expectations of their children and may exhibit a role reversal whereby caretakers expect their needs to be met by the child *13-14+. in the current study, less than a quarter of nurses recognized that depression and substance abuse of caregiver is a risk factor for sbs of children. this is in agreement with a study, which shows that the most common risk factor for perpetrators, most frequently parents, is the inability to cope with stress, substance abuse, infants born to mothers who suffer from depression or consume alcohol during pregnancy *15+. regarding nurses’ knowledge about complications of sbs, the current study found that about a quarter of nurses know that brain damage, cerebral palsy and blindness are complications of sbs. this result is supported by walls and castiglia who mention that the main complications of sbs involve impaired mental, physical, and sensory development, visual impairments, blindness, seizure disorder, developmental delays, motor dysfunction, spasticity, cerebral palsy *16+. regarding the overall level of nurses’ knowledge of sbs, the majority of nurses had poor knowledge about sbs. according to the discussion and interpretation of the study findings, researchers concluded that majority of nurses don’t know the signs and symptoms, risk factors, complications of sbs, and overall, the majority of nurses have poor knowledge level about sbs. researchers recommend establishing a health education program for nurses in hospitals to raise awareness of all aspects of sbs. conclusion https://doi.org/10.15218/ejnm.2021.02 erbil j. nurs. midwifery, vol. 4 no. (1), may, 2021 original article 22 erbil journal of nursing & midwifery there is no conflict of interest and no financial support for any of the authors. *1+ ronald g, marilyn b, takeo f, jocelyn c, nicole c, and rollin b. do educational materials change knowledge and behavior about crying and shaken baby syndrome? a randomized controlled trial. canadian medical association journal, 2014; 180(7): 727-33. *2+ centers for disease control (cdc), what is shaken baby syndrome? www.cdc.gov/ concussion/headsup/sbs/html, 2015. *3+ christian, c, block, r. abusive head trauma in infants and children. pediatrics, official journal of american academy of pediatrics, 2009; 123(5), 1409-11. doi: https:// doi.org/10.1542/peds.2009-0408. *4+ arabinda k choudhary, ramsay ishak, thomas t zacharia, mark s dias affiliations. imaging of spinal injury in abusive head trauma: a retrospective study. pub med pediatr radiol. doi: 2015 may;45 (5):784. doi: 10.1007/s00247-015-3335-7. *5+ national mch center for child death review, child abuse and neglect fact sheet, http://www.childdeathreview.org/ causescan.htm, 2011. *6+ lee lm, teutsch sm, thacker sb, st. louis me. (eds). principles and practice of public health surveillance. oxford scholarship online; 2010. doi: 10.1093/acprof:oso/ 9780193572922.001.0001. *7+ sharyn e parks, scott r kegler, joseph l annest, james a mercy characteristics of fatal abusive head trauma among children in the u.s. 2003-2007: an application of the cdc operational case definition to national vital statistics data. injury prevention, 2011;18 (3), p.193-9. *8+ parks sh, kegler s, annest j, mercy j, characteristics of fatal abusive head trauma among children in the u.s. 2003-2007: an application of the cdc operational case definition to national vital statistics data. injury prevention, 2011; 18(3), 193-9. *9+ child welfare information gateway, 2011. child abuse and neglect fatalities, statistics and interventions. washington, dc: u.s. department of health and human services, children’s bureau. http://www.child re.gov/ pubs/factshsheets/fatality.cfm 2009. *10+ maguire s, watts p, shaw a, holden s, taylor r, watkins w, and et al, retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review. eye, 2013; 27(1), 28-36. *11+ brubaker-vincent, c. l., and evaluation of nurses' knowledge of "period of purple crying" program: shaken baby syndrome prevention, dnp projects, 76. https:// uknowledge.uky.edu/dnp_etds/76, 2016. *12+ bravo, m. s., shaken baby syndrome: the implementation and evaluation of an education program for parents, journal of nursing education and practice, 2014; 4(9), 91-9. *13+ ronald g, do educational materials change knowledge and behavior about crying and shaken baby syndrome? a randomized controlled trial, canadian medical association journal, 2009; 180(7), 727-30. *14+ kairys s, alexander r, block r, everett d, hymel k, jenny c, and et al, shaken baby syndrome: rotational cranial injuriestechnical report, pediatrics, 2001;108(1), 206-10. *15+ altimier, l., shaken baby syndrome, journal of perinatal & neonatal nursing, 2008; 22 (1), 68-76. *16+ walls, c., shaken baby syndrome education: a role for nurse practitioners working with families of small children, journal of pediatric health care, 2006; 20(5), 30410. reference conflict of interests https://doi.org/10.15218/ejnm.2021.04 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article lived experiences of patients with covid-19 in the kurdistan region, iraq: a qualitative study abstract introduction covid-19 emerged in 2019 and became an invisible assassin in 2020 which spread around the world. since then, it has been threatening people’s health and lives. it has also led to substantial economic and financial difficulties around the world [1]. the statistics of july 21, 2020, released by the world health organization. (who), revealed that there were 14,883,578 positive cases of individuals with covid-19, of which 8,937,163 recovered and 614,019 died. the same report showed that there were 94,693 positive cases of covid-19 in iraq by the same date, of which 62,836 recovered and 3,869 died. the report also showed 7,936 positive cases of covid-19 in the kurdistan region of iraq, of which 3,233 recovered and 266 died [2].a very high rate of infection is one of the consequences of covid-19, resulting in a high background and objective: covid-19 has adverse effects on physical and mental health and threatens the quality of life significantly; therefore, it is necessary to help covid-19 patients with their lifestyle, which is tightly bound to the quality of their lives. the present study aims to develop plans to improve the quality of life among covid-19 patients by analyzing their lived experiences. methods and patients: the present qualitative study was conducted from august to september 2020 on twelve covid-19 patients hospitalized in erbil’s emirates hospital, the kurdistan region of iraq. in-depth semi-structured interviews (12) were utilized to collect data. trustworthiness was ensured by making an excellent prolonged relationship with the patients, peer-checking, member-checking, and implementing experts’ suggestion at every stage. four main themes were extracted from the interviews, which were transcribed verbatim and analyzed using the six methodological activities proposed by van manen. results: the present study results indicated that covid-19 patients have a difficult time dealing with the disease and getting adapted to their new situation, leading to a remarkable decrease in the quality of their lives. analyzing the transcribed interviews led to emergence of four main themes: “disbelief in being really ill,” “fear and stress,” “changes in lifestyle,” and “seriously adhering to health guidelines.” conclusion: our results showed that covid-19 patients suffer from physical pain and undergo poor mental health due to fear and stress resulting in worsening quality of life. a deep understanding of covid-19 patients’ states and situations is highly significant to help nurses and nursing managers plan effective strategies for caring for patients with covid19. keywords: covid-19 pandemic, phenomenological study, covid-19 patients’ lived experience sarhang qadir ibrahim ;department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: sarhang.ibrahim@hmu.edu.krd) 32 erbil journal of nursing & midwifery received: //20 accepted: 18/2/2021 published: 30/05/2021 https://doi.org/10.15218/ejnm.2021.04 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article level of fear and anxiety of getting infected as a result, this pandemic caused almost all countries’ lockdown and imposed strict restrictions on people’s free movements [3]. it is necessary to focus and observe the emotions involved in a pandemic, such as anger and fear, to understand the psychiatric and psychological repercussions. as an adaptive animal defense mechanism and a key to survival, fear includes several biological processes that involve in readiness to respond to events that are potentially threatening. however, in case of disproportionate or chronic fear, it will become a harmful element that causes various psychiatric disorders to develop [4]. in a pandemic, stress and anxiety levels in healthy individuals rise due to fear, and preexisting psychiatric symptoms intensify [5]. the level of infection risk should be considered and protective steps need to be taken into account by individuals who are at higher risk of covid-19 and those who live with them. in places where social distancing is challenging to maintain, and protective measures are impracticable, general rules need to be considered [6]. during epidemics, the number of those whose mental health is negatively affected is more than those affected by the infection; therefore, quality of life decreases dramatically among all people. as revealed by past tragedies, the mental health implications are more prevalent and can last longer than the epidemic itself. moreover, the economic and psychosocial effects cannot be calculated if their resonance is considered in different contexts. in addition, mental disorders can lead to high economic costs. appropriate strategies adopted to improve mental health may benefit the physical health and economic sectors [5].since covid-19 is a relatively new virus, there is limited understanding of the risk of being affected. in this regard, a study conducted in the kurdistan region of iraq revealed that protective behavior measures were adhered to the respondents reasonably. however, there was a relatively low frequency of undertaking some significant protective behaviors. it was also shown that protective behaviors were provoked by the risk perception of covid-19 to a limited extent, such that it is a challenge to modify behaviors even for those who are well aware and well-educated [7].in addition to death and fear, the covid-19 pandemic has negative impacts on families, schools, companies, public places, and work routines resulting in isolation and feelings of helplessness and abandonment. moreover, its negative effects on the economy can raise the level of insecurity in society [8]. many laboratory and histopathological tests have been performed to devise protocols to deal with the highly infective virus of covid-19. these tests have largely neglected real-life experiences of covid-19 patients’ which are highly significant in developing strategies to improve patients’ quality of life. [9].the investigation into the psychological issues and lived experiences of covid-19 patients during their hospitalization has a high decisive impact on the process of recovery for these patients. given the high prevalence of covid-19 infection in the kurdistan region of iraq, this study was conducted to evaluate the lived experiences of covid-19 patients during their hospitalization period to devise techniques to improve the quality of their lives. study design: the present qualitative study was carried out by van manen’s (1990) hermeneutic phenomenological method [10].patients and setting: the study sample consisted of 12 covid-19 patients hospitalized in erbil’s emirates hospital, the kurdistan region of iraq. the study was conducted over three months from august 33 erbil journal of nursing & midwifery methods and patients https://doi.org/10.15218/ejnm.2021.04 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article down the interviews into words, phrases, and sentences to depict the patients’ lived experiences. transcripts were reread and scrutinized several times to confirm understanding of patients’ lived-experiences. trustworthiness: trustworthiness in qualitative studies refers to the level of soundness or adequacy [10]. to ensure a qualitative study’s trustworthiness, it is essential to justify the results’ reliability and describe the data analysis procedure [11]. in the current study, trustworthiness and the accuracy and rigor of the findings were ensured through peer checking conducted by two professors who also revised the transcripts and the extracted codes. additionally, a friendly relationship between the participants and the researcher ensured the rigor of this study. following data analysis, member checks, discussions of the study results between patients and the researcher, were conducted to obtain patients’ feedback. every stage of the study was monitored by two more expert professors in the field, and their suggestions were taken into account. data collection was conducted during a period of 3 months to ensure prolonged engagement. ethical considerations: approval from the ethics committee of college of nursing, hawler medical university (no. 7 on 26-72020) was obtained for this study. patients were provided with sufficient information about the study’s objectives, data collection methods, and confidentiality of the collected information. patients were assigned a unique code to keep the collected data anonymous and to protect their confidentiality. all files were stored in a safe and secure place. patients were informed of the right to abandon the study whenever they wanted to. informed written consent were obtained from patients prior to the start of the study. 2020 to september 2020. patients were selected using a purposeful sampling method. the inclusion criteria were being diagnosed with covid-19, age of over 18 years, willingness and consent to participate in the study, and having undergone treatment and hospitalization procedures. exclusion criteria were lack of willingness or consent to participate in the study and inability to describe their lived experiences. data collection: in-depth semi-structured interviews were conducted with the patients in order to collect the required data. for this purpose, a small relaxing room at erbil’s emirates hospital was used. the interviewers established a friendly relationship with the patients to elicit as much information as possible. patients were informed and reassured about the confidentiality of their information. the duration of the interviews was flexible, ranging from 55 to 70 minutes, and enough time was given to the patients to answer the questions with as many details. to ensure patients’ comfortability, they were interviewed by interviewers of the same gender. predetermined questions used to direct the interviews included general questions such as “how is it like to suffer from covid-19?”, “when did you notice you had coronavirus?”, “how did it feel in the beginning?”, and “what is it like to have covid-19?” and were followed by more specific questions such as “how has covid19 changed your life?” or “what have been the effects of covid-19 on your daily life?”. with the patients’ permission, all interviews were recorded and transcribed verbatim and then translated for further analysis. data analysis: the transcripts of the interviews were analyzed through content a analysis approach. the accuracy of the translated transcripts was checked by comparing them to the recorded interviews several times. afterward, holistic, detailed, selective approaches were used to break 34 erbil journal of nursing & midwifery ) https://doi.org/10.15218/ejnm.2021.04 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article table 1 describes the patients’ sociodemographic characteristics. the majority of the patients were males (66.66%), over 36 years old (75%), muslims (75.5%) and reside in urban areas (83.33%). of the patients, 33.33% had university degrees, 25% had high school degrees, 16.66% had primary degrees, and 25% were illiterate. half of the patients had a good socioeconomic status (see table 1). content analysis of the scripts based on van manen’s (1990) hermeneutic phenomenological method led to the emergence of four main themes: “disbelief in being really ill,” “fear and stress,” “changes in lifestyle,” and “seriously adhering to health guidelines.” these themes are presented in two major categories: before getting the disease and after getting the disease. theme 1: disbelief in being really ill interviews with the covid-19 patients revealed that some of them had not taken the disease seriously before they got it. patients described their experiences in this regard as follows.“before i got corona, i thought that this disease did not even exist, and it was just a political game played by the governments to control people, cut their salaries or wages, and even kill senior citizens to cut their pension.” (patient 3) “before i developed the disease, i never wore a face mask or gloves because i did not take the disease seriously, and i believed that it did not exist and it was a rumor spread by governments all over the world. i really regret my wrong belief which caused me to be hospitalized here for more than 10 days.” (patient 7) “i didn’t trust the media and statistics of coronavirus until i myself got the disease. in the beginning, i couldn’t believe, so i visited 2 different clinics, and finally came here. they all confirmed that i had corona disease.” (patient 9) theme 2: fear and stress patients’ accounts of their experiences revealed that covid-19 caused immense fear and stress in their lives. their fear and stress were related to the probability death and concerns of the disease spreading among their family members. patients described their experiences in this regard as follows. “once i was diagnosed with coronavirus, i was filled with fear and stress. i was really scared to die. i had a lot of stress to transfer the disease to my 35 erbil journal of nursing & midwifery results table 1: the patients’ socio demographic data socio-demographic and clinical variables n(%) sex female 4(33.33) male 8(66.66) age (years) 18-25 1(8.33) 26-35 2(16.66) 36-45 4(33.33) 46 ≤ 5(41.66) place of residence urban 10(83.33) rural 2(16.66) education level illiterate 3(25.0) primary 2(16.66) high school 3(25.0) university 4(33.33) religion muslim 9(75.5) christian 3(25.0) employment employed 8(66.66) unemployed 4(33.33) socioeconomic status poor 3(25.0) good 6(50.0) very good 3(25.0) https://doi.org/10.15218/ejnm.2021.04 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article water.” (patient 5). “the treatment has been a long procedure. i remember on the first days of my hospitalization, i couldn’t breathe without the ventilator. it’s really hard not to be able to breathe in or out. i’m an active person, but i’ve been here on this bed for more than 8 days without any activities, which is really boring.” (patient 8)theme 4: seriously adhering to health guidelines the final theme that emerged from the patients’ stories was their emphasis on following the guidelines recommended by the ministry of health. patients described their experiences in this regard as follows.“ i remember i always made jokes about those who followed the health guidelines and were wearing face masks and gloves until i myself got the disease and i came to know that this disease is quite serious and fatal, so i recommend all my friends and people to follow the health guidelines.” (patient 4) “if i had followed the health guidelines recommended by the ministry of health, i wouldn’t have got the disease. so, i recommend everybody that they take corona seriously, it’s really debilitating, and its treatment is quite costly.” (patient 5) “if you love your life, family, and friends, please adhere the health guidelines, wear face masks and gloves, wash your hands regularly, eat healthy food, drink a lot of water, and more importantly keep social distance. i wish i had adhered all the guidelines recommended by the ministry of health.” (patient 11) the spread of covid-19 is remarkably high, and it results in uncommon effects. the symptoms of covid-19 include shortness of breath, dry cough, aches, and fever. it can also lead to respiratory failure and dysfunction of different organs [12]. its adverse effects have been observed on all sectors of society, including education, 36 erbil journal of nursing & midwifery family members. it’s a really painful disease, and during my treatment, i felt i was going to die many times.”(patient 1). “it’s a really painful and stressful disease. its pain is not just physical, it is also mental. the physical side is related to the pain it causes in your muscles, legs, chest, and eyes. its mental pain is related to the fear and stress it causes because of your family members and the society which consider coronavirus as a shame and almost everybody gets away from you, even your dearest ones.”(patient 10). “before i got the disease, i heard and read a lot about its pain, and when i was told that my coronavirus test was positive, i got quite shocked and felt fear and stress deep inside. i feared that i might transfer the disease to my family members. i was also filled with a feeling of shame because our society has really negative attitude toward this disease.” (patient 12)theme 3: changes in lifestylepatients stated that covid-19 had changed their lives significantly, and they had to live in a quite different way. in their accounts, they talked about changes in their sleep, food, physical activities, and special treatment. patients described their experiences in this regard as follows. “being a corona patient means to live a quite new life. i used to sleep about 5 to 6 hours, but since i got covid-19, i have to sleep about 10 hours, following my doctor’s order. i’m a quite sociable person, and i like to spend most of my time with my family members and friends, but because of my disease i haven’t seen anyone in person for more than two weeks. i only speak to them on the phone.”(patient 2) “i didn’t use to do any exercise before i got corona, but these days i’m doing exercise for about half an hour every day. it’s a part of my treatment. i’ve also had to change my eating habits. nowadays i’m eating a lot of watery food and fruits like watermelon and cucumber. i also drink a lot of discussion https://doi.org/10.15218/ejnm.2021.04 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article economy, and food. successful dealing with the covid-19 pandemic and its impacts on society requires collective efforts and cooperation of organizations, governments, and individuals [13]. adverse effects of covid-19 on physical and mental health continues to threaten quality of life [14]. supporting covid-19 patients with their lifestyle can improve the quality of their lives. in this study, nearly all patients stated that prior to being infected with covid19 they did not believe that covid-19 existed. rather, they believed it was a political game by the government used to control people. this finding aligns with uscinski et al. (2020) which reported people’s belief in covid-19 conspiracy theories. uscinski et al. found that believing in such theories were rooted in psychological predispositions resulting in distrust of information distributed by experts and other authorities as well as believing that major events like the covid-19 pandemic are products of conspiracies, and ideological and partisan motivations. uscinski et al. further remarked that such conspiracy beliefs have negative effects on devising and adhering to treatment as well as developing coping strategies to reduce the consequences of such events [15]. as the results of the present study indicated, considering covid-19 as a political game or a conspiracy led to individuals being infected by the virus. almost all countries in the world are currently affected by the covid-19 pandemic. the number of covid-19 patients in the kurdistan region of iraq continues to increase. the second theme in the present study was fear and stress felt by both patients and heathy individuals. in this regard, it is stated that since covid-19 is highly infectious, people in affected countries are suffering from fear, stress, and anxiety which in turn threaten their mental health and wellbeing [14], and the negative attitude of the community toward covid-19 disease and patients worsen these critical situations [16]. to prevent infection of more people who might surge to hospitals, home treatment and quarantine are the best solutions for reliable and educable patients who have mild or no symptoms and observe all due diligence. quarantining in the home which is one of most effective control measures for epidemic diseases can also reduce people’s stress and fear due to being with family members and being helped by them [17,18].it was also stated that the patients felt shameful to have covid-19 disease. in this regard, it is stated that quarantine and restricted interpersonal relationships may result in senses of shame and loneliness which can be tackled by taking these measures for the purpose of recovery and family reunion. in addition, psychiatric nurses are recommended to develop programs in the form of psychological support or comprehensive spiritual care packages and utilize multiple media channels to help patients overcome such feelings [19].the third theme was found to be changes in lifestyle of patients and people. this finding is also emphasized by other studies which showed that the covid19 pandemic has disrupted trades and movements all over the world and negatively impacts day-to-day businesses and life. dramatic changes can happen in dietary and sleep patterns as a result of adhering to quarantine rules and can cause additional stressful conditions or exacerbate existing stressful conditions[20,21]. such stress can be the result of people’s worry about their next paycheck, shortage of food on the grocery shelves, and staying at home all day long [22]. additionally, both physical and mental health can negatively be influenced by poor quality sleep. the ability of the immune system to resist infections can also decrease. in this regard, it is recommended that electronic devices should be turned off, watching news needs 37 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.04 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article impossible to recruit more patients. another limitation is related to the relatively short duration of engagement with the patients and data collection, which can affect the reliability and validity of the findings because trust and good relationship which form over time and are vital for phenomenological studies can highly be affected. covid-19 patients have a poor quality of life which is even worsened as a result of fear and stress. a deep understanding of such patients’ situations is vital to help nurses and nursing managers plan effective strategies to provide care to patients with covid-19. this includes making changes in their lifestyle, encouraging them to adhere to health guidelines, and providing them with psychological support and appropriate treatment. the author declares no competing interests. [1] byrne l, wykes t. a role for lived experience mental health leadership in the age of covid19. journal of mental health. 2020;29(3):243 –6.https:// doi.org/10.1080/09638237.2020.1766002 [2] coronavirus disease (covid-19) situation reports [internet]. who.int. [cited 2020 aug 25]. available from: https://www.who.int/ emergencies/diseases/novel-coronavirus2019/situation-reports . [3] cascella m, rajnik m, cuomo a, dulebohn sc, di napoli r. features, evaluation, and treatment of coronavirus. 2020 oct 4. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2020 jan–. pmid: 32150360. [4] garcia r. neurobiology of fear and specific phobias. learning and memory. 2017;24 (9):462–71. [5] shigemura j, ursano rj, morganstein jc, kurosawa m, benedek dm. public responses to the novel 2019 coronavirus (2019-ncov) in japan: mental health consequences and to be minimized, alcoholic and caffeine drinks should be avoided, and regular schedule for sleeping needs to be made [23]. the patients in the current study referred to complete changes in their lifestyles due to covid-19 pandemic. in a similar study, it is mentioned that people’s day-to-day life around the world has changed due to destructive effects of covid-19 pandemic. it is also stated that taking up a new lifestyle and being provided with special treatment are keys to improvement in the quality of their lives. moreover, adhering to health guidelines such as wearing masks and gloves, washing hands regularly, eating and drinking healthy, and keeping social distance are key to preventing covid-19 [24]. in addition, remote conduction of business training and assessments needs to be taken into account to avoid gatherings [25,26].it has been stated that social media can provide the public with disseminating information, and many individuals will experience isolation during hospitalization or quarantine at home [27,28]. however, social media needs to turn into an effective source of information and means for keeping abreast of the broad amount of medical knowledge [29]. countries with humanitarian-cooperative culture, low education levels, and pronounced social disparity are reported to have no parameters for estimating the effects of covid19 on the population’s behavior or mental health .8 as a result, it is necessary to provide health guidelines aimed at improving individuals’ mental health in such countries [30].the present study had some limitations. the first limitation is related to the limited number of the patients who participated in the present study, which limits the generalizability of the findings to other groups of people in other places. however, due to the situation of covid-19 patients, it was almost 38 erbil journal of nursing & midwifery conclusion competing interests references https://doi.org/10.15218/ejnm.2021.04 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article [15] uscinski je, enders am, klofstad cm, seelig m, funchion j, everett c, et al. why do people believe covid-19 conspiracy theories? the harvard kennedy school misinformation review [internet]. 2020; available from: http://dx.doi.org/10.37016/mr-2020-015. [16] duan, l., zhu, g. psychological interventions for people affected by the covid-19 epidemic. the lancet psychiatry. 2020;7(4):300302. http://10.1016/s2215-0366(20)30073-0 [17] world health organization (who). home care for patients with middle east respiratory syndrome coronavirus (mers-cov) infection presenting with mild symptoms and management of contacts: interim guidance. world health organization; 2018: 2.3.2020. [18] li d. challenges and responsibilities of family doctors in the new global coronavirus outbreak. family medicine community health. 2020;8(1):e000333. https://10.1136/fmch2020-000333. [19] asgari p, jackson ac, bahramnezhad f. resilient care of the patient with covid-19 in iran: a phenomenological study [internet]. research square. 2020. available from: http://dx.doi.org/10.21203/rs.3.rs-24733/ v1. [20] jin yh, cai l, cheng zs, cheng h, deng t, fan yp, et al. a rapid advice guideline for the diagnosis and treatment of 2019 novel coronavirus (2019-ncov) infected pneumonia (standard version). military medical research. 2020;7(1), 4. https:// doi.org/10.1186/s40779-020-0233-6. [21] haleem, a., javaid, m., vaishy, r. and vaishb, a. effects of covid-19 pandemic in the field of orthopaedics. journal of clinical orthopaedics and trauma. 2020;11(3):498– 499. https://10.1016/j.jcot.2020.03.015. [22] brooks sk, webster rk, smith le, woodland l, wessely s, greenberg n, et al. the psychological impact of quarantine and how to reduce it: rapid review of the evidence. lancet. 2020;395(10227):912–20. https:// doi.org/10.1016/s0140-6736(20)30460-8. [23] abdurahman aa, bule m, shab-bidar s, rezaei s, djafarian k. the association between sleep duration and risk of abnormal lipid profile: a systematic review and metaanalysis. obesity medicine. 2020;18:100236. https://doi.org/10.1016/ j.obmed.2020.100236. [24] haleem a, javaid m. effects of covid-19 pandemic in daily life. current medicine research and practice. 2020;10(2):78–9. target populations. psychiatry and clinical neurosciences; 2020;74:281-2. [6] sahoo s, mehra a, suri v, malhotra p, yaddanapudi ln, dutt puri g, et al. lived experiences of the corona survivors (patients admitted in covid wards): a narrative real -life documented summaries of internalized guilt, shame, stigma, anger. asian journal of psychiatry. 2020;53 (102187):102187. [7] shabu s, amen km, mahmood ki, shabila np. risk perception and behavioral response to covid-19 in iraqi kurdistan region [internet]. research square. 2020. http://dx.doi.org/10.21203/rs.3.rs-22025/ v1 . [8] ornell f, schuch jb, sordi ao, kessler fhp. “pandemic fear” and covid-19: mental health burden and strategies. brazilian journal of psychiatry. 2020;42(3):232–5. http://dx.doi.org/10.1590/1516-44462020-0008. [9] aziz py, hadi jm, sha am, aziz sb, rahman hs, ahmed ha, et al. the strategy for controlling covid-19 in kurdistan regional government (krg)/iraq: identification, epidemiology, transmission, treatment, and recovery. international journal of surgery open. 2020;25:41–6. [10] holloway i, wheeler s. qualitative research in nursing and healthcare. 2010. oxford: wiley-blackwell. [11] elo s, kyngäs h. the qualitative content analysis process. journal of advanced nursing. 2008;62(1):107–15. http://10.1111/ j.1365-2648.2007.04569.x. [12] weible cm, nohrstedt d, cairney p, carter dp, crow da, durnová ap, et al. covid-19 and the policy sciences: initial reactions and perspectives. policy sciences. 2020;53 (2):1–17. https://doi.org/10.1007/s11077020-09381-4. [13] adolph c, amano k, bang-jensen b, fullman n, wilkerson j. pandemic politics: timing state-level social distancing responses to covid-19. journal of health politics, policy and law internet]. 2020; available from: http:// dx.doi.org/10.1215/03616878-8802162. [14] liu, x., kakade, m., fuller, c.j., fan, b., fang, y., kong, j., et al. depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic. comprehensive psychiatry. 2012;53(1):15–23. 39 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.04 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article doi: https://10.1016/j.cmrp.2020.03.011. [25] guidance for surgeons working during the covid-19 pandemic [internet]. rcseng.ac.uk. [cited 2020 aug 20]. available from: https://www.rcseng.ac.uk/ coronavirus/joint-guidance-for-surgeonsv1. [26] osha guidance on preparing workplaces for covid-19. 2020. u.s. department of labor occupational safety and health administration, osha 3990-03 2020. [27] ahmad ar, murad hr. the impact of social media on panic during the covid-19 pandemic in iraqi kurdistan: online questionnaire study. journal of medical internet research. 2020;22(5): e19556). https://10.2196/19556. [28] pappot n, taarnhøj ga, pappot h. telemedicine and e-health solutions for covid -19: patients’ perspective. telemedicine journal and e-health. 2020;26(7):847–9. https://10.1089/tmj.2020.0099. [29] mcgowan bs, wasko m, vartabedian bs, miller, rs, freiherr, dd, abdolrasulnia, m. understanding the factors that influence the adoption and meaningful use of social media by physicians to share medical information. journal of medical internet research. 2020;14(5):e117.doi: https://10.2196/jmir.2138. [30] dieltjens, t., moonens, i., van praet, k., de buck, e. and vandekerckhove, p. a systematic literature searches on psychological first aid: lack of evidence to develop guidelines. plos one. 2014;9(12), e114714. https://doi.org/10.1371/ journal.pone.0114714. 40 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.15 erbil j. nurs. midwifery, vol. 3, no. (2), nov. 2020 original article quality of immediate postoperative nursing care for patients in public and private hospitals in erbil city, iraqcomparative study abstract introduction the postoperative time period is a critical phase that requires a highly standardized measure of care, starts where patients are admitted to the post anesthesia care unit (pacu) or a nursing unit and ends with the patient’s postoperative assessment in the physician’s office after 24 hours [1]. the immediate postoperative nursing care starts when the patient is finished following the surgery and includes a short time that remain after pacu for around 1 to 2 hours [2]. the world health organization (who) defined quality of care as a process that conveying effective delivering health care and medical services for people and networks, in light of need [3]. nurses provide the majority of immediate care for all the patients [4]. since the 1970s, there is proof that nursing outstanding task is related with the nature of patients; also nurse can be offered the best quality level in serious consideration especially in intensive care and subsequently critical care units [5].the main role of nurse background and objective: the 1 to 2 hours for the first 24 hours after surgical operation is a crucial time to perform patient care. the study aimed to assess and compare quality of immediate post operation nursing care for patients undergoing surgeries in the public and private hospitals in erbil city. methods: a comparative study design was conducted on non-probability and purposive sample of 106 nurses (53 nurses of public hospitals and 53 nurses from private hospitals) in the surgical unit in all public and some private hospitals in erbil city. the data was collected between february and july, 2019 by direct observation and using an observational questionnaire. results: the majority of the nurses were young adults who had graduated from a nursing institute who were of middle income and lived in an urban area. the duration of experience as a nurse was between 1 to 10 years. the majority of the nurses (98.1%) in the public hospitals they practiced poor nursing care practice, while most of the nurses (69.8) in the private hospitals practiced good nursing care practices. very high significant difference found between immediate post operation nursing care in public and private hospitals (p <0.000). conclusion: the study concluded that; postoperative nursing care is very important to improve health services, but the quality of the nursing care in the public hospitals as a generally was very poor when compared with the private hospitals. we recommended improving their skills by implementation job description, opening training course and monitoring of the nurses as well as awareness and follow-up. keywords: quality of immediate postoperative; nursing care; patient; public hospitals; private hospitals. sideeq sadir ali; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: sideeq.ali@hmu.edu.krd) 126 erbil journal of nursing & midwifery received: 28/11/2019 accepted: 22/12/2019 published: 30/11/2020 mailto:sideeq.ali@hmu.edu.krd https://doi.org/10.15218/ejnm.2020.15 erbil j. nurs. midwifery, vol. 3, no. (2), nov. 2020 original article immediately after surgical operation are transferred patient from the operation room to the pacu, and doing critical care that includes maintaining an intact surgical incision, monitoring for potential vascular changes, keeping the patients temperature, positioning of the patient, drains do not closed, and the vital signs are also very important [6]. the fundamental job of nursing care is centered around or dependent on the patients’ vital signs, torment evaluation, focal venous weight, implantation rates and hourly pee yield [7], and agony evaluation and dispensing medications [8]. a descriptive study about quality nursing care as perceived by patients in china were found that most of patients (83.69%) they had good perceptions about quality nursing care [9]. another crosssectional study was conducted at kenyatta national hospital showed that most members (40.5%) showed that they had a good perception of the nursing care and [10]. also another study that conducted to explore patients’ opinions of nursing care and to identify predictors of patients’ experiences of nursing care on 225 adult patients in medical-surgical in jordan, the encounters of nursing care all out score in this examination were relatively high 74% [11]. the immediate postoperative period is a critical phase of operation, because the patient requires closely monitoring and nurses can provide cares to patients to facilitate good operative outcomes and decrease the risks of post-operative complications. poor nursing care after operation in the hospitals lead to high re-hospitalization rates, complications and in some situations due to the death. for those reasons, this study assesses the immediate postoperation nursing care in the public and private hospitals in erbil city. this direct observation and comparative study was conducted in all public and some private hospitals in erbil city/ kurdistan region from february to july, 2019 by using a direct observation of the nurses during immediate post operation. the data was collected from 106 nurses who were doing immediate postoperative care. inclusion criteria included nurses who were worked in surgical ward during morning shifts who provided post-operative nursing care. this study excluded all the nurses who were worked in the kidney transplantation unit. this study was approved by the scientific and ethics committee of the college of nursing at hawler medical university. institutional approval for conducting the study was also obtained from general directorate of health in erbil to the public hospitals, and for private hospitals, permission was provided by college of nursing registration departments. the data was collected through direct observational method by using observational checklist for assessing the nurses during doing immediate postoperative care for the patients; each nurse was assessed by observation individually, the questionnaire of the study consists of two parts based on the research objectives which are; socioeconomic data sheet (age, sex, marital status, educational level, economic status, residential area, duration of experience in nursing, duration of experience as a nurse in surgical ward, training course related to postoperative nursing care and how many hours doing training course), take those information after observed the nurse from post operation procedure. the observational checklist for immediate postoperative nursing care which consisted of 36 observational procedure items with two options: achieved (doing the procedure) and not achieved (not doing the procedure), 127 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2020.15 erbil j. nurs. midwifery, vol. 3, no. (2), nov. 2020 original article was considered statistically significant. table 1 shows socioeconomic characteristics of 106 nurses in private and public hospitals; regarding age group, it was ranged between 21-55 years old, in public hospitals nearly half of the of participants were young adults (52.8%), while in private hospitals nearly all of participants were young adults (98.1%). in public hospitals, most participants (56.6%) were males, but in private most (62.3%) were females. in public hospitals, the majority of participants (90.6%) were married, but in the private ones, 50.9% were single. the majority of participants in both hospitals had graduated from institute of nursing in the public 75.5% and in the private 71.7%. about income, majority of the nurses in both hospitals were in the level of middle income (public= 86.8%, private 81.1%). most (90.6%) nurses in the both type of hospitals lived in an urban area. in public hospitals, less than half of participants (47.2%) had 1 -10 years of experience, while in private, the majority of participants (90.6%) had 1-10 years of experience. in public hospitals, less than half of them (47.2%) had 6-10 years of experience, while nurses in the private majority of them (88.7%) had 1-5 years of experience. finally about training course related to postoperative nursing care which shows; in public hospitals, most (92.5%) hadn’t completed any training course, but in private hospitals, half (56.6%) hadn’t completed any training course, and only 47.8% nurses in private hospitals had completed a course of up to five hours. table 2 explores the quality of immediate post-operation nursing care action in public and private hospitals. all nurses in public hospitals performed poorly practice while, in the private hospitals, above half of the nurses (52.8%) performed fairly. which was divided in to three actions steps including: pre-procedure actions, intraprocedure actions, and post-procedure actions. intra-procedure actions were divided into some subscales as followed; vital signs, neurological assessment, wound care, check intake and output and medication. this observational procedure scale was developed and organized by two references; first who department of essential health technologies; clinical procedures unit (who/eht/cpr) 2004 reformatted 2007, with the aim of creating strategic choices in the health systems [2, 12], second one developed by lynn and lebon in the 2011 that organized procedures skill checklists for taylor’s clinical nursing skills (a nursing process approach) [13], those references are the same procedures that used in our hospitals (public and private hospitals) for caring patients post operation. the age group of the nurses was categorized as: 18 35 years old (young adult), 36 55 years old (middle-aged adults) and 56 years old and above (older adult), but the range of the participants nurses of the study between 2155 years old. regarding the observational check list, 36 items of questionnaire divided into three categories ‘poor practice’, ‘fair practice’ and ‘good practice.’ to calculate overall practice, the score of poor practice ranged from 0-12, fair practice ranged from 13-24 and good practice’ ranged from 256. the data was analyzed by using the statistical package for social sciences (spss, version 23), by applying two statistical approaches: descriptive data analysis (frequency and percentage) and for comparative between both types of hospitals used independent samples ttest, mean and standard deviation, mean difference, 95% confidence interval of the difference. for comparing between both hospitals regarding the immediate post operation nursing care used a p-value of ≤ 0.05 128 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2020.15 erbil j. nurs. midwifery, vol. 3, no. (2), nov. 2020 original article all nurses in public hospitals performed taking of vital signs poorly (100%), but in the private hospitals, the majority of the nurses (69.8%) good performed the practice well. regarding neurological assessment, the majority of the participants in public hospitals (84.9%) performed poorly, while the nurses in the private hospitals performed well (77%). regarding wound care; in public hospitals, the majority of participants (73.6%) performed poorly, and in private hospitals, the majority of participants (98.1%) performed well. regarding checking intake and output of the patients 56.6% of nurses in the public hospitals performed poorly, and all of the nurses in the private hospitals (100%) performed well. regarding dismemberment of medication in both types of hospitals, nurses performed well. finally the last actions which include post procedure actions; all of the nurses in the public hospitals (100%) performed poorly, but in private hospitals the majority of participants (66%) performed well. 129 erbil journal of nursing & midwifery table 1: socioeconomic characteristics of the nurses socioeconomic characteristics type of hospital public n=53 private n=53 f (%) f (%) age group (years) 21-35 (young adult) 28 (52.8) 52 (98.1) 36-55 (middle-aged adults) 25 (47.2) 1 (1.9) gender male 30 (56.6) 20 (37.7) female 23 (43.4) 33 (62.3) marital status single 5 (9.4) 27 (50.9) married 48 (90.6) 26 (49.1) educational levels preparatory of nursing school graduated 11 (20.8) 0 (0) institute of nursing graduated 40 (75.5) 38 (71.7) college of nursing graduated 2 (3.8) 15 (28.3) economic status low income 4 (7.5) 10 (18.9) middle income 46 (86.8) 43 (81.1) high income 3 (5.7) 0 (0) residential area urban 48 (90.6) 48 (90.6) sub urban 5 (9.4) 5 (9.4) duration of experience in nursing (years) 1-10 25 (47.2) 48 (90.6) 11-20 19 (35.8) 4 (7.5) 21-30 9 (17) 1 (1.9) duration of experience in surgical word (years) 1-5 8 (15.1) 47 (88.7) 6-10 25 (47.2) 6 (11.3) 11-15 15 (28.3) 0 (0) 16-20 5 (9.4) 0 (0) did you do any training course related to post operation nursing care yes 4 (7.5) 23 (43.4) no 49 (92.5) 30 (56.6) (if yes) how many hours did you do training (*no.=4, 23) 1-5 0 (0) 11 (47.8) 6-10 3 (75) 6 (26.1) 11-15 1 (25) 3 (13) 16-20 0 (0) 3 (13) total 53 (100) 53 (100) https://doi.org/10.15218/ejnm.2020.15 erbil j. nurs. midwifery, vol. 3, no. (2), nov. 2020 original article 130 erbil journal of nursing & midwifery table 2: quality of immediate post operation nursing care in public and private hospital main domain of item type of hospital public private f (%) f (%) pre procedure actions poor practice 53 (100) 13 (24.5) fair practice 0 (0) 28 (52.8) good practice 0 (0) 12 (22.6) intra procedure actions avital signs poor practice 53 (100) 0 (0) fair practice 0 (0) 16 (30.2) good practice 0 (0) 37 (69.8) bneurological assessment poor practice 45 (84.9) 2 (3.8) fair practice 6 (11.3) 10 (18.9) good practice 2 (3.8) 41 (77.4) cwound care poor practice 39 (73.6) 1 (1.9) fair practice 9 (17) 0 (0) good practice 5 (9.4) 52 (98.1) dcheck intake and output poor practice 30 (56.6) 0 (0) fair practice 12 (22.6) 0 (0) good practice 11 (20.8) 53 (100) emedication poor practice 0 (0) 0 (0) fair practice 4 (7.5) 0 (0) good practice 49 (92.5) 53 (100) post procedure actions poor practice 53 (100) 3 (5.7) fair practice 0 (0) 15 (28.3) good practice 0 (0) 35 (66) https://doi.org/10.15218/ejnm.2020.15 erbil j. nurs. midwifery, vol. 3, no. (2), nov. 2020 original article standard deviation of public hospitals were 3.792 ± 2.213, while the mean and standard deviation of private hospitals were 26.23 ± 3.528. the mean difference between public and private hospitals was (-22.434). the confidence interval of the difference practice of the nurses lower was -18.147 and the upper was -12.519. the difference in quality between the two types of hospitals varied significantly (p <0.001). 131 erbil journal of nursing & midwifery level of nursing care type of hospital public private f (%) f (%) poor practice 52 (98.1) 0 (0) fair practice 1 (1.9) 16 (30.2) good practice 0 (0) 37 (69.8) total 53 (100) 53 (100) table 3 illustrates the overall immediate post operation nursing care practice in public and private hospitals. nearly all nurses in the public hospitals provided poor nursing care practice for patients immediately after operation. in private hospitals most of the nurses (69.8%) performed well. table 4 compares quality of care between both public and private hospitals regarding immediate post operation nursing care practice; the mean and table 3: level of immediate post operation nursing care table 4: comparative between public and private hospitals regarding immediate post operation nursing care practice total practices of the nurses public *m ± sd private m ± sd mean difference 95% confidence interval of the difference p value lower upper < 0.001 **vhs 3.792± 2.213 26.23± 3.528 -22.434 -23.568 -21.299 *m±sd= mean and standard deviation. **vhs= very highly significant. https://doi.org/10.15218/ejnm.2020.15 erbil j. nurs. midwifery, vol. 3, no. (2), nov. 2020 original article in the different physiological systems [17]. regarding neurological assessment majority of nurses in public hospital achieved poor practice while in private hospitals the majority of nurses achieved fair practice; the result was supported by the study of postoperative pain assessment in hospitalized patients national survey and secondary data analysis which suggests that the implementation of measuring pain in hospitals is still insufficient [18]. regarding wound care parts majority of the nurses in public hospital was done poor practice, while in private hospitals the majority of nurses they do good practice, this result was supported by that study of maurya and mendhe in the maharashtra, india; which was showed in their study the nurses in the private hospitals performed good practice for wound after operation [19]. about medication, majority of nurses in both public and private hospitals was performed good practice, the result was similar of the cross sectional study in tigray, ethiopia; the quality of nursing care generally in the high level during medicine administration in public and private hospitals [20]. regarding last part, post procedure actions, majority of nurses in private they were performed good practice while in public hospitals they were do poor practice, this result, partially supported by the descriptive study of merkouris et al, in cyprus, which founded overall patients they were satisfied with the post operation nursing care in their hospitals [21].as a generally, all of the nurses in the public hospitals they were done poor nursing care for patients immediately after operation, while mostly nurses in the private hospitals they were done good nursing care practice, the main standpoint of researcher behind these results was some point; majority of the nurses in the private hospitals younger than the nurses in the public hospitals, so the younger person are this study observed and compares immediate post operation nursing in public and private hospitals in erbil city. the monitoring and caring of the patient is the one of the main duties of the nurse [14]. when nurses neglect to provide care, there are opportunities for post-operation complications, including postoperative morbidity and mortality [15]. the main fact that was founded in the table two; was about the quality of immediate post operation nursing care in both hospitals as a domain; as a generally the nurses in the public hospitals in general domain they were done poor practice except in the medication domain, but nurses in the private hospitals in general domain they were done good practice except in the pre procedure actions domain they were done fair practice, the reasons behind that, could be because of the policy of hospitals; in the private hospitals distributes the job description between the health staff, so the nurses in the private they were done mostly of immediate post operation care, while in the public hospitals most of the immediate post operation care done by the physicians because of in the public hospitals they was no any distributes of the job description between the health staff. the result was unsupported by cross-sectional study that conducted in nairobi, kenya about examining surgical patients’ expectations of nursing care which was finding that there was good care present for postoperative patients [16]. the result of the study regarding intraprocedure actions in public hospitals performed taking of vital signs poorly, but in the private hospitals, performed the practice well, the result was supported by cross sectional study that conducted by serra et al. 2015, about nursing care in the immediate postoperative period, it was observed that nursing care is not fully offered 132 erbil journal of nursing & midwifery discussion https://doi.org/10.15218/ejnm.2020.15 erbil j. nurs. midwifery, vol. 3, no. (2), nov. 2020 original article participation of nurse in training [24]. while the result of the study disagree with the cross-sectional survey study that conducted by rahman et al on 652 nurses in kedah, malaysia, that working in the medical and surgical wards in 12 private hospitals, reported in their study; nurses with higher education were not significantly associated with both quality of care and patient safety [25]. another main reason could be about the style of working in the hospitals, generally the nurses in public hospital was formal employed (permanent) they do not get the sack if they neglected or don’t doing work well, but the nurses in the private hospital was temporary employed if they do well work they became continuing on work contrarily may become get the sack. also another important thing behind this reason the nurses in the private hospital are continuously invigilated on them if they don’t work well also get the sack or punished, per contra that, the nurses in the public hospital very rarely invigilated. the other cause could be due to certification of the nurses. some of the nurses in the private hospitals had graduated from nursing colleges, while the majority public hospital nurses graduated from nursing institute, this result was supported by the doctoral dissertation study of wulff 2019; majority of public nurses was less actives because of graduated majority nurses from institute [26]. regarding mean difference that illustrated in this table, there were founded that the practice of the nurses from private hospitals larger than the practice of the nurses from public hospital, so the result was explored as a minus, because of practice minus private the results became minus. also very high significant relationship was founded between public and private hospitals, because the practice of post operation nursing care from private was more than from the public. silva et al, more active than the older one. this result was agreed with the previous cross sectional study that conducted by serra et al. 2015; majority of the nurses that was participated in their study young and very active during post operation [17]. also the result was supported by descriptive study that conducted in selected private and public hospitals at ludhiana, punjab; it was founded the majority of the patient satisfaction with nursing care score was significantly higher in private hospitals as compared to public hospitals [22]. another reason could be the different point in the marital status, majority of the nurses in the public hospital was married, but nearly half of percentage of the nurses in the private was single, so the married person in our society was more devoir in general sector of the life than the un married persons, so the devoir persons are less than active than the other. the result was supported by the descriptive study that conducted by the devi and saju among staff nurses and the nursing students in narayana medical college hospital, nellore, they were explore socioeconomic character such as educational status, age, sex and year of experiences was significantly associated for increasing level of knowledge as well as source of information, association with it in the other hand [23]. so the researcher commented on that was additional factored may be affected; was about training course related to postoperative nursing care which was founded in the table one; most of the nurses in the private hospital was participated training course, while very low percentage of the nurses in the public hospitals doing training course. this result was supported by the descriptive study that conducted by qadir and younis in the erbil city; there was a significant relationship was founded between the levels of quality of nursing care with age, gender, levels of education, nurse’s experience and 133 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.15 erbil j. nurs. midwifery, vol. 3, no. (2), nov. 2020 original article [accessed: 29th jan 2019]. [5] padilha kg, stafseth s, solms d, hoogendoom m, monge fj, gomaa oh, et al. nursing activities score: an updated guideline for its application in the intensive care unit. revista da escola de enfermagem da usp· 2015; 49 (esp): 131-7. available from: doi: 10.1590/s0080-623420150000700019 [accessed: 30 th jan 2019]. [6] timby bk, smith ne. introductory medicalsurgical nursing. us philadelphia: 10th ed. wiley-blackwell publishing; 2010. [7] liddle c. principles of monitoring postoperative patients. nursing times. 2013; 109 (22): 24-6. available from: http// www.nursingtimes.net [accessed: 1st jan 2019]. [8] dumolard p, gök m, le n. nurses' responsibilities in postoperative pain management following total hip arthroplasty. bachelor’s thesis. jamk university of applied science. 2017; available from: https:// www.theseus.fibitstreamhandle/10024/131 818/dumolard_pierre.pdf? sequence=1&isallowed=y [accessed: 3rd jan 2019]. [9] zhao sh, akkadechanunt t. patients perceptions of quality nursing care in a chinese hospital. international journal of nursing and midwifery. 2011; sep 30; 3(9): 145-9. [10] shawa e, omondi l, mbakaya b. examining surgical patients’ expectations of nursing care at kenyatta national hospital in nairobi, kenya. european scientific journal. 2017; available from: doi: 10.19044/ esj.2017.v13n24p344 [accessed: 3rd jan 2019]. [11] ahmad mm, alasad ja. predictors of patients’ experiences of nursing care in medical-surgical wards. international journal of nursing practice. 2004; 10 (5): 235-41. [12] world health organization. best practice protocols: clinical procedures safety. who surgical care at the district hospital 2003. geneva 27, switzerland. available from: https://www.who.int/surgery/publications/ bestpracticeprotocolscpsafety07.pdf [accessed: 3rd july 2019]. [13] lynn p. lebon m. skill checklists for taylor’s clinical nursing skills, a nursing process approach. 3rd ed. london: wiley-blackwell publishing; 2011. [14] sun h, okochili m. patients' perceptions of the nurse patient relationship in postoperative care. bachelor’s thesis. jamk university reported in their study; nursing care should be developed in immediate post-operative period with quality and competence by nurses and all team [27]. the result was supported by a comparative study in cyprus that about assessment of patients' satisfaction with care provided in public and private hospitals, which show, those patients hospitalized in private hospitals seem to be more satisfied than those who were admitted to the public hospital [28]. while the quality of postoperative nursing care is important, the quality of immediate post operation nursing care in the public hospitals in erbil city is insufficient. to improve quality in the public hospitals, high quality guidelines regarding post operation nursing care should be implemented. finally monitoring the nurses during any procedure, especially post operation practice are very important, as well as should be implemented policy program for awareness and punishment. the author declares no any conflicts of interest. [1] williams ls, hopper pd. understanding medical-surgical nursing. 2nd ed. us, philadelphia: f.a. davis company publishing; 2003. [2] lynn p. taylor's clinical nursing skills: a nursing process approach. 3rd ed. london: wileyblackwell publishing; 2011. [3] world health organization. quality of care: a process for making strategic choices in health systems. geneva switzerland: who library cataloguing publishing; 2006. available from: http://www.health.org.uk/qquipp [accessed: 18th sep 2018]. [4] renganayaki s, sugunakumari s. quality of post-operative nursing care among patients subjected to cardiac surgery. journal of nursing and health science (iosr-jnhs). 2016; 5 (1): 71-3. available from: doi: 10.9790/1959-05137173 134 erbil journal of nursing & midwifery conclusion conflicts of interest reference https://doi.org/10.15218/ejnm.2020.15 erbil j. nurs. midwifery, vol. 3, no. (2), nov. 2020 original article [22] sharma sk, kamra pk. patient satisfaction with nursing care in public and private hospitals. nursing and midwifery research journal. 2013; 9 (3): 130-41. [23] devi a, saju a. knowledge regarding postoperative care in adult, among the staff nurses and nursing students. international journal of applied research. 2017; 3 (4): 674-7. [24] qadir do, younis ym. quality of nursing care for patients with acute myocardial infarction at coronary units of erbil city hospitals. zanco journal of medical sciences. 2015; 19 (2): 1011-8. [25] rahman ha, mu’taman jarrar ms. nurse level of education, quality of care and patient safety in the medical and surgical wards in malaysian private hospitals: a cross-sectional study. global journal of health science. 2015; 7 (6): 331-7. available from: doi:10.5539/gjhs.v7n6p331 [accessed: 2nd mar 2019]. [26] wulff t. knowledge and clinical practice of nurses for adult post-operative orthopedic pain management (doctoral dissertation, stellenbosch: stellenbosch university). 2012; available from: http://www scholar.sun.ac.za [accessed: 2nd mar 2019]. [27] silva ka, medeiros sm, paulino ts, da costa pereira fc, da rocha kd, de sousa rosso ic, et al. nurses’ role in post-operative immediately myocardial revascularization in intensive care unit. international archives of medicine. 2016; 9 (199): 1-7. available from: doi: 10.3823/2070 [accessed: 2nd mar 2019]. [28] charalambous m, sisou g, talias ma. assessment of patients' satisfaction with care provided in public and private hospitals of the republic of cyprus: a comparative study. international journal of caring sciences. 2018; 11(1):125-35. of applied science. 2018; available from: https://www.theseus.fi/bitstream/ handle/10024/141453/thesis%20okochili% 20sun%20bachelors%20final%20bn..pdf? sequence=1&isallowed=y. [accessed: 4th jul 2018]. [15] jammer ib. perioperative interventions and postoperative outcomes (doctoral dissertation). university of bergen. university of bergen, norway. 2015; available from: https:// pdfs.semanticscholar.org/c399/ beb4033a7afc0f4ddebad45f1676584b10ac.p df [accessed: 3rd feb 2019]. [16] shawa e. patients' perceptions regarding nursing care in the general surgical wards at kenyatta national hospital (doctoral dissertation). university of nairobi, school of nursing sciences. kenyatta. 2012; available from:https://www.nursingrepository.org/ bitstream/handle/10755/621210/ shawa_thesis.pdf;jsessionid=a3e9e5369f69 986a9ba776c716c974f0?sequence=1 [accessed: 30 th jan 2019]. [17] serra maao, filho ffs, albuquerque ao, santos caa, carvalho junior fa, silva ra. nursing care in the immediate postoperative period: a cross-sectional study. online brazilian journal of nursing. 2015; 14 (2): 161-7. available from: http:// www.objnursing.uff.br/index.php/nursing/ article/view/5082 [accessed: 30 th jan 2019]. [18] hoogervorst-schilp j, van boekel rl, de blok c, steegers ma, spreeuwenberg p, wagner c. postoperative pain assessment in hospitalised patients: national survey and secondary data analysis. international journal of nursing studies. 2016; nov 1; 63: 124-31. [19] maurya a, mendhe s. prevention of postoperative wound infection in accordance with evidence based practice. international journal of science and research (ijsr). 2014; 3 (7): 1173-7. [20] gerensea h, solomon k, birhane m, medhin bg, mariam th. quality of nursing care among in-patient of medical-surgical ward in axum st. marry hospital, tigray, ethiopia. enzyme engineering. 2015; 4 (2): available from:doi:10.4172/23296674.1000132 [accessed: 2nd mar 2019]. [21] merkouris a, andreadou a, athini e, hatzimbalasi m, rovithis m, papastavrou e. assessment of patient satisfaction in public hospitals in cyprus: a descriptive study. health science journal. 2013; 7 (1). 27-40. 135 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.12 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article nurses’ awareness toward risk factors of breast cancer in kirkuk city hospitals abstract introduction breast cancer, the proliferation of cells in breast tissue, is a deadly malignancy worldwide. this disorder is characterized by lumps in the breast, persistent pain in the breast or armpit, dimpling of the skin, shifting the location of the nipples, rashes on the nipple and swelling under the armpit. this condition is not limited to women only. in both developed and developing countries, it is the most common form of cancer diagnosed in women around the world, with more than one million cases background and objectives: in women worldwide, breast cancer is the most common cancer. it is one of the leading causes of cancer death in women, accounting for 15% of all cancer deaths in the female population. in most countries, breast cancer incidence rates are higher than they have ever been at an early age. this study aimed to identify the level of nurses’ awareness towards risk factors of breast cancer. methods: a cross-sectional study was carried out among 341 nurses from different departments in three kirkuk city hospitals (azadi teaching hospital, kirkuk general hospital, and pediatric hospital) from 25 february to 25 june 2021. a non-probability/convenient sampling technique was utilized to collect data. a socio-demographic characteristics data form and awareness of breast cancer risk factors form were used to collect data through face-to-face interviews. data were analyzed using statistical package for the social sciences, version 21, presenting descriptive and inferential statistics comprising frequency, percentage and chi-square test. results: out of the 341 nurses, 44.9% were from azadi teaching hospital, while more than one-third (38.1%) were from kirkuk general hospital, and 17% were from pediatric hospital. most of the nurses, 38.4%, were between the ages of 21 and 25, 64.8% were female, and 66.9% were married. about 36.1% of nurses report acceptable level of awareness and 5.9% report being with good level of awareness about risk factors associated with breast cancer. conclusion: the awareness level of breast cancer risk factors among nurses working in kirkuk city hospitals was generally high. younger age was associated with higher level of awareness of risk factors. regarding to the gender was highly significant differences between the nurses’ awareness of breast cancer risk factors. keywords: breast cancer, risk factors, nurses, awareness. burhan qader saadoon; department of nursing, college of nursing, sulaimani university, sulamani, iraq. (correspondence: borhanqader@gmail.com ) salih ahmed abdulla; department of nursing, college of nursing, hawler medical university, erbil, iraq. 105 erbil journal of nursing & midwifery received: 14/09/2021 accepted: 18/11/2021 published: 30/11/2021 mailto:borhanqader@gmail.com https://doi.org/10.15218/ejnm.2021.12 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article occurring annually [1]. breast cancer development can be categorized by genetic, lifestyle and environmental factors. genetic factors include age, race, familial/personal history of breast cancer, early menstruation (before age 12), late menstruation (after age 51), genetic influences, and dense breast tissue. lifestyle and environmental factors include parity, contraceptive use, hormone replacement therapy after menopause, breastfeeding, tobacco use, obesity or overweight, and poor diet and exercise [2]. in most countries, breast cancer incidence rates are higher than they have ever been at an early age, and these results are generally highest where historically low rates have been reported [3]. the first and most common symptom of breast cancer is a painless lump or thickening in the breast. breast pain or heaviness, changes in breast size and form, swelling, and nipple defects, such as spontaneous discharge (especially if bloody), erosion, or retraction, are other signs and symptoms [4]. on mammograms, the first symptoms of breast cancer are typically seen, even before lumps can be felt [5]. breast cancer is a big health issue for women and society. community and general nurses are the primary teams of health care professionals who are easily approachable and can serve as the future health educator. the preventive services provided by nurses in the form of health evaluation, screening, and therapy can be incorporated into systematic health promotion and safety programs at the community level. the optimal initial step for the community health nurse is to evaluate women’s history awareness and attitudes prior to the planning and involvement in conducting breast cancer teaching programs [6]. breast cancer compensates one-tenth of all newly diagnosed cancer cases worldwide. five percent of new breast cancer diagnoses occur in women less than 40 years of age. this may contribute to higher rates of mortality from breast cancer in younger women. the 5-year relative survival rate of young women who are 40 years of age or younger is significantly lower compared to women who are 40 and older. screening for early detection and having awareness about risk reduction is important for young people [7]. the presence of a lump in the breast that progressively enlarges over time is usually an early sign. if these symptoms are identified, it is better to obtain immediate medical advice [8]. the purpose of this study is to evaluate nurse’s level of awareness about breast cancer risk factors and explain how that may influence their ability to provide information and care for their patients. a cross-sectional study was carried out among 341 nurses at different departments in three kirkuk city hospitals from 25 february to 25 june 2021. a nonprobability/convenient sampling technique was utilized to collect data. the inclusion criteria were male and female nurses working morning, evening, and night shifts who agree to participate in this study. exclusion criteria are those who refused participation or absent during the period of data collection, and nurses who work in managerial role. the sample size was determined by k = components (k-items or test lets). σ2x = the variance of the observed total test scores. σ 2 yi = the variance of component i for the current sample of persons [9] reliability was determined using the cronbach’s alpha (0.82) values. in order to collect the proper information of the study, the questionnaire was designed and constructed by the researcher to measure the variables underlying the present study. the researcher prepared a questionnaire for collecting data based on the review literature. the questionnaire 106 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2021.12 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article social science (spss) version 21 and the following statistical test were used in data analysis: descriptive statistical data analysis: this approach applied through the measurement of the following: a. frequencies (f): n. of samples b. percentages (%): c. means: d. standard deviation (sd): sd inferential statistical data analysis: for the abbreviations of the comparative significance (cs), we used the following: ns: not significant at p. value ≥ 0.05 s: significant at p. value < 0.05 hs: highly significant at p. value < 0.01 analysis of variance (anova) test: a parametric statistical test used to compare the differences between the means of two or more groups by comparing the variability between groups and within groups. this test was used to determine the differences in the means of nurses' awareness level about the risk factors for breast cancer to different subject variables. table 1 shows the socio-demographic characteristics of the sample. nearly half of the sample (44.9%) were from azadi teaching hospital, more than a third (38.1%) were from kirkuk general hospital, and about 17% were from pediatric hospital. 38.4% of the sample were aged 21-25 years old, 64.8% were female, and 66.9% were married. less than half (41%) of the population were institute graduates. about 18.8% of the population worked in medical wards, and 14.7% worked in surgical wards. 47.8% of the population had 1-5 years of experience. 94.4% of the population reported they had not had breast cancer, and 61.3% reported not caring for breast cancer patients. finally, based on participation in the trainings, the nonparticipated sample made the majority consists of two parts: 1) socio demographic characteristics section, and 2) observation checklist with information related to level awareness about breast cancer risk factors, each questionnaire item regarding level of awareness had 3 responses: yes rated as (1), no is rated as (2) and, i don't know rated as (3). the level of awareness is scored by calculating the lowest total of the incorrect answers "yes" or "no". a value of "015.5" indicated poor level of awareness, a value of "16-20" indicated an acceptable level, a value of "21-25" indicated an intermediate level, and a value of "26-31" indicated a good level. face-to-face interviews of 30 minutes was also used to collect data. all participants were informed that the information will be kept confidential and use for scientific purposes only. the questionnaire was verified by a panel of experts who have extensive experience from different specialties. based on their comments, the questionnaire was corrected and modified for appropriate data collection. before conducting interviews, the researchers explained the purpose to all participants and acquired their oral consent, with ethical permission from the university of sulaimani/college of medicine and its ethics committee the no: 112 and date of the approval 25/5/2021. the hospital's director gave approval prior to data collection, and the unit's nurse in charge were informed. a pilot study was carried out on 30 nurses through the period from 16-24 february in 2021. the pilot study was beneficial to determine the reliability of the study instrument. the result of the pilot study revealed that the items of the questionnaire were clear and understandable to the participants and required some modification in the "socio-demographic characteristics" section. each questionnaire took approximately 30 minutes to complete. the data was summarized and analyzed through using the application statistical package for 107 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2021.12 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article percentage (65.1%) of whole sample. table 2 shows the levels of awareness about breast cancer risk factors for the study sample. as shown in this table, most of the study sample (36.1%) have an acceptable level of awareness about breast cancer risk factors. 108 table 1: distribution of the socio-demographical data characteristics of the study sample (no.: 341). the socio-demographical characteristics subgroups f. (%) hospital name azadi teaching hospital 153 (44.9) kirkuk general hospital 130 (38.1) pediatric hospital 58 (17) age groups/years 21 – 25 131 (38.4) 26 – 30 101 (29.6) 31 – 35 21 (6.2) 36 – 40 29 (8.5) 41 – 45 30 (8.8) 46 – 50 16 (4.7) more than 50 13 (3.8) gender male 120 (35.2) female 221 (64.8) marital status single 111 (32.5) married 228 (66.9) separated 1 (0.3) divorced 1 (0.3) education level preparatory graduated 92 (27) institute graduated 140 (41) college graduated 105 (30.8) post-graduate 4 (1.2) departments surgical ward 50 (14.7) medical ward 64 (18.8) pediatric ward 15 (4.4) gynecology & obstetric ward 34 (10) consultant clinics 26 (7.6) emergency room 33 (9.7) operation theater 34 (10) ccu 24 (7) rcu 19 (5.6) premature unit 27 (7.9) mammography unit 5 (1.5) dialysis unit (artificial kidney) 10 (2.9) the socio-demographical characteristics subgroups f. (%) years of experience less than 1 year 47 (13.8) 1 – 5 163 (47.8) 6 – 10 54 (15.8) 11 – 15 25 (7.3) 16 – 20 21 (6.2) 21 – 25 15 (4.4) 26 – 30 10 (2.9) 31 years + more 6 (1.8) suffered from bc yes 19 (5.6) no 322 (94.4) cared of bc patients yes 132 (38.7) no 209 (61.3) participating in trainings non-participated 222 (65.1) yes one training 119 (34.9) erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.12 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article table 4 shows highly significant differences between the study sample responses regarding gender (p-value < 0.001). 109 erbil journal of nursing & midwifery table 3 shows no significant differences between the study samples regarding their age groups (p-value = 0.978). table 2: distribution of the levels of the awareness about breast cancer risk factors for the study sample (no.: 341) awareness levels about breast cancer risk factors f. % mean s.d. poor level 106 31 2.08 0.901 acceptable level 123 36.1 intermediate level 92 27 good level 20 5.9 total 341 100 table 3: comparisons the levels of the awareness about breast cancer risk factors regarding to the age group of the study sample by one-way anova test. awareness age groups f. % mean ± sd f. value sig. value awareness levels about breast cancer risk factors 21-25 y. 131 38.42 2.11 ±0.897 0.195 0.978 n.s. 26-30y. 101 29.62 2.10 ±0.911 31-35 y. 21 6.16 2.05 ±1.024 36-40 y. 29 8.50 1.97 ±0.865 41-45 y. 30 8.8 2.10 ±0.960 46-50 y. 16 4.69 2.00 ±0.894 more than 50 y. 13 3.81 1.92 ±0.760 total 341 100 2.08 ±0.901 f. value: anova test value. table 4: comparisons the levels of the awareness about breast cancer risk factors regarding to the sex of the study sample by chi-square test. awareness sex f. % mean ± sd f. value sig. value awareness levels about breast cancer risk factors male 120 35.19 2.07 ±0.914 72.243 0.001 h.s. female 221 64.81 2.08 ±0.896 f. value: chi-square test. https://doi.org/10.15218/ejnm.2021.12 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article table 5 shows a significant difference between the study sample responses a high percentage of the sample (38.4%) were between the ages of 21-25, and those over 50 contributed to the lower percentage (3.8%). this result agrees with the result of the study [10] in their research “assessment of knowledge of breast cancer and screening methods among nurses in university hospitals in addis ababa, ethiopia, 2011”. this might be explained because of the need for new staff nurses to work at all hospital departments, and these ages were capable of bearing and tolerating the burdens of working with patients. the majority of sample were female (643.8%) which is in agreement with the result of a study with the higher percentage of the population (89%) were female [11]. the majority of sample in the study were married (66.9%), a finding which is in disagreement with the result of the study [12] which mentions that most of the nurses (51.2%) are single. which is in agreement with the study done in jordanian nurses [13] which mentions that most of the nurses (51.8%) are married. concerning graduation level, most of the sample study (41%) had a degree in nursing, and 1.2% had higher studies of nursing science regarding marital status at (p-value 0.041). degree. a higher proportion of the sample (18.88%) worked in medical wards, and 14.7% worked in surgical wards. this finding was similar with the finding of another study [11]. there are separate wards for men and women in the medicine and surgery departments in kirkuk city hospitals. regarding the years of experience in departments, it has been noted that 47.8% of nurses had 1 to 5 years, while 1.8% of nurses had more than 31 years of experience. this result in agreement with the result of the study among nurses in university hospitals in addis ababa, ethiopia, 2011 which reported 61.1% of nurses had below 5 years of experience, while 1.5 of nurses had more than 31 years of experience [10]. 94.4% of the sample reported they had not had breast cancer ad, 61.3% reported not caring for any breast cancer patients. this finding was similar with the finding of another study which reported 99.3% of the sample had not had breast cancer and, 54.1% not caring for any breast cancer patients [11]. training courses are necessary to improve nurses’ awareness of breast cancer in all hospital departments. based on participation in the 110 erbil journal of nursing & midwifery discussion table 5: comparisons the levels of the awareness about breast cancer risk factors regarding to the marital status of the study sample by one-way anova test. awareness marital status f. % mean ± sd f. value sig. value awareness levels about breast cancer risk factors single 111 32.6 2.26 ±0.922 2.779 0.041 s. married 228 66.8 1.98 ±0.880 separated 1 0.3 2.00 ±.000 divorced 1 0.3 3.00 ± .000 total 341 100 2.08 ±0.901 https://doi.org/10.15218/ejnm.2021.12 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article differences in level of awareness about breast cancer risk factors due to age groups as indicated by p-value =0.294) [15]. the level of awareness of breast cancer risk factors was generally high among nurses working in kirkuk city hospitals. the lower the age group the higher awareness on breast cancer risk factors. the study findings report highly significant differences between the nurses’ awareness of breast cancer risk factors by gender. based on the findings of this study, the promotion of future health policies, such as mandatory continuing education is highly recommended to improve awareness levels of breast cancer risk factors among nurses. there is a need for the ministry of health, hospital management, training institutions to improve breast cancer content in the nursing curriculum. as the implementation of the revised curriculum may take some time, workplace training courses for the nurses can be introduced relatively earlier. nurses are encouraged to disseminate this knowledge effectively and appropriately within the general population. the author declares no competing interests. trainings, the non-participated sample made the majority proportion (65.1%) of whole sample, and the participated sample (34.9%) made the lowest percentage of the sample. continuing education is the best way to update the nurses’ awareness of breast cancer regarding risk factors. concerning awareness levels about breast cancer risk factors items have a mean score of 2.08 and a standard deviation of .901. this indicates that total average of breast cancer risk factors events that occur in the workplace perceived by nursing staff in many hospital departments. nurses in kirkuk city hospital had poor level of awareness (31%) which is in agreement with the study results among nurses in teaching hospitals of karachi, pakistan reporting 25% of nurses had poor level of awareness of breast cancer risk factors [14]. the overall level of awareness towards this breast cancer was similar among male and female nurses, single and married nurses, younger and older nurses, and among nurses with different educational levels. the level of awareness was also not influenced by years of experience, previous history of breast cancer, or a history of caring for a breast cancer patient. the results of present study disagree with the study among nurses and midwives in mulago hospital which reports 91.11% of the sample had poor level of awareness of breast cancer risk factors [11]. this could be explained by the lack training programs and sensitization workshops for the health care professionals in the hospital. the finding indicated that there were no statistical significant differences between the study samples regarding their age groups (p-value=0.978). the outcome of the study agrees with the result of a study among a cohort of nurses in iran that showed there were no statistically significant statistically 111 erbil journal of nursing & midwifery conclusion recommendation competing interests https://doi.org/10.15218/ejnm.2021.12 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article [11] ekong, o. awareness of breast cancer risk factors and early detection measures and associated factors among nurses and midwives at mulago hospital. unpublished masters’ thesis). makerere university, kampala, uganda. 2009. [12] andegiorgish, a. k., kidane, e. a., & gebrezgi, m. t. knowledge, attitude, and practice of breast cancer among nurses in hospitals in asmara, eritrea. bmc nursing, 17(1), 1 -7, 2018 [13] amasha, h. a. r. breast self-examination and risk factors of breast cancer: awareness of jordanian nurses. health science journal, 2013: 7(3), 303. [14] ahmed, f., mahmud, s., hatcher, j., & khan, s. m. breast cancer risk factor knowledge among nurses in teaching hospitals of karachi, pakistan: a cross-sectional study. bmc nursing, 2006, 5(1), 1-7. [15] ghahremanfard, f., ghorbani, r., & hemmati, s. knowledge of breast cancer risk factors among a cohort of nurses in iran. iranian journal of blood and cancer, 2014, 183-187. [1] maggle, a. knowledge, attitudes and practices of women on breast cancer and breast self examination in kisaasi, kawempe division (doctoral dissertation, makerere university). 2015. [2] badr, l. k., bourdeanu, l., alatrash, m., & bekarian, g. breast cancer risk factors: a cross-cultural comparison between the west and the east. asian pacific journal of cancer prevention: apjcp, 2018; 19(8), 2109. [3] el-nasr, e. m. s. breast cancer risk factors and screening practices among women attending family health centers in cairo governorate. journal of nursing and health science, (iosr-jnhs, 6(3), 12-23, 2017. [4] hamad, k. j., khalil, h. m., & awlla, h. a. knowledge of breast cancer risk factors and practice of breast selfexamination among female students of soran technical institute. polytechnic journal, 2018, 8(3), 203-218. [5] agbonifoh, j. a. breast self -examination practice among female students of tertiary institutions. journal of education and practice, 2016, 7(12), 11-18. [6] al-rikabi, a., & husain, s. increasing prevalence of breast cancer among saudi patients attending a tertiary referral hospital: a retrospective epidemiologic study. croatian medical journal, 2012; 53 (3), 239. [7] ansah, m. b. female students’ knowledge, beliefs, attitude and practice of breast selfexamination in a university in the western cape (doctoral dissertation, cape peninsula university of technology). 2015. [8] chowdhury, s., & sultana, s. awareness on breast cancer among the women of reproductive age,2011. [9] yount r., correlation coefficient, chapter 22 reliability, 4th edition, 2006, pp:2-7 [10] lemlem, s. b., sinishaw, w., hailu, m., abebe, m., & aregay, a. assessment of knowledge of breast cancer and screening methods among nurses in university hospitals in addis ababa, ethiopia, 2011. international scholarly research notices 2013, 2013. 112 erbil journal of nursing & midwifery references https://doi.org/10.15218/ejnm.2019.02 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article knowledge and self-care practices of adolescent students with premenstrual syndrome in erbil city abstract introduction premenstrual syndrome (pms) is one of the most common disorders among women of reproductive age that can be seen in different intensities in 90-85% of women. pms is approximately defined as the group of symptoms occurring only during the luteal phase of a woman’s menstrual cycle, meaning that occurs 14 days before the menstrual period and decrease with the onset of the menstrual *1+. it is associated with physical, psychological and behavioral changes. pms can affect menstruating women of any age and the effect is background and objectives: premenstrual syndrome includes recurrent, troublesome physical and emotional symptoms that develop 7–14 days before the onset of menstruation and subsides when menstruation occurs. this study aimed to assess adolescent student's knowledge and self-care practices toward premenstrual syndrome in intermediate and secondary schools at kurdistan region of iraq. methods: a descriptive study was carried out in primary and secondary schools in erbil city from january 2018 to june 2018. purposive (non-probability) sampling technique was used to target 200 adolescent students through in person interviews by a questionnaire. the clinical criterion of american college of obstetricians and gynecologists for premenstrual syndrome was used. data were presented using descriptive statistics in the form of frequencies, percentages, and chi square test. results: the majority (72.5%) of adolescent students were between ages 13-16 years. the majority (75.5%) of students knew about symptoms of premenstrual syndrome different from woman to woman or cycle to cycle, while most (63%) of school girls never practiced yoga to decrease premenstrual syndrome symptoms. the results revealed that the majority of overall study sample, 60% had fair knowledge toward premenstrual syndrome. the assessment of student's mother is fair because majority (42%) of their mothers were illiterate, while most (71.5%) of subjects sometimes used self-care practices to manage or control symptoms of premenstrual syndrome. there was no significant association between levels of knowledge of students with self-care practices. conclusions: knowledge and self-care measures about premenstrual syndrome were insufficient among the adolescent school girls. students are needing educational program to increase female awareness and practice about premenstrual syndrome . keywords: premenstrual syndrome; adolescent; knowledge; self-care, iraq. sazan bahram ahmed; department of nursing, college of nursing, hawler medical university, erbil, iraq. awaz aziz saeed; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: sazan.bahram@nur.hmu.edu.krd ) 9 erbil journal of nursing & midwifery received: 9/7/2018 accepted: 17/12/2018 published: 30/5/2019 mailto:sazan.bahram@nur.hmu.edu.krd https://doi.org/10.15218/ejnm.2019.02 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article different for each woman. this is a difficult problem in adolescence as the psychological changes that are occurring during this time of a woman’s life are often complex and stressful *2+. the american college of obstetrics and gynecology (acog) published the diagnostic criteria for pms. pms is considered to exist if at least one of the six affective and one of the four somatic symptoms are reported five days prior to onset of menses in prior three cycles and cease within four days of onset of menses. there are numerous emotional and behavioral symptoms such as depression, angry outbursts, irritability, crying spells, anxiety, confusion, social withdrawal, poor concentration, as well as sleep disturbance, thirst, and appetite changes. there are also physical symptoms, including breast tenderness, bloating, and weight gain, in addition to headache, swelling of hands or feet, and aches or pains. it is estimated that up to 85% of women who menstruate experience at least one premenstrual symptom, occurring within 2 weeks before menses and easing after menses begins *3+.the causes of pms are unclear, though an underlying neurobiological vulnerability to normal fluctuations in the circulating sex hormones levels during the menstrual cycle is thought to contribute *4+. self-care refers to those activities an individual performs independently throughout life to promote and maintain personal wellbeing*5+. management of premenstrual syndrome in young aged women focus on pharmacological treatments for pms in the form of -hormonal interventions, antidepressants, high-dose estrogen as transdermal patches or subcutaneous implants, nonsteroidal anti-inflammatory drugs for severe degrees. also positive coping techniques and life style modifications are often recommended for alleviated severity of physical and psychological symptoms of pms especially among mild and moderate degrees in the form of yoga, exercises. dietary restrictions through (sodium restriction has been proposed to minimize bloating, fluid retention, and breast swelling and tenderness. also caffeine restriction is recommended because of the association between caffeine and premenstrual irritability and insomnia *5+.pms has been studied and evaluated extensively in the west and only a handful amount of research studies have been conducted in asia *6+. very little information is available on premenstrual syndrome self management. knowledge about pms is presumed to help with coping with the negative impacts of pms among the adolescent girls. therefore the investigator assessed the knowledge on pms among adolescent girls. a descriptive study design was used to assess their knowledge and self-care practices of 200 adolescent female students about premenstrual syndrome from january to april 2018 at four schools. the number of samples consisted of 50 students from each school, include: shamamk secondary school, layla zana intermediate school, kazhin secondary school and razhan intermediate school in erbil city in the kurdistan region of iraq. a nonprobability, purposive sample technique was used. diagnostic of pms based on acog criteria for diagnosing premenstrual syndrome as national institute of mental health that must be present in the five days before menses for at least three previous menstrual cycles in a row, end within four days after of the onset and must be present in the absence of any pharmacologic therapy, hormone ingestion, or drug or alcohol use. girls who had not attained menarche, those who have irregular methods 10 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.02 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article the responds of the management and selfcare practice items were include three answers (0 =never, 1= sometimes and 2=always). the calculation of overall levels of practice (10 items) was categorized to three groups of never practiced (0-6), sometimes practiced (7-13), and always practiced (14-20).the validity of the questionnaire was checked initially by panel of 14 experts from different field. the expert responses were based on agreement or disagreement with items of questionnaire. the results indicated that all experts agreed the content of the questionnaire with some modifications. the researcher took into consideration their responses and prepared the final version of the questionnaire. a pilot study was conducted on 20 participants that were not included for the final study, in order to determine the reliability of the questionnaire (internal consistency by split-half). the alpha correlation coefficient was 0.792, which is statistically adequate. formal administrative approval was obtained from the directorate of education/ministry of education in kurdistan region and permission to carry out the study was obtained from relevant school authorities for the purpose of data collection. informed oral consent was obtained from each participant. in addition, the researcher told each participant that their participation was voluntary, and that they were free to leave at any time, even the interview process was not finished. after data collection, the variables and data were entered to statistical application (statistical package for social science -spss version 23). the data were analyzed through using spss software that included descriptive statistical analysis (frequency, percentage, and chi square test). the pvalue of each test >0.05 considered nonstatistically significant. menstrual cycles, those who are suffering from chronic diseases and girls who are taking hormonal therapy or antidepressants were excluded. the data were collected through direct interviews. the questionnaire comprised of four main parts, part one include socio-demographic characteristics of the adolescent students such as age, marital status, a parent's level of education, parent's occupational state, height and weight and family history with pms. height and weight were obtained for each student. height was taken by asking the student to stand in the front of the wall then a mark was taken then by using measuring tape the height was obtained in cm (centimeter); on the other hand the weight was obtained by asking the student to remove her shoes then step on the weighing scale to measure her weight in kg then the body mass index (bmi) was calculated by the following equation: bmi = *weight/ kg+ *height/m+². part two-includes severity of premenstrual symptoms assessment according to acog. the students were asked to rate 19 symptoms commonly found in pms on a three-point scale with responses ranging from: 1=mild; 2=moderate; 3=severe disabling with regard to the degree of interference and disruption to usual family, school, and social activities. part threeinclude 11 questions related to knowledge regarding the premenstrual syndrome such as definition, cause, factors associated with pms, signs and symptoms, and ways to reduce pms symptoms. the responds of the knowledge items were include two answers (0 =incorrect and 1=correct). the calculation of overall levels of knowledge (11 items) was categorized to three groups of poor knowledge (0-3), fair knowledge (4-7), and good knowledge (811).part fouritems related to self-care practice assessment which includes care for pms, used dietary changes, exercise, mind-body interaction, and medication. 11 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.02 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article students who participated in the study were between seventh and twelfth grades. table 1shows the sociodemographic characteristics of the 200 students. regarding age group, the highest percentage of the study sample was between age 13-16 years old (72.5%) and the highest percentage of students (24%) at 10th grade. the same table indicates (42%) of student's mother was illiterate, while 26% of fathers was able to read and write. the same table also shows that the majority (80%) of students' mother were housewives, while 53% of their fathers had free work. the highest percentage (85%) of the study sample had own house. the result of the current study revealed that a high percentage (61%) of the students in the sample were healthy ( normal ) weight and more than half (55%) had a family history with premenstrual syndrome. table 2 shows the knowledge levels of the 200 participants regarding premenstrual syndrome. the result of the current study indicated that the majority (75.5%) of the study sample had correct knowledge for the question “the symptoms of pms vary from cycle to cycle or from one woman to another “. most (74.5%) of school girls had known for the question " symptoms of pms that interfere with lifestyle functioning". over half (60%) of students had sufficient information regarding " as a woman matures, symptoms may improve or worsen". conversely, regarding students are mentioned incorrect answer is lower that correct answer and include: the highest percentage (60.5%) of samples had insufficient information regarding" the exactly cause of pms is unknown as general", while 57.5% of them had incorrect knowledge about knowledge score" too much caffeinated beverages are worsens symptoms" and more than half (53%) of students had insufficient information related to " high-sugar diet is one of the risk factors to get pms". table (3) describes management and practice of students with premenstrual syndrome. the results indicated that most (63%) and (56%) of them never practiced yoga and meditation to reduce symptoms of pms respectively. more than half (54%) of study sample stated that they sometimes drunk of fluids daily to diminish symptoms of pms. more than half (52%) of study sample never took drugs to manage premenstrual symptoms. the same table indicates that the highest percentage (46.5%) of the study sample stated that they were taking sleep sometimes throughout the month and less than half (45.5%) of the students stated that they sometimes eaten frequent, small meals. only 9.5% of them always practiced regular exercise throught the month to decrease pms symptoms. regarding overall evaluation of student's knowledge about premenstrual syndrome, results in table 4 show that the majority of the students indicated that school girls had a fair knowledge regarding premenstrual syndrome (60%), while 14% of them had poor knowledge about premenstrual syndrome. table 5 reveals overall management and self-care practices, a highest percentage (71.5%) of study sample sometimes had practices concerning management and self -care, while only (2%) of adolescent students always did practice related premenstrual syndrome. table 6 describes the correlation between knowledge of students with their practices that the majority (70%) of students sometimes had a fair knowledge concerning management and self-care regarding premenstrual syndrome. there were nonsignificant statistical association between knowledge and self-care practice (p=0.139). 12 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2019.02 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article 13 erbil journal of nursing & midwifery table 1: demographic characteristics of the study sample demographic characteristics f (%) age group(years) 13-16 17-20 145 (72.5%) 55(27.5%) class 7th 8th 9th 10th 11th 12th 36 (18%) 41 (20.5%) 23 (11.5%) 48 (24%) 41 (20.5%) 11 (5.5%) education level for student's mother illiterate read and write primary school intermediate school secondary school institute/college 84 (42%) 45 (22.5%) 47 (23.5%) 8 (4%) 9 (4.5%) 7 (3.5%) education level for student's father illiterate read and write primary school intermediate school secondary school institute/college 38 (19%) 52 (26%) 40 (20%) 25 (12.5%) 22 (11%) 23 (11.5%) occupational state for student's mother government employee special sector employee free work retiring unemployed/housewife student 13 (6.5%) 1 (0.5%) 18 (9%) 6 (3%) 160 (80%) 2 (1%) occupational state for student's father government employee special sector employee free work retiring unemployed 66 (33%) 9 (4.5%) 106 (53%) 9 (4.5%) 10 (5%) house ownership own rent 170 (85%) 30 (15%) body mass index underweight normal weight overweight obese 26 (13%) 122 (61%) 42 (21%) 10 (5%) family history with pms yes no 110 (55%) 90 (45%) https://doi.org/10.15218/ejnm.2019.02 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article 14 erbil journal of nursing & midwifery table 2: knowledge of student's regarding premenstrual syndrome premenstrual syndrome knowledge questionnaire incorrect correct f (%) f (%) pms usually starts 1 to 2 weeks before your period. 105 (52.5%) 95 (47.5%) pms improves when menstruation begins, or soon after. 98 (49%) 102 (51%) premenstrual syndromes are a group of physical, mental and emotional. 96 (48%) 104 (52%) the exactly cause of pms is unknown as general. 121 (60.5%) 79 (39.5%) psychological factors (stress) do not cause pms. 102 (51%) 98 (49%) high-sugar diet is one of the risk factors to get pms. 106 (53%) 94 (47%) too much caffeinated beverages are worsens symptoms. 115 (57.5%) 85 (42.5%) symptoms of pms that interfere with lifestyle functioning. 51 (25.5%) 149 (74.5%) the symptoms of pms vary from women to another. 49 (24.5%) 151 (75.5%) as a woman matures, symptoms may improve or worsen. 80 (40%) 120 (60%) change in lifestyle has an important role for relieve symptoms. 86 (43%) 114 (57%) table 3: management and self-care practices of student's regarding premenstrual syndrome questions never sometimes always f (%) f (%) f (%) do you drink a plenty of fluids? 56 (28%) 108 (54%) 36 (18%) do you eat frequent, small meals or snacks? 45 (22.5%) 91 (45.5%) 64 (32%) have you a balanced diet with whole grains, fruits and vegetables? 48 (24%) 89 (44.5%) 63 (31.5%) -do you eat plenty of fiber-rich foods like vegetables? 63 (31.5%) 87 (43.5%) 50 (25%) -do you do regular exercise? 93 (46.5%) 88 (44%) 19 (9.5%) -do you try to get plenty of sleep? 17 (8.5%) 93 (46.5%) 90 (45%) do you do yoga or deep-breathing exercises? 126 (63%) 51 (25.5%) 23 (11.5%) do you do meditation exercise to reduce stress? 112 (56%) 57 (28.5%) 31 (15.5%) do you massage yourself to relax? 99 (49.5%) 71 (35.5%) 30 (15%) do you use pain relievers? 104 (52%) 49 (24.5%) 47 (23.5%) table 4: overall knowledge of adolescent students with premenstrual syndrome level of knowledge f (%) poor 28 (14%) fair 120 (60%) good 52 (26%) total 200 (100) https://doi.org/10.15218/ejnm.2019.02 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article of school girls had adequate information regarding the relationship between premenstrual symptoms and life style, this finding is agreeing with a study performed by barry in 2013, at newfoundland/ canada, included 521 social workers, reported that the majority (85%) of respondents had correct answer regarding pms influence work and daily life functioning (9). the highest percentage (60.5%) of samples had insufficient information regarding the exactly cause of pms is unknown as general but change in hormone may play a role. the finding is similar with the results of a study done by abdalla and gibreel in 2016, conducted in saudi arabia and included 60 students to determine the effects of an educational program in increasing knowledge and reducing premenstrual syndrome symptoms and severity among nursing college students, they found that less than half (45%) of students had knowledge regarding disorders of female hormones may cause pms (10). this study was conducted among adolescent school girls their age ranged from 1320 years old. results of the present study revealed that the majority (72.5%) of the study sample were within the ages (13-16) years and these results are similar with a study carried by sarkar and mandal in 2015, conducted a cross – sectional descriptive study, which included 244 adolescent students in india, mentioned that 61.5% of girls were within ages 13-17 years *7+. in the current study, percentage of students knowing symptoms of pms vary from women to women or cycle to cycle is high. these findings are similar with a study carried by taylor and colino at new york in 2002, they documented that premenstrual symptoms are change over reproductive lifespan and fluctuate in intensity from cycle to cycle (8). in the same study, we found that the highest percentage (74.5%) 15 erbil journal of nursing & midwifery table 5: overall management and self-care practices of the study sample regarding premenstrual syndrome overall management and self-care practice f (%) never 53 (26.5%) sometimes 143 (71.5%) always 4 (2.0%) total 200 (100) table 6: association between knowledge and self-care practices of adolescent students with pms overall knowledge overall management and self-care practice p-value never sometimes always f (%) f (%) f (%) poor 11(39.3%) 17 (60.7%) 0 (0%) 0.139 ns fair 34 (28.3%) 84 (70%) 2 (1.7%) good 8 (15.4%) 42 (80.8%) 2 (3.8%) discussion https://doi.org/10.15218/ejnm.2019.02 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article they sometimes drinked fluid. in contrast to the present study carried by gamal and shahin in egypt and yemen , at 2015, and included 2000 clients to evaluate the effect of evidence-based nursing management on severity of premenstrual syndrome. they indicated that a low percentage (33%) of school girls are taken fluid (14). half (45%) of study sample stated that they were taking sleep to feel comfortable and ease pms symptoms. the findings are in contrast with the result of a study done by abdalla and gibreel, in saudi arabia at 2016 and included 60 students between 20-24 years to determine the effects of an educational program in increasing knowledge and reducing premenstrual syndrome symptoms and severity among nursing college students, they reported that the majority of the students were taking sleep throught month to manage symptoms of pms (10). regarding the overall evaluation of student's knowledge related to pms by the researcher, most of the students required of needing the major improvement in knowledge by researcher. the majority (60%) of students had fair knowledge about premenstrual syndrome. the study results are similar with a study by mohib et al in 2018 at pakistan and majority of the female students were familiar of pms (15). furthermore, another study are in contrast with a study done by habib et al in 2014, included 448 female students to find out the existence, knowledge, and the attitude of female students towards premenstrual syndrome (pms) between the ages of 18 to 30 years, reported that almost all female students (96.4%) had knowledge about premenstrual syndrome *16+. regarding overall assessment of adolescent student's practice about pms. in the current study most (71.5%) of all school girls sometimes used self-care practices to manage their symptoms of pms because menstruation and related subjects are considered in our the present study assess knowledge of students regarding the factors associated with premenstrual syndrome such as drinking tea or coffee, most (57.5%) of students had lack of knowledge about drinking too much caffeinated beverages like tea or coffee are worsens pms symptoms. these results were contrast with the results of a study carried by rossignol et al, in 1989 at china to evaluate the fact that drinking tea causes premenstrual syndrome, they found that a strong association between tea consumption and the prevalence of premenstrual syndrome (11). the practice of healthier behavior like lifestyle modifications and self-care practices during pms are important indicators of health and determinant of health especially during the reproductive age of a woman (see table 3). regarding doing yoga relaxation technique, the highest percentage of students never practiced yoga actions to alleviate pms symptoms. results of this study is contrast with a study carried by tsai at taiwan in 2016 to assess the effects of yoga intervention on premenstrual syndrome, they found that the regular yoga exercise intervention decreased abdominal cramps, breast tenderness, work stress, abdominal swelling and improved sleep status (12). in the current study, more than half of students were never using meditation exercise to reduce pms symptoms especially for stress and depression. these results are inaccordance with a study done by askari and abbaspoor in 2018, at iran to assess the effect of mindfulness-based cognitive behavioral therapy on pms symptoms. they supported the effect of a mindfulness -based cognitive therapy such as meditation and breathing exercise intervention on reducing the severity of symptoms in the ones with premenstrual syndrome (13). regarding fluid intake, more than half (54%) of the study sample mentioned that 16 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.02 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *2+ ramya s, rupavani k , bupathy a. effect of educational program on premenstrual syndrome in adolescent school girls. international journal of reproduction, contraception, obstetrics and gynecology .2014; 3(1). india. available from: http://www.ijrcog.org/ index.php/ijrcog/article/view/809*accessed: 18th june 2018+. *3+ seedhom ae, mohammed es, mahfouz em. life style factors associated with premenstrual syndrome among el-minia university students, egypt. international scholary research notices. 2013; 2013 (617123). available from: https://www.hindawi.com/ journals/isrn/2013/617123/*accessed: 18th june 2018+. *4+ kroll-desrosiers ar, ronnenberg ag, zagarins se, houghton sc, takashima-uebelhoer bb, bertone-johnson er. recreational physical activity and premenstrual syndrome in young adult women. peer-reviewed open access scientific journal. 2017; 12(1): available from: http://journals.plos.org/plosone/ article?id=10.1371/journal.pone.0169728. *accessed 19thjune 2018+. *5+ elnagarma, awed ha. self –care measures regarding premenstrual syndrome among female nursing students.international journal of nursing didactics. 2015; 5(2): 22315454. available from: http:// innovativejournal.in/ijnd/index.php/ijnd/ article/view/53 *accessed 19thjune 2018+. *6+ + ali fh, al-saffar fa. assessment of adolescent student's knowledge toward premenstrual syndrome in nursing secondary schools at aldiwanyia governorate. journal of kufa for nursing science. 2014; 4(1). available from: https://www.iasj.net/iasj? func=fulltext&aid=88989 *accessed 20thjune 2018+. *7+ sarkar ap, mandal r, ghorai s. premenstrual syndrome among adolescent girl students in a rural school of west bengal, india. international journal of medical science and public health. 2015; 5 (4): 2407201566. available from: https://www.ejmanager.com/ mnstemps/67/67-1437749170.pdf *accessed 19thjune 2018+. *8+ taylor d, colino s. taking back the month: the ages and stages of pms. a personalized solution for managing pms and enhancing your health. new york. p20. 2002. society and included in curriculum of school. this result is similar with a study done by ozturk et al at turkey in 2006, they found that most (94.1%) of women taked sleep and rest and more than half (57.1%) of them preferred taking painkillers to reduce fatigue and control symptoms (17). there is no association between knowledge and self-care practices of adolescent students regarding premenstrual syndrome were found. the results of this study is agreeing with findings of a study carried by mohib et al in 2018, at university students in karachi, which found that there was not association between knowledge and management and practices with premenstrual syndrome and it statistically not significant (p>0.001) *15+. small sample size, limited number of involved schools and not welcoming by mangers of the schools were the main limitation of the present study. the findings indicated inadequate levels of knowledge about pms and regarding selfcare practices. further research is required for a larger population and including students from various socio-economic backgrounds to better assess the situation and strategies to manage this rising problem. *1+ siahbazi s, montazeri a, taghizadeh z, masoomie r. the consequences of premenstrual syndrome on the quality of life from the perspective of affected women. journal of research in medical and dental sciences. 2018; 6(2): 284-292. available from: https:// www.jrmds.in/articles/the-consequences-ofpremenstrual-syndrome-on-the-quality-oflife-from-the-perspective-of-affectedwomena-qualitative-stu.pdf *accessed: 14th june 2018+. 17 erbil journal of nursing & midwifery references conclusions https://doi.org/10.15218/ejnm.2019.02 erbil j. nurs. midwifery, vol. 2, no. (1), may, 2019 original article *9+ barry l. social workers' knowledge of premenstrual syndrome (pms) and premenstrual dysphoric disorder: implications for assessment practices with mothers. canada. interdisciplinary committee on ethics in human research. 2013. 20130078-sw. available from: https://s3.amazonaws.com/ academia.edu.documents/52242731/ ph.d._final_dissertation__july_31__2016.pd f? awsaccesskeyid=akiaiwowyygz2y53ul3a&expires=1 541997745&signature=hgbi2b83%2fth% 2fiq21xud1kivjyty%3d&response-contentdisposition=inline%3b%20filename% 3dph.d._final_dissertation*accessed 9th november 2018+. *10+ abdalla no, gibreel ms. effects of an educational program in increasing knowledge and reducing premenstrual syndrome signs, symptoms and severity among nursing college students. ksa. international journal of basic and applied sciences. 2016; 5 (4). 200209. available from: file:///c:/users/sazan% 20blbass/downloads/ijbas-6001%20(4) *accessed 11th november 2018+. *11+ rossignol am, zhang j, chen y, xiang z. tea and premenstrual syndrome in the people's republic of china. china. american journal of public health. 1989; 79 (1). available from: https://ajph.aphapublications.org/doi/ pdf/10.2105/ajph.79.1.67*accessed 10th november 2018+. *12+ tsai sy. effect of yoga exercise on premenstrual symptoms among female employees. taiwan. international journal of environmental research and public health. 2016; 8 (13). available frm: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc4962262/pdf/ijerph-13-00721.pdf *accessed 7th november 2018+. *13+ askari s, behroozi n, abbaspoor z. the effect of mindfulness-based cognitive-behavioral therapy on premenstrual syndrome. iran. iranian red crescent medical journal. 2018; 20 (2). available from: http://ircmj.com/en/ articles/57538.html*accessed 7th november 2018+. *14+ gamal am, shahin ma. premenstrual syndrome, associated symptoms and evidence – based nursing management: a comparative study between rural menoufia governorate (egypt) and hodidha governorate (yemen). american journal of nursing science. 2015; 4 (3): 2328-5745. available from: https:// www.researchgate.net/.../282410943_prem enstrual_syndrome_associated_symptoms *accessed 22th june 2018+. *15+ mohib a, zafar a, najam a, tanveer h, rehman r. premenstrual syndrome: existence, knowledge, and attitude among female university students in karachi. cureus journal. 2018; 10(3): 10.7759. available from: .ncbi.nlm.nih.gov/pub med/29744256 *accessed 21thjune 2018+. *16+ habib f, alayed a, al humedi h, al msalem i. impact of an educational session about premenstrual syndrome management using complementary and alternative medicine on young adult females’ knowledge and practice. international organization of scientific research journal. 2014; 3(2): 2320– 1959. available from: www.iosrjournals.org/ iosr-jnhs/papers/vol3-issue2/version-1/ k03216369 *accessed 21thjune 2018+. *17+ ozturk s, tanrrverdi d, erci b. premenstrual syndrome and management behaviours . turkey. australian journal of advanced nursing. 2006; 28 (3). available from: http:// www.ajan.com.au/vol28/28-3_ozturk.pdf *accessed 7th november 2018+. erbil journal of nursing & midwifery 18 https://doi.org/10.15218/ejnm.2022.06 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article knowledge and attitude of mothers about children immunization and barriers to adherence the program, in erbil city abstract introduction immunity can be defined as a state of creating sufficient biological defenses in the body to fight harmful microbes (including bacteria or viruses) to avoid infections, disease, or another unwanted biological invasion. immunization is one of the processes of enhancing the immune system against certain infectious diseases. therefore, immunization can develop an immune system and body resistance against background and objective: immunization programs are one of the most important methods to prevent infections and sickness among children. we can overcome many obstacles if mothers have the necessary knowledge and attitude regarding vaccines. the study aims to assess mothers’ knowledge, attitudes, and barriers related to immunization programs and associations related to socio-demographic characteristics. methods: a cross-sectional study design was carried out in erbil city across six primary health care centers (hawkari, azadi, runaki, shadi, mala afandi, and nazdar bamarni) during the period of january 5, 2021, to april 8, 2021. non-probability convenience sampling methods were used. the sample consisted of 410 mothers ages 18 and older. a questionnaire with four parts (socio-demographic characteristics, knowledge, attitude, and barriers to adherence immunization programs) was used to collect data. statistical package for social science (version 23) was used for data analysis. chi-square and fisher exact tests were used to determine the association between socio-demographic characteristics and knowledge and attitudes. frequency and percentage were used to identify barriers. results: the study findings showed a statistically significant association between the knowledge of mothers and their age, educational level, occupation, and socioeconomic status. mothers have a high attitude regarding immunizations. the majority (69.3%) of mothers have not had any missed opportunities for not given immunizations. the most common reasons for not giving immunizations were mothers being busy and child sickness at the time of immunizations. conclusions: there was statistically significant association between mother’s knowledge and age, education, occupations, and socioeconomic status. a high level of attitude was recorded among mothers regarding immunizations. mothers reported being busy on the day of the immunizations and child sickness as the most common barriers to receiving immunizations. keywords: childhood immunization; mothers; knowledge; attitude; barriers. suham mirhamad abdullah; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: suham.barza@gmail.com) ibrahim hasan mustafa; department of nursing, college of nursing, hawler medical university, erbil, iraq. 51 erbil journal of nursing & midwifery received: 30/11/2021 accepted: 01/02/2022 published: 30/5/2022 mailto:suham.barza@gmail.com?subject=suham.barza@gmail.com https://doi.org/10.15218/ejnm.2022.06 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article harmful infections [1]. immunizations are cost-effective methods to prevent death and disease caused by harmful infectious diseases. globally immunization itself represents the gateway to providing comprehensive health care to which all children have been entitled. moreover, pediatric immunization programs played a vital role in eradicating many childhood infectious diseases [2, 3]. many studies indicated the importance of knowing parents' impressions toward vaccination to find the positive and negative attitudes and emphases on vaccine rejection. therefore, there is a need to carry out studies to understand people's behavior, which plays a role in the failure to comply with the vaccination, and then to find scientific recommendations about targeting efforts to fight misinformation on certain deviant types. these are also giving rise to a new research approach such as studying all these factors that are focusing on underlying attitudes that goes beyond notions of vaccine acceptance, including knowledge of communities, knowledge about how they relate and trust the institutions involved with vaccination services, and knowledge of how much active demand there is for vaccination at the community level and others [4]. a study carried out in sub-saharan africa to identify the best methods for achieving the desired levels of immunizations found many barriers mothers face in giving vaccinations to their children. these barriers include social and environmental barriers (gender, beliefs, and socio-culture factors) and barriers related to the health care system. the study recommended combined efforts of healthcare systems and providers, appropriately addressing socio-cultural factors among the communities and emphasizing scientific evidence on effective interventions to address these barriers and achieve higher vaccination rates. vaccination is one of the leading public health methods for preventing many infectious diseases, especially among children. there is a need to encourage parents to involve their children in immunization programs and improve compliance with immunization programs [5]. the study aimed to assess mothers' knowledge, attitude, and barriers to immunization programs. a descriptive study was carried out across six primary health care centers (phcc) in erbil city from january 5, 2021, to april 8, 2021. due to social distancing and preventative measures against covid 19, only a few centers (hawkari, azadi, runaki, shadi, mala afandi, and nazdar bamarni) were randomly selected to be included in the study. the sample size was calculated using the statstm micros phot program (california inc., california university, 1998), which depends on the population. the sample consisted of 410 mothers distributed among the six phccs depending on the proportions of visitors in each phcc (hawkari: 50, azadi: 117, runaki: 60, shadi: 53, mala: 68, and nazdar bamarni: 62). data were collected by using the nonprobability convenience sampling technique. mothers aged ≥18 years were included. a questionnaire was constructed for data collection consisted of four parts. part i includes mothers’ sociodemographic characteristics, including age, years of formal education, family income, occupation, and socio-economic status (ses), family income classified according to monthly income, and daily physiological needs in this manner, income was classified as insufficient if it did not cover daily needs, sufficient if it did cover daily needs but without extra, and surplus if it covered daily needs while saving money. hasan (2010) [17] adapted the sec. we give ten points for educational level (half a point for each year of study), ten points for 52 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2022.06 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article shadi, hawkari, nazdar bamarni, and azadi primary health care centers for data collection. the required information was explained, and informed oral consent was obtained from all participants. confidentiality was assured about the participant’s identity and personal information. the data collected were stored in the spss file was password protected. table 1 shows the socio-demographic and socioeconomic characteristics of the study population. more than half (53.4%) of the population were in aged 22 to 31, and only 2.2% were aged 42 and older. 40.2% of mothers graduated college, 9.3 % of mothers were postgraduates, and 39.8% were intermediate and secondary graduates. approximately half (51%) of mothers worked unskilled jobs, 10% were unemployed, and 26.8% were migrants. results show that 22.2% of mothers had exceeded income for daily needs, 40% were of medium socio-economic status, and a little over a quarter (26%) were of low socioeconomic. table 2 describes mother’s knowledge related to vaccinations. most women (95.1%) have knowledge that measles is prevented by vaccination, 75.1% of women have no knowledge that diphtheria is prevented by vaccination, and 67.1% of women have no knowledge that hepatitis b can be prevented by vaccination. most of the mothers (99%) in the sample have information that vaccination prevents infectious diseases. 91% of women reported that vaccinations help maintain their health, and 82% report that vaccinations help reduce child mortality and protect children from complications. the highest percentage (64.4%) of mothers reported rash as a side effect of vaccines, followed by fever (61.2%), swelling (52%), and redness (51%). husbands' education, eight points for crowding index, five points for mother occupation, five points for husband occupation, four points for house ownership, and three points for car ownership (with some modifications). the total total score was 45, which was divided into three parts: low (15), middle (15 to 30), and high (15) scores (30 to 45) [6]. the mothers' occupations were classified. part ii related to mothers’ knowledge about immunization and was assessed by 14 items. the questionnaire was scored and rated on two options (1 for yes and 0 for no). the mothers' knowledge is categorized into three levels: low (a score ≤ 4.7), middle (a score between 4.8 to 9.4), and high level (a score ≥ 9.5). part iii related to mothers’ attitudes and was assessed by 14 items scored on likert scales as recommended by polite and hungler (1999) [8]. mothers’ attitudes were classified into three levels: (1) low attitude (a score ≤ 14), (2) no idea ( a score between 15 to 28 ), and (3) high attitude (a score ≥ 29). part iv related to barriers to adherence to immunization programs assessed by 20 questions on a yes or no scale. data were analyzed using the statistical package for social science (spss, version 23). the mean was calculated to summarize numerical variables, and proportions were calculated for categorical variables. chi-square test was used to compare the proportions of two groups’ sociodemographic characteristics and knowledge and attitude. fisher exact tests were used in case 20% or more of cells have less than five. the scientific and ethical committee of the college of nursing hawler medical university approved the study protocol. in addition, formal permission was granted by the erbil directorate of health planning department to braiaty, kurdistan, mala afandi, 53 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2022.06 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article 54 erbil journal of nursing & midwifery table 1: distribution of study sample by socio demographic and socioeconomic characteristics variables n=(410) no. (%) age group <22 47 (11.5) 22-26 107 (26.1) 27-31 112 (27.3) 32-36 65 (15.9) 37-41 70 (17.1) 42+ 9 (2.1) educational levels of mothers primary 44 (10.7) intermediate 72 (17.6) secondary 91 (22.2) institute and college 165 (40.2) postgraduate 38 (9.3) occupation of mother unemployed or housewife 41 (10) unskilled 208 (50.7) professional 119 (29) high professional 42 (10.2) immigration status migrant 110 (26.8) resident 300 (73.2) monthly family income sufficient for daily needs 157 (38.3) insufficient for daily needs 162 (39.5) exceed for daily needs 91 (22.2) socio-economic status low 105 (25.6) medium 162 (39.5) high 143 (34.9) table 2: descriptive statistics related to mothers’ knowledge about vaccination variables n=(410) no. (%) disease controlled by obligatory vaccination 1.measles yes 390 (95.1) no 20 (4.9) 2.poliomyelitis yes 327 (79.8) no 83 (20.2) 3.tetanus and pertussis disease yes 237 (57.8) no 173 (42.2) 4.diphtheria yes 102 (24.9) no 308 (75.1) 5.hepatitis b virus yes 135 (32.9) no 275 (67.1) 6.mumps yes 269 (65.6) no 140 (34.1) what are the important of vaccination 7.prevent infectious diseases yes 405 (98.9) no 5 (1.2) 8.reduce child mortality rate yes 335 (81.7) no 75 (18.3) 9.protect child from complication yes 336 (82) no 74 (18) vaccine side effect 10.fever yes 251 (61.2) no 159 (38.8) 11.rash yes 264 (64.4) no 146 (35.6) 12.redness yes 207 (50.5) no 203 (49.5) 13.pain yes 173 (42,2) no 237 (57.8) 14.swelling yes 213 (51.9) https://doi.org/10.15218/ejnm.2022.06 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article and mothers’ knowledge and socioeconomic status (p<0.001). table 5 shows the associations between mothers’ attitudes and their sociodemographic and socioeconomic status. most mothers (93.4) expressed a high level of attitude toward vaccination. there was no statistically significant association between mothers’ level of attitude related to immunizations and their age (p=0.116) or education levels (p=0.064). the results show that 63 % of mothers with a medium level of attitude worked unskilled jobs, and 40.8% of mothers with a high level of attitude worked professional jobs. a statistically significant association was observed between mothers’ attitudes and \occupations (p=0.024). there was no significant association between mothers’ attitude and their levels of income (p=03.65), and socioeconomic status (p= 0.083). table 6 shows that the majority of mothers (69.3%) have not had any missed opportunities for immunization. among those who had one or more missed opportunities, 19 % have one missed opportunity to the given immunizations for their children. table 7 shows that, in general, most mothers report no barriers to giving immunizations to their children. the most common barriers reported were mothers busy on the day of immunizations (43.4%), and children's sickness at the time of immunization (29%). 55 erbil journal of nursing & midwifery table 3 describes the mother’s positive and negative attitudes towards vaccinations. most of the sample (73%) report minor side effects with immunization, and 91% of mothers believe that vaccines help children’s health. the data shows that 17.2% have no idea about health authority (education role) in the vaccination programs and that 87.1% of mothers have a positive attitude towards reducing missing opportunities of child vaccinations. the majority of mothers (82.9%) believe that it is essential to advise other mothers to vaccinate their children. the data shows that 66.1% of mothers prefer a female vaccinator. 69.0% of the sample believe in delaying baby bath till two days after bcg vaccination, 42.9% have no idea if a child who came in contact with another child with measles should not be vaccinated against measles, and 48% of mothers believe that it is better to get immunity by catching a disease instead of by being vaccinated. table 4 describes the associations between mothers’ level of knowledge and their socio demographic and socioeconomic status. mothers with a high level of knowledge (53%) were aged 37 to 41 years, and mothers with a low level of knowledge (32.2%) were aged 22 to 26 years. forty percent of mothers with a low level of knowledge have primary and intermediate levels of education, and 68% of mothers with high levels of education graduated from college and institutes or were postgraduates. mothers with low and medium levels of knowledge (46% and 45%, respectively) report a medium socioeconomic status, while mothers with a high level of knowledge report a high socioeconomic status. statistically significant associations were observed between mothers’ age and their knowledge about immunizations (p<0.001), levels of education and knowledge (p<0.001), occupation and knowledge of mothers (p<0.001), https://doi.org/10.15218/ejnm.2022.06 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article 56 erbil journal of nursing & midwifery table 3: descriptive statistics of sample according to their positive and negative attitudes toward vaccination items no. (%) 1. do you believe that minor side effect occur with immunization? correct 298 (72.7) no ides 53 (12.9) incorrect 59 (14.4) 2. do you believe that vaccination helps the child’s health? correct 373 (91) no idea 27 (6.6) incorrect 10 (2.4) 3. do you believe that health authority should emphasize the important of immunization (education role) of children? correct 326 (79.5) no idea 70 (17.2) incorrect 14 (3.4) 4. do you believe that the responsibility of mothers reduce missing opportunity of child vaccination? correct 357 (87.1) no idea 32 (7.8) incorrect 21 (5.1) 5. do you believe less knowledgeable mothers do not support immunization in the community? correct 12 (2.9) no idea 93 (22.7) incorrect 305 (74.4) 6. do you believe that advising other mothers for vaccinating their children? correct 340 (82.9) no idea 59 (14.4) incorrect 11 (2.7) 7. do you believe that child with allergy to egg is contraindicated to be vaccinated? correct 152 (37.1) no idea 246 (60) incorrect 12 (2.9) 8.do you prefer vaccination at public health centers correct 271 (66.6) no idea 126 (30.7) incorrect 13 (3.2) 9.do you believe that vaccination of children having cold and cough should be delayed until full recovery? correct 300 (73.2) no idea 97 (23.7) incorrect 13 (3.1) 10. do you believe that preferring female vaccinator than male? correct 271 (66.1) no idea 78 (19) incorrect 61 (14.9) 11. do you believe that delaying baby bath till two days after vaccination bcg? correct 283 (69) no idea 99 (24.1) incorrect 28 (6.8) 12. do you believe that communicable disease weakens the immune system? correct 77 (18.8) no idea 191 (46.6) incorrect 142 (34.6) 13. do you believe that children who come in contact with a child who got measles should not be vaccinated against measles? correct 63 (15.4) no idea 190 (46.3) incorrect 157 (38.3) 14. do you believe that it is better to get immunity by catching to a disease instead of by being vaccinated? correct 38 (9.3) no idea 176 (42.9) incorrect 196 (47.8) https://doi.org/10.15218/ejnm.2022.06 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article 57 erbil journal of nursing & midwifery table 4: association between mothers’ level of knowledge with their socio-demographic and socio-economic status items knowledge low medium high no. (%) no. (%) no. (%) p-value mothers age groups <22 22 (18) 22 (8.9) 3 (7.5) 0.001 22-26 39 (32) 63 (25) 5 (13) 27-31 27 (22) 76 (31) 9 (23) 32-36 21 (17) 42 (17) 2 (5) 37-41 8 (6.7) 41 (16) 21 (53) 42+ 4 (3.1) 5 (2) 0 (0) education levels of mothers primary 24 (20) 19 (7.6) 1 (2.5) 0.001 intermediate 24 (20) 45 (18) 3 (7.5) secondary 31 (26) 51 (22) 9 (23) institute &college 41 (34) 112 (45) 12 (30) postgraduate 1 (0.8) 22 (8.8) 15 (38) occupation of mother unemployed 14 (12) 25 (10) 2 (5) 0.001 unskilled 85 (70) 112 (45) 11 (28) professional 20 (16) 87 (35) 12 (30) high professional 2 (1.4) 25 (10) 15 (38) immigration statue migrant 38 (30) 63 (25) 9 (23) 0.378 resident 83 (70) 186 (75) 31 (78) monthly family income sufficient for daily needs 25 (24) 122 (49) 10 (25) 0.165 insufficient for daily needs 42 (35) 113 (11) 7 (18) exceed for daily needs 48 (40) 33 (13) 10 (2.5) socio-economic status of mothers low 48 (40) 44 (18) 5 (13) <0.001 medium 55 (46) 111 (45) 9 (23) high 18 (15) 94 (38) 26 (65) table 5: association between mothers’ attitude with their socio-demographic and socioeconomic status items attitude p-value medium high no. (%) no. (%) mothers age group 17-21 5 (18.5) 42 (11) 0.116 22-26 6 (22.2) 101 (26.4) 27-31 3 (11.1) 109 (28.5) 32-36 8 (29.7) 57 (14.9) 37-41 5 (18.5) 65 (17) 42+ 0 (0) 9 (2.2) total 27 (100) 383 (100) educational levels of mother primary 2 (7.4) 42 (11) 0.064 intermediate 9 (33.3) 63 (16.4) secondary 6 (22.1) 85 (22.2) institute &college 10 (37) 155 (40.5) postgraduate 0 (0) 38 (9.9) occupation of mothers unemployed 5 (18.5) 36 (9.3) 0.024 unskilled 17 (63) 191 (49.9) professional 5 (18.5) 114 (29.8) high professional 0 (0) 42 (11) immigration statue migrant 9 (33.3) 101 (26.4) 0.43 resident 18 (66.7) 282 (73.6) monthly family income sufficient for daily needs 10 (37) 147 (38.3) 0.65 insufficient for daily needs 9 (33.2) 100 (26.1) exceed daily needs 4 (14.8) 46 (12) socio-economic statues of mothers low 7 (25.9) 90 (23.5) 0.083 https://doi.org/10.15218/ejnm.2022.06 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article 58 erbil journal of nursing & midwifery table 6: data related to number of missed opportunity number of missed opportunity n=(410) (%) 1 item 78 (19) 2 items 24 (5.9) 3 items 11 (2.7) 4 items 13 (3.1) total 126 (30.7) no missed opportunity 284 (69.3) total 410 (100) table 7: barriers of incomplete immunization barriers yes no no. (%) no. (%) domestic work 60 (14.6) 350 (85.4) corona virus 57 (13.9) 353 (87.3) quarantine 5 (1.2) 405 (98.8) mother was too busy 178 (43.4) 232 (56.6) there is no risk of infection 13 (3.2) 397 (96.8) the vaccine was not available 18 (4.4) 392 (95.6) the time for vaccination was not convenient 88 (21.5) 322 (78.5) the child was not vaccinated because of illness 82 (20) 328 (80) was not aware for need of immunization 78 (19) 332 (81) mother does not have information about the need for second and third dose 17 (4.1) 393 (95.9) distrust in the vaccination 45 (11) 365 (89) fear of side effect after vaccination 55 (13.4) 355 (86.6) mother health state 118 (21.8) 292 (71.2) social engagements 26 (6.3) 384 (93.7) traveling 41 (10) 369 (900 complications from previous injections 28 (6.8) 382 (93.2) long distance trekking/walking 35 (8.5) 375 (91.5) long waiting time 16 (3.9) 394 (96.1) lack of financial reasons 49 (12) 361 (88) child sickness 117 (28.5) 293 (71.5) https://doi.org/10.15218/ejnm.2022.06 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article al., indicated that mothers with a medium level of knowledge about immunizations were associated with medium or high levels of income, and a high level of knowledge was associated with completion of higher education and higher income [7].the present study found that mothers working in professional occupations had high attitudes regarding immunizations. a 2019 cross-sectional study carried out in malaysia of 200 postnatal mothers reported a statistically significant association between mothers’ occupations and their attitudes regarding vaccination [15]. the present study shows that around one-third of mothers in the sample have missed opportunities for vaccinating their children. the main barriers to not giving immunization were that mothers were busy and their children were sick at vaccination. a 2020 study in mogadishu, somalia, report that full vaccination of children under five years were very low. older marital status of caregivers, low educational background of fathers, low monthly income, premature birth, younger age of children, vaccine unavailability at health centers, cost unaffordability, mothers who were given their births in home, low level of knowledge of caregiver, low levels of attitude, and level of low practice on immunization were found to be the main barriers to full immunization coverage [8]. the results of a systematic study carried out in sub-saharan africa indicated that gender, beliefs, and socio-culture factors of communities that the parents live play a role in parents’ decision to vaccinate their children [9]. there were statistically significant associations between mothers’ age and vaccination knowledge, mothers’ know ledge and the present study shows a statistically significant association between mothers’ age and levels of knowledge regarding vaccination. increasing age was associated with increased knowledge. in contrast, a study in saudi arabia by almutairi et al., reported no significant association between mothers’ age and knowledge regarding vaccination. the differences may be related to the width of age categories, which were not fixed in all levels in the study [10]. the present study shows an association between an increased level of mothers’ education and an increased level of knowledge. the output of the present study agrees with a 2016 study by faris et al., which reported a significant association between mothers’ knowledge and their educational levels [11]. another study indicated that a high level of knowledge was associated with completing higher education and higher income [12]. in the present study, there was an association between mothers’ knowledge and occupation. in contrast with a study by almutairi et al., there was no evidence of an association between mothers’ knowledge and occupation. the differences may be related to the classification jobs between both studies and differences related to culture. the present study indicated no association between income and mothers’ knowledge regarding vaccination. the present study shows that increased occupational classes were associated with knowledge classes. findings from almutairi et al. indicated no evidence of an association between mothers’ level knowledge and mothers’ occupation type [9]. the current study indicated that an increase in mothers' knowledge was associated with an increase in socioeconomic status. a study by kyprianidou et 59 erbil journal of nursing & midwifery discussion conclusion https://doi.org/10.15218/ejnm.2022.06 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article [9] almutairi wm., alsharif f., khamis f., sallam l., sharif l., alsufyani a., et al assessment of mothers’ knowledge, attitudes, and practices regarding childhood vaccination during the first five years of life in saudi arabia. nurses. repots. 2021, 11, 506–516. [10] ramadan ha, soliman sm, el-kader rg. knowledge, attitude and practice of mothers toward children's obligatory vaccination. journal of nursing and health science. 2016 jul;5(4):22-8. [11] mahalingam s, soori a, ram p, achappa b, chowta m, madi d. knowledge, attitude and perceptions of mothers with children under five years of age about vaccination in mangalore, india. asian journal of medical sciences. 2014 may 16;5(4):52-7. [12] singh j, deepti ss, mahajan s, lal m, singh t, neki ns. assessment of socio-demographic factors affecting immunization status of children of age 0-2 years in slums of amritsar city. international journal of current research in pubmed science. 2018;4(3):17-25. [13] gul s, khalil r. immunisation knowledge and practices among mothers attending a paediatric clinic in karachi, pakistan. international journal of advances in medicine. 2016 jul;3 (3):656-1. [14] awosan kj, ibrahim mt, yunusa eu, isah ba, raji mo, abubakar n. knowledge, attitude and compliance with full immunization of children against vaccine preventable diseases among pregnant mothers in sokoto, nigeria. international journal contemp med research. 2018; 5(6):f10-6. [15] umeh ca, ahaneku hp. the impact of declining vaccination coverage on measles control: a case study of abia state nigeria. pan african medical journal. 2013; 15(1). [16] al-lela, o. q. b., bahari, m. b., al-qazaz, h. k., salih, m. r., jamshed, s. q., & elkalmi, r. m. are parents' knowledge and practice regarding immunization related to pediatrics’ immunization compliance? a mixed method study. bmc pediatrics, 2014. 14(1), 1-7. [17] hasan ba. malocclusion and orthodontic treatment need and demand among 13-18 years students in erbil city. ph.d. thesis, college of dentistry hawler medical university, erbil, iraq. (2010) educational levels, and mothers' attitudes and occupation. around one-third of the sample have missed the opportunity of provided immunizations; among them, the highest percentages were recorded in mothers who were busy or their infants sick at the time of immunizations. no conflict of interest. [1] chris-otubor go, dangiwa da, ior ld, and anukam nc. assessment of knowledge, attitudes and practices of mothers in jos north regarding immunization. iosr journal of pharmacy. 2015 jun; 5(6):34-45. [2] bergin n, murtagh j, philip rk. maternal vaccination as an essential component of life-course immunization and its contribution to preventive neonatology. international journal of environmental research and public health. 2018 may; 15(5):847. [3] reporter dn. bacterial meningitis. guest editor executive director’s column. 39 (2):3. [4] yufika a, wagner al, nawawi y, wahyuniati n, anwar s, yusri f, haryanti n, wijayanti np, rizal r, fitriani d, maulida nf. parents’ hesitancy towards vaccination in indonesia: a cross-sectional study in indonesia. vaccine. 2020 mar 4;38(11):2592-9. [5] dimala ca, kika bt, kadia bm, blencowe h. current challenges and proposed solutions to the effective implementation of the rts, s/as01 malaria vaccine program in sub-saharan africa: a systematic review. plos one. 2018 dec 31;13 (12):e0209744. [6] al-ansari nb. pattern of malocclusion in iraqi patients seeking orthodontic treatment. [7] kyprianidou m., tzira e., galanis p., giannakou k. knowledge of mothers regarding children’s vaccinations in cyprus: a cross-sectional study. plos one. 2021; 16 (9): e0257590. doi: 10.1371/ journal.pone.0257590. [8] polit df, beck ct. nursing research: principles and methods. lippincott williams & wilkins; 2004. 60 erbil journal of nursing & midwifery conflict of interest references erbil j. nurs. midwifery, vol. 1, no. (2), 2018 the significance of qualitative research in nursing practice dara abdulla al-banna; assistant editor, assistant lecturer of adult nursing, nursing department, college of nursing, hawler medical university, erbil, iraq. dara.albanna@hmu.edu.krd 49 according to the world health organization, qualitative research aims to explore people’s needs, values, perceptions and experiences of the world around them, including of health, illness, healthcare services, and more broadly of social systems and their policies and processes. qualitative evidence is very important for understanding on how, and whether, people perceive health interventions to be effective and acceptable or more fundamentally, whether they work. qualitative evidence is also essential to understanding the factors effecting the application of health policies and interventions. in recent years, most of the healthcare institution and organizations have shifted their focus to a patient-centered model in which patients are involved in decisionmaking and their preferences are honored. qualitative research has an important role in nursing science and is becoming well recognized. qualitative studies are also used to gain novel information, meaning, views, more understanding, and insights of the concepts on previous definitions of nursing care theories, natural phenomena, specific groups, individuals, health issues, dilemmas, or experiences. qualitative research in nursing science deals with the lived experiences of patients and nurses in different filed in providing of health care and services for achieving favorable patient outcomes. the high way for getting information regarding patients’ and families’ perspectives is to ask, listen, and learn from them to increase the delivery of health care services. findings of the qualitative studies can guide nurses in assessing, planning, implementation, and evaluation during the process of nursing care for meeting patients’ needs. clinical nurse can utilize the findings of the qualitative research as evidence for improving nursing practice. finally, the patients' needs of psychological, spiritual, emotional and social aspects are not fully satisfied, qualitative interviews and observation methods could increase the rate of agreement and make positive perceptions and attitude environment about the nursing care for patients and family. erbil journal of nursing & midwifery “qualitative research is multimethod in focus, involving an interpretive, naturalistic approach to its subject matter. this means that qualitative researchers study things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them”. denzin and lincoln. editorial https://doi.org/10.15218/ejnm.2021.05 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article indications of labor induction at delivery room of maternity teaching hospital in erbil city abstract introduction induction of labour means stimulation of contractions before the birth starts spontaneously, with or without ruptured membranes. when the cervix is uneffaced and closed, labour induction often begins with the ripening of the cervix, a process that generally uses prostaglandins to open and soften the cervix[1]. the position and consistency of the cervix are not necessary to predicting successful labour induction by oxytocin and amniotomy [2]. induction is indicated when the benefits to the mother or fetus outweigh the benefits of continuing the pregnancy. the most common indications include oligohydramnios, pre-labour rupture of the membranes, high blood pressure during pregnancy, severe fetal growth restriction, background and objectives: induction of labour means stimulation of contractions before the birth starts spontaneously, with or without ruptured membranes. the most common indications include oligohydramnios, pre-labour rupture of the membranes, high blood pressure during pregnancy, severe fetal growth restriction, post-term pregnancy, and various maternal medical conditions such as chronic hypertension and diabetes. the aim of the study was to find out the different indications of labour and associated obstetrical factors in a local tertiary hospital. methods: a cross-sectional study was conducted among 120 parturient women who attended a delivery room in the maternity teaching hospital in erbil city from the period of 2nd june to 2nd october 2020. after reviewing the literature, a questionnaire was prepared to obtain socio-demographic data, data related to reproductive characteristic and data related to the indications for labour induction. the data were analyzed using descriptive and inferential statistical approaches. results: the study included 120 patients with the highest percentage of the patients (49.1%) were 16 to 23 years old and more than half of the sample (51.6%) had a postterm pregnancy, gestational hypertension and pre-eclampsia (15%). there were highly significant statistical differences between parity, gestational age and indication of labour induction, and significant differences between gravidity and antenatal care visits and indications for labour induction. conclusions: the majority of the sample had a post-term pregnancy of 40 and 42 weeks as an indication for induction of labour followed by gestational hypertension and preeclampsia, oligohydramnios and pre-labour rupture of membrane. there was a statistically significant difference between the antenatal care visit and parity with the induction of labour. keywords: indication of labour induction; post-term pregnancy; oligohydramnios bewar husamaldeen noori ; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: bewar.husamaldeen@gmail.com) awaz aziz saeed ; department of nursing, college of nursing, hawler medical university, erbil, iraq. 41 erbil journal of nursing & midwifery received: 06/11/2020 accepted: 01/02/2021 published: 30/05/2021 mailto:bewar.husamaldeen@gmail.come https://doi.org/10.15218/ejnm.2021.05 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article various maternal medical conditions such as chronic hypertension and diabetes [3] . and post-term pregnancy, particularly between 40 and 42 weeks [4]. there are potential medical advantages of scheduled induction of full-term delivery, such as reduced stillbirth and further fetal growth, leading to macrosomia and its consequences. according to some studies, the risk of cesarean section (cs) is lower among women whose labour was induced than among those expectantly managed in term and post-term pregnancies with the benefits to the fetus and no increased risk of maternal death [5]. induction of labour, regardless of the method used, is associated with a higher risk of postpartum haemorrhage [6], failed induction of labour [7], increased risk of cs [8], uterine hyperstimulation [9], increased risk of cord prolapse [10] and increased risk of uterine rupture [11].labour induction is the most common interventional procedure in obstetrics. it is applied in 20% to 25% of all pregnancies [12]. the indication of labour induction affects the risk of cs. specifically, the induction of labour for fetal indications greatly increases its risk in nulliparous women[13]. induction of labour for gestational diabetes mellitus, post-term, hypertensive disorders in pregnancy and macrosomia is associated with a higher risk for cs, while induction of labour for intrauterine growth restriction and previous fast labour carries a lower risk for cs [14]. according to the reports of patients who were hospitalized in the maternity teaching hospital in erbil city, the number of women inducing labour is increasing daily. this is a problematic and risky process that has a negative impact on the health of the mother and the infant. this study aimed to find out the different indications for labour induction and associated sociodemographic and obstetrical factors. a quantitative, cross-sectional descriptive study was conducted on 120 parturient women in the maternity teaching hospital in erbil city (mth) from the period of 2nd june to 2nd october 2020. the sample size was determined by using the following formula [15]: n=n/ (1+ne2) n=140/1+140(0.05)2 n=103 n= the sample size n=the size of the population (based on mth report of admissions of the parturient women for the induction of labour every month (35 cases), so the estimated population for four months was 140 patients) e= the alphaerror of 0.05 accordingly, the estimated sample size was 103 women but the study included 120 patients. the researcher obtained the permission of the ethics committee at the college of nursing. (number 92), hawler medical university in erbil and the official approval from the erbil general directorate of health. a non-probability purposive sampling method of parturient women was done and the data were gathered through a direct interview and observation by using the questionnaire. the questionnaire was prepared for collecting data after reviewing the literature. the pilot study was conducted on 15 patients who were selected purposively from the mth from 20 april to 31 may 2020. the pilot study was useful to determine the reliability, clarity, acceptability of the tool. the results were checked to determine reliability by calculating cronbach’s alpha (0.81). sociodemographic data of patients included age, educational level, residency, occupation, socio-economic state, smoking, passive smoking, and the body mass index before pregnancy and after pregnancy (< 18.5 underweight, 18.5-25 normal weight, 25 42 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2021.05 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article infertility zero (no years of infertility) and 91.7% of women attended the antenatal care visits (59.2% of women attended 1-5 visits). based on the parity, para 1-4 represented the highest proportion (52.5%), and 81.7% of the sample were the gravida 1 4. 53.3% of cases were at a gestational age of 41-42 weeks. 29.9 overweight, 30-35 obesity, and > 35 morbid obesity). data related to reproductive characteristic included the history of infertility, antenatal care visits, parity (0 nulliparous, 1-primiparous, 2-4 – multiparous, and ≥ 5 grand multipara), gravidity (1primigravida, 2-4 -multigravida, and ≥ 5 grand multigravida) and gestational age. the data related to the indication of labour induction included post-term pregnancy, decreased fetal movement, pre-labour rupture of membranes, gestational hypertension plus pre-eclampsia, gestational diabetes, oligohydramnios, vaginal bleeding, and chorioamnionitis. data were analyzed using the statistical package for social sciences (spss, version 21), by using descriptive (frequency and percentage) and inferential (one-way anova test) statistical approaches. table 1 shows the socio-demographic characteristics of the study sample. the highest percentage of the women (49.1%) were within the age range of 16 to 23 years of age. regarding the educational level and the place of living, 26.6% were primary school graduates and 45% lived in a rural area. in terms of occupation, 97.5% were housewives, and about three quarters (76.7%) were not satisfied with their socioeconomic status. the body mass index (bmi) data measured before pregnancy showed that 36.7% of women had normal weight, but this percentage decreased to 11.7% after pregnancy. assessment of the smoking status indicated that the majority (96.7%) were non-smokers, but about half (50.8%) of the participants were exposed to secondary smoking. table 2 shows the distribution of the reproductive data of the study sample, in which more than threequarters of the sample (78.3%) had no history of infertility. 78.3% had the years of 43 erbil journal of nursing & midwifery results table 1: distribution of the demographic data of the study sample (no.: 120). the characteristics subgroups induced labor f. % age groups (years) 16 – 23 59 (49.1) 24 – 31 33 (27.5) 32 – 39 26 (21.7) 40 years and more 2 (1.7) mean ± s.d. 1.76 ± 0.850 education level illiterate 28 (23.3) able to read and write 17 (14.2) primary school 32 (26.6) secondary school 26 (21.7) college or institute 17 (14.2) residence urban 35 (29.2) suburban 31 (25.8) rural 54 (45) occupation government employee 1 (0.8) student 2 (1.7) house wife 117 (97.5) socio-economic status satisfy 28 (23.3) none satisfy 92 (76.7) bmi before pregnancy under weight 1 (0.8) normal weight 44 (36.7) over weight 45 (37.5) obesity 27 (22.5) morbid obesity 3 (2.5) bmi after pregnancy under weight 0 (0) normal weight 14 (11.7) over weight 41 (34.2) obesity 40 (33.3) morbid obesity 25 (20.8) smoking yes 4 (3.3) no 116 (96.7) secondary smoking yes 59 (49.2) no 61 (50.8) grand mean: 2.59, bmi: body mass index, f.: frequency, no.: number, %: percentage. https://doi.org/10.15218/ejnm.2021.05 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article table 3 shows the distribution of the indications for induction of labour data, which shows that 51.6% of the sample had postterm pregnancy followed by gestational hypertension + pre-eclampsia (15%) and oligohydramnios (13.4%). 44 erbil journal of nursing & midwifery table 2: distribution of the reproductive data of the study sample (no.: 120). the characteristics subgroups induced labor f. % history of infertility yes 26 (21.7) no 94 (78.3) years of infertility 0 94 (78.3) 1-3 years 23 (19.2) 4-6 years 3 (2.5) antenatal care visit (follow-up) yes 110 (91.7) no 10 (8.3) no. of visits 0 10 (8.3) 1-5 visits 71 (59.2) 6-10visits 39 (32.5) number of para 0 51 (42.5) 1 25 (20.8) 2-4 38 (31.8) 5 and more 6 (4.9) number of gravida 1 47 (39.2) 2-4 51 (42.6) 5 and more 22 (18.2) gestational age 37-38weeks 31 (25.8) 39-40weeks 25 (20.8) 41-42weeks 64 (53.3) bmi: body mass index, f.: frequency, no.: number, %: percentage. table3: distribution of the indications of labor induction of the study sample (no.: 120). indications of induction f % postdate pregnancy 62 (51.6) decrease fetal movement 3 (2.6) pre-labor rupture of membrane 10 (8.4) gestational hypertension + preeclampsia 18 (15) gestational diabetes 7 (5.3) oligohydramnios 16 (13.4) vaginal bleeding 4 (3.4) total 120 (100) f.: frequency, %: percentage. table 4 shows the difference between the reproductive characteristics and the indications for labour induction. there were non-significant differences between the history of infertility at p-value = 0.956, years of infertility at p-value = 0.938, and the number of antenatal care visits at pvalue = 0.254 and the indication for labour induction. there were significant differences between antenatal care visits at pvalue = 0.038 and gravidity at p-value = 0.01 and an indication of labour induction. there were highly significant statistical differences between parity at p-value < 0.001, gestational age at p-value < 0.001 and an indication for labour induction. https://doi.org/10.15218/ejnm.2021.05 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article 45 erbil journal of nursing & midwifery table4: difference between reproductive characteristics and indications of induction by one-way anova test (n=120). reproductive characteristics indications of induction mean s. d. f. value p-value history of infertility postdate pregnancy 1.79 0.410 0.257 0.956 decrease fetal movement 2.00 0.000 pre-labor rupture of membrane 1.80 0.422 gestational hypertension + preeclampsia 1.72 0.461 gestational diabetes 1.86 0.378 oligohydramnios 1.75 0.447 vaginal bleeding 1.75 0.500 years of infertility postdate pregnancy 1.03 0.178 0.295 0.938 decrease fetal movement 1.00 0.000 pre-labor rupture of membrane ‎0011‎ 0.422 gestational hypertension + preeclampsia 1.06 0.236 gestational diabetes 1.00 0.000 oligohydramnios 1.00 0.000 vaginal bleeding 1.00 0.000 antenatal care visits postdate pregnancy 1.05 0.216 2.322 0.038 decrease fetal movement 1.33 0.577 pre-labor rupture of membrane 1.10 0.316 gestational hypertension + preeclampsia 1.06 0.236 gestational diabetes 1.14 0.378 oligohydramnios 1.06 0.250 vaginal bleeding 1.50 0.577 no. of visits postdate pregnancy 1.53 0.646 1.320 0.254 decrease fetal movement 1.67 1.155 pre-labor rupture of membrane 1.70 0.675 gestational hypertension + preeclampsia 2.00 0.840 gestational diabetes 1.71 0.756 oligohydramnios 1.56 0.629 vaginal bleeding 1.25 0.500 para postdate pregnancy 1.11 0.319 4.699 < 0.001 *** decrease fetal movement 2.00 0.000 pre-labor rupture of membrane 1.00 0.000 gestational hypertension + preeclampsia 1.17 0.383 gestational diabetes 1.14 0.378 oligohydramnios 1.06 0.250 vaginal bleeding 1.00 0.000 gravida postdate pregnancy 1.18 0.385 3.545 0.01 ** decrease fetal movement 2.33 0.577 pre-labor rupture of membrane 1.10 0.316 gestational hypertension + preeclampsia 1.22 0.428 gestational diabetes 1.29 0.756 oligohydramnios 1.13 0.342 vaginal bleeding 1.00 0.000 gestational age postdate pregnancy 2.98 0.127 78.783 < 0.001 *** decrease fetal movement 1.33 0.577 pre-labor rupture of membrane 1.80 0.789 gestational hypertension + preeclampsia 1.44 0.616 gestational diabetes 1.43 0.535 oligohydramnios 1.44 0.512 vaginal bleeding 1.75 0.500 grand mean: 2.98, d.f.: 239, anova: analysis of variance, f.: frequency, f. value: fisher test, ***: high significant, no.: number, s.d.: standard deviation, ≤: less than and equal to, %: percentage, +: plus. https://doi.org/10.15218/ejnm.2021.05 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article in the current study about half of the sample (49.1%) between 16–23 years old, which agrees with the results of a previous study done in oromia [16]. however, it is in disagreement with the results of the previous study, which was done in eastern nepal. [17]. most of the women in the current study were primary school graduates, which is similar to the result of the previous study done by lawani et al. [18]. concerning the occupation, housewives represented the largest group, which contrasts with the study conducted in brazil [19]. before the pregnancy, the majority of this study participants were overweight, which disagrees with the study done by dundar et al. [20].the present study’s findings showed that the highest percentage of patients were overweight at term and are supported by other studies [20]. but they contradict the study conducted in saudi arabia [21]. based on the parity, the result of the present study showed that 1-4 para represented the highest proportion, which is similar to the results of the previous study [22]. in terms of gravidity, the 1-4 gravida group of the study sample made up more than a third of the sample, which agrees with the previous study [22]. regarding the gestational age, the result of the present study showed that the 41-42 weeks gestational age was present in the highest percentage of cases, which disagrees with the result of the study done in sweden [23].the most common indication for the induction of labour was the postterm pregnancy, which is similar to the previous study conducted in tanzania [24], but different from the report by lueth et al., which identified the pre-labour rupture of membranes as the most common indication, followed by the post-term pregnancy [25]. the second most common indication in this study was gestational hypertension + pre-eclampsia followed by oligohydramnios and the pre-labour rupture of the membranes. there was a statistically significant difference between the antenatal clinic follow-up and the induction of labour, which agrees with earlier studies that demonstrated similar results [16]. the data also showed a highly significant difference between parity and all indications for labour induction. this finding is similar to a study conducted in turkey [26]. furthermore, the results indicated that there was a statistically significant difference between gravidity and the indications for labour induction similarly to the reported study done in ethiopia [25]. the present study revealed that gestational age was one of the factors that yielded a highly significant difference with the indication of labour induction. a previous study also indicated that gestational age makes a significant difference in labour induction [27]. this study shows that the highest proportion of the sample had post-term pregnancy as an indication for the induction of labour followed by gestational hypertension + pre-eclampsia, oligohydramnios and prelabour rupture of the membranes. there was a statistically significant difference between antenatal care visits and gravidity with the induction of labour. the researcher recommends doing further research on a larger sample size. further research is needed to determine the risk factors for indications of labour induction. this work has no potential conflicts of interest, whether of financial or other nature. 46 erbil journal of nursing & midwifery discussion conclusion and recommendations conflicts of interest https://doi.org/10.15218/ejnm.2021.05 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article 2013 jan 25;8(1):e54858. available from: [accessed 3rd sep 2020 ].https:// journals.plos.org/plosone/article? id=10.1371/journal.pone.0054858 [7] banos n, migliorelli f, posadas e, ferreri j, palacio m. definition of failed induction of labor and its predictive factors: two unsolved issues of an everyday clinical situation. fetal diagnosis and therapy. 2015;38 (3):161-9. available from: https:// www.karger.com/article/abstract/433429 [accessed 3rd sep 2020 ] [8] obando pv, arana an, izaguirre a, arana i, burgos j. multiscale texture analysis of cervical tissue for labor induction. in2015 ieee international workshop of electronics, control, measurement, signals and their application to mechatronics (ecmsm) 2015 jun 22 (pp. 1-6). ieee. available from: https:// ieeexplore.ieee.org/abstract/ document/7208707[accessed 3rd sep 2020 ] [9] heuser cc, knight s, esplin ms, eller ag, holmgren cm, richards d, et al. tachysystole in term labor: incidence, risk factors, outcomes, and effect on fetal heart tracings. american journal of obstetrics and gynecology. 2013 jul 1;209(1):32-e1. available from: https://www.sciencedirect.com/science/ article/abs/pii/s0002937813003530 [accessed 11th oct 2020 ] [10] pergialiotis v, fanaki m, bellos i, tzortzis a, loutradis d, daskalakis g. evaluation of umbilical cord entanglement as a predictive factor of adverse pregnancy outcomes: a meta-analysis. european journal of obstetrics & gynecology and reproductive biology. 2019 dec 1;243:150-7. available from: https://www.sciencedirect.com/science/ article/abs/pii/s0301211519304944 [accessed 3rd sep 2020 ] [11] harper lm, cahill ag, boslaugh s, odibo ao, stamilio dm, roehl ka, et al. association of induction of labor and uterine rupture in women attempting vaginal birth after cesarean: a survival analysis. american journal of obstetrics and gynecology. 2012 jan 1;206 (1):51-e1.available from: https:// www.sciencedirect.com/science/article/abs/ pii/s0002937811012099[accessed 3rd sep 2020 ] [12] kim hi, choo sp, han sw, kim eh. benefits and risks of induction of labor at 39 or more weeks in uncomplicated nulliparous women: a retrospective, observational study. obstetrics & gynecology science. 2019 jan 1;62 [1] world health organization. who recommendations on intrapartum care for a positive childbirth experience. world health organization; 2018 jun 25. available from: https:// books.google.iq/books? hl=en&lr=&id=hhoydwaaqbaj&oi= fnd&pg=pr5&dq=world+health+or ganization,+2018.+who+recommen dations:+induction+of+labour+at+or +byond+term.+world+health+orga nization.+&ots=edwm [2] ivars j, garabedian c, devos p, therby d, carlier s, deruelle p, et al. simplified bishop score including parity predicts successful induction of labor. european journal of obstetrics & gynecology and reproductive biology. 2016 aug 1;203:309-14. available from: https:// www.sciencedirect.com/science/ article/abs/piis0301211516302895 [accessed 1st sep 2020 ] [3] viteri oa, sibai bm. challenges and limitations of clinical trials on labor induction: a review of the literature. american journal of psychiatry. 2018 oct;8(4):e365. available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc6306280/[accessed 3rd sep 2020 ] [4] galal m, symonds i, murray h, petraglia f, smith r. postterm pregnancy. facts, views & vision in obgyn. 2012;4(3):175. available from https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc3991404/ [accessed 23rd dec 2020 ] [5] mishanina e, rogozinska e, thatthi t, uddin-khan r, khan ks, meads c. use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis. canadian medical association journal. 2014 jun 10;186(9):665-73. available from: https://www.cmaj.ca/ content/186/9/665.short[accessed 3rd sep 2020 ]. [6] khireddine i, le ray c, dupont c, rudigoz rc, bouvier-colle mh, deneux-tharaux c. induction of labor and risk of postpartum hemorrhage in low risk parturients. plos one. 47 erbil journal of nursing & midwifery reference https://doi.org/10.15218/ejnm.2021.05 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article www.scielo.br/scielo.php? script=sci_arttext&pid=s010407072018000100300&lng=en&nrm=iso&tln g=en[accessed 18th oct 2020 ] [20] dundar ö, çiftpınar t, tütüncü l, ergür ar, atay mv, müngen e. the effects of the prepregnancy maternal body mass ındex on the pregnancy outcomes. perinatal journal. available from: https:// perinataljournal.com/files/archive/en-us/ articles/pd-1052.pdf[accessed 18th oct 2020 ] [21] el-gilany ah, hammad s. body mass index and obstetric outcomes in saudi arabia: a prospective cohort study. annals of saudi medicine. 2010 sep;30(5):376-80. available from: https://www.annsaudimed.net/doi/ pdf/10.4103/0256-4947.67075 [accessed 20th oct 2020 ] [22] whittington jr, ounpraseuth st, magann ef, wendel pj, newton l, morrison jc. a comparison of maternal and perinatal outcomes with vaginal delivery: indicated induction versus spontaneous labor. the journal of maternal-fetal & neonatal medicine. 2020 jun 3:1-6. available from: https:// www.tandfonline.com/doi/ abs/10.1080/14767058.2020.1774545? journalcode=ijmf20 [accessed 20th oct 2020 ] [23] ekéus c, lindgren h. induced labor in sweden, 1999–2012: a population-based cohort study. birth issues in prenatal care. 2016 jun;43(2):125-33. available from: https:// onlinelibrary.wiley.com/doi/full/10.1111/ birt.12220 [accessed 20th oct 2020 ] [24] jaiswal s. indications, methods and outcome of induction of labor at muhimbili national hospital, dar es salaam, tanzania (doctoral dissertation, muhimbili university). available from:http://dspace.muhas.ac.tz:8080/xmlui/ handle/123456789/2259[accessed 24th oct 2020 ] [25] lueth gd, kebede a, medhanyie aa. prevalence, outcomes and associated factors of labor induction among women delivered at public hospitals of mekelle town-(a hospital based cross sectional study). bmc pregnancy and childbirth. 2020 dec;20:1-0. available from:https:// bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/ s12884-020-02862-7 [accessed 8th sep 2020 ] [26] kandemir o, dede h, yalvac s, aldemir o, (1):19-26. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc6333763/[accessed 8th sep 2020 ] [13] parkes i, kabiri d, hants y, ezra y. the indication for induction of labor impacts the risk of cesarean delivery. the journal of maternal-fetal & neonatal medicine. 2016 jan 17;29(2):224-8. available from: https://www.tandfonline.com/doi/ abs/10.3109/14767058.2014.993965 [accessed 8th sep 2020 ] [14] mei-dan e, pittini a, barrett j, melamed n. 945: indication for induction of labor and risk for cesarean section. american journal of obstetrics & gynecology. 2017 jan 1;216(1):s534-5. available from: https:// www.ajog.org/article/s0002-9378(16) 31833-6/abstract[accessed 8th sep 2020 ] [15] yamane t. statistics, an introductory analysis. 2nd ed. new york: harper and row, 1967. [16] abdulkadir y, dejene a, geremew ma, dechasa b. induction of labor prevalence and associated factors for its outcome at wolliso st. luke. catholic hospital, south west shewa, oromia. internal medicine. 2017;7(255):2. available from: https:// www.longdom.org/open-access/induction -of-labor-prevalence-and-associatedfactors-for-its-outcome-atwolliso-st-lukecatholic-hospital-south-west-shewaoromia-2165-8048-10002455.pdf [accessed 8th sep 2020 ] [17] regmi rp, regmi mc, agrawal a, uprety d, katwal b. indications for induction of labour: a prospective analysis. health renaissance. 2010;8(2):114-6. available from:https://www.researchgate.net/ publication/277854959_indications_for_inductio n_of_labour_a_prospective_analysis [accessed 18th oct 2020 ] [18] lawani ol, onyebuchi ak, iyoke ca, okafo cn, ajah lo. obstetric outcome and significance of labour induction in a health resource poor setting. obstetrics and gynecology international. 2014 jan 1;2014. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc3918372/[accessed 18th oct 2020 ] [19] quitolina scapin s, petters gregório vr, sorgatto collaço v, knobel r. induced labor in a university hospital: methods and outcomes. texto & contexto enfermagem. 2018 jan 1;27(1). available from: https:// 48 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.05 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article yirci b. the effect of parity on labor induction with prostaglandin e2 analogue (dinoprostone): an evaluation of 2090 cases. journal of pregnancy and child health 2015;2(149):2. available from: https://www.researchgate.net/ publication/277907708 [accessed 24th oct 2020 ] [27] abdulkadir y, dejene a, geremew ma, dechasa b. induction of labor prevalence and associated factors for its outcome at wolliso st. luke. catholic hospital, south west shewa, oromia. internal medicine. 2017;7(255):2. available from: https:// www.longdom.org/open-access/induction -of-labor-prevalence-and-associatedfactors-for-its-outcome-atwolliso-st-lukecatholic-hospital-south-west-shewaoromia-2165-8048-10002455.pdf [accessed 26th oct 2020 ]. 49 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.20 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article the effect of kangaroo mother care intervention on the newborns health outcome delivers at sulaymaniyah maternity teaching hospital abstract introduction kangaroo mother care (kmc) was first initiated in colombia in 1978 [1]. the method involves babies being carried on the chest, usually by the mother, with skin-toskin contact (ssc). scs is a specially designed form of kmc which influences the physical and psychological development and the health of an infant over the first years of life and provides neurological, autonomic, somatic, behavioural, background and objectives: kangaroo mother care is an intervention for all newborns but especially for premature and low birth weight infants. the method involves babies being carried, usually by the mother, with skin-to-skin contact. it is the most achievable way for decreasing neonatal morbidity and mortality and is practical, inexpensive especially for developing countries. this study intended to assess the effect of kangaroo mother care on the newborns’ health outcome at sulaymaniyah maternity teaching hospital in sulaymaniyah, kurdistan region, iraq. methods: a quasi-experimental, pre-post intervention study was conducted in the neonatal intensive care unit and baby friend unit of the hospital. one hundred newbornmother pairs participated in the kangaroo mother care procedure. the newborns were physiologically monitored before, in the middle and after the procedure. result: the highest mean of newborn temperature was 37 ̊c after kangaroo mother care in the visit three and the lowest mean temperature was 36.1 ̊c before kangaroo mother care. there were statistically significant differences between the before, middle and afterprocedure measurements in temperature, heart rate and respiratory rate (p-value <0.05) on all three visits, while there was no significant difference between the means of the oxygen saturation at all three visits (p-value was more than the standard alpha 0.05 ftest=0.961). there was a highly significant association between oxygen saturation and newborn birth weight and gestational age. individual vital signs abnormalities were often corrected during the kangaroo mother care sessions. newborns involved in the procedure showed steady and statistically significant improvement in vital physiological parameters during three sessions on all three days. conclusion: majority of babies who received kangaroo mother care showed significant improvement in vital physiological parameters on all three days without using special equipment showing that this strategy can offer improved care to newborn infants. these findings support wider implementation of this strategy. keywords: kangaroo, mother, care, newborn, health, outcome, effects awat hassan azeez; department of nursing, college of nursing, university of sulaimani, sulaimani, iraq. (correspondence: awathassan91@yahoo.com) pary muhammad azize; department of nursing, sulaimani technical institute sulaimani polytechnic university sulaimani, iraq. 178 received: 06/03/2020 accepted:27/07/2020 published: 30/11/2020 https://doi.org/10.15218/ejnm.2020.20 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article and motor development benefits. kmc can be applied after birth for maximal effect and can continue to be implemented through the first years of life. many factors are connected with an infant's growth and development, as well as the initiation and practising of kmc. [2]. the procedure of kmc between the mother and the baby is a secure and economical procedure that has proven advantages for mothers and children in comparison to an incubator caring method. it plays a symbolic role in infant survival, neurodevelopment, and the quality of mother-infant bonding. kmc balances good essence care and helps providers to ration the use of expensive basics such as warmers and incubators for all newborn babies especially pre-term and those with a low-birth-weight (lbw). skin-to-skin bonding between the mother and her infant reduces maternal postpartum, depressive symptoms and improves autonomy [3].the kmc is done in three stages, the first and second one are performed in the hospital and the third in the family setting. the first stage is practised at the intensive care unit (icu) facilitating the bonding of the parents with the baby and positioning of the newborn. the second stage occurs in the kangaroo nursery/unit, where the mother actively co-operates in the care of her child under the supervision of the health team. the third stage occurs after discharge at home where the baby should remain in the kangaroo position most of the day [4].the birth of a premature baby is an extremely stressful situation for parents, producing feelings of fear and insecurity. therefore, the newborn-mother relationship is essential. kmc for pre-term babies is always related to better cognitive and motor development at six months of age. in addition to neonatal and maternal health outcomes, kmc is an essential tool in reducing the postpartum hospital stay and overall healthcare expense. it provides economic profit to the parents, as preterm and lbw babies who were given kmc require less time for hospitalization [5]. the world health organization (who) supported study in nepal, which showed that hypothermia was common in newborn infants early after birth; increased mortality was noted across all ranges of hypothermia, and the risk was 12 times greater among pre-term babies. [6]. kmc is a practical, inexpensive intervention, for developing countries. it implies putting the newborn baby in intimate skin-to-skin contact with the mother's chest and abdomen with repeated and preferably unique breastfeeding. this is similar to caring for a surrogate, where the premature baby is kept warm in the mother's bag and near to the breasts for unlimited feeding. kmc has emerged as a non-conventional low-cost method that provides warmth, touch, and security to the newborn and is believed to have a significant survival benefit. a recent cochrane study reported that kmc improves breastfeeding outcomes and cardio -respiratory stability in infants without adverse effects [7]. a quasi-experimental study at hawler maternity teaching hospital in erbil, iraq from february to may 2017 showed that 48% of mothers who received ssc and 46% with routine care had successful breastfeeding. newborns who received ssc initiated breastfeeding within 2.41 ± 1.38 (m ± sd) minutes after birth, however, newborns who received routine care started breastfeeding in 5.48  ± 5.7 (m ± sd) minutes. [8]moreover, the prevalence of hypothermia in the newborns who received ssc and routine care was 2 and 42% respectively. this study was conducted to assess the effect of kmc on the newborns’ physiological parameters as there has been no research on this subject in the sulaymaniyah province 179 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.20 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article classification of both gestational age and birth weight was used: gestational age (9) < 28 weeks extremely pre-term 28 to less than32 weeks very pre-term 32 to less than 37 weeks moderate to late pre-term 37 to less than 40 weeks full-term weeks post-term newborn birth weight/gram (10) <1500 extremely low birth weight(elbw) 1500 to less than 2000 very low birth weight(vlbw) 2000 to less than 2500 low birth weight(lbw) 2500 to less than 3500 normal weight (nw) 3500 overweight(ow) regarding age and birth weight as follow re, heart rate, respiratory rate and oxygen saturation) part two contained maternal demographic information such as age, education level, occupation, residency, employment and parity. part three included the monitoring of physiological parameters, such as body temperature, heart rate, respiratory rate, and oxygen saturation of newborns before and after the demonstration of kmc. the purpose of the study was clearly explained to all the postnatal mothers and relatives, and their verbal consent was obtained before filling the questionnaire. the kmc custom-made was applied on the mother's bare chest, with newborns wearing only a diaper for at least 30 minutes with covering the baby head, back and feet to avoid hypothermia. for implementing kmc, mothers were asked to use any frontopening light dress. babies were dressed in a cap, socks, and nappy and no other a quasi-experimental, pre-post intervention design was used in this study at sulaymaniyah maternity teaching hospital in sulaymaniyah in the kurdistan region of iraq. all mothers of newborn babies in the neonatal intensive care unit (nicu) and baby friend unit (bfu) were asked to participate in this study. a purposive nonprobability sample of one hundred newborn-mother pairs was recruited to participate in the study. the study data were collected from all nicu newborn babies. the mothers were interviewed before kmc and monitored with newborns during kmc procedures in the period between the 8th of january 2019 and the 28th of may 2019. the researchers were trained for a month about kmc as preparation for data collection.the research tool included a fieldtested questionnaire about the mother and their newborn demographic information. direct monitoring and documentation were done in the nicu and bfu. the data collection tool was prepared in english and translated to the kurdish language to be used for the mothers’ interview. the council of the college of medicine number 4 accepted protocol of the study on the 7th of february 2019, which was also approved by the ethical committee of the college of nursing at university of sulaymaniyah. an official letter from the college of nursing at the university of sulaymaniyah was sent to the maternity teaching hospitals in sulaymaniya to obtain facilitation and cooperation during data collection of this study from the 13th of november 2018.data were collected through direct structured interview of postnatal mothers using a questionnaire. the study questionnaire consisted of three parts, as follows: part one included four questions about neonatal demography and medical history: gestational age (weeks), birth weight (grams), gender and feeding type. the standard 180 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2020.20 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article c-parried samples t-test d-one way anova (f-test) reliability of questionnaire it can be seen in table 1 that the alpha cronbach measure was used to get the result of the reliability of the questionnaire. as a result, the value of alpha cronbach equalled to 0.896, and the validity was 0.803 showing the high reliability of the questionnaire. table 2 demonstrates that 36% of the newborns were full-term and post-term in gestation age (the highest rate among all levels of gestational age) followed by 19% of moderate and late pre-term (9%). regarding the birth weight, more than half of newborns (51%) had normal weight (2500 3500gms) followed by 18% of low birth weight infants (2000 2500gms). the majority of the newborns were male reaching 60% of the total. regarding the feeding type, 46% of newborns were bottle-fed, which was the highest percentage among all the feeding types, 24% were breastfed, and only 3% were on the nasogastric tube (ngt) feeding. table 3 indicates that out of 100 mothers, 51% were between 20 – 30 years of age. the second-largest group of mothers were 30 to 40 years old (40%). most of the participants (63%) lived in urban areas. regarding educational level, the data showed that 26% of mothers had a secondary level of education and 24% were educated at higher education institutions. the most frequent occupation was being a housewife (83%). among the study 181 erbil journal of nursing & midwifery garments. after placing into kmc bag, the baby was placed upright inside mother's clothing against the bare skin of the chest and abdomen. head was turned to one side and placed in a slightly extended position, and eye-to-eye contact between mother and baby was encouraged. the hips were kept flexed and abducted in a ′ frog′ position; the arms were also flexed. the baby was allowed to suck on the breast as often as it wanted. the newborns were physiologically monitored before the kmc, in the middle, and after the procedure for consecutive three days in three sessions. four vital physiological parameters of the newborns, such as axillary temperature, respiration rate (rr/ min), heart rate (hr/ min), and oxygen saturation (spo2) were assessed, monitored and recorded. an axillary temperature was taken in °c by a digital thermometer. respiration rate was assessed by observing chest movements for a full one minute. the heart rate and oxygen saturation were monitored by the pulse-oximeter. all mothers of newborns including full-term, pre-term babies, low birth weight babies, and postmature babies were trained about kmc. newborns on continuous positive airway pressure (cpap) and unwilling mothers were excluded from participation in the study. all statistical computation was enhanced using the statistical method software spss 21. the data were coded, tabulated, and presented in a descriptive form. the statistical procedures that were applied to determine the results of the present study included: 1. alpha-cronbach has been used for testing the reliability of the questionnaire. 2. descriptive statistical data analysis (newborn demographic characteristics and mother demographic characteristics) 3. inferential data analysis: a. one sample t-test b. independent samples t-test results table 1: reliability and validity methods result alpha cronbach 0.896 validity 0.803 https://doi.org/10.15218/ejnm.2020.20 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 182 erbil journal of nursing & midwifery participants, 57% of the mothers’ parity was low multipara , which represented the highest frequency among all levels of table 2: distribution of the newborns’ demographic characteristics characteristics frequency percent gestational age/week < 28 weeks extremely pre-term 0 (0) 28 to less than32 w very pre-term 9 (9) 32 to less than 37 w moderate to late pre-term 19 (19) 37 to less than 40 w full-term 36 (36) > 40 weeks post-term 36 (36) total 100 (100) birth weight (grams) < 1500 extremely low birth weight (elbw) 7 (7) 1500 to less than 2000 very low birth weight (vlbw) 8 (8) 2000 to less than 2500 low birth weight( lbw) 18 (18) 2500 to less than 3500 normal weight (nw) 51 (51) ≥ 3500 overweight (ow) 16 (16) total 100 (100) gender male 60 (60) female 40 (40) total 100 (100) feeding type breastfeeding 24 (24) bottle feeding 46 (46) mixed feeding 9 (9) ngt ( nasogastric tube) 3 (3) npo ( nothing per oral) 18 (18) total 100 (100) table 3: distribution of the mothers’ demographic characteristics characteristic frequency percent mother age/ years less than 20 6 (6) 20 – 30 51 (51) 30 – 40 40 (40) more than 40 3 (3) total 100 (100) residency rural 11 (11) urban 63 (63) suburban 26 (26) total 100 (100) level of education illiterate 17 (17) read & write 16 (16) secondary educated 26 (26) preparatory educated 17 (17) higher education 24 (24) total 100 (100) employment employed 17 (17) housewife 83 (83) total 100 (100) parity primipara 29 (29) low multipara (1-3) 57 (57) grand multipara (4-8) 14 (14) total 100 (100) https://doi.org/10.15218/ejnm.2020.20 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 183 erbil journal of nursing & midwifery table 4 shows the means of the physiological parameters of the whole sample. there were highly statistically significant differences in means between the before, middle and after kmc measurements in temperature, heart rate and respiratory rate at all three visits (p< 0.05). the highest mean of temperature (37 ̊c after kmc) was at visit 3 and the lowest mean (36.1 ̊c before kmc) was recorded at visit 1. there were no statistically significant differences between the means of the oxygen saturation at visit 1 (p=0.088), visit 2 (p=0.721) and visit 3 (p=0.384) because the result of the p-value was more than the standard alpha 0.05.table 5 shows the association between gestational age and temperature at all three visits(before kmc, in the middle of kmc, after kmc). there were statistically significant differences between gestational age and temperature because the pvalues were less than the standard alpha 0.05 by using anova table (f-test). the mean ± sd of temperature (visit 3 after kmc) in full-term and post-term newborns was 36.9 ± 0.18, which was the highest value of the mean. furthermore, the mean ± s.d in at visit 1 in very pre-term infants was 35.6 °c ± 0.72, which was the lowest value of the mean.table 6 shows the association between gestational age and heart rate. data show that there was a statistically significant difference between gestational age and heart rate (during and after kmc (p=0.01). in contrast, the data from visit 1 (p= 0.22), visit 2 (p=0.165), and visit 3 (p=0.645),(all visits, p=0.18) before kmc (p=0.222), in the middle of kmc (p=0.43) show that there was no statistically significant difference between gestational age and heart rate because the p-value was greater than the common alpha 0.05. the mean ± sd of heart rate before kmc in moderate to late pre-term was 144 ± 14.99, which was the highest value of the mean. furthermore, the mean and standard deviation of heart rate after kmc in post-term newborns was 116 ± 7.37, which was the lowest value of the mean. table 7 demonstrates the association between gestational age and respiratory rate during all three visits, before kmc, in the middle of kmc and after kmc). there was a statistically significant difference between gestational age and respiratory rate at visit 3 (p-value = 0.001) and after kmc (p-value = .048) because the p-value was less than the standard alpha 0.05. the means ± sds of the respiratory rate before kmc in very pre-term and moderate to late pre-term infants were 43 ± 6.5 and 43 ± 6.16 respectively, which were the highest values of the mean. otherwise, the mean ± sd of respiratory rate after kmc in postterm newborns was 35 ± 3.42, which was the lowest value of the mean. table 8 indicates the association between gestational age and oxygen saturation., there was statistically significant difference between gestational age and oxygen saturation at visit 1 (p=0.046), visit 2 (p=0.005), visit 3 (p=0.047), (all visits, p=0.003), before kmc (p=0.008), in the middle of kmc (p=0.045), and after kmc (p=< 0.001) because the p-values were less than the common alpha 0.05. table 9 shows the association between birth weight and temperature. there was a statistically significant difference between birth weight and temperature at visit1 (p=0.028), visit 2 (p=0.001), visit 3 (p=< 0.001), (al visits, p=0.001), before kmc (p=0.007), in the middle of kmc (p=0.001) and after kmc (p=< 0.001) because of the p-value < 0.05 . the mean ± s.d of the temperature after kmc in babies weighing less than1500 grams was 36 ± 0.69 which was the lowest value of the mean. https://doi.org/10.15218/ejnm.2020.20 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 184 erbil journal of nursing & midwifery table 4: the mean values of physiological parameters of newborns at three visits table 5: the association between gestational age and temperature physiological parameter visits 1 visits 2 visits 3 before middle after before middle after before middle after temperature °c mean 36.1 36.4 36.6 36.5 36.6 36.8 36.6 36.8 37 s.d 0.73 0.54 0.49 0.5 0.41 0.35 0.42 0.33 0.27 minimum 33.8 34.6 34.6 34.6 35.2 35 38.1 37.9 37.8 maximum 38.3 38.1 38.1 35.1 35.6 35.9 37.8 37.9 37.8 ftest 17.23 15.808 23.458 sig. < 0.001 < 0.001 < 0.001 heart rare beats/ minute mean 145 130 123 138 130 119 132 123 115 s.d 19.39 14.69 12.2 17.04 14.86 12.8 6 12.89 13.7 10.92 minimum 79 91 96 99 100 93 100 98 95 maximum 184 178 158 190 168 154 160 168 152 ftest 52.745 40.142 44.141 sig. < 0.001 < 0.001 < 0.001 respiratory rate breath/ minute mean 43 40 37 42 39 37 41 39 36 sd. 6.73 4.93 5.3 6.19 5.65 5.55 7.08 7.1 6.96 minimum 20 22 24 28 26 24 28 24 24 maximum 72 58 58 56 54 52 62 60 60 ftest 27.984 23.640 10.775 sig. < 0.001 < 0.001 < 0.001 oxygen saturation% mean 98 98 99 98 98 98 98 99 99 sd. 2.33 2.1 1.77 1.79 1.97 1.67 1.55 1.57 1.41 minimum 88 91 92 92 92 91 94 94 95 maximum 100 100 100 100 100 100 100 100 100 ftest 2.452 0.24 0.961 sig. 0.088 0.787 0.384 temperature gestational age / weeks 28 to < 32 w 32 to < 37 w 37 to < 40 w ≥ 40 w very pre-term moderate to late pre-term full-term post-term visit 1 mean± s.d 35.6 ± 0.72 36.5 ± 0.72 36.4 ± 0.41 36.5 ± 0.57 f-test 8.039 sig. < 0.001 visit 2 mean± s.d 36.1 ± 0.55 36.6 ± 0.57 36.7 ± 0.24 36.7 ± 0.27 f-test 7.307 sig. < 0.001 visit 3 mean± s.d 36.3 ± 0.44 36.8 ± 0.37 36.9 ± 0.18 36.9 ± 0.23 f-test 13.813 sig. < 0.001 general mean± s.d 36 ± 0.53 36.6 ± 0.52 36.7 ± 0.24 36.7 ± 0.27 f-test 10.687 sig. < 0.001 before mean± s.d 35.7 ± 0.63 36.5 ± 0.68 36.5 ± 0.34 36.5 ± 0.37 f-test +68.159 sig. < 0.001 middle mean± s.d 36 ± 0.49 36.6 ± 0.51 36.7 ± 0.24 36.7 ± 0.27 f-test 10.251 sig. < 0.001 after mean± s.d 36.3 ± 0.52 36.8 ± 0.4 36.9 ± 0.17 36.9 ± 0.18 f-test 13.595 sig. < 0.001 https://doi.org/10.15218/ejnm.2020.20 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 185 erbil journal of nursing & midwifery table 6: the association between gestational age and heart rate heart rate gestational age / weeks 28 to < 32 w 32 to < 37 w 37 to < 40 w ≥ 40 w very pre-term moderate to late pre-term full-term post-term visit 1 mean± s.d 130 ± 10.64 138 ± 14.17 133 ± 12.74 131 ± 13.43 f-test 1.497 sig. 0.22 visit 2 mean± s.d 131 ± 15.17 134 ± 15.64 128 ± 10.29 127 ± 13.11 f-test 1.737 sig. 0.165 visit 3 mean± s.d 125 ± 8.61 125 ± 10.19 123 ± 11.42 122 ± 11.02 f-test 0.557 sig. 0.645 general mean± sd. 129 ± 9.04 133 ± 11.09 128 ± 9.41 126 ± 10.15 f-test 1.662 sig. 0.18 before mean± sd. 134 ± 11.22 144 ± 14.99 137 ± 12.16 137 ± 14.29 f-test 1.492 sig. 0.222 middle mean± sd. 127 ± 8.49 131 ± 11.73 127 ± 10.49 126 ± 11.86 f-test 0.929 sig. 0.43 after mean± sd. 125 ± 9.00 123 ± 10.09 118 ± 9.63 116 ± 7.37 f-test 3.57 sig. 0.017 table 7: the association between gestational age and respiratory rate respiratory rate gestational age / weeks 28 to < 32 w 32 to < 37 w 37 to < 40 w ≥ 40 w very pre-term moderate to late preterm full-term post-term visit 1 mean± s.d 37 ± 5.1 39 ± 4.59 41 ± 5.25 41 ± 3.83 f-test 1.842 sig. 0.145 visit 2 mean± s.d 41 ± 6.67 41 ± 6.54 39 ± 4.87 38 ± 4.39 f-test 1.581 sig. 0.199 visit 3 mean± s.d 45 ± 9.23 40 ± 6.12 38 ± 5.98 36 ± 5.49 f-test 5.732 sig. 0.001 general mean± sd. 41 ± 5.2 40 ± 4.89 39 ± 3.93 38 ± 3.66 f-test 1.534 sig. 0.211 before mean± sd. 43 ± 6.5 43 ± 6.16 42 ± 4.72 41 ± 4.57 f-test 0.658 sig. 0.58 middle mean± sd. 42 ± 5.22 40 ± 5.12 39 ± 3.81 38 ± 3.81 f-test 1.528 sig. 0.212 after mean± sd. 39 ± 5.18 38 ± 4.65 36.7 ± 4.18 35 ± 3.42 f-test 2.586 sig. 0.048 https://doi.org/10.15218/ejnm.2020.20 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 186 erbil journal of nursing & midwifery table 8: the association between gestational age and oxygen saturation table 9: the association between birth weight and temperature oxygen saturation gestational age / weeks 28 to < 32 w 32 to < 37 w 37 to < 40 w ≥ 40 w very pre-term moderate to late pre-term full-term post-term visit 1 mean± s.d 97 ± 2.39 98 ± 1.85 98 ± 1.84 99 ± 1.37 f-test 2.769 sig. 0.046 visit 2 mean± s.d 97 ± 2.25 98 ± 1.79 98 ± 1.3 99 ± 1.12 f-test 4.482 sig. 0.005 visit 3 mean± s.d 98 ± 1.57 98 ± 1.27 99 ± 0.95 99 ± 1.32 f-test 2.752 sig. 0.047 general mean± sd. 97 ± 1.88 98 ± 1.48 99 ± 0.94 99 ± 0.91 f-test 5.012 sig. 0.003 before mean± sd. 97 ± 2.24 98 ± 1.6 98 ± 1.25 99 ± 1.02 f-test 4.199 sig. 0.008 middle mean± sd. 97 ± 1.89 98 ± 1.69 98 ± 1.05 99 ± 1.08 f-test 2.77 sig. 0.045 after mean± sd. 97 ± 2.05 98 ± 1.4 99 ± 0.83 99 ± 0.89 f-test 6.931 sig. < 0.001 temperature birth weight (grams) <1500 1500 – 2000 2000 – 2500 2500 – 3500 > 3500 elbw vlbw lbw nw ow visit 1 mean± s.d 36 ± 1.1 36 ± 0.99 37 ± 0.5 36 ± 0.4 37 ± 0.34 f-test 2.85 sig. 0.028 visit 2 mean± s.d 36 ± 0.76 36 ± 0.79 37 ± 0.29 37 ± 0.24 37 ± 0.19 f-test 5.411 sig. 0.001 visit 3 mean± s.d 36 ± 0.6 37 ± 0.51 37 ± 0.2 37 ± 0.2 37 ± 0.22 f-test 8.186 sig. < 0.001 general mean± s.d 36 ± 0.79 36 ± 0.71 37 ± 0.32 37 ± 0.25 37 ± 0.19 f-test 5.434 sig. 0.001 before mean± s.d 36 ± 0.99 36 ± 0.91 37 ± 0.45 36 ± 0.33 37 ± 0.3 f-test 3.756 sig. 0.007 middle mean± s.d 36 ± 0.73 36 ± 0.71 37 ± 0.31 37 ± 0.26 37 ± 0.18 f-test 5.473 sig. 0.001 after mean± s.d 36 ± 0.69 37 ± 0.58 37 ± 0.2 37 ± 0.18 37 ± 0.13 f-test 8.12 sig. < 0.001 https://doi.org/10.15218/ejnm.2020.20 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 187 erbil journal of nursing & midwifery table 10 demonstrates the association between birth weight and heart rate. there was a statistically significant difference between birth weight and heart rate after kmc (p=0.042) because the result of the p -value was less than the standard alpha 0.05 using anova table (f-test). the temperature at all visits before kmc and in the middle kmc showed no statistically significant differences between the birth weight and heart rate because of the p-value >0.05. the mean ± sd of the heart rate in the middle of kmc in newborns with a weight of 2000 – 2500 grams was 125 ± 6.45, which was the lowest value of the mean, and the majority of the means of the heart rate in the middle of kmc in infants weighing less than 1500 grams were 133.table 11 shows the association between birth weight and respiratory rate. there was a statistically significant difference between birth weight and respiratory rate at visit 3 (p=< 0.001), (all visits, p=0.049) in the middle of kmc, (p=0.015) and after kmc (p=0.024) as indicated by the p-value < 0.05. in contrast, at visit 1 (p=0.438) , visit 2 (p=0.093) and before significant difference between birth weight and respiratory rate as the pvalue was more than the common alpha 0.05 by using anova table (f-test). the mean± sd of the respiratory rate before kmc in newborns with a weight of less than 1500grams was 41 ± 4.18), which was the highest value of the mean. table 12 shows the association between birth weight and oxygen saturation. there was a statistically significant difference between birth weight and oxygen saturation at visit 1 (p=0.007) ,visit 2 (p=< 0.001), visit 3 (p=0.048), (all visits ,p=0.001), before kmc (p=< 0.001), in the middle of kmc (p=0.018) and after kmc (p=0.001) because of the pvalue < 0.05 by using anova table (ftest). the mean ± sd of oxygen saturation in the middle of kmc in newborns weighing 2500 – 3500 grams was 99 ± 1.07 had the highest value of the mean. at the same time, the mean ± sd of oxygen saturation in the middle of kmc in infants with weight less than 1500 grams was 97 ± 1.66, which was the lowest value of the mean. table 10: the association between birth weight and heart rate heart rate birth weight (grams) <1500 1500 – 2000 2000 – 2500 2500 – 3500 > 3500 elbw vlbw lbw nw ow visit 1 mean± s.d 133 ± 11.75 135 ± 15.98 132 ± 11.0 132 ± 13.58 134 ± 12.42 f-test 0.212 sig. 0.931 visit 2 mean± s.d 140 ± 12.05 123 ± 12.35 130 ± 12.61 127 ± 12.61 132 ± 13.76 f-test 2.153 sig. 0.08 visit 3 mean± s.d 129 ± 10.94 125 ± 8.31 119 ± 5.62 123 ± 11.81 125 ± 11.99 f-test 1.329 sig. 0.265 general mean± sd. 134 ± 8.94 128 ± 11.29 127 ± 7.68 127 ± 10.42 130 ± 11.16 f-test 0.972 sig. 0.427 before mean± sd. 141 ± 9.08 137 ± 15.37 138 ± 14.11 138 ± 13.0 140 ± 16.49 f-test 0.158 sig. 0.959 middle mean± sd. 133 ± 10.36 127 ± 9.61 125 ± 6.45 126 ± 11.84 132 ± 12.55 f-test 1.674 sig. 0.162 after mean± sd. 129 ± 9.57 121 ± 11.05 119 ± 7.12 117 ± 9.35 119 ± 8.35 f-test 2.582 sig. 0.042 https://doi.org/10.15218/ejnm.2020.20 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 188 erbil journal of nursing & midwifery table 11: the association between birth weight and respiratory rate respiratory rate birth weight (grams) <1500 1500 – 2000 2000 – 2500 2500 – 3500 > 3500 elbw vlbw lbw nw ow visit 1 mean± s.d 37 ± 5.97 39 ± 3.05 40 ± 4.83 40 ± 4.78 41 ± 4.32 f-test 0.952 sig. 0.438 visit 2 mean± s.d 44 ± 5.19 41 ± 7.55 39 ± 5.73 38 ± 4.88 39 ± 3.93 f-test 2.055 sig. 0.093 visit 3 mean± s.d 48 ± 7.91 43 ± 7.39 39 ± 5.43 37 ± 5.94 37 ± 5.27 f-test 6.015 sig. < 0.001 general mean± sd. 43 ± 4.31 41 ± 5.04 39 ± 4.21 38 ± 3.97 39 ± 3.54 f-test 2.476 sig. 0.049 before mean± sd. 44 ± 5.47 44 ± 7.23 42 ± 5.88 41 ± 4.63 43 ± 4.29 f-test 1.025 sig. 0.398 middle mean± sd. 44 ± 4.29 41 ± 4.88 39 ± 3.87 38 ± 4.15 39 ± 3.48 f-test 3.25 sig. 0.015 after mean± sd. 41 ± 4.18 38 ± 4.09 37 ± 4.14 36 ± 4.03 36 ± 3.66 f-test 2.958 sig. 0.024 table 12: the association between birth weight and oxygen saturation oxygen saturation birth weight (grams) < 0011 0011 – 0111 0111 – 0011 0011 – 0011 < 0011 elbw vlbw lbw nw ow visit 1 mean± s.d 69 ±5961 69 ±59.1 69 ±599 69 ±5911 69 ±.9.9 f-test .9..1 sig. .9... visit 2 mean± s.d 69 ±.9.9 69 ±5916 69 ±591. 66 ±59.. 66 ±.99. f-test 191.. sig. <.9..5 visit 3 mean± s.d 6. ±5919 69 ±5956 66 ±59.. 66 ±595. 66 ±595. f-test .916. sig. .9.19 general mean± sd. 6. ±5995 69 ±595. 69 ±591 66 ±.96. 69 ±595. f-test 191.. sig. .9..5 before mean± sd. 69 ±599 66 ±.9.6 69 ±5995 69 ±5955 69 ±59.6 f-test 99.61 sig. <.9..5 middle mean± sd. 6. ±5999 69 ±5919 69 ±591 66 ±59.. 69 ±59.9 f-test .95.9 sig. .9.59 after mean± sd. 6. ±5999 69 ±5911 66 ±59.. 66 ±.99. 66 ±59.9 f-test 1991. sig. .9..5 https://doi.org/10.15218/ejnm.2020.20 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 189 erbil journal of nursing & midwifery a study was performed at nicu/bfu at the maternity teaching hospital in sulaimaniyah over six months between the 8th of january 2019 and the 28th of may 2019. the period of one month before the study was used for training about kmc. the procedure of kmc is an easy and inexpensive procedure for the care of newborns. kmc enhances both newborn and maternal well-being and can be practised in any situation without the requirement of special equipment such as special cots, heaters and incubators. even though initially perceived for use only in developing countries with limited resources, its use has gradually expanded globally as medical caregivers, parents, and administrators have become highly familiar with its physiological, psychological, and cost benefits. (11,12,13) this study is generally in agreement with earlier studies, as the regular upward trend in temperature during kmc sessions and throughout our study had a p -value of 0 (p=< 0.001), which was a very highly significant finding. another study about the kmc on pre-term babies found that the mean axillary temperature and the mean heart rate was higher during kmc than during routine care. (14) kmc raises the newborn’s temperature, and as the goal is to ‘retain the warm of the newborn’, the intervention is one of the most inexpensive ways to protect babies during the critical neonatal period (15). similarly, in this study, very highly significant differences were found in heart rate and respiratory rate before and after kmc at p=< 0.001. similarly, hoe et al. who studied the kmc effect on the mother and newborn physiology, stated that kangaroo care promotes stability of physiological function. (16) in his study, the heart rate remained stable, but the respiratory rate ranged between 20 to 72 (mean 41.2), and breathing difficulties did not x occur during kmc (17). in agreement to the finding of this study, studies about the effects of kmc on the vital signs of low-birth-weight and pre-term newborn found no significant changes in the physiological parameter of oxygen saturation among newborns (18,19). in contrast to that, another study showed increased spo2 (93.8% vs 97.3%) after performing kmc (20). earlier studies about kmc and oxygen saturation and paternal bonding found a decrease in apnea and improvement in oxygen saturation in mechanically ventilated newborns who were able to tolerate kmc transfer and position changes. (21 ) in the cohort study by nurian et al. who compared the effect of kmc and conventional care methods on physiological criteria in low birth weight infants in shahid beheshti university of medical sciences at tehran in 2009, significant changes were seen between two groups in terms of heart rate, oxygen saturation and respiratory rate 5 minutes after the intervention (p < 0.05). the result shows that kmc affects the sustainability of physiological parameters during care. thus, caregivers should use kmc for mothers and infants [22].in this study, the infants born before 32-week gestation gained more benefits from kmc application than moderate to late pre-term. in these babies the temperature and gestational age had the p-value = < 0.001 at all three visits and (before, middle, after kmc). heart rates difference between the general means of three visits and the three checking periods had p-value between 0.18 and 0.017 that indicates there was a significant difference in the mean and standard deviation of heart rate before kmc in moderate to late pre-term (144 ±14.99). otherwise, the mean and sd of heart rate after kmc in post-term newborns was 116± 7.37, which was discussion https://doi.org/10.15218/ejnm.2020.20 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 190 erbil journal of nursing & midwifery the lowest value of the mean, respiration rate had minimal changes, and oxygen saturation had the p-value = < 0.001 at three visits. contrary to this study findings, a meta-analysis study to determine the physiological effects of skin-to-skin contact on newborns and mothers concluded that, although there was an increase in body temperature of 0.22°c, there was no change in heart rate. likewise, change in oxygen saturation in another study was statistically not clinically significant; showing the decline in oxygen saturation of 0.60% during periods of kmc. prematurity did not affect the regularity of these parameters. [23]regarding the association between kmc and birth weight, it can be stated that all newborns especially low birth weight newborns receiving kmc showed a modest but statistically significant rise in temperature, respiration rate, heart rate, and oxygen saturation without the requirement for any special equipment. this can aid to avoid complications and the need for more detailed measurements. there is a room for making kmc the standard of care for the lbw newborns in most settings. nonetheless, adequate planning and labour would be required to motivate and train mothers to carried out kmc and to monitor that they do so satisfactorily [24].furthermore, kmc does have comparative benefits over conventional care, especially with aspects of improving neonatal survival, supporting exclusive breastfeeding, and promoting early discharge from the hospital. even though it was initially proposed for resource-constrained settings to decrease the high neonatal mortality rates related with pre-term and lbw infants, kmc is now been recommended by the who for neonatal care in both developed ( highin come) and developing (low-income) countries. in developed countries, there appears to be a huge gap in its implementation due to the high accessibility of incubators and other technology components of conventional care. inputs have been made regarding kmc implementation in many developing countries where facility-based kmc has been individualized. continuous training for health professionals and provision of facilities is needed, which could be financed by international aid organizations to scale up the program in these settings (25,26). kangaroo mother care is protective against a variety of adverse effects on newborn outcomes and has not shown evidence of harm. from the available evidence, kmc significantly improves physiological variables and thus it may positively influence the newborns' physical health. the kmc is one of the essential, inexpensive methods that significantly improves the newborns' physiological outcomes. in sulaymaniyah, it has the potential to improve neonatal survival, support exclusive breastfeeding, and promote early discharge from the hospital. the authors wish to thank the staff of maternity teaching hospital in sulaymaniyah and the hospital administration for their cooperation. a great thank you to all mothers who accepted to participate in this study. the authors report no conflict of interests. conclusion acknowledgement conflict of interest https://doi.org/10.15218/ejnm.2020.20 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 191 erbil journal of nursing & midwifery [1] heidarzadeh m, hosseini m b, ershadmanesh m, tabari m g, khazaee s. the effect of kangaroo mother care (kmc) on breast feeding at the time of nicu discharge. iran red crescent medical journal. 2013; 15(4): 302–306. [2] campbell-yeo m l, disher t c, benoit b l, johnston cc. understanding kangaroo care its benefits to pre-term infants. pediatric health medicine and therapeutics. 2015; 6:1532. [3] mekonnen, a.g., yehualashet, s.s. & bayleyegn, a.d. the effects of kangaroo mother care on the time to breastfeeding initiation among pre-term and lbw infants: a metaanalysis of published studies. international breastfeed journal. 2019, 14, 12. https:// doi.org/10.1186/s13006-019-0206 [4] amaral wn, ramos ba, evangelista pg, saidah tk, saidah mk, formiga ckmr perception of mothers on breastfeeding, kangaroo method and pre-term baby development. scholar journal of applied health and science, 2018; 1(2): 712. [5] santos lm, morais ra, miranda jof.maternal perception of the skin-to-skin contact with premature infants through the kangaroo position. revista de pesquisa: cuidado é fundamental online. 2013; 5: 3504-3514. [6] mullany lc, katz j, khatry sk, leclerq sc, darmstadt gl, tielsch jm. risk of mortality associated with neonatal hypothermia in southern nepal. archives of pediatric and adolescence medicine. 2010;164(7):650– 656. [7] moore er, anderson gc, bergman n, dowswell t. early skin-to-skin contact for mothers and their healthy newborn infants. cochrane database systematic review. 2012; 5: cd003519. [9] safari, k., saeed, a.a., hasan, s.s. et al. the effect of mother and newborn early skin-toskin contact on initiation of breastfeeding, newborn temperature and duration of the third stage of labor. international breastfeeding journal, 2018; 13( 1): 32. https://doi.org/10.1186/s13006-018-0174-9 [6] quinn j a, munoz f m, gonik b, et al., the brighton collaboration pre-term birth working groupvaccine. pre-term birth: case definition & guidelines for data collection, analysis, and presentation of immunization safety data, 2016; 34(49): 6047–6056. [10] cutland c l, lackritz e m, mallett-moore t, et al. the brighton collaboration low birth weight working groupvaccine. low birth weight: case definition & guidelines for data collection, analysis, and presentation of maternal immunization safety data. vaccine. 2017, 4; 35(48part a): 6492 –6500. [11] thukral a, chawla d, agarwal r, deorari ak, paul vk. kangaroo mother care an alternative to conventional care. indian journal of pediatric. 2008;75:497–503. [12] hendricks-muñoz kd, li y, kim ys, prendergast cc, mayers r, louie m. maternal and neonatal nurse perceived value of kangaroo mother care and maternal care partnership in the neonatal intensive care unit. american journal of perinatology 2013;30(10):875–880.https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc4417481 [13] pallás-alonso cr, losacco v, maraschini a, greisen g, pierrat v, warren i, et al. european science foundation network. parental involvement and kangaroo care in european neonatal intensive care units: a policy survey in eight countries. pediatric critical care medicine. 2012;13: 568–577. [14] priya jj kangaroo care for low birth weight babies. nursing journal of india. 2004;95:209–12. [15] singh a, yadav a, singh a. utilization of postnatal care for newborns and its association with neonatal mortality in india: an analytical appraisal. bmc pregnancy childbirth. 2012;12:33. [16] ludington-hoe sm. evidence-based review of physiologic effects of kangaroo care. current women's health review. 2011;7:243–253. [17] ludington-hoe sm, anderson gc, simpson s, hollingsead a, argote la, rey h. birth related fatigue in 34-36-week preterm neonates: rapid recovery with very early kangaroo (skin-to-skin) care. journal of obstetrics and gynecology neonatal nursing. 1999;28:94–102. [18] almeida cm, almeida af, forti em. effects of kangaroo mother care on the vital signs of low-weight pre-term newborns. brazilian journal of physical therapy 2007; 11:1-5. [19] ali sm , sharma j , sharma r , alam s. reference https://doi.org/10.15218/ejnm.2020.20 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 192 erbil journal of nursing & midwifery kangaroo mother care as compared to conventional care for low birth weight babies. dicle medical journal. 2009;36:155-60 [20] jain g, malpani p, biswas m. kangaroo mother care and its physiological effects in low birth weight and pre-term neonates. indian journal of child health. 2018; 5 (5):386-389. [.5] mishra p, rai n, mishra nr, das rr. effect of kangaroo mother care on breastfeeding morbidity and mortality of very low birth weight neonates: a prospective observational study. indian journal of child health 2017;4:379-82. [..] nurian m my, yaghmaei f, akbarzadeh baghbani ar, heydarzadeh h . effects of kangaroo and routine care on physiologic parameters of low-birth-weight infants. journal of nursing & midwifery, 2009, shahid beheshti university of medical sciences and health services. ;19(65):19– 24. [google scholar] [..] mori r, khanna r, pledge d, nakayama t; meta-analysis of physiological effects of skin -to-skin contact for newborns and mothers. journal of pediatr international; 2010, 52:161–175. [.1] bera a, ghosh j, singh a k, hazra a, som t, munian d. effect of kangaroo mother care on vital physiological parameters of the low birth weight newborn, indian journal of community medicine. 2014 oct-dec; 39 (4): 245-249. [.1] bergh am, rogers-bloch q, pratomo h, uhudiyah u, sidi ip, rustina y, et al.; progress in the implementation of kangaroo mother care in 10 hospitals in indonesia. journal of tropical pediatrics ,2012;58:402– 5. [.9] maulik pk, darmstadt gl; communitybased interventions to optimize early childhood development in low resource settings. journal of perinatology; 2009; 29:531–42. https://doi.org/10.15218/ejnm.2020.06 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article heart failure patients’ knowledge and barriers of low sodium diet adherence in erbil city abstract introduction heart failure, often referred to as congestive heart failure (chf), is the inability of the heart to pump sufficient blood to meet the needs of the tissues by providing oxygen and essential nutrients. however, the term chf is misleading, because it indicates that patients must experience pulmonary or peripheral congestion [1]. heart failure, an exceedingly common cardiac condition, is associated with high rates of morbidity and mortality including frequent hospital admissions [2]. sodium restriction has remained a core therapy for managing sodium and fluid retention in patients with acute and chronic heart failure [3]. heart failure is a chronic illness that afflicts more than 5,000,000 americans and contributes to more than 286,700 background and objective: a low sodium diet is a cornerstone of non-pharmacologic therapy for heart failure patients. the objective of the study was to assess knowledge and perceived barriers of low sodium diet adherence of heart failure patients in erbil city. methods: a descriptive, cross sectional study design was conducted among a sample of 50 patients diagnosed heart failure in medical wards and cardiac care units at both rizgary and hawler teaching hospitals in erbil city from feb 2018 to oct 2019. patients who met the inclusion criteria were selected for participation of the study, interviews based on a questionnaire patient’s sociodemographic, clinical characteristics and the dietary sodium restriction questionnaire (dsrq). frequency, percentage, and the chisquare test were used for analyzing data. results: the results show that majority of heart failure patients were low knowledge (80%) and high perceived barriers (66%) to low sodium diet adherence. there were significant associations between knowledge and barrier with age group (p-value=0.01; pvalue=0.04), gender, (p-value=0.00; p=0.05), level of education (p-value=0.00; pvalue=0.02) and economic status (p-value= < 0.001; p-value= <0.001). conclusion: results of the study show that heart failure patients had low knowledge and perceived more barriers to adherence of low sodium diet. key words: heart failure; knowledge; perceived barriers; low sodium diet chnar salahaddin qadir; department of nursing, college of nursing, hawler medical university, erbil, iraq. )correspondence: chnar.qadir@hmu.edu.krd) 47 erbil journal of nursing & midwifery received: 6/11/2019 accepted: 22/12/2019 published: 30/5/2020 https://doi.org/10.15218/ejnm.2020.06 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article deaths annually. the prevalence of heart failure increases by approximately 550,000 patients [4]. a low-sodium diet is an accepted treatment of patients with heart failure, although minimal evidence exists on the appropriate amount of sodium intake for this population. certain heart failure guidelines have liberalized dietary sodium recommendations, which actually exceed guidelines for healthy adults [5]. although the low-sodium diet is a fundamental non-pharmacologic component of heart failure care, most people with heart failure have considerable difficulty in following such a diet [6]. fluid overload, usually secondary to dietary sodium indiscretion, was identified as a major reason for heart failure exacerbations that resulted in hospitalization and high prevalence of nonadherence to the low-sodium diet [7]. moreover, restricting sodium intake, the role of dietary sodium in heart failure management has been fully established in highly effective medical therapy. recent data highlighted an alternative hypothesis that sodium restriction may be harmful in heart failure patients and low-sodium diet in combination with high-dose diuretics and fluid restriction promoted increases in hospital readmission and death [8]. the purpose of this study is to determine the knowledge of a low-sodium diet in the care of patients with heart failure and substantial barriers to adherence that patients face. there are no prior studies done for assessment of patients’ knowledge and barriers toward adherence of low-sodium diet in erbil city. a descriptive cross sectional study design was used to assess heart failure patients’ knowledge and perceived barriers to lowsodium diet adherence in medical wards and cardiac care units at both rizgary and hawler teaching hospitals from february 2018 to october 2019 in erbil city. in order to obtain accurate data and a representative sample, a non-probability (purposive) sample was used to select heart failure patients according to the following criteria: patients who agree to participate in the study, patients with a medical diagnosis of heart failure, age more than 18 years old and have been taking treatment for at least the past one month. sample size estimation was calculated by following statistical formula: sample size =z² pq/d² {z=confident interval 95% or 1.96, p= prevalence 0.02.9, q= (1-p) =0.971, d= sampling error 0.05}[9]. sample size = z²pq/d² = (1.96) ² * (0.029) * (0.971) / (0.05) ² =43, for representative sample of 50 heart failure patients chosen in this study. data were collected through a standardized questionnaire comprising of sociodemographic and clinical characteristics including age, gender, level of education, marital status, occupation, residential area, economical status, cigarette smoking, hospitalization in last year, and comorbidity in addition to the new york heart association class (nyha), a clinical tool used to evaluate cardiac symptoms on a patient’s daily activities. class i patients do not have any limitations of physical activity. class ii patients have slight limitations of physical activity, but ordinary physical activity results shortness of breath, or chest pain. class iii patients have limitations of limited physical activity and class iv patients are unable to carry out any physical activity without discomfort [10]. the dietary sodium restriction questionnaire (dsrq), an instrument based on the theory of planned behavior which was cross-culturally adapted [7] and validated for use in brazilian portuguese, with the name (questionário de restrição de sódio na dieta) was used in part two. the dsrq demonstrated to be a reliable tool for measuring adherence to dietary sodium 48 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2020.06 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article more than three quarters (78%) of the heart failure patients were hospitalized in the last year and higher proportion of the patients had hypertension (72%), coronary heart disease (64%) and diabetes (56%). restriction in patient’s heart failure and comprises of two subscales: knowledge (6 items) and perceived barriers (8 items). patients responded to each item by recording one of three options (agree =2, neutral=1, disagree =0) [7,11]. regarding level of knowledge, if total score is equal to or less than 6, the patient is considered to have low knowledge, while scoring more than 6 is considered high knowledge. low perceived barriers were indicated if total score is equal to or less than 8, whereas scoring more than 8 indicated high perceived barriers. data was analyzed using statistical package for the social sciences (spss) version 22, descriptive and inferential statistics were used to finding outcome of the study such as frequency, percentage, mean and standard deviation and statistical tests such as chisquare, p-value of equal or less than 0.05 was considered a statistically significant. table 1 shows the sociodemographic and clinical characteristics of 50 patients with heart failure (hf) who participated in the study. regarding age range from 30-69 years, 36% of patients ranged their age group between 50-59 with a mean age of 58.07±12.39, more than half percentage (58%) of them were males and 42% were females; 54% were illiterates while 6% of them graduated from university and majority of the participants (78%) were married. moreover, 36% were unemployed, more than three quarters (88%) of patients resided in urban areas, 46% of them reported insufficient economic status and 72% of them were non-smokers. severity of heart failure as measured by new york heart association (nyha) showed that most of patients had symptomatic and functionally compromised set in their classes of ii and iii (32%, 42% respectively). 49 erbil journal of nursing & midwifery results table 1: socio-demographical of heart failure patients variables n=50 n (%) age group (years) 30-39 17 (34) 40-49 5 (10) 50-59 18 (36) 60-69 10 (20) gender male 29 (58) female 21 (42) level of education illiterate 27 (54) primary school 11 (22) secondary school 9 (18) university graduated 3 (6) marital status married 39 (78) widowed 7 (14) divorce 4 (8) occupation high profession 2 (4) unskilled worker 15 (30) housewife 15 (30) unemployed 18 (36) residential area rural 6 (12) urban 44 (88) economic status insufficient 23 (46) sufficient 17(34) exceed need 10(20) cigarette yes 14 (28) smoking no 36(72) new york heart association class i 9 (18) class ii 16 (32) class iii 21 (42) class iv 4 (8) hospitalized yes 39 (78) in last year no 11(22) comorbidity hypertension 36 (72) coronary heart disease 32 (64) diabetes mellitus 28 (56) https://doi.org/10.15218/ejnm.2020.06 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article whereas, lowest percentage (28%) of perceived barrier in item “following a low-salt diet is hard to do because rarely cooked”.table3 reveals overall patient’s knowledge and perceived barriers of following a low-sodium diet adherence among heart failure patients. the majority (80%) of patients had low knowledge and perceived high barriers (66%) to following a low sodium diet adherence 50 erbil journal of nursing & midwifery table 2 illustrates items of knowledge and perceived barriers of adherence to a low sodium diet. heart failure patients had highest percentage (42%) of knowledge in item “eating a low-salt diet will keep swelling down”, while they had lowest percentage (20%) knowledge in item “understand how to follow a low-salt diet”. also, heart failure patients reported perceived main barrier (62%) in item “family members are not following a low salt diet” table 2 :patient knowledge and perceived barriers about following a low-sodium diet knowledge and perceived barriers (n=50) disagree neutral agree n (%) n (%) n (%) items of knowledge 1-understand how to follow a low-salt diet. 23 (46) 17 (34) 10 (20) 2keep track of the total amount of salt eating in a day. 17 (34) 22 (44) 11 (22) 3pick out which foods on the grocery are low in salt. 18 (36) 21 (42) 11 (22) 4eating a low-salt diet will keep fluid from building up in body 24 (48) 14 (28) 12 (24) 5eating a low-salt diet will keep swelling down. 14 (28) 15 (30) 21 (42) 6eating a low-salt diet will breathe easier 18 (36) 17 (34) 15 (30) items of barriers 1food does not taste good on a low-salt diet 7 (14) 20 (40) 23 (46) 2-there are enough types of low-salt foods to satisfy my appetite 1 (2) 21 (42) 28 (56) 3-following a low-salt diet is hard to do because rarely cooked 12 (24) 24 (48) 14 (28) 4-following a low-salt diet takes too much time. 12 (24) 21 (42) 17 (34) 5-following a low-salt diet takes too much money. 10 (20) 21 (42) 19 (38) 6-following a low-salt diet is hard to understand. 18 (36) 16 (32) 16 (32) 7-the families members are not follow a low-salt diet. 10 (20) 9 (18) 31 (62) 8-following a low-salt diet is hard to do when i go out to eat. 16 (32) 8 (16) 26 (52) https://doi.org/10.15218/ejnm.2020.06 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 51 erbil journal of nursing & midwifery table 4 and 5 illustrates the association between demographic data with knowledge and perceived barriers of low low-sodium diet adherence. the results show that there is a significant association between age group and knowledge (p-value=0.01) and perceived barrier (p-value=0.04). also, gender is significantly associated with knowledge (p-value= <0.001) and perceived barrier (p-value=0.05). concerning educational level, there is a significant association between level of education with knowledge (p-value= <0.001) and perceived barrier (pvalue=0.02). there is a significant association between economic status and knowledge (p-value= <0.001) and barrier (p-value= <0.001). in regard to smoking, there is a significant association found with knowledge (p-value= <0.001), while not significant in barrier (p-value =0.06). table 3: overall patient knowledge and perceived barriers about low-sodium diet overall of knowledge and perceived barriers (n=50) n (%) -knowledge low knowledge (0-6 score). 40 (80) high knowledge (7-12 score). 10 (20) -barriers perceived low barriers ( 0-8 score) 17 (34) perceived high barriers ( 9-16 score ) 33 (66) table 4:association between demographic data and knowledge of low low-sodium diet adherence variables (n=50) knowledge low high n (%) n (%) df p-value chisquare age group (years) 30-39 15 (30) 2(4) 3 0.01 9.94 40-49 3(6) 2(4) 50-59 17(34) 1(2) 60-69 5(10) 5(10) gender male 28(56) 1(2) 1 <0.001 11.82 female 12(24) 9(18) educational level illiterate 24(48) 3(6) 3 <0.001 17.42 primary school 4(8) 7(14) secondary school 9(18) 0(.0) university graduate 3(6) 0(0) economic status insufficient 13(26) 10(20) 2 <0.001 14.67 sufficient 17(34) 0(0) exceed need 10(20) 0(0) smoking status yes 36(72) 0(0) 1 <0.001 32.14 no 4(8) 10(20) df=degree of freedom, p-value less than 0.05 consider significant https://doi.org/10.15218/ejnm.2020.06 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 52 erbil journal of nursing & midwifery heart failure is an eminent problem, and patient awareness of the disease and subsequent adherence to the treatment may decrease the burden of this serious problem. in this study, the minority of heart failure patients (20%) reported that they understand how to follow a low-salt diet. this result is comparable with the observation study that shows that 40% of the patients were following a low sodium diet [12]. while this result is contrast with study reported the majority of patients reported that they received a recommendation to follow a low-sodium diet and that they understood how to follow the diet. one explanation for this result may be that patients recalled only limited information about how to follow a low-sodium diet despite reporting that they know how to follow the diet. when asked about what they were told regarding how to follow the diet, most patients recalled that they were simply told to watch the amount of salt they ate or to avoid adding salt to foods. it is not possible in this study to determine whether the limited information recalled was due to reduced memory, poor concentration or inadequate teaching by health care providers or patients’ illiteracy. the present study displayed that major barriers faced by heart failure patients was within the item “the family members are not following low-salt diet”. it is supported by previous research which demonstrated that having an involved spouse increases dietary adherence. unfortunately, the most common barriers reported by patients were related to friends and family. majority of family members did not eat the same diet and most friends and relatives did not serve appropriate foods when patients visited. it is not possible to determine whether this was due to lack of awareness or lack of consideration. regardless, working with patients to help them determine the best strategies table 5:association between demographic data and perceived barriers of low low-sodium diet adherence variables (n=50) barriers low high n (%) n (%) df p-value age group (years) 30-39 9(18) 8(16) 3 0.04 7.95 40-49 2(4) 3(6) 50-59 6(12) 12(24) 60-69 0(0) 10(20) gender male 13(26) 16(32) 1 0.05 3.60 female 4(8) 17(34) educational level illiterate 13(26) 14(28) 3 0.02 9.69 primary school 2(4) 9(18) secondary school 0(0) 9(18) university graduate 2(4) 1(2) economic status insufficient 2(4) 21(42) 2 <0.001 13.86 sufficient 11(22) 6(12) exceed need 4(8) 6(12) smoking status yes 15(30) 21(42) 1 0.06 3.36 no 2(4) 12(24) discussion df=degree of freedom, p. value less than 0.05 consider significant https://doi.org/10.15218/ejnm.2020.06 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 53 erbil journal of nursing & midwifery to inform friends and families of their dietary needs may help. close friends and family members should be included in all teaching about following a low-sodium diet. alternatively, clinicians, whenever possible should speak directly with friends and family members to increase their awareness of the important role they play in the ability of patients to adhere to recommendations [13]. a study stated that adherence of low-sodium diet is influenced by the opinions of significant others/spouses, family members, nurse, physicians, and other health care professionals. including family members in heart failure treatment particularly regarding adherence to non-pharmacological measures appears to be crucial and has been gaining ground as a self-care strategy [14]. moreover, a recent us study found that patients with heart failure whose family members also followed a low-sodium diet were 1.6 times more likely to be adherent [15]. one of major contributing factor in continuing poor adherence to a low-sodium diet is lack of knowledge, because majority of patients not received a recommendation and information of sodium restricted diets (srd) from health care providers. this indicates that health care providers simple recommendation may not be enough to motivate patient’s adherence behavior. researchers suggested that lack of knowledge is a key barrier in diet adherence [16]. in this study, the highest proportion (80%) of patients had low knowledge and high barriers (66%) to adherence low-sodium diet which is supported by the study showing the overall adherence to sodium diet was poor [17]. also another study found that 86% of heart failure patients were not aware of a srd guideline, 42% could not determine sodium content from a nutrition label, and 56% could not distinguish high and low sodium foods [6].the result in this study reveals that poor adherence in srd in hf patients is still problematic and health care providers need to attend to dietary sodium adherence to improve health outcome of hf patients. diet education should be included strategies of how to follow a srd guideline in daily life and strategies of how to overcome barriers of adherence to srd. patient education should be focused on understating how srd adherence contributes their hf management. many studies simply do not report associations between demographic variables and adherence; thus, it is important to continue to explore whether and how these variables are related to adherence. in the present study there is a significant association found between age group and knowledge (p-value=0.01) and perceived barrier (p-value=0.04) to low sodium diet adherence which is supported by study that found that age is positively related to adherence [18]. while study have reported no association between age and adherence to low sodium diet [19]. gender is significantly associated with knowledge (p-value= <0.001) and perceived barrier to low sodium diet adherence (p-value=0.05). another study revealed that women are less adherent than men [20] possibly due to lifestyle alterations that involve shopping for and preparing meals might be harder for men to make and traditional domestic roles that call for the wife to prepare meals. moreover, concerning educational level there was a significant association between level of education with knowledge and perceived barrier to low sodium diet adherence, p-value= <0.001 and p-value =0.02 respectively, reported that number of years of education and adherence were significantly positively related [21]. the findings of present study shows there was is significant association between economic status and knowledge https://doi.org/10.15218/ejnm.2020.06 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 54 erbil journal of nursing & midwifery (p-value= <0.001) and barrier (pvalue=0.001).a study reported that income was negatively related to low-salt diet adherence is surprising, as one might expect that those who are more affluent are more likely to seek out and afford healthier foods, and thus would be more adherent to a low-salt diet [22]. the study showed that higher proportion of heart failure patients were older age, male, had low levels of education, were having insufficient economic status, most of them hospitalized in last year, majority of patients had symptomatic and functionally compromised (new york heart association nyha classes ii and iii) and high proportion of the patients had co-morbidity (hypertension, coronary artery disease and diabetes mellitus). in general, most of patients had poor knowledge and more barriers to adherence to low-sodium diet. there was a significant association between heart failure knowledge and barrier with age group, gender, level of education, economical status. i declare that there is no conflict of interest in this study [1] smeltzer, s. c, bare, b. g, hinkle, j. l., and cheever, k. h., (2010). brunner & suddarth’s textbook of medical-surgical nursing, 12th edition, lippincott williams &wilkins. philadelphia, usa. p.1197. [2] ko dt, alter da, austin pc, you jj, lee ds, qiu f, et al. life expectancy after an index hospitalization for patients with heart failure: a population-based study. american heart journal. 2008; 155(2):324-31. doi: 10.1016 [3] dickstein k, cohen-solal a, filippatos g, mcmurray jj, ponikowski p, poole-wilson pa. esc guidelines for the diagnosis and treatment of acute and chronic heart failure, the task force for the diagnosis and treatment of acute and chronic heart failure of the european society of cardiology. developed in collaboration with the heart failure association of the esc (hfa) and endorsed by the european society of intensive care medicine (esicm). european journal heart failure. 2008;10(10);933–89. [4] bentley b, lennie ta, biddle m, chung ml, and moser dk, . demonstration of psychometric soundness of the dietary sodium restriction questionnaire in patients with heart failure. heart lung journal. 2009;38 (2):121-8. doi: 10.1016. [5] arcand, j, ivanov j, sasson a, floras v, alhesayen a, azevedo er, et al. a highsodium diet is associated with acute decompensated heart failure in ambulatory heart failure patients: a prospective followup study. the american journal of clinical nutrition. 2002 143(1):29-33. pubmed/11773909 [6] neily j b, toto k h, gardner e b, rame j.e , yancy cw. sheffield ma.,, et al. potential contributing factors to noncompliance with dietary sodium restriction in patients with heart failure. american heart journal.2002;143(1):29–33. [7] lennie ta, carter lw, hammash m, forren jo, roser lp, smith cs, etal. relationship of heart failure patients’ knowledge, barriers regarding lowsodium diet recommendations to adherence. progress in cardiovascular nursing. 2008;23(1):6-11. [8] paterna s, parrinello g, cannizzaro s, fasullo s, torres d, sarullo fm, et al. medium term effects of different dosage of diuretic, sodium, and fluid administration on neurohormonal and clinical outcome in patients with recently compensated heart failure. american journal of cardiology 2009; 103(1):93–102. [9] araoye mo research methodology with statistical for health and social science .nathadex publisher iorin, 2003; p.1-9. [01] dickson vv, lee, cs. and riegel b. how do cognitive function and knowledge affect heart failure self-care? journal of mixed methods research. 2011; 5(2) 167–189 [00] lennie ta, chung ml, moser dk. what should we tell patients with heart failure about sodium restriction and how should we counsel them? current heart failure reports journal. 2013; 10(3): 219–226. conclusion conflict of interest references https://doi.org/10.15218/ejnm.2020.06 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 55 erbil journal of nursing & midwifery [12] bennett sj, cordes dk, westmoreland g, castro r, donnelly e. self-care strategies for symptom management in patients with chronic heart failure. nursing research journal. 2000;49(3):139–145. [13] chung ml, moser dk, lennie ta, worrallcarter l, bentley b, trupp r, et al. gender differences in adherence to the sodiumrestricted diet in patients with heart failure. journal of cardiac failure. 2006 oct; 12(8): 628. doi: 10.1016/j.cardfail.2006.07.007 [14] welsh d, lennie ta, marcinek r, biddle mj, abshire d, bentley b, , et al. lowsodium diet self management intervention in heart failure: pilot study results. european journal cardiovascular nursing. 2013; 12 (1): 87-95. pmid:22492785 [15] chung ml, lennie ta, mudd-martin g, moser dk. adherence to a low sodium diet in patients with heart failure is best when family members also follow the diet: a multicenter observational study. the journal of cardiovascular nursing. 2015; 30(1): 44-50. pmid:24165698 [16] chung ml, moser dk, lennie ta, worrallcarter li, bentley b and trupp r, et al gender differences in adherence to the sodiumrestricted diet in patients with heart failure. journal cardiac failure. 2006; 2(8): 628. doi:10.1016/j.cardfail. 07.007. [17] evangelista ls, berg j, dracup k. relationship between psychosocial variables and compliance in patients with heart failure. heart & lung: the journal of critical care. 2001; 30(4):294–301. [pubmed: 11449216] [18] maguire lk, hughes cm, mcelnay jc. exploring the impact of depressive symptoms and medication beliefs on medication adherence in hypertension-a primary care study. patient education and counseling. 2008;73 (2):371-6. doi: 10.1016/j.pec.2008.06.016. [19] wu jr, moser dk, lennie ta, and burkhart pv. medication adherence in patients who have heart failure: a review of the literature. the nursing clinics of north america 2008;43(1):133-53; vii-viii. doi: 10.1016/ j.cnur.2007.10.006. [21] chapman rh, benner js, petrilla aa, tierce jc, collins sr, battleman ds, et al. predictors of adherence with antihypertensive and lipid-lowering therapy. archives of internal medicine,2005;165,11471152.pubmed: v116n4,oct. 1965-v172n22, dec. 2012. [21] bane c, hughes cm, and mcelnay jc. the impact of depressive symptoms and psychosocial factors on medication adherence in cardiovascular disease. patient education and counseling, 2006; 60(2), 187-193. [22] khanderia u, townsend ka, erickson sr, vlasnik j, prager rl, and eagle ka. medication adherence following coronary artery bypass graft surgery: assessment of beliefs and attitudes. the annals of pharmacotherapy, 2008 ;42(2):192-9. doi: 10.1345/ aph.1k497. epub 2008 jan 15. https://doi.org/10.15218/ejnm.2021.09 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article anxiety and depression levels with risk factors of breast cancer patients in erbil city – iraq abstract introduction breast cancer appears to be becoming more common around the world. it is the most common type of cancer in women in the middle east and the west [1]. urological (21.3%), hematological (18.0%), head and neck malignancies (15.0%), and breast (14.0%) cancer are the most prevalent cancer diagnoses [2].globally, breast cancer is still the most frequent cancer among women and accounts for 14 to 42 percent of all female cancers in the arab world. its treatment can be a difficult experience for women, affecting their self-image and sexual relationships that can result in psychological reactions such as denial, rage, or acute dread toward their condition and treatment. patients with breast cancer are at an increased risk of acquiring background and objectives: breast cancer appears to be becoming more common worldwide. it is the most common type of cancer in women in the middle east and the western countries. patients with breast cancer are at a high risk of developing psychological problems such as anxiety and depression. this study aimed to evaluate the severity of anxiety and depression levels in breast cancer patients and their risk factors for breast cancer. methods: a quantitative descriptive study design was conducted at rizgary teaching hospital and nanakali oncology hospital in erbil city in the kurdistan region of iraq from 1st september 2020 to 5th august 2021. the duration of data collection was four months and purposive sampling was used to select 298 patients who were admitted to both hospitals. a questionnaire format was used to gather the data, and the hospital anxiety and depression scale (hads) standardized questionnaire was utilized to measure the level of anxiety and depression. results: the average age of the patients was 45.28±9.17 years, 80.5% were married, 60.7% of the studied sample had a low socio-economic status. almost a third (30.5%) of the participants had severe anxiety and 60.4% had severe depression. concerning the risk factors of breast cancer, 82.2% of patients were obese, 91.9% did not do exercise, 35.6% had breast cancer family history, 93.6% were non-smoker, and 6.4% of them were smokers. conclusion: according to the findings, the majority of breast cancer patients suffer from anxiety and depression, and obesity is one of the risk factors for breast cancer. keywords: anxiety; depression; breast cancer; risk factors. mosleh saber kareem; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: mosleh.kareem@hmu.edu.krd) diyar hussain taher; department of psychiatry, college of medicine, hawler medical university, erbil, iraq. 76 erbil journal of nursing & midwifery received: 29/08/2021 accepted: 14/ 11/2021 published: 30/11/2021 mailto:mosleh.kareem@hmu.edu.krd https://doi.org/10.15218/ejnm.2021.09 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article psychological problems such as depression and anxiety [3], and the treatment can cause patients a lot of sadness [4]. breast cancer is one of the most researched oncological illnesses in terms of its impact on quality of life. the patients frequently experience high levels of anxiety and sadness, lowering their quality of life [5]. the diagnosis and treatment of this malignancy are well known for causing severe psychological suffering and discomfort, which is found to be present in more than 30% of cancer patients. breast cancer patients have a high level of anguish following their diagnosis, which included sadness and anxiety. the amount of anxiety decreases over time. however, while anxiety and depression are both common in breast cancer patients, their effects on suffering differ. anxiety, which is linked to a sense of uncertainty, appears to have a larger role in breast cancer patients' discomfort. depression, on the other hand, which is characterized by negative emotions, does not correlate with the level of perceived distress in cancer patients. in contrast to depression, anxiety is frequently overlooked in the treatment of breast cancer patients' psychological well-being. based on the current findings, a greater emphasis on assisting breast cancer patients in reducing their worry in the future is critical in lowering their perceived degree of discomfort [6]. breast cancer patients may be uniquely susceptible to depression, anxiety, and resultant distress due to decreased estrogen levels secondary to hormone therapy and chemotherapy. it is important to routinely assess breast cancer sufferers for distress, and in collaboration with their primary care physicians, for signs and symptoms of insomnia, depression, anxiety, and distress. counselling, mindful meditation and pharmacological interventions have helped many breast cancer survivors. the rate of depression in breast cancer patients (4.5%–46%) is higher than rates in most other cancer types, also anxiety rates are (14.7%) very high in people with breast cancer. during the first year following a diagnosis, patients are at the highest risk for major depressive disorder, especially for younger patients and those who have received chemotherapy. these high rates of depression may be due to a multi-factor including body image issues, physical effects of treatment, loss of sexual function, ongoing fatigue, and perpetual concern about recurrence. anxiety rates are also very high in breast cancer patients. one large cohort study found pure anxiety symptoms in 14.7% [7]. according to the study done by kameran et al. (2012) in erbil city – iraq, increased levels of melancholy and anxiety following a breast cancer diagnosis underscore the need for specialized psychiatric services [8].breast cancer risk factors include both social and biological aspects including women's age, menarche at a young age, delayed first birth and menopause, nulliparity, short-term lactation, birth control pills, obesity, excessive fat consumption, hormone replacements moreover, several epidemiological and clinical investigations have identified women with a family history of breast cancer as significant risk factors for the disease. on the other hand, the majority of breast cancer intervention literature suggests that modifiable risk factors can be avoided by promoting a healthy diet, regular physical activity, regulating alcohol consumption, and controlling weight, all of which are likely to reduce breast cancer incidence over time [9]. one study in south india discovered that urban regions have a higher incidence of breast cancer than rural ones. this study also found that the risk of breast cancer increased when the proportion of overweight or obese women in both premenopausal and post-menopausal women increased. the majority of breast cancer 77 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.09 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article the level of anxiety and depression. . hads included 14 questions, 7 questions for anxiety and 7 questions for depression. each question had 4 responses ranked from 0 to 3, and the client selected one response that was appropriate to their situation. normal scores ranged from 0 to 7, borderline abnormal scores ranged from 8 to 10, and abnormal scores ranged from 11 to 21 [11]. the ethical permissions for performing this study came from the college of nursing's ethical committee at hawler medical university. the goal of the study was described to the patients before their interview, and a verbal agreement was obtained. patients were informed that they could withdraw from the study at any time. the data were entered into spss (version 23) for analysis, and the frequency, percentage, mean and standard deviation, t-test, and chi-square test were used to analyze the data. table 1 shows that 41.6 percent of the participants were between the ages of 36 and 45. the participants' mean age (sd) was 45.28 ± 9.17. regarding the educational level and occupation, most (29.5 %) of the studied sample graduated from an intermediate school and three quarters (74.8 %) of patients had unskilled manual occupations (housewives). the majority (80.5%) of the study sample was married, more than half (60.7%) had low economic status, and most (66.8%) most lived in an urban area. table 2 illustrates that almost a third of the women had a high level of anxiety (30.5 %) and most (64.4 %) of them suffered from high depression levels. table 3 shows some of the risk factors of breast cancers. concerning the age of the participants, less than half (41.6%) were in the age group of 36-45 years, the risk factors of breast cancer. the majority (82.2 %) of the women were obese. concerning cases were found in women aged 40–49, who were mostly housewives. breast cancer risk was shown to be 8 times greater among unmarried women, 3 times higher among nulliparous women, 2 times higher among postmenopausal women, and 10 times higher among those who never nursed. in comparison to married, nonnulliparous, premenopausal, women who breastfed, who have not been exposed to hormonal contraceptives, and women without any ovarian diseases, women who were exposed to hormonal contraceptives were 1.5 times more likely and women with ovarian diseases were 4.5 times more likely to be diagnosed with breast cancer [10]. a quantitative descriptive study design was conducted at the oncology department of rizgary teaching hospital and nanakali oncology hospital in erbil city in the kurdistan region of iraq from 1st september 2020 to 5th august 2021. the duration of data collection was four months, and 298 patients in both hospitals were selected as a purposive sample. a questionnaire format was modified and developed for the data collection. the sample selection was based on the following criteria: female breast cancer, undergoing treatments, new cases, no psychiatric diagnosis, ability to communicate verbally. the exclusion criteria included refusal of participation, metastasis, age (66 years and above). ). the data was gathered by the same researcher using an interview technique in the kurdish language. each patient's interview lasted 25-30 minutes and was divided into three parts: part one included participants' sociodemographic characteristics, part two examined the breast cancer risk factors, and part three consisted of the hospital anxiety and depression scale (hads) standardized questionnaire to measure 78 erbil journal of nursing & midwifery methods results https://doi.org/10.15218/ejnm.2021.09 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article the daily exercise, the data showed that a high percentage (91.9%) of participants did not do daily exercise. less than half (35.6%) of the study sample had a family history of breast cancer, while more than half (51.7%) had a family history of other types of cancer. 86.2 % of the study sample had menarche between13-15 years of age, and more than half (57.4 %) were married at the age of 13-24 years old. 84.2 % of women had children, and 15.8 % were childless. regarding the type of child's feeding, 75.8 % of the participants breastfed their children. concerning contraceptive medication, 76.5% of them did not take any contraceptive medication. a high percentage (93.6%) of the study sample was nonsmokers. almost all (93.6% ) of respondents did not do breast self–examination, and 78.9 % of them were diagnosed with breast cancer before the menopausal period. 79 table1: socio-demographic characteristics of patients (n=298) (%) no. variables (14.1) 42 26-35 age group/years (41.6) 124 36-45 (27.9) 83 46-55 (16.4) 49 56-65 (29.2) 87 primary school (or can read and write) educational level (29.5) 88 intermediate school (14.8) 44 high school or vocational (5) 15 diploma (institute) (8.1) 24 bachelor degree (college) (12.4) 37 master degree or equivalent, e.g., higher diploma (1) 3 phd or equivalent (74.8) 223 unskilled manual occupations jobs (9.7) 29 skilled manual and non-manual occupations (13.4) 40 associate professional occupations (2.1) 6 skilled professional or senior managerial occupations (80.5) 240 married marital status (9.7) 29 single (2.7) 8 divorced (7.1) 21 widow (60.7) 181 low socio-economic status (28.9) 86 middle (10.4) 31 high (66.8) 199 urban residency (21.1) 63 suburban (12.1) 36 rural https://doi.org/10.15218/ejnm.2021.09 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article 80 erbil journal of nursing & midwifery table 2: levels of anxiety and depression among breast cancer patients (n=298) levels anxiety depression no. (%) no. (%) normal 137 (46) 65 (21.8) borderline abnormal (borderline case) 70 (23.5) 41 (13.8) abnormal (case) total 91 298 (30.5) (100) 192 298 (64.4) (100) table 3: risk factors of breast cancer among 298 female breast cancers (n=298) (%) no. risk factors (14.1) 42 26-35 ageing (41.6) 124 36-45 (27.9) 83 46-55 (16.4) 49 56-65 mean ± sd = 45.28 ± 9.17 (2) 6 underweight body mass index (15.8) 47 normal (82.2) 245 obesity (8.1) 24 yes daily exercise before breast cancer (91.9) 274 no (35.6) 106 yes family history of breast cancer (64.4) 192 no (51.7) 154 yes family history of all types of cancer (48.3) 144 no (11.1) 33 10-12 menarche/ years (86.2) 257 13-15 (2.7) 8 16-18 (57.4) 171 13-24 age of marriage/years (28.1) 84 25-36 (4.4) 13 37 and above (10.1) 30 single (84.2) 251 yes do you have children (15.8) 47 no (infertility, single) (75.8) 226 yes breastfeeding (24.2) 72 no (23.5) 70 yes did you use contraceptive drugs? (76.5) 228 no (6.4) 19 yes smoking before breast cancer (93.6) 279 no (21.1) 63 yes breast self-examination (78.9) 235 no (81.5) 243 pre-menopause menopausal period (18.5) 55 post-menopause https://doi.org/10.15218/ejnm.2021.09 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article table 4 shows that there was a significant association between the levels of anxiety and risk factors of breast cancer such as menopause , sleep after diagnosis and cigarette smoking. the same table shows that there were no statistically significant differences between anxiety levels and body mass index, sleep before the diagnosis, exercise and breastfeeding. 81 erbil journal of nursing & midwifery table 4: association between risk factors of breast cancer and their levels of anxiety (n=298) anxiety levels and risk factors normal borderline case case total pvalue no. (%) no. (%) no. (%) menopause period pre-menopause 102 (34.2) 59 (19.7) 82 (27.5) 243 0.009 post-menopause 35 (11.7) 11 (3.6) 9 (3) 55 body mass index underweight (bmi<18.5) 3 (1) 1 (0.3) 2 (0.6) 6 0.231 normal (bmi≥18.5 and<25) 18 (6) 8 (2.7) 21 (7) 47 obesity (bmi≥25) 116 (39) 61 (20.5) 68 (22.8) 245 sleep/hour before breast cancer 1-3 hours 13 (4.3) 13 (4.3) 13 (4.3) 39 0.065 4-6 hours 20 (6.7) 14 (4.7) 23 (7.7) 57 7 and above 104 (34.9) 43 (14.4) 55 (18.4) 202 sleep/hour after breast cancer 1-3 hours 12 (4) 6 (2) 14 (4.6) 32 0.044 4-6 hours 78 (26.1) 47 (15.7) 61 (20.4) 186 7 and above 47 (15.7) 17 (5.7) 16 (5.3) 80 smoking before breast cancer yes 7 (2.3) 9 (3) 3 (1) 19 0.034 no 130 (43.6) 61 (20.4) 88 (29.5) 279 daily exercise before breast cancer yes 13 (4.3) 1 (0.3) 10 (3.3) 24 0.061 no 124 (41.6) 69 (23.1) 81 (27.1) 274 total 137 (45.9) 70 (23.6) 91 (30.5) 298 breast feeding yes 107 (35.9) 55 (18.4) 64 (21.5) 226 0.337 no 30 (10.1) 15 (5) 27 (9) 72 total 137 (45.9) 70 (23.6) 91 (30.5) 298 https://doi.org/10.15218/ejnm.2021.09 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article the same table shows that there were no statistically significant differences between depression levels and body mass index, sleep before diagnosis, exercise and breastfeeding. table 5 shows that there were significant statistical associations between the levels of depression and risk factors of breast cancer such as menopause and sleep after diagnosis. 82 erbil journal of nursing & midwifery table 5: association between risk factors of breast cancer and their levels of depression (n=298) depression levels and risk factors normal borderline case case total pvalue no. (%) no. (%) no. (%) menopause period pre-menopausal 55 (18.4) 25 (8.3) 163 (54.7) 243 0.001 post-menopausal 10 (3.3) 16 (5.3) 29 (9.7) 55 body mass index underweight (bmi<18.5) 3 (1) 1 (0.3) 2 (0.7) 6 0.345 normal (bmi≥18.5 and<25) 11 (3.7) 4 (1.3) 32 (10.7) 47 obesity (bmi≥25) 51 (17.1) 36 (12) 158 (53.1) 245 sleep/hour before breast cancer 1-3 hours= poor sleep 8 (2.7) 6 (2) 25 (8.4) 39 0.143 4-6 hours= fair sleep 8 (2.7) 4 (1.3) 45 (15.1) 57 7 and above =good 49 (16.4) 31 (10.4) 122 (40.1) 202 sleep/hour after got breast cancer 1-3 hours 1 (0.3) 3 (1) 28 (9.4) 32 0.001 4-6 hours 33 (11) 27 (9) 126 (42.3) 186 7 and above 31 (10.4) 11 (3.7) 38 (12.7) 80 smoking yes 2 (0.7) 3 (1) 14 (4.7) 19 0.469 no 63 (21.1) 38 (12.7) 178 (59.7) 279 exercise before breast cancer yes 8 (8.1) 5 (1.7) 11 (3.7) 24 0.14 no 57 (19.1) 36 (12) 181 (60.7) 274 breast feeding yes 49 (16.4) 37 (12.4) 140 (46.9) 226 0.063 no 16 (5.3) 4 (1.3) 52 (17.4) 72 https://doi.org/10.15218/ejnm.2021.09 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article the majority of the studied patients were obese. weight gain before menopause and being overweight or obese after menopause are both linked to an increased risk of breast cancer [1, 18]. regarding breast self-examination, the majority of the participants did not do breast selfexamination monthly. these results are consistent with the study conducted in india in 2020 [10]. furthermore, the majority of studied patients were affected during the pre-menopausal period, which is in agreement with the study done by chen et. al. in china [18]. the present study shows that less than half of the study sample had a family history of breast cancer and most of the study sample had a negative family history of breast cancer. these results are in concordance with the who (2021), which shows that breast cancer is more likely in families with a history of the disease, but the majority of women diagnosed with the disease have no known family history of the disease. the absence of a known family history does not always imply that a woman is at a lower risk. [14]. according to the data collected in this study, there were no statistically significant differences between anxiety levels and exercise, similar to the study by sunil et al. (2012). similarly, the combined data from 53 epidemiological studies showed no relationship between smoking and breast cancer [13]. the findings of this study revealed that anxiety and depression symptoms were common in studied breast cancer sufferers. over half (60.4) percent of women had depression and 30.5 percent had anxiety symptoms based on hads questionnaires. the prevalence of depression and anxiety in patients with breast cancer in our study was similar to the previous studies [3,15]. according to the findings of this study, there was no statistically significant relationship between the severity of depression and the according to our knowledge, this is the first study to look at anxiety, depression, and breast cancer risk factors in breast cancer patients. patients with breast cancer have a variety of symptoms related to the disease and its treatment and may have various psychological problems. in this study, anxiety and depression in breast cancer patients were chosen for examination. regarding the age of the participants, less than half of the study sample was in the age group of 36-45 years. this is supported by the study done by majid et .al (2009) and other researchers [1, 13, 3,17]. the majority of the participants in the study were married, which is consistent with the study done by huang (2019) and others [12, 3, 17, 18]. according to the results of this study, the majority of the participants completed secondary school and lived in urban areas, which is compatible with the results of a study conducted by tsaras, et al. (2018) [3, 17]. the findings of the present study indicate that the majority of the respondents were married, housewives, had low socioeconomic status and were pre-menopausal. these results are compatible with the results of a study conducted in egypt by alagizy (2020) [17]. in this study, data on socioeconomic status were collected from breast cancer patients to investigate the relationship between economic position and anxiety and depression. the percentage of women who were anxious or depressed was directly related to their socioeconomic level and treatment costs. in addition, extra expenses were needed to buy the medications, because sometimes they were not available in hospitals. at that time, iraq faced many problems such as; economic crisis and covid -19. regarding risk factors of breast cancer; 83 erbil journal of nursing & midwifery discussion https://doi.org/10.15218/ejnm.2021.09 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article smoking. . for the rest of the variables, there were no statistically significant differences between anxiety and body mass index, sleep before diagnosis, exercise and breastfeeding. there were significant associations between depression and risk factors of breast cancer such as breast surgery, menopause period, sleep after diagnosis and having a child. the body mass index, sleep before diagnosis, exercise and breastfeeding were not associated with depression levels. the study results indicate that the patients should be guided to psycho-education programs that can significantly reduce anxiety and depression. furthermore, the availability of a psychiatric nurse or a clinical psychologist who can provide adequate psycho-oncological therapy to patients who are most likely to develop psychopathological issues would be very beneficial for cancer care in the region. they are currently not available but very much needed and recommended by the author of this research. the authors report no conflicts of interest and any sources of financial support. [1] majid ra, mohammed ha, saeed hm, safar bm, rashid rm, hughson md. breast cancer in kurdish women of northern iraq: incidence, clinical stage, and case-control analysis of parity and family risk. bmc women's health. 2009;9(1):1-6. [2] jadoon na, munir w, shahzad ma, choudhry zs. assessment of depression and anxiety in adult cancer outpatients: a crosssectional study. bmc cancer. 2010;10(1):1-7. [3] tsaras k, papathanasiou iv, mitsi d, veneti a, kelesi m, zyga s, et al. assessment of depression and anxiety in breast cancer patients: prevalence and associated factors. asian pacific journal of cancer prevention. 2018;19(6):1661. [4] akel r, el darsa h, anouti b, mukherji d, temraz s, raslan r, et al. anxiety, socio-demographic characteristics of patients. these findings matched those of research conducted in taiwan [16]. furthermore, the present study revealed no significant difference between anxiety and depression levels and demographic characteristics of participants as in the research of alagizy et al. [17]. the present study showed that there was a significant association between the levels of anxiety and risk factors of breast cancer such as menopause period, sleep after diagnosis and cigarette smoking. on the other side, there were no statistically significant differences between anxiety levels and body mass index, sleep before diagnosis, exercise and breastfeeding. the present study results illustrated a significant association between the levels of depression and risk factors of breast cancer such as breast surgery, menopause period, sleep after diagnosis and having a child. examining depression levels and body mass index, sleep before diagnosis, exercise and breastfeeding revealed that there was no statistically significant association between them. the differences between this study's findings and other studies could be attributed to the questionnaire technique, sample size, culture, religion, ethnicity, and economic level. according to the findings, the majority of the patients showed severe anxiety and depression symptoms. in general, there was no statistically significant relationship between anxiety and depression levels and socio-demographic factors; only the age group was statistically significant. there were significant differences between the anxiety and risk factors of breast cancer such as menopause period, sleep after diagnosis and cigarette 84 erbil journal of nursing & midwifery conclusion conflict of interests references https://doi.org/10.15218/ejnm.2021.09 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article [14] who. breast cancer, 2021. https:// www.who.int/news-room/fact-sheets/ detail/breast-cancer. [15] civilotti c, botto r, maran da, leonardis bd, bianciotto b, stanizzo mr. anxiety and depression in women newly diagnosed with breast cancer and waiting for surgery: prevalence and associations with sociodemographic variables. medicina journal scientific journal of the lithuanian university of health sciences 2021;57(5):454. https:// www.mdpi.com/1648-9144/57/5/454. [16] su j-a, yeh d-c, chang c-c, lin t-c, lai c-h, hu p-y, et al. depression and family support in breast cancer patients. neuropsychiatric disease and treatment. 2017; 13:2389. [17] alagizy h, soltan m, soliman s, hegazy n, gohar s. anxiety, depression and perceived stress among breast cancer patients: single institute experience. middle east current psychiatry. 2020;27(1):1-10. [18] chen x, zheng y, zheng w, gu k, chen z, lu w, et al. prevalence of depression and its related factors among chinese women with breast cancer. acta oncologica journal. 2009;48(8):1128-36. [19] wali omer, tariq al-hadithi. developing a socio-economic index for health research in iraq. eastern mediterranean health journal. vol.23no.10,https:// pubmed.ncbi.nlm.nih.gov/29270967. depression and quality of life in breast cancer patients in the levant. asian pacific journal of cancer prevention: 2017;18 (10):2809. [5] bellver-perez a, peris-juan c, santaballabeltrán a. effectiveness of therapy group in women with localized breast cancer. international journal of clinical and health psychology. 2019;19(2):107-14. [6] ng cg, mohamed s, kaur k, sulaiman ah, zainal nz, taib na, et al. perceived distress and its association with depression and anxiety in breast cancer patients. plos one. 2017;12(3):e0172975. [7] tkaczuk kh, kesmodel sb, feigenberg sj. handbook of breast cancer and related breast disease: springer publishing company; 2016. [8] ismail kh, tahir dh, barzinji bk. depression and anxiety in women with breast cancer in erbil city: a case-control study. zanco journal of medical sciences. 2012;16(1):6570 [9] ] prusty rk, begum s, patil a, naik d, pimple s, mishra g. knowledge of symptoms and risk factors of breast cancer among women: a community-based study in a low socio-economic area of mumbai, india. bmc women's health. 2020; 20:1-12. [10] ranjan kumar prusty, shahina begum, anushree patil, dd. naik, sharmila pimple and gaurav mishra. knowledge of symptoms and risk factors of breast cancer among women: a community-based study in a low socio-economic area of mumbai, india. bmc women's health (2020) 20:106.p.12.https:// bmcwomenshealth.biomedcentral.com. [11] yasin ym, al-hamad a. anxiety and depression as key determinants of cancerrelated fatigue among patients receiving chemotherapy. european scientific journal. 2015;11(33). [12] hsiu-mei huang, jun-hung lai, tsai-wei huang. mediating effects of depression on anxiety and leisure constraints in patients with breast cancer. bmc women’s health. 2019nov20;19(1):141.https:// bmcwomenshealth.biomedcentral.com. [13] sunil r, lakhani ian o. ellis stuart j. schnitt puay hoon tan marc j. van de vijver. who classification of tumours of the breast, 4th edition. international agency for research on cancer. lyon, 2012. p.17. 85 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2023.6 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article knowledge and practices of high school teachers regarding healthy life style in erbil city/iraq abstract background and objective: health promotion in a school setting involves educating the students and teachers about health-related matters that reflect on health in a more holistic way. lifestyle includes behaviors such as food habits, sleeping and resting, physical activity and exercising, weight controlling, smoking and others. the purpose of this study is to assess the knowledge and practices of teachers about healthy lifestyles in the high school in erbil city. methods: a descriptive cross-sectional study was used. the data were collected from 3th december 2021 to 28th march 2022. a cluster random sampling technique was used to collect 400 teachers who attended high school in erbil city. a valid questionnaire was used for data collection by face to face; it contained three parts of sociodemographic data, items of knowledge and practices. the validity and reliability were conducted for the tool and the value of cronbach's alpha was 0.826. results: the teachers had good knowledge and practices about promoting healthy lifestyles. there was a significant association between age, education level and experience with their knowledge and practices. there was no significant association between their knowledge and gender, marital status, or economic status, and no significant association between their practices and variables like gender, marital status and economic status. conclusion: the outcome of the study revealed that most of the teachers had good knowledge and practices regarding healthy lifestyles in high school in erbil city /iraq, so they might be as a source of healthy life styles to the public. there was significant association between knowledge, practices and their age and education level, while there was no significant association between their knowledge, practices and gender and marital status. keywords: knowledge; practices; high school; teachers healthy life style. mohammed-tahr abdul-jabbar; department of nursing, college of nursing, hawler medical university, kurdistan region, iraq. (correspondence: mharki37@gmail.com) kareem fattah aziz; department of nursing, college of nursing, hawler medical university, kurdistan region, iraq. 45 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 21/06/2022 accepted: 21/08/2022 published: 30/5/2023 mailto:mharki37@gmail.com?subject=mharki37@gmail.com%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article health-related matters instructed within the school have a remarkable effect on creating the correct state of mind among schoolchildren and instructors health care experts and community nurses have an essential part in making mindfulness concerning health promotion in school settings [1].individuals' lifestyle choices, as well as their knowledge and attitudes toward adopting healthy behaviors, can be improved through health promotion education, especially when novel approaches are implemented. [2].health promotion advances and includes instructors with pioneers within exercises from the school a sound. the health education method empowering individuals to extend progress has characterized advancement. it passes a person in the middle. behavior towards a wide extent of social and natural interventions. [3].the term "lifestyle" may be a moderately common hypothesis that regularly is utilized to allude to individuals' complete run reflection of social values, states of mind and exercises [4]. diseases and infections, which are now linked to the global mortalities are due to several threatening behaviors resulting from the inappropriateness of individual and social lifestyles, the most common of which are inappropriate diet, low physical activity, smoking, and sedentary behavior. controlling risk factors in lifestyle and healthy habits such as poor diet, lack of physical activity, smoking, alcohol intake, and drug use can nearly halve the number of people who die prematurely. [5]. the aim of the study is to identify teachers' knowledge and practices regarding healthy lifestyles. this study is important because it is necessary to identify teachers' knowledge and practices regarding healthy lifestyles so they can teach their students and other staff in school regarding healthy behaviors and healthy lifestyles as a snowball system so that such knowledge and practices from them may be reached to other kurdish populations. a descriptive cross-sectional quantitative study of 400 teachers in high schools in erbil city was conducted from 3th december 2021 to 28th march 2022. the inclusion criteria were that the researcher selected all participants, who had the desire to participate. the exclusion criteria were teachers who refused participate in the study. the sample size was calculated using the epi info program (issued by cdc) issue. these criteria were used for sample size calculation: population 5751, confidant level is 95%, the prevalence of perception and satisfaction 50%, and margin error 5%. a cluster random sampling technique was used. the research obtained the permission from the ethics committee at hawler medical university/college of nursing in 7th october 2021 (number 119). in addition, the official approval was obtained from the general directorate of education in the center of erbil city. the researcher constructed a questionnaire after an extensive review of relevant literature. the questionnaire included three parts. the first part contained socio-demographic information of teachers which included 7 items: age, gender, marital status, address, education level, socioeconomic status and years of experience. the second part consisted of 15 items which were related to the teachers' knowledge of promoting a healthy lifestyle. the third part was consisted of 15 items which were related to the teacher's practices in promoting healthy lifestyles. the data were analyzed descriptively using frequency and percentage. 46 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article most of the participants live in the urban which is about 97%. regarding the years of experience, it indicates that most of the participants have more than 10 years, which was about 89.2%, which indicates that high schools focuses on highly experienced teachers. regarding the socioeconomic status, the results indicates that most of the teachers are of the middleclass status, which is about 61.8%.table 2 demonstrates that 36% of teachers expressed a good level of knowledge about promoting healthy lifestyles while 35.5% of them expressed a fair level, and 28.5% of them expressed a poor level. table 3 indicates that there was a significant association between the teachers' knowledge for promoting healthy lifestyles and variables of age, education level, address and years of experience in the study sample, where the significance value was less than the alpha value 0.05. the result was accepted the alternative hypothesis, which means that the variables are not independent, and reject the null hypothesis. additionally, there was no significant association between the knowledge and the variables of gender, marital status and socio-economic status in the study sample, where the significance value was more than the alpha value of 0.05. the result accepted the null hypothesis, which is that the variables are independent, and rejected the alternative hypothesis. (significant: age p value=0.001, education level p value=0.002, address p value=˂ 0.001, years of experiences p value=˂ 0.001; no significant: gender p value=0.095, marital status p value=0.449, socio economic status=0.976).table 4 demonstrates that 38% of teachers expressed a good level of practice in promoting healthy lifestyles while 33.7% of them expressed a poor level and 28.3% of them expressed a fair level. the responses to the teachers' knowledge items included three answers (3 = know, 2= natural, and 1= do not know). the calculation of overall teachers' knowledge (15 items) was categorized into three groups poor knowledge (0-5), fair knowledge (6-10), and good knowledge (11-15). the responses to the teachers' practice items included three answers (3 = done, 2= sometimes done, and 1= never done). the calculation of overall teachers' practice as follows (15 items) was categorized into three groups poor practice (0-5), fair practice (6-10), and good practice (11 -15). a pilot study was conducted on 40 participants to determine the reliability of the questionnaire. it was carried out between 1ts to 4th november 2021 for the test, and some participants were excluded from the study sample. the tool and time estimation for each participant to give full was obtained. the results were checked to determine reliability by calculating cronbach's alpha (0.826) (spss, version 23). table 1 shows that most of the teachers were 36-45 and 46 and above years old, as the number of teachers was within these two categories is 335 teachers, which is 83.7%, we infer from this percentage that due to lack of appointments in the past ten years, the percentage of a large age within teachers is greater than the percentage of young. it is also noted that half of them were female which were 206 participants, which is 51.5%. this indicates that most of the teachers who teach in high schools are females. the majority of them are married which are 324 teachers 81%. most 90.7% of teachers hold a bachelor degree, with a percentage of 90.7%. this indicates that the high schools are interested in recruiting individuals with bachelor degrees. 47 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 48 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: socio-demographic characteristics of study sample items variables f (%) age ≤ 25 7 (1.8) 26-35 58 (14.5) 36-45 200 (50) ≥ 46 135 (33.7) total 400 (100) gender male 194 (48.5) female 206 (51.5) total 400 (100) marital status married 324 (81) single 61 (15.2) divorced 6 (1.5) widowed 9 (2.3) total 400 (100) education level diploma 21 (5.3) bsc. 363 (90.7) msc. 15 (3.7) phd 1 (0.3) total 400 (100) address urban 388 (97) suburban 5 (1.3) rural 7 (1.7) total 400 (100) years of experiences ≤ 5 21 (5.3) 6-10 22 (5.5) > 10 357 (89.2) total 400 (100) socio economic status lower class 13 (3.3) lower middle class 75 (18.7) middle class 247 (61.8) upper middle class 63 (15.7) upper class 2 (0.5) total 400 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 49 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: overall teachers' knowledge of promoting healthy lifestyles overall knowledge f (%) good 144 (36) fair 142 (35.5) poor 114 (28.5) total 400 (100) table 3: relationship between socio-demographic characteristics of the study sample with their level of knowledge variables overall knowledge pvalue do not know neutral know total age under 25 1 2 4 7 ˂ 0.001 vhs 26-35 8 22 28 58 36-45 18 67 115 200 46 and above 17 46 72 135 total 44 137 219 400 gender male 22 69 104 195 0.095 ns female 23 68 115 206 total 45 137 218 400 marital status married 35 111 178 324 0.449 ns single 7 22 32 61 divorced 1 2 3 6 widowed 1 3 5 9 total 44 138 218 400 education level diploma 4 6 11 21 0.002 hs bsc. 38 125 200 363 msc. 2 6 7 15 phd 0 0 1 1 total 44 137 219 400 address urban 43 133 212 388 ˂ 0.001 vhs suburban 0 2 3 5 rural 1 2 4 7 total 44 137 219 400 years of experiences less than 5 years 4 6 11 21 ˂ 0.001 vhs 6-10 5 8 9 22 more than 10 years 36 123 198 357 total 45 137 218 400 socio economic status lower class 2 4 7 13 0.976 ns total 45 137 218 400 lower middle class 10 26 39 75 middle class 28 86 133 247 upper middle class 5 20 39 64 upper class 0 0 1 1 total 45 136 219 400 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 50 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 5 shows that there was a significant association between the teachers' practices about promoting healthy lifestyles andvariables of age and years of experience in the study sample, where the significance value is less than the alpha value of 0.05. the result accepted the alternative hypothesis, which means that the variables are not independent, and reject the null hypothesis. additionally, there was no significant association between the teachers' practices and the variables of gender, marital status, education level, address and socioeconomic status in the study sample, where the significance value was more than the alpha value of 0.05. the result accepted the hypothesis, which is that the variables are independent, and rejected the alternative hypothesis. (significant: age p value=0.001, years of experiences p value=˂ 0.001; no significant: gender p value=0.887, marital status p value=0.423, education level p value=0.055, address p value=0.356 socio economic status p value=0.952). table 4: overall teacher's practices in promoting healthy lifestyles overall practices f % good 152 38 fair 113 28.3 poor 135 33.7 total 400 100 table 5: relationship between socio-demographic characteristics of the study sample with their level of practices variables overall practices pvalue never done sometime done done total age under 25 1 3 3 7 ˂0.001 vhs 26-35 11 20 27 58 36-45 25 62 113 200 46 and above 21 43 72 136 total 58 128 214 400 gender male 27 64 103 194 0.887 ns female 30 64 113 207 total 57 128 215 400 marital status married 44 106 174 324 0.423 ns single 12 18 31 61 divorced 1 1 4 6 widowed 1 3 6 10 total 58 128 214 400 education level diploma 3 8 10 21 0.055 ns bsc. 51 113 199 363 msc. 2 7 6 15 phd 0 1 0 1 total 56 129 215 400 address urban 55 124 210 389 0.356 ns suburban 1 1 3 5 rural 1 3 3 7 total 57 128 215 400 years of experiences less than 5 years 3 8 10 21 ˂ 0.001 vhs 6-10 6 8 8 22 more than 10 years 47 113 197 357 total 56 129 215 400 socio economic status lower class 2 4 7 13 0.952 ns lower middle class 12 25 38 75 middle class 37 78 132 247 upper middle class 6 21 36 63 upper class 0 1 1 2 total 57 129 214 400 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article discussion 51 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. regarding the practices of teachers, most of them had good practices about healthy lifestyles to promote health and disease prevention this was a good indicator for teachers to educate their students and population to prevent the disease this finding was agreed with the study done by [6]. regarding the teachers' knowledge for promoting healthy lifestyles, the degree of acceptance was good, the results support that the teachers have good knowledge to promote healthy lifestyles in high schools in erbil city. the outcome of the study indicated that teachers had good knowledge and practices about their healthy lifestyle in school this outcome was contraindicated or not accepted with a study done by [7] who revealed that the knowledge and practice of school teachers regarding healthy lifestyles was poor. the outcome of the study was focused on a healthy diet among teachers and staff it was not agreed with the study done by [7] who revealed that the teachers in this study had poor knowledge about healthy lifestyles and good diet education for students and staff in the school, therefore, it is necessary to increase their knowledge and practices [8]. in some items of our work, the author focused on enhancing healthy lifestyles by assessing their knowledge and practices so these findings are accepted by the study done by [9] who reported that it is necessary to include a teacher in school, or university to train about healthy lifestyle and health promotion. according to the outcome of the study, there were some items of a healthy lifestyle that teachers did not respond properly or there were some poor responses, therefore, it is necessary to train teachers in secondary school regarding health promotion, disease prevention, and healthy life styles, these findings similar with the study conducted by [10] who mentioned aspects of health promotion to be sources of such information for their students and staff in school [10]. the outcome of the study revealed that there was significant association between age, years of experiences and their knowledge and practices while no association between gender, economic and their knowledge and practices. this is because such variables affect teachers to increase their knowledge and practices to promote health and healthy lifestyles this study similar to the study conducted by [11] regarding their knowledge and practices according to their variables. after all, if teachers have knowledge and practices about health promotion and a healthy lifestyle it is the effect on students and other staff in school depends on a snowball process for distribution of the healthy knowledge to the public [11]. the findings indicated that teachers have adequate practices to promote healthy lifestyles this finding is similar to a study done by [12] who revealed that teachers have good practices for healthy lifestyles. the findings of the study indicated that the knowledge and practices of teachers were good for promoting lifestyles and healthy behavior, this finding is dissimilar by the study done by [13] who mentioned that the knowledge and practices of teachers were low for promoting health and lifestyles. the study revealed that teachers had good knowledge and practices aspects of healthy eating and educating students so these findings were accepted by a study done by [14] who said that it is necessary to train more teachers on healthy foods as a healthy lifestyle to avoid themselves and students from diseases and at the same time educating students and staff for that. the outcome of our study revealed that there was a normal distribution of knowledge, practices, and healthy lifestyles so the majority of teachers have good responses about knowledge, https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 52 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [1] campbell sh. lactation: a foundational strategy for health promotion: a foundational strategy for health promotion. jones & bartlett learning. journal of human lactation. 2022;38(1):89-99. [2] abdo nm, mortada em, el seifi os. effect of knowledge about cardiovascular diseases on healthy lifestyle behavior among freshmen of zagazig university: an intervention study. the open public health journal. 2019 jun 30;12(1):300-08. [3] dowling j. key concepts of lactation as health promotion. lactation: a foundational strategy for health promotion: a foundational strategy for health promotion. 2021 jan 25:19. [4] pirzadeh a, sharifirad g, kamran a. healthy lifestyle in teachers. journal of education and health promotion. 2012;1. [5] fesharaki m, sahebalzamani m, rahimi r. the effect of education on life style in ardabil primary over weight students in 2009. iran journal diabetes lipid disord. 2010;9 (3):290-5. [6] fergus s, zimmerman ma. adolescent resilience: a framework for understanding healthy development in the face of risk. annu. rev. public health. 2005; 26:399-419. doi:10.1146/ annurev.publhealth.26.021304.144357. [7] saadia ag. knowledge and view of teacher regarding school health program in two localities khartoum, sudan 2019. international journal of sciences basic and applied research. 2019; 45:181-6. [8] danielle falkenbach1 helen freitas d'avila2 elza daniel de mello3, knowledge, attitudes and practices of primary school teachers on nutrition and food, international journal of nutrology. 2018;11:21–29. [9] levchenko v, levchenko a. enhancing healthy lifestyle in professional teachers' training programs in universities of russia. advances in economics, business and management research. 2020;131:29-31. [10] chavan gm, chavan vm. knowledge, attitude and practices of secondary school teachers regarding school health services in children. international journal of community medicine and public health. 2018;5 (4):1541-46. practices, and lifestyles about promotion the health and life style this finding was similar with study done by [14] who indicated that teachers had good responding about healthy life styles and knowledge and practices toward promotion health [15]. the teachers had good knowledge and practices about promoting healthy lifestyles in high schools. there was a significant association between age, education level, and experience and their knowledge and practices. there was no significant association between their knowledge and gender, marital status, or economic status, and no significant association between their practices and variables like (gender, marital status, and economic status). based on the outcomes of the study, the following recommendations will be recommended to the policymakers in the ministry of education and ministry of health to encourage teachers to participate in different activities about promoting a healthy lifestyle, health promotion and disease prevention, including school curriculum with such health programs so by this way the teachers will be a good source of knowledge and practices for students and staff and for the public. the authors would like to express their heartfelt gratitude to all the teachers at high school in erbil city who participated in the study. the author reports no conflict of interests. conclusion recommendation aknowledgment conflicts of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 53 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [11] jillian hill, catherine e, annizn de. suraya mohamad, whadi ah parker, nelia steyn, promoting healthy lifestyle behaviour through the life-orientation curriculum: teachers' perceptions of the healthkick intervention. south african journal of education. 2015;35(1). [12] htun ym, lwin kt, oo nn, soe k, sein tt. knowledge, attitude and reported practice of primary school teachers on specified school health activities in danuphyu township, ayeyarwaddy region, myanmar. south east asia journal of public health. 2013;3(1):24-9. [13] cheng ny, wong my. knowledge and attitude of school teachers towards promoting healthy lifestyle to students. journal scientific research health. 2015;7(01):11926. [14] bezerra kf, capuchinho lc, de pinho l. knowledge and approach to healthy eating by primary education teachers. demetra: food, nutrition & health. 2015;10(1):11932. [15] pirzadeh a, sharifirad g, kamran a. healthy lifestyle in teachers. journal of education and health promotion. 2012; 1:46. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2020.14 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article patient’s satisfaction with health care services in erbil city/iraq abstract introduction patient satisfaction with health care providers is of great significance. thus, it is important to identify weaknesses in the health system, through the patient’s eyes, to improve the quality of provided care[1]. awareness has grown of how patients perceive the quality of their care. patient satisfaction has become a tool to gain attention and value among the patients as well as providers. hospitals and other health care centres are increasingly using this information while making important decisions regarding the operational and treatment plans [2]. the patient satisfaction data is the key indicator of the quality of care and treatment delivered background and objective: patient satisfaction is one of the most important factors to determine the success of a health care facility. it is a relative phenomenon, which evaluates the patients’ perceived needs, their expectations from a health system, and the experience of health care. patient satisfaction is the main goal today for most health care organizations, from hospitals to physician practices and other health care agencies. this study aimed to compare patient satisfaction with the health care services provided by public and private hospitals in erbil city. methods: a cross-sectional study was conducted using a non-probability purposive sample of 450 patients (225 from public and 225 from private hospitals) who were seeking health care in hospitals in erbil city. the data were collected between the 7th of january and 15th of november 2016 by direct interviews and filling of the standardized questionnaires (patient satisfaction questionnaire-18). results and discussion: most of the patients in public hospitals expressed a neutral level of satisfaction with received health services (80.9%) while 10.7% were dissatisfied and only 8.4% were satisfied with the provided health care. on the contrary, most of the patients in private hospitals (80%) were satisfied with their care, with only 20% expressing a neutral level of satisfaction with private health care services. these findings show that there is a very high statistical difference between patient satisfaction in the governmental and private hospitals in erbil city (mean ± standard deviation 45.35 ± 3.520), (56.42 ± 5.696) (pvalue= <0.001). conclusion: most of the patients were satisfied with private health care services but not with public hospitals health services in selected hospitals in erbil city in iraq. keywords: patient satisfaction; health care services; governmental; public and private hospitals. dlzar omer qadir; department of nursing, college of nursing, hawler medical university, erbil, iraq. saleem saaed qader; department of kurdistan board of medical specialties, erbil, iraq. dara abdulla al-banna; department of nursing, college of nursing, hawler medical university, erbil, iraq. ahmed ali rasool; college of dentistry, hawler medical university, erbil, iraq. jamal kareem shakor; nursing department, sulaimani polytechnic university, sulaymaniyah, iraq )correspondence: jamal.shakor@spu.edu.iq) 119 erbil journal of nursing & midwifery received: 13/4/2020 accepted:19/7/2020 published: 30/11/2020 mailto:jamal.shakor@spu.edu.iq https://doi.org/10.15218/ejnm.2020.14 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article by the physicians, other health staff and the hospital as a whole. the health centres can use survey results to design and track quality improvement over time, as well as compare themselves to other health centres [3]. by conducting their own surveys, the health care organizations can recognize and resolve potential patient satisfaction problems and thus improve their future strategies. having satisfaction surveys also helps to identify the specific needs of the patients for the health care providers [4]. hospitals that are committed to providing excellent health care services, including patient satisfaction, establish multiple programs and initiatives to achieve these goals. measuring performance is essential to assessing the effects of continuous efforts to improve the quality of care and ensuring the pursuit of excellence in hospitals [5]. increasingly, patient satisfaction is acknowledged as a key organizational performance measure. in addition to providing a unique perspective on the performance of a hospital, patient satisfaction is considered as a predictor of a patient’s willingness to follow treatment, to return, or to recommend a service to others e.g. friends or relatives [6]. patient satisfaction has emerged as a critical outcome of medical care due to increasing emphasis on patients as consumers of services in the medical marketplace [7]. improved patient care has become a priority for all health care service providers with the optimum objective of achieving a high degree of patient satisfaction [8] patients’ socioeconomic background influences their perception of health care services to various degree. a study in korea has shown that low-income people were more satisfied with the university health service than the hospitals [10]. similarly, high education is mostly associated with patient satisfaction [11]. this study aims to compare patient satisfaction with the health care services provided by public and private hospitals in erbil city. the study was conducted in some public and private hospitals in erbil city, kurdistan region, iraq. governmental hospitals were rizgary, maternity and hawler teaching hospitals, and private hospitals including the paky hospital, zheen international hospital, and cmc hospital. the hospitals were randomly selected according to their recognition and those with a high number of patients. a non-probability, convenience (purposive) sampling was used to obtain the representative sample according to inclusion criteria. in this study, 450 patients (225 from public and 225 from private hospitals) were recruited to the study. the study included patients of both genders, aged 18 years and over who had been admitted for more than 24 hours and agreed to participate in the study. the patients at the end stage of their life were excluded from the study. this study was approved by the scientific and ethics committee of the college of nursing, hawler medical university, erbil, iraq. institutional approval for conducting the study in public hospitals was also obtained from the general directorate of health in erbil. formal permission to undertake the study in private facilities was attained directly from the hospital administrations. the study was explained to the patients in their native kurdish language and the patients were told that they have the rights to withdraw from the study at any stage. the information about the patients was kept confidential throughout the study and afterwards. each form for each patient was coded with a number. the patients were informed that in case of any interest achieved from the study in the future, they would have a right of free access to the health care provided by these 120 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2020.14 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 52.4%), from the urban residential area (79.6% and 73.8%) as demonstrated in table 1. table 2 shows the overall level of patient satisfaction with health care services in both governmental and private hospitals. most of the patients answered neutrally regarding the health care services in the governmental hospitals (80.9%), while 10.7% of participants were dissatisfied and only 8.4% satisfied with health care services. most of the patients in private hospitals were satisfied with the health care services they received (80%), with only 20% of the patients being dissatisfied. table 3, shows a very high statistical difference between the mean of patient satisfaction in governmental and private hospitals (p-value= <0.001) with 11.067 mean difference (m ± sd of governmental hospitals 45.35 ± 3.520 and 56.42 ± 5.696 of private hospitals), which means that most patients were more satisfied with the private health services than with governmental health care. hospitals for a certain period of time. data were collected using a standardized questionnaire (short-form patient satisfaction questionnaire psq-18), which was developed by rand health research organization for medical outcomes study. the psq18 is a short-term version that retains many characteristics of its full-length counterpart. the psq sub-scales show acceptable internal consistency reliability. the questionnaire contains 18 items tapping each of the seven domains of satisfaction which includes: general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with doctors, and accessibility and convenience with some modifications. the responses contain both positively worded and negatively worded items, ranging from strongly agree to strongly disagree [7]. the method of data collection was through direct interview with each patient by researchers. the questionnaire was translated into the kurdish language by the linguistic expert and fully explained to the patients. statistical analysis the data were analysed using the statistical package for social sciences (spss, version 23) application for statistical data analysis. independent t-test was used to know the statistical difference in the mean of patient satisfaction in private and public hospitals. 450 patients (225 from public and 225 from private hospitals) who were seeking health care in erbil city were recruited to this study. concerning the sociodemographic characteristics, the highest percentage of the patients in both governmental and private hospitals were in the age group 19-32 years (41.8% and 57.8%), female in gender (68.9% and 65.3%), graduated from secondary school (24.4% and 30.2%), currently married (87.1% and 83.6%), keeping house/homemaker (54.7% 121 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2020.14 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 122 erbil journal of nursing & midwifery table 1: sociodemographic characteristics of the study sample sociodemographic characteristics hospital setting total governmental private no. (%) no. (%) no. (%) age groups/years 19-32 94 (41.8) 130 (57.8) 224 (50) 33-46 87 (38.7) 59 (26.2) 146 (32) 47-60 29 (12.9) 21 (9.3) 50 (11) 61-74 15 (6.7) 15 (6.7) 30 (7) total 225 (50) 225 (50) 450 (100) gender male 70 (31.1) 78 (34.7) 148 (30) female 155 (68.9) 147 (65.3) 352 (70) total 225 (50) 225 (50) 450 (100) level of education illiterate 32 (14.2) 21 (9.3) 53 (12) can read and write 38 (16.9) 16 (7.1) 54 (12) primary school 51 (22.7) 56 (24.9) 107 (24) secondary school 55 (24.4) 68 (30.2) 123 (27) institution or college 49 (21.8) 64 (28.4) 113 (25) total 225 (50) 225 (50) 450 (100) marital status never married 20 (8.9) 34 (15.1) 54 (12) currently married 196 (87.1) 188 (83.6) 384 (85) divorced 1 (0.4) 2 (0.9) 3 (0) widowed 8 (3.6) 1 (0.4) 9 (2) total 225 (50) 225 (50) 450 (100) occupational status paid work 5 (2.2) 4 (1.8) 9 (2) self-employed 38 (16.9) 47 (20.9) 85 (19) (volunteer or charity) 10 (4.4) 11 (4.9) 21 (5) student 16 (7.1) 18 (8.0) 34 (8) housewife 123 (54.7) 118 (52.4) 241 (57) retired 4 (1.8) 6 (2.7) 10 (2) unemployed (health reason) 20 (8.9) 8 (3.6) 28 (6) unemployed (other reason) 9 (4) 13 (5.8) 22 (6) total 225 (50) 225 (50) 450 (100) residential area urban 179 (79.6) 166 (73.8) 345 (77) rural 46 (20.4) 59 (26.2) 105 (23) total 225 (50) 225 (50) 450 (100) times of visit 1-4 187 (83.1) 217 (96.4) 404 (90) 5-8 38 (16.9) 8 (3.6) 46 (10) total 225 (50) 225 (50) 450 (100) https://doi.org/10.15218/ejnm.2020.14 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 123 erbil journal of nursing & midwifery patient satisfaction with health care provided by doctors and other health staff is of great importance. thus, it is important to identify the weaknesses of the health system from the patients’ perspective to improve and promote health care in the region [9]. this cross-sectional study was based upon direct interviews of 450 patients who received health care in public and private hospitals in erbil city. most of the patients were young in their 2nd and 3rd decade (19-32 years) of their life (41.8% in public versus 57.8% in private hospitals) and 33-46 years (38.7% in public versus 26.2% in private hospitals). the rest of the patients were above 47 years of age (19.6% in public versus 16% in private hospitals). so, in the current study, young people attended private hospitals more than public hospitals while aged people were admitted to public hospitals more. in this study, there were 68.9% females, 14.2% were illiterate, while 85.8% graduated either from university (21.8%) or secondary school, so most of the patient are aware of health services offered by the hospitals whether in private or public. 8.9% of the patients were single, 3.6% were widow, 38% were self-employed, 79.96% were living in the city of erbil and 83.1% had 14 visits to the hospital. according to the current study, more educated people utilized private hospitals rather than governmental hospitals. high satisfaction in the private hospital might be related to sociodemographic factors such as age and education. there is another study that confirmed that the level of education is a predictor for patient satisfaction [11]. table 2: overall level of satisfaction among patients visiting governmental and private hospitals overall level of satisfaction hospital setting total governmental private no. (%) no. (%) no. (%) highly satisfied 0 (0) 0 (0) 0 (0) satisfied 19 (8.4) 180 (80) 199 (44) neutral 182 (80.9) 45 (20) 227 (50) dissatisfied 24 (10.7) 0 (0) 24 (5) strongly dissatisfied 0 (0) 0 (0) 0 (0) total 225 (50) 225 (50) 450 (100) table 3: comparison between governmental and private hospitals regarding the patient’s satisfaction hospital setting n mean std. deviation std. error mean t-value mean difference p-value government 225 45.35 3.520 0.235 24.79 11.067 < 0.001 private 225 56.42 5.696 0.380 discussion https://doi.org/10.15218/ejnm.2020.14 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 124 erbil journal of nursing & midwifery the level of satisfaction of the patients in the public facilities during their visit to the hospital was neutral in 80.9%, 10.7% of patients were dissatisfied and only 8.4% were satisfied with provided health services. in private hospitals, 80% of patients were satisfied and 20% gave a neutral response. thus, this study has shown that health care in erbil city differs between public and private hospitals. this finding is consistent with another study, which has shown the difference in the level of satisfaction seen in korea where people mostly more prefer the university health system rather than hospitals [10]. private hospitals have high levels of patient satisfaction and aim to continuously optimize health service provision. they always compete among themselves to attract patients locally and nationally. in some countries, medical tourism plays an important role in the economy of the country e.g. jordan, turkey, and india. research studies have shown that patient satisfaction plays a major role in medical tourism, and patient satisfaction is unique to influence international medical tourists [12, 13]. currently, the private hospitals in kurdistan play an important role in health care services and they help the public hospitals to decrease the burden on the government and provide many benefits for the patients and the society. patients can get senior doctors and health care immediately at any time in private hospitals unlike in the public health sector [14]. a major barrier to private hospitals attendance is out-of-pocket costs as there is no health insurance system in the region for the people to use private hospitals and outpatient or consultant clinics services. outpatient and hospital costs at the national level are not clear, but it is clear that they are high for the patients and their families e.g. in australia out-ofpocket consultation costs to patients vary nationally ($110–$480) [15]. in erbil city, the patients are more satisfied with the health care in private hospitals than in public hospitals. the government should improve the care provided in the public sector and strengthen the weaknesses in the health system. research and education about decisionmaking regarding the choice between public and private hospital attendance should be encouraged, and information about diseases and the way of management is critical in extending and improving the lives of people and decreasing the complications of diseases. the government should improve the health services to assimilate all the society’s need and to encourage both public and private health insurance. encouragement of private health insurance in the region is very important to decrease the out-ofpocket expenses for the patients. patient satisfaction is an important tool to assess the quality of health care and to encourage medical tourism from the rest of iraq in the near future and from the neighboring countries in the long term. the author declares no conflicts of interest. the authors’ involvement in the study is reflected in the order of their names. [1] thayaparan aj, mahdi e. the patient satisfaction questionnaire short form (psq-18) as an adaptable, reliable, and validated tool for use in various settings. medical education online. 2013, 18:21747. [2] crow r, gage h, hampson s, hart j, kimber a, storey l, et al. the measurement of satisfaction with healthcare: conclusion recommendations conflict of interest references https://doi.org/10.15218/ejnm.2020.14 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 125 erbil journal of nursing & midwifery implications for practice from a systematic review of the literature.; health technological assess. 2002, 6 (32):1-244. [3] bergenmar m, nylen u, lidbrink e, bergh j, brandberg y. improvements in patient satisfaction at an outpatient clinic for patients with breast cancer. acta oncologica, 2006. 45 (5):550-8. [4] lis cg, rodeghier m, grutsch jf, gupta d. distribution and determinants of patient satisfaction in oncology with a focus on health-related quality of life. bmc health serves research. 2009; 9:190. [5] freeman t. using performance indicators to improve health care quality in the public sector: a review of the literature. health serves manage research. 2002; 15 (2):12637. [6] kone pefoyo aj, wodchis wp. organizational performance impacting patient satisfaction in ontario hospitals: a multilevel analysis. bmc research notes. 2013; 6:509. [7] rand health care. patient satisfaction questionnaire from rand health. douglas aircraft company of santa monica, california. (accessed on 29 april 2015). available from: http://www.rand.org/health/ surveys_tools/psq.html. [8] faiza manzoor, longbao wei, abid hussain, muhammad asif, and syed irshad ali shah. patient satisfaction with health care services; an application of physician’s behavior as a moderator. international journal of environmental research and public health. sep 2019; 16(18): 3318 . available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc6765938/ [9] anthony janahan thayaparan and eamon mahdi. the patient satisfaction questionnaire short form (psq-18) as an adaptable, reliable, and validated tool for use in various settings. medical education online 2013. 18: 10.3402/meo.v18i0.21747. [10] cho y, chung h, joo h, park hj, joh h-k, kim jw, et al. comparison of patient perceptions of primary care quality across healthcare facilities in korea: a cross-sectional study. (2020), plos one 15(3): e0230034. https:// doi.org/10.1371/journal.pone.0230034 [11] macki m, alvi ma, kerezoudis p, xiao s, schultz l, bazydlo m, et al. predictors of patient dissatisfaction at 1 and 2 years after lumbar surgery. journal of neurosurgery. 2019 nov 22:1-10. doi: 10.3171/2019.8 spine19260. [12] park, jungkun; ahn, jiseon; yoo, weon sang, the effects of price and health consciousness and satisfaction on the medical tourism experience. journal of healthcare management. 2017, 62(6):405-417, november/december. [13] kim, minseong. “from servicescape to loyalty in the medical tourism industry: a medical clinic's service perspective.” inquiry: journal of medical care organization, provision and financing. (2017): vol. 54:46958017746546.doi:10.1177/004695 8017746546 [14] karadaghi g, willott c. doctors as the governing body of the kurdish health system: exploring upward and downward accountability among physicians and its influence on the adoption of coping behaviours. human resources for health (2015) 13:43. doi: 10.1186/s12960-015-0039-x. [15] katherine walker, michael ben-meir. choosing public or private emergency departments in australia. emergency medicine australasia. 2017 https:// doi.org/10.1111/1742-6723.12879). https://doi.org/10.15218/ejnm.2020.16 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article attitudes of faculty and students toward open-book examination as a teaching strategy in nursing education at hawler medical university abstract introduction open-book examinations (obes) are one of the tools progressively offered today in order to diminish test anxiety and to help students show their information and abilities and, correspondingly, have a more optimistic attitude towards tests. an ideal meaning of a classroom obe is one in which test takers (students) are allowed to access their notes, textbooks, and other approved reading material while answering examination questions. it may be oral or written, a component of, or a complete exam. to be effectively used for assessment, obes have to be part of the learning experience (formative assessment).[1] obes emphasize problem solving, background and objectives: open-book examinations (obes) is a non-traditional teaching strategy increasingly offered today in nursing education programs. open-book examination is one in which students are allowed to use their notes, textbooks, and other approved material (preferably not electronic) while answering examination questions. the purpose of this study was to evaluate the attitudes of faculty and students towards openbook examinations as a teaching strategy in nursing education. methods: a descriptive study was carried out at college of nursing in hawler medical university. a self-administered questionnaire was used to collected data. the validity of the questionnaire was confirmed because it produced accurate results of the study. also, the questionnaire was reliable because it gave a consistent result throughout the study. total of 100 nursing students and 35 teaching staff were participated in the study. data were analyzed by using frequency and percentage for students and teachers. results: the majority of the students (45%) and faculties (45.7%) agreed that obes facilitate thinking at higher cognitive levels. most of the students (61%) and teachers (51.4%) agreed that obes decreases students’ test anxiety. also, teachers (48.6%) and students (41%) agreed that obes promote critical thinking regarding the contents of the course. teachers and students agreed that obes encourage self-directed learning, decrease memorizing contents, promote student-centered approach to education, encourage students to read textbooks and articles more, and help students to be long-life learners. conclusion: this study confirmed that open-book examinations when used as a teaching strategy in nursing education programs played an important role in improving nursing curriculum. to decrease students’ anxiety regarding examinations, this study pointed out that obes can minimize the students’ anxiety during examinations. key words: open-book examination, nursing education, teaching strategy, critical thinking, faculty dlzar sedeeq anwer; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: dlzar.anwer@valpo.edu) asma mamhusseini; civil engineering department college of engineering/ tishk international university, erbil, iraq. yousif bakr omar; department of nursing, college of nursing, hawler medical university, erbil, iraq. murad sherzad othman; department of nursing, college of nursing, hawler medical university, erbil, iraq. 136 erbil journal of nursing & midwifery received: 04/11/2019 accepted: 22/12/2019 published: 30/11/2020 https://doi.org/10.15218/ejnm.2020.16 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article creativity or deep knowledge rather than a simple recall. obes have achieved both the requirements of an assessment tool and a student-centered method to education, as a technique that reduces the level of testing anxiety experienced by students. [2]studies have presented that students identify five key benefits in obes, specifically practice in the creative use of course content, course content ability, increased chance for student self-evaluation and feedback, less test anxiety and more student regulation of content studied. [3]obes have been recommended as a proper alternative because they lessen anxiety in students, who feel less worried by the need to rote memorize information and inspire students to apply their information to realistic problems that they might encounter in real life. also, obes encourage a broader reading around a subject and combination of information from several sources and facilitate thinking at higher cognitive levels, such as problem solving and reasoning. obes, which appear to foster self-directed learning by promoting deep learning, critical thinking, and interdisciplinary problem solving—are a form of authentic assessment. [4]obes may also encourage more accurate learning opportunities that emphasize higher order thinking skills. closed book examinations test only what students can memorize, while obes have an increased potential to measure higher level thinking skills and relate more closely to real-world work environments. obes is one method for integrating realistic, openended tasks into higher education[5]. authentic assessment is based on students’ abilities to perform meaningful tasks they may have to do in the “real world and also requires students to apply what they have learned. [6]obes push student to read more and places a higher emphasis on understanding thoughts and principles. however, it mentioned that the grades achieved by students who did obes were lower than those obtained by traditional manner possibly due to the higher level of difficulty and difficulty of the questions, thus required higher order of critical thinking [7]. the purpose of this study was to evaluate the attitudes of faculty and students towards open-book examinations as a teaching strategy in nursing education. a quantitative, descriptive study was used to evaluate the attitudes of faculty and students regarding open-book examinations among teachers and students. the participants of this study were selected from students and faculty of college of nursing at hawler medical university. this study was conducted from june 2019 until october 2019. a non-probability-convenience sample (n =35) of faculty and (n=100) because it was easier to collect data and catch samples. fourth stage students of midwifery and nursing department in college of nursing at hawler medical university were sampled in this study. all teachers and fourth stage students of midwifery and nursing department from college of nursing at hawler medical university were included. the reason why chose fourth stage students because they had more experiences with formats and types of examinations than first, second, and third stage students. this study was submitted to the scientific committee of college of nursing to get approval prior to beginning of this study. also, the oral informed consent of the participants was taken as an ethical requirement to participate the study. statistical package for the social sciences (spss) was used (frequency and percentage) in this study. participants were recruited by explaining the purpose of the study. a questionnaire was developed by researchers and the questionnaires’ validity and reliability were confirmed 137 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2020.16 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article moderately agreed that open-book examinations facilitate thinking at higher cognitive levels, such as problem solving and reasoning. 36% students moderately agreed that open-book examinations make student-centered approach to education while 34 %n teachers strongly agreed that open-book examinations make studentcentered approach to education. the majority of the students and teachers agreed (strongly & moderately) that openbook examinations encourage students to decrease memorizing contents. the majority of the students strongly (40%) and moderately (40%) agreed that open-book examinations are preferable way to teaching and learning than closed-book examinations, while the majority of the teachers moderately (31.4%) and somewhat (31.4%) agreed that open-book examinations are preferable way to teaching and learning than closed-book examinations. the highest percentage of the teachers (60%) and students (48%) strongly agreed that openbook examinations encourage students more reading textbooks and articles. also, both students (47%) and teachers (37.1%) strongly agreed that open-book examinations help students to be longlife learners. the majority of the teachers (28.6%) moderately agreed that open-book examinations are less time-consuming for preparation, while the majority of the students (46%) strongly agreed that open-book examinations are less time-consuming for preparation. the perspective of overall students and teachers toward open-book examinations as a teaching strategy in the classroom were relatively very close. before collecting data. the questionnaire consisted of two parts; part one is demographic data (age, gender, and occupation) and the second part is about students’ and teachers’ attitudes regarding open-book examinations. this part consisted of 10 items, each with the following options: strongly agree, moderately agree, somewhat agree, and disagree. researchers distributed questionnaire among students and teachers in order to fill them out. prior to collecting data collection, participants were informed of methods to ensure confidentiality and his/her right to refuse participation at any time. after collecting data, all data were secured in locked box in order to protect participants’ confidentiality. the majority of the teachers between ages 36-55 years old (62.9%), were male (54.3 %). the majority of occupations of the study sample were students (74.07%). while the majority of the students were between 20-22 years old (70 %), 78 % were female. more than half of the students (60%) strongly agreed that open-book examinations are believed to be able to reduce students’ anxiety, while more than half of the teachers (51.4%) moderately agreed that open-book examinations are believed to be able to reduce students’ anxiety. the highest percentage (41.0%) of students and teachers (48.6%) strongly agreed that open-book examinations encourage students to think critically regarding the contents of the course. most of the students (42 %) and teachers (40%) strongly agreed open-book examinations encourage self-directed learning by promoting deep learning and critical thinking. the majority of the students (45%) strongly agreed that open-book examinations facilitate thinking at higher cognitive levels, such as problem solving and reasoning. while the majority of the teachers (45.7%) 138 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2020.16 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article 139 erbil journal of nursing & midwifery table 1: demographic data of the study sample variables no. (%) teacher age 25-35 10 (28.6) 36-55 22 (62.8) ≤ 56 3 (8.6) students age 20-22 70 (70) 23-29 22 (22) ≤30 8 (8) teacher gender male 19 (54.3) female 16 (45.7) students gender male 22 (22) female 78 (78) occupation teacher 35 (25.92) students 100 (74.08) https://doi.org/10.15218/ejnm.2020.16 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article 140 erbil journal of nursing & midwifery table 2: students’ and teachers’ perspective regarding open-book examinations sn items strongly agree moderately agree somewhat agree disagree f (%) students f (%) teachers f (%) students f (%) teachers f (%) students f (%) teachers f(%) students f (%) teachers 1 open-book examinations are believed to be able to reduce students’ anxiety 60 (60) 12 (34.3) 23 (23) 18 (51.4) 13 (13) 3 (8.6) 4 (4) 2 (5.7) 2 open-book examinations encourage students to think critically regarding the contents of the course. 41 (41) 17 (48.6) 36 (36) 5 (14.3) 9 (9) 11 (31.4) 14 (14) 2 (5.7) 3 open-book examinations encourage self-directed learning by promoting deep learning and critical thinking. 42 (42) 14 (40) 30 (30) 12 (34.3) 14 (14) 8 (22.9) 14 (14) 1 (2.9) 4 open-book examinations facilitate thinking at higher cognitive levels, such as problem solving and reasoning. 45 (45) 11 (31.4) 31 (31) 16 (45.7) 13 (13) 7 (20) 11 (11) 1 (2.9) 5 open-book examinations make student-centered approach to education. 35 (35) 12 (34.3) 36 (36) 12 (34.3) 13 (13) 8 (22.9) 16 (16) 3 (8.6) 6 open-book examinations encourage students to decrease memorizing contents. 49 (49) 19 (54.3) 26 (26) 9 (25.7) 12 (12) 7 (20) 13 (13) 0 (0) 7 open-book examinations are preferable way to teaching and learning than closed-book examinations 40 (40) 9 (25.7) 40 (40) 11 (31.4) 14 (14) 11 (31.4) 6 (6) 4 (11.4) 8 open-book examinations encourage students more reading textbooks and articles. 48 (48) 21 (60) 24 (24) 6 (17.1) 17 (17) 5 (14.3) 11 (11) 3 (8.6) 9 open-book examinations help students to be long life learner 47 (47) 13 (37.1) 29 (29) 9 (25.7) 15 (15) 12 (34.3) 9 (9) 1 (2.9) 10 open-book examinations are less time-consuming for preparation 46 (46) 9 (25.7) 35 (35) 10 (28.6) 12 (12) 7 (20) 7 (7) 9 (25.8) https://doi.org/10.15218/ejnm.2020.16 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article the majority of the students and teachers agreed (strongly & moderately) that openbook examinations encourage students to decrease memorizing contents. the present study is supported by another study conducted in hong kong which indicated that open-book examinations are believed to be able to reduce students’ anxiety and rote memorizing of facts. the purpose of the study was to assess what preparations students have undertaken before taking open-book examinations and what learning style they adopted during the preparation of this non-traditional approach to subject testing. the results of the study indicated that students had a positive perception towards open-book examinations. [8]in this study, the highest percentage of the teachers (60%) and students (48%) strongly agreed that open-book examinations encourage students more reading textbooks and articles. this finding is supported by a study conducted in the united states of america; the findings indicated that students taking open-book pre-quizzes performed better on open book final exams. this research approach also showed preliminary indications that the students value their textbooks more, and used them more frequently and broadly, to prepare for class using open-book testing protocols as opposed to using traditional closed-book testing procedures. [9]in this study, the majority of the teachers (28.6%) moderately agreed that open-book examinations are less time-consuming for preparation, while the majority of the students (46%) strongly agreed that open-book examinations are less time-consuming for preparation. a study had been conducted in finland, which does not support this study, indicated that the students used approximately the same time to study for an online examination as for faculty examination, but over half of them reported using more time for responding and learning more from an online examination compared to a faculty examination. the purpose of this study was to investigate university students’ experiences of open-book and open-web online examinations compared to traditional class examinations regarding preparing, responding, and learning. the data (n = 110) were collected by an online survey from the university students who took an online examination. [10]in this study, the majority of the students strongly (40%) and moderately (40%) agreed that openbook examinations are preferable way to teaching and learning than closed-book examinations, while the majority of the teachers moderately (31.4%) and somewhat (31.4%) agreed that open-book examinations are preferable way to teaching and learning than closed-book examinations. these findings are supported by the results of a study conducted in singapore which evaluated the influence of open book examinations on the learning habits of students in the nanyang technological university in singapore. a survey was conducted in order to determine whether students preferred open book examination and the reasons for their preference. the results of the survey exhibited that almost two-thirds of the students preferred open book examinations despite being more familiar with closed book examinations. they felt that preparations for open book examinations were less time-consuming and that they required less memorization and left more room for logical thinking. [11] another study results indicated that students preparing for a closed book examination tend to delay their study at the end of the semester, focus on the given texts and memorize information. students preparing for an open-book examination tend to access various sources and interrelate the information acquired; when taking the exam, they work innovatively while, 141 erbil journal of nursing & midwifery discussion https://doi.org/10.15218/ejnm.2020.16 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article [5] rakes gc. open book testing in online learning environments. journal of interactive online learning 2008; 7(1): 1541-4914. [6] dale vh, wieland b, pirkelbauer b, nevel a.value and benefits of open-book examinations as assessment for deep learning in a post-graduate animal health course. journal of veterinary medical education 2009; 36(4): 403-410. [7] abdul jalal mf, ain fadhil ss, hasini h. students, assessment through open-book concept for final exam. international journal of asian social science 2014; 2(1): 217-225. [8] linda dh, snyder j. authentic assessment of teaching in context. teaching and teacher education 2000; 16: 523-545. [9] green sg, ferrante cj, heppard ka. using open-book exams to enhance student learning, performance, and motivation. the journal of effective teaching 2016; 16(1): 19-35. [10] myyry l, joutsenvirta t. open-book, openweb online examinations: developing examination practices to support university students’ learning and self-efficacy 2015; active learning in higher education 2015; 16(2): 119-132. [11] loi sl, chuah jc. the impact of open book examinations on student learning 1999. nanyang technological university. [12] theophilides c, koutselini m. study behavior in the closed-book and the open-book examination: a comparative analysis. educational research and evaluation 2010; 6 (4):379-393. at the same time, they probe deeply into the knowledge gained. [12]there are several potential limitations to the study: (a) small sample size, (b) geographical area consisting only of college of nursinghawler medical university, (c) dependence on students’ and teachers’ attitude regarding obes, and (d) the inexperience of the researchers could introduce researchers’ bias. this study supports the use of open-book examinations as a teaching strategy in nursing education programs and openbook examinations have an important role on improving nursing curriculum. also, students and faculty stated that open-book examination encourages students’ critical thinking, decrease students’ test anxiety, encourage self-directed learning, decrease memorizing contents, make studentcentered approach to education, encourage students more reading textbooks and articles, and help students to be long-life learners. the authors declared that there is no conflict of interest with this study. [1] doghonadze n, demir h. critical analysis of open-book exams for university students.2018. international black sea university. [2] chan my. the use of open-book examinations to motivate students: a case study from hong kong. world transactions on engineering and technology education 2004; 3(1): 111-114. [3] gujral s, gupta m. a study of attitude of teachers and students towards open book and closedbook assessment. international journal of scientific research and management 2015; 5(7): 6034-6038. [4] brightwell r, daniel j, stewart a. evaluation: is an open book examination easier. bioscience education e-journal 2004; 3. 142 erbil journal of nursing & midwifery conclusion conflict of intrest references https://doi.org/10.15218/ejnm.2022.01 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article knowledge and practices of students regarding the use of face masks to limit the spread of coronavirus disease (covid-19) abstract introduction coronavirus disease is a respiratory infection caused by coronavirus 2 (sars-cov2) that causes severe acute respiratory syndrome [1]. it first occurred in china in december 2019 and has since spread to almost every country globally, resulting in the coronavirus pandemic of 2019-2020 [2,3]. the virus spreads primarily by background and objectives: many countries are implementing face masks as part of their pandemic prevention strategies. because the virus is so widespread, incorrect usage and disposal of masks can increase the transmission rate. the purpose of this study was to assess knowledge and practices of students in wearing facemask to prevent the spread of the new coronavirus (covid-19). methods: a cross-sectional descriptive study of 365 undergraduate students at hawler medical university was conducted from june 15th to october 15th, 2021. the data was gathered through direct interviews using a questionnaire that had been modified include demographic information, ten questions about knowledge, and 17 questions about practices for using surgical face masks to reduce covid-19 exposure. result: the result revealed that highest percentage of students were 18 to 20 years old (66.6%). most of the participants in this study were female (59.5%). participants demonstrated fair knowledge (n=218, 59.7%). concerning the using surgical facemask to prevent the spread of covid-19 and good practical knowledge (n=273, 74.8%). the highest levels of practical knowledge were related to wearing face masks in hospital premises to protect against covid-19 (91.8%) and wearing masks in public spaces to protect against covid-19 (87.1%). conclusion: the studied students had a poor understanding of how to utilize face masks. enhancing one’s knowledge and appropriate use of face masks takes time and effort. it is necessary to implement massive education campaigns at the level of hawler medical university to increase the proportion of knowledge about covid-19 and stop its spread. keywords: knowledge; practice; students; face mask; coronavirus. burhan izzaddin sabir; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: burhan.sabir@hmu.edu.krd) shahab ahmad sideeq; department of nursing, college of nursing, hawler medical university, erbil, iraq. yousif baker omer; department of nursing, college of nursing, hawler medical university, erbil, iraq. nasir khadir khalaf; department of nursing, college of nursing, hawler medical university, erbil, iraq. sideeq sadir ali; department of nursing, college of nursing, hawler medical university, erbil, iraq. 01 erbil journal of nursing & midwifery received: 14/10/2021 accepted: 06/02/2022 published: 30/05/2022 mailto:burhan.sabir@hmu.edu.krd https://doi.org/10.15218/ejnm.2022.01 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article respiratory droplets, which are released when an infected person coughs or sneezes, or by touching contaminated surfaces or objects and then touching their mouth, nose, or possibly their eyes [4, 5]. students are obliged to adopt standard infection control techniques to reduce the risk of infection. the routine usage of a face mask is one of the infection control methods. a face mask is a single-use, loose-fitting mask covering the nose, mouth, and chin. it is a simple, cost-efficient non-pharmaceutical individual intervention for safeguarding oneself and preventing respiratory infections from spreading [6].incorrect use of face masks may have the opposite effect of reducing the spread of respiratory illnesses. correct knowledge and practice are required for the appropriate use of face masks. evaluating these two components can provide helpful information for building health promotion programs to increase face mask efficacy [7]. students are strongly advised to wear a face mask as a standard for transmission-based precaution by the world health organization (who) and the centers for disease control and prevention (cdc). furthermore, the correct use of these face masks is critical, especially now that their use is becoming more prevalent [8]. with large student populations, higher education institutions can become outbreak hotspots that may negatively impact the community [9].maintaining proper personal hygiene habits and instilling a positive attitude toward wearing a face mask during illness is critical to controlling and limiting the spread of coronavirus. the study’s main objective was to assess the knowledge and practices of hawler medical university students about using surgical face masks to prevent the spread of covid-19. a cross-sectional study was carried out from june 15th, 2021, to october 15th, 2021. the sample size of the study was estimated according to the total number of registered students at hawler medical university (3862) using power analysis with a 95% confidence interval (ci) and a 5% margin of error [14]. the estimated sample size was 365. all male and female undergraduate students in colleges of nursing, medicine, dentistry, pharmacy, and health sciences were included in the study. the exclusion criteria included those who refused to be interviewed or could not participate in the study. informed consent was obtained after confirmation of confidentiality. ethical approval was obtained from the research ethics committee at the college of nursing (no. 8, dated july 23, 2021). a questionnaire consisting of three parts was developed to collect data. the first part of the questionnaire included sociodemographic characteristics such as age, stage, gender, marital status, and religion. the second part of the questionnaire collected data on the overall knowledge of students regarding the use of surgical face masks using ten items and was divided into three categories: “poor”, “fair”, and “good”. the scores for overall knowledge ranged from 0-10, poor knowledge ranged from 0–3, fair knowledge ranged from 4–7, and good knowledge ranged from 8–10. the third part of the questionnaire included 17 questions about practices related to face mask use and was divided into three categories: “poor”, “fair”, and “good”. the overall practical knowledge was ranged from 0-17, poor practical knowledge ranged from 0–5, fair practical knowledge ranged from 6–11, and good practical knowledge ranged from 12–17. questions were adapted from previously published 02 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2022.01 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article table 2 illustrates the results of students’ knowledge regarding the correct usage of face masks. most participants (n=158, 43.3%) incorrectly identified the first person answered to recommend wearing a mouth mask as joseph lister. johan mikulicz is the first person who recommended wearing a mouth mask (n=69, 18.9%). most students correctly answered the questions “can wearing a surgical facemask protect you from covid19?” (n=311, 85.2%), “which is the correct way of using surgical face masks to protect against covid-19?” (n=277, 75.9%), “how many layers does a surgical mask covid-19 questionnaires and were filled out by the students using direct interview technique. the data were analyzed using the statistical package for social sciences (spss, version 23). the association between all sociodemographic variables with students' overall knowledge and practical knowledge was assessed using inferential statistics and the chi-square test. a p-value of ≤ 0.05 was considered statistically significant. table 1 presents participants’ sociodemographic information. according to the results, the college students in the field of medicine constituted the highest frequency (n=83) and percentage (22.7%). inc comparison, the students in health science constituted the lowest responses (n=64, 17.5%). the students in their first stage of studies constituted the highest (n=157, 43%) response, while those in their fifth year of study constituted the lowest response (n=27, 7.4%). moreover, the highest responses (66.6%) of students were among the age group 18-20 years old, whereas the 24-26 years old age group had the lowest responses with eight frequencies (2.2%). with respect to gender, female students constituted the maximum number of participants in this study (n=217, 59.5%) and were subsequently followed by their male counterparts (n=148, 40.5%). those students who were single made up most of the participants (n=346, 94.8%), followed by those who were married (n=19, 5.2%). the majority of the participants (n=358, 98.1%) identified as muslims, followed by others (n=4, 1.1%), and then christians (n=3, 0.8%). 03 erbil journal of nursing & midwifery results table 1: socio-demographic data of study participants variables n =365 college nursing 71 (19.5) medicine 83 (22.7) dentistry 76 (20.8) pharmacy 71 (19.5) health science 64 (17.5) stage first 157 (43) second 76 (20.8) third 73 (20) forth 32 (8.8) fifth 27 (7.4) age group 18-20 243 (66.6) 21-23 114 (31.2) 24-26 8 (2.2) gender male 148 (40.5) female 217 (59.5) marital status single 346 (94.8) married 19 (5.2) religion christian 3 (0.8) muslim 358 (98.1) others 4 (1.1) total 365 (100) https://doi.org/10.15218/ejnm.2022.01 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article have?” (n=237, 64.9%), and “which layer acts as a filter media barrier?” (n=246, 67.4%). a majority of students incorrectly responded to the “which type of masks actually protect against covid19?” (n=116, 31.8%) choosing 99% bfe & pfe. the correct answer for this question is 95% bfe & pfe (n=87, 23.8%). a significant number of participants (n=98, 26.8%) indicated eight hours as a correct answer to the question “how long can you wear a surgical mask?”. the majority (n=267, 73.1%) correctly answered the question “for proper wearing, to what extent should the surgical mask cover the face?”, with nose, mouth, and chin being the correct answer. many of the participants (n=256, 70.1%) correctly answered “yes” to the statement “wearing a mask for an extended period time can lower o2 levels and raise co2 levels in the body”. when asked if the cloth facial mask was as effective as a standard surgical facial mask, many participants (n=237, 64.9 percent) correctly answered “no”. table 3 shows the practical knowledge of students regarding the correct usage of face masks. according to the results, a significant number of the student (n=271, 74.2%) correctly answered the question “during clinics, if there is a need to talk to the patient, will you remove your mask?”. however, a substantial number of the students (n=200, 54.8%) incorrectly indicated “yes” to the question “if you are not sick, do you store the used surgical mask in a bag for later use?”. most of the participants correctly responded to the questions such as “do you wear a mask in public places to protect yourself against covid-19?” (n=318, 87.1%), “do you wear a mask on hospital premises to protect yourself against covid-19?” (n=335, 91.8%), and “is it necessary to clean hands before wearing a mask?” (f=303, 83%). participants correctly responded to the statements “identify the inside and outside of a mask before wearing it on” (n=275, 75.3%), “it's important to confirm the metal nose band on the top (n=283, 77.5%), “you should place the loop around on the ear” (n=290, 79.5%), “extending the folds by pulling the top and bottom of the mask” (n = 293, 80.3%), “it is necessary to press the nose band (n=285, 78.1%)”, “you should not touch mask (n=283, 77.5%), “whilewearing the mask, avoid eating, drin king, and smoking (n=224, 61.4%). participants also correctly responded to the statements “remove the mask from your face, only touching the bands” (n=277, 75.9%), and “avoid pulling the mask over the forehead or down over the chin” (n=269, 73.7%). participants correctly responded to the statements “you should dispose of the mask when soiled or wet” (n=308, 84.6%), "you should clean your hands after taking off” (n=307, 84.1%), and “you should not reuse a single -use mask” (n=284, 77.8%). the overall results for knowledge and practical knowledge of the students are displayed in table 4. based on total score the overall knowledge is scored as fair (n=218, 59.7%), while overall practical knowledge is scored as good (n=273, 74.8%). table 5 explores the association between sociodemographic data and overall knowledge of the participants. there was a significant association between good knowledge of the students and the two groups of sociodemographic variables: college group of students (50.7% for pharmacy students, 31.6% for dentistry students, 29.7% for health sciences students, 27.7% for medicine students, and 19.7% for nursing students, p = 0.010) and stage of students (53.1% for forth stage, 51.9 % for fifth stage, 28.8% for third stage, 27.6% for second stage, and 27.4 % for first stage, p = 0.015). there was no significant difference between good knowledge of the students with the other variables of 04 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2022.01 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article 05 erbil journal of nursing & midwifery socio demographic; age group (p = 0.097), gender (p = 0.756), marital status (p = 0.584) and religion (p = 0.792).table 6 exhibits the association between sociodemographic data and overall practical knowledge. a significant association between good practical knowledge and college group of students (85.9% for pharmacy students, 31.6% for dentistry students, 75% for health sciences students, 68.7% for medicine students, and 67.6% for nursing students, p= 0.042), age group (84.2% for 21-23 years old, 71.6% for 1820 years old, and 37.5% for 24-26 years old, p= 0.010) and gender(79.3% for females vs. 68.2% for males, p = 0.021). there was no significant association between practical knowledge with the stage of students (p= 0.766), marital status (p = 0.935) and religion (p = 0.828). items n (%) in 1897, he was the first person to recommend wearing a mouth mask. johan mikulicz (correct) 69 (18.9) carl flugge 54 (14.8) joseph lister 158 (43.3) louis pasteur 84 (23) can wearing a surgical mask protect you from covid19? yes (correct) 311 (85.2) no 54 (14.8) which way should a surgical face mask be used to protect against covid-19? whiteside facing in (correct) 277 (75.9) whiteside facing out 88 (24.1) a surgical mask consists of how many layers? two 117 (32.1) three (correct) 237 (64.9) four 11 (3) which layer serves as a filter media barrier? first 96 (26.3) middle (correct) 246 (67.4) last layer 23 (6.3) what types of facemasks are effective against covid19? 95% bfe & pfe (correct) 87 (23.8) 97% bfe & pfe 97 (26.6) 91% bfe & pfe 65 (17.8) 99% bfe & pfe 116 (31.8) how long may a surgical mask be worn? 2 hours 98 (26.8) 4 hours 169 (46.4) 8 hours (correct) 98 (26.8) to what extent should the surgical mask cover the face? mouth only 27 (7.4) mouth and nose 71 (19.5) nose, mouth, and chin 267 (73.1) wearing a facemask for an extended period of time leads to the body’s o2 level dropping and co2 level rising? yes (correct) 256 (70.1) no 109 (29.9) is a cloth facial mask as effective as a standard surgical mask? yes 128 (35.1) no (correct) 237 (64.9) total 365 (100) table 2: knowledge of students about correct usage of face masks https://doi.org/10.15218/ejnm.2022.01 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article 06 erbil journal of nursing & midwifery table 3: practical knowledge of students regarding correct usage of face mask items correct incorrect will you remove your mask during clinics if you need to talk with a patient? 271 (74.2) 94 (25.8) if you are not sick, do you store the used surgical mask in a bag for later use? 165 (45.2) 200 (54.8) do you protect yourself from covid-19 by wearing a mask in public places? 318 (87.1) 47 (12.9) do you wear a mask in hospital premises to protect yourself against covid-19? 335 (91.8) 30 (8.2) is it necessary to clean hands before wearing a mask? 303 (83) 62 (17) identify the inside and outside of a mask before wearing it on. 275 (75.3) 90 (24.7) it’s important to confirm the metal noseband on the top. 283 (77.5) 82 (22.5) you should place the loop around on the ear. 290 (79.5) 75 (20.5) extending the folds by pulling the top and bottom of the mask. 293 (80.3) 72 (19.7) it is necessary to press the nose band. 285 (78.1) 80 (21.9) you should not touch the mask. 283 (77.5) 82 (22.5) while wearing the mask, avoid eating, drinking, and smoking. 224 (61.4) 141 (38.6) remove the mask from your face, only touching the bands. 277 (75.9) 88 (24.1) avoid pulling the mask over the forehead or down over the chin. 269 (73.7) 96 (26.3) you should dispose of the mask when soiled or wet. 308 (84.6) 56 (15.4) you should clean your hands after taking off. 307 (84.1) 58 (15.9) you should not reuse a single-use mask. 284 (77.8) 81 (22.2) overall n (%) knowledge poor 31 (8.5) fair 218 (59.7) good 116 (31.8) practical knowledge poor 2 (0.5) fair 90 (24.7) good 273 (74.8) total 365 (100) table 4: overall knowledge and practical knowledge of the students https://doi.org/10.15218/ejnm.2022.01 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article 07 erbil journal of nursing & midwifery variables overall knowledge p value poor fair good n (%) n (%) n (%) college nursing 8 (11.3) 49 (69) 14 (19.7) 0.010 medicine 10 (12) 50 (60.2) 23 (27.7) dentistry 7 (9.2) 45 (59.2) 24 (31.6) pharmacy 2 (2.8) 33 (46.5) 36 (50.7) health science 4 (6.3) 41 (64.1) 19 (29.7) stage first 17 (10.8) 97 (61.8) 43 (27.4) 0.015 second 8 (10.5) 47 (61.8) 21 (27.6) third 3 (4.1) 49 (67.1) 21 (28.8) forth 3 (9.4) 12 (37.5) 17 (53.1) fifth 0 (0) 13 (48.1) 14 (51.9) age group 18-20 25 (10.3) 151 (62.1) 67 (27.6) 0.097 21-23 6 (5.3) 62 (54.4) 46 (40.4) 24-26 0 (0) 5 (62.5) 3 (37.5) gender male 13 (8.8) 85 (57.4) 50 (33.8) 0.756 female 18 (8.3) 133 (61.3) 66 (30.4) marital status single 29 (8.4) 205 (59.2) 112 (32.4) 0.584 married 2 (10.5) 13 (68.4) 4 (21.1) religion christian 0 (0) 2 (66.7) 1 (33.3) 0.792 muslim 30 (8.4) 214 (59.8) 114 (31.8) others 1 (25) 2 (50) 1 (25) table 5: association between socio demographic data with overall knowledge https://doi.org/10.15218/ejnm.2022.01 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article 08 erbil journal of nursing & midwifery table 6: association between socio demographic data with overall practical knowledge variables overall practical knowledge pvalue poor fair good n (%) n (%) n (%) college nursing 2 (2.8) 21 (29.6) 48 (67.6) 0.042 medicine 0 (0) 26 (31.3) 57 (68.7) dentistry 0 (0) 17 (22.4) 59 (77.6) pharmacy 0 (0) 10 (14.1) 61 (85.9) health science 0 (0) 16 (25) 48 (75) stage first 2 (100) 42 (46.7) 113 (41.4) 0.766 second 0 (0) 21 (27.6) 55 (72.4) third 0 (0) 14 (19.2) 59 (80.8) forth 0 (0) 7 (21.9) 25 (78.1) fifth 0 (0) 6 (22.2) 21 (77.8) age group 18-20 2 (0.8) 67 (27.6) 174 (71.6) 0.010 21-23 0 (0) 18 (15.8) 96 (84.2) 24-26 0 (0) 5 (62.5) 3 (37.5) gender male 2 (1.4) 45 (30.4) 101 (68.2) 0.021 female 0 (0) 45 (20.7) 172 (79.3) marital status single 2 (0.6) 85 (24.6) 259 (74.9) 0.935 married 0 (0) 5 (26.3) 14 (73.7) religion christian 0 (0) 1 (33.3) 2 (66.7) 0.828 muslim 2 (0.6) 89 (24.9) 267 (74.6) others 0 (0) 0 (0) 4 (100) https://doi.org/10.15218/ejnm.2022.01 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article the college, stage, and age of the students, but there was no significant relationship between gender, marital status, and religion and overall knowledge of the use of face masks. this result is like the findings of a descriptive study conducted by imtaz ahmed et al. on 60 students at the university of raiwind road, lahore [6]. there was a significant relationship between college, age, and gender of the students with overall practice knowledge regarding the usage of face masks in the resent study. there was no significant relationship between the stage, marital status, and religion of the students with the overall practice of using face masks. face masks are necessary to implement for prevention in mass gatherings due to the rising number of cases of covid-19 and the threat of respiratory infection. the study concluded that the knowledge and practice of students regarding the use of surgical face masks were found to be inadequate. according to the findings of the study, during this pandemic crisis, there is an urgent need to implement periodic educational interventions and training programs on infection control techniques and the use of protective equipment among hawler medical university students. regular instructional webinars with guidelines and content to enhance student awareness are necessary for them to be healthy and safeguard our society from diseases like covid-19. the authors would like to express their heartfelt gratitude to all the students at hawler medical university who participated in the study. the highest percentage of the study sample were from medicine college in the first stage and ranged from 1820 years old. this result is similar to the results of a descriptive study done on 592 students who found that most students were in medicine but in the second stage [10]. the findings are consistent with those of a cross-sectional study of 104 students, which found that most students were between the ages of 18 and 25 [11]. more than half of the study sample were females, and the remainder were males. this study agrees with the study done by hamed alzoubi, in 2020, which reported more than half of the sample were female [10]. the current study found that the highest percentage of the students were single and muslims. concerning the knowledge of students about the correct usage of face masks, most questions were answered correctly. the present study revealed that majority of students answered all questions correctly except one question (“if you are not sick, do you store the used surgical mask in a bag for later use?”). the result of the present study agrees with the findings of the study by hamed alzoubi et al. which reported a positive practical attitude toward covid-19 [10]. joshi et al. conducted a cross sectional study on 407 students which revealed that around 95.58% were knowledgeable about face mask usage while going out duringthe pandemic [12]. the current study showed that the more than half of the sample were at a fair level of overall knowledge and most of the sample were at a good level of practical knowledge. in terms of the relationship between sociodemographic data and overall knowledge, the study found that there was a significant relationship between 09 erbil journal of nursing & midwifery discussion conclusion acknowledgements https://doi.org/10.15218/ejnm.2022.01 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article [9] akan h, gurol y, izbirak g, ozdatlı s, yilmaz g, vitrinel a et al. knowledge and attitudes of university students toward pandemic influenza: a cross-sectional study from turkey. bmc public health. 2010;10(1). [10] alzoubi h, alnawaiseh n, al-mnayyis a, abu lubad m, aqel a, al-shagahin h. covid-19 knowledge, attitude and practice among medical and non-medical university students in jordan. journal of pure and applied microbiology. 2020;14(1):17-24. [11] olum r, chekwech g, wekha g, nassozi d, bongomin f. coronavirus disease-2019: knowledge, attitude, and practices of health care workers at makerere university teaching hospitals, uganda. frontiers in public health. 2020;8. [12] joshi k, madhura l, jamadar d. knowledge and awareness among nursing students regarding the covid-19: a cross sectional study. international journal of community medicine and public health. 2020;7(7):2518. doi: http://dx.doi.org/10.18203/23946040.ijcmph20202536. [13] ahmad, imtiaz; altaf, sehar; ahmad, hafiz m. assessment of knowledge, practice and barrier in use of facemask among university students. pakistan journal of medical & health sciences, 2017, 11.4: 1657-58. doi:10.11622/smedj.2014037. [14] ho hs. use of face masks in a primary care outpatient setting in hong kong: knowledge, attitudes and practices. public health. 2012 dec 1;126(12):1001-6. the author reports no conflict of interest. [1] anikwe c, ogah c, anikwe i, okorochukwu b, ikeoha c. coronavirus disease 2019: knowledge, attitude, and practice of pregnant women in a tertiary hospital in abakaliki, southeast nigeria. international journal of gynecology & obstetrics. 2020;151(2):197-202. [2] radonovich l, simberkoff m, bessesen m, brown a, cummings d, gaydos c et al. n95 respirators vs medical masks for preventing influenza among health care personnel. jama. 2019;322(9):824. [3] azlan a, hamzah m, sern t, ayub s, mohamad e. public knowledge, attitudes and practices towards covid-19: a crosssectional study in malaysia. plos one. 2020;15(5):e0233668. [4] sohrabi c, alsafi z, o'neill n, khan m, kerwan a, al-jabir a et al. world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19). international journal of surgery. 2020;76:71-76. [5] olum r, chekwech g, wekha g, nassozi d, bongomin f. coronavirus disease-2019: knowledge, attitude, and practices of health care workers at makerere university teaching hospitals, uganda. frontiers in public health. 2020;8. [6] ahmad, imtiaz; altaf, sehar; ahmad, hafiz m. assessment of knowledge, practice and barrier in use of facemasks among university students. pakistan journal of medical & health sciences, 2017, 11.4: 1657-58. [7] lee l, lam e, chan c, chan s, chiu m, chong w et al. practice and technique of using face mask amongst adults in the community: a cross-sectional descriptive study. bmc public health. 2020;20(1). [8] wada k, oka-ezoe k, smith d. wearing face masks in public during the influenza season may reflect other positive hygiene practices in japan. bmc public health. 2012;12(1). 10 erbil journal of nursing & midwifery conflict of interest references https://doi.org/10.15218/ejnm.2020.05 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article appraising quality of nursing practices in the medical and surgical wards of public hospitals in erbil city abstract introduction nurses represent the largest occupational group in the healthcare workforce, providing the most care at all levels of the care continuum and accounting for a significant proportion of hospitals’ operating costs. yet nursing’s contribution most often remains invisible to policy-makers and healthcare managers, and many analysts consider it undervalued and understudied [1].nurses are nearly always available on the ward, monitoring patients’ conditions and delivering patient care. many studies have found that nurses assume responsibility for first contact and ongoing care for all presenting patients. they are the key personnel in providing direct patient care. anything that affects nurses’ work can directly affect the quality of nursing care [2]. registered nurses complete a wide variety of tasks in the work shift, ranging from simple activities such as gathering items to complex coordination with other nurses, physicians, aides, social workers, physical therapists, and others. information on background and objectives: appraising the quality of nursing practices is a cornerstone for improving the nursing services. the objective of the study was to appraise the quality of nursing care provided to patients in the medical and surgical wards methods: a cross-sectional study was conducted in the medical and surgical wards of hawler, rizgary, and the maternity teaching hospitals located in erbil city, kurdistan region of iraq, starting from december 17, 2016, until september 30, 2017. the researcher used to visit the hospital wards four days per week in order to monitor the nursing practices using a questionnaire adapted from the who. all the nurses were included in the study except for those who were not present during the researcher’s visit. data were analyzed by the spss program, and a p-value of less than 0.05 was considered significant. results: only 37.8% of the nurses performed assignments in a good manner, and none performed assignments in a very good manner. nearly all the nurses performed poorly in the following areas: disposal of soiled linen promptly; ventilation and adequate lighting in the ward; cleanliness in ward/room; hand washing before and after patient treatment; and observation rules and upholding standards. results showed that 52.7% of nurses showed a genuine interest in the comfort and health improvements of patients. conclusions: the performance of nurses working in erbil public hospitals was, in general, not so satisfactory (fair). it is recommended to engage the nurses in courses of continuing professional development (cpd) and to set standards for nursing care in the mentioned hospitals. keywords: nurses; appraisal; assessment; performance; erbil zhyan abdullah esmael; department of nursing, college of nursing, hawler medical university, erbil, iraq. )correspondence: zhianismahil@yahoo.com ) namir ghanim altawil; department of community medicine , college of medicine, hawler medical university, erbil, iraq. 38 erbil journal of nursing & midwifery received: 2/ 10/2019 accepted: 22/12/2019 published: 30/5/2020 mailto:zhianismahil@yahoo.com https://doi.org/10.15218/ejnm.2020.05 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article such intricate nurse workflow is useful in assessing performance, the efficiency of care, and resource planning and allocation, all of which are of immediate importance given the challenges facing the nursing profession and today’s healthcare delivery system [3]. nurses carry out many types of activities starting from simple ones like holding the patient’s hand, to complicated technical procedures. the person who receives the care is the central focus of nursing care and the physical, emotional, social and spiritual dimensions of that person should be considered when providing the care [4].the quality of health care is of great importance to patients’ outcomes and their safety, however, improvements in this aspect is still slow. review of the literature showed that the practicing nurses had a trivial role in the improvement programs of health care [5].research shows that a heavy nursing workload adversely affects patient safety. furthermore, it negatively affects nursing job satisfaction and, as a result, contributes to high turnover and the nursing shortage [ 6]. nurses will have the ability to demonstrate the impact of nursing care on patient outcomes [7]. the nursing process is an orderly systematic manner of determining the client’s health status specifying the problems, initiating and implementing plans to solve them and evaluating the extent to which the plan was effective. clinical practice guidelines (cpgs) are relatively new quality improvement tools which is developed for maintaining quality, minimizing costs and improving out comes. the quality of nursing care is monitored based on the nursing process where nurse decides, plans, implements and evaluates the nursing care [8]. the objectives of the study were to appraise the quality of nursing care provided to patients in the medical and surgical wards and to find out the association between the quality of nursing care and some nurses’ demographic characteristics such as age, gender, level of education, and duration of experience in nursing. a cross-sectional study was conducted in the medical and surgical wards of hawler, rizgary, and the maternity teaching hospitals located in erbil city, kurdistan region of iraq, starting from december 17, 2016, until september 30, 2017.the researcher used to visit the hospital wards four days per week, either during the morning shift, evening shift and during the night shift. all the nurses who were in charge during the presence of the researcher in the hospital have been included in the study (74 nurses were included using the convenience method of sampling), knowing that the total number of nurses in the mentioned wards was 104 nurses. no nurse was excluded from the study. in the present study, the researcher developed and used a structured observational checklist (standardized checklist) of the who [9] after modification for assessment of the quality of nursing care which was divided into two parts: part i consisted of items related to the demographic data such as age, gender, educational qualifications and years of work experience. part ii consisted of 20 items related to various aspects of nursing. items categorized under seven main dimensions which are (adequate staff, patient’s care, nurses’ neatness, health, adaptability, loyalty, and environment). a five-point likert scale was used to assess each item, giving one score for the very bad and five scores for the very good. accordingly, a 100 score scale was calculated (20 questions x five scores). ethical approval was obtained from the research ethics committee of the college of nursing (no. 60, dated dec 17, 2017). statistical analysis: the statistical package for social sciences (spss, version 22) was used 39 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2020.05 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article or comments before the patient (87.8%); q13: show understanding and courtesy to her/his co-workers (86.5%); q6: establish good rapport with patients (81.1); q14: meet new situation calmly (77%); q15: accept suggestions for improvement graciously (73%); q7: in uniformwithout jewelry and tidy (66.2). the performance in the other areas was neutral as mentioned in table 2. for data entry and analysis. the chi-square test of association was used to compare proportions. fisher’s exact test was used (instead of chi-square test) when the expected count of more than 20% of the cells of the tables was less than 5. a p-value of ≤ 0.05 was considered as statistically significant. the total number of nurses was 74, their mean age + sd was 37.35 + 9.27 years, ranging from 22 to 63 years. the median was 35 years. around half (48.6%) of the sample aged 30-39 years as presented in table 1 which shows that 62.2% of the sample were females. more than one third (37.8) of the nurses were working in rizgary teaching hospital, and another 37.8% were working in hawler teaching hospital and 24.3% were working in the maternity teaching hospital the majority of the nurses were working in surgical wards (71.6%), and the rest were working in medical wards. the table shows also that the majority (79.7%) of the nurses were married. table 2 shows that there was a shortage of nurses during the day (q1), and during the night (q2). the table shows that only 37.8% of the nurses perform assignments in a good manner, and none of them perform assignments in a very good manner (q3). the performance of nurses was very bad or bad in the following areas: q19: disposal of soiled linen promptly (100%); q20: adequate lighting in the ward (98.7%); q18: cleanliness inward/room (98.7%); q10: hand washing before and after patient treatment (98.6%); q17: observe rules and uphold standards (90.6%); q4: show a genuine interest in comfort and progress of patients (52.7%). on the other hand, the performance of nurses was good in the following areas: q9: observe good health habits, cleanliness , good posture (89.2); q16: avoid criticism 40 erbil journal of nursing & midwifery results table 1: demographic characteristics of the study sample variable no. (%) age (years) < 30 14 (18.9) 30-39 36 (48.6) 40-49 17 (23) ≥ 50 7 (9.5) gender male 28 (37.8) female 46 (62.2) hospital rizgary teaching hospital 28 (37.8) hawler teaching hospital 28 (37.8) maternity teaching hospital 18 (24.3) ward medical 21 (28.4) surgical 53 (71.6) marital status married 59 (79.7) single 15 (20.3) total 74 (100) https://doi.org/10.15218/ejnm.2020.05 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 41 erbil journal of nursing & midwifery table 2: distribution of sample by the performance of nursing personnel. performance score (5 points likert scale) 1 (very bad) 2 (bad) 3 (neutral) 4 (good) 5 (very good) no. (%) no. (%) no. (%) no. (%) no. (%) q1-adequate staff available at the ward 15 (20.3) 53 (71.6) 6 (8.1) 0 (0) 0 (0) q2adequate staff available at the night 74 (100) 0 (0) 0 (0) 0 (0) 0 (0) patient-does she/he q3perform assignments skillfully 0 (0) 3 (4.1) 43 (58.1) 28 (37.8) 0 (0) q4show a genuine interest in comfort and progress of patients 0 (0) 39 (52.7) 29 (39.2) 6 (8.1) 0 (0) q5observe and report unusual incidents and symptoms 0 (0) 11 (14.9) 45 (60.8) 18 (24.3) 0 (0) q6establish a good rapport with the patient 0 (0) 0 (0) 14 (18.9) 60 (81.1) 0 (0) neatness-does she/he q7in uniformwithout jewelry and tidy 8 (10.8) 4 (5.4) 9 (12.2) 49 (66.2) 4 (5.4) q8in workdoes she return articles to their proper place and aid in keeping units neat 0 (0) 1 (1.4) 38 (51.4) 35 (47.3) 0 (0) health-does she/he q9observe good health habits, cleanliness, and good posture 0 (0) 0 (0) 8 (10.8) 66 (89.2) 0 (0) q10hand washing before and after patient treatment 51 (68.9) 22 (29.7) 1 (1.4) 0 (0) 0 (0) q11use hand rub gel with gloves 8 (10.8) 19 (25.7) 34 (45.9) 13 (17.6) 0 (0) q12provide nursing service immediately even if too busy 0 (0) 5 (6.8) 64 (86.5) 5 (6.8) 0 (0) adaptability-does she/he q13show understanding and courtesy to co-workers 0 (0) 0 (0) 10 (13.5) 64 (86.5) 0 (0) q14meet new situation calmly 0 (0) 0 (0) 17 (23) 57 (77) 0 (0) q15accept suggestions for improvement graciously 0 (0) 0 (0) 20 (27) 54 (73) 0 (0) loyalty-does she/he q16avoid criticism or comments before the patient 0 (0) 0 (0) 9 (12.2) 65 (87.8) 0 (0) q17observe rules and uphold standards 1 (1.4) 66 (89.2) 6 (8.1) 1 (1.4) 0 (0) environment-does she/he q18cleanliness inward/room (sheets, floor) 54 (73) 19 (25.7) 1 (1.4) 0 (0) 0 (0) q19nurses dispose of soiled linen promptly 63 (85.1) 11 (14.9) 0 (0) 0 (0) 0 (0) q20adequate lighting in the ward 60 (81.1) 13 (17.6) 1 (1.4) 0 (0) 0 (0) https://doi.org/10.15218/ejnm.2020.05 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 42 erbil journal of nursing & midwifery results showed that the mean total scores was 54.52 out of 100, the median was 55, ranging from 45 to 63 out of 100. table 4 shows that nearly two thirds (64.3%) of nurses in the rizgary teaching hospital got a high-performance score, compared with 50% in each of hawler's teaching hospital and the maternity hospital, but the differences were not significant (p = 0.487). a higher proportion of nurses in the medical wards (61.9%) got high scores than the surgical wards (52.8%), but the difference was not significant (p = 0.479). the performance of female nurses was better than the male nurses, where it is evident in the table that 60.9% of females got high scores compared with 46.4% of males (p = 0.225). those who scored less than 55 out of 100 were considered as having low scores (44.6%), and the rest (55.4%) as having high performance scores, as presented in table 3. regarding the marital status, more than half (59.3%) of married nurses got a high-performance score, while only 40% of single nurses got high scores (p = 0.179).regarding the no. of years of formal education, the majority (80.0%) of the nurses who got high scores were in the secondary school of nursing, while only 40% of single nurses got high scores (p = 0.179).regarding the duration of service, around two-thirds (60%) of the nurses with ≥20 years of experience got high scores (p = 0.738). table 3:distribution of nurses according to total performance score scores (out of 100) no. (%) 45-49 7 (9.5) 50-54 26 (35.1) 55-59 35 (47.3) 60-64 6 (8.1) total 74 (100) https://doi.org/10.15218/ejnm.2020.05 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 43 erbil journal of nursing & midwifery low score high score total p-value no (%) no. (%) no. (%) hospital rizgary teaching hospital 10 (35.7) 18 (64.3) 28 (100) 0.487 hawler teaching hospital 14 (50) 14 (50) 28 (100) maternity teaching hospital 9 (50) 9 (50) 18 (100) ward 0.479 medical 8 (38.1) 13 (61.9) 21 (100) surgical 25 (47.2) 28 (52.8) 53 (100) gender 0.225 male 15 (53.6) 13 (46.4) 28 (100) female 18 (39.1) 28 (60.9) 46 (100) marital status 0.179 married 24 (40.7) 35 (59.3) 59 (100) single 9 (60) 6 (40) 15 (100) total 33 (44.6) 41 (55.4) 74 (100) table 4: nurses’ performance scores by the hospital, ward type, gender, and marital status. table 5: nurses’ performance scores by years of formal education and duration of service low score high score total p-value 0.236* no. (%) no. (%) no. (%) no. of years of formal education 9 1 (20) 4 (80) 5 (100) 12 10 (37) 17 (63) 27 (100) 14 22 (53.7) 19 (46.3) 41 (100) 16 0 (0) 1 (100) 1 (100) duration of service 0.738 <10 15 (50) 15 (50) 30 (100) 10-19 10 (41.7) 14 (58.3) 24 (100) ≥ 20 8 (40) 12 (60) 20 (100) total 33 (44.6) 41 (55.4) 74 (100) * fisher’s exact test. https://doi.org/10.15218/ejnm.2020.05 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 44 erbil journal of nursing & midwifery it was evident that there was a shortage of nurses, especially at night. a shortage of staff could be considered as a contributing factor for poor nurse performance, and this was supported by a study done in namibia by soilkki et al (2014) [10], and a study was done in egypt by sleem and elsayed (2011) [11]. in general, one nurse should serve a maximum of five patients, but according to the researcher’s observation one nurse served around 10 patients especially at night (12) knowing that the number of patients is not fixed everyday. the performance of nurses was very bad or bad in the following areas: disposal of soiled linen, ventilation, cleanliness of the ward/room. this may be attributed to the presence of a ‘cleaning services company’, accordingly, the nurses feel that they are not responsible for these tasks. hand washing before and after patient treatment was not practiced by the nurses because there was no special washbasin in the ward, so the nurses used to use the hand sanitizers instead. noncompliance with the observing rules and upholding standards, and showing a genuine interest in comfort and progress of patients was poor. the reason for this could be due to poor training of the nurses, knowing that the majority of them were not college graduates. a study done in malawi by montgomery et al (1949) showed that some challenges identified by the health care providers can hinder the implementation of standards including a shortage of staff, high workload, and inadequate knowledge and skills [13]. another study done in erbil by ai-banna (2018) showed that the highest percentage of the participants (nurses) answered that they were dissatisfied with the use of skills and abilities, and work activities [14].on the other hand, the performance of the nurses was good in the following areas: personal cleanliness, and good posture; avoiding criticism or comments before patient; showing understanding and courtesy to her/his co-workers; establishing a good rapport with patients; meeting new situations calmly; accepting suggestions for improvement graciously; and wearing the tidy uniformwithout jewelry. overall levels of quality of nursing care regarding the quality of nursing care in the ward, table 4 showed that more than half of the nurses provided a high level of quality of care. a study done in erbil hospitals by qadir (2015) showed that the highest percentage (75.7%) of nurses provided a fair level of quality of care and the rest provided a good level of quality of care [15]. the result of the study done by alfatlawy (2012) in najaf showed that the nursing care did not reach the desired level due to the deficiency in the level of knowledge and practice of the nursing staff and its effect on the type of nursing care [16].it was supported by the study done in delhi by ara et al (2015) which showed that the majority (77%) of the staff nurses provide average quality of nursing care [17]. this also was consistent with a study done in the west pomerania province by rotter et al (2014) [18] on nurses working at medical, surgical and psychiatric wards, which showed that more than half of them rated as moderate. this finding was consistent with trin koff et al (2010) [19] who conducted a study on nurses working in the american center and found the level of performance was moderate. kamati et al (2014) conducted a study on nurses working at the referral and training hospital in namibia and stated that the majority of nurses rated their level of performance at a moderate level [20].in contrast, shang et al (2013) who conducted a study on nurses working in medical, surgical and discussion https://doi.org/10.15218/ejnm.2020.05 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 45 erbil journal of nursing & midwifery oncology units and mentioned that nurses rated their level of performance as bad [21]. the present study showed no significant differences between nurses' performance scores of medical and surgical wards. a similar study done by soliman et al (2015 )in el mansoura, egypt, showed no significant differences between the mean scores for nurses' caring behavior (performance) in medical and surgical wards [22]. the present study also revealed that there was no significant association between the quality of nursing care with nurses’ age, educational level and years of work experience. this coincides with the results of a study done in delhi by ara et al (2015) which showed that there was no significant association between quality of nursing care performance by staff nurses and their age, educational level, and duration of service [17]. one of the limitations of the study is that not all the nurses were included in the study (we included the majority of them). some of the items of the questionnaire doesn’t fit exactly the current system of erbil hospitals. the strength of this study is that this study will form a baseline for future researches in order to improve the nursing care in erbil hospitals. it is recommended to create a system for monitoring and evaluation of the health care delivery. all the stakeholders should be involved in that system. providing training programs for nurses to improve performance, decrease time waste, and increase patient care time. conducting continuing education programs (training courses) for the nurse managers about: management functions (clinical, managerial, professional skills) and how it can be used to empower subordinates to increase productivity. it is recommended to engage the nurses in courses of continuing professional development (cpd) and to set standards for nursing care in the mentioned hospitals. the performance of nurses working in erbil governmental hospitals was, in general, not so satisfactory (fair). the authors report no conflict of interest [1] dubois ca, d’amour d, pomey mp, girard f, brault i. conceptualizing performance of nursing care as a prerequisite for better measurement: a systematic and interpretive review. bmc nursing. 2013 dec;12 (1):7. [2] al-kandari f, thomas d. perceived adverse patient outcomes correlated to nurses’ workload in medical and surgical wards of selected hospitals in kuwait. journal of clinical nursing. 2009 feb;18(4):581-90. [3] cornell p, riordan m, herrin-griffith d. transforming nursing workflow, part 2: the impact of technology on nurse activities. jona: the journal of nursing administration. 2010 oct 1;40(10):432-9. [4] semachew a. implementation of the nursing process in clinical settings: the case of three governmental hospitals in ethiopia, 2017. bmc research notes. 2018 dec;11 (1):173:1-5 [5] burhans lm, alligood mr. quality nursing care in the words of nurses. journal of advanced nursing. 2010 aug 1; 66(8):1689-97. [6] faltas sf, abd-allah kf. the relation between nurses' workload and patients' safety in surgical and neurological intensive care units. journal of nursing and health science (iosr-jnhs). 2018; 7(6): 21-33 [7] westra bl, clancy tr, sensmeier j, warren jj, weaver c, delaney cw. nursing knowledge: big data science—implications for nurse leaders. nursing administration quarterly. 2015 oct 1;39(4):304-10. [8] johny sa, moly kt, sreedevi pa, nair rr. effectiveness of nursing process based clinical practice guideline on quality of nursing care among post cabg patients. international journal of nursing education. 2017 apr;9(2):120-6. conclusion conflict of interests references https://doi.org/10.15218/ejnm.2020.05 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 46 erbil journal of nursing & midwifery [9] world health organization. principles of administration applied to nurse service 1985. monograph series; no.41 [10] soilkki kk, cassim n, karodia am. an evaluation of the factors influencing the performance of registered nurses at the national referral hospital in namibia. australian journal of business and management research. 2014 may 1; 4(2):47. [11] sleem wf, el-sayed nm.the effect of job conscientiousness on job performance. nature and science. 2011 9(1) 130-136. retrieved on may 9, 2015, from https:// www.sciencepub.net/nature. [12] duffield c, diers d, o'brien-pallas l, aisbett c, roche m, king m, et al. nursing staffing, nursing workload, the work environment and patient outcomes. applied nursing research. 2011 nov 1;24(4):244-55. [13] montgomery tl, steward re, shenk ep. observations on the rooming-in program of baby with mother inward and private service. american journal of obstetrics & gynecology. 1949 jan 1;57(1):176-86. [14] al-banna da. impact of nurse’s satisfaction on work performance. erbil journal of nursing and midwifery. 2018 may 5;1(1):2-9. [15] qadir do, younis ym. quality of nursing care for patients with acute myocardial infarction at coronary units of erbil city hospitals. zanco journal medical science. 2015; 19 (2): 1011-1018 theses msc [16] al-ftlawy dm. determination of nurses' knowledge toward care provided to patients with acute myocardial infarction innajaf city. kufa journal for nursing sciences. 2012; 2(2):1-1. [17] ara bn, somibala t, urmila b. quality of nursing care rendered by staff nurses and patients satisfaction: a comparative study. international journal of nursing education. 2015 apr; 7(2):87-92. [18] rotter i, kemicer-chmielewska e, lipa p, kotwas a, jurczak a, laszczyńska m, et al. assesment of psychosocial work conditions of nurses at selected hospital wards. med. pr. 2014 jan 1; 65:173-9. [91] trinkoff am, johantgen m, storr cl, han k, liang y, gurses ap, hopkinson s. a comparison of working conditions among nurses in magnet® and non-magnet® hospitals. journal of nursing administration. 2010 jul 1;40 (7/8):309-15. [20] kamati sk, cassim n & korodia am. an evaluation of the factors influencing the performance of registered nurses at the national referral hospital in namibia. australian journal of business and management research. 2014; 4(2) 47-62. [21] shang dj, friese dc, wu me, aiken lh. nursing practice environment and outcomes for oncology nursing. cancer nursing. 2013 may;36(3):206. [22] soliman hm, kassam ah, ibrahim aa. correlation between patients' satisfaction and nurses' caring behaviors. journal biol agriculture and healthcare. 2015; 5(2):30 -41. https://doi.org/10.15218/ejnm.2021.11 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article attitudes of couples attending family counselling clinic in sulaimani city towards the premarital screening and genetic counseling programme abstract introduction the choice of a marriage partner is normally unrestricted. many intended partners, however, join the lifetime union of marriage with no information about their future partner's health status. many medical problems, especially those related to the health of the offspring, may be diagnosed and treated before or after marriage. this could aid in the avoidance or reduction of certain regrettable long-term obligations [1]. premarital screening (pms) is a test performed before getting married to diagnose certain inherited blood disorders (such as sickle cell anaemia and thalassemia) as well as infectious diseases (such as hepatitis b and c/hiv"aids"). pre-marital testing is an effective method for monitoring, reducing, and avoiding genetic abnormalities and certain viral infections; restricting the transmission of infectious background and objectives: premarital screening is an effective method for monitoring, reducing, and avoiding genetic abnormalities and certain viral infections. this study aimed to explore the attitudes of couples who attended a family counselling clinic in sulimani city towards the premarital screening and genetic counselling programme. methods: a cross-sectional, descriptive-analytic study was carried out on 310 couples attending the family counselling clinic in sulaimani city. the statistical analysis was performed by using descriptive and inferential statistical data analysis including frequency, percentage, mean and stranded deviation, independent samples t-test and one way anova (f-test). results: the study findings revealed that the majority of the study participants were 20-30 years old. in terms of attitudes, 73.55% of the couples had a favourable attitude toward premarital screening and genetic counselling. there were statistically significant differences between couples' attitudes and age (p=0.012), educational level (p=0.013), and consanguinity (p < 0.001), but there were no statistically significant differences between couples' attitudes and gender (p=0.49), employment (p=0.785), residential area (0.116), and family history of hereditary blood disease (p=0.45) because of p-value >0.05. conclusion: couples' attitudes about premarital screening and genetic counselling programmes are positive. keywords: premarital screening; genetic counselling; attitude; couple. nyan luqman aziz; department of nursing, college of nursing, sulaimani university, sulamani, iraq. (correspondence: nyanluqman1@gmail.com) salih ahmed abdulla;department of nursing, college of nursing, hawler medical university, erbil, iraq. 96 erbil journal of nursing & midwifery received: 18/09/2021 accepted: 10/11/2021 published: 30/11/2021 mailto:nyanluqman1@gmail.com?subject=nyanluqman1@gmail.com https://doi.org/10.15218/ejnm.2021.11 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article diseases; and reducing the prevalence of some genetic blood diseases. stopping social and psychological issues for families with children that have inherited diseases encourages the idea of universal healthy marriage [2].currently, premarital counselling (pmc) is one of the most important strategies for the prevention of genetic disorders, congenital anomalies and several medical and psychological marital problems [4]. the community health nurses play a fundamental role in providing premarital care services that include assessing a hereditary risk, providing information, discussing available testing options and providing appropriate counselling [5]. it is therefore important for couples to have adequate knowledge and a positive attitude towards pmc and thus increase the possibility of a successful marriage [6]. in the iraqi kurdistan region, a programme to avoid significant hemoglobinopathies was established in 2008. in the three provinces of the region, a premarital screening programme to detect hemoglobinopathies carriers was established in duhok, erbil and sulaimani. the programmes' application was assisted by legislation enacted by the provincial parliament rendering premarital hemoglobinopathies screening obligatory. in the programmes, the are no attempts by the counsellors to influence the couples' decision-making; rather they focus on providing qualified information on the many alternatives for couples who are at high risk of having affected children. the couples pay a little fee for premarital screening for major hemoglobinopathies, which also includes blood group screening, hepatitis b surface antigen, and hepatitis c antibodies [7]. this study aimed to identify the attitudes of couples regarding premarital screening and genetic counselling and to determine the association between socio-demographical data and the couples' attitudes regarding premarital screening and genetic counselling. a cross-sectional, descriptive study was carried out on the couples in sulaimani city in the kurdistan region of iraq from 20th january 2021 to 30th january 2022. the duration of data collection was three months.a convenience sampling technique was used for the data collection. there were 310 couples included in the study based on the inclusion criteria and an agreement to participate. this study was accepted by the scientific committee of the college of nursing and approved by the ethical committee of the college of medicine of the university of sulaimani. an official letter from the college of nursing of the university of sulaimani was presented to the general directorate of health (doh) in sulaimani to obtain an agreement for data collection, which was then provided to the family counselling clinic. the couples were chosen according to the inclusion criteria, which included age ≥ 16, both genders, ability to communicate in kurdish language, willingness to participate in the study and the first marriage. the couples who had mental health disorders were excluded. the data were collected through the face to face interviews by using a questionnaire, which consisted of two parts based on the proposed research objectives. the first part contained the couple's socio-demographic information such as age, gender, educational level and employment, consanguinity, personal history of hereditary disease, and family history of hereditary disease. the second part included an assessment of the couple's attitudes regarding the premarital screening and genetic counselling programme that consisted of 17 items with 5 points likert scale (1 = strongly disagree, 2 = disagree, 3 = unsure, 4 = agree, and 5 = strongly agree). 97 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2021.11 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article blood diseases. the consanguinity marriages represented 26.8% of couples, out of which, 65.1% were first-degree cousins, and 34.9% were second-degree cousins. regarding the family history of hereditary blood disease, it was found that only 1.3% of the study population had a genetic disease in the family (thalassemia 50% and g6pd 50%). the data in table 4 reveal the distribution of couples according to their attitudes in a five-point likert scale and three levels of attitude, the table shows that out of seventeen items couples had a good attitude in twelve items, fair attitude in four items and poor attitude in one item, with total mean and standard deviation 2.55±0.59, and a good level of attitude in general. as shown in table 5, the studied factors of age, educational level, and consanguinity were significantly associated with the attitude level of the couples toward premarital screening and genetic counselling programme because the result of the p-value was less than the common alpha 0.05, whereas there were no statistically significant differences between couples’ attitude and gender, employment and a residential area. twelve of the items were written positively and the remaining seven items were worded negatively. the scores of the negative items were reversed to calculate the attitudes. the validity of the questionnaire was checked initially by a panel of 10 experts specialized in nursing and medicine, and their comments were taken into consideration. alpha cronbach was used to determine the reliability of the questionnaire. as a result, the value of reliability (alpha cronbach) was equal to 0.912 and the validity was 0.832, which indicates a highly reliable questionnaire. all statistical computations were enhanced using statistical software (spss 24). the data were coded, tabulated, and presented in a descriptive form and analyzed using basic statistical methods including alphacronbach used for testing the reliability of the questionnaire. descriptive statistical data analysis included frequency, percentage, mean and standard deviation. inferential data analysis included the parametric test: independent samples t-test and one way anova (f-test). the criteria of the probability level and determining the significance of the test p -value were: highly significant (p< 0.001), significant (p< 0.05), and non-significant (p> 0.05). table 1 shows that the reliability and validity of the couple's attitudes were 0.912 and 0.832 respectively. table 2 demonstrates that the majority of couples were 20-30 years old. the lowest percentage of participants (8.4%) was more than 30 years old with a mean ± sd of 24.00 ± 4.64 years. most of the study sample (30%) achieved a secondary school educational level, most of them (53.9%) were employed in different sectors, and 62.9% resided in urban areas. table 3 shows the distribution of the sample according to consanguinity, and personal and family history of hereditary 98 erbil journal of nursing & midwifery results table 1: reliability and validity methods reliability (alpha cronbach) validity couple’s attitude 0.912 0.832 https://doi.org/10.15218/ejnm.2021.11 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article 99 table 2: distribution of the samples according to age, gender, educational level, employment and residential area characteristic variables items frequency percentage age less than 20 years old 45 (14.5) 20-30 years old 239 (77.1) more than 30 years old 26 (8.4) mean ± s.d 23.9 24.00 ± 4.64 gender female 155 (50) male 155 (50) educational level illiterate 2 (0.6) primary school graduated 31 (10) intermediate school 49 (15.8) secondary graduated 93 (30) institute 61 (19.7) college 74 (23.9) employment governmental employed 14 (4.52) private sector employed 32 (10.32) self-employed 121 (39.03) unemployed 143 (46.13) residential area urban 195 (62.9) sub-urban 115 (37.1) total 310 (100) table 3: distribution of the sample according to consanguinity, personal and family history of hereditary blood disease characteristic variables frequency percentage consanguinity yes 83 (26.8) no 227 (73.2) total 310 (100) if yes type of relation 1st cousins 54 (65.1) 2nd cousins 29 (34.9) total 310 (100) personal history of hereditary blood disease yes 0 (0) no 310 (100) total 310 (100) family history of hereditary blood disease yes 4 (1.3) no 306 (98.7) total 310 (100) if yes type of family history of hereditary blood disease thalassemia 2 (50) skill cell anaemia 0 (0) g6pd 2 (50) others 0 (0) total 4 (100) erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.11 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article 100 erbil journal of nursing & midwifery table 4: distribution of the sample according to the attitudes towards premarital screening and genetic counselling program note / no.: frequency (number) , weight average (mean) for 3point likert scales: 1.0-1.66 : poor attitudes , 1.67-2.33: fair attitudes,2.34-3.0: good attitudes. questions poor attitudes fair attitudes good attitudes mean (s.d) level of attitudes no. no. no. (%) (%) (%) pmsgc must be done for every partner before marriage 1 0 309 2.99 (0.11) good attitude (0.3) (0) (99.7) pms is to detect some diseases that transmitted to my offspring 8 15 287 2.9 (0.38) good attitude (2.6) (4.8) (92.6) pmsgc is to avoid transmission of diseases to me 31 16 263 2.75 (0.62) good attitude (10) (5.2) (84.8) it is important to raise awareness about pmsgc before marriage to reduce genetic and stds 5 9 296 2.94 (0.3) good attitude (1.6) (2.9) (95.5) pmsgc should be performed only for couples who have a family history of genetically inherited diseases 8 16 286 2.9 (0.38) good attitude (2.6) (5.2) (92.3) pmsgc is interference with god's will for a sick baby to be born 11 27 272 2.84 (0.45) good attitude (3.5) (8.7) (87.7) pmsgc brings conflict between couples 214 32 64 1.51 (0.82) poor attitude (69) (10.3) (20.7) i prefer consanguineous marriage 114 44 152 2.12 (0.92) fair attitude (49) (14.2) (49) in a case of carrying genetic or inherited diseases, marriage decisions must be left to the couples 43 21 246 2.65 (0.71) good attitude (13.9) (6.8) (79.4) positive test results that indicate the presence of genetic diseases should affect and change marriage decisions. 111 65 134 2.07 (0.89) fair attitude (35.8) (21) (43.2) you would decide to stop the marriage if there was a communicable disease. 186 41 83 1.67 (0.87) fair attitude (60) (13.2) (26.8) there should be a law to prevent marriage in case of positive results for the presence of genetic diseases. 127 40 143 2.05 (0.93) fair attitude (41) (12.9) (46.1) the national premarital screening and counselling program has an important role in preventing genetic diseases in the community 23 28 259 2.76 (0.58) good attitude (7.4) (9) (83.6) hereditary diseases have a psychological impact on families 18 31 261 2.77 (0.55) good attitude (5.8) (10) (84.2) hereditary diseases have an economic impact on families 21 26 263 2.78 (0.54) good attitude (6.8) (8.4) (84.8) pmsgc is against my religious/cultural beliefs. 19 27 264 2.79 (0.54) good attitude (6.1) (8.7) (85.2) religious leaders should deliver messages about the importance of pmcs and genetics counselling 9 7 294 2.92 (0.36) good attitude (2.9) (2.3) (94.8) total 949 445 3876 2.55 (0.59) good attitudes (%) (18.01) (8.44) (73.55) https://doi.org/10.15218/ejnm.2021.11 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article less than three-quarters of couples strongly agreed that pre-marital screening and genetic counselling pmsgc must be done for every partner before marriage, while 0.3% disagreed that it should be done for everyone. furthermore, when asked about the negative items, most of the participants (92.6%) disagreed that pmsgc should be performed only for couples that have a family history of genetically inherited diseases. previously, it was reported that the majority of students (97.3%) believe that premarital screening should be done for both men and women. [8]. 92.5% of participants agreed that mandatory premarital screening (mpms) is done to detect some diseases that can be transmitted to the offspring. furthermore, 101 erbil journal of nursing & midwifery table 5: comparing means attitude scores and socio-demographic groups of the respondents. variables items no. mean s.d significant test (p-value) age less than 20 years old 45 2.4915 0.18181 4.494 ** (0.012) 20 – 30 years old 239 2.5624 0.16475 more than 30 years old 26 2.6018 0.16412 gender female 155 2.5488 0.16653 -0.691 * (0.49) male 155 2.5620 0.17198 educational level illiterate 2 2.6176 0.20797 2.942 ** (0.013) primaryschoolgraduated 31 2.4687 0.23158 intermediate school 49 2.5450 0.17881 secondary graduated 93 2.5414 0.15816 institution 61 2.5921 0.13451 college 74 2.5843 0.15949 employment governmental employed 14 2.6008 0.15508 0.356 ** (0.785) private sector employed 32 2.5570 0.16570 self-employed 121 2.5527 0.17292 unemployed 143 2.5529 0.16901 residential area city 195 2.5613 0.19588 1.576 * (0.116) out city 115 2.5263 0.17524 consanguinity yes 83 2.4848 0.17733 -4.589 * (< 0.001) no 227 2.5812 0.15874 if yes, type of relation first cousins 54 2.4935 0.18440 0.898 * (372) second cousins 29 2.4564 0.16907 family history of hereditary blood disease yes 4 2.6176 0.16031 0.757 * (0.45) no 306 2.5532 0.16914 if yes, type of family history of hereditary blood disease thalassemia 2 2.7353 0.04159 (0.432)* g6pd 2 2.7059 0.00001 note: g6pd: glucose-6-phosphate dehydrogenase * test (independent samples t-test), ** test (one way anova –f-test) weight average (mean) for 3point likert scales: 1.0-1.66: poor attitudes, 1.67-2.33: fair attitudes,2.34-3.0: good attitudes. discussion https://doi.org/10.15218/ejnm.2021.11 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article accepted that the positive test results that indicated the presence of genetic diseases should affect and change couples' decisions before the marriage, while 35.8% of participants disagreed that the positive test results should affect and change a decision to get married. these results demonstrate a fair attitude as hereditary diseases have a great impact on family and community. the results of the present study indicate that most couples (60%) would decide not to get married if there was a communicable disease, however, 26.8% disagreed and would not stop the marriage if a communicable disease was detected. this outcome indicates a fair attitude as there is no need not to proceed with the marriage but the communicable disease should be treated before the sexual intercourse. in this study, 46.1 % of couples agreed that there should be a law to prevent marriage in case of positive pms results but 41% of the participants disagreed, while 12.9% had no idea about it. another study also found that the opinions regarding the need for the law to prevent any marriage with positive results varied with 48.16% strongly disagreed, 35% agreed, 19.33% didn't know, and 7% disagreed [13]. the findings of this study showed that 83.6% of the sample agreed and 7.4 % disagreed that the national premarital screening and counselling program has an important role in preventing genetic diseases in the community, which is a good attitude. the premarital screening and counselling programs are important because many people are not aware of their state of health as well as that of the person they want to marry before entering the marriage. in the recent study majority of couples' agreed that genetic disorders have a great psychological and economic impact on families (84.2%, 84.8% respectively). this result is in agreement with another study, in which most participants sample agreed that pmsgc is meant to avoid the transmission of diseases. a large percentage (92.3%) of couples had a positive attitude regarding the importance of raising awareness about pmsgc before marriage to reduce genetic diseases and sexually transmitted diseases (stds) but only 2.6% had a negative attitude. a previous study reported that the majority of students (86.3%) strongly agreed that the pms program is important and that pms should be used to reduce some genetic and stds and raise awareness about the pms before marriage [9]. in the present study, more than 87.7% of couples disagreed with the notion that pmsgc is interference with god's will for a sick baby. another survey found that the majority of those who did not accept the pmc believed that it interfered with god's will. [10]. the majority (69%) of participants disagreed regarding the conflicting attitudes towards pmsgc among the couples, while 20.7% agreed. the important finding of the study was that almost half (48%) of the study sample disagreed with choosing a consanguineous marriage, while 36% of the sample agreed with consanguineous marriage. one of the previous studies showed that most of the studied sample (82.07%) did not prefer to marry blood relatives whereas 12.87% were confused [11]. only 5.07% showed a preference to marry a blood relative. approximately three-quarters of the participants (79.4.%) believed that in a case of carrying genetic or inherited diseases, marriage decisions should be left to the couples, while 13.9% disagree with couples' freedom to decide. another study [12] showed that the majority of the respondents (65.1%) believed that in the case of carrying genetic or inherited diseases, a marriage decision must be made by the affected couple. 43.2% of the participants 102 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.11 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article this study identified an overall good attitude towards premarital screening and genetic counselling, especially among the respondents between 20-30 years of age, of the male gender, a secondary school educational level, living in urban areas and unemployed. the authors are thankful to the staff at the family counselling clinic in sulaimani city in the kurdistan region of iraq. our warmest thanks and wishes of good health go to the couples who participated in this study. there is no conflict of interest and no financial support for any of the authors. [1] lafta fm, alshammary ag, jaafar sm, sabah e, dhafer g. pre-marital clinical test among intending couples in baghdad: clinical findings knowledge and attitudes. indian journal of public health research & development. 2019 may; 10(5):591. [2] khalil em, abdelkader sm, alsaeed md, alshahrany nm. knowledge, beliefs and behaviour intention about premarital screening among king saud university female students in riyadh. scholars journal of applied medical sciences. 2014; 2(5e):1797-805. [3] ali m, elshabory n, hassan he, zahra n, alrefai h. perception about premarital screening and genetic counselling among males and females nursing students. international organization of scientific research journal of nursing and health science. 2018; 7(1):517. [4] shaimaa hm, samah ae, hanan a. effect of application of health belief model on females' knowledge and practice regarding the premarital counselling. international organization of scientific research journal of nursing and health science.2017. agreed that hereditary diseases had psychological and economic effects on the families (88.7%, 79.8% respectively) [14].in the current study, the majority (85.2%) of respondents disagreed that the pmsgc was against their religious/ cultural beliefs. in addition, almost all (94.8%) of the studied sample agreed that religious leaders should deliver messages on the importance of the pmcs and genetic counselling, which is a good attitude. finally, the majority (73.55%) of the sample had a good attitude, 18.1% had a poor attitude and 8.44% had a fair attitude (mean 2.55). table 4 compares the means of the partner's attitudes and socio-demographic characteristics. the results of the study show that there were statistically significant differences between couples' attitudes and age (p=0.012), educational level (p=0.013) and consanguinity (p=0.000) because the result of the p-value was less than the common alpha 0.05. but there were no statistically significant differences between couples' attitudes and gender (p=0.49), employment (p=0.785), residential area (0.116), and family history of hereditary blood diseases (p=0.45) because p-value >0.05. this study demonstrated that there is an association between level of attitude toward premarital screening program and sociodemographic factors like female gender (p = <0.001), higher years of study (p = 0.002), and a higher income (p = 0.019), which were significantly associated with better attitude scores toward premarital screening program [15]. 103 erbil journal of nursing & midwifery conclusion acknowledgement conflict of interests references https://doi.org/10.15218/ejnm.2021.11 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article [14] melaibari m, shilbayeh s, kabli a. university students’ knowledge, attitudes, and practices towards the national premarital screening program of saudi arabia. journal of egyptian public health association. 2017 mar 1; 92 (1):36-43. [15] al-enezi k, mitra ak.knowledge, attitude, and satisfaction of university students regarding premarital screening programs in kuwait. european journal of environment and public health. 2017 dec 28; 1(2):07. [5] kamel mm, fahmy hi, aly se. knowledge and attitude of adolescent students' toward premarital examination in secondary schools at assiut city. assiut scientific nursing journal. 2019 mar 1; 7(16):13947. [6] fawzy rs, abd-allah im, el-shahat ibrahim m. knowledge, attitudes and needs of individuals attending premarital care at ismailia city. journal of nursing and health science. 2018; 7:10-20. [7] al-allawi na, al-doski aa, markous rs, amin ka, eissa aa, badi ai, et al. premarital screening for hemoglobinopathies: experience of a single centre in kurdistan, iraq. journal public health genomics. 2015; 18(2):97-103. [8] alhowiti a, shaqran t. premarital screening program knowledge and attitude among saudi university students in tabuk city 2019.international journal of medical research & health sciences. 2019; 8 (11):75-84. [9] ibrahim nk, al-bar h, al-fakeeh a, al ahmadi j, qadi m, al-bar a, milaat w.an educational program about premarital screening for unmarried female students in king abdul-aziz university, jeddah. journal of infection and public health. 2011 mar 1; 4 (1):30-40. [10] alkhaldi sm, khatatbeh mm, berggren ve, taha ha. knowledge and attitudes toward mandatory premarital screening among university students in north jordan. international journal for hemoglobin research. 2016 mar 3; 40(2):118-24. [11] mithila sn. a study on knowledge, perception and attitude towards premarital carrier screening (pmcs) among students attending universities (doctoral dissertation, east west university).2017. [12] bener a, al-mulla m, clarke a. premarital screening and genetic counselling program: studies from an endogamous population. international journal of applied and basic medical research. 2019 jan; 9(1):20. [13] albadrani gm, alshanbari hm, baraja da, alahaideb lk, alabdullah sm, alzahrani sm, alqahtani hw, almuhaisen.evaluating knowledge and attitude about premarital screening among princess nourah bint abdulrahman university students in riyadh. journal of research in medical and dental science. 2020; 8(6), 205–214. 104 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.07 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article physical activities among diabetic patients attending diabetic centers in kurdistan region, iraq abstract introduction diabetes mellitus is a metabolic disease involving the under production in insulin secretion or action, due to hyperglycemia. when uncontrolled, diabetes mellitus can cause many complications like blindness, renal failure, heart disease, atherosclerosis, and strokes [1]. in addition, exercise and physical activity are the main ways to control blood glucose levels. exercise can also improve blood circulation, lowers cholesterol and triglyceride levels due to improved muscle tone [2].nowadays, regular physical activity and exercise enhances body health in a general way and improves quality of life [3]. in type 2 diabetes mellitus, randomized controlled trials illustrated background and objective: physical activity is defined as basic public health for the human body and one of the main treatments for many chronic diseases, especially diabetes mellitus. the aim of this study to assess the level of physical activity among diabetic patients in kurdistan and determine the association between levels of physical activity and certain variables of socio-demographic and clinical data. methods: this cross-sectional study was conducted on 444 diabetes patients in the kurdistan region of iraq. the data was collected from 20th june to 10th september 2018 through interviews by using a questionnaire checklist. the data was analyzed by using the statistical package for the social sciences program. results: nearly half of the participants (49.1%) were middle-aged (36 55 years). majority of them were females (65.1%), married (88.1%) and illiterate (42.3%). nearly half of them (43.9%) were obese, having high blood glucose levels (76.8%) and half of them (50%) had hypertension. majority (75.5%) of participants were within high levels of physical activity. a highly significant relationship was found between the level of physical activity and sex (p -value < 0.001), presence other chronic diseases, hypertension and heart disease. there were significant relationships between the body mass index and diagnostic duration of diabetes mellitus with the presence of other chronic diseases, presence hypertension, and heart disease. conclusion: the majority of diabetic patients had high levels of physical activity, high blood sugar levels, obese, and had many chronic diseases. there was a statistically significant association between the level of physical activity with some variables of sociodemographic and clinical data. there was a highly significant association between body mass index and diagnostic duration of diabetes mellitus with the presence of other chronic disease. keywords: physical activity; diabetic mellitus; kurdistan region. jawdat mamand alhagbaker; department of nursing, college of nursing, hawler medical university, erbil, iraq. sideeq sadir ali; department of nursing, college of nursing, hawler medical university, erbil, iraq. correspondence: (sideeq.ali@hmu.edu.krd) bekhal saber ahmed; department of nursing, college of nursing, hawler medical university, erbil, iraq. 56 erbil journal of nursing & midwifery received: 18/9/2019 accepted: 22/12/2019 published: 30/5/2020 mailto:sideeq.ali@hmu.edu.krd https://doi.org/10.15218/ejnm.2020.07 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article that physical activity can delay advancement of impaired glucose tolerance if combined with dietary changes [4]. in spite of this evidence, diabetes organizations very strongly advocate incorporating some level of physical activity in the treatment of diabetes mellitus [5]. the american diabetes association (ada) council on exercise recommended that patients with type 2 diabetes should perform resistance exercise at least two times per week on the nonconsecutive days, but three times a week would be preferred. more ideally, physical activity for patients with type 2 diabetes should incorporate regular aerobic activities [6]. much of the guidelines about physical activity also applied in patients with type 1 diabetes mellitus. people with type 2 diabetes mellitus should be doing at least 150 min per week of moderate to strong physical activity outside their home at least three days per a week, with no more than two days of consecutive activity [7].despite groups of diabetes patients (both type 1 and type 2) being afraid that their hyperglycemia would act as a barrier to performing such physical activity, it is still advised that they are physically active as an important component of their diabetes management [8]. globally, prevalence of diabetes mellitus estimated by world health organization (who) in 1997 was more than 135 million and expected to increase by the year 2025 by 120% [9]. according to the who, prevalence of diabetes mellitus among patients 18 years of age and over was raised; in 1980 it was 4.7% but in 2014 it was 8.5%. according to their estimates, in 2016, diabetes mellitus was considered as the seventh leading cause of death, and estimated 1.6 million persons’ deaths were caused by diabetes mellitus directly [10]. shaw et al found that the world prevalence of diabetes mellitus among adults (aged 20 –79 years) was 285 million adults (6.4%) in 2010, and will be increased to 439 million (7.7%) by 2030 [11].prevalence of diabetes increased in all the countries and researchers noted the role of physical activity among diabetic patients in controlling glucose levels and decreasing complications. the researchers intended to assess the levels of physical activity and determine the association between levels of physical activity with socio demographical and clinical data. they also seek to determine the, if any, association between the presence of other diseases with the bmi and diagnostic duration of diabetes mellitus. a cross-sectional study was carried out in the three diabetes centers that are available in the iraqi kurdistan region, namely layla qasm diabetes center in erbil city, diabetes & endocrine center in sulaimania city and duhok diabetes center in duhok city. among 88,442 of diabetic patients who were registered in the registrations department of these diabetic centers, 62,767 of them were adults (erbil 36,325, sulaimania 3,098 and duhok 23,344), 444 nonprobability (purposive) adult diabetes patients participated in this study (erbil 176, sulaimania 140 and duhok 128). these diabetic patients were visiting the diabetic centers monthly for their medical checkups. the proportionate of sample size became approximately 400 participants for all three centers; erbil, sulaimani and duhok were 158, 136 and 106 participants respectively. the sample size was increased to account for a potentially higher prevalence of diabetes related to undiagnosed cases in the population. the sample size was estimated and calculated by using the formula for calculating the minimum sample size for cross-sectional studies. a sample size of 113 participants was estimated based on having a prevalence of diabetes of 0.08 with a degree of precision of 5% [12]. the inclusion criteria included 57 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2020.07 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article or more days weekly, or 5 or more days of any combination of walking, moderateintensity or vigorous intensity level activities reaching a minimal total physical activity of at least 600 met minutes/week, and category 3; high physical activity level conceived as vigorous-intensity activity, at least 3 days reaching a minimal total physical activity of at least 1500 met-minutes/ week, or 5 or more days of any combination of walking, moderate-intensity or vigorous intensity activities reaching a minimal total physical activity of at least 3000 met-minutes/week. all of the activities were set apart as ipaq scoring protocol [13, 14]. the study was carried out from may 1st, 2018 to august 1st, 2019. the data was collected from june 20th to september 10th, 2018. official permission was obtained from the directorates of health from erbil, suleimania and duhok. during the survey, the researchers briefly explained the purpose of the survey, obtained verbal consent from each participant, and completed the questionnaire by direct interview. data was analyzed by the statistical package for the social sciences (spss, version 20). descriptive and inferential statistics were used in this study with descriptive statistics used for calculating frequencies and percentages of participants. the association between levels of physical activity with the different sociodemographic and clinical characteristics of the participants was assessed by using inferential statistics and chi-square test. a p value of ≤ 0.05 was considered statistically significant. table 1 shows the socio-demographic characteristics of diabetic patients. 39.6% of the study participants were in erbil city. nearly half of the participants (49.1%) were middle-aged (36 55 years old). majority of the study participants were all diabetic patients who attend the diabetic center in those centers that mentioned above. patients who refused to participate and with limited communication wereexcluded. the investigators used the international physical activity questionnaire (ipaq), short form in the survey and data was collected through using the interview technique. part 1: the sociodemographic part, which included data about age, sex, marital status, location of the home, occupational status, and educational level. part 2: the clinical information part, which included the body mass index (bmi), diagnostic duration of diabetes mellitus, presence of other chronic diseases and type of chronic disease. part 3: the questions of ipaq short form were about specific types of physical activities during the seven days, under the following four domains: leisure time; domestic and gardening; work-related; and transportrelated physical activities. three levels of physical activity were assessed which included; walking; moderate-intensity activities (e.g., gardening, washing the car or clothes by hand, or bicycling at normal speed); and vigorous-intensity activities (e.g., heavy weightlifting, running or swimming). total physical activity of metabolic equivalent task (met)-minutes/week = walking + moderate + vigorous met minutes/week scores. note: met scores of 3.3, 4.0 and 8.0 for walking, moderate and vigorous intensity activity, did not reported days per week in which any of walking, moderate and vigorous intensity activity was reported. in regards to these three categories of physical activity, they were defined by ipaq as category 1 being low physical activity level, category 2 being moderate physical activity level including at least 20 minutes of vigorous intensity level activities done per day for 3 or more days per week, or at least 30 minutes of moderate intensity activity per day for five 58 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2020.07 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article diabetes mellitus with some chronic disease and complication of diabetes mellitus. there was a highly significant relationship found between groups diagnostic duration with the presence of heart disease (p-value < 0.001), and high significant relationship found between presence other chronic diseases (p-value = 0.001), presence hypertension (p-value = 0.007), presence kidney disease (p-value = 0.003), finally, a significant association was also found with the presence of anemia (p-value = 0.024). 59 erbil journal of nursing & midwifery female (65.1%). most of them were married (88.1%) and from urban areas (83.8%). finally, 60.6% of them were unemployed and 42.3% of them were illiterate. table 2 demonstrates the clinical information of the diabetic patients. around 44% of the diabetic patients were obese and 54.5% were diagnosed between 1 and 9 years duration. regarding the blood glucose level, majority of the participants (76.8%) had a high blood glucose level. regarding presence of other diseases, half of them (50%) had hypertension. table 3 explores the levels of physical activity of diabetic patients with the majority (75.5%) of them being at a high level of physical activity, 15.3% of them were at moderate level of physical activity and 9.2% were at low level of physical activity. table 4 focuses on the association between sociodemographic data and levels of physical activity of diabetic patients. there was a very high significant association between the sex of patients and the level of physical activity (p-value < 0.001) and another significant association was found between age groups and levels of physical activity with (p-value = 0.032). table 5 displays the association between some of the clinical information variables with the levels of physical activity. a highly significant relationship was found between levels of physical activities with the presence of other chronic diseases, such as hypertension and heart disease (p-value <0.001). another significant relationship was found with the presence of retinopathy (p-value = 0.009). table 6 shows the association between bmi groups with the presence of some chronic disease and complication of diabetes mellitus. there was a highly significant relationship between bmi with the presence other chronic diseases (p-value =0.002) and presence of hypertension (pvalue =0.001).table 7 shows the relationships between duration of diagnoses of table 1: socio-demographic characteristics of diabetic patients socio-demographic variables n= 444 f (%) residential area erbil 176 (39.7) sulaimania 140 (31.5) dahuk 128 (28.8) age groups 18 35 years old ( young adult ) 20 (4.5) 36 55 years old (middle-aged adults) 218 (49.1) 56 years old and above (older adult) 206 (46.4) sex of participants male 155 (34.9) female 289 (65.1) marital status married 391 (88.1) widowed 35 (7.9) location of home urban 372 (83.8) sub – urban 53 (11.9) rural 19 (4.3) occupational status of participants self employed 44 (9.9) retired 60 (13.5) governmental employee 71 (16) unemployed 269 (60.6) educational status of participants illiterate 188 (42.3) can read and write 85 (19.1) primary school 90 (20.3) secondary school 36 (8.1) institute or college 45 (10.1) total 444 (100 ) https://doi.org/10.15218/ejnm.2020.07 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 60 erbil journal of nursing & midwifery table 2: medical information of diabetic patients clinical information variables n= 444 f (%) bmi groups of participants under weight 3 (0.7) normal weight 81 (18.2) over weight 165 (37.2) obese 195 (43.9) diagnostic duration of diabetes mellitus 1 9 years 242 (54.5) 10 19 years 154 (34.7) 20 29 years 34 (7.7) 30 40 years 14 (3.2) level of blood glucose normal level of blood glucose 28 (6.3) above normal level of blood glucose 75 (16.9) high level of blood glucose 341 (76.8) presence of other chronic diseases yes 279 (62.8) no 165 (37.2) total 444 (100) type of chronic disease (*n=279) hypertension 222 (50) heart disease 109 (24.5) kidney disease 45 (10.1) retinopathy 60 (13.5) anemia 30 (6.8) stroke 3 (0.7) asthma 8 (1.8) neuropathy 48 (10.8) table 3: levels of physical activity physical activity n= 444 f (%) low level of physical activity 41 (9.2) moderate level of physical activity 68 (15.3) high level of physical activity 335 (75.5) total 444 (100) https://doi.org/10.15218/ejnm.2020.07 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 61 erbil journal of nursing & midwifery table 4: association between socio-demographic variables and levels of physical activity clinical information variables sub-groups levels of physical activity low level of physical activity (%) moderate level of physical activity (%) high level of physical activity (%) p-value age groups 18 35 years old ( young adult ) (0.5) (0.5) (3.6) 0.032 36 55 years old (middleaged adults) (2.5) (7.2) (39.4) 56 years old and above (older adult) (6.3) (7.7) (32.4) sex of participants male (4.1) (8.3) (22.5) <0.001 female (5.2) (7.0) (52.9) widowed (1.4) (1.4) (5.2) occupational status of participants self employed (0.2) (2.3) (7.4) 0.395 retired (1.4) (2.7) (9.5) governmental employee (1.6) (2.5) (11.9) unemployed (6.1) (7.9) (46.6) educational status of participants illiterate (4.5) (4.5) (33.3) 0.484 can read and write (1.1) (3.4) (14.6) primary (1.8) (3.6) (14.9) secondary (0.9) (1.6) (5.6) institute or college (0.9) (2.3) (7.0) total (9.2) (15.3) (75.5) https://doi.org/10.15218/ejnm.2020.07 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 62 erbil journal of nursing & midwifery table 5: association between clinical information and levels of physical activity levels of physical activity clinical information variables sub-groups low level of physical activity (%) moderate level of physical activity (%) high level of physical activity (%) pvalue bmi groups of participants under weight (0) (0) (0.7) 0.753 normal weight (1.4) (2.3) (14.6) over weight (3.6) (5.2) (28.4) obese (4.3) (7.9) (31.8) diagnostic duration of participants 1 9 years (3.8) (8.6) (42.1) 0.610 10 19 years (4.3) (4.7) (25.7) 20 29 years (0.7) (1.6) (5.4) 30 40 years (0.5) (0.5) (2.3) did you have any other chronic diseases yes (7.9) (11.3) (43.7) <0.001 no (1.4) (4.1) (31.8) did you have hypertension no (2.3) (6.1) (41.7) <0.001 yes (7.0) (9.2) (33.8) did you have heart disease no (5.4) (9.7) (60.4) <0.001 yes (3.8) (5.6) (15.1) did you have kidney disease no (8.1) (14.4) (67.3) 0.432 yes (1.1) (0.9) (8.1) did you have retinopathy no (7.9) (11.5) ( 67.1) 0.009 yes (1.4) (3.8) (8.3) did you have anemia no (8.3) (14.2) (70.7) 0.687 yes (0.9) (1.1) (4.7) did you have stroke no (9.2) (15.1) (75.0) 0.622 yes (0) (0.2) (0.5) did you have neuropathy no (8.1) (13.3) (67.8) 0.723 yes (1.1) (2.0) (7.7) normality and abnormality of blood sugar normal level of blood sugar (0.7) (0.7) (3.4) 0.570 above normal level of blood sugar (0.3) (1.0) (12.9) high level of blood sugar (6.8) (15.0) (59.2) total (7.8) (16.7) (75.5) https://doi.org/10.15218/ejnm.2020.07 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 63 erbil journal of nursing & midwifery table 6: association between clinical information and bmi groups some variable bmi groups of participants under weight normal weight over weight obese p-value (%) (%) (%) (%) did you have any other chronic diseases yes (0) (49.4) (63.0) (69.2) 0.002 no (100) (50.6) (37.0) (30.8) did you have hypertension no (100) (64.2) (52.7) (41.0) 0.001 yes (0) (35.8) (47.3) (59.0) did you have heart disease no (100) (82.7) (77.6) (70.3) 0.089 yes (0) (17.3) (22.4) (29.7) did you have kidney disease no (100) (90.1) (88.5) (90.8) 0.834 yes (0) (9.9) (11.5) (9.2) did you have retinopathy no (100) (88.9) (87.3) (84.6) 0.673 yes (0) (11.1) (12.7) (15.4) did you have anemia no (100) (98.8) (92.1) (91.8) 0.163 yes (0) (1.2) (7.9) (8.2) did you have stroke no (100) (100) (98.8) (99.5) 0.716 yes (0) (0) (1.2) (0.5) did you have neuropathy no (100) (88.9) (88.5) (89.7) 0.081 yes (0) (11.1) (11.5) (10.3) table 7: association between clinical information and group’s diagnostic duration some variable diagnostic duration of participants 1 9 years 10 19 years 20 29 years 30 40 years p-value (%) (%) (%) (%) did you have any other chronic diseases yes (54.5) (71.4) (76.5) (78.6) 0.001 no (45.5) (28.6) (23.5) (21.4) did you have hypertension no (57.0) (44.2) (32.4) (35.7) 0.007 yes (43.0) (55.8) (67.6) (64.3) did you have heart disease no (83.9) (68.2) (55.9) (57.1) <0.001 yes (16.1) (31.8) (44.1) (42.9) did you have kidney disease no (92.6) (90.3) (76.5) (71.4) 0.003 yes (7.4) (9.7) (23.5) (28.6) did you have retinopathy no (88.8) (85.7) (76.5) (78.6) 0.179 yes (11.2) (14.3) (23.5) (21.4) did you have anemia no (95.9) (91.6) (88.2) (78.6) 0.024 yes (4.1) (8.4) (11.8) (21.4) did you have stroke no (99.2) (99.4) (100) (100) 0.938 yes (0.8) (0.6) (0) (0) did you have neoropathy no (92.6) (85.1) (85.3) (85.7) 0.099 yes (7.4) (14.9) (14.7) (14.3) https://doi.org/10.15218/ejnm.2020.07 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 64 erbil journal of nursing & midwifery physical inactivity could be a global health problem as most studies focused and discussed leisure time physical activity, while physical activity at work, domestic and amid transport has not been assessed [15]. physical activity in adults with type 2 diabetes significantly increases by interventions of their behavioral [16]. such activity is linked to improving personal fitness and therefore could reduce the complications of chronic diseases and disabilities preventing an unhealthy weight [3]. the study was assessed by using ipaq, a suitable instrument and simple measurement to assess overall physical activity for diabetic patients. ipaq also provides information for the best way for control of blood glucose without using prescription drugs. the study determined that most of the study sample had a high level of physical activity. however, the majority of them had other chronic illnesses which further complicated their diabetes symptoms. moreover, nearly half of them were obese. the reason may be that the majority of them neglected to manage and control their blood glucose because as their blood glucose was high and may have neglected taking their medications. this study did not agree with that of acheampong in 2011 which was conducted on 350 diabetic patients in kumasi, ghana with more than half of their study sample having not received formal education at all, and a greater number of these patients not performing any physical exercise [17]. a very high significant relationship was shown between the sex of patients and the level of physical activity as well as between the age groups and the levels of physical activity. this may be due to nearly half the study population being middle aged and the highest level of physical activity is typically found within this age group. the result agreed with the cross sectional study conducted on 320 patients with type two diabetes in hamadan, iran; there was a significant (p<0.05) relationship between physical activity level and age group [18], the study was also agreed with a crosssectional nation-wide study conducted by sibai et al., 2013 on 2,195 haphazardly chosen adults aged 25 years and older in lebanese governorates. they found in their study that physical activity was significantly higher among the middle-age group [19].a very high significant association was found between levels of physical activity and the presence of other chronic diseases, especially with the presence of hypertension and heart disease, as well as with the presence of retinopathy. a high significant association was found between bmi with the presence of other chronic disease, especially with the presence of hypertension. the reason behind this could be that diabetes could lead to various complications in the arteries and arterioles making them more susceptible to developing atherosclerosis. also, the participants in this study majority of them were obese and high level of blood glucose. the result is similar to the findings of the previous cross-sectional study conducted by ali et al in determining the prevalence of diabetes mellitus complications among patients in duhok, erbil and suleimania cities of iraq. their study showed a significant association between some diabetes mellitus complications with demographic variables and showed highly significant differences in diabetic laboratory tests with bmi [9]. in addition, the results of our study were supported by the cross-sectional study conducted in 2009–2010 in spain by brugnara et al. in this study, low physical activity especially among women is associated with several cardiovascular risk factors and could discussion https://doi.org/10.15218/ejnm.2020.07 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 65 erbil journal of nursing & midwifery be responsible with an increasing prevalence of obesity and diabetes [20]. there was a highly significant association found between group’s diagnostic duration with presence of other disease, especially with the presence of heart disease and a high significant association with presence of other chronic diseases, like hypertension, kidney disease, anemia and normality and abnormality of blood sugar. for similar reasons, nearly half of the study group had been diagnosed for diabetes mellitus between one to nine years ago, but the majority of them had other chronic diseases that indicated diabetes mellitus complications. nearly half of them were obese and most of them had high blood glucose levels. petrie et al., 2018 reported that diabetes and hypertension are closely related together and diabetes is related to an increased risk of cardiovascular disease, which is overstated with coexistent hypertension [21]. the study was in agreement with the non-experimental, cross-sectional study of gutierrez et al., (2018) conducted in tabuk city in saudi arabia. in this study, researchers studied 432 participants and the results in their study showed a positive correlation between bmi with hypertension and diabetes mellitus (p <0.001); whereas the relationship between hypertension and diabetes mellitus was (p <0.001). thus, this relationship was the strongest correlation observed among those variables [22].in general, the study revealed that the majority of the study group was at a high level of physical activity, while the majority of diabetes patients were overweight and obese, had other chronic diseases, high levels of blood glucose, and were illiterate. not having statistically relationships between the levels of physical activity with the majority of the variables may be due to the limitations of the study such as lack of information about factors that controlling blood sugar such as; family history, illness, side effects of steroids or anti-psychotic medication, overconsumption of foods, stress, menstrual periods, pain and dehydration. also, our study only included asking about and not observing the exercise. patients might not have answered the question correctly or honestly. the study concluded that the physical activity among diabetic patients was high, but because of negligence of other parts of treating diabetes mellitus disease by the patients such as diet and medication, blood sugar remained high, patients remained obese and other side effects were present as well. there was a very high significant association between the levels of physical activity and bmi and some side effects, as well as an association between of level of physical activity with the patients’ sex and age. the authors report no conflicts of interest and any sources of financial support. [1] williams ls, hopper pd. understanding medical-surgical nursing. 2nd ed. usa, philadelphia: f.a. davis company publishing; 2003. p. 645-7. [2] timby bk, smith ne. introductory medicalsurgical nursing. usa, philadelphia: 10th ed. wiley-blackwell publishing; 2010. p. 788. [3] haskell wl, lee i-m, pate rr, powell ke, blair sn, franklin ba, et al. physical activity and public health: updated recommendation for adults from the american college of sports medicine and the american heart association. medicine and science in sports and exercise. 39(8), 1423-1434. available from:doi:10.1161circulation.107.18564 9 [accessed: 18th march 2019]. conclusion conflicts of interest references https://doi.org/10.15218/ejnm.2020.07 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 66 erbil journal of nursing & midwifery [4] knowler wc, barrett-connor e, fowler se, hamman rf, lachin jm, walker ea, et al. reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. the new england journal of medicine. 2002; 346 (6): 393-403. available from: doi: 10.1056/nejmoa012512 [accessed: 18th march 2019]. [5] rydén l, standl e, bartnik m, van den berghe g, betteridge j, de boer m-j, et al. guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary: the task force on diabetes and cardiovascular diseases of the european society of cardiology (esc) and of the european association for the study of diabetes (easd). european heart journal. 2007; 28 (1):88-136. available from: doi: 10.1093/ eurheartj/ehl260 [accessed: 18th march 2019]. [6] moy cs, songer tj, laporte re, dorman js, kriska am, orchard tj, et al. insulindependent diabetes mellitus, physical activity, and death. american journal of epidemiology. 1993; 137 (1): 74-81. available from: doi: 10.1093/oxfordjournals.aje.a116604 [accessed: 18th march 2019]. [7] colberg sr, sigal rj, fernhall b, regensteiner jg, blissmer bj, rubin rr, et al. exercise and type 2 diabetes: the american college of sports medicine and the american diabetes association: joint position statement executive summary. diabetes care. 2010; 33 (12): 2692-6.available from: doi: 10.2337/dc10-9990 [accessed: 18th march 2019]. [8] brazeau a-s, rabasa-lhoret r, strychar i, mircescu h. barriers to physical activity among patients with type 1 diabetes. diabetes care. 2008; 31(11): 2108-9. available from: doi: 10.2337/dc08-0720 [accessed: 18th march 2019]. [9] ali nsm, allela oqb, salih hm, ahmed ih. prevalence of type 2 diabetes associated complications ion kurdistan region iraq. journal of basic and clinical physiology and pharmacology. 2018; 9 (2): 262-269. [10] nadeau kj, regensteiner jg, bauer ta, brown ms, dorosz jl, hull a, et al. insulin resistance in adolescents with type 1 diabetes and its relationship to cardiovascular function. the journal of clinical endocrinology and metabolism. 2010; 95 (2): 513-21. available from: doi: 10.1210/jc.2009-1756 [accessed: 18th march 2019]. [11] shaw je, sicree ra, zimmet pz. global estimates of the prevalence of diabetes for 2010 and 2030. diabetes research and clinical practice. 2010; 1; 87 (1): 4-14. available from: doi: 10.1016/ j.diabres.2009.10.007 [accessed: 18th march 2019]. [12] araoye mo. research methodology with statistics for health and social sciences. 1st ed. nathadex: llorin publishing; 2004;p. 120. [13] hasandokht t, farajzadegan z, siadat zd, paknahad z, rajati f. lifestyle interventions for hypertension treatment among iranian women in primary health-care settings: results of a randomized controlled trial. journal of research in medical sciences.2015;20 (1): 54. [14] duarte ck, de almeida jc, merker aj, de oliveira brauer f, da costa rodrigues t. physical activity level and exercise in patients with diabetes mellitus. revista da associacao medica brasileira. 2012; 58 (2):215-21. [15] agha sy, al dobbagh sa. level of physical activity among teaching and support staff in the education sector in dohuk, iraq. eastern mediterranean health journal. 2010; 16 ( 12) : 1278-84. available from: doi:10.26719/2010.16.12.127[accessed: 18th march 2019]. [16] colberg sr, sigal rj, yardley je, riddell mc, dunstan dw, dempsey pc, et al. physical activity/exercise and diabetes: a position statement of the american diabetes association. diabetes care.2016; 1 39 (11): 2065-79 .available from: doi: 10.2337/dc16-1728 [accessed: 18th march 2019]. [17] acheampong ay. the relation between diabetes with hypertension and other cardiovascular risk factors using logit and probit model. (doctoral dissertation) 2011. (accessed july 15, 2018, available from: http://ir.knust.edu.gh/ bitstream/123456789/4067/1/ abraham%20yeboah% 20acheampong%20thesis202011.pdf) [accessed: 18th march 2019]. [18] fattahi a, barati m, bashirian s, heydari moghadam r. physical activity and its related factors among type 2 diabetic patients in hamadan. iranian journal of diabetes and obesity. 2014; 6 (2): 85-92. https://doi.org/10.15218/ejnm.2020.07 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 67 erbil journal of nursing & midwifery [19] sibai am, costanian c, tohme r, assaad s, hwalla n. physical activity in adults with and without diabetes: from the ‘high-risk ‘approach to the ‘population-based ‘approach of prevention. bmc public health. 2013; 13 (1): 1002. available from: doi: 10.1186/1471-2458-13-1002[accessed:18th march 2019]. [20] brugnara l, murillo s, novials a, rojomartínez g, soriguer f, goday a, et al. low physical activity and its association with diabetes and other cardiovascular risk factors: a nationwide, population-based study. plos one. 2016; 11 (8): e0160959. available from: doi: 10.1371/journal.pone.0160959 [accessed: 18th march 2019]. [21] petrie jr, guzik tj, touyz rm. diabetes, hypertension, and cardiovascular disease: clinical insights and vascular mechanisms. the canadian journal of cardiology. 2018; 34 (5): 575-84. available from: doi: 10.1016/ j.cjca.2017.12.005 [accessed: 18th march 2019]. [22] gutierrez j, alloubani a, mari m, alzaatreh m. cardiovascular disease risk factors: hypertension, diabetes mellitus and obesity among tabuk citizens in saudi arabia. the open cardiovascular medicine journal. 2018; 12:41. available from: doi: 10.2174/1874192401812010041 [accessed: 18th march 2019]. https://doi.org/10.15218/ejnm.2021.07 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article a qualitative investigation into the lived experiences of critical care nurses working on night shifts abstract introduction due to the nature of health care and given the emergencies that may arise, nurses who are a major part of the healthcare team are often required to work at any time of the day or night to provide continuing care to patients. in doing so, nurses usually suffer from different health problems either due to the stressful work environment or because of the sophisticated equipment used in the intensive care unit [1]. despite the importance of these health problems and their effect on the quality of health care delivered to patients, few studies have focused on background and objectives: shift work is used in the hospitals and residential treatment centres to provide patients with continuous health care. during their night shift, nurses are often faced with different health problems either due to the stressful work environment or because of the sophisticated instruments to be utilized in intensive care units. the present study was aimed at investigating the lived experience of nurses working on the night shifts at rizgary teaching hospital located in erbil, iraqi kurdistan region. methods: a qualitative phenomenological study was conducted to describe the lived experiences of nurses working on night shifts. in doing so and in order to collect the required data, open-ended semi-structured in-depth interviews were carried out to explore thoughts, feelings, and lived experiences of 15 nurses who were working on the night shifts in the intensive care unit (icu) at rizgary teaching hospital in erbil. the collected data were then analyzed by van manen’s (1990) method. results: study participants were between 26 and 38 years old. the majority were male (60%) and 40% were female. regarding marital status, 10 participants were married and 5 were single. most of the nurses had bachelor degrees (86.6%). the respondents work experience was between 3 and 8 years. almost all of the participating nurses had similar lived experiences during their night shifts. the nurses' lived experiences gave way to the emergence of four themes namely workload, psychosocial issues, sleep disturbance and physiological issues. conclusion: the present study showed that nurses working on night shifts faced many problems and issues such as poor sleep quality sleep, working for a long time, fatigue and anxiety, back pain, mood disturbance and lack of concentration. keywords: nurses, critical care unit, qualitative research, interview, lived experience halmat authman rasheed; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: halmat.rasheed@hmu.edu.krd) newroz ghazi aziz; department of nursing, college of nursing, hawler medical university, erbil, iraq. goran aboobaker osman; department of nursing, college of nursing, hawler medical university, erbil, iraq. 60 erbil journal of nursing & midwifery received: 24/07/2021 accepted: 22/09/2021 published: 30/11/2021 https://doi.org/10.15218/ejnm.2021.07 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article the nurses' lived experiences during the night shift and the effects on their day-today routine activities. it is stated that female nurses who work night shifts experience more issues and difficulties, especially if they have responsibilities in their family [2]. results of relevant research studies have shown that working the night shift can have a negative impact on sleep, social life, physical and mental health, family life, job-related stresses, and job performance [3].as a result of shift rotation, extended work schedules, and prolonged contact with irritable and depressed patients, nurses are exposed to psychological stress, which may emerge as taking on extra work, showing emotional withdrawal, engaging in substance abuse, or exhibiting depression [4]. therefore, and to deliver healthcare services of acceptable quality, nurse managers need to monitor nursing personnel regarding such behaviors, confront inefficient nurses whose poor performance leads to a decline in productivity, and refer them to appropriate support groups and or medical care [5]. as shown by results of relevant research studies, nurses working in certain specialities and departments such as intensive care units (icu) are more likely to experience psychological stress because icus are characterized by the presence of intricate machinery, high noise level, physical contact with blood, vomitus and infection hazards, continual time pressure, and unpredictable emergencies [6].shift working schedules have been studied in few studies whose results indicated that the quality of health care, patient satisfaction, treatment duration, absenteeism at work, the effectiveness of healthcare measures, and productivity can be seriously influenced by a poorly designed working schedule [7]. therefore, healthcare and hospital authorities need to take different factors into account while designing the nurses' working schedules. in general, medical and nursing services cannot be delivered well without assigning nurses to work in night shift; however, working the night shift can have serious effects on the nurses' personal and working life, and as a result the quality of the delivered healthcare services and the patients and nurses' satisfaction drop dramatically. in this regard, it is necessary to consider the lived experiences of nursing personnel working night shifts to design working schedules in a way that quality of healthcare services and patient and nurse satisfaction rise [8]. the present qualitative study was carried out to investigate the lived experience of nurses working the night shift at rizgary teaching hospital located in erbil, iraqi kurdistan region. since the present study was aimed at investigating the lived experience of the nurses working the night shift in icu, which is a complicated phenomenon due to a particular cultural and religious background of the target population, i.e. kurdish nurses living in the iraqi kurdistan region, a phenomenological method was employed. participants: 15 nurses (9 male and 6 female) working night shifts in the icu of rizgary teaching hospital of erbil, iraqi kurdistan region participated in the study. each of the nurses worked two days per week, 12 hours per shift, and they had approximately 4 years of work experience in intensive care units. a purposive sampling method was used to investigate their lived experiences of working night shifts. data collection: it is suggested that data collection in qualitative studies should be carried out through semi-structured interviews allowing the interviewer to control the pace, style, and question order to elicit the interviewee's fullest responses and help the interviewee answer the research questions in their own way [9].generally, 61 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2021.07 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article be completely confidential [12].data analysis: in order to investigate the lived experiences of the nurses working the night shifts at rizgary teaching hospital, the six methodological steps proposed by vanmanen’s method (1990) were utilized to analyze the collected data. to analyze qualitative data and reach a high level of abstraction, as suggested by research studies, hermeneutic approaches such as the one proposed by vanmanen are commonly utilized [13]. the 6 methodological steps proposed in this method include “turning to the nature of lived experience”, “investigating experience as we live it”, “reflecting on the essential themes which characterize the phenomenon”, “describing the phenomenon in the art of writing and rewriting”, “maintaining a strong and orientated relation to the phenomenon”, and “balancing the research context by considering the parts and the whole” [14].lincoln and guba's fourcriterion gold standard consisting of credibility, dependability, conformability, and transferability was used to maintain the rigour of the study [15]. moreover, to ensure the credibility of the findings, we kept a prolonged engagement with the data, two researchers were involved in the analysis and interpretation of data. different sources of the same information, such as numerous interviews, were used to validate the findings.[16]. the dependability and confirmability of the findings were assured by an academic auditor. the auditor checked whether the analysis was in line with accepted standards and examined the analysis process and records for accuracy. ethical considerations after the required permission was obtained from the hospital president, the necessary approval was gained from the ethics committee of college of nursing, hawler medical university (hmu) no. (4) on 29 january 2020. before the data collection, informed consent was qualitative methods through in-depth interviews are employed to gather information about the lived experience of individuals, and because the individuals' culture, the system of values, standards and expectations shape their lived experience, a phenomenological method was utilized in the present study. phenomenology is aimed at clarifying the meaning, nature, quality, and context of the individuals' experiences of a unique issue [10], and semistructured in-depth interviews were used to investigate the thoughts, feelings, and lived experiences of nurses working on the night shift. data were collected from 1st of march, 2020 to 1st of april, 2020. before the interviews, a list of main questions aimed at scaffolding the interviews, keeping the questioning on the topic, and linking what was asked in individual interviews to the overall design was devised. during the interviews, as suggested by research, some probing questions such as (tell me more about that, how did that make you feel, how will this affect you…. etc.) were asked in relation to the subject area [11]. in addition, open-ended questions were used in the in-depth interviews to obtain more insight into the issue under investigation. moreover, to come up with a deeper understanding of the lived experiences, feelings, and thoughts of the nurses, a friendly relationship was established with the nurses [10].interviews, each of which lasted 30 minutes, were held at the nurses’ home. following the nurses’ consent, the interviews were recorded and then transcribed verbatim. the transcripts were proofread by both the nurses and the researcher to see if there would be any mistakes or not. nurses were given unique codes (as nurse no. 1, no. 2, etc.), which were used in the transcripts, since the responses given by the interviewees may be affected if the anonymity is not assured. the participants were assured that their information would 62 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.07 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article participants were between 27and 38 years old. the majority of them were male (60%) and 40% were female. regarding marital status, 10 of the participants were married and 5 of the respondents were single. most of the nurses had bachelor degrees (86.6%). the respondents work experience was between 4 and 8 years. four main themes with sub-themes were identified: workload, psychosocial issues, sleep disturbance, and physiological issues. 63 erbil journal of nursing & midwifery results table 1: characterization of interviewees by sex, age, marital status, education and work experience. sn sex age marital status educational level work experience/years 1 male 32 married bachelor degree 6 2 female 30 marie bachelor degree 4 3 male 29 single bachelor degree 4 4 male 38 married bachelor degree 9 5 female 30 married bachelor degree 4 6 male 32 married bachelor degree 7 7 female 29 single diploma degree 4 8 male 31 married bachelor degree 5 9 male 33 married bachelor degree 4 10 female 35 married diploma degree 8 11 male 28 single bachelor degree 4 12 female 27 single bachelor degree 4 13 female 32 married bachelor degree 5 14 male 30 single bachelor degree 5 15 male 36 married bachelor degree 8 https://doi.org/10.15218/ejnm.2021.07 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article the nurses had to deal with numerous difficulties and problems due to the requirements of the icu ward where they have to be highly alert and have the ability to make critical, often life or death decisions, which was interpreted as psychosocial issues. it was observed that working on the night shift caused the nurses to experience fatigue, which might in turn result in personal and family issues, including mood disturbances, decreased performance, and negative effects on personal relationships with colleagues, if it is not dealt with appropriately. the night shift also caused the nurses to experience stress and anxiety, such that they interpreted the night shift as strenuous due to the lack of nursing staff and the resulting increased workload. in this regard, nurse no. 5 said: "as nurses, we encounter several challenges during the night shift. the challenges that we face include exhaustion, anxiety, stress, and poor social relationships because of the responsibilities that we have at home. these challenges are attributed to the inefficiency of the nursing staff..." most of the nurses pointed out that their social status within the community could influence their adaptation to and attitude towards night shifts. for example, the nurse's marital status, family needs, social values, and lifestyle within the community can influence her attitude and feelings towards working at night. in this regard, nurse no. 2 said: “i've got a 2-year-old daughter, and i have to ask my mother or sister to take care of her whenever i work in night shift, which automatically makes me hate the night shift, and it also affects my performance during the night shift because i'm always thinking of my daughter and worried about her." the nurses also thought that the night shifts disturb the balance between the desired lifestyle and work. women play a major role in domestic life, and they are expected to undertake domestic chores 64 erbil journal of nursing & midwifery workload the analysis of the transcripts of the in-depth interviews indicated, the nurses believed that work demand in the night shift depends on the department. they stated that the workload during the day and night shifts do not differ significantly in some departments. working hours in both day and night shifts are 12 hours, which is quite long. they thought; however, work demand during the night shift is heavier because there are fewer nurses to shoulder the workload. in this regard, nurse no. 3 said: "when it comes to the work demand during night and day shift, there is no significant difference, because both shifts consist of 12 hours of work, and we are in shortage of nurses during the night shift. some departments are busy during day and night shift." nurse no. 13:“…night shifts are a bit strenuous because there are usually fewer nurses compared to day shifts… nurses who work the night shifts need to work as a team because of the nurse shortage…" as stated above, this nurse believes that if the nurses working on night shifts form a team and work together, the workload can decrease, which leads to their better performance and as a result an increase in the quality of the delivered healthcare services. lack of sufficient nursing staff during the night shifts, which leads to an increase in workload, was also mentioned by nurse 7 who said: "it's not about longer working hours, the working hours are equal to those of day shift, both are 12 hours, but most of the time we have to work alone, and there are not enough nursing or medical staff to help and take a part of the responsibility. as a result, the workload during the night shift is felt as heavier." the same issue was referred to by nurse no. 9 who said, "if there are more nurses in the night shift, the work demand will be the same as day shift." psychosocial issues the results of the present study indicated that https://doi.org/10.15218/ejnm.2021.07 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article such as taking care of their children and doing family chores. in this regard, nurse no. 10, a 35-year-old woman, said: "most of the time, i leave my family and provide care to patients during the night shift which usually starts at 7 pm and finishes at 7 am. because of my career, i have to get someone to attend to my children and do my housework. i am married and would like to have the company of my husband, but because of work issues, social relationships are affected in some ways because i cannot accompany my husband when he attends social events" social and familial issues affect working the night shift and vice versa. in this regard, nurse no. 6 said, “workload of working in night shift makes me stressed out, which in turn influences my social and family life." sleep disturbance sleep was referred to by the nurses as the main function disturbed by working the night shifts. nurses who work night shifts have to sleep during the day and when the surrounding conditions (light, noise, and temperature) are not desirable, their sleep will be disturbed and its duration drops. working the night shift can also affect sleep quality because sleeping during the day is light and more distracted compared to night sleep, which greatly affects the nurses’ performance at work during their shift. in this regard, nurse no. 4, a 38year-old male nurse, said: "poor quality of sleep at night is the problem that i encounter regarding the sleep when working the night shift; the sleep duration becomes too short. our sleep during the day is affected by our surroundings such as noise and light. to fall asleep, i usually go to bed early, read novels, or drink beverages. this helps me to sleep especially during the first day when i need to work the night shift" nurse no. 8 also referred to sleep problems and said: “the day before my night shift, i cannot usually sleep well, because everywhere is so light, and there is a lot of noise from outside, so i feel sleepy at work all the time, and i’m sure it has a negative effect on what i do at work” moreover, lack of concentration during night shifts because of lack of sleep was mentioned as one of the challenges those night shift nurses encountered. in this regard, nurse no. 15 said, “icu nurses need to be quite alert and pay attention to everything, but i cannot concentrate well during my night shifts, because i usually feel sleepy.” nurse no. 1 also had the same problem and said, “because i cannot sleep well during the day, my performance is negatively affected during night shifts.” health issues nurses who work on night shifts usually experience health issues ranging from the lack of concentration as a result of workload and lack of sleep during their night shifts to physiological hazards, headache, persistent tiredness, backache, and even abortion because they have to stand for hours, lift heavy things, walk a lot, and make lots of decisions. nurse no. 12, a 27-year-old female nurse, described the night shift as more strenuous and tiring and stated that nurses working in night shifts are more likely to undergo occupational injuries such as pricks and muscular strains. she said: “health issues that i face include headache, persistent tiredness, backache due to long hours of standing, and lack of sleep. most of the time, we also face or have heard that nurses complain about their occupational injuries such as needle pricks and muscular strains due to too much workload and lack of concentration.” nurse no. 11 also stated, “i experience fatigue and feel tired during and after my night shifts due to lack of breaks and workload.” moreover, nurse no. 14 referred to her health problems caused by working night shifts and said, “in addition to sleep problems and lack of concentration, i sometimes cannot stand on my feet because of my backache.” 65 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.07 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article with numerous familial and social issues which might be resolved by making or changing the public culture and ideology about night-shift working nurses through the mass media. the third theme that emerged out of the nurses’ lived experience was sleep disturbance, which as participants claimed, caused the work performance and concentration at work to drop significantly. this finding is also in agreement with the study done by zion and shochat (2019) [21], who stated that taking short naps during night shifts, is considered as an effective way to lower levels of sleepiness and improve nurses’ psychomotor performance. the last theme of the present study was physiological issues including stress, headache, persistent tiredness, backache, and even abortion. insomnia, fatigue, and stomachache are common physiological problems that night-shift working nurses are faced with. this problem might be resolved by increasing the number of nurses attending night shifts so that the workload drops significantly, and the nurses will not have to stand and work all their shifts long, which in turn causes such health problems to improve [22].limitation of the study took place only in one hospital (rizgary teaching hospital), and it would be better to include nurses from different hospitals and also from different cities. participants could be asked why they chose the night shift to work in, which was not asked by the researcher. the nurses in the present study faced many problems and issues during their night shift work, such as poor quality of sleep, working for a long time without rest, fatigue and anxiety, back pain, mood disturbance and lack of concentration, which in turn affect the quality of their performance. the results of the present study showed that the nurses interpreted their lived experience of working night shifts as extra workload, psychosocial issues, sleep problems, and physiological issues. data analysis indicated that there was an extra workload on nurses during their night shifts, although they worked the same 12 hours as day shifts, because, as nurses mentioned, there were fewer nurses during night shifts, and they had to deliver healthcare services to patients alone. this finding is in line with those of the study conducted by moattari & jahromi in 2013) [17], who referred to the fact that nurses undergo excessive working pressure, which is an organizational issue and needs to be resolved by the hospital management by increasing the number of nurses working night shifts. this finding is also in agreement with the study done by abdullah karim et al. (2017) [18]. however, nasrabadi et al. (2009) [19], stated that lack of nursing staff can have some advantages for nurses. firstly, they have to do most of the tasks by themselves, which makes them more skillful, and secondly, they need to establish friendly relationships with most patients, which in turn affects their social life and working performance positively. another theme emerging out of the nurses' lived experience was psychological issues which included personal and family issues such as mood disturbances, decreased performance, negative effects on personal relationships with colleagues and family members, and imbalance between the desired lifestyle and work. this finding is in agreement with those of the studies carried out by costa (2016) [20] and moattari and jahromi (2013) [17], who declared that night shift nurses in family-oriented communities are faced 66 erbil journal of nursing & midwifery discussion conclusion https://doi.org/10.15218/ejnm.2021.07 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article [6] vahedian-azimi a, hajiesmaeili m, kangasniemi m, fornés-vives j, hunsucker rl, rahimibashar f, et al. effects of stress on critical care nurses: a national crosssectional study. journal of intensive care medicine. 2019; 34(4): 311–22. https:// doi.org/10.1177/0885066617696853. [7] redeker ns, caruso cc, hashmi sd, mullington jm, grandner m, morgenthaler ti. workplace interventions to promote sleep health and an alert, healthy workforce. journal of clinical sleep medicine. 2019; 15(4): 649–57. https://doi.org/10.5664/jcsm.7734. [8] vidotti v, ribeiro rp, galdino mj, martins jt. burnout syndrome and shift work among the nursing staff. revista latino-americana de enfermagem. 2018; 26(0). https:// doi.org/10.1590/1518-8345.2550.3022 [9] devadas b. a critical review of qualitative research methods in evaluating nursing curriculum models: implication for nursing education in the arab world. journal of education and practice. 2016; 7(7): 119–26. [10] burns m, peacock s. interpretive phenomenological methodologists in nursing: a critical analysis and comparison. nursing inquiry. 2019; 26(2): 1–10. https://doi.org/10.1111/ nin.12280. [11] au a. thinking about cross-cultural differences in qualitative interviewing: practices for more responsive and trusting encounters. qualitative report. 2019; 24(1): 58–77. [12] johnson jl, adkins d, chauvin s. a review of the quality indicators of rigor in qualitative research. american journal of pharmaceutical education. 2020; 84(1): 138–46. https:// doi.org/10.5688/ajpe7120 [13] saleh my, al-amer r, al ashram sr, dawani h, randall s. exploring the lived experience of jordanian male nurses: a phenomenological study. nursing outlook. 2020; 68(3): 313 –23.https://doi.org/https://doi.org/10.1016/ j.outlook.2019.10.007 [14] imani b, mohamad khan kermanshahi s, vanaki z, kazemnejad lili a, zoghipaydar mr. iranian hospital nurses’ lived experiences of emotional intelligence: a phenomenological study. issues in mental health nursing. 2019; 40(8): 712–19. https:// doi.org/10.1080/01612840.2017.1395497 [15] nikbakht nasrabadi a, mohammadpour a, fathi m. a new horizon in life: experiences of patients receiving chemotherapy. global journal of health science. 2016; 8(4): 102– 08.https://doi.org/10.5539/gjhs.v8n4p102. it is recommended that the number of nurses in each night shift should be reviewed by the hospital administration and nurses could cooperate during their night to provide patients with healthcare services of better quality and to minimize psychosocial and physiological problems among the nursing staff. there is no conflict of interest and funding source. [1] chappel se, verswijveren sj, aisbett b, considine j, ridgers nd. nurses’ occupational physical activity levels: a systematic review. international journal of nursing studies. 2017; 73: 52–62.https://doi.org/ https://doi.org/10.1016/ j.ijnurstu.2017.05.006. [2] saksvik ib, bjorvatn b, hetland h, sandal gm, pallesen s. individual differences in tolerance to shift work – a systematic review. sleep medicine reviews. 2011; 15(4): 221-35.https://doi.org/https:// doi.org/10.1016/j.smrv.2010.07.002. [3] cheng wj, cheng y. night shift and rotating shift in association with sleep problems, burnout and minor mental disorder in male and female employees. occupational and environmental medicine. 2017; 74(7): 483–88. https://doi.org/10.1136/ oemed-2016-103898. [4] shiffer d, minonzio m, dipaola f, bertola m, zamuner ar, dalla vecchia, et al. effects of clockwise and counterclockwise job shift work rotation on sleep and work-life balance on hospital nurses. international journal of environmental research and public health. 2018; 15(9): 2038.https://doi.org/10.3390/ ijerph15092038. [5] raffenaud a, unruh l, fottler m, liu ax, andrews d. a comparative analysis of work-family conflict among staff, managerial, and executive nurses. nursing outlook.2020; 68(2): 231–41. https:// doi.org/https://doi.org/10.1016/ j.outlook.2019.08.003. 67 erbil journal of nursing & midwifery recommendation conflict of interest and funding of the study references. https://doi.org/10.15218/ejnm.2021.07 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article [16] faghihi sa, khankeh hr, hosseini sj, arabshahi sk, faghih z, parikh sv, et al. improving continuing medical education by enhancing interactivity: lessons from iran. journal of advances in medical education & professionalism. 2016; 4(2), p.54. [17] moattari m, jahromi mf. novice nurses’ perception of working night shifts: a qualitative study. journal of caring sciences.2013;2(3):169–76.https:// doi.org/10.5681/jcs.2013.021. [18] abdulla karim m, rafii f, nikbakht nasrabadi a, kurdistan nurses’ feelings and experiences about patients’ death in icus: a case study in kurdistan region, iraq. journal of client-centered nursing care. 2017; 3(1): 3-10. [19] nasrabadi an, rasoolzadeh n, emami a, seif h, latifi m. night shift work experiences among iranian nurses: a qualitative study: original article. international nursing review. 2009; 56(4): 498–503. https:// doi.org/10.1111/j.14667657.2009.00747.x. [20] costa g. no title. in: iskra-golec i, barnesfarrell j. ed. social and family issues in shift work and non-standard working hours. springer, cham; 2016: 19–35. https://doi.org/https:// doi.org/10.1007/978-3-319-42286-2_2. [21] zion n, shochat t. let them sleep: the effects of a scheduled nap during the night shift on sleepiness and cognition in hospital nurses. journal of advanced nursing. 2019; 75(11): 2603–615. https:// doi.org/10.1111/jan.14031. [22] mahmoued tm, mohamed n, saleh a, ali n. night shift work and its impact on health status of nurses. zagazig nursing journal. 2017; 13(2): 53–66. 68 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.10 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article effect of video game on school achievement in school age children in erbil/city abstract introduction with advancement of high-tech devices (e.g. smartphone, tablets and computers), internet and electronic games have become increasingly widespread among people of all ages especially among children and adolescents [1, 2, 3]. current estimations have revealed that one in three children under the age of 18 uses background and objectives: playing video games is associated with poor academic achievement, student who got their game systems directly spent less time on homework and, four months later, they got lower reading and writing scores, their teachers were more likely to report academic difficulties. the aim of study is to identify the effect of play video game on school achievement. methods: a cross sectional descriptive study was carried out at five primary school in erbil city 50 students was taken as a case group compared with 200 students as control group started from 15 september to 15 november 2020. a questionnaire format was used as a tool for data collection and consists ,demographic information of the students, parents and some items about students game, official permission has been obtained from college of nursing / hawler medical university, ministry of education and primary schools. data was analyzed thorough using frequency, percentage and chi square by using spss, 22. results: the study reveal that 58% of participants were age group between 12-14 years old, 74% of them were boys among playing group, 18% of father were graduated from college, 60% of played children were from middle socio-economic status, 16% of game players have missed school, 66% of played students were missed homework, about 10% of the students have a good school achievement among who played video games and more than half (58%) among non-play students.. there is highly significant association between parent educational levels with their children school achievement. conclusions: playing video game was negatively associated with poor school achievement. the study recommended the parent to limit the time of playing less than one hour daily, also limit the number and type of game especially fighting game and replaced with educational game. key words: effect; videogame; school achievement; children. nazar ramadhan othman; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: nazar.othman@hmu.edu.krd ) rozhan tofiq khedir; department of nursing, college of nursing, hawler medical university, erbil, iraq. gulala kareem azeez; department of nursing, college of nursing, hawler medical university, erbil, iraq. kaify jamil qadir; department of nursing, college of nursing, hawler medical university, erbil, iraq. 86 erbil journal of nursing & midwifery received: 29/08/2021 accepted: 16/11/2021 published: 30/11/2021 mailto:nazar.othman@hmu.edu.krd?subject=nazar.othman@hmu.edu.krd https://doi.org/10.15218/ejnm.2021.10 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article the internet worldwide, and 75% of adolescents play electronic games daily in developed countries [4,5,6]. according to united nations international children's emergency fund (unicef) estimations that one third of internet users universally are children, with the proportion of internet users likely to be higher in lower income countries where the internet is quickly penetrating all scopes of public life. the international telecommunication union (itu) reports that in developing countries, young people between age 15 and 24 outnumber the overall population by 2 or 3 times [7].in the past few decades, electronic media has grown from virtual non-existence to one of the primary means of entertainment for college students. in more recent years, the internet has entirely changed the landscape of electronic media from something personal and static into something with the potential to be interactive and social [8]. playing video games is often related in our society with poor academic achievement [9]. some study concludes there is little indication to suggest that communicating media improves the learning experience [10]. one study tracked boys’ academic performance, and findings indicate that those kids who got their game systems directly spent less time on homework and data at four months show lower reading and writing scores, and teachers were more likly to report academic difficulties [11]. in one representative sample of american adolescents, aged 10 to 19, those who played video games spent 30% less time reading and 34% less time doing homework [12]. among video game players, time spent playing time was associated with low school performance [13]. according to anand (2007), the penetration of video games into the united states alone is huge, with at least 90% of homes having children that have played (rented or owned) video games [14]. this is a record level that continues to increase. of players over the age of 18, 55% are console players and 66% of online players. however, there is also plenty of research to suggest that interactive video games can actually lead to increased academic performance [15]. the practice of games is often linked to an increase in visual-spatial skills, which often come in handy in the fields of science, mathematics, technology, and engineering [16]. there are many studies a negative relation between addiction of video games and homework preparation and decreased academic performance [17, 18] at the same time educational games are, considered an effective alternative to supporting traditional teaching methods in terms of educators’ responsibility, such as inspiring students to learn, teaching them to love learning, and making learning fun [19]. there is a great deal of research showing the effect of educational games on learning are positive in encouraging the learning. educational games, incorporated at the opening or end of a lesson, of concepts, and that they allow students to discuss target concepts [20]. for this reason, they can foster students’ interest and motivation towards lessons, or review, strengthen and assess the learned topics. therefore, educational games promote students’ active contribution in lessons and thus assist with their learning [21]. the aim of this study is to examine the effect of video game on school achievement in school age children. a case control study design was conducted at five primary school in erbil city according to geographical designations (east, west north ,south and center). the study was carried out from 15 september to 15 november 2020. a convenience sample of (50) students were takenas a case group with (200) students as a control group. 87 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2021.10 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article achievement. among the playing group, about 18% of fathers graduated from college, and 33% reported low socioeconomic status. there was a highly significant association between parent educational level and their children's’ school achievement. regarding parent occupation there was a significant association between mothers’ of playing children with school achievement, but no significant association with parent of non-playing children and school achievement. no significant association between parent socioeconomic status and children school achievement was observed (table 2). both genders and students from fourth, fifth and sixth stage were included handicaps students and those who refused to participate were excluded from the study. a questionnaire tool was used to collect data by face to face interview which composed of four parts, students’ sociodemographic characteristics (age , gender and education level) , and sociodemographic characteristics of students' parents ( age, level of education ,occupation and socio-economic status). questions related to game playing, and questions regarding academic performance. a written official scientific approval was obtained from college of nursing / hawler medical university no. 7.26/7/2020 . verbal permission was obtained from participations and participants were informed privacy and confidentiality. statistical analyses: data were analyzed using the statistical package for social sciences (spss) version 21. frequency and percentages were used for categorical data, and the chi-square test was used to find out the association between variables, with p-value ≤ 0.05 being considered as statistically significant. in present study 58.0% of video games players were 12-14 year's old, , 74% were boys and 46% video game players were stage six. there was no significant association between age and academic achievement in both groups. among game players, around 4% of children failed school for 3 years. there is a highly significant association between years of failure and academic achievement among the not-played group (table 1). among the playing group, 42 % of fathers belonged to the 41-45 years old age group and among the non-playing group, 31.5% of mothers belonged to the 41-45 years old age group. there is no significant association between parents in case group with their children school 88 erbil journal of nursing & midwifery results table 1: association between child’s demographical characteristics and game players of the student not playing play category variable (%) f. (%) f. (54) 108 (42) 21 9-11 age/ years (46) 92 (58) 29 12-14 0.115 s 0.743 ns x2 (42.5) 85 (74) 37 male gender (57.5) 115 (26) 13 female 0.004 hs 0.194 ns x2 (28.5) 57 (26) 13 four stage (31) 62 (28) 14 five (40.5) 81 (46) 23 six 0.948 ns 0.018 s x2 (80.5) 161 (68) 34 no failure number of years failure (12) 24 (14) 7 1 years (6) 12 (14) 7 2 years (1.5) 3 (4) 2 3 years < 0.001 hs 0.153 ns x2 https://doi.org/10.15218/ejnm.2021.10 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article 89 table 2: parent socio demographic characteristics not playing play category variable (% ) f. (%) f. (2) 4 (2) 1 26-30 fathers age/years (15) 30 (6) 3 31-35 (28) 56 (30) 15 36-40 (35.5) 71 (42) 21 41-45 (6.5) 13 (12) 6 46-50 (13) 26 (8) 4 <50 0.265 ns 0.662 ns (11) 22 (6) 3 26-30 mothers age/years (19) 38 (16) 8 31-35 (31.5) 63 (46) 23 36-40 (23.5) 47 (20) 10 41-45 (15) 30 (12) 6 46-50 0.297 ns 0.620 ns x2 (29.5) 59 (14) 7 illiterate fathers level of education (13.5) 27 (20) 10 can read and write (26) 52 (32) 16 primary school graduate (16.5) 33 (16) 8 secondary school graduate (14.5) 29 (18) 9 institute and college graduate 0.002 hs 0.004 hs x2 (52) 104 (44) 22 illiterate mothers level of education (11.5) 23 (22) 11 can read and write (18) 36 (22) 11 primary school graduate (9.5) 19 (8) 4 secondary school graduate (9) 18 (48) 24 institute and college graduate 0.018 s 0.000 hs x2 (30.5) 61 (34) 17 employed fathers occupation (2) 4 (2) 1 nonemployee (1.5) 3 (64) 32 retired (66) 132 (34) 17 free work 0.264 ns 0.324 ns x2 (12) 24 (6) 3 employed mothers occupation (88) 176 (94) 47 house wife 0.141 ns 0.040 s x2 (18.5) 37 (8) 4 high socio-economic status (48.5) 97 (60) 30 middle (33) 66 (32) 16 low 0.207 ns 0.356 ns x2 https://doi.org/10.15218/ejnm.2021.10 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article games reported poor duration of study at home and 2.5% of those that did not play video games reported duration of study. only 10% of students who play video games reported good school achievement while 58% of non-playing students report good achievement (table 4). 90 erbil journal of nursing & midwifery among players, 46% of their parent agreed to playing, 14 % of them played daily and 48% of used a mobile device to play. used mobile for play game.46% of children enjoyed fighting games and 86 % reported their father bought the gaming device (table 3). among students who played video games, 16% did not attend school daily and among non-playing students14.5% did not attend school daily. among playing students, 66% did not bring their homework to school while only 10.5% of non-playing student did not bring their homework to school. about 22% of those tht played video table 3: distribution of played children item category f. (%) parents agree to play. yes 46 (92) no 4.0 (8) encouraging parents to play yes 39 (78) no 11 (22) who bought the device for children father 43 (86) mother 5 (10) brother 2 (4) type of device using by children mobile 24 (48) computer 3 (6) i pad 18 (36) play sta5 (10) type of play children like it ball 14 (28) fighting 23 (46) crushing 4 (8) education 3 (6) music 1 (2) playing daily no 43 (86) yes 7 (14) duration of using play game / hours per day 1 hours 23 (46) 2 hours 13 (26) 3 hours 13 (26) 4 hours 1 (2) bring device to school for playing no 12 (24) yes 38 (76) time of playing after8 (16) evening 26 (52) night 16 (32) table 4: assessment of children school achievement among case and control group. item category case control f. (%) f. (%) attending daily to school yes 42 (84) 171 (85.5) no 8 (16) 29 (14.5) attending to all class session yes 45 (90) 178 (89) no 5 (10) 22 (11) bringing home work to school yes 17 (34) 179 (89.5) no 33 (66) 21 (10.5) thinking that play video game affect school achievement yes 25 (50) 151 (75.5) no 25 (50) 49 (24.5) duration of study at home 1 hours 24 (48) 47 (23.5) 2 hours 20 (40) 77 (38.5) 3 hours 6 (12) 48 (24) 4 hours 0 (0) 26 (13) 5 hours 0 (0) 2 (1) school achievements poor 11 (22) 5 (2.5) fair 34 (68) 79 (39.5) good 5 (10) 116 (58) https://doi.org/10.15218/ejnm.2021.10 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article the main purpose of this research study was to explore the effect of playing video game on primary school students’ achievement. our study came in line with a previous study by hakan tuzun et al. which examined primary school students’ achievement and motivation in learning geography through an educational computer game [22]. (table1). we reported that 58% of children who played video games in present study their age group belonged to 1214 years old agreeing with islam et.al which found that average children age were 15.38% among player [23]. concerning gender about 74% among played children were boys agreeing with studies suggesting that there are gender differences in time spent playing video games and preferred content [24, 25]. boys tend to play video games more frequently than girls [26]. girls had more addictive tendency towards internet/game-play in comparison to boys [23]. unfortunately, this may be due to our culture of gifting playing devices to. boys more than girls. (table 2). our study found that 18% of fathers graduated from college agreeing with islam et al., reporting 33.2% primary career's highest level of education [23]. concerning family income, 66% of played children family were from low socio-economic status agreeing with hasting et al., which reported that most of the family income in middle-class (annual family income) [27].concerning parent educational level the present study showed a highly significant association between parent educational levels with their children school achievement. this result completely agrees with matilov et al., which reported an educational level of children in the family depends more on the level of the parent’s education. this factor strongly affects family relationships and the successful development of children [28]. similarly, hoover et al., found that parental involvement broadly includes home-based activities (e.g., helping with homework, discussing school events or courses) and school-based activities (e.g., volunteering at school, coming to school events). they argued that parental involvement is a function of a parent's beliefs about parental roles and responsibilities, a parent's sense that they can help their children succeed in school, and the opportunities for involvement provided by the school or teacher [29]. likewise garg et al., showed that the impact of family factors on influencing students’ educational aspirations through their impact on extracurricular reading, attitudes towards school and homework and students’ perceptions of their parents’ educational aspirations [30].regarding parental occupation there are significant associations between parents with played children and school achievement while no significant associated with parents with non-played children and school achievement. our result agrees with result of the study done by usaini and abubakar indicating that students from a parent with formal occupation performed well than those from parents with informal occupation[31].concerning socio-economic status there are non-significant associations between parent socio-economic status and children school achievement. our finding is in line with ripple and luthar who found that socio-economic status has little to no relevance for academic achievement [32]. likewise a meta-analysis performed by sirin of more than 70 studies published from 1990 to 2000 reported that there was no significant correlation between socio-economic status and academic achievement [33].our study illustrated that about 16% of children who played video games have missed school (table 3). this finding totally agrees with terry and malik who found a significant association regarding missing school among children 91 erbil journal of nursing & midwifery discussion https://doi.org/10.15218/ejnm.2021.10 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article by jackson et.al, which reported that internet use is positively associated with improved reading skills and higher scores on standardized tests [38].about 22% of students in our study who played video game have poor school achievement while only 2.5% had poor achievement among nonplay students. our finding strongly agrees with islam et al., which found that adolescents who played no electronic games at all have better scores in writing compared to those who played electronic games. addiction tendency to internet and electronic -gaming is found to be adversely associated with academic achievement [23]. similarly, evidence argues that the use of the internet and electronic games have negative effects such as reduced sleeping time, behavioral problems (e.g. low self-esteem, anxiety, depression), attention problems and poor academic performance in adolescents [1,5,39]. academic performance is negatively associated with internet use and electronic games, particularly when the internet is used for non-academic purpose [34]. studies also found that playing electronic games develops cognitive skills (e.g. mental rotation abilities, dexterity), which can be attributable to better academic achievement [40,41]. these varied consequences require an urgent need of understanding the effect of the internet use and electronic gaming on the development of children and adolescents, mainly on their school achievement. most of boys were among played children, most of player missed homework, majority of parent was agree to play, most of children were use the mobile for playing, playing daily and bringing the device to school. there are significant association between mother of case group with school achievement while no significant with parent with control group in school achievement, that played video games (spearman rho coefficient 0.003)[34]. the present study showed that 46.0% of students played video games dailt for 1 hour which agrees with islam et al., reported 46.6% of student playing 1-2 hours daily. this could be attributed to the increased availability of computers/smart-phones and the internet use among under-12 years old [23]. similarly, 48.0 % of children used mobile devices to play games which may be due to availability and easy access. hastings et al., reported that over half (56%) owned and played some type of hand-held game system [27].in our study we found that 46% of children played fighting games which may due to the continuous war environment for more than decade, tv programs, movies and film with fighting. this result disagrees with hastings et al., which reported children’s gaming consists mostly 61% of educational games [27]. hastings et.al., stated that over a fifth (21.4%) of parents responded that they did not know the rating level of their children’s video and computer games, suggesting a lack of parental monitoring [27]. our finding also showed that 14% of children played daily in contrast with aaron boyce et al., which reported that 48.2% of children play per week [35]. about 66% of played student in our study missed homework which is consistent with gentile et al., and sharif and sargent’s findings that video gaming creates time conflicts that reduce the amount of time that gamers devote to homework. the results of this study clearly evaluated that the non-academic use of internet during weekdays, particularly, spending more than four hours on internet is harmful for academic performance, whereas, internet use on the weekends is likely to incur a positive effect on academic performance [36,37]. this result is consistent with a usa study 92 erbil journal of nursing & midwifery conclusions https://doi.org/10.15218/ejnm.2021.10 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article [7] itu (international telecommunication union). measuring the information society. geneva: itu. (2013). [8] luis concepcion, marilyn nales-torres, ana rodriguez-zubiaurre. the relationship between videogame use, deviant behavior, and academic achievement among a nationally representative sample of high school seniors in the united states. american journal of educational research. 2016; 4 (16):1157-1163. doi: 10.12691/education-416-6. [9] anderson ca, dill ke. video games and aggressive thoughts, feelings, and behavior in the laboratory and in life. journal of personality and social psychology. 2000 apr;78 (4):772-90.doi:10.1037//00223514.78.4.772. pmid: 10794380 . [10] schmidt me and vandewater ea. media and attention, cognition, and school achievement.the future of children. (2008).18(1):63 -85.doi:10.1353/foc.0.0004.pmid: 21338006. [11] weis r, cerankosky bc. effects of videogame ownership on young boys' academic and behavioral functioning: a randomized, controlled study. psychological science. (2010).apr;21(4):463-70.doi: 10.1177/0956797610362670.epub 2010 feb 18. pmid: 2042 4 084. [12] cummings hm, vandewater ea. relation of adolescent video game play to time spent in other activities. archives of pediatrics & adolescent medicine. (2007). jul;161(7):684-9. doi:10.1001/archpedi.161.7.684.pmid: 17606832; pmcid: pmc5761323. [13] hastings ec, karas tl, winsler a, way e, madigan a, tyler s. young children's video/ computer game use: relations with school performance and behavior. issues in mental healthnursing.(2009);30(10):638-649. doi:10.1080/01612840903050414 . [14] vivek anand. a study of time management: the correlation between video game usage and academic performance markers. cyber psychology & behavior.aug 2007. 10(4), 552559.http://doi.org/10.1089/cpb.2007.9991 . [15] linda a. jackson, yong zhao, anthony kolenic, hiram e. fitzgerald, rena harold, and alexander von. race, gender, and information technology use: the new digital divide. eye .cyber psychology & behavior. (2008). 11(4), 437-442.http:// doi.org/10.1089/cpb.2007.0157 . highest percent of students in case group had poor school achievement while in control group were opposite result was founded so we founded that playing videogame had negatively affected school achievements we would like to express deepest appreciation to school managers and great thanks to dr. yousif muhammad gardi and dr. ibrahim (dean and assistant dean of the college of nursing, respectively), special thanks to all children who participated in study. [1] wang, c. -w., chan, c. l., mak, k. -k., ho, s. -y., wong, p. w. & ho, r. t. prevalence and correlates of video and internet gaming addiction among hong kong adolescents: a pilot study the scientific world journal, vol. 2014, article id 874648, 9 pages,2014.https:// doi.org/10.1155/2014/874648. [2] anderson, e. l., steen, e. & stavropoulos, v. internet use and problematic internet use: a systematic review of longitudinal research trends in adolescence and emergent adulthood. international journal of adolescence and youth, (2017).22 (4), 430 –454 . [3] oliveira, m. p. m. t., cintra, l. a. d., bedoian, g.,nascimento, r., ferré, r. r., silva, m. t. a. use of internet and electronic games by adolescents at high social risk. trends in psychology (2017), 25 (3), 1167-1183. doi: 10.9788/tp2017.3-13pt. [4] unicef. children in a digital world. united nations children's fund (unicef) (2017). [5] daniel l king , michael gradisar, aaron drummond, nicole lovato, jason wessel, gorica micic,. et al. the impact of prolonged violent video-gaming on adolescent sleep: an experimental study. journal of sleep research. (2013). 22(2):13743.doi:10.1111/j.1365-2869.2012.01060. [6] byrne, j. & burton, p. children as internet users: how can evidence better inform policy debate?. journal of cyber policy. (2017).2(1):1-14.doi:10.10 80/23738871.2 017.12 91698. 93 erbil journal of nursing & midwifery acknowledgements references https://doi.org/10.15218/ejnm.2021.10 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article [26] lucas k, sherry jl. sex differences in video game play: a communication-based explanation.communication research .(2004);31 (5):499–523. [27] hastings, e. c., karas, t. l.,winsler, a., way, e., madigan, a., & tyler, s. young children's video/computer game use: relations with school performance and behavior. issues in mental health nursing,(2009). 30(10),638– 649. doi.org/ 10.1080/016 1284090305 414. [28] matilov, naum, (2002), brak i semejstvo, skopje, 194-195. [29] hoover-dempsey, k. v., & sandler, h. m. parental involvement in children's education: why does it make a difference? teachers college record, (1995). 97(2), 310–331. [30] garg, r., kauppi, c., lewko, j. and urajnik d. a structural model of educational aspirations. journal of career development . (2002).29, 87–108 doi.org/10.1023/ a:10199 64119690. [31] usaini, m.i., & abubakar, n.b. the impact of parentsâ occupation on academic performance of secondary school students in kuala terengganu. .journal of education and social sciences, (2015) .3 (1), 112-120. doi:10.6007/majess/v3-i1/1899. [32] ripple, c. h., and luthar, s. s. academic risk among inner-city adolescents: the ole of personal attributes. journal of school psychology. (2000). 38, 277–298. doi: 10.1016/ s0022-4405(00)00032-7. [33] sirin, s, r. socioeconomic status and academic achievement: a meta-analytic review of research. review of educational research. (2005). 75,417–453.doi: 10.3102/00346543075003417. [34] terry, m. and malik, a. video gaming as a factor that affects academic performance in grade nine. psychology (2018). corpus id: 149703626. [35] boyce, a., schanding, g. t., jr., burridge, a. b., & keller-margulis, m. effect of videogame play and extracurricular activities on parent perceived socio-emotional functioning in children and adolescents. international journal of psychology: (2013). 12, 29–48. https ://doi.o rg/10.7220/1941-7233.12.2. [36] gentile, d. a., lynch, p. j., linder, j. r., & walsh, d. a. the effects of violent video game habits on adolescent hostility, aggressive behaviors, and school performance. journal of adolescence, (2004). 27, 5-22. [37] sharif, i., & sargent, j. d. association between television, movie, and video game [16] wack, e., & tantleff-dunn, s. relationships between electronic game play, obesity, an psychosocial functioning in young men. cyberpsychology and behavior. (2009). 12 (2), 241-244. [17] anderson, c., & dill, k.video games and aggressive thoughts, feelings, and behavior in the laboratory and in life. journal of personality and social psychology, (2000). 78(4), 772-790. [18] jaruratanasirikul s., wongwaitaweewong k. and sangsupawanich p. electronic game play and school performance of adolescents in southern thailand. cyberpsychology and behavior, (2009). 12(5), 509-512. [19] lujan, h. l., & dicarlo, s. e. too much teaching, not enough learning: what is the solution? advances in physiology education, (2006). 30(1), 17-22. [20] odenweller, c. m., hsu, c. t., & dicarlo, s. e.educational card games for understanding gastrointestinal physiology. advances in physiology education, . (1998). 275(6), s78. [21] ülküdür, m. a. proje tabanlı öğrenme etkinlikleri ile oyun tabanlı öğrenme etkinliklerinin akademik başarı, tutum ve motivasyona etkisi. yüksek lisans tezi, amasya üniversitesi fen bilimleri enstitüsü, amasya. (2016). [22] tüzün, h., yilmaz-soylu, m., karakus, t., inal, y. & kizilkaya, g.the effects of computer games on primary school students' achievement and motivation in geography learning.. computers & education. . (2009)., 52, 68-77. [23] islam, m.i., biswas, r.k. & khanam, r. effect of internet use and electronic gameplay on academic performance of australian children. scientific reports.(2020). 10, 21727 https://doi.org/10.1038/s41598 -020-78916-9 . [24] brunborg, g.s.; mentzoni, r.a.; melkevik, o.r.; torsheim, t.; samdal, o.; hetland, j.; etal., gaming engagement, and psychological health complaints among norwegian adolescents. media psycholology.( 2013), 16, 115–128. [crossref] [25] brown, a. younger men play video games, but so do a diverse group of other americans.( 2017). available online: http:// www.pewresearch.org/facttank/2017/09/11/younger-men-play-video -games-but-so-do-a-diverse-group-ofother-americans. 94 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.10 erbil j. nurs. midwifery, vol. 4, no. (2), nov 2021 original article exposure and school performance. pediatrics,(2006).118(4),1061-1070. doi:10.1542/peds.20052854 [38] jackson, l. a., von eye, a., witt, e. a., zhao, y. & fitzgerald, h. e. a longitudinal study of the effects of internet use and videogame playing on academic performance and the roles of gender, race and income in these relationships. computers in human behavior, (2011). 27(1), 228– 239.https://doi.org/10.1016/ j.chb.2010.08.001. [39] rikkers, w., lawrence, d., hafekost, j. & zubrick, s. r. internet use and electronic gaming by children and adolescents with emotional and behavioural problems in australia–results from the second child and adolescent survey of mental health and wellbeing. bmc public health. (2016). 16, 399 . [40] barlett, c. p., anderson, c. a. & swing, e. l. video game effects—confirmed, suspected, and speculative: a review of the evidence. simulation & gaming, (2009). 40 (3), 377–403 . [41] suziedelyte, agne, can video games affect children's cognitive and noncognitive skills? (august 13, 2012). unsw australian school of business research paper no. 2012 econ 37, available at ssrn: https://ssrn.com/abstract=2140983 or http://dx.doi. org/10.2139 /ssrn.2140 983. 95 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.13 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article prevalence of cancer-related fatigue among women with breast cancer in erbil city abstract introduction cancer is a global health issue regardless of a country’s economic status. the incidence and mortality of cancer are continuously increasing universally, and in 21st century cancer is a major health concern that decreases the life continuum of people all over the world. in 2015, cancer was expected to be the first and second leading reason of death among adults in 91 countries before age 70[1], in 2017, the second cause of death in united states was cancer [2], and the cancer rate in the united states is estimated to be 1,762,450 new cases, and breast cancer is predicted to be third most common cancer for women with approximately 62,930 new cases in 2019 [3].breast cancer (bc) is the most frequent cancer diagnosis among women worldwide, and incidence bc is steadily increasing, but-the rate of background and objective: cancer-related fatigue is greatest frequent upsetting sense of tiredness or exhaustion can happen regardless of cancer type and could be experienced physically or emotionally, and or cognitively, that is associated with the tumor or its treatment. the current study aimed at assessing prevalence of cancer related fatigue among women with breast cancer. method: a descriptive crosssectional study design was conducted from 8th of october 2018 to 8th october 2019. to find out the prevalence of cancer-related fatigue among female breast cancer patients at nankali hospital in erbil city. a sample of 60 breast cancer patient was obtained through non-probability purposive convenience sampling techniques. data were analyzed using statistical package for the social sciences version 23 for windows. results: the results showed that the highest percentage of participants (45%) were from age group between 39-54, most of them were from urban area, graduated from primary school, married, however; 53.3% of breast cancer women they had family history of breast cancer. regarding breast cancer stages, 40% of participants were in third stage. most of the breast cancer patients were receiving chemotherapy treatment and they had surgery (81.7% and 71.7% respectively). concerning cancer related fatigue 75% of participants suffered from fatigue, nonetheless; fatigue severity among participants range from severe 53.3% to moderate 48.3%. also, physical fatigue was a common type of fatigue among women with breast cancer. conclusion: one of the most common complains symptom of patient with cancer is fatigue. cancer related fatigue impact physical, emotional, cognitive domains of patients’. moreover, cancer-related fatigue has undesirable effect on patients, mood, daily task performance, and the patient’s life. keywords: prevalence; cancer related fatigue; breast cancer; severity of fatigue; types of fatigue. shinwy bakhtyiar radha; department of nursing, college of nursing, hawler medical university, erbil, iraq. )correspondence: shinwy.radha@hmu.edu.krd) yousif muhammed younis ; department of nursing, college of nursing, hawler medical university, erbil, iraq. 108 received: 09/11/2019 accepted:15/1/2020 published: 30/11/2020 https://doi.org/10.15218/ejnm.2020.13 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article mortality is declining in developed countries in contrast to developing countries[4], bc accounts for 14% to 42% of all cancer cases in women younger than 50 years, which indicates that bc has occurred a decade earlier in arab women when compared with women in developed countries that a half of bc women are aged, older than 65 years [5].in turkey bc is the leading type of cancer among women, which accounts for 40.6% of all cancer cases, and it is predicted that annually, up to 10,000 women are diagnosed with bc in turkey [6], in iran bc was the fifth most common cause of death among women [7], and in iran, bc was accounted for 24.6% which was less than the incidence of bc in iraq and turkey. the mean age of women living with bc in iran was 49.7 years [8], the incidence of bc among iraqi population has been rising over the last 20 years. however, bc is now the most common type of cancer, and among women approximately 33.3% of all cancer diagnosis were bc [9]. treatment of bc includes utilizing different treatment approaches. either a single treatment or combination. treatment options consist of surgery, radiation, systematic treatment with chemotherapy, hormonal therapy, biological and immune therapy. the selection of treatment regimen depends on tumor type and stage, hormone receptor, and clinical health state of patients[10]. one of the most symptom complaints reported among cancer patients and survivors is fatigue, regardless the cancer type [11], cancer related fatigue (crf) is a complex and multifactorial symptom that affect around 70% to 100% of cases with the moderate to severity intensity for the period of receiving treatment, and impact 30% of all survivors[12]. cancer related fatigue (crf) is defined by nccn (national comprehensive cancer network) as a, “ is a distressing, persistence, subjective sense of physical, emotional and cognitive tiredness and/or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning” [13].crf rates frequently vary among patients receiving different treatments, and occurs among nearly 90% patients with radiotherapy and 80% of patient receiving systematic treatment. crf has a great impact on physical, emotional, cognitive, and over patients quality of life [14], it can remains for months or even years after completing of cancer treatment, and as a result this symptom has a significant influence on patients quality of life [15]. management of crf includes both pharmacological and non-pharmacological ways. there are a wide range of nonpharmacological options including patient education, exercise, psychosocial education, suitable nutrition and hydration, cognitive behavior, and relaxation[16].cancer related fatigue decreases patient quality of life, capacity, and possibly decreases patient chance for survival [17], and also crf affects emotional and spiritual suffering for both patients and their families [18].in the kurdistan region of iraq patients do not have sufficient information regarding cancer and their consequence, as a result, patients face issues with many tasks including incapacity to perform normal daily tasks to restricted and devastated from society. there is a big gap between patients and health care providers concerning and utilizing the various ways of treatment side effect management, patients are still believe that they should not assume any physical exercise as well as they do not have information regarding valuable nutrition, except the patients insufficient information, also health providers are kind of careless to saturate patient with recent and available dietary and exercise guidelines to eliminate patients suffering, and they do not use any specific guideline. it is crucial to determine the prevalence of crf 109 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.13 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article cancer who were at least 18 years old and who suffered from cancer stages 0 through four. the exclusion criteria included female patients with end stage breast cancer and patients with mental disorders. ethical consideration ethical approval was obtained from the ethical and scientific committees in the college of nursing, hawler medical university (code no.72 in 2019.06.20). the researcher also obtained official approval from the nanakaly hospital in erbil city. oral informed consent was obtained from patients after a detailed explanation about the aim of the study. data were coded maintain anonymity. data collectiona face-to-face interview technique was used to gather information about socio-demographics, patient medical information, and crf. data collection was started from the period of 1st april to 1st june 2019, using a questionnaire that was designed by the researcher through literature review. the data of each sample has been separately obtained that spent at least 20 minutes; the interview took place in an outpatient oncology unit. the reliability of the questionnaire was obtained through review by medical experts in the fields of nursing, medicine, oncology, and psychiatry. the researcher assessed the relevant socio-demographic characteristics including age, residential area, education level, marital status, employment statue, family income, and family history of breast cancer. the medical history, information was collected through six questions that assessed disease status, disease stage, types of breast cancer treatment regimen, information on usual and current body mass index. according to american cancer society (acs) in 2016, bmi for adult person are illustrate below [19]: among breast cancer patients to encourage health care providers to develop an educational program to educate patients for better selfcare, how manage adverse effects, including crf. a descriptive cross-sectional study was undertaken to determine the prevalence of crf among female breast cancer patients at nankali hospitals in erbil city, iraq. study setting and participant the study was conducted at outpatient oncology department of nanakali hospital, a government hospital located near nine shahed mosque in azady q, erbil, which provides specialty care for blood diseases and cancer. nanakali hospital, opened in 2004, comprises of two essential departments including administration and the scientific/art department. the hospital has a staff of 246 professionals including, 103 medical staff (51 occupied nurses, 52 volunteers) and 60 specialized physicians (oncologist, hematologist, pediatrician, anesthetist, dentist, radiologist, pharmacist). the hospital has 95 beds. each oncologic cases is admitted at either the in-patient and out-patient oncology department. there are 11 oncology staff including two shifts (morning, evening). during the morning shift, there are eight nurses and during the evening shift, there are three nurses. on average, six nurses work during the morning shift and there are 25 beds in the oncology department including, ten beds for male outpatients, ten bed for female outpatients, and five for in-patients cases. the study sample includes female breast cancer patients who were admitting outpatient oncology department and the study used a nonprobability, purposive convenience sampling techniques to collect the relevant study data. a total of 60 women participated. the inclusion criteria included adult female patients diagnosed with breast 110 erbil journal of nursing & midwifery methods bmi range underweight <18.5 normal body weight 18.5-24.9 overweight 25-29.9 obese ≥30 https://doi.org/10.15218/ejnm.2020.13 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article demographic and questionnaire data was coded and entered statistical package for the social sciences (spss) version 23 for windows, for descriptive statistics (frequency and percentage). sociodemographic characteristics of the study samplethe table 1 shows the sociodemographic characteristics of participants. the highest percentage of sample were between 39-54 years old (45%), and 23.3% were between 23-38 years old. most (70%) were from urban areas. the highest percentage had graduated from primary school (38.8%), meanwhile only 3.3% were graduated from the high school. more than half of participants were married (66.7%), and only one was divorced. most (86.7%) were unemployed, and 13.3% were employed. more than half (63.3%) have sufficient economic status. regarding the family history half of study samples had family history of breast cancer (50.3%), from first degree relevant. 111 erbil journal of nursing & midwifery current hgb level, according to national institute of health (nih) in 2019 adult women who hgb level less than 12.0 g/dl were identified anemic as following [20]: chronic diseases assessing, and treatment regimen data consist of whether the patient had undergone chemotherapy, radiotherapy, surgical therapy, biology therapy, and hormonal therapy. the crf assessment consisted, of seven unique questions to determine crf over the prior two weeks, and the scoring included (0) for none, (1) for not much, (2) for some, (3) for a great deal. question two and six were recoded as following: (0) for none, (1) for a great deal, (2) for some, (3) for not much. fatigue severity was assessed using two questions about asking patients to rate fatigue severity levels during two different times (once in previous weeks vs. current fatigue). regarding nccn in 2018 the fatigue severity level is rating on numerical rating scale from 0 to 10 as (0 for no fatigue and 10 for worst fatigue can be imagine),also fatigue has been divided as the different types of fatigue during cancer were also assessed. physical fatigue questions included contains five questions; emotional fatigue included seven questions, and cognitive fatigue included five questions. each type was assessed, that using a four scale level (none, not much, some, a great deal), the scoring were as (0) for none, (1) for not much, (2) for some, and (3) for a great deal. data analysis hgb range mild anemia 10g/dl moderate anemia 8-9.9g/dl severe anemia 6.5-7.9g/dl life-threatening >6.5g/dl fatigue score mild fatigue 1-3 moderate fatigue 4-6 sever fatigue 7-10 results table 1: socio-demographic characteristics of the study sample socio-demographic characteristics f. (%) age group (years) 23-38 14 (23.3) 39-54 27 (45) 55-70 19 (31.7) residential area urban 42 (70) rural 18 (30) level of education illiterate 19 (31.7) primary school 23 (38.3) secondary school 7 (11.7) institute graduate 6 (10) college graduate 5 (8.3) marital status single 10 (16.7) married 40 (66.7) divorced 1 (1.7) widowed 9 (15) employment status employed 8 (13.3) unemployed 52 (86.7) family income sufficient 38 (63.3) insufficient 22 (36.7) family history of breast cancer no 28 (46.7) yes 32 (53.3) total 60 (100) https://doi.org/10.15218/ejnm.2020.13 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 112 erbil journal of nursing & midwifery past medical history of women with breast cancer table 2 shows medical history. the highest percentages (73.3%) of participants’ breast cancer condition were progress. concerning the breast cancer stage, 40% of the patients were in the third stage, 31.7% were in second stage, and one in the zero stage of breast cancer. most of the breast cancer patients were under the treatment of chemotherapy and surgery (81.7% and 71.7% respectively), moreover only 18.3%, 16%, and 15% were under the biology, hormonal, and radiation therapies respectively, and some cases were under more than one therapy. about body mass index, 48.33% of participants were obese, meanwhile; only one case was underweight. regarding anemia, the majority of patients (83.3%) had mild anemia and 16.7% had moderate anemia. on the subject of having comorbid diseases 68.3% did not have any comorbid diseases, while; 31.7% had comorbid diseases including, 16.7%, 6.7%, and 3.3% came beyond diabetes mellitus and hypertension, hypothyroidism, and heart failure respectively. cancer related fatigue among breast cancer women table 3 shows overall history of crf during the last two weeks. no participants reported no fatigue it. the highest percentage of study samples (75%) suffered from a great deal of fatigue, while; 20% assumed some degree of fatigue, and 5% were not much fatigued. severity of fatigue among participants table four illustrates the severity of fatigue among study samples. concerning the severity of fatigue since last week, almost half of breast cancer patients 53.3% were experience severe degree, 30% were moderately fatigued, and 16.7% had mild fatigue. current fatigue included moderate (48.3%), severe (25%), and mild (26%). cancer related fatigue domains table five shows the domains of fatigue. concerning the findings all women patients were experienced physical, emotional, and cognitive with some degree of fatigue as 60%, 40%, and 40% respectively. table 2: past medical history of women with breast cancer past medical history f (%) breast cancer condition recurrent 16 (26.7) progress 44 (73.3) breast cancer stage zero stage 1 (1.7) first stage 8 (13.3) second stage 19 (31.7) third stage 24 (40) four stage 8 (13.3) chemotherapy use no 11 (18.3) yes 49 (81.7) radiation therapy no 51 (85) yes 9 (15) surgery no 17 (28.3) yes 43 (71.7) biology therapy no 49 (81.7) yes 11 (18.3) hormonal therapy no 50 (83.3) yes 10 (16.7) body mass index underweight 1 (1.7) norm weight 10 (16.7) overweight 20 (33.3) obese 29 (48.3) anemia moderate 10 (16.7) mild 50 (83.3) comorbid disease no 41 (68.3) yes 19 (31.7) dm no 50 (83.3) yes 10 (16.7) ht no 50 (83.3) yes 10 (16.7) hypothyroidism no 56 (93.3) yes 4 (6.7) hf no 58 (96.7) yes 2 (3.3) total 60 (100) table 3: in-depth fatigue history since two weeks ago fatigue history f (%) not much 3 (5) some 12 (20) a great deal 45 (75) total 60 (100) https://doi.org/10.15218/ejnm.2020.13 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 113 erbil journal of nursing & midwifery breast cancer is a major global health concern for women. one of the concerning of cancer and its treatment is crf that leads to decline person capabilities of physical, or emotional, and/ or mental capability. the present study aimed to assessing the prevalence of cancer related fatigue among women with breast cancer ghiasvand et al , 2011 in iran, found that the mean age of cancer occurrence was 41 years old, while ; research in the united kingdom among illustrated that 24.8% of bc occurred in age among women aged 20 to 39 years [21]. in this study, breast cancer occurred a in younger women because kurdistan a developing country that economic status, health care system, are under the development. meanwhile; kurdish civilian constantly suffer from stress, war, they have poor education, all are being the reason of bc occurring in young age which is supported by a research that says bc occurs earlier in younger age women in asian’s and african’s countries which is more forceful and tense, mostly metastasis.[22]. the present study found that the majority of samples were from urban areas, the explanation for that is because in urban area the number of, industrial companies, cars, manufacturing wastes are increased randomly without taking public health in consideration, and most of urban civilians have sedentary lifestyle, all are helping factors for developing different kind of cancers, that is why the incidence of cancer are growing up. correspond to research in china, that found as a result of changing global claiming cancer generally has been increased the entire world and is being an urbanizing disease [23]. low education levels are associated with poor disease progress and affect the survival rate too [24]. current study results showed that most participants graduated from primary school. in kurdistan, migration and financial crisis have contributed to people not being able to complete their education. this study’s results are supported by findings from a cross-sectional study among patients receiving anti-neoplastic treatment table 4: fatigue severity level severity of fatigue f. (%) level of fatigue on the average during the past week mild 10 (16.7) moderate 18 (30) severe 32 (53.3) current fatigue level mild 16 (26) moderate 29 (48.3) severe 15 (25) total 60 (100) table 5: cancer related fatigue domains fatigue domains none not much some a great deal total f. (%) f. (%) f. (%) f. (%) f. (%) physical fatigue 6 (10) 12 (20) 36 (60) 6 (10) 60(100) emotional fatigue 11 (18.3) 2 (3.3) 24 (40) 23 (38.4) 60(100) cognitive fatigue 11 (18.3) 21 (35) 24 (40) 4 (6.7) 60(100) discussions https://doi.org/10.15218/ejnm.2020.13 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 114 erbil journal of nursing & midwifery in india in 2012, which demonstrated that participants were mainly from primary school too. [25]. regarding marital status more than half of present study participants were married, the similar result found in the research performed among 60 breast cancer patients in united state at 2012; represented that most of study sample were married [26]. most patients were in the third stage of their cancer. this is likely because of prevention programs in iraq. while; the result of a research carried out in india at 2017 closed to existence study found that most of breast cancer were diagnosed in advance stage, is that because india like kurdistan they may not have spent enough budget to health promotion and prevention [27]. moreover; the current study result is disagree with american association for cancer research finding in 2012 that found utmost of women diagnosed with bc were in first stage, that is because of existence of good and strong health policy in america [28]. most of the patients were under the treatment of chemotherapy and surgery, nonetheless; the result is supported by a clinical practice guideline published by oxford university, which showed that approximately one eight of bc cases will undergo surgery [29], and also a survey of 1954 women patient with bc illustrated that third-fourth of women were used chemotherapy, it is point out that two of the most effective and powerful management for bc are surgery and chemotherapy [30]. nearly half the participants were obese, meanwhile; only one case were underweight, on the same time; the study finding is dissimilar with a research conducted in bangladesh in 2015 represented that 69% of participants were had normal body weight. this differences is might related to the bangladesh’s’ women awareness regarding knowing the values of healthy foods and consuming balance in diet to maintain healthy body weight. [31]. on the subject of having comorbid diseases 68.3% of current study did not have any comorbid diseases, while; 31.7% had comorbid diseases, this result is dissimilar with the american cancer society prospective surveillance model study for rehabilitation for women with breast cancer in georgia at 2012 among 1500 patients discovered that 66% of participant had at list one comorbidities, while; 33% of them were have more than two comorbidities, and the most common comorbid disease was hypertension[37]. cancer related fatigue assessment nearly every cancer patients go through some kind of fatigue during cancer treatment according to present study finding all the participants were fatigued with different level of fatigue, because there were no participants that were not being fatigue it. the highest percentage of study samples (75%) were suffered from a great deal of fatigue, this is similar with the cross-sectional observational study finding that was performed in malwa region of punjab at 2017 under the title “assessment of cancer-related fatigue among cancer patients receiving various therapies” among 126 participants the percentage of study fatigue was 83.3% [38].severity of cancer related fatigue concerning the severity of fatigue of present study since last week, almost half of breast cancer patients 53.3% were experience severe degree; whereas 30% got moderate fatigue, and 16.7% were assume mild degree of fatigue, the study result is reinforced by the study conducted by campos et al at 2011 in brazil among 260 patients demonstrated fatigue severity as 47% for sever fatigue, 42% for moderate fatigue, and 10% for mild fatigue[39], while; american cancer society accomplished research in 2015 to under the title “screening, evaluation, https://doi.org/10.15218/ejnm.2020.13 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 115 erbil journal of nursing & midwifery and management of cancer related fatigue” illustrated that the most common fatigue severity among cancer patient was severe fatigue ranged 98% [40]. fatigue domains fatigue domains finding in current study all women patients were experienced physical, emotional, and cognitive with some degree of fatigue as 60%, 40%, and 40% respectively, this is supported by review of literature research carried out in netherland at 2013 stated that physical fatigue was more frequent fatigue among study participants who were under therapy than the mental (cognitive) fatigue [41]. the study illustrated that the highest percentage of participants (45%) were ages 39 to 54, most were from urban areas, bad graduated from primary school, and were married. most of study samples were unemployed (86.7%), however; 53.3% of breast cancer women they had family history of bc, first degree relevant with breast cancer history were affected 62.5% of samples. regarding breast cancer stages, 40% of participants were in third stage, most of the breast cancer patients were under the treatment of chemotherapy and surgery (81.7% and 71.7% respectively, most of them were obese, while; majority of patients had mild anemia (83.3%). on conclusion, as a study result showed every breast cancer patients were assuming some level of fatigue while; concerning fatigue severity among participants were ranging between sever to moderate degree of fatigue 53.3% and 48.3% respectively coming beyond fatigue level in past week, and fatigue rate right now. also physical fatigue was common type of fatigue among breast cancer women. as a result of highly prevalent of crf the researcher are recommending following things:  further study on larger sample to be conducted for dipper analysis of cancer related fatigue and its impact on patients’ life.  instruct health care provider to assess all patients for presenting of crf, and utilizing various ways (pharmacological and nonpharmacological) to increase patient’s quality of life and decreasing suffering.  prepare an educational program for cancer patient to educate those regarding cancer and treatment consequences, and how can be handle it [1] bray f, ferlay j, soerjomataram i, siegel rl, torre la, jemal a. global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. 2018; 1;68(6):394–424. cancer journal of clinician. available from https://www.ncbi.nlm.nih.gov/ pubmed/30207593. [2] rebecca l, siegel mph, kimberly d, miller mph, ahmedin jamel , 2017;67(1):7-30. cancer statistics: a cancer journal for clinicians. available from: https:// acsjournals.onlinelibrary.wiley.com/doi/ full/10.3322/caac.21387. [3] siegel rl, miller kd, jemal a. cancer statistics:cancer journal of clinician, 2019;69 (1):7–34. available from https:// www.ncbi.nlm.nih.gov/pubmed/30620402. [4] abulkhair o, saghir n, sedky l, saadedin a, elzahwary h, siddiqui n, et al. modification and implementation of nccn guidelinestm on breast cancer in the middle east and north africa region,2010;1;8(3):s-8-s-15. journal of national comprehensive cancer network. available from: https:// www.nccn.org/about/news/ebulletin/ ebulletindetail.aspx?ebulletinid=362. conclusions recommendations reference https://doi.org/10.15218/ejnm.2020.13 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 116 erbil journal of nursing & midwifery [5] karadag g, gungormus z, surucu r, savas e, bicer f. awareness and practices regarding breast and cervical cancer among turkish women in gazientep, 2014 1;15(3):1093–8. asian pacific journal of cancer prevention. available from https:// www.ncbi.nlm.nih.gov/nlmcatalog?term=% 22asian+pac+j+cancer+prev. [6] taghavi a, fazeli z, vahedi m, baghestani ar, pourhoseingholi a, barzegar f, et al. increased trend of breast cancer mortality in iran, 2012;13(1):367–70. asian pacific journal of cancer prevention. available from https://www.ncbi.nlm.nih.gov/ pubmed/22502702. [7] gonzalez-angulo am, timms km, liu s, chen h, litton j, potter j, et al, incidence and outcome of brca mutations in unselected patients with triple receptor-negative breast cancer. 2011 13. clinical cancer research. available from https:// www.ncbi.nlm.nih.gov/pubmed/21233401. [8] mualla fhf, al-alwan nas. promoting clinical breast examination as a screening tool for breast cancer in iraq. 2014;27(1):76–82. nursing national iraqi specialty. availabe from https://www.iasj.net/iasj? func=article&aid=91480. [9] gradishar wj, anderson bo, balassanian r, blair sl, burstein hj, cyr a, et al. breast cancer version 2.2015;1;13(4):448–75. journal of national comprehensive cancer network. available from https:// www.ncbi.nlm.nih.gov/pubmed/25870381. [10] berger am, mitchell sa, jacobsen pb, pirl wf. screening, evaluation, and management of cancer-related fatigue: ready for implementation to practice? 2015;65(3):190 –211.cancer journal of clinician. available from https://www.ncbi.nlm.nih.gov/ pubmed/25760293. [11] ripamonti ci, antonuzzo a, bossi p, cavalieri s, roila f, fatigoni s. fatigue, a major still underestimated issue. 2018;30(4):219. current opinion in oncology. available from https://www.ncbi.nlm.nih.gov/ pubmed/29877886. [12] pearson ejm, morris me, stefano m di, mckinstry ce. interventions for cancerrelated fatigue: a scoping review. 2018;27 (1):e12516. european journal of cancer care. available from https:// www.ncbi.nlm.nih.gov/pubmed/27254272. [13] strebkova r, petkova m, minev m. assessment of cancer related fatigue. trakia j sci. 2017;15(3):238–43. trakia journal of sciences. available from http:// tru.uni-sz.bg/tsj/ vol15_n3_2017/11_r.strebkova.pdf. [14] cramp f, byron-daniel j. exercise for the management of cancer-related fatigue in adults. 2012;97. the cochrane database of systematic reviews. available from https://www.ncbi.nlm.nih.gov/ pubmed/23152233. [51] borneman t. assessment and management of cancer-related fatigue, 2013 apr;15(2):77. journal of hospice & palliative nursing. available from https:// nursing.ceconnection.com/ ovidfiles/00129191-20130400000005.pdf. [51] mustian, k.m., sprod, l.k., janelsins, m., peppone, l.j., mohile, s, 2012;8, 81–88. exercise recommendations for cancerrelated fatigue, cognitive impairment, sleep problems, depression, pain, anxiety, and physical dysfunction: oncology & hematology review. available from https://www.ncbi.nlm.nih.gov/ pubmed/23667857. [51] mitchell, s.a., hoffman, a.j., clark, j.c., degennaro, r.m., poirier, p., robinson, c.b., weisbrod, b.l, 2014;18, 38–58. putting evidence into practice: an update of evidence-based interventions for cancer-related fatigue during and following treatment. clinical journal of oncology nursing. https://www.ncbi.nlm.nih.gov/ nlmcatalog?term=% 22clin+j+oncol+nurs%22. [51] .jemal, a., bray, f., center, m.m., ferlay, j., ward, e., forman, d, 2011;61, 69–90. global cancer statistics. a cancer journal of clinician. https:// acsjournals.onlinelibrary.wiley.com/doi/ full/10.3322/caac.20107. [51] normal weight ranges: body mass index (bmi) [internet]. [cited 2019 jul 16]. available from: https://www.cancer.org/ cancer/cancer-causes/diet-physicalactivity/body-weight-and-cancer-risk/ adult-bmi.html . [22] badireddy m, baradhi km. chronic anemia. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2019 [cited 2019 jul 16]. available from: http:// www.ncbi.nlm.nih.gov/books/ nbk534803/. [25] .antoniou ac, casadei s, heikkinen t, barrowdale d, pylkäs k, roberts j, et al. https://doi.org/10.15218/ejnm.2020.13 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 117 erbil journal of nursing & midwifery breast-cancer risk in families with mutations in palb2. 2014 7;371(6):497–506. the new england journal of medicine.available from https://www.nejm.org/doi/ full/10.1056/nejmoa1400382. [22] youlden dr, cramb sm, dunn nam, muller jm, pyke cm, baade pd. the descriptive epidemiology of female breast cancer: an international comparison of screening, incidence, survival and mortality. 2012 1;36 (3):237–48. cancer epidemiology. available from https://www.ncbi.nlm.nih.gov/ pubmed/22459198. [23] zeng h, zheng r, zhang s, zou x, chen w. female breast cancer statistics of 2010 in china: estimates based on data from 145 population-based cancer registries. 2014;6 (5):466–70. journal of thoracic disease. available from https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc4014998/. [24] herndon je, kornblith ab, holland jc, paskett ed. effect of socioeconomic status as measured by education level on survival in breast cancer clinical trials, 2013;22 (2):315–23.psycho oncology. available from https://www.ncbi.nlm.nih.gov/nlmcatalog? term=%22psychooncology%22. [25] karthikeyan, g., jumnani, d., prabhu, r., manoor, u.k., supe, s.s., 2012;18, 165–175. prevalence of fatigue among cancer patients receiving various anticancer therapies and its impact on quality of life: a cross-sectional study. indian journal of palliative care. available from; https:// www.ncbi.nlm.nih.gov/pubmed/23439783 [26] citrin dl, bloom dl, grutsch jf, mortensen sj, lis cg. beliefs and perceptions of women with newly diagnosed breast cancer who refused conventional treatment in favor of alternative therapies. 2012 may 1;17(5):607–12. the oncologist. available from https://www.ncbi.nlm.nih.gov/ pubmed/22531358 . [21] malvia s, bagadi sa, dubey us, saxena s. epidemiology of breast cancer in indian women. 2017;13(4):289–95. asiapacific journal of clinical oncology. available from https://www.ncbi.nlm.nih.gov/ pubmed/28181405. [21] haque r, ahmed sa, inzhakova g, shi j, avila c, polikoff j, et al. impact of breast cancer subtypes and treatment on survival: an analysis spanning two decades. 2012 oct 1;21(10):1848–55. cancer epidemiology, biomarkers & prevention. available from https://www.ncbi.nlm.nih.gov/ pubmed/22989461. [29] senkus, e., kyriakides, s., penault-llorca, f., poortmans, p., thompson, a., zackrisson, s., etal, 201324, (7–23). primary breast cancer: esmo clinical practice guidelines for diagnosis, treatment and follow-up. journal of the european society for medical oncology.availble from https://www.ncbi.nlm.nih.gov/ pubmed/23970019. [30] valentini a, finch a, lubiński j, byrski t, ghadirian p, kim-sing c, et al. chemotherapy-induced amenorrhea in patients with breast cancer with a brca1 or brca2 mutation. 2013;1;31(31):3914–9. journal of the american society of clinical oncology. available from https:// www.ncbi.nlm.nih.gov/ pubmed/23980083. [31] iqbal j, ferdousy t, dipi r, salim r, wu w, narod sa, et al. risk factors for premenopausal breast cancer in bangladesh. 2015. international journal of breast cancer. [cited 2019 apr 2]. available from: https://www.hindawi.com/journals/ ijbc/2015/612042/. [32] berger am, gerber lh, mayer dk. cancerrelated fatigue. 2012;118(s8):2261–9. journal of american society of therapeutic radiologists. available from https:// www.ncbi.nlm.nih.gov/ pubmed/22488700. [33] banipal, r.p.s., singh, h., singh, b. assessment of cancer-related fatigue among cancer patients receiving various therapies: a cross-sectional observational study, 2017;23, 207–211. indian journal of palliative care.. available from https:// www.ncbi.nlm.nih.gov/ pubmed/28503042 . [34] berger, a.m., mitchell, s.a., jacobsen, p.b., pirl, w.f, screening, evaluation, and management of cancer-related fatigue: ready for implementation to practice? 2015a;65, 190–211a cancer journal for clinicians...available from https:// www.ncbi.nlm.nih.gov/ pubmed/25760293. [35] campos, m.p.o., hassan, b.j., riechelmann, r., del giglio, a., 2012; 2, 1273–1279. cancer-related fatigue: a practical review. journal of the european society for medical oncology. available from https://www.ncbi.nlm.nih.gov/ https://doi.org/10.15218/ejnm.2020.13 erbil j. nurs. midwifery, vol. 3, no. (2), nov, 2020 original article 118 erbil journal of nursing & midwifery pubmed/21325448. [36] raaf pj de, klerk c de, rijt ccd van der. elucidating the behavior of physical fatigue and mental fatigue in cancer patients: a review of the literature. 2013;22(9):1919–29. psycho oncology. available from https:// www.ncbi.nlm.nih.gov/pubmed/23147803. https://doi.org/10.15218/ejnm.2022.08 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article mothers’ knowledge regarding home care management of neonatal jaundice in qaladze sulaymaniyah city abstract introduction jaundice is a yellow coloring of the skin and/or the whites of the eyes, a common condition in babies. when bilirubin accumulates in the skin of infants, the skin turns yellow. high bilirubin levels in the blood is a condition known as background and objectives: jaundice is the most common condition requiring medical attention in newborn babies. the mother has a significant role in reducing the effects. early discharge of mothers and neonates from the hospitals increased the responsibility of mothers in recognizing jaundice has increased. this study aimed to assess the level of the mothers’ knowledge regarding home care management of neonatal jaundice. methods: a quantitative, cross-sectional descriptive study was carried out in the neonatal intensive care unit at shahidan qaladze teaching hospital from the period of january 2021 to march 2022. purposive (non-probability) sampling techniques were used to recruit participants. the study sample included 114 mothers. data was collected using a questionnaire prepared by the investigator, and direct interviews were conducted. descriptive statistics including, frequencies and percentages, and inferential statistical analysis of chi-square was used to analyze the data. results: the results show that 34.2% of the mothers were between 26-32 years. concerning occupation, more than three-quarters (86%) of the sample were housewives. the study demonstrated that the majority (64.9%) of mothers did not have enough information about jaundice. there was a statistically significant association between parents’ relatives and the source of information regarding the mother’s knowledge. the study showed a statistically significant association between mothers’ knowledge and early initiation of breastfeeding. factors associated with mother’s knowledge include the mother’s age, occupation, years of formal education, residency areas, received health education on neonate jaundice, and the source of information. conclusion and recommendations: the study concluded that most mothers had a deficit of knowledge regarding home care management of neonatal jaundice. it is recommended to provide mothers with comprehensive health education about neonatal jaundice care to improve their knowledge and practice in caring for neonates with jaundice. keywords: mothers; neonatal; intensive care units; home care services. banaz kamal mohammad; department of pediatrics, college of nursing, sulaimania university, sulaimania, kurdistan region, iraq. (correspondence: banazkamal72@gmail.com) shukir saleem hasan; department of nursing, college of nursing, hawler medical university and tishk international university, erbil, kurdistan region, iraq. 72 received: 04/01/2022 accepted: 26/03/2022 published: 30/11/2022 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:banazkamal72@gmail.com https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.08 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article hyperbilirubinemia [1about half of term and 80% of preterm babies get jaundice, which arises two to four days after birth and goes away on its own within one to two weeks without treatment [2]. the main symptom is a yellowish skin color that appears and extends to the face, chest, abdomen, legs, and soles of the feet. clinical indicators of hyperbilirubinemia include hepatomegaly, poor weight gain, lethargy or irritability, poor breastfeeding or bottlefeeding, and visual jaundice (yellow of the sclera) [3]. subtypes of neonatal jaundice include jaundice due to breastfeeding, jaundice due to breast milk, and hemolytic jaundice due to rhesus factor (rh) incompatibility, and abo blood group incompatibility [4]. poor feeding, high-pitched cries, convulsions, hearing loss, cerebral palsy, and mental retardation are all side effects of jaundice [5]. kernicterus is a dangerous consequence connected with jaundice and can cause cerebral palsy and deafness if not appropriately treated [6]. a mother with blood group o or rhesus negative, rapid rise of total serum bilirubin (tsb), sepsis, lactation failure in exclusive breastfeeding, high pre-discharge bilirubin level, cephalohaematoma or bruises, babies of diabetic mothers [7]. jaundice is a common reason for re-admission to the hospital after an early discharge of a newborn baby. “in a study conducted in the iraqi-kurdistan region, the neonatal mortality rate was 37 deaths per 1000 live births” [9]. in 2002, 18% of neonatal admissions at the national hospital of pediatrics (nhp) were admitted with hyperbilirubinemia [8]. among turkish infants, jaundice is seen in 10.5 % of term infants and 25.3 % of near-term infants [10]. a study confirmed that 75% of neonatal mortality occurs in though asia and sub haran african, deaths occurring within the first 28 days, and add that more than third of neonatal death occurs in ethiopia [11]. neonatal jaundice is increased in infants of east asian, american indian, and greek descent. african infants are affected less often than non-african infants [10]. early detection and treatment of ureteric neonates may help to reduce difficulties [6]. in newborns, jaundice is the most prevalent ailment that necessitates medical treatment, such as jaundice presentation sites, danger signs, causes, complications, diagnosis ways, and effective treatments, are included with in mothers’ awareness regarding home care management of neonatal jaundice [12]. according to the nonofficial census at shahidan qaladze there were 250 neonatal jaundices admitted to the hospital last year [13]. the goal of this study is to assess mothers’ knowledge regarding home care management of neonatal jaundice. this study was a descriptive-analytic crosssectional study using a quantitative design. the research was conducted between january 2021 and the end of march 2022. the sample was a non-probability (purposive) sample of 114 eligible mothers based on a formula devised by yamane in 1967 [14], as follows n=n/1+ n (e)2; (n= total number e= alpha errors of 0.05). eligibility criteria included mothers who were admitted with their neonate with jaundice. mothers who attended shahidan qaladeze teaching hospital in qladadeze sub-district in sulaymaniyah city of the iraqi kurdistan region were recruited. prior to the interview, an administrative agreement was taken from the faculty of nursing/sulaymani university's scientific and ethical committee, and the shahidan qaladeze teaching hospital's scientific and ethical committee. verbal consent was received from mothers who accepted to participate. personal information, such as phone numbers, and 73 methods copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.08 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article status. around half (57%) of the respondents were pregnant more than once (multigravida), and 43% had one child (primigravida). sixty-four percent of mothers had no previous history of neonatal jaundice. mothers breastfeeding exclusively accounted for 61.4% of the sample. the study revealed that 68.4% of mothers had received health education about neonatal jaundice and 18.4% received health education on neonatal jaundice from their relatives. a statistically significant association was found between mothers' knowledge of home care management and parameters such as source of information (pvalue=0.030), and relative between parents (p-value=0.036) respectively (table 2). table 3 indicates a statistically significant link between mother’s knowledge and the initiation of breastfeeding (colostrum). table 4 shows a statistically significant relationship between mothers’ knowledge of home care management and parameters such as source of information (pvalue=0.00), occupation (p-value=0.04), and health education (p-value=0.05). the study found non-significant association between mothers’ experiences of home care management and their age (p= 0.64). part i: socio demographic characteristics of mothers (table 1) most of the respondents were 26-32 years of age. this study is like a study carried out by an iraqi researcher, who revealed that 43.2% of caregivers were aged between 26-31 [16]. in contrast, a study conducted in nigeria revealed that most of respondents were aged 20-35 years [17].the current study found that housewives made up the largest percentage of participants. this finding is consistent with a study conducted in karbala which found that more than three quarters addresses, were not included in the tool, and the researcher agreed to keep the data secure for anonymity and confidentiality. the questionnaire consisted of two parts. part 1 gathered information regarding participants’ socio-demographic characteristics, and part 2 assessed mother’s knowledge regarding home care management of neonatal jaundice. the knowledge items were rated on a two-point dichotomous scale (know and don’t know) and scored as 1 for correct and 0 for incorrect. data was collected through direct (face-toface) interviews for about 25 to 35 minutes. the validity of the study instrument was first determined by a panel of 20 experts from various fields. it assessed the consistency, precision, repeatability, and trustworthiness of research. it demonstrates the extent to which the survey instrument is free of bias and ensures consistent measurement throughout and across the various elements in the instruments [15]. pearson correlation(r) was used to determine the reliability (r=0.81) and indicated that the scale is sufficiently trustworthy. a pilot study was conducted on 15 mothers. the data were processed using spss software version 25 for statistical analysis (frequency and percentage). the association between the variables was determined using inferential statistical analysis (chi-square and regression). it is considered statistically significant if the pvalue is equal and less than 0.05 and rejects the null hypothesis. the socio-demographic characteristics of mothers are presented in table 1. the results show that 34.2% of the mothers were between 26-32 years. concerning occupation, more than three-quarters (86%) of the sample were housewives. the results showed that more than half (68.4%) of the sample are of middle level socioeconomic 74 results discussion copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.08 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article (79.5%) of mothers providing home care were housewives [18]. in terms of the participants’ economic status, the results suggest that 68.4% had a middle economic status. this is contradicted by a study conducted by researchers in vietnam which found that the average household economy was middle level [8]. in karbala, a study found that 60% of the mothers have a low socioeconomic status [18]. the current study showed that around half (57%) of mothers were pregnant more than once (multigravida), and 43% had one child (primigravida). similar results were also found in a study in ghana which mentioned that 55% of the sample were nulliparous and 45% were primigravida [19]. according to the type of feeding, 61.4% of mothers started exclusive breastfeeding. this finding is consistent with an iraqi researcher which found that 65.2% of women exclusively breastfed their children [16]. according to the current study, less than a quarter of mothers (64.9%) have never heard of newborn hyperbilirubinemia, with relatives accounting for 18.4% of information and social media accounting for 14.0%. this contradicts the findings in ghana which found that 82.7% of women had heard of neonatal jaundice. the primary source of knowledge concerning newborn jaundice was the school (34.6^), followed by friends (15.4%) [20].part ii: association between sociodemographic characteristics and mother’s knowledge regarding neonatal jaundice (table 2)our study found no statistically significant relationship between mothers’ knowledge of newborn jaundice and their age, level of education, or socioeconomic status. this contradicts the findings in karbala which found that the mothers’ knowledge was substantially related to their age, degree of education, and socioeconomic status at a p-value of 0.05 [18]. no significant association between occupational and residential status of mothers was found at a p-value of 0.05. furthermore, our findings contradict the findings of a study carried out in egypt which found that mother’s knowledge was influenced greatly by the degree of education, age, parity, and past history [12]. another study found that knowledge was substantially connected with a history of neonatal jaundice, a child’’s birth rank, and the mother’s age [20]. this contradicted the findings of the present investigation, which found no statistically significant link between mother’s knowledge, mother’s age, and previous history of jaundice. also, the findings of the present study diasagrees with a study conducted in iraq which found that older women’s knowledge, attitude, and behavior about several aspects of neonatal jaundice were considerably better than younger women’s [21]. in contrast to the earlier study was carried out in egypt [22], our study found that occupation and residency had no effect on mothers’ knowledge. working mothers and those who live in cities had much higher levels of knowledge than other mothers. similar findings were observed in an indian study by gopalakrishnan et al., [23]. the respondents’ degree of education, as well as the number of prior babies that had neonatal jaundice, were found to have a substantial impact on their understanding of the condition in this study. however, there was no correlation between the mother’s age and their expertise (p=0.005). the current study found a statistically significant relationship between maternal education and awareness of neonatal jaundice (p= 0.020), as well as the number of previous babies who had experienced neonatal jaundice and respondents’ knowledge of neonatal jaundice (p=0.0001). a study discovered in baghdad shows a statistically significant relationship between mother’s knowledge and mother’s age (p=0.001) [24] and an iraqi researcher found 75 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.08 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article 76 and the need to seek early hospital care when neonatal jaundice is detected [2829]. the study found that most mothers lacked knowledge and procedures for managing newborn jaundice care at home. it was suggested that mothers of children with newborn jaundice receive comprehensive health education regarding neonatal jaundice care to improve their knowledge and practice. the authors acknowledge the mothers who participated in the study and qaladeze shahida hospital for their support and participation. ethical approval was obtained from the scientific and ethical committee at the faculty of nursing/ sulaymani university, and shahidan qaladeze teaching hospital. verbal permission was taken from the mothers before conductng the interviews. the tool did not consist of personal information such as personal phone number, address, personal information, and the researcher promised to keep the data for confidentiality and anonymity the authors (s) report no conflict of interest. the authors (s) report no funding support. [1] mansor mn, yaacob s, hariharan m, basah sn, jamil sa, khidir mm, and et al,. jaundice in newborn monitoring using color detection method. procedia engineering. 2012 jan 1; 29:1631-5. a statistically significant relationship between mothers’ level of education and their practices [25]. according to our findings, there is a statistically significant link between parents’ relatives and the source of information on the mother’s expertise. our findings contradict with a study conducted in nigeria which found no influence of source of information and mother’s knowledge on neonatal jaundice, and no relationship between a relative of parents and mother’s knowledge on neonatal jaundice [26].part iiiassociation between biographical information of neonatal jaundice and mother’s knowledge (table 3)there was no statistical link between mothers’ educational levels and the age of their newborns. a similar study in karbala found no significant link between mothers’ knowledge and neonatal age (p=0.016). the current study found a statistically significant link between mother’s knowledge and biographical information of newborns related breastfeeding (colostrum) initiation which is consistent with a study conducted in karbala which found a link between mothers’ knowledge and colostrum in terms of socio-demographic variables [27].part v: identify the factors associated with mothers’ knowledge regarding home care management (table 4)our result reveals a statistically significant relationship between mothers’ knowledge of home care management and parameters like source of information, occupation, and health education, years of schooling, and residential area, with p-values of 0.00 and 0.05, 0.010, and 0.034, respectively. a study in mosul, iraq discovered a statistically significant relationship between the age of the care, level of education, occupation, and residential areas, and homecare management of neonatal jaundice babies [24]. a study conducted in ghana reported that health education should emphasize phototherapy as the main treatment plan, conclusion acknowledgment ethical considerations conflict of interest funding references copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.08 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article [13] non-official census of shahidan qaladeze teaching hospital, 2020, no 124 in 10, 01, 2021. [14] chawarwan sa. home care management of preterm baby among mothers attending neonatal intensive care unit in erbil city, 2019; 26-27. (msc. thesis) [15] mohajan hk. two criteria for good measurements in research: validity and reliability. annals of spiru haret university. economic series. 2017;17(4):59-82. [16] al doori nm, ameen wa, talib m. mother’s knowledge of initiative breast feeding in relation to neonatal jaundice. medico legal update. 2020 jul 24;20(3):1436-41. [17] ezeaka cv, ugwu ro, mukhtar-yola m, ekure en, olusanya bo. pattern and predictors of maternal care-seeking practices for severe neonatal jaundice in nigeria: a multicentre survey. bmc health services research. 2014 dec;14(1):1-0. [18] hussein hs, aziz ar. assessment of mothers' knowledge and beliefs toward care of neonatal jaundice in pediatric teaching hospital in holy karbala city. reading and writing an interdisciplinary journal. 2016; 8(8). [19] adoba p, ephraim rk, kontor ka, bentsil jj, adu p, anderson m, and et al. knowledge level and determinants of neonatal jaundice: a cross-sectional study in the effutu municipality of ghana. international journal of pediatrics. 2018 mar 1;2018. [20] khalesi n, rakhshani f. knowledge, attitude and behaviour of mothers on neonatal jaundice. the journal of the pakistan medical association. 2008 dec;58(12):671-4 [21] al-zamili ah, saadoon za. knowledge, attitude and practice of mothers to neonatal jaundice. medico legal update. 2020 apr 9;20(1):1065-70. [22] moawad em, abdallah ea, ali yz. perceptions, practices, and traditional beliefs related to neonatal jaundice among egyptian mothers: a cross-sectional descriptive study. medicine (baltimore). 2016 sep;95(36). [23] gopalakrishnan s. assessment of knowledge regarding new-born care among mothers in kancheepuram district, tamil nadu. international journal of community medicine and public health. 2014 oct;1(1):58. [24] hameed nn, abdul-hussain nj, ahmed me. assessment of mother's knowledge, practices and believes toward home management of neonatal jaundice in two pediatric teaching hospitals. journal of the faculty of medicine baghdad. 2019;61(3, 4). 77 [2] jardine la, woodgate p. neonatal jaundice. american family physician. 2012 apr 15;85 (8):824-5. [3] cohen rs, wong rj, stevenson dk. understanding neonatal jaundice: a perspective on causation. pediatrics & neonatology. 2010 jun 1;51(3):143-8. [4] ullah s, rahman k, hedayati m. hyperbilirubinemia in neonates: types, causes, clinical examinations, preventive measures and treatments: a narrative review article. iranian journal of public health. 2016 may;45 (5):558. [5] hamad kj, khalil hm. assessment of knowledge of neonatal jaundice among mothers attending maternal and pediatric hospital in soran city. polytechnic journal. 2019 jun 30;9(1):32-6. [6] boskabadi h, ashrafzadeh f, azarkish f, khakshour a. complications of neonatal jaundice and the predisposing factors in newborns. journal of babol university of medical sciences. 2015 sep 10;17(9):7-13. [7] wan as, daud sm, teh sh, choo ym, kutty fm. management of neonatal jaundice in primary care. malaysian family physician: malaysian family physician. 2016;11(23):16. [8] le lt, partridge jc, tran bh, le vt, duong tk, nguyen ht, and et al,. care practices and traditional beliefs related to neonatal jaundice in northern vietnam: a populationbased, cross-sectional descriptive study. bmc pediatrics. 2014 dec; 14(1):1-8. [9] moazzem hossain sm, el nakib s, ibrahim s, al-harun a, muhammad s, zaka n. maternal and neonatal health in select districts of iraq: findings from a recent household survey. journal of pregnancy and child health. 2018;5(395):10-4172. [10] zimmerman jj, fuhrman bp. pediatric critical care e-book. elsevier health sciences; 2011 mar 24; 6 (1): 96-105. [11] lake ea, abera gb, azeze ga, gebeyew na, demissie bw. magnitude of neonatal jaundice and its associated factor in neonatal intensive care units of mekelle city public hospitals, northern ethiopia. international journal of pediatrics. 2019 apr 39(4) : . 159–163. [12] allahony dm, hegazy nn, kasemy za, bahgat em. mothers' perception toward neonatal jaundice in kafr el-batanoon village, menoufia, egypt. menoufia medical journal. 2016;29(3):743. copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.08 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article [25] jamil ei, jamil nf. knowledge & health seeking behavior of newly delivered mothers regarding neonatal jaundice. iraqi journal of community medicine. 2017;30(2). [26] ogunfowora ob, daniel oj. neonatal jaundice and its management: knowledge, attitude and practice of community health workers in nigeria. bmc public health. 2006 dec;6(1):1-5. [27] hussein ka, aziz ar. assessment of knowledge and attitude of colostrum among postnatal mothers. mosul journal of nursing. 2013 mar 1;1(1):1-6. [28] salia sm, afaya a, wuni a, ayanore ma, salia e, kporvi dd, and et al. knowledge, attitudes and practices regarding neonatal jaundice among caregivers in a tertiary health facility in ghana. plos one. 2021 jun 4;16(6):e0251846. [29] schuler c, ntow ge, agbozo f. mothers' experiences with neonatal care for low-birth -weight infants at home; a qualitative study in the hohoe municipality. ghana journal of pediatric nursing. 2019 mar 1; 45:e44-52. 78 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.02 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article pregnant women's perception and attitude towards mode of delivery in erbil citya qualitative study abstract introduction childbirth is regarded as one of the divine blessings to reproduce human beings on the earth and has persisted up to the present time. the objectives of childbirth control policies are to have safe deliveries and healthy childbirth. cesarean section (cs) was utilized to assist mothers with high-risk pregnancies in the last few decades [1]. cesarean section is a lifesaving surgical intervention for women and newborns, though overutilization is a public health concern [2].the childbirth experience has always been a significant event in women's lives, a special moment marked by the woman's conversion into her new role as a mother. in developed countries, women often decide on cesarean delivery due to their understanding of its role and safety and the increasing importance of the right to self-decision-making regarding mode of delivery [3].the world health organization (who) reported that 35% of all deliveries worldwide are by mode of cesarean sections. furthermore, these rates background and objective: the childbirth experience has always been represented as a significant event in women’s lives. with the rising rates of cesarean sections in the kurdistan region and lack of evidence, this study was conducted to explore women’s perceptions and attitudes towards a mode of delivery. method: an exploratory qualitative design with in‑depth interviews was used to collect data from 18 pregnant women. all in-depth interviews were tape-recorded, transcribed, and subsequently analyzed. inductive content analysis methods were used to establish the meaning units, subthemes, and main themes. result: from the analysis of depth-interview data of 18 pregnant women, 48 meaning units were obtained. these meaning units were collected into four themes and nine subthemes. these themes were identified as perceived advantages and disadvantages of a mode of delivery, knowledge deficit, weak healthcare provider's role, and fear related to vaginal delivery. conclusion: results showed that women’s decision-making on the mode of delivery depended on their family and friends’ opinions. health care providers had few roles in providing the necessary information about the advantages and disadvantages of delivery modes, childbirth, and decreasing their fear of vaginal delivery. keywords: pregnant women; attitude; perception; knowledge; mode of delivery khadija mirkhan ahmed; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: khmirkhan@yahoo.com) tiran jamil piro; department of midwifery, college of nursing, hawler medical university, erbil, iraq. 11 erbil journal of nursing & midwifery received: 23/11/2021 accepted: 09/02/2022 published: 30/05/2022 mailto:khmirkhan@yahoo.com https://doi.org/10.15218/ejnm.2022.02 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article are estimated at 50% in asia and 48% in china. however, according to who recommendation, this rate should be reduced to 5-15%. the safest and most common mode of childbirth is vaginal delivery, and in most cases, cesarean section is done on women with high-risk pregnancies [1].the cause of increased cesarean section rate and choosing cesarean section are influenced by many factors, including previous cesarean section, multiple gestations, malpresentation, fetal distress, failure in labor progress, and mother’s medical conditions [5]. nowadays, maternal request is the most common non-medical reason that may increase the cesarean rate, despite the extra cost for families and medical costs for health facilities. according to lewis's theory, pain and fear associated with cs could affect mothers' decisions because they think they will have less pain in cesarean delivery [6]. unnecessarily high cesarean rates have adverse implications regarding women's health, health charge, and resources benefits at the personal, family, and social levels. non-clinical factors have equally essential factors as clinical factors when looking at the rapidly increasing cesarean section rate. women who select cesarean delivery believe that vaginal delivery is a more painful and dangerous procedure without considering the negative outcome of unnecessary operation intervention [2]. the high cesarean section rate and the role of women's preference for mode of delivery are disputed. assessing these preferences are complicated because they are influenced by family, knowledge about risks and benefits, and cultural and social factors [3]. knowledge of pregnant women about delivery comes from family exchanges and others’ experiences. evidence confirms that hearing the experiences of others is an effective way to help women select the mode of delivery [7]. optional cs inflict high costs on the healthcare system and lead to many complications for mothers. identifying the intellectual and internal factors that affect their preference for childbirth methods and educating primiparous mothers can reduce their anxiety and fear related to vaginal delivery and motivate them to choose a vaginal delivery method [7]. women’s beliefs and perceptions regarding cs play a significant role in selecting a birthing method. women’s decision making sometimes depends on cultural factorss, social support, and women's knowledge and attitude. selecting a childbirth method does not depend on the maternal and fetus condition identified by sanavi et al. [9]. the cesarean rate in 2012 in iraq was 24.4% for all births, 25.4% in iraqi kurdistan, and 24.3% in center/south of iraq rates of cesarean, which were far above the who recommended rate of 10%. from 2008 to 2012, iraq had a rapid upward trend in the cesarean rate, with much of this trend attributed to the kurdistan region [11]. women's perceptions and attitudes regarding the mode of delivery and factors associated with the preferred delivery method were explored in the present study. study design an exploratory qualitative design with in‑depth interviews was used to explore women’s perceptions and attitudes toward the mode of delivery.participants and setting this study was conducted from january to march 2021 at two primary health care (phc) centers (nazdar bamarny and tayrawa) which provides antenatal care unit in erbil city, iraq. eighteen pregnant women who attended the antenatal care unit without significant complications (no indication for cesarean section, no medical condition) were eligible for the study. the participants were between fifteen to thirty-five weeks of gestation. those who did 12 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2022.02 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article data analysis all in-depth interviews were tape-recorded, transcribed, and later analyzed. inductive content analysis methods were used to establish the themes. data collection, transcription, and analysis were assumed on an iterative process. starting transcriptions were in kurdish, which was taken then back-translated to english before coding. who recommended that the "onwards backward technique" for qualitative data transcription between two languages be followed [2]. all transcribed data were read carefully after gaining a general understanding of the information, highlighted the text that obtained the theme related to the questions, and categorized into meaningful units that were subsequently coded manually by the researcher. finally, the main themes and subthemes were determined according to extracted meaning units. the findings consist of four main themes and nine subthemes. table 1 presents an example of themes, subthemes, and meaning units. this study interviewed eighteen pregnant women aged 17 to 34 years old. the mean age at marriage of the total sample was 21.66 years old. sixteen participants were housewives, one was employed, and one was a businesswoman. the participant’s education level was 6 in each level, and none of the participants was illiterate. after analyzing the qualitative content of interviews, 48 meaning units were obtained. the findings consist of four themes and nine subthemes. these themes were identified in the analysis of interviews addressing perceptions and attitudes of women’s preferred mode of delivery. the main themes were perceived advantages and disadvantages of a mode of delivery, knowledge deficit, weak healthcare providers role, and fear related to vaginal delivery. not want to be interviewed or ended the interview were excluded from the study. the number of participants was determined on the data saturation. data collectiondata was collected via semi-structured face-to-face interviews with pregnant women attending antenatal care visits in the primary health care center after completing their antenatal care unit schedule. the duration of the interviews was between 30 to 40 minutes. interviews were conducted in the obstetrician or antenatal care unit staff room. participants were asked questions relevant to the research objective ("what is your preferred mode of delivery? what are the advantage and disadvantages of vaginal and cesarean delivery? what is the factor affecting the choice of delivery? what are the sources of information? do you take any education regarding vd and cs delivery during antenatal care unit checkups?"). after 18 interviews, the data did not lead to any new themes. the number of samples was adequate when data saturation was reached. according to hancock et al., the gold standard for qualitative research is data saturation [12]. data saturation or sufficiency is reached when there are no new meaning units of information in the data, the point in coding when no new meaning units occur in the data [13]. ethical considerationsthe scientific and ethical committee of the college of nursing hawler medical university approved the study protocol. in addition, formal permission was granted by the directorate of health-erbil/ planning department to nazdar bamarne and tayrawa health care centers in erbil city for data collection. the required information was explained, and informed oral consent was obtained from all participants. confidentiality was assured about the participant’s identity and personal information. the data collected were stored in microsoft word files and were password protected. 13 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2022.02 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article 14 erbil journal of nursing & midwifery table 1: extracted themes and subthemes of women’s perception and attitude towards a mode of delivery. themes subthemes meaning units 1 perceived advantages & disadvantages of a mode of delivery perceived pros of vaginal delivery fast recovery after vd care of the baby immediate breastfeeding pain restricted after delivery perceived cons of cesarean section more painful after delivery tearing of abdomen, stitches, and scars on the abdomen. side effects of anesthesia restricted physical activities need care and rest after cs 2 knowledge deficit source of knowledge family source mother's experience having no information about childbirth no information about characteristics of labor pain inability to choose the mode of delivery due to lack of information about vd and cs no information about the ways to reduce vd pain. 3 weak health care provider's role inadequate information received from a healthcare provider none of the pregnant women received any information about vd and cs delivery during antenatal care unit checkups. not allocated time for the mothers the physician does not have time to explain more to mothers in the clinic mother feels the private hospital's doctors drown them to do an operation to finish the labor process as soon as possible. 4 fear related to vaginal delivery fear from vaginal delivery in primigravida women fear from labor pain do not tolerate pain fear from vaginal episiotomy and wound stitches in multipara women having awful experience of vd episiotomy and stitches. https://doi.org/10.15218/ejnm.2022.02 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article she is still in pain and has not recovered as before…" (participant 8). b:perceived cons of cesarean section tearing of the abdomen, stitches, pain, restricted physical activity, wound healing, anesthesia side effects, and cesarean complications were some of the perceived cons of cesarean delivery mentioned by participants. a 20 year old primiparous woman stated: "…in a normal delivery, if there is a stitch, it will heal soon, but in a cesarean section, the wound site will not heal soon, and mother cannot lift heavy things, and any duties cannot be done, the others said the wound scar is always itching and painful…" (participant 3). a 24 year old primigravida woman referred to this issue in this way: "… the side effect of cesarean after delivery will turn out, mothers after cesarean will faced anesthesia side effect, back pain, and many diseases..." (participant 15). another participant concerned about the care after delivery stated: "…i have seen that my sister and the brother's wife have so much pain after cesarean and just need someone to care and served them for a month…" (participant 12). theme ii: knowledge deficit the second them obtained from data analysis was knowledge deficit. source of information and limited knowledge regarding modes of delivery are two subthemes identified within this theme ( table 1). a: source of knowledge in response to the researcher's question regarding the source of information, all participants mentioned they had obtained information from the family’s [mother] experience and word of advice from others. one of the woman pointed out: "… due to it is my first baby, i heard from others that vaginal delivery better than cesarean section, my mother and my family said that 15 erbil journal of nursing & midwifery theme i: perceived advantages and disadvantages the first theme that emerged from data analysis was “perceived advantages and disadvantages of vaginal delivery and cesarean sections”. within this, two main subthemes were identified, “perceived pros of vd” and “perceived cons of cs." participants mentioned several advantages of vaginal delivery and disadvantages of cesarean section (table 1). a:perceived pros of vaginal delivery in this study, most of the participants mentioned the reasons of choosing vaginal delivery as a preferred mode of delivery included a fast recovery, can take care and have a healthy baby. a 25 year old primigravida woman said, "i prefer natural delivery instead of the cesarean section because i feel that the baby will come at the right time and it's healthier for the baby. also it's better for my body too, so i can get up and do exercise sooner, in natural delivery mother can take care and breastfeed sooner…" (participant 2). another participant said: "i like to have vaginal delivery because after delivery you can get up very soon, but cesarean section need to be in bed for a month, my sister in law had a cesarean section, and she was in bed for a month while i had a vaginal delivery and it was better than cs…" (participant 18). another perceived pros of vaginal delivery mentioned by a participant were restricted pain in vaginal delivery. women’s perceieved that pain is limited to the labor time in vaginal delivery. in contrast, cesarean section's pain will start after delivery. a 30 year old multigravida women declared that: "…the pain of normal delivery is only one day, and pain will be finished after the baby is born. however, the pain of cesarean delivery starts after the baby is born, my sister had a cesarean section, and https://doi.org/10.15218/ejnm.2022.02 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article too…". another woman said: "…i have taken this information from the persons around me that have been vaginal or cesarean delivery….". a 30 year old multipara woman with two prior vaginal deliveries states: "… i know that the vaginal delivery easier than cesarean i had two vaginal deliveries, nobody has given me information about mode of delivery…". two participants in this study referred to media and television as sources of information besides family sources. none of the participants mentioned the healthcare provider as a source of information. b: having no information about mode of delivery women with high knowledge about mode delivery have more power to choose the preferred mode of delivery. regarding the limited knowledge and many misconceptions about the mode of delivery, one participant said: "… this is my first child, and i don't know any better method of delivery, my friends told me that a cesarean section is a better way, but i do not know what the difference between vaginal and cesarean delivery is" (participant 4). c: no information about characteristics of labor pain the only disadvantage of vaginal delivery was recognized as pain, but managing the labor pain will be helpful to have a pleasant vaginal delivery. some participants stated that they did not have information about pain management during vaginal delivery, which made them interested in cesarean section. in this regard, a 27 year old primigravida women said: "…i fear from normal labor because i heard vaginal delivery has severe pain like to die, but in cesarean section, i don't feel anything during labor, i don't receive any information on reduced pain during labor before" (participant 17). theme iii: weak healthcare provider's role the third theme that emerged from data analysis was the weak healthcare providers’ role. two subthemes have resulted from data transcripts: inadequate information received from the healthcare provider and lack of allocated time for the mothers (table 1) a: inadequate information received from the healthcare provider in response to the researcher’s question, most participants had not received any information regarding the mode of delivery during anc checkups. one response in that regard was: "… my family and people around me tell me the natural delivery is better, and i don't know what the best way is, no one explains to me about the advantage or disadvantage of vd and cs…" (participant 21). b:not allocated time for the mothers most anc programs in phc centers and doctor’s clinic does not have an educational program for labor and delivey modes. they only have to check the women physically and conduct routine blood tests. in addition, the anc units and some doctor’s clinic are crowded because of many visitors. they do not give more time to the client’s question. regarding this issue, one participant said: "…i didn't receive any information towards a mode of delivery, when i visit the doctor's clinic it was too crowded. the doctor doesn't have time to explain more about a delivery, only writes the prescription and give next appointment time to…" ( participant 24). another participant stated: "…i feel that doctors in private hospitals push the mothers to do a cesarean section, to finish the labor process faster and doesn't need to spend more 16 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2022.02 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article delivery are painful and unpleasant. a 34 year old primiparous woman with previous vaginal deliverystated: "… i had a previous vaginal delivery, i liked to have a cesarean section in this pregnancy because i had many stitches in vaginal delivery, i could not sit for weeks after delivery. vaginal delivery is better than cesarean delivery, but if i had pain for a month after labor, i prefer to do cesarean section" (participant 7). also, another participant said: "… both modes of delivery are unpleasant, but in case i prefer cesarean section because i had many sutures in previous vaginal delivery, in last pregnancy i had cesarean and i can get up sooner than vaginal delivery because i didn't have any stitches..." (participant 10). this study explored the women’s perceptions and attitudes toward modes of delivery. study findings showed attitude towards vaginal delivery was positive in most pregnant women. most of the participants believed that vaginal delivery is a natural and the safest mode of delivery. vaginal delivery have more advantages than cesarean section, including fast recovery, limitation of pain to the labor, ability to breastfeed, care of baby and ability to partake in physical activities. women in north of iran believed that vaginal delivery, as a safe method, is not associated with complications occurring due to cesarean section. short-term pain, easier breastfeeding, and the ability of the mother to carry out child-related activities ate the advantages of vaginal delivery [15]. canadian mothers believe that vaginal delivery has advantages such as healthier babies, better breastfeeding, and quick recovery [16]. in our study, some women discussed pain, restricted physical activities, wound healing, and tearing of the abdomen as time caring for the mothers during the labor process….". theme iv: fear related to vaginal delivery fear was recognized as the most apparent disadvantage of vaginal delivery. fear of pain and not tolerating the pain in all pregnant women were identified. the fourth theme that emerged from data analysis was fear related to vaginal delivery. two subthemes were obtained within this: fear from vaginal delivery pain in primigravida women and fear from vaginal episiotomy and wound stitches in multipara women. a:fear from vaginal delivery in primigravida women lack of previous delivery experience in primigravida and not knowing about the labor process leads to the fear of delivery. some of the participants were afraid of labor pain due to words and experience of others. this is highlighted by one of the participants: "i like to have cesarean delivery because i am afraid of vaginal delivery, i'm afraid of the pain of labor, i will not be aware the labor process with cesarean, my mother told me vaginal delivery is better for birthing baby, but i can't tolerate the pain, i heard from people, and i watched in the net that vaginal delivery have severe pain…" (participant 11). b: fear from vaginal episiotomy and wound stitches in multipara women many multiparous women did not have good experiences of previous vaginal delivery because of stitches and episiotomies. episiotomy has more pain in cases of suturing done without using any local anesthesia. women who had an episiotomy in vaginal delivery and cesarean sections perceived that both modes of 17 erbil journal of nursing & midwifery discussion https://doi.org/10.15218/ejnm.2022.02 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article section [20]. according to the study findings, healthcare providers have an insufficient role in educating pregnant women about labor mode, childbirth, and decision making. healthcare and health facilities have a weak position in providing information for pregnant women regarding mode of delivery and childbirth education. this study finding also showed that educational programs regarding childbirth were not found in antenatal care programs in the primary health centers in erbil. none of the participants received any information about the medical indications for cesarean section, nor its benefits and risks during third-trimester antenatal checkups [2]. another study also revealed a need to provide better information for pregnant women during the antenatal period about modes of delivery, indications, advantages, and adverse consequences, which will help them in informed decision-making [43]. this study also highlighted some participants’ perception that the healthcare providers and physicians have not allocated time to educate them towards childbirth because of many visitors and crowded places, even in the private clinics. the findings are consistent with some of the studies that staff cannot monitor labor and insufficient facility and human power in the hospital [2]. the present study report that some participants believed that the private hospital-physician performed cesarean section without any indication due to inadequate time to monitor the normal labor process. according to the study findings, most of the participants have a positive attitude to vaginal delivery, but fear is the main disadvantage of vaginal birth. this study showed that some primiparous women had a fear of childbirth. other studies also showed that most primiparous women had doubts about their preference for delivery due to fear before childbirth and fear from other women's experiences the disadvantages of cesarean section. other studies also reported that cesarean sections had more complications than vaginal delivery, including bleeding, wound infections, and breastfeeding problems [17, 18]in this study, findings revealed that women’s lack of knowledge of advantages, disadvantages, indications, pain management, and labor process influenced their decision about the mode of delivery. some study findings showed that increased knowledge and information influence personal ability to obtain critical points and increase their understanding and perception. increaing knowledge was more effective the decision to consider vaginal delivery and reducing elective cesarean section [8,19]. according to the finding, the participants of primiparous women with their first pregnancy experience as well as multipara women have family sources and relative words as their primary source of information. in erbil city, antenatal care programs in primary health centers did not include information, difference, benefits, and risks of vaginal and cesarean delivery during antenatal visits. the significant sources of information for pregnant women are family, friends, and other women who had similar experiences. few participants pointed to books and media as a source of information. other findings of this study shows that primiparous women’s perception of vaginal birth as a painful process, lack of knowledge regarding pain management, and diverse ways to cope with the pain affected their decision to give birth vaginally or cesarean. these findings are consistent with a quantitative study that pointed out that women with more information about painless vaginal delivery methods may reduce the number of women with fear of childbirth and the rate of preferred elective cesarean 18 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2022.02 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article [1] mohammadzadeh, fatemeh and sheidaei, sedigheh and jafarnejad, farzaneh and tajiheravi, ala. the effect of peer education on pregnant women's choosing mode of delivery. journal of midwifery and reproductive health. 2019 .vol.7. 1880-1887. available from doi:10.22038/jmrh.2019.38654.1429. [accessed 2020 nov 21] [2] begum, t., ellis, c., sarker, m. et al. a qualitative study to explore the attitudes of women and obstetricians towards cesarean delivery in rural bangladesh. bmc pregnancy childbirth 2018.vol.18, 368. available from doi: https://doi.org/10.1186/s12884-0181993-9. [accessed 2020 nov 20] [3] dogra, pooja and reena sharma. "preferences of pregnant women regarding mode of delivery: a questionnaire-based study." international journal of scientific 2017.vol. 3: 292-295.available form doi:10.18203/issn.24542156.intjscirep20174870. [accessed 2020 des 12] [4] ajeet s, jaydeep n, nandkishore k, nisha r. women's knowledge, perceptions, and potential demand towards caesarean section. national journal.2011. vol. 2. 243-248. [accessed 2020 nov 20] [5] varghese s, singh s, kour g, dhar t. knowledge, attitude and preferences of pregnant women towards the mode of delivery in a tertiary care center. international journal of research in medical sciences,2016.vol 4, no 10. available from doi: http://dx.doi.org/10.18203/23206012.ijrms20163299. [accessed 2020 nov 20] [6] taheri z, mazaheri ma, khorsandi m, hassanzadeh a, amiri m. effect of educational intervention on self-efficacy for choosing delivery method among pregnant women in 2013. international journal of preventive medicine.2014.vol. 5,10 : 1247-1254. pmcid: pmc4223943. [accessed 2020 nov 21] [6, 21]. this study highlighted that fear of episiotomy during vaginal delivery in the multiparous women who had previous episiotomy experience and chose cesarean section as preference mode for future deliveries. similar to this study, maternal requests for cesarean delivery after an episiotomy and painful sexual intercourse were mentioned in some research [2, 22]. strength and limitation of the study focusing on women’s perception toward a mode of delivery for the first time in the kurdistan region and involving women of different ages are the strengths of the present study. most of the participants are housewives which may be considered as one limitation of the study because the different backgrounds of knowledge may affect the result of the study. another limitation is not examining the relationship between the previous experiences of women with the current attitude regarding mode of delivery. the main themes that emerged from the study were the perceived advantages and disadvantages of a mode of delivery, knowledge deficit, weak health care provider’s role, and fear related to vaginal delivery. vaginal delivery was the preferred mode of most participants. however, preference of mode of delivery depended on experiences of families and friends experiences. developing a health policy for advancing the role of health care providers in supporting women empowering them in decision making, and providing childbirth education programs for pregnant women regarding mode of delivery is recommended there is no conflict of interest 19 erbil journal of nursing & midwifery conclusion conflict of interest reference https://doi.org/10.15218/ejnm.2022.02 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article [14] moretti f, van vliet l, bensing j, deledda g, mazzi m, rimondini m, et al. a standardized approach to qualitative content analysis of focus group discussions from different countries. patient education and counseling journal,2011. vol. 82,3: 420-8. doi:10.1016/ j.pec.2011.01.005. [accessed 2021 aug 11] [15] zakerihamidi m, latifnejad roudsari r, merghati khoei e. vaginal delivery vs. cesarean section: a focused ethnographic study of women's perceptions in the north of iran. international journal of communitybased nursing and midwifery .2015. vol. 3 (1):39-50. pmcid: pmc4280556. [accessed 2021 oct 29] [16] malacrida c, boulton t. the best laid plans? women's choices, expectations and experiences in childbirth. health. 2014.vol. 18 (1):41-59. doi:10.1177/1363459313476964. [accessed 2021 oct 29] [17] moazzem hossain sm, ibrahim s, al-harun a, muhammad s, oudah k, jaffar i. maternal and neonatal health in select districts of iraq: findings from a recent household survey. journal of pregnancy child health.2018. vol. 5: 395. doi: 10.4172/2376127x.1000395. [accessed 2021 oct 29 . [18] bodner k, wierrani f, grünberger w, bodner -adler b. influence of the mode of delivery on maternal and neonatal outcomes: a comparison between elective cesarean section and planned vaginal delivery in a low-risk obstetric population. arch gynecol obstet journal. 2011. vol.283(6):1193-1198. doi:10.1007/s00404-010-1525-y. [accessed 2021 oct 29] [19] abedian z, navaee m, sani hj, ebrahimzadeh s. comparing two instructional methods of role-playing and lecture on primigravida females, a decision about the type of delivery. journal of education health promottion.2017.vol. 6 (1): 29.available from doi:10.1007/s00404-010-1525-y [accessed 2021 oct 29] [20] aksoy m, aksoy an, dostbil a, celik mg, ince i. the relationship between fear of childbirth and women's knowledge about painless childbirth. obstetrics and gynecology international. 2014. vol. 2014:274303. doi:10.1155/2014/274303 [accessed 2020 nov 20] [21] storksen ht, eberhard-gran m, garthusniegel s, eskild a. fear of childbirth; the relation to anxiety and depression. acta obstetricia et gynecologica scandinavica. 2012. [7] khatony, a., soroush, a., andayeshgar, b. saedpanah, n. abdi, a. attitude of primiparous women towards their preference for delivery method: a qualitative content analysis. arch public health 2019.vol.77, 38 . doi: https:// doi.org/10.1186/s13690-019-0364-y. [accessed 2020 nov 22] [8] navaee, maryam, and zahra abedian. effect of role play education on primiparous women's fear of natural delivery and their decision on the mode of delivery." iranian journal of nursing and midwifery research 2015.vol. 20,1: 40-6. pmcid: pmc4325412. [accessed 2020 nov 21] [9] solima, safaa. effect of an interventional program on pregnant women's knowledge and attitude toward mode of delivery at beni -surf city, egypt. american journal of nursing science. 2017.vol. 6:135. available from: doi:10.11648/ j.ajns.20170602.18. [accessed 2020 des 1] [10] seyedi-andi s j, borhani m, koshki g, fadaei e, saber m, mehri a. effect of education on choosing delivery mode among pregnant women referred to health centers of minoodasht city: an application of basnef model. journal of health education and health promotion. 2017, vol. 5 (1) :67-78.available from doi:http:// hehp.modares.ac.ir/article-5-12379en.html. [accessed 2020 aug 1] [11] shabila, n.p. rates and trends in cesarean sections between 2008 and 2012 in iraq. bmc pregnancy childbirth.2017. vol. 17, 22.available from doi: https:// doi.org/10.1186/s12884-016-1211-6. [accessed 2020 aug 11] [12] hancock, m. e., amankwaa, l., revell, m. a., & mueller, d.. focus group data saturation: a new approach to data analysis. the qualitative report, 2016. vol 21(11), 2124-2130. available from doi: https:// doi.org/10.46743/2160-3715/2016.2330 [accessed 2021 jun 8] [13] sendo, e. g., chauke, m. e., & gangalimando, m. why some women who attend focused antenatal care fail to deliver in health facilities: a qualitative study of women's perspectives from slums of addis ababa, ethiopia. bmj open, 2020. vol.10 (12), e039189. https://doi.org/10.1136/ bmjopen-2020-039189. [accessed 2021 aug 5] 20 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2022.02 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article vol. 91:237–242.available from: doi: https://doi.org/10.1111/j.1600 0412.2011.01323.x [accessed 2021 oct 30] [22] serçekuş p, okumuş h. fears associated with childbirth among nulliparous women in turkey. journal of midwifery. 2009.vol. 25(2):155-162. doi: 10.1016/ j.midw.2007.02.005. pmid: 17600599. 21 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.10 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article consequences of emotional intelligence in nursing: a concept analysis abstract introduction emotional intelligence (ei) refers to the competence to manage and regulate the emotions of oneself and others. it is observed across several nursing domains, given its nurses’ wellbeing, which successively influences patients and their families [1].there is a general lack of understanding of ei and its overall significance and scope with various competing definitions and models [2]. when integrated in practice, unclear concepts can lead to a significant amount of misapprehension and confusion, since ei is a concept already emerged with confusion. ei is identified through four major aspects, including emotionality, sociability, wellbeing, and self-control [3]. emotionality is a skill for showing empathy, being concerned about the insights of others in a situation, and communicating feelings [4]. the social competence of individuals, their competence to explain strong social skills and to influence others is concerned within the sociability component. wellbeing includes a person having the attributes of feeling happy and satisfied with a positive outlook on life and a good level of self-esteem [5]. lastly, self-control shows the competence of a person to control and regulate his emotional responses and skills for handling stress. landa et al. [6] showed that emotional intelligence was initially mentioned in the nursing field background and objectives: emotional intelligence refers to a social skill, which enables individual to better regulate emotions and cope up with the different demands and environmental pressures. this assists in enhancing professional competence enabling better delivery of services. this paper aimed to examine the consequences of emotional intelligence in the nursing profession by presenting its concepts, definitions, models, and implications. methods: a literature review study was made and articles were searched from various databases including scopus, embase, proquest, psychinfo, and cinahl, using key terms “emotional intelligence,” “nursing,” and “concept analysis” from 2000 to 2019. twenty articles were included following their compliance with the inclusion and exclusion criteria and removing of the duplications. results: social and personal attributes affect emotional intelligence. self-awareness, relationships, self-management, and social awareness are other important components of emotional intelligence. the nursing professional explains a social and personal aspect that emotional intelligence entails and further portrays a meaningful role of emotional intelligence in both the sensitivity and moral dimension of clinical practice. conclusion: the nursing professionals who possess increased emotional intelligence experience few emotional psychosomatic symptoms and emotional exhaustion, greater workshop collaboration and teamwork, more satisfaction with their jobs, fewer unidentified patient care needs, and better emotional health. keywords: concept analysis; emotional intelligence; nurses; nursing; psychology abdulaziz mohsen alsufyani; comprehensive rehabilitation center, ministry of labour and social development, taif, saudia arabia )correspondence: a.aziz987@hotmail.com ) omar ghazi baker; department of community and psychiatric nursing, college of nursing, king saud university, ryiadh, saudi arabia yasir mohsen alsufyani; department of nursing, college of nursing, king khalid university, abha, saudi arabia 82 erbil journal of nursing & midwifery received: 29/12/2019 accepted: 30/3/2020 published: 30/5/2020 mailto:a.aziz987@hotmail.com https://doi.org/10.15218/ejnm.2020.10 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article after 2000.ever since then, studies have shown its integration with various nursing competencies, improved practices, educational achievements, compliance with the discipline, enhanced professional behaviour, and patients’ satisfaction [7,8]. however, smith, profetto-mcgrath, & cummings [9] have described it as an ambiguous term in nursing, given its relatively new development [10]. various studies confirm that the adequate use of the concept and its clear understanding assists nurses across different disciplines, including education, research and practice [11-13]. thereby, this research aims to investigate the emotional intelligence concept for clarifying the definition and its implementation in the healthcare setting, primarily by the nurses. a strong and positive link of emotional intelligence with staff wellbeing and performance [8-15], further necessitates its assessment. a vivid comprehension of ei and its consequences is incremental in nursing practice, which assists in understanding the association of emotions with cognition. ei allows nurses to make better decisions, improve relationships, positively affect care quality and their families, and effectively manage their patients. identifying the consequences of ei might enhance its adoption within the nursing profession, especially due to the ei impact on nursing actions. certainly, this paper aims to examine the consequences of ei in the nursing profession by presenting its concepts, definitions, models, and implications. it is important to clarify concepts such as ei throughout nursing practice, as concepts majorly contribute to the development of awareness. unclear attributes and definitions of concepts significantly prevent the fundamental use of the concept because there might be doubt concerning related or similar concepts. the concept analysis methods are adopted for providing clarity on concepts, its strengths, and limitations so that it can provide an improved contribution to its application and knowledge. several methods have been proposed for concept analysis. however, this paper uses an evolutionary method for concept analysis proposed by rodger in 1989 due to its strong viewpoints in evaluating subject to change. rodgers [15] assumes that concepts are revealed by a cluster of situations, phenomena, or attributes that are experienced concerning similarities. this method refers to the concepts that are constantly enriched and approves that conceptual variations and innovations might be defined over time because concepts are discussed and transferred through social interactions and education. therefore, attributes and consequences related to ei were searched and presented in this paper. lastly, related concepts were acknowledged, and an exemplifying model case of the concept was developed to provide conceptual clarity. data source the concept of ei was explored using a comprehensive literature review, considering the rodgers evolutionary method concept analysis. this approach provides the best way of examining ei in nursing practice. one of the strengths of using this approach is its viewpoint toward changes that happen over time, rather than defining an ultimate truth, which can be used later for developing a general understanding of ei. no particular range or limitations were identified for supporting the dates of publications to support this approach. the articles were searched from databases such as scopus, embase, proquest, psychinfo, and cinahl for the key terms “emotional intelligence,” “nursing,” and “concept analysis” from 2000 to 2019.to narrow the results, the boolean approach was used, such as “emotional intelligence” and “nursing.” the objective of the literature 83 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2020.10 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article definitions in the area of psychology, several different types of ei are identified, such as the development of cultural intelligence and its association with social intelligence [17]. emotional intelligence is interlinked within the theory of multiple intelligences, where the role of emotions and relationships was first considered within the concept of intelligence [9,18]. ei is originally defined as based on a set of interlinked competencies. currently, it is defined as a heterogeneous combination of attributes as compared to ability [19]. goleman [20] defined one of the innovative definitions of ei, which is widespread in the discipline of nursing. according to the definition, ei is defined as competence to identify the feelings of a person and emotions interlinked with other relationships. it is essential to focus on the general implications of this ei definition and the contributions of goleman [20], mayer and salovey [21], and bar-on [22] as they contributed to this realm by developing their models. attributes attributes of emotional intelligence are classified into two major categories, including social and personal attributes. firstly, social attributes are based on social awareness and relationship management. social awareness refers to the observations and understanding of emotions, concerns, and needs of others, the ability to explore things with other people’s insights, and picking up emotional cues [23-25]. relationship management is a competence for managing better relationships, inspiring and influencing others, and communicating clearly for managing relationships with others [24, 26, 27]. self-awareness, in personal attributes, entails understanding and identifying emotions and motivations of a person along with his strengths, weaknesses, and needs. self-management is a competence of controlling or redirecting review was to obtain published peerreviewed articles that were presented in the english language. articles presented in abstracts were also considered in the inclusion criteria. no restrictions were applied in terms of geographical setting to obtain a broader view of definitions, concepts, and consequences of ei in nursing. articles focusing on the behaviours of adolescence and ei and other specific subjects were excluded from the search process. these were excluded as these are too specific, whereas the focus of the present paper is to provide a general ei understanding. psychology, business and management, education, and healthcare were several disciplines in which we were restricted to extract the articles related to ei. the articles that had an emotional intelligence word in their title or abstract were selected. the quality assessment was conducted to ensure that the selected article meets the points laid out for the study selection. the studies’ methodological quality was ranked using the hierarchy of evidence: nursing resources [16]. 20 articles were included in this concept analysis paper after completing the inclusion and exclusion process and removing the duplications. figure 1 presents the selection procedure of the number of articles included in this research. 84 erbil journal of nursing & midwifery figure 1: study procedure results https://doi.org/10.15218/ejnm.2020.10 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article potential for facilitating and strengthening their capacity to provide palliative care that mr. m might be experiencing substantial negative feelings. this evidence might inform the next actions for the apn in support and planning care that is individualized to mr. m, as she will be able to effectively work through their emotional state and interpret that into supportive strategies towards mr. m. contrary outcomes in a contrary case, an example of the lack of emotional support is presented, which helps in exploring the ways that differentiate it from the model case. “david is admitted to the local palliative care unit. over the last few days, his condition has deteriorated, and he cannot move from his bed. the senior nurse evaluates that david will require a bed bath the next morning. so, two nurses have been asked to attend to the personal care of david during their shift. the nurses enter the room of david and inform him that they will be aiding him to wash. both nurses start communicating with each other discussing their daily routine while carrying out personal care, and communicate with david whenever he needs help”. the feelings of frustration and dismay of a nursing professional can be translated into formulating evaluations. a negative evaluation may have the possibility to inhibit the development of a therapeutic relationship if the nursing professional shows this reaction to the patient. consequently, the needs and issues of a patient might not be appropriately addressed and communicated, if a therapeutic relationship is not established. the nursing professional will also be troubled by the responses and feelings of a frustrated patient. identifying the emotions of a patient can either help the nursing professional to understand him/her or may enable the nursing professional to interfere with how she delivers care. related case in a related case, the concept is associated 85 erbil journal of nursing & midwifery emotions constructively. it enables a person to deny evaluation until sufficient information is collected and to assume before acting [24].development of casesmodel cases and examples the model case presented here is based on clinical experience for representing the concept of emotional support. the patient called mr. m (names are altered within this section to protect confidentiality and anonymity) was referred by an advanced practice nurse (apn). see the below case: “the nurse was shocked that mrs. m did not start cpr on her husband. the idea that mr. m may have had a better consequence regardless of any shortages led to feelings of frustration for the nurse. she might not be cognizant of her behaviours if the nurse did not identify her emotions. inadequate reactions can result in negative implications for family care. to be precise, emotional intelligence allows persons to be aware of their reactions and emotions and reflects the way they respond to others. the feelings of frustration and disappointment can interpret into formulating evaluations of the nurse. in particular, the needs and concerns of mrs. m may not be appropriately communicated and addressed if a therapeutic relationship is not developed. awareness of her emotions might either help the nurse to understand mrs. m or may enable her emotions to lead how she delivers care”. apn is allowed by being in charge of the emotions of mr. m in emotional prediction. affective prediction forecasts how people will feel in response to a future event. the apn observed the conditions of mr. m, considering that his unanticipated medical emergency and his prognosis was deprived under different situations. an emotionally intelligent person is capable of identifying and managing his emotions in a way that would positively affect her relationship with mr. m. consequently, the competence of apn has the https://doi.org/10.15218/ejnm.2020.10 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 86 erbil journal of nursing & midwifery with the concept being investigated but does not comprise all the defining characteristics. “sarah is a 45-year old woman who comes to see her husband, joseph, at the local community hospital. joseph was diagnosed with a malignant brain cyst 19 months before and received proper treatment, resulting in modifications to his mobility, personality, and cognitive function. diagnoses have indicated advanced disease, and he has currently been complaining about rapid seizures. sarah was informed that joseph is working with the physiotherapist, so she has to wait for him to return. the nurse offers sarah a cup of tea while using the chance to ask how joseph is. the nurse sits beside sarah and asks her a few simple questions, which allow her to talk. she tells the nurse about the negative effect of joseph’s illness on their personal lives”. motivation indicates having a distinctive focus to gain, and empathy is the ability to understand emotions, perspectives, and thoughts of another person. a person would have to be motivated to understand emotions and be clear in accepting the emotions of other individuals. the related case presented above shows an example of the concept of empathy, which refers to actively listening, feelings with sensitivity and accuracy, and feeding back thoughts. the apn explains empathy by making efforts to understand what is happening from the perspective of jensen. the apn manages to convey her understanding of jensen’s situation by acknowledging her feelings using verbal and non-verbal behavior .borderline example in a borderline case, an example is presented comprising the defining characteristics but varies significantly in one of them. a borderline case is presented below concerning emotional intelligence. “peter is a 58-year-old gentleman who has progressive lung cancer, and he has to initiate a course of palliative chemotherapy. peter has been contacted by the local community nurse at home to arrange her first visit to obtain a pre-chemotherapy blood sample. while obtaining his sample, the nurse talks with peter about his recent scans. the nurse listens to peter about the negative effect of the news and how he understands what is happening. he becomes quite upset when explaining what the future may hold for him, and he quickly attempts to regain his composure. the nurse portrays what a distressing time it must be for him and his family and reconfirms peter that the primary health care team is there for helping and supporting him”. being responsible for one’s emotions enables an individual to involve in emotional prediction. affective prediction forecasts how a person will feel in reaction to a future event. consider an example; if a patient had an unexpected medical emergency and the prognosis of a patient was adverse, the nursing professional should respect the feelings of that patient under different conditions, and therefore, forecast future feelings. a nursing professional is emotionally intelligent who is competent enough for identifying and managing her emotions in a way that positively impacts her working relationship with the patient. consequently, the ability of nursing professionals can facilitate and strengthen their competence to provide supportive care to the patient, as the nursing professional identifies his/her own emotions. a nursing professional who possesses ei has competence in identifying and understanding that the patient might be facing substantial adverse feelings or emotions. this information may assist in inspiring the nursing professional to plan her next actions in caring for and supporting the patient. furthermore, a nursing professional will be able to effectively work through her emotional state and transmit that into supportive actions https://doi.org/10.15218/ejnm.2020.10 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 87 erbil journal of nursing & midwifery towards the patient, which consequently enriches the antecedents of empathy. antecedents of emotional intelligence selfmanagement and self-awareness are important factors to maintain the well-being of both the nurse and their patients. to be precise, apns who developed a sense of empathy are motivated to cope with their own emotions, to experience less stress, burnout, and job dissatisfaction. these antecedents influence the care of patients, the overall well-being, and the families of nurses. in addition, emotional intelligence is also comprehending the influence of emotions on other individuals and pacifying emotions of an individual at times. consequences of emotional intelligence consequences are incidents or events that can occur due to the occurrence of a concept. determining consequences throughout the context of a model case enhances the transparency of ei in the nursing practice. the consequences of ei throughout the nursing practice are related to the wellbeing of nurses as working experts. for instance, the evidence is present between nurses and job satisfaction, stress levels, retention, and burnout [28]. a nursing professional possessing ei would be able to comprehend the process to predict future emotional reactions of an individual, in terms of patient and family care [29]. a nursing professional can help the development of positive relationships as they are aware of predicting their feelings, reactions, and responsiveness to a future interaction or event [30]. consider a case where inadequate reactions of a nursing professional can result in adverse implications to the patient and family, which might be due to the feelings of frustrations. precisely, ei enables people to be aware of their reactions and emotions and reflect the way they respond to others. this is particularly useful for the nurses in leading positions as they affect as well as influence the practices of the staff nurses and more. tyczkowski et al. [31] stated that emotional intelligence enables the individuals to become emotionally sound, fostering transformational leadership within nursing practice. given that the concept of ei is not generally recognized in the nursing discipline, it is integral for the nurses to further research this area to improve and develop their understanding, which will promote better understanding, information synthesizing, as well as generating and assisting in improved decision making [32, 33]. sarrionandia and garaigordobil [34] also emphasized emotional intelligence development among the nurses as it reduces the emotional psychosomatic symptoms and burnout, promoting satisfaction towards their job. emotionally intelligent nurses can employ researchbased knowledge and knowledgetransfer techniques for delivering quality -infused results. this understanding is likely to refine the quality as well as delivery of nursing care. the preliminary focus of this concept analysis was to understand the consequences of ei in the nursing practice, specifically on the nursing professional, who can meet the needs of a person, families, communities, and a population. a nursing professional can address her own emotions and feelings for understanding how they affect her ability and collaboration to explain leadership [1113]. emotions are an important component of critical decision-making and are a fundamental aspect of the quality of clinical care. a broad foundation of nursing expertise required in decisionmaking directly affects patients and family care. particularly, decisions are more patient and family-focused and discussion https://doi.org/10.15218/ejnm.2020.10 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 88 erbil journal of nursing & midwifery empathetic and support and improve the role of the nursing professionals. in this situation, the nursing professional explains a social and personal aspect that ei entails and further portrays a meaningful role of ei in both the sensitivity and moral dimension in clinical practice [23-25]. selfawareness enables nurses to connect thoughts, actions, and emotions in an influential manner [24], and therefore, is a vital competency in decision-making and creative procedures that might be based on intuitions and feelings. ei supports nurses in using empathy as a resource to understand situations that are based on moral evaluations and professional reflection associated with decision-making [4]. it also enables nurses to ensure the safety of the patients. ei has been associated with stress, emotional wellbeing, and mental health throughout the context of nursing. patients who are not able to adequately manage their emotions do not seek help or encouragement. the competence of a nursing professional to encourage emotional management among patients and their families might assist in facilitating therapeutic associations between nurses and patients if nurses exemplify an emotionally intelligent practice. the nursing professionals with high emotional intelligence explain less emotional psychosomatic symptoms and emotional exhaustion, greater workshop collaboration and teamwork, more satisfaction with their jobs, fewer unidentified patient care needs, and better emotional health [8, 7, 28]. however, for improving the outcomes, the clinical instructions, and the regulatory system should be established for devising effective decisions. guidelines can be set for training the employee which not only improves the emotional intelligence competence but also helps in increasing the satisfaction of nurses as well as patients. emotional intelligence is an essential aspect of nursing practice as emotions and sensitivity to mood are prime components of care and cannot be ignored from how we assume and act like experts. much work remains to be done, especially for the inconsistency of attributes, whereas a great deal of work is attempted for understanding and exposing ei as a concept. ei facilitates emotional wellbeing among the nursing professionals and helps in improving the competence to practice abilities that will benefit patients, colleagues, and families as working professionals and as individuals. emotional competence and effectiveness are used interchangeably with emotional intelligence and are regarded as surrogate terms. reflexivity and reflection are terms that are associated with emotional intelligence insofar as they are words that have something common with emotional intelligence but do not have the same attributes. consequently, ei encourages more than just awareness of emotions; it enables nurses to provide quality care and support to their patients. the ability to identify and understand ei will remain an essential aspect of nursing practice moving forward, despite the misapprehension and confusion about ei as a concept. the author is very thankful to all the associated personnel in any reference that contributed to this research. the author reports no conflicts of interest. the study is self-funded. conclusion acknowledgement conflict of interest funding https://doi.org/10.15218/ejnm.2020.10 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 89 erbil journal of nursing & midwifery [1] hurley j, hutchinson m, kozlowski d. emotional intelligence can help regional nurses maintain their mental wellbeing. australian nursing and midwifery journal. 2018 may 1;25(10):35 [2] ackley d. emotional intelligence: a practical review of models, measures, and applications. consulting psychology journal: practice and research. 2016 dec;68(4):269. doi: doi.org/10.1037/cpb0000070 [3] robinson e, hull l, petrides kv. big five model and trait emotional intelligence in camouflaging behaviors in autism. personality and individual differences. 2020 jan 1; 152:109565.doi:doi.org/10.1016/ j.paid.2019.109565 [4] fiori m. emotional intelligence compensates for low iq and boosts low emotionality individuals in a self-presentation task. personality and individual differences. 2015 jul 1;81:169-73.doi:doi.org/10.1016/ j.paid.2014.08.013 [5] zeidner m, olnick-shemesh d. emotional intelligence and subjective well-being revisited. personality and individual differences. 2010mar1;48(4):431-5.doi:doi.org/10.1016/ j.paid.2009.11.011a [6] landa jm, lópez-zafra e, del carmen aguilar -luzón m, de ugarte mf. predictive validity of perceived emotional intelligence on nursing students’ self-concept. nurse education today. 2009 oct 1;29(7):801-8. [7] di lorenzo r, giulia v, spiga g, ferri p. emotional intelligence, empathy and alexithymia: a cross-sectional survey on emotional competence in a group of nursing students. acta biomed for health professions. 2019; 90 (4): 32-43. doi: 10.23750/ abm.v90i4-s.8273 [8] huang h, liu l, yang s, cui x, zhang j, wu h. effects of job conditions, occupational stress, and emotional intelligence on chronic fatigue among chinese nurses: a crosssectional study. psychology research and behavior management. 2019; 12:351. [9] smith kb, profetto-mcgrath j, cummings gg. emotional intelligence and nursing: an integrative literature review. international journal of nursing studies. 2009 dec 1;46 (12):1624-36. [01] fernandez r, salamonson y, griffiths r. emotional intelligence as a predictor of academic performance in first-year accelerated graduate entry nursing students. journal of clinical nursing. 2012 dec;21(23-24):348592. [11] aradilla-herrero a, tomás-sábado j, gómez -benito j. death attitudes and emotional intelligence in nursing students. omegajournal of death and dying. 2013 feb;66 (1):39-55. [02] jung hj, cho chung hi. effects of selfesteem, emotional intelligence and social support on college adjustment in first year nursing college students. journal of korean academy of psychiatric and mental health nursing. 2012 sep 1;21(3):188-96. [03] lee os, gu mo. the relationship between emotional intelligence and communication skill, clinical competence & clinical practice stress in nursing students. journal of the korea academia-industrial cooperation society. 2013;14(6):2749-59. [04] wilson j. the awareness of emotional intelligence by nurses and support workers in an acute hospital setting. journal of health sciences. 2014;2(9):458-64. [05] rodgers bl. concepts, analysis and the development of nursing knowledge: the evolutionary cycle. journal of advanced nursing.1989apr;14(4):330-5.doi: doi.org/10.1111/j.13652648.1989.tb03420. [06] ingham-broomfield jr. a nurses’ guide to the hierarchy of research designs and evidence. australian journal of advanced nursing (online). 2016 mar 1;33(3):38. available at: https://www.ajan.com.au/ archive/vol33/issue3/5broomfield.pdf [07] crowne ka. cultural exposure, emotional intelligence, and cultural intelligence: an exploratory study. international journal of cross-cultural management. 2013 apr;13 (1):522.doi:doi.org/10.1177/14705958124 52633 [08] codier e, kooker bm, shoultz j. measuring the emotional intelligence of clinical staff nurses: an approach for improving the clinical care environment. nursing administration quarterly. 2008 jan 1;32(1):8-14. doi: doi.org/10.1097/01.naq.0000305942.3881 6.3b [09] cherry mg, fletcher i, o’sullivan h. the influence of medical students’ and doctors’ attachment style and emotional intelligence on their patient–provider communication. patient education and counseling. 2013nov1;93(2):177-87.doi: references https://doi.org/10.15218/ejnm.2020.10 erbil j. nurs. midwifery, vol. 3, no. (1), may, 2020 original article 90 erbil journal of nursing & midwifery doi.org/10.1016/j.pec.2013.05.010 [20] goleman d. emotional intelligence. new york, ny, england. 1995 [21] mayer jd, salovey p, caruso dr. emotional intelligence: new ability or eclectic traits?. american psychologist. 2008 sep;63(6):503. doi: doi.org/10.1037/0003-066x.63.6.503 [22] bar-on r. the bar-on emotional quotient inventory (eq-i): rationale, description and summary of psychometric properties. in g. geher (ed.), measuring emotional intelligence: common ground and controversy (p. 115–145). nova science publishers. 2004. [23] mccallin an, bamford a. interdisciplinary teamwork: is the influence of emotional intelligence fully appreciated? journal of nursing management. 2007 may;15(4):38691.doi:doi.org/10.1111/j.13652834.2007.00711.x [24] stichler jf. emotional intelligence. a critical leadership quality for the nurse executive. association of women’s health, obstetric, and neonatal nurses lifelines. 2006; 10(5): 422-5. [25] şenyuva e, kaya h, işik b, bodur g. relationship between self-compassion and emotional intelligence in nursing students. international journal of nursing practice. 2014 dec;20(6):588-96.doi:doi.org/10.1111/ ijn.12204 [26] kooker bm, shoultz j, codier ee. identifying emotional intelligence in professional nursing practice. journal of professional nursing. 2007jan 1;23(1):30-6. doi: doi.org/10.1016/ j.profnurs.2006.12.004 [27] lucas v, spence laschinger hk, wong ca. the impact of emotional intelligent leadership on staff nurse empowerment: the moderating effect of span of control. journal of nursing management. 2008 nov;16(8):96473.doi:doi.org/10.1111/j.13652834.2008.00856.x [28] toh sg, ang e, devi mk. systematic review on the relationship between the nursing shortage and job satisfaction, stress and burnout levels among nurses in oncology/ haematology settings. international journal of evidence-based healthcare. 2012 jun;10 (2):126-41.doi:doi.org/10.1111/j.17441609.2012.00271.x [29] vitello-cicciu jm. exploring emotional intelligence: implications for nursing leaders. jona: the journal of nursing administration.2002apr1;32(4):203-10.doi: doi.org/10.1097/00005110-200204000[30] rego a, godinho l, mcqueen a, cunha mp. emotional intelligence and caring behaviour in nursing. the service industries journal. 2010 aug 1;30(9):1419-37. doi:doi.org/10.1080/0264206080262148 6. [31] tyczkowski b, vandenhouten c, reilly j, bansal g, kubsch sm, jakkola r. emotional intelligence (ei) and nursing leadership styles among nurse managers. nursing administration quarterly. 2015 apr 1;39 (2):172-80.doi:10.1097/ naq.0000000000000094. [32] lievens f, chan d. practical intelligence, emotional intelligence, and social intelligence. in handbook of employee selection 2017 mar 27 (pp. 342-364). routledge. doi: 10.4324/978131569019315. [33] kaya h, şenyuva e, bodur g. developing critical thinking disposition and emotional intelligence of nursing students: a longitudinal research. nurse education today. 2017 jan 1;48:72-7. doi: 10.1016/ j.nedt.2016.09.011. [34] sarrionandia a, garaigordobil m. effects of an emotional intelligence program on socioemotional factors emotional and psychosomatic symptoms. latin american journal of psychologygía. 2017 aug;49 (2):110-8. https://doi.org/10.15218/ejnm.2020.19 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article nurses’ self-report on the infection control unit activities and their experience in the hospital toward nosocomial infections in the sulaimani hospitals abstract introduction nosocomial infections (nis) are present in both developed and developing countries, but 75% of this burden occurs in developing countries [1]. the number of nis in lowincome countries is three times higher than in high-income countries and the neonatal incidence is 3-20 times higher [2]. background and objectives: nurses can prevent the occurrence and transmission of nosocomial infections by following infection control measures such as wearing gloves and masks, using appropriate disinfection of skin and preventing accidental needle-stick injuries. this research aimed to evaluate the availability of hospital uniforms, personal protective equipment, and infection control activities at hospitals in sulaimani in the kurdistan region of iraq, and to examine nurses’ experience of nosocomial infections. methods and materials: a cross-sectional study was performed at 10 governmental hospitals during the period from 20th february to 28th september 2018. 525 nurses were selected as participants by a convenience sampling method. a self-administrated questionnaire was used to collect data, which were analysed using spss software. results: the results showed that 268 nurses (51%) reported that their hospitals provided sufficient uniforms to all the medical staff and the majority of nurses, 444 respondents (84.6%) stated that they were responsible for cleaning their working uniforms. 441 nurses reported that they did not acquire a nosocomial infection, and 479 (91.2%) did not have an accident during their work in the hospital. 79.9% of the nurses (404) reported recapping syringe needles after the usage, and 98 (18.7%) gave a low rating to the infection control unit activity in their hospitals. finally, more than half of nurses (330) representing 62.9% of the sample were vaccinated against nosocomial infections. conclusions: most of sulaimani governmental hospitals are providing sufficient uniforms for the health staff, the majority of nurses were vaccinated against one or more nosocomial infections, and the majority of nurses do needle syringe recapping. keywords: nosocomial infection, infection control unit, nurse’s accident. ramand muhammad haji; department of community health, technical college of health, sulaimani polytechnic university, sulaimani, iraq. (correspondence: ramandranya@yahoo.com ) dana abdilmagid abdilkarim; department of medical laboratory, technical college of health, sulaimani polytechnic university, sulaimani, iraq. salar ibrahim ali; department of community health, technical college of health, sulaimani polytechnic university, sulaimani, iraq. srwa salih mohammad; department of community health, technical college of health, sulaimani polytechnic university, sulaimani, iraq. 166 erbil journal of nursing & midwifery received: 17/03/2020 accepted: 27/7/2020 published: 30/11/2020 according to samuel and alp, this difference in developing countries is related to the ineffective infection control programmes resulting from lack of problem awareness, understaffing, heavy workload, overcrowding, erratic electricity supply, poor water supply, ineffective https://doi.org/10.15218/ejnm.2020.19 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article antibiotic policies with the emergence of multiple antibiotic-resistant microbes, poor laboratory backup, poor funding, lack of personal protective equipment, and unsafe working practices [3, 4]. nis have serious negative consequences such as increased costs of healthcare, prolonged hospital stay, economic hardship to patients and their families, long-term disability, increase mortality rate and increase of antimicrobial resistance [5-8]. nis are caused by everpresent pathogens that are present in the air, on surfaces and equipment such as bacteria, viruses and fungi [9]. furthermore, nosocomial cases do not include only patients but also healthcare workers, visitors and suppliers who got the infection during work in a hospital environment [10, 11].nurses are vital healthcare workers who are in more continuous and direct contact with patients than other health staff. they are therefore at higher risk of nis and also play a vital role in their transmission [12]. research studies show that nurses have a big effect on transfer of nis [9, 13, 14]. furthermore, nis are an occupational hazard for nurses [15] and including this topic in a nursing curriculum has a significant role in their prevention [16]. infection prevention and control measures aim to protect patients and hospital staff from acquiring an infection while they are inside the hospital [17]. infection control should be one of the main responsibilities of all hospital workers and they should have appropriate knowledge and essential related skills [18]. nurses can prevent the occurrence of nis by following control measures such as putting on gloves and masks, using appropriate disinfection of skin, changing the infusion sets, avoiding contact with secretions, applying standard precaution principles, appropriate isolation of patients and preventing accidental needling [19]. this study aimed to evaluate the availability of hospital uniforms, personal protective equipment and infection control activities in sulaimani hospitals and to investigate the nurses’ experiences of nosocomial infections a cross-sectional study was carried at governmental hospitals in sulaimani in the kurdistan region of iraq (table 1). the study included 887 nurses and excluded nurses who were on vacation during the period of study and who worked in positions without direct contact with patients. data were collected from 20th february to 28th september 2018. to determine the study sample size, daniel’s method with the formula (n = (z)2 *p*( 100 – p ) / d2) was used [20]. the prevalence rate (p) assumed was 45% depending on kaushal’s study in 2015 [21], confidence level zalpha (z) 1,96, confidence interval difference (d) 4.5 at 10% of the prevalence and power of prevalence was 45% decreased to 39% to cover the missing data. after applying this formula, the sample size of the study was approximately 525 nurses. a convenience sampling method was used to select the participating nurses. the sample size was divided for each of the 10 hospitals by a proportion formula, which is as follows: (number of nurses in a group / total number of nurses *sample size). the sample size number for each hospital is shown in table 1.a self-administrated questionnaire was utilised to collect data and the firs section included questions about demographical information and workplace characteristics such as age, gender, professional education, work experience, hospital, department etc. (table 1). the second section contained multiplechoice questions about personal protective equipment (ppe) provided by hospitals. the third section included questions about nosocomial infections-related subjects studied at the university, nis training in 167 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2020.19 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article 168 erbil journal of nursing & midwifery this study was approved by the sulaimani directorate of health and the administrations of the involved hospitals. furthermore, the researchers obtained the verbal informed consent from nurses after explaining the details and importance of the study. this study included 525 nurses at 10 general hospitals in sulaimani (table 1). the mean ± standard deviation (sd) of nurses’ age were 33.28±8.42 with a range of 19-62 years old. most of the nurses were in the 26-36 years old group (41.5%), followed by the 37-47 years old group (27.3%) and the 25 or less years old group (19.8%) . figure 2 and 3). in terms of place of work, 192 nurses (36.6%) worked on hospital adult wards, 99 (18.9%) practised in an emergency room, 78 (14.8%) in the operating theatre, 67 (12.8%) in the icu, 28 (5.3%) on the paediatric ward, 11 (2.1%) in the premature babies unit, and 50 (9.5%) of nurses did not disclose their workplace. results figure 1. nurses’ age groups figure 2. nurses’ gender the hospital, nurses’awareness of infection control unit, their estimate of the safety of their hospital, experiences of accidents and acquired nis, and recommendation to their hospital regarding ni control. the validity of the questionnaire was confirmed through review by infection control experts at the sulaimani hospitals and sulaimni polytechnic university. after the collection, the data were analysed using spss (statistical package for the social sciences) version 22.to obtain descriptive statistics, the mean, standard deviation, frequency and percentage were calculated. in addition, the endnote software version 7.5 was used for management of the references. as demonstrated in figure 1. the majority of respondents were females (67%) in comparison to males (33%). most of the nurses held institute diploma certificate (66.1%), followed by a bachelor degree (16.4%), and a high school diploma degree (14.5%). table 1: representative number of nurses and selected nurses in each governmental hospitals in sulaimani hospital number of nurses selected nurses shar general hospital 262 155 maternity teaching hospital 105 62 internal teaching hospital 88 52 paediatric teaching hospital (dr.jamal) 87 52 cardiac specialists hospital 72 43 emergency surgery hospital 70 41 burn and plastic emergency hospital 69 41 surgery teaching hospital 58 34 internal emergency hospital (hemn) 40 24 hiwa hospital for cancer 36 21 total 887 525 https://doi.org/10.15218/ejnm.2020.19 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article (table 2).the majority of nurses (295) had 8 or fewer years of experience (56.2%), 116 nurses worked for 9-17 years (22.1%), while there was 1 nurse who had 36 years of experience (0.2%). 14 nurses (2.7%) did not provide this information. furthermore, near half of the participated nurses (227/ 43.3%) had every workday contact with patients, followed by 3-4 days of contact per week (177/33.6%). 111 (21.2%) of nurses had less than 3 days of patient contact per week and 10 nurses (1.9%) did not answer the question (table 2).the results in table 3 show that 268 nurses (51%) reported that hospitals provided sufficient uniforms for staff. however, one-third (194) of the participated nurses (37%) indicated that the hospitals did not provide uniforms and 58 (11%) of respondents did not have information about whether hospitals provided uniforms and gloves. the inquiry into the experiences of participated nurses with the cleaning of their working uniforms at hospitals revealed that 444 nurses (84.6%) stated that they were responsible for washing their working uniforms and 41 (7.8%) stated that their working uniforms were cleaned by the hospital cleaning staff (table 3).furthermore, a large number of nurses stated that their hospitals did not have a dedicated team for checking and cleaning medical staff uniforms; whereas, 144 (27.4%) of the participating nurses said that the hospitals had such a team. 86 (16.4%) of participants did not have information to answer this question. 139 (26.5%) of participating nurses gave low and 139 (26.5%) allocated a very good satisfaction rating for their hospital uniforms followed by a good satisfaction rating by 118 nurses (22.4%). 169 erbil journal of nursing & midwifery figure 3. nurses’ professional education table 2: distribution of nurses' workplace characteristics variables groups frequency percentage hospital working units emergency room 99 (18.9) intensive care unit (icu) 67 (12.8) paediatric wards 28 (5.3) premature unit 11 (2.1) surgery room 78 (14.8) adult wards 192 (36.6) total 475 (90.5) missing 50 (9.5) experience (year) ≤ 8 295 (56.2) 9-17 116 (22.1) 18-26 79 (15) 27-35 20 (3.8) ≥ 36 1 (0.2) total 511 (97.3) missing 14 (2.7) period in contact with the patients per week always (every workday per week ) 227 (43.3) sometimes (3-4 days per week) 177 (33.6) few-times (less than 3 days per week ) 111 (21.2) total 515 (98.1) missing 10 (1.9) https://doi.org/10.15218/ejnm.2020.19 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article 170 erbil journal of nursing & midwifery table 3 :distribution of personal protective equipment availability variable groups frequency percentage does the hospital provide sufficient uniforms for health staff? yes 268 (51) no 194 (37) do not know 58 (11) total 520 (99) missing 5 (1) who has the responsibility of cleaning your work uniforms in the hospital? hospital cleaning staff 41 (7.8) myself 444 (84.6) others 29 (5.5) total 514 (97.9) missing 11 (2.1) does the hospital have a special team for checking and cleaning health staff uniforms? yes 144 (27.4) no 292 (55.6) do not know 86 (16.4) total 522 (99.4) missing 3 (0.6) if yes, how often are the uniforms washed? monthly 8 (6.4) weekly 11 (8.8) daily 52 (41.6) not in regular times 54 (43.2) total 125 (100) missing 19 if you rate your working uniform, what rate do you give it out of 100%? very low (≤ 25%) 63 (12) low (26%-50%) 139 (26.5) good (51%-75%) 118 (22.4) very good (76%-100%) 139 (26.5) total 459 (87.4) missing 66 (12.6) https://doi.org/10.15218/ejnm.2020.19 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article table 4 reveals that 441 nurses (84%) reported that they did not acquire any nis, and 80 nurses (15.2%) claimed that they acquired infection from working in the hospital. furthermore, the infection was the most repeated (21 nurses, 34.4%) occupational health problem compared with allergy and influenza at 20 nurses (32.8%) for each. the majority of nurses (479) did not have an accident during their duty at the hospital (91.2%), while 41 respondents (7.8%) experienced an accident at work. a needle-stick injury was the most common accident suffered by 18 nurses (51.4%), 16 respondents (45.7%) accidentally cut themselves with a sharp object, while a spillage of blood was the least common accident (1 case, 2.9%). the majority of nurses (404) reported recapping syringe needles after using it on the patients (76.9%), and 119 (22.7%) of nurses denied recapping. the results related to nurses’ knowledge about an infection control unit in their hospitals showed that 320 nurses (61%) were aware that their hospital had an infection control unit, 109 (20.7%) of nurses reported that there was no such a unit in their workplace, and 89 nurses (17%) did not know. in addition, most (98) of participating nurses (18.7%) gave a low rating to an infection control unit activity in their hospitals and followed by 80 good ratings (15.2%), and 68 very good ratings (13%). the very low rating of the activity of the infection control unit was given by 29 nurses (5.5%).nurses’ reports on their safety and vaccinations for nosocomial infections. the results in table 5 indicate that most of the nurses 330 (62.9%) were vaccinated against ni and 185 nurses (35.2%) of nurses did not receive vaccinations. 198 nurses (76.7%) were vaccinated against the hepatitis b virus (hbv), followed by 33 nurses who received an influenza vaccine (12.8%), tetanus (tt) 24 nurses (9.3%) and tuberculosis (tb) 3 nurses (1.2%). nurses’ reports on their safety and vaccinations for nosocomial infections. the results in table 5 indicate that most of the nurses 330 (62.9%) were vaccinated against ni and 185 nurses (35.2%) of nurses did not receive vaccinations. 198 nurses (76.7%) were vaccinated against the hepatitis b virus (hbv), followed by 33 nurses who received an influenza vaccine (12.8%), tetanus (tt) 24 nurses (9.3%) and tuberculosis (tb) 3 nurses (1.2%).concerning the safety of their working place, the majority (145) of nurses (27.6%) gave a low rating to their working place safety, followed by a very good rating by 127 nurses (24.2%), and 110 good ratings (21%). 64 nurses (12.2%) evaluated safety in their hospital as very low. furthermore, the study investigated the nurses’ fear of acquiring occupational nis during work in the hospital. the majority of nurses (427/81.3%) stated that they were afraid of getting nis, while 85 nurses (16.2%) of respondents were not afraid. moreover, this study explored, how nurses maintained hygiene during nursing procedures. most of the nurses (347), which represents 66.1% self-reported that their compliance was very good, followed by a good rating by 87 nurses (16.5%), and low rating by 34 respondents (6.5%), while 4 nurses rated their compliance to hygiene as very low (0.8%).finally, the majority (397) of nurses (75.6%) who participated in this study reported that they consider nis very seriously during their work in the hospital environment and 45 of them (8.6%) stated that they do not consider ni seriously. according to the results, 10 nurses (1.9%) did not care about nis and 57 respondents (10.9%) were not sure how to deal with ni in their working environment. 171 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.19 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article 172 erbil journal of nursing & midwifery table 4: distribution of nurses' accidents and nosocomial infections variable groups frequency percentage have you acquired any infection related to your work in the hospital? yes 80 (15.2) no 441 (84) total 521 (99.2) missing 4 (0.8) if yes, what was the type of infection? allergy 20 ((32.8 infection 21 ( 33.3( influenza 20 (32.8) not mentioned 19 did you have an accident in the hospital that may cause nosocomial infection? yes 41 (7.8) no 479 (91.2) total 520 (99) missing 5 (1) if yes, what was the type of accident? spill blood 1 (2.9) cut 16 (35.7) needle-stick injury 18 (51.4) not mentioned 6 do you recap needle syringes after been used on the patients? yes 404 (76.9) no 119 (22.7) total 523 (99.6) missing 2 (0.4) does your hospital have an infection control unit? yes 320 (61) no 109 (20.7) do not know 89 (17) total 518 (98.7) missing 7 (1.3) if yes, out of 100% how do you rate their activity? very low (≤ 25%) 29 (5.5) low (26%-50%) 98 (18.7) good (51%-75%) 80 (15.2) very good (76%-100%) 68 (13) total 275 (52.4) missing 250 (47.6) https://doi.org/10.15218/ejnm.2020.19 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article 173 erbil journal of nursing & midwifery table 5 :distribution of nurses' perception of safety and vaccinations to nosocomial infections variable groups frequency percentage have you taken any vaccine to protect you against nosocomial infections in the hospital? yes 330 (62.9) no 185 (35.2) total 515 (98.1) missing 10 (1.9) if yes, for what disease or infection? tetanus (tt) 24 (9.3) tuberculosis (tb) 3 (1.2) influenza 33 (12.8 hepatitis b virus (hbv) 198 (76.7) not mentioned 72 how do you rate the safety of your workplace for nosocomial infections out of 100%? very low (≥25%) 64 (12.2) low (26%-50%) 145 (27.6) good (51%-75%) 110 (21) very good (76%-100%) 127 (24.2) total 446 (85) missing 79 (15) are you afraid to get an infection in the hospital? yes 427 (81.3) no 85 (16.2) total 512 (97.5) missing 13 (2.5) how do you rate your compliance with hygiene rules during your procedures on patients? very low (≥25%) 4 (0.8) low (26%-50%) 34 (6.5) good (51%-75%) 87 (16.5) very good (76%-100%) 347 (66.1) total 472 (89.9) missing 53 (10.1) how seriously do you take nosocomial infections? very serious 397 (75.6) not seriously 45 (8.6) not care 10 (1.9) not sure 57 (10.9) total 509 (97) missing 16 (3) https://doi.org/10.15218/ejnm.2020.19 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article vides sufficient uniforms for all nurses. oliveira’s review on nine articles from 2000 to 2010 shows that medical staff uniforms and gloves are among the main sources of microorganisms, including the resistant microorganisms [22]. the white coat used by some medical staff and students for hospital work practices is known as a source of potential microorganisms [23, 24]. hospital staff clothes acquire nis during different procedures and through various contacts in the hospital environment and can transmit the infection from one patient to another. wiener recommends that health staff should wear daily washed uniforms, cleaned through adequate laundry by a specialist hospital team under the supervision of the infection control unit [25]. the infection control unit is responsible for the application and monitoring of all infection control guidelines to prevent nis [26]. unorganized and ineffective infection control unit is one of the main causes of nis in developing countries compared to developed countries [3]. in the current study, 84.6% of nurses reported that they wash their uniform themselves, and 55.6% of nurses reported there is no special team at the hospital to check and monitor uniform hygiene. the majority of nurses in this study reported that they did not experience an accident in the hospital that may cause them nis, the needlestick injury was the highest accident among those nurses who experienced accidents, followed by cutting by sharp objectives. alazawy’s study on the prevalence of needle-stick accidents and knowledge on standard precaution and blood-borne diseases among medical staff reported that 53% of nurses in his study experienced a needle-stick injury [27], and honda reported that 55.5% of nurses experienced sharp injuries accident, 91.1% of accidents involved blood, and the most common injuries were a needle-stick injury (52.8%) nurses’ suggestions to the hospitals regarding the control of nosocomial infections. most nurses (110) suggested establishing a more effective infection control unit as the best way for their hospital to be more effective against nis (48.2%), followed by continuing training to staff suggested by 54 nurses (23.7%), care more about hospital hygiene by 24 nurses (10.5%), better hospital building by 17 nurses (7.5%), better administration to hospital by 13 nurses (5.7%) and provide more ppes by 10 nurses (4.4%) (figure 4). this cross-sectional study evaluated nurses’ self-report on the infection control unit activities and their experiences toward nosocomial infections in 10 sulaimani governmental hospitals from 20 february to 28 september 2018 with the convenience sampling of 525 nurses using a questionnaire for data collection. in developing countries, the main obstacle to infection control units is the lack of or insufficient basic personal protective equipment for all staff [4]. in this study, the majority of nurses reported that the hospital provides 174 erbil journal of nursing & midwifery figure 4 nurses’ suggestions to the hospital regarding control of nosocomial infections discussion https://doi.org/10.15218/ejnm.2020.19 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article and working in the hospital environment. the majority of nurses reported that their hospital provided uniforms, which they washed themselves, and there was no dedicated team for checking and cleaning health staff uniforms. most of the participating nurses were vaccinated against one or more nosocomial diseases, mostly against hepatitis b. in addition, the majority of nurses did not feel safe in hospitals and were afraid to acquire nosocomial infections. most nurses recommended the establishment of more effective infection control units that can be more active against nosocomial infections. [1] obiero cw, seale ac, berkley ja. empiric treatment of neonatal sepsis in developing countries. the pediatric infectious disease journal. 2015;34(6):659-61. doi:10.1097/ inf.0000000000000692. [2] nejad sb, allegranzi b, syed sb, ellis b, pittet d. health-care-associated infection in africa: a systematic review. bulletin of the world health organization. 2011;89:757-65. doi:10.2471/blt.11.088179. [3] samuel s, kayode o, musa o, nwigwe g, aboderin a, salami t, et al. nosocomial infections and the challenges of control in developing countries. african journal of clinical and experimental microbiology. 2010;11(2). doi:10.4314/ajcem.v11i2.53916. [4] alp e, leblebicioglu h, doganay m, voss a. infection control practice in countries with limited resources. annals of clinical microbiology and antimicrobials. 2011;10(1):36. doi:https://doi.org/10.1186/1476-0711-1036. [5] engemann jj, friedman jy, reed sd, griffiths ri, szczech la, kaye ks, et al. clinical outcomes and costs due to staphylococcus aureus bacteremia among patients receiving long-term hemodialysis. infection control and hospital epidemiology. 2005;26(6):5349. doi:https://doi.org/10.1086/502580. followed by cutting by ampule (26.2%). the majority of nurses in the current study were aware of the fact that their hospital has an infection control unit and the majority of them gave a low rating to the unit’s role in the hospital. all the hospitals included in the current study have an infection control unit with low activity as nurses reported. non-organized or non-active infection control units remain one of the main obstacles in developing countries against good control and prevention of nis. the infection control unit is responsible for all applications and monitoring of standard and special precautions in each hospital including improving nurses’ knowledge by training. infection control units should be working more actively, to be provided with more guidelines and to be stricter in implementing the guidelines. more than half of the nurses who participated in this study were vaccinated against nis, and hbv was the most common diseases nurses were vaccinated against. these results are in agreement with eskander’s study that showed that 80% of nurses received a vaccine against nis, 74% of those vaccines were for hbv and 11% for the influenza virus. fashafsheh reported that more than 80% of nurses who participated in their study were vaccinated against hbv [28].the majority of nurses in the current study gave a low rating to the safety in their hospital. low perception of safety during their work in hospital decreases nurses performance and can cause injuries to themselves and the patients [29]. also, the majority of nurses in this study were afraid of occupational nis during their work in the hospital, they took nis very seriously, and gave a high rating to their compliance to hygiene during procedures on patients. nurses’ fear of occupational nis might make nurses more compliant and more careful about infection control precautions when dealing with patients 175 erbil journal of nursing & midwifery conclusion references https://doi.org/10.15218/ejnm.2020.19 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article [15] joshi r, reingold al, menzies d, pai m. tuberculosis among health-care workers in low -and middle-income countries: a systematic review. plos medicine. 2006;3(12):e494. doi:10.1371/journal.pmed.0030494. [16] kelcíkova s, skodova z, straka s. effectiveness of hand hygiene education in a basic nursing school curricula. public health nursing. 2012;29(2):152-9. doi:https:// doi.org/10.1111/j.1525-1446.2011.00985.x [17] damani n. manual of infection prevention and control: oup oxford; 2011. [18] saleh moghadam r, mir salari n. knowledge and practice of nurses in relation to operating room pollution. journal of knowledge management. 2005;39:21-8. [19] stone pw, hasan s, quiros d, larson el. effect of guideline implementation on costs of hand hygiene. nursing economic. 2007;25 (5):279. [20] daniel w. biostatistics: a foundation for analysis in the health sciences, 7th ed r wiley. new york. 1999. [21] kaushal g, doke p, shah a, verma v. an analysis of knowledge, attitude and practices regarding standard precautions of infection control and impact of knowledge and attitude of icu nurses on self-reported practices of infection control. international journal of hospital and health care administration. 2015;2:79-85. [22] oliveira acd, silva mdm, garbaccio jl. clothing of health care professional as potential reservoirs of micro-organisms: an integrative review. texto & contextoenfermagem.2012;21(3):684-91. doi:https://doi.org/10.1590/s010407072012000300025 [23] robati r, farokhi mm, jaberi fm, hashemi sa. effect of white coats on spread of nosocomial infection. european journal of experimental biology. 2013;3(3):156-9. [24] banu a, anand m, nagi n. white coats as a vehicle for bacterial dissemination. journal of clinical and diagnostic research: jcdr. 2012;6(8):1381.doi:10.7860/ jcdr/2012/4286.2364 [25] wiener-well y, galuty m, rudensky b, schlesinger y, attias d, yinnon am. nursing and physician attire as possible source of nosocomial infections. american journal of infection control. 2011;39(7):555-9. [6] kaye ks, anderson dj, sloane r, chen lf, choi y, link k, et al. the effect of surgical site infection on older operative patients. journal of the american geriatrics society. 2009;57 (1):46-54. doi:https://doi.org/10.1111/ j.1532-5415.2008.02053.x [7] scott rd. the direct medical costs of healthcare-associated infections in us hospitals and the benefits of prevention. 2009. [8] glance lg, stone pw, mukamel db, dick aw. increases in mortality, length of stay, and cost associated with hospital-acquired infections in trauma patients. archives of surgery. 2011;146(7):794-801.doi:10.1001/ archsurg.2011.41. [9] lepelletier d, perron s, bizouarn p, caillon j, drugeon h, michaud j-l, et al. surgical-site infection after cardiac surgery: incidence, microbiology, and risk factors. infection control and hospital epidemiology. 2005;26 (5):466-72.doi:https:// doi.org/10.1086/502569. [10] who. the burden of healthcare-associated infection worldwide 2016 [available at: http://www.who.int/gpsc/country_work/ burden_hcai/en/. [11] mcbryde e, bradley l, whitby m, mcelwain d. an investigation of contact transmission of methicillin-resistant staphylococcus aureus. journal of hospital infection. 2004;58 (2):104-8.doi:https://doi.org/10.1016/ j.jhin.2004.06.010. [12] shinde mb, mohite vr. a study to assess knowledge, attitude and practices of five moments of hand hygiene among nursing staff and students at a tertiary care hospital at karad. international journal of science and research (ijsr). 2014;3(2):311-21. [13] de oliveira am, white kl, leschinsky dp, beecham bd, vogt tm, moolenaar rl, et al. an outbreak of hepatitis c virus infections among outpatients at a hematology/ oncology clinic. annals of internal medicine. 2005;142(11):898-902. [14] pessoa-silva cl, hugonnet s, pfister r, touveneau s, dharan s, posfay-barbe k, et al. reduction of healthcare-associated infection risk in neonates by successful hand hygiene promotion. pediatrics. 2007;120(2):e382e90. doi:https://doi.org/10.1542/peds.20063712. 176 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2020.19 erbil j. nurs. midwifery, vol. 3, no. (2), nov 2020 original article [26] storr j, twyman a, zingg w, damani n, kilpatrick c, reilly j, et al. core components for effective infection prevention and control programmes: new who evidence-based recommendations. antimicrobial resistance & infection control. 2017;6(1):6. doi:https:// doi.org/10.1186/s13756-016-0149-9 [27] alazawy sa. the prevalence of needle stick injuries among health care workers in baquba teaching hospital. diyala journal for pure science. 2010;6(3):260-71. [28] fashafsheh i, ayed a, eqtait f, harazneh l. knowledge and practice of nursing staff towards infection control measures in the palestinian hospitals. journal of education and practice. 2015;6(4):79-90. [29] barton a. patient safety and quality: an evidence-based handbook for nurses. aorn journal. 2009;90(4):601-2. doi:https:// doi.org/10.1016/j.aorn.2009.09.014 177 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2022.12 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article monitoring peripheral intravenous catheters complications in pediatric patients in erbil city/iraq abstract introduction peripheral intravenous (iv) catheterization (pivc) is one of the most commonly used procedures in hospitalized children [1]. each year worldwide, over a billion pivcs are inserted in hospitalized children [2]. it is also calculated that above 80% of patients undergo this procedure across hospitalization [1, 3]. the procedure is applied backgrounds and objectives: although most problems of peripheral intravenous catheterization are inconsiderable and easily treated, some are dangerous and require rapid management. this study aimed to explore peripheral intravenous catheter-related complications and the quality of nursing care for dressing sites of peripheral intravenous catheterization among the pediatric population. methods: the study was conducted at raparin teaching hospital for children inpatient units in erbil city/iraq, using an observational study design. a purposive sample from 296 hospitalized children with peripheral intravenous catheterization was chosen for this study. the data was collected using a special check list (pivc-miniq) developed for checking the signs and symptoms and the quality of care for the catheter insertion site. furthermore, the obtained data on peripheral intravenous catheterization problems was evaluated for exploring grades of phlebitis using the phlebitis scale developed by the infusion nursing society in 2011. the data was processed and analyzed using spss using descriptive statistical analysis (frequency, percentage) and inferential statistical tests (chi-squared, contingency coefficient). the probability value of ≤0.05 was regarded as statistically significant. results: most (82.4%) of patients were recruited in the emergency unit, with the highest percentage (36.8%) were toddlers. more than two-thirds (72.3%) of participants were assessed within the first peripheral catheter insertion. regarding overall grades of patients’ peripheral intravenous catheterization complications (pivc), less than a quarter (21.6%) were within the first grade, indicating being at risk for complications, and 6.8% were within the second grade, indicating slight phlebitis. regarding the nursing care for pivc site care, 62.5% of participants received fair care, and 22.3% received poor care. conclusions: a quarter of observed children were at risk for having phlebitis and less than ten percent had slight phlebitis. about a quarter of patients received poor nursing care for the catheter insertion site. most participants have not a documentation of peripheral intravenous catheter insertion date on the dressing and on the patient's chart. keywords: quality of care; peripheral intravenous catheters; complications. norhan zeki shaker; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: norhan.shaker@hmu.edu.krd ) 105 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 25/05/2022 accepted: 08/08/2022 published: 30/11/2022 mailto:norhan.shaker@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.12 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article to assist in various managements, such as hydro-electrolytic imbalances, blood losses, and dysfunctions of multiple organs [4]. it can also be injected in some patients prophylactically before procedures and in unsteady patients for crisis use [5,3]. although pivc is common, the risk of complications is high [6] and sometimes can lead to local and systemic complications. these complications include hematoma, occlusion, phlebitis, thrombophlebitis, infiltration, leakage, pain, edema and local infection [7,8]. while most problems are minor and manageable, some can be lifethreatening and necessitate immediate attention. the most frequently seen consequences are infections and mechanical issues such as occlusion, leakage, and dislodgment [9].over a person's lifetime, particularly if hospitalization starts in childhood, informed and patient-focused iv care is vital [10]. most of the post-insertion iv care and maintenance is handled by nurses, who frequently perform pivc insertions [11]. as a result, nurses are crucial in monitoring and preventing pivc problems and failure. the global trend of pivc insertion studies and experiences are more than conservation. when maintenance of pivc have important role in confirming catheter patency for many days [14]. the nurse must document using a standardized scale, the signs and symptoms of phlebitis, the interventions used, and the patient's reaction to treatment in the patient's charts. international data on prevalence and management of pivcs are lacking, although pivc use is highly evident in hospitalized patients internationally [15]. in addition, there are no published studies in iraq on pivc among pediatric patients. the national and international quality agency recommended strategies for prevention of pivc complications including designated trained personnel to insert and maintain pivcs, surveillance, hand hygiene, proper use of aseptic non-touch technique and recommendations regarding catheter site care and early removal when no longer necessary [16]. this study aimed to explore peripheral intravenous catheter-related complications and nursing care for the dressing at the site of pivc among the pediatric population in erbil city and to determine the association between grades of pivc complication and levels of nursing care for the pivc site, inserted pivc number, and children age. an observational design was used for conducting this study in 2022 at inpatient units (emergency, surgical, and neonatal care) of riparian teaching hospital for children (rthch) in erbil city kurdistan region, iraq. the sample size estimation in this study has been calculated through this formula: n=z2 p (1-p)/d2 [22,24]. when n is representing sample size, z is the statistic corresponding to level of confidence, p is expected proportion in population (expected prevalence or based on previous studies), and d is precision or absolute error. the level of confidence is 95%, precision is 5%, and expected prevalence is 40 %. a sample size of 303 children with pivc was recruited. the sample size was 296 after seven children were discharged before 24 hours of hospitalization. the sample included hospitalized children who required at least one pivc in rthch during the data collection period. patients referred from other hospitals with previously inserted pivc were excluded from sample. data were collected between april and july 2022. the researcher preformed the sample selection during routine morning visits. each patient was given a case number, and the pivc followed after 24 hours to assess the complications and the failure. each patient needs ten to fifteen minutes for taking the relevant information. nurses were 106 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.12 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article inferential data. the results were considered statistically significant at p-value ≤0.05. table 1 shows that the majority (82.4%) of participants were recruited from the emergency unit. the highest percentage (36.8%) were toddlers, and more than half (58.4) of the patients were male. more than twothirds (72.3%) of participants were assessed within the first pivc insertion, and more than three quarter (76.6) of inserted pivcs size was 24 gauge of yellow color. concerning the site of pivc insertion, 64.2% of children had the cannula in their hands, and 64.2% on the right side. regarding the indication of insertion, almost all the children (99.3%) used it for medication or receiving fluid. table 2 reveals just above a quarter (26%) of patients had pain or tenderness, 26.7% had redness at the site of insertion, 67.6% complained of warmth at the site of insertion, 26.7% had swelling >1cm from the insertion site, 67.6% had hard vein beyond iv tip when palpated, and 21.3%had partial/complete dislodgement. regarding iv dressing and connection, 66.6% had loose or lifting edges of the tape, 98.0% did not have pivc insertion date documented on dressing, and 73% lack the date of pivc insertion in the patient's chart. table 3 shows the overall grades of pivc complication. the highest percentage (71.6%) of participants were within grade zero indicating no complications, 21.6% were within the first grade indicating being at risk for complications, and 6.8% were within second grade which indicates having slight phlebitis. table 4 displays statistically significant associations between grades of pivc complication and levels of nursing care for the pivc site (p=0.04), and no statistically significant association with inserted pivc number (p=0.24), and children’s age (p=0.183). not informed about the study. after a review of many previous articles, the researcher decided to use peripheral intravenous catheter mini questionnaire (pivcmini q) https://doi.org/10.1186/s12913019-4497-z:, this tool is developed by hovik et al., and tested for reliability in measuring rates of pivc problems. the tool included four sections. the first sections reveals phlebitis related signs and symptoms at/around insertion site (9 items: pivc pain or tenderness, redness, swelling, warmth, purulence, hardness of tissue, streak/red line along vein, palpable hard vein beyond iv tip, and partial/complete dislodgement). the second section reveals pivc dressing, and iv connection related to pivc failure (5 items: dressing soiled with blood or fluids, loose or lifting dressing edges, dressing fixed with tape only, blood in the line, and absence of insertion date on pivc dressing). the third area consisted of 1 item, lack of documentation of pivc in patient chart. the fourth section consisted of 1 item, indication for pivc use. each problem that accounts for 1 point. overll score (0-16) reflects pivc quality [17]. furthermore, the obtained data on pivc problems was evaluated for exploring grades of phlebitis using the phlebitis scale developed by the infusion nursing society in 2011 that has already obtained validity and inter-rater reliability [15]. the official permission to conduct the study was obtained from the erbil general directorate of health. the college of nursing/hawler medical university research ethics committee evaluated and approved the study protocol. verbal informed consent for participation in the study was obtained from all mothers of children. the data were analyzed using the statistical package for social science (spss, version 23). statistical tests frequency and percentage were used for categorical data. chi-squared and nominal contingency coefficient were used for 107 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.12 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article 108 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: characteristics of children with pivc at rchth (296) item category f. (%) patient unit emergency 244 (82.4) ncu 14 (8.1) surgical 28 (9.5) age/months newborn < 1 m 13 (4.4) infant 1-<12 m 91 (30.7) toddler 12 -<36 m 109 (36.8) preschool 36< 60 m 83 (28) gender male 173 (58.4) female 123 (41.6) number of inserted pivc in current hospitalization 1st 214 (72.3) 2nd 46 (15.5) ≤ 3rd 36 (9.2) insertion environment emergency unit 234 (79) surgical unit 33 (11.2) ncu 29 (9.8) insertion site right 184 (62.2) left 112 (37.8) pivc size (gauge) 24 g yellow 227 (76.7) 22 g blue 69 (23.3) pivc site hand 190 (64.2) wrist
 38 (12.8) forearm 11 (3.7) antecubital fossa 12 (4.1) foot 42 (14.2) head and neck 1 (0.3) upper arm 2 (0.7) reason for pivc insertion medication or fluid 294 (99.3) unknown indication 2 (0.7) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.12 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article 109 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: distribution of participants (n=296) children according to the assessed signs and symptom of pivcs complications signs and symptoms no yes f. (%) f. (%) pivc site assessment pain/tenderness on palpitation 219 (74) 77 (26) redness >1 cm from insertion site 228 (77) 68 (23) swelling >1 cm from insertion site 217 (73.3) 79 (26.7) warmth 96 (32.4) 200 (67.6) purulence 296 (100) 0 (0) streak/ red line along vein 290 (98) 6 (2) induration/ hardness of tissues >1 cm 240 (81.1) 56 (18.9) palpable hard vein beyond iv tip 96 (32.4) 200 (67.6) partial/ complete dislodgement pivc 233 (78.7) 63 (21.3) iv dressing and connection assessment soiled with blood or fluids 273 (92.2) 23 (7.8) loose or lifting edges 99 (33.4) 197 (66.6) tape only 149 (50.3) 147 (49.7) blood in line 167 (56.4) 129 (43.6) pivc insertion date not documented on dressing 6 (2) 290 (98) indication for pivc medication and fluid 2 (0.7) 294 (99.3) documentation date of pivc insertion in patient chart is lacking 80 (27) 216 (73) table 3: distribution of participants among the levels of pivc complications grades of pivc complication f (%) grade 0 (without clinical signs; healthy) 212 (71.6) grade 1 (presence of erythema on the insertion of the catheter with or without pain; at risk for complication) 64 (21.6) grade 2 (pain at the site of insertion of the catheter with erythema and/or edema; slight phlebitis). 20 (6.8) total 296 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.12 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article the current study was designed to explore peripheral intravenous catheter-related complications through assessment of the signs and symptoms related to pivc complications among purposive sample of 296 children with pivcs at riparian teaching hospital for children in erbil city. the current study found that majority of participating children were hospitalized in the emergency unit, and the highest percentage of them were toddlers. the mean age was 23.08 ± 19.25 weeks and 58.4% were male. another researcher conducted a study with 98 children and found, the mean age was 5.2 ± 4.7 years and the 50% of them were of the male gender [3]. in recent study most of patients were assessed within the first pivc insertion, and lowest percentage of them were within third or more inserted pivcs. unluckily, after the pivc inserted more than 50% of these will fail before finishing the treatment [16].the infusion nursing society has abolished the practice of replacing catheters after every 72 hours and suggests that catheters should only be removed or replaced when they are no more required or 110 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: association between grades of complication with quality of nursing care, inserted pivc number, and child’s age variables grade 0 grade 1 grade 2 total p-value quality of nursing care for the pivc site good 36 7 2 45 0.04 s fair 134 37 14 185 poor 42 20 4 66 total 212 64 20 296 inserted pivc number 1st 162 41 7 210 0.24 ns 2nd 32 16 6 54 3rd &> 18 7 7 32 total 212 64 20 296 child age /month < 1 6 4 3 13 0.183 ns 1-<12 62 22 7 91 12-<36 86 20 3 109 3660 58 18 7 83 total 212 64 20 296 figure 1 : shows levels of nursing care for pivc site care. the highest percentage (62.5%) of participants were received fair care at the site of pivc dressing, and 22.3% received poor care. figure 1: levels of nursing care for the pivc site dressing care discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.12 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article observed children were within first grade having erythema on the catheter insertion site with or without pain indicating they were at risk for complication. this finding is similar with another studying showing the most frequent symptom at the insertion site was pain and tenderness [18]. the minority of children was within second grade having pain at the catheter insertion site with erythema and/or edema indicating slight phlebitis. one study reports complications among 111(51.9%) of pivc subjects [3] and another stated the reported rates of phlebitis at 13%, extravasation at 28%, and bacterial colonization at 11% [19]. regarding nursing care for the pivc site, the current study finding shows that about a quarter of patients were suffering from poor nursing care for the pivc dressing site. this finding is consistent with another study which found that pivc complications were common in pediatric departments and are often associated with misuse of device [3].there was a statistically significant association between grades of pivc complication and levels of nursing care for the pivc site and inserted pivc number. there was no statistically significant association between grads of pivc complication and children’s age and site of pivc insertion. in contrast, another stated that age, hospitalization in surgery unit, insertion in antecubital vein have role in development of phlebitis study [20]. results from another study revealed that younger ages are risk factors for pivc complications in children [21]. a quarter of observed children were at risk for having phlebitis and less than ten percent had slight phlebitis. about a quarter of patients received poor nursing care for the pivc insertion site, which leads to pivc complications. most participants did not have the pivc insertion date documented have impaired function [15]. the incidence of pivc failure in pediatric patients is still high, despite the global and vital role in health care. a systematic review of 32 studies confirmed that an average of 34% of pivc in pediatric patients fail before the completion of the therapies, with infiltration as the most frequent complication [14].moreover, in the current study, the majority of participants have the pivc insertion for receiving medication or fluid, as mentioned in another study where 67.8% of pivc insertions were used for drug administration [3].regarding the signs and symptoms of pivc complications, the current study found more than a quarter of the monitored children were complaining of pain and redness at the site of pivc site. this finding agrees with a study done by zempsky who found that pivc is a primary cause of procedure related pain in the hospital [18]. the current study revealed that two-thirds of the participants had a hard vein beyond the iv tip when palpated. monreal et al., listed the criteria of phlebitis which includes symptoms of pain, erythema, swelling, and palpable thrombosis of the cannulated vein [23].regarding iv dressing and connection assessment, the current study reveals that more than two-thirds of pivc had loose or lifting edges of the tape. in addition,, many participants have no pivc insertion date documented on the dressing, and most of them lack documentation of the date of pivc insertion in the patient's chart. similarly, another study found that the most dominant overall problem was lack of documentation of pivc (26.8%) [17]. concerning the levels of pivc complication which explored the grades of phlebitis using the phlebitis scale developed by the infusion nursing society [15], the results reveal that most of the participants were free from complications (grade zero). at the same time, less than a quarter of 111 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.12 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article in ill neonates. neonatal network j. 2001; 20(5), 33–38. [7] danski mtr, oliveira glr, johann da, pedrolo e, vayego sa. incidence of local complications in peripheral venous catheters and associated risk factors. acta paul enferm. 2015; 28(6):517-23. doi: 10.1590/19820194201500087. [8] batista oma, moreira rf, sousa afl, moura meb, andrade d, madeira mza. local complications of peripheral intravenous therapy and associated factors rev cubana enferm, 2018; 34(3). available from: http:// www.revenfermeria.sld.cu/index.php/enf/ article/view/1246/374. [9] pettit j, 
 wyckoff m, peripherally inserted central catheters: guideline for practice, national association of neonatal nurses. u.s. second edition. 2007; isbn 978-09787636-3-3, available from: www. nann.org [10] hallam c, weston v, denton a, hill s, bodenham a, dunn h, & et al. development of the uk vessel health and preservation (vhp) framework: a multi-organizational collaborative. journal of infection prevention. 2016; 17(2), 65–72. https:// doi.org/10.1177/1757177415624752. [11] alexandrou e, ray-barruel g, carr p j, frost s, inwood, s, higgins n, and et al. use of short peripheral intravenous catheters: characteristics, management, and outcomes worldwide. journal of hospital medicine. 2018; 13(5). available from: https:// doi.org/10. 12788/jhm.3039. [12] almeida tjc, miranda jof, santos lm, santana rcb, camargo cl, nascimento sobrinho cl. peripheral venous accesses in hospitalized children: a photographic study. journal of nursing ufpe on line. 2016; 10(2): 701-7. [13] costa ab da, medeiros lnb de, neves ad, barbosa mmb, souza e silva rgs, siqueira rm de. nursing technicians and peripheral venous catheterization in pediatrics. journal of nursing ufpe on line. 2020; 14: e244663 doi: https://doi.org/10.5205/19818963.2020.244663. [14] indarwati f, munday j, keogh s. nurse knowledge and confidence on peripheral intravenous catheter insertion and maintenance in pediatric patients: a multicenter cross-sectional study, journal of pediatric nursing. 2022; 62: 10–16. pmid: 34798582 doi: 10.1016/j.pedn.2021.11.007 on the dressing and in their medical chart. nurses should give more importance to the pivc site dressing and documentation. further, studies need in this field for exploring the quality of postpivc insertion care, and the risk factors of pivc complication among pediatric patients. the author would like to acknowledge the collaboration of all children and mothers at rthch in erbil city who participated in the study, also special thanks for mr. malik f. saber a graduated nurse for contribution in data collection. nothing to declare. [1] waitt c, waitt p, pirmohamed m. intravenous therapy. postgraduate medical journal. 2004; 80(939): 1–6. [2] alexandrou e., ray-barruel g., carr p. j., frost s., inwood sh., higgins n., alberto l., and et al , international prevalence of the use of peripheral intravenous catheters journal of hospital medicine. 2015;10(8): 560-3. [3] abdelaziz r b, hafsi h, hajji h, boudabous h a, chehida a b, mrabet a kh, and et al, peripheral venous catheter complications in children: predisposing factors in a multicenter prospective cohort study, bio medical centre pediatrics. 2017; 17:208 doi 10.1186/s12887-017-0965-y. [4] bolcato m, russo m, donadello d, rodriguez d, aprile a. disabling outcomes after peripheral vascular catheter insertion in a newborn patient: a case of medical liability? the american journal of case reports, 2017; 18:1126-9. doi: 10.12659/ ajcr.904736. [5] datta s, hanning cd. how to insert a peripheral venous cannula. british journal of hospital medicine, 1990; 43(1): 67–9. [6] franck l s, hummel d, connell k , quinn d , & montgomery j.the safety and efficacy of peripheral intravenous catheters 112 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. acknowledgements conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.12 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article [23] monreal m, quilez f, rey‐joly c, vega j, torres t, valero p, & et al. infusion phlebitis in patients with acute pneumonia: a prospective study. chest. 1999; 115:1576‐80. [24] sharma s k, mudgal sh k, thakur k, gaur r. how to calculate sample size for observational and experimental nursing research studies? national journal of physiology, pharmacy and pharmacology. 2020;10(1):1-8 [15] infusion nurses society (ins). infusion nursing standards of practice, journal of infusion nursing. 2011; 34(1s), 64s-71s, available from: www.ins1.org. [16] kleidon t, jullman a. implementation of a pediatric peripheral intravenous catheter care bundle: a quality improvement initiative: success pivc bundle of care, journal of pediatrics and child health. 2019; 55 (10): 1214-1223. doi:10.1111/jpc.14384 [17] høvik l h, gjeilo k h, lydersen s, rickard c m, røtvold b, damås j k, and et al. monitoring quality of care for peripheral intravenous catheters; feasibility and reliability of the peripheral intravenous catheters mini questionnaire (pivc-miniq), bmc health services research. 2019; 19:636 https://doi.org/10.1186/s12913-019-4497 -z [18] zempsky wt. optimizing the management of peripheral venous access pain in children: evidence, impact, and implementation. pediatrics. 2008; 122(3): s121–4. [19] garland j s , dunne jr w, havens p, hintermeyer m, bozzette m a, wincek j, bromberger t,& et al. peripheral intravenous catheter complications in critically ill children: a prospective study. pediatrics. 1992; 89 (6 pt 2): 1145-50. pmid: 1594367. [20] karaoğlan n, hatice yıldırım sarı h y, devrim i. complications of peripheral intravenous catheters and risk factors for infiltration and phlebitis in children. british journal nursing. 2022; 31(8): s14-s23. doi: 10.12968/bjon.2022.31.8. s14. [21] unbeck m, forberg u, ygge bm, ehrenberg a, petzold m, johansson e. peripheral venous catheter related complications are common among paediatric and neonatal patients. acta paediatr. 2015; 104 (6): 566 –74. [22] charan j , biswas t . how to calculate sample size for different study designs in medical research, indian j. psychol. med. 2013; 35(2), 121–126. available from: https://doi.org/10.4103/02537176.116232 113 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article anxiety and depression among infertile couples undergoing invitro fertilization treatment in erbil city abstract background and objectives: infertility affects millions of couples worldwide and is a major public health problem. it is identified as a significant psychosocial crisis and a pathological state. the most prevalent psychological responses in infertile couples are anxiety and depression. this study aimed to assess the status of anxiety and depression symptoms in infertile couples attending ivf centers in erbil city. methods: a quantitative cross-sectional study was conducted in two private ivf centers for infertility diagnosis and treatment at sardam and hawler private hospitals in erbil city, kurdistan region, from 1st september 2021 to 1st november 2022. a nonprobability (convenience) sampling technique was used on 150 infertile couples. data were collected through the interview method by using data collection tools including a socio-demographic part and the hospital anxiety and depression (hads). results: the results of the present study revealed that 58% of the participants were between the ages of 29-39 years old, and 23.7% of husbands had selfjobs, whereas wives, (26 %) were housewives, and the highest percentage of husbands and wives (14%) and (15%) graduated from university. the family income of the majority of couples was ≥1000,000iqd per month. the highest proportion 35.7% were married between 6-10 years. levels of anxiety in wives were (13.3% mild, 16% moderate, and 7.3% severe) compared with (11%, 11%, and 6%) levels of anxiety among husbands. wives had 17.7% mild,6.3% moderate, and 3.7% severe depression compared with 18%,3%, and 3 % depression levels in husbands. anxiety levels were higher in wives than in husbands but no significant difference was shown for depression. conclusion: the study found that infertile couples receiving ivf treatment had a higher proportion of anxiety and depression symptoms, which could have negative effects on treatment for couples seeking assisted conception. according to the study, couples' psychosocial intervention should be a key component of standard infertility treatments. keywords: infertility couples; anxiety; depression; in-vitro fertilization. zhyan hussein khdhir; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: zhianhussen859@gmail.com) abdulqader hussein hamad; department of nursing, college of nursing, hawler medical university, erbil, iraq. 169 received: 31/08/2022 accepted: 20/09/2022 published: 30/11/2023 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:zhianhussen859@gmail.com?subject=zhianhussen859@gmail.com mailto:yousif.omar@hmu.edu.krd?subject=yousif.omar@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article infertility is a common and big health problem globally. in 2010, it was assessed that there are 48.5 million infertile couples worldwide. defined by (who) as a disease of the reproductive system by the failure to achieve a clinical pregnancy after one year or more of consistent unprotected sexual intercourse [1,2], and it has been found to affect about 10–12% of spouses overall in the world [3]. an organism's natural adaptive response to stressful or dangerous events is anxiety. the most prevalent mental disorders are anxiety disorders, which are equally prevalent across all peoples and cultural groups. when anxiety is more intense or doesn't respond as well to the cause, it is considered pathological and needs to be treated by medical care [8]. anxiety disorders affect more than 260 million individuals worldwide (3.6%) of the global population. between 2005 and 2015, the prevalence of anxiety disorders including generalized anxiety disorder, panic disorder, posttraumatic stress disorder, and obsessive-compulsive disorder— increased globally by 14.9%, with the americas accounting for the majority of this rise. anxiety disorders are currently the sixth-leading cause of disability. additionally, more women than men are affected [41].depression is a widely recognized and serious mental health problem with no current effective treatment, and about one out of every ten individuals globally suffers from depression. depression may need long-term therapy. they are currently the fourth-leading cause of disability worldwide, and the who has determined that in 2020, they will be ranked second after cardiovascular disease. the most severe signs of depression include a depressed mood, decreased activity, loss of interest, and an inability to experience pleasure from joyful events (world health organization, 1992). about 5–10% of people experience clinical depression, and today as much as 30% of people experience depressive symptoms at varying intensities throughout their lives [10,42].infertility can be initiated by a man, a woman, or both of the causes of infertility, 40% can be attributed to men, 40% to women, 10% to both couples and 10% to unknown causes [4]. the inability to conceive a child naturally can lead to feelings of guilt, and shame. these negative feelings may be associated with varying grades of depression, anxiety, distress, and a poor. quality of life, although they dramatically affect the selfesteem and body image of infertile couples, social life, and marriage relationships [5,6]. the use of artificial reproductive technology (art), including in vitro fertilization (ivf) is one option for people with infertility who wish to become pregnant. pregnancy loss can cause posttraumatic stress disorder and increased levels of anxiety in women, as well as an increased risk of the spousal relationship dissolving. studies have also shown that the use of ivf itself has associated physical, psychological, emotional, and financial effects. the prevalence of infertility, as well as the subsequent rates of treatment failure and spontaneous abortion, are widespread problems [7].the first negative emotional reaction to both infertility and assisted reproductive treatment (art) is frequently either anxiety (a sense of threat, tension, or worry) or depression (a sense of loss, sadness, or lack of control) [10]. the risk of distress, depression, and anxiety is high for infertile couples. despite the prevalence of infertility, the majority of infertile men and women do not share their stories with people around them (family or friends), thus increasing the susceptibility of their psychological disorders [9]. in our region, most married couples wish to become parents because they believe that 170 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article interviews using data collection tools including a socio-demographic part, and the hospital anxiety and depression scale (hads) by the investigator. the researcher distributed an interview questionnaire among the infertile couples in the centers. during the process of completing the questionnaire, the researcher interviewed illiterate candidates who had difficulty understanding the questionnaires. the interview with each client lasted around 25-30 minutes. the questionnaire was composed of two parts. the first part was on the socio-demographic characteristics of the study sample. this part was composed of 8 questions regarding (age, gender, occupation and education for both genders, and family income per month. duration of marriage, religion, and nationality). the second part was related to assessing infertile couples’ anxiety and depression levels, which were measured through the hospital anxiety and depression scale (hads) which was used as a scale that was modified by the researcher to organize it according to infertility cases. hads is a selfadministered rating scale composed of 14 items: seven for anxiety and seven for depression. items are rated on a 4-point severity scale ranging from 0 to 3. both anxiety and depression can be scored separately, with each subscale scored from 0 to 21. higher scores on each subscale indicate a higher level of anxiety and depression [12]. scores of 0-7 are normal, 8-10 are mild,11-14 are moderate,15-21is severe for both anxiety and depression scales [13].the questionnaires have been validated by a panel of eleven experts to investigate the content of the questionnaire for clarity, relevancy, and adequacy. the experts’ responses were evaluated based on their agreements or disagreements. the results showed that the majority of the experts agreed with the items of the questionnaire for the study. some small childbearing is important for the stability of any couple. some kurdish people still believe that infertility is exclusively limited to female causes. kurdish women often come face to face with questions such as, “are you married? do you have a child? however, if the cause of infertility is diagnosed as due to male factors, marital conflict can increase and couples may become more separated. psychologically, women lose their motherhood and sense of gender distinctiveness when they cannot conceive, and men are not measured “to be a man” if they do not have a child [11]. a cross-sectional descriptive study was carried out in erbil city of kurdistan/iraq. from 1st september 2021 to 1st november 2022. a convenience (non-probability) sample (of 300 infertile husbands and their wives) of either of those diagnosed with infertility and undergoing treatment for infertility at an ivf center was included in the study; they were taken from two private hospitals; (sardam and hawler private hospitals). the investigator used a convenient sampling method for recruiting the patients and included all infertile couples attending ivf centers (primary and secondary infertile couples), those infertile couples who did not have a history of mental disorders, and the duration of infertility of more than one year. while those couples who were not willing to participate in the study and who suffered from chronic illnesses were excluded. a pilot study was carried out on (12) infertile couples. statistical analysis has been done by using reliability-testing methods to measure internal consistency and detect the concordance among the items of the scale using the alpha cronbach. the reliability coefficient was high (r=0.97) for anxiety and (r=0.68) for depression, such items were statistically adequate. data was collected through 171 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article changes have been made to the study instrument according to their recommendation.before data collection, formal approval was obtained from the ethical committee at the college of nursing, hawler medical university. formal permission was also obtained from ivf centers in hawler and sardam private hospitals. furthermore, informed oral consent was obtained from the candidate’s participation in the study after confirmation of confidentiality, and anonymity, and participants were withdrawn from the study's selfdetermination by the researcher. participants have withdrawn from the study. the statistical package for social science (spss, version 28) was used for data processing and statistical analysis. the statistical analysis included descriptive statistical analysis such as frequency and percentage to describe the basic features of the data in a study and provide simple summaries about the sample and the measures. inferential statistical analyses such as the chi-square test and fisher-exact test were applied to make a judgment about inferences from our data to more general conditions. the confidence interval was 95%. the p-value of each test of ˂ 0.05 is considered statistically significant. table 1: shows the socio demographic characteristics of the study sample. this table also shows that 58% of couples were between the age groups of 29-39 years old and ranging from 18 to 50 years old. regarding the occupation of the husbands, 23.7% of husbands were selfemployed whereas wives, (26 %) were housewives. 14% of husbands graduated from university and only 2.3% of them were illiterate. the same trend existed in the wife’s education as most of them 15% graduated from university and 3% were illiterate. the family income of the majority of study samples was ≥1000,000iqd per month [44], the highest proportion of couples (35.7%) were married between 6-10 years. 172 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result table 1: basic characteristics of the infertility couples (n=300) variables categories f (%) gender male 150(50) female 150 (50) age 18 – 28 74 (24.7) 29 – 39 174 (58) ≥40 52 (17.3) occupation (husbands) governmental employed 58 (19.3) nongovernmental employed 10 (3.3) unemployed 6 (2) self-job 71(23.7) student 2 (0.7) no work 3 (1) occupation (wives) governmental employed 34(11.3) nongovernmental employed 12(4) unemployed 12(4) self-job 7(2.3) student 7(2.3) housewife 78(26) educational level (husbands) illiterate 7(2.3) able to read and write 18 (6) primary school 31(10.3) high school 24 (8) institution graduate 16(5.3) university graduate 42(14) post graduate 12(4) total 300(100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 173 depression levels among husbands and wives,48.3% of total infertile couples were normal. while wives had (mild=17.7%, moderate =6.3%, severe=3.7%) depression compared with (mild=18%, moderate=3%, severe=3%) levels of depression of husbands (pvalue 0.200). table 2: illustrates the comparison of anxiety, and depression levels among husbands and wives, 35.3% of the study sample were normal. wives had (mild=13.3%, moderate=16%, severe=7.3%) levels of anxiety compared with (11%,11%, 6%) of their husbands; a significant difference was detected (pvalue 0.016). no significant 0.200).association was detected between copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. cont. table variables categories f (%) educational level (wives) illiterate 9(3) able to read and write 13(4.3) primary school 35(11.7) high school 27 (9) institution graduate 14(4.7) university graduate 45(15) post graduate 7(2.3) the family income per month < 500.000iqd 55(18.3) 500.000 – 749.000iqd 82(27.3) 750.000 – 999.000iqd 28(9.3) ≥1000.000iqd 135(45) years of marriage 1 – 5 100(33.3) 6 – 10 107(35.7) 11 – 15 75(25) ≥16 18(6) religion islam 300(100) nationality kurdish 182(60) arab 118(39.3) total 300(100) f= frequency; %= percentage table 2: comparison of the overall level of anxiety, and depression between husbands and wives hads calcification (score) male female total p-value no. (%) no. (%) no. (%) anxiety normal (0-7) 66 (22) 40 (13.3) 106 (35.3) 0.016 (s) mild (8-10) 33 (11) 40 (13.3) 73 (24.3) moderate (11-14) 33 (11) 48 (16) 81 (27) severe (15-21) 18 (6) 22 (7.3) 40 (13.3) depression normal (0-7) 78 (26) 67 (22.3) 145 (48.3) 0.200 (ns) mild (8-10) 54 (18) 53 (17.7) 107 (35.7) moderate (11-14) 9 (3) 19 (6.3) 28 (9.3) severe (15-21) 9 (3) 11 (3.7) 20 (6.7) total 150 (50) 150 (50) 300 (100) s= significant levels; ns= non-significant levels; by chi-square test. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article association betweenthe educational level of both spouses and anxiety level was detected (pvalue 0.001), those who graduated from university had a higher level of anxiety. a very highly significant association was detected between family income and anxiety (pvalue 0.001). no significant association was found between anxiety and years of marriage (pvalue 0.150). 174 table 3: demonstrates the association between socio-demographic characteristics and level of anxiety. this table showed that no significant association was detected between age (pvalue 0.532) and anxiety. a significant association was detected between working status and anxiety for both couples(p-0.003), and the highest level of anxiety was shown among housewife females. and a very highly significant copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: association between socio-demographic characteristics and level of anxiety anxiety p-value variables categories normal mild moderate severe no. (%) no. (%) no. (%) no. (%) age (years) 18 – 28 31 (10.3) 17 (5.7) 17 (5.7) 9 (3) 0.532 (ns) 29 – 39 53 (17.7) 47 (15.7) 50 (16.7) 24 (8) ≥ 40 22 (7.3) 9 (3) 14 (4.7) 7 (2.3) occupation governmental employed 37 (12.3) 21 (7) 22 (7.3) 12 (4) 0.003 (hs) nongovernmental employed 13 (4.3) 7 (2.3) 2 (0.7) 0 (0) unemployed 4 (1.3) 6 (2) 4 (1.3) 4 (1.3) self-job 29 (9.7) 18 (6) 20 (6.7) 11 (3.7) student 4 (1.3) 4 (1.3) 1 (0.3) 0 (0) housewife 16 (5.3) 17 (5.7) 32 (10.7) 13 (4.3) non-workers 3 (1) 0 (0) 0 (0) 0 (0) educational level illiterate 0 (0) 1 (0.3) 11 (3.7) 4 (1.3) 0.001 (vhs) able to read and write 7 (2.3) 6 (2) 11 (3.7) 7 (2.3) primary school 17 (5.7) 14 (4.7) 25 (8.3) 10 (3.3) high school 22 (7.3) 15 (5) 11 (3.7) 3 (1) institution graduate 13 (4.3) 8 (2.7) 2 (0.7) 7 (2.3) university graduate 36 (12) 24 (8) 19 (6.3) 8 (2.7) post graduate 11 (3.7) 5 (1.7) 2 (0.7) 1 (0.3) the family income per month <500,000iqd 9 (3) 10 (3.3) 26 (8.7) 10 (3.3) 0.001 (vhs) 500,000 – 749,000iqd 28 (9.3) 24 (8) 17 (5.7) 13 (4.3) 750,000 – 999,000iqd 7 (2.3) 6 (2) 11 (3.7) 4 (1.3) ≥1000,000 iqd 62 (20.7) 33 (11) 27 (9) 13 (4.3) years of marriage 1-5 37 (12.3) 28 (9.3) 24 (8) 11 (3.7) 0.150 (ns) 6-10 45 (15) 26 (8.7) 25 (8.3) 11 (3.7) 11-15 19 (6.3) 14 (4.7) 28 (9.3) 14 (4.7) ≥16 5 (1.7) 5 (1.7) 4 (1.3) 4 (1.3) ns= non significant; hs= highly significant; vhs= very highly significant. by chi-square test and fisher’s exact test. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article the majority of infertile couples' family income per month was 1000,000 iqd or more and they had (mild =14.7%, moderate = 3.7%, severe =1.3%) levels of depression and levels of depression (mild =8.3%, moderate = 3%, severe =2%) when family income 500,000iqd or less with a lower study sample (pvalue 0.015). a significant association was found between depression and the duration of the marriage. the proportion was (mild depression =11.3%, moderate depression = 2.7%, and severe depression =3%) when the duration of marriage was between 11-15 years (pvalue 0.042). table 4: indicates the relationship between the socio demographic characteristics of infertile couples and their level of depression. the result shows that a significant association was detected between depression and the age group 29-39 (p value 0.004). the level of depression of both spouses with the jobs was significantly associated (pvalue 0.028). a very highly significant association between depression and the educational level of both couples was detected (pvalue 0.001), and levels of depression were higher among primary school and university graduates. the result showed that (mild = 10%, moderate =2.3 %, severe =1.3%) and (mild=12%, moderate=1.3%, severe=0.3%). 175 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: association between socio-demographic characteristics and level of depression depression p-value variables categories normal mild moderate severe no. (%) no. (%) no. (%) no. (%) age 18 – 28 47 (15.7) 17 (5.7) 9 (3) 1 (0.3) 0.004 (hs) ⸸ 29 – 39 75 (25) 70 (23.3) 17 (5.7) 12 (4) ≥ 40 23 (7.7) 20 (6.7) 2 (0.7) 7 (2.3) occupation governmental employed 44 (14.7) 37 (12.3) 7 (2.3) 4 (1.3) 0.028 (s) ⸸ nongovernmental employed 18 (6) 4 (1.3) 0 (0) 0 (0) unemployed 7 (2.3) 7 (2.3) 3 (1) 1 (0.3) self-job 36 (12) 31 (10.3) 4 (1.3) 7 (2.3) student 5 (1.7) 3 (1) 1 (0.3) 0 (0) housewife 32 (10.7) 25 (8.3) 13 (4.3) 8 (2.7) non-workers 3 (1) 0 (0) 0 (0) 0 (0) educational level illiterate 0 (0) 5 (1.7) 5 (1.7) 6 (2) 0.001 (vhs) ⸸ able to read and write 12 (4) 9 (3) 4 (1.3) 6 (2) primary school 25 (8.3) 30 (10) 7 (2.3) 4 (1.3) high school 33 (11) 11 (3.7) 6 (2) 1 (0.3) institution graduate 14 (4.7) 12 (4) 2 (0.7) 2 (0.7) university graduate 46 (15.3) 36 (12) 4 (1.3) 1 (0.3) post graduate 15 (5) 4 (1.3) 0 (0) 0 (0) the family income per month < 500,000 15 (5) 25 (8.3) 9 (3) 6 (2) 0.015 (s) ⸸ 500,000 – 749,000 43 (14.3) 25 (8.3) 7 (2.3) 7 (2.3) 750,000 – 999,000 11 (3.7) 13 (4.3) 1 (0.3) 3 (1) ≥1000,000 76 (25.3) 44 (14.7) 11 (3.7) 4 (1.3) years of marriage 1-5 54 (18) 33 (11) 10 (3.3) 3 (1) 0.042 (s) ⸸ 6-10 61 (20.3) 32 (10.7) 8 (2.7) 6 (2) 11-15 24 (8) 34 (11.3) 8 (2.7) 9 (3) ≥16 6 (2) 8 (2.7) 2 (0.7) 2 (0.7) s= significant level; hs= highly significant. ⸸ by chi-square test.⸸ by fisher exact test. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article depression was significantly higher among females as compared to males in contrast with our result [38]. another study conducted on infertile italian couples refused our result because the level of anxiety and depression among women was significantly higher than in men (pvalue ˂ 0.0001) [40]. faramarzi et al. showed that women reported statistically significantly higher levels of anxiety and depression when compared with men, in contrast to the present study [43]. socio-demographic characteristics of both couples and their association with anxiety and depression levels age and gender the result of this study revealed that the highest percentage (58%) of the present study samples were between the ages of 29-39 years old, and the lower proportion of the study was between the ages of 40 and more (17.3%). a similar study in bangladesh on the psychological state of infertile couples revealed that (75.9%) of the study samples were between the ages of 29-38 years old and only (3.9%) of couples aged ≤ 39 years old [15]. it means that people in the age group 2939, who are of reproductive age had a higher desire and ability to be pregnant and to have a child, especially women. regarding gender, 150 husbands and their wives participated in our study at the same time to assess and compare the rates of anxiety and depression among couples regarding the association of study samples' age with anxiety and depression levels (table 3), the current study illustrated no significant association between anxiety and age. a similar study was conducted in iran and found no significant association between anxiety and age [16]. our result refused by this study conducted on infertile women in china demonstrated that the psychopathological symptoms of the infertile women were aggravated by advanced age [17].regarding the relationship between age and depression levels, compression level of anxiety and depression in husbands and wivesthe present study found that husbands and their wives had higher anxiety levels; the levels were significantly higher among infertile women compared with men. anxiety among infertile women: the percentage of those with mild, moderate, and severe anxiety was (13.3%, 16%,7.3%) compared to their husbands, and the percentage of those with mild, moderate, and severe anxiety was (11%, 11%, 6%). regarding the depression levels among couples, our result shows that depression was higher among women than men but not statistically significant. among infertile women, the percentages of those with mild, moderate, and severe depression were (17.7%,6.3%, and 3.7%) compared with (18%= mild,3% =moderate,3%= severe) levels of depression among men. this study was conducted in china on infertile couples under ivf treatment. regarding anxiety in women it was demonstrated that women significantly had a higher level of anxiety compared to men (p-value ˂ 0.05), and also about the level of depression, women had more depression than men but it was not statistically significant;it was similar to our study results [39]. another supportive study shows that the prevalence rates of anxiety and depression were (49.6%) and (33%), respectively, and women were 2.26 times more likely to have anxiety symptoms than men, but it disagreed with our results regarding depression because it revealed that depression was not related to sex [16]. also, another study conducted in india supports our finding regarding anxiety and found that among 270 consecutive couples’, the prevalence of anxiety was observed in 49.6% of females and 45.6% of males. the difference was statisticallysignificant. also, the prevalence of 176 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article occupation among study samples. high levels of anxiety and depression were detected among the housewives’ group. an individual's working status affects both their social and economic lives women with economic power have much more selfconfidence and a sense of control over their lives. however, this study in turkey carried out on infertile couples discovered that depression ratios in infertile housewives were higher.it was similar to our result, but anxiety did not have relationship with working status. it was demonstrated that. there were no statistically significant differences between occupation and anxiety and depression levels among infertile men, this disagreed with our study results [24]. however, this study in turkey on infertile this women also shows that the majority of the participants were unemployed, and found a positive relationship between the employment status of participants receiving infertility treatment with anxiety and depression. participants who did not have wage-earning employment had higher anxiety and depression than those who had jobs. it was similar to our results [25]. educational level the highest percentage of the study participants in this current study graduated from university and only a few of them were illiterate. a descriptiveanalytical study conducted in iran revealed that the majority of the participants had a high level of education (university) (63.92%) which was similar to our result [26]. although this study carried out in vietnam had the same results as the highest study sample graduated from university [27].regarding the association between the educational level of couples and the level of anxiety and depression (table 3,4), a higher percentage of the study sample graduated from university, so the level of anxiety and depression was higher among those groups. maybe it is related to the our result in (table 4) demonstrated a highly significant association between depression and age, the age group 29-39 years had a higher level of depression because they were closer to menopause in this age group or they also may have been receiving treatment for infertility for a long time, especially in cases of long-term marriage. this supported study in japan shows a significant association between depression and age; higher depression was detected among patients in their twenties and those in the 35-39, 40, and over age groups. as age increased, participants exhibited a greater tendency toward depression [18]. another study in nigeria reported that the age of the respondents is associated with increased psychological distress [19]. equally, drosdzol et al reported that there is an increased risk of psychiatric disorders (anxiety and depression) in infertile women older than 30 years [20]. on the contrary, gameiro et al reported that older age was a protective factor against developing mental health problems in individuals undergoing fertility treatment [21]. occupation regarding the occupation of the husband, the majority (23.7%) of husbands were self-employed and only 1% were non-workers. whereas the wives (26%) were housewives, and, only 2.3% had self-employed. similar results were shown in a study conducted in turkey on infertile couples, in which the researcher revealed that all of the men worked. meanwhile, the highest percent of the wives were housewives [22]. in contrast, another cross-sectional study conducted on infertile turkish couples showed that a higher percentage of husbands and wives were self-employed [23].regarding the relationship between occupation with anxiety and depression levels (table 3,4). the finding in this study indicated that anxiety was significantly associated with 177 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article participants had a high level of income [35]. another supportive study found that infertile females and males’ monthly income was significantly associated with a psychiatric disorder [37]. the result of this study in egypt opposed to our result reveals that there is a highly significant correlation was found between family income and depression, but depression was more observed in low family incomes compared with high ones [45]. duration of marriage, n this study, we demonstrated that the highest percentage of couples (35.7%) were married between (6-10) years. it is similar to a cross-sectional study done by singh et al in india, (43.3%) of the couples were married between (6-10) years [38]. in contrast to our study, in this study in nigeria, the highest percentage of couples’ marriages is equal to or less than 5 years [19].regarding the relationship between anxiety and depression with the duration of marriage (table 3,4), in the present study, a significant association was not found between anxiety and the duration of married couples, but according to the relationship between depression and the duration of marriage, we found a significant association. the finding was different from the result of this study conducted by chen et al. established that there was no significant association between anxiety, depression, and duration of marriage [14]. another study also shows that there was no statistically significant correlation between marriage span, and depression as well between marriage span and anxiety [36]. religion and nationality a recent study found that all candidates who participated in the study were muslims. regarding nationality, the highest proportion of them were kurdish people because the study was carried out in a city in the kurdistan region of iraq. only (39.3%) of the cases were arabic people. fact that they had graduated from university but had not been employed or had job opportunities, in public institutions or the private sector. our result was rejected by this study in iran. the results demonstrated that the level of educational background had an input on the psychological strains of patients. in general, illiterate couples compared with educated couples, were shown to have the highest rates of both depression and anxiety. also, severe depression and anxiety were observed in 27% and 22% of illiterate women, respectively. these levels were reduced to 4.5% and 0% in women with university educations, respectively [28]. although numerous studies have shown that education levels have a protective impact on depression and anxiety, they revealed that the level of anxiety and depression tends to decrease when the level of education increases [29,30,31,32]. the family income per month in the present study, the highest percentage of infertile couples (45%) had one million iqd or more per month, which means that they had high economic status. the results were similar to the study in iran, (48.3%) of the couples had a high level of income (20.000.000irrs or more) [34]. in this study in turkey, the finding in disagreement with the present study was that (33.3%) of the study samples had lower categories (equal to or less than 1000tl) [33]. regarding family income per month (table 3,4), the current study demonstrated that there was a highly significant association between family income and anxiety level and a significant association between family income and depression. the highest percentage 45% of the study sample had a higher level of income. findings of this study in pakistan reported by razzaque et al. similar to the present study stated that monthly income was associated with anxiety and depression and most of the 178 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 2021; 15:161. [8] demartini j, patel g, fancher tl. generalized anxiety disorder. annals of internal medicine. 2019;2;170(7): itc49-64. [9] zaidouni a, fatima o, amal b, siham a, houyam h, jalal k, “et al”. predictors of infertility stress among couples diagnosed in a public center for assisted reproductive technology. journal of human reproductive sciences. 2018 ;11(4):376 [10] gdańska p, drozdowicz-jastrzębska e, grzechocińska b, radziwon-zaleska m, węgrzyn p, wielgoś m. anxiety and depression in women undergoing infertility treatment. ginekologia polska. 2017;88(2):10912. [11] mahadeen a, mansour a, al halabi j, al habashneh s, bani kenana a. psychosocial wellbeing of infertile couples in jordan. emhjeastern mediterranean health journal. 2018;24(02):169-76. [12] zigmond, a.s. and snaith, r.p. the hospital and anxiety scale. acta psychiatric scandinavica.1983;67(6):361-370. [13] stern af. the hospital anxiety and depression scale. occupational medicine. 2014 ;1;64(5):393-4. [14] chen th, chang sp, tsai cf, juang kd. prevalence of depressive and anxiety disorders in an assisted reproductive technique clinic. human reproduction. 2004; 1;19(10):2313-8. [15] irfan sn, rahman mm, mithun s, arafat sy, zafreen f. psychological state of selected infertile couples of bangladesh. journal of armed forces medical college, bangladesh. 2018;14(1):41-5. [16] maroufizadeh s, ghaheri a, almasi-hashiani a, mohammadi m, navid b, ezabadi z,” et al”. the prevalence of anxiety and depression among people with infertility referring to royan institute in tehran, iran: a crosssectional questionnaire study. middle east fertility society journal. 2018; 1;23(2):103-6. [17] wang k, li j, zhang jx, zhang l, yu j, jiang p. psychological characteristics and marital quality of infertile women registered for in vitro fertilization-intracytoplasmic sperm injection in china. fertility and. fertility and sterility.2007;87(4), pp.792-798. [18] ogawa m, takamatsu k, horiguchi f. evaluation of factors associated with the anxiety and depression of female infertility patients. biopsychosocial medicine. 2011 ;5(1):1-5. [19] omoaregba jo, james bo, lawani ao, morakinyo o. psychosocial characteristics of the study found that infertile couples receiving ivf therapy had greater rates of anxiety and depression, which could increase the treatment burden for couples seeking assisted conception. according to the study, couples' psychosocial intervention should be a key component of standard infertility treatments and play a significant part in them. there are no conflicts of interest or sources of financial support for any of the authors. [1] mascarenhas mn, flaxman sr, boerma t, vanderpoel s, stevens ga. national, regional, and global trends in infertility prevalence since 1990: a systematic analysis of 277 health surveys. plos medicine. 2012;18;9 (12): e1001356. [2] elhussein og, ahmed ma, suliman so, adam i. epidemiology of infertility and characteristics of infertile couples requesting assisted reproduction in a low-resource setting in africa, sudan. fertility research and practice. 2019 ;5(1):1-5. [3] cui c, wang l, wang x. effects of selfesteem on the associations between infertility-related stress and psychological distress among infertile chinese women: a crosssectional study. psychology research and behavior management. 2021; 14:1245. [4] luk bh, loke ay. the impact of infertility on the psychological well-being, marital relationships, sexual relationships, and quality of life of couples: a systematic review. journal of sex & marital therapy. 2015; 2;41 (6):610-25. [5] rooney kl, domar ad. the relationship between stress and infertility. dialogues in clinical neuroscience. 2022; 1. [6] çavdar nk, coskun am. the effect of infertility upon quality of life and self-esteem. medcrave online journal of women's health. 2018;7(3):89-94. [7] forgie m. exploring women's experiences of infertility, reproductive loss, and grief (doctoral dissertation, université d'ottawa/university of ottawa). 179 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article [30] benbella a, ktiri f, kasouati j, aboulmakarim s, hardizi h, zaidouni a. depression and anxiety among infertile moroccan women: a cross-sectional study in the reproductive health center in rabat. journal of depression and anxiety. 2018;7(312):2167-1044. [31] verma p, rastogi r, sachdeva s, gandhi r, kapoor r, sachdeva s. psychiatric morbidity in infertility patients in a tertiary care setup. journal of clinical and diagnostic research: jcdr. 2015;9(9):vc01. [32] maroufizadeh s, karimi e, vesali s, samani ro. anxiety and depression after failure of assisted reproductive treatment among patients experiencing infertility. international journal of gynecology & obstetrics. 2015;1;130(3):253-6. [33] güleç g, hassa h, yalçin eg, yenilmez c. the effects of infertility on sexual functions and dyadic adjustment in couples that present for infertility treatment. turk psikiyatri dergisi. 2011; 1;22(3):166. [34] bakhtiar k, ardalan a, ebrahimzadeh f, almasian m, bastami f. depression severity and sexual satisfaction in fertile and infertile women in iran: a population-based case -control study. jundishapur journal of health sciences. 2022; 31;14(1). [35] razzaque ma, ali a, ahmed w, hussain s, wahid a, razzaque a. assessment of the level of depression, anxiety, stress among infertile women (20-45 years age) in tertiary care hospital. journal of liaquat university of medical & health sciences. 2021;20(5):358-62. [36] yassa m, arslan e, gulbahar ds. effects of infertility treatment on anxiety and depression levels. cukurova medical journal. 2019;44(2):410-5. [37] alosaimi fd, altuwirqi mh, bukhari m, abotalib z, binsaleh s. psychiatric disorders among infertile men and women attending three infertility clinics in riyadh, saudi arabia. annals of saudi medicine. 2015;35 (5):359-67. [38] singh v, bhirud yr, lele p, bhagasra s. a study to screen infertile couples for psychological problems by using the perceived stress scale, brief cope scale and hospital anxiety and depression scale. international journal of research in medical sciences. 2021 ;9(3):750. [39] liu yf, fu z, chen sw, he xp, fan ly. the analysis of anxiety and depression in different stages of in vitro fertilization-embryo female infertility in a tertiary health institution in nigeria. annals of african medicine. 2011;10(1). [20] drosdzol a, skrzypulec v. depression and anxiety among polish infertile couples–an evaluative prevalence study. journal of psychosomatic obstetrics & gynecology. 2009; 1;30(1):11-20. [21] gameiro, s., van den belt-dusebout, a.w., bleiker, e., braat, d., van leeuwen, f.e. and verhaak, c.m. do children make you happier? sustained child-wish and mental health in women 11–17 years after fertility treatment. human reproduction. 2014; 29(10), pp.2238-2246. [22] yilmaz t, oskay uy. the evaluation of methods used to cope with infertility stress of infertile couples in turkey. international journal of caring sciences. 2017 sep 1;10(3). [23] erdem k, apay se. a sectional study: the relationship between perceived social support and depression in turkish infertile women. international journal of fertility & sterility. 2014 ;8(3):303. [24] kazandi m, gunday o, mermer tk, erturk n, ozkınay e. the status of depression and anxiety in infertile turkish couples. iranian journal of reproductive medicine. 2011;9(2):99. [25] kamışlı s, terzioğlu c, bozdağ g. the psychological health of women with infertility: hopelessness, anxiety and depression levels. journal of psychiatric nursing. 2021;12(1):43 -9. [26] karimzadeh m, salsabili n, asbagh fa, teymouri r, pourmand g, naeini ts. psychological disorders among iranian infertile couples undergoing assisted reproductive technology (art). iranian journal of public health. 2017;46(3):333. [27] ho tt, le mt, truong qv, nguyen vq, cao nt. psychological burden in couples with infertility and its association with sexual dysfunction. sexuality and disability. 2020 ;38(1):123-33. [28] yasini m, khalili ma, hashemian z. the level of anxiety and depression among iranian infertile couples undergoing in vitro fertilization or intra cytoplasmic sperm injection cycles. journal of research in medical sciences .2005;10(6):358-62 [29] pinar g, zeyneloglu hb. quality of life, anxiety and depression in turkish women prior to receiving assisted reproductive techniques. international journal of fertility & sterility. 2012 ;6(1):1. 180 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.18 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article transfer in couples in china. neuropsychiatric disease and treatment. 2021; 17:649. [40] chiaffarino f, baldini mp, scarduelli c, bommarito f, ambrosio s, d’orsi c, “et al”. prevalence and incidence of depressive and anxious symptoms in couples undergoing assisted reproductive treatment in an italian infertility department. european journal of obstetrics & gynecology and reproductive biology. 2011;1;158(2):235-41. [41] friedrich mj. depression is the leading cause of disability around the world. journal of american medical association. 2017; 18;317(15):1517-. [42] vaioleti t. talanoa: differentiating the talanoa research methodology from phenomenology, narrative, kaupapa maori and feminist methodologies. reo, te. 2013 ; 56:191212. [43] faramarzi m, pasha h, esmaelzadeh s, jorsarai g, mir mra, abedi s. is coping strategies predictor of anxiety and depression in couple infertile? health;2013; 5(3): pp. 643– 9. [44] krso, iom, unfpa. the demographic survey of the kurdistan region of iraq .2018. available from: https://krso.gov.krd/en/ pressreleases/demographic-survey-of-thekurdistan-region-of-iraq-press-release. [45] hassan he, hassan se, mohammed a, baraka ma. a survey of relationship between duration of infertility and depression among infertile women in benisuef governorate. ijsr. 2013;4:1169-77. 181 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.10 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article home health care services delivered by nurses to the relatives with covid-19 abstract introduction the world health organization (who) designated covid-19 a global pandemic on march 11, 2020 [1]. the fast spread of this virus, along with the limited number of viable therapies now available, has resulted in a global catastrophe, with overburdened healthcare systems scrambling to respond to the emergency. this has been particularly case for the kurdistan region, iraq, with the presence of limited medical recourses and highly recorded cases. at the time of writing, at least background and objective: kurdish community have a long-standing history of looking after family members and loved one in times of sickness. caring for covid-19 patients at home is a huge responsibility and challenging. despite fear of losing family members, relatives working in the health care system dedicated their time to care for their relatives affected by covid-19. no studies have been done to investigate the care provided to the covid-19 patients at home-setting by nurses. the purpose of this study is to investigate the health care services provided to covid-19 patients at home-setting by nurses. methods: this study is a descriptive quantitative study with a sample size of seventyfour nurses. the nurses claimed that they looked after more than 180 patients at the home setting. the data was collected through an online questionnaire format prepared by the researcher after an extensive literature review and discussion with the nurses who provided home care to covid-19 patients. the researcher also utilized the guidelines and data published on the world health organization (who), national institutes of health (nih) and centers for disease control (cdc) websites for constructing the tool. data was collected through google forms from 1st january 2022 to 29th march 2022. results: of the seventy-four nurses that completed the questionnaire, half held a bachelor’s degree in nursing. the nurses reported caring for more than 180 patients in total with 37.8% of nurses caring for one patient. more than half (52.7%) of patients were aged 50-64 years. the results of the study showed that the home care included health assessment, nursing intervention, evaluation, reassessment, and practicing preventive measures. conclusion: depending on the data received from the nurses, covid-19 patients in home setting received holistic nursing care and patients were under close and constant monitoring. keywords: covid-19; pandemic; home health care; nursing care. newroz ghazi aziz; department of nursing, college of nursing, hawler medical university and tishk international university, erbil, iraq. (correspondence: newroz.aziz@hmu.edu.krd) 86 received: 12/05/2022 accepted: 20/08/2022 published: 30/11/2022 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:newroz.aziz@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.10 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article 437,643 cases were confirmed, and 7,450 people have died since the pandemic has started [2]. on 22 february 2020, the first case of covid-19 infection was confirmed in iraq/najaf city. the following month, the number of confirmed covid-19 patients exceeded the hundred [3, 4].the data provided by the kurdistan regional government reported high number of recoveries with 205, 290 cases discharged from the hospitals [2]. however, the provided data does not include patients treated at home since there is no available record. homebased care is an important alternative to facility-based care, especially for infection prevention during the covid-19 pandemic [5]. who recommended that “patients with mild symptoms and without underlying chronic conditions such as lung or heart disease, renal failure, or immune compromising conditions that place him/her at increased risk of developing complications may be cared for in the home environment” in case of limited health care service capacity and resources [6].at some points in the kurdistan region, patients preferred to be treated at home, where they felt most secure and stress-free [3]. kurdish community have a long-standing history of looking after family members and loved one in time of sickness. although, looking after the covid-19 patient at home is a huge responsibility and challenging fear of losing family members, relatives working in the health care system dedicated their time to look after relatives affected by covid-19. no studies have been done to investigate the care provided to covid-19 patients in home-settings. therefore, the purpose of this study was to investigate the health care services provided to the covid -19 patients at home-setting by nurses. a quantitative descriptive design was used to collect data from nurses who provided home health care services for covid-19 patients. the study was conducted in the kurdistan region/iraq. inclusion criteria: one of the main inclusion criteria for the recruitment was the care recipient must be participants’ next of kin, not admitted to the hospital and the care recipient must be still alive. tool and method of data collection:the data was collected through a questionnaire format prepared by the researcher after an extensive literature review and discussion with the nurses who provided extensive nursing care to covid-19 patients. the researcher also utilized the guidelines and data published on the who [6], nih [1] and the cdc websites [7] for constructing the tool of data collection. to ensure the validity of the questionnaire, it was sent to three nurses who dedicated their time to look after covid-19 patients at homesettings and their comments were put into consideration. parts of questionnaire: the questionnaire included four parts. part one included general information from the participants, part two included questions on the health history of the patients who received the care, part three included a list of nursing care that was delivered by the nurses to the covid-19 patient at-home settings, and part four included questions on personal protection measures. the list was based on the coronavirus disease 2019 (covid-19) treatment guidelines developed by the nih for hospitalized and nonhospitalized adult patients with covid-19 [1]. the personal protection measures questions were based on the guideline developed by the who for taking care of covid-19 patients at home [6]. 87 methods copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.10 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article patients received care was 4 to 6 hours per 24 hours. about 46 % of the nurses reported it took 10 to 20 days for covid-19 symptoms to subside among the patients who received care. table 2 provides information about the health history of covid19 care recipients. hypertension was recorded among 31.1 % of the patients followed by diabetes mellitus (29.7%) and cardiovascular disease (25.7%). the highest percentage of participants (37.8%) recorded oxygen saturation levels (spo2) between 86% and 95%. the highest body temperature recorded was between 38 and 38.5°c with a percentage of 35.1%. the most concerning sign and symptoms exhibited by patients for more than one week were fatigue (77%), fevers (74.3 %,), body aches (66.2%,), and dry cough 6 (4.9%). the most common psychological problems noticed by the participants during care were insomnia (48.6%) and anxiety (47.3%). table 3 shows the frequency and percentage of nursing care providers for the covid-19 patient in a home setting. as it is shown in the table, the most frequent nursing care provided by the study participants were checking vital signs and spo2 levels (91.9 %), medication administration (71.6%), and checking laboratory test (68.9%). activities performed less were hot shower/bath and steam for loosening up phlegm and mucus in the chest (24.3%) and helping with the activity of daily (27 %). table 4 shows the extent the study participants followed who guidelines recommended for preventing covid19 spread at-home settings. overall, the percentage of practicing the guideline is high. hand hygiene, handling waste products properly, and wearing disposable masks were the most frequent items in the guideline practiced by the nurses during the care with the percentages of 71.6 %, 67.6 %, and 64.9% respectively. data collection and data analysis: depending on the personal contact and with the help of snowballing technique the questionnaire was purposively sent out to more than 120 nurses on the first of january 2022 via a google form. till 29th of march 2022 a total of 81 surveys were returned (response rate 67.5%). of these 7 surveys had substantial amounts of missing information and were eliminated from further analyses. final analyses were performed on 74 surveys, which had responses to nearly all survey questions. the frequency and percentage of the data were received via a google form. the overall of the fourth part of the study result was obtained by dividing the sum of the frequencies to the number of the protection measure’s statement. ethical considerations: ethical approval was obtained from the scientific committee of the college of nursing, hawler medical university with code no. 5 on 16th dec. 2021. participation was voluntary. the participants were informed about the purpose, benefits, and risks of the study, and they were allowed to withdraw the form from the study at any point felt insecure or uncomfortable. table 1 demonstrates general information collected from the participants. exactly half of the participants were held a bachelor’s degree in nursing. the nurses reported caring for more than 180 patients in total with 37.8% of nurses caring for one patient. more than half (52.7%) of patients were aged 50-64 years. supervised physicians were the main support of the nurses (35.1%) concerning decision-making during the care. exactly half of the nurses reported that their presence was the main reason behind patient’s refusal of hospitalization as they preferred to be looked after the nurses. about 37.8% of nurses report the highest number of hours covid-19 88 results copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.10 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article 89 table 1: general information collected from the participants. variables (n= 74) f. (%) level of education phd 11 (14.9) m.sc. 26 (35.1) b.sc. 37 (50) number of the patient looked after by the study participants from the beginning of the pandemic one 28 (37.8) two 11 (14.9) three 10 (13.5) four 8 (10.8) >four 17 (23) patients’ age 18-29 5 (6.8) 30-39 14 (18.9) 40-49 16 (21.6) 50-64 39 (52.7) the main support of study participants in decision making regarding patients’ health. decision made independently 18 (24.3) a supervised physician 26 (35.1) a health worker who had experience with looking after covid-19 patient 13 (17.6) with the help of a supervised physician and experienced health care worker 17 (23) the reasons the patients were not admitted to the hospital. the patient preferred to be looked after by the study participants. 37 (50) patient refused to go to hospital/ un explained reason 23 (31.1) the doctor recommended to stay at home 22 (31.1) unavailability of bed at hospital / governmental hospital 3 (4.1) financial constrain. not being able to go to private hospital 5 (6.8) unavailability of corona unit at hospital (private and governmental), where the patient lived. 2 (2.7) the approximately hours/24 hrs. the patients were looked after by the study participants. 1-3 hr. 16 (21.6) 4-6 hrs. 28 (37.8) 7-9 hrs. 24 (32.4) >9 6 (8.1) after how many days the patients got well (symptom subside) approximately <10 days 18 (24.3) 10-20 days 34 (45.9) 21-29 days 12 (16.2) >1 month 10 (13.5) copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.10 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article 90 table 2: health history of the patients variables f. (%) medical history hypertension 23 (31.1) diabetes mellitus 22 (29.7) cardiovascular disease 19 (25.7) kidney diseases 9 (12.2) asthma 5 (6.8) no medical history 20 (27) spo2 level 75-65 8 (10.8) 85-76 10 (13.5) 95-86 28 (37.8) 95< 22 (29.7) not checked 6 (8.1) temperature (°c) 35.5-38 26 (35.1) 39-38.6 20 (27) 40-39.1 11 (14.9) 40< 4 (5.4) not checked 13 (17.6) the most concerned sign and symptoms that stayed in the patient more than one week fever 55 (74.3) body ache 49 (66.2) dry cough 48 (64.9) headache 38 (51.4) low level of spo2 35 (47.3) chills 34 (45.9) loss of taste 28 (37.8) shortness of breath 27 (36.5) chest pain 26 (35.1) productive cough 23 (31.1) loss of smell 20 (27) loss of voice 13 (17.6) hyperglycemia 10 (13.5) unstable heart rate 9 (12.2) hypotension 6 (8.1) nausea and vomiting 5 (6.8) fatigue 57 (77) common psychological distress noticed on the patient during the care. insomnia 36 (48.6) anxiety 35 (47.3) stress 33 (44.6) loss of hope 21 (28) sense of helplessness 8 (10.8) incompliant with the care 8 (10.8) copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.10 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article 91 table 3: nursing interventions provided to the covid-19 patients by the study participants. variables yes f. (%) no f. (%) checking vital signs and spo2 level regularly. 68 (91.9) 6 (8.1) administering medication as ordered. 53 (71.6) 21 (28.4) checking laboratory test for signs of infection. 51 (68.9) 23 (31.1) teaching deep breathing technique 45 (60.8) 29 (39.2) teaching and performing coughing technique for patients with chest infection 45 (60.8) 29 (39.2) providing food that improve optimal health. 38 (51.4) 36 (48.6) stress reduction technique (listening to quran, music, watching mobile or tv, chatting with the patient.....etc.) 31 (41.9) 43 (58.1) help the patient to stay hydrated. 30 (40.5) 44 (59.5) percussion for lung clearance, removing phlegm and mucus. 26 (35.1) 48 (64.9) oxygen administration when needed 26 (35.1) 48 (64.9) postural drainage: repositioning and avoiding supine position 23 (31.1) 51 (68.9) helping with activity of daily living [ bathing, toileting, dressing, eating….etc.] 20 (27) 54 (73) hot shower/bath and steam for loosen up phlegm and mucus in the chest. 18 (24.3) 56 (75.7) copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.10 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article 92 table 4:the extend the study participants practiced who guideline recommended to prevent covid-19 spread at home settings home prevention measures always f. (%) sometimes f. (%) never f. (%) the patient was placed in a well-ventilated single room. 46 (62.2) 20 (27.0) 8 (10.8) only one person took care of the patient (had direct contact). 33 (44.6) 36 (48.6) 5 (6.8) no visitors allowed 35 (47.3) 32 (43.2) 7 (9.5) household members maintain at least 1m distance from the patient 30 (40.5) 31 (41.9) 13 (17.6) the patient’s movement limited. 21 (28.4) 39 (52.7) 9 (12.2) the caregiver wore disposable mask when in the same room with patient. 48 (64.9) 19 (25.7) 7 (9.5) the mask discarded properly and performed hand hygiene 41 (55.4) 22 (29.7) 11 (14.9) hand hygiene was performed after any contact with the patient 53 (71.6) 19 (25.7) 2 (2.7) disposable paper towel was used to dry the hands 40 (54.1) 26 (35.1) 8 (10.8) respiratory hygiene was practiced by all (respiratory hygiene refers to covering the mouth and nose during coughing or sneezing using medical masks, cloth masks, tissues or flexed elbow, followed by hand hygiene) 45 (60.8) 24 (32.4) 5 (6.8) used materials discarded properly 45 (60.8) 21 (28.4) 8 (10.8) direct contact with patient’s body fluid was avoided 35 (47.3) 32 (43.2) 7 (9.5) no items were shared with the patient (eating utensil, towels, clothes…..etc.) 47 (63.5) 19 (25.7) 8 (10.8) the patients’ room environment and touched surface cleaned and disinfected daily. 34 (45.9) 35 (47.3) 5 (6.8) bathroom cleaned and disinfected daily. 36 (48.6) 32 (43.2) 6 (8.1) all the waste product generated by the patient or in the care of the patient placed in a special container before disposal. 50 (67.6) 22 (29.7) 4 (5.4) bed lines, clothes, towel…etc. of the patient washed regularly and separately and dried thoroughly. direct contact with these materials were avoided. 34 (45.9) 35 (47.3) 5 (6.8) ppe was used and discarded properly 25 (33.8) 36 (48.6) 13 (17.6) the patient stayed at home until all the symptoms subsided or after two negative rt-pcr, 24 hr. apart 41 (55.4) 26 (35.1) 7 (9.5) all household members considered contacts with the covid-19 and their health were monitored regularly. 38 (51.4) 29 (39.2) 7 (9.5) copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.10 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article discussion will die due to neglection and not providing close and constant follow-up [2]. the covid-19 dynamic infographic dashboard for iraq revealed that most of the deaths in the hospitals occurred during a period of less than 7 days. this indicates that most cases ending with death started treatment at home and were admitted to hospitals only after worsening the situation to an extent that little can be done by the hospitals [8]. as a result, patients preferred to be looked after by a trusted family member working in the health sector. comparing the data collected in the study with the research done on covid-19 in 2020 to 2022, the nurses agreed to participate in a highly risky and challenging task. first, more than half of the patients received care aged 50 to 64. in iraq, patients aged 60–69 years contributed to the highest proportion of total covid-19 deaths followed by those aged 50–59 years [3]. in 2022, the cdc reported that older adults are at higher risk of health deterioration from covid-19. covid death by age group 50-64 reached 17.8% on march 13, 2022 in the usa. the death rate was four times lower among the age group 40-49 (4.1 %) and is even lower among the younger generation reported [1,7,9,10]. second, 54 nurses in the current study reported that patients who received the care had comorbidities including hypertension, cardiovascular diseases (cvd), and diabetes mellitus (dm). the presence of an underlying medical condition increases the death risk ratio among covid-19 patients, to the point if the patient had only one medical condition the death risk ratio (rr) increases by 1.5 [11]. most studies done on the prognosis rate among covid-19 patients concluded that the risk of mortality increases in the presence of comorbidities especially hypertension, cvd, and dm [12,13,14,15]. third, spo2 of less than 94% indicates the presence of lung inflammation and the figure 1 illustrates the overall distribution of how closely the study participants followed who guidelines recommended to prevent covid-19 spread in at-home settings. thirty-nine participants of seventy-four always practiced steps in the guideline, 28 reported sometimes, and 7 reported they never practiced the guideline. the study aimed to identify home health care services delivered by nurses for relatives with covid-19. half of the participants held a bachelor degree in nursing and participants reported caring for a sum of more than 180 patients. patients voluntarily decided to be cared for at home despite their advanced age, presence of chronic conditions, and presence of severe covid-19 symptoms. the directorate of health in erbil city claimed that patients with covid-19 and their relatives seek health when they reach a stage where patients’ survival rate is significantly low. this attitude gave a message to the public that most patients admitted to hospital 93 figure 1: the extent the study participants practiced who guideline recommended to prevent covid-19 spread at home-settings copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.10 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article survival rate [23]. isolation and supportive management play a crucial role for decreasing mortality rate [24]. nurses have a long-standing history of providing supportive measures but in times of health crisis missed nursing care is predicted due to inadequate staffing levels. inadequate patient surveillance has been highlighted in much research conducted during the covid-19 pandemic [25]. in the current study, isolating patients with mild to severe covid symptoms in a home setting considering all the guidelines released by who, cdc, and local government increased the chance of close monitoring by health professionals. importance of the study and recommendations: the strength of the study comes from the fact that the nurses successfully looked after covid-19 patients and proved that holistic care increase the survival rate. furthermore, the outcome of the study could be used as a guide for health care professionals taking care of patients with covid-19 and diseases with similar characteristics at home-setting and as a starting point to developed multiple professional home health care agencies. nurses working in-home services play a crucial role in decreasing the pressure on hospitals in times of pandemic and health crises. in addition, with the services nurses provide in the home settings, fewer patients are at risk of nosocomial infection. the covid-19 pandemic proved that nurses are ready to look after patients successfully, however, no nurse should work at home services informally without governmental and medical supervision. the work should be legalized, legal protocol should be developed, the quality of care should be assured. additionally, the nurses’ rights and patients’ rights must be secured by the ministry of health. limitations: the study has several limitations. first, the study did not collect data patient must be hospitalized to receive proper care [16]. home spo2 of less than 92% increases the likelihood of intensive care unit admission. based on the study done on the spo2 parameters as an indicator for hospitalization 48 health workers in the current study provided care to patients who needed immediate hospitalization. body temperature is another significant parameter collected in the current study where almost all the patients had high body temperature. studies found that temperature elevation is common during covid-19 and it is present among the majority of hospitalized patients with covid19 [7, 16,17). studies suggest that poor control of body temperature is an indicator of poor outcomes. the mortality rate increased for every 0.5° elevation in body temperature in a study done at mount sinai in new york city [16]. the covid-19 outbreak is mentally and physically challenging for patients and relatives [18]. in many studies since the emergence of the covid-19 virus, it has been concluded that individuals experience high levels of negative emotions such as fear, anxiety and anger [19].participants noticed a wide range of mental break downs among the patients during the care ranging from fatigue, insomnia, anxiety, and stress. severe anxiety and depression have been found among covid-19 patients both previously and not previously diagnosed with psychological distress [20, 21, 22]. difficulty breathing, prolonged quarantine, insufficient information, and social stigma were some causes of psychological distress [22].the holistic home care provided by the study participants to the covid-19 patients included health assessment, nursing intervention, evaluation, reassessment, and practicing preventive measures. although, the administration of multiple effective antiviral and monoclonal treatment for covid-19 has increased the 94 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.10 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article conclusion references [1] national institutes of health. coronavirus disease 2019 (covid-19) treatment guidelines. available at https:// www.covid19treatmentguidelines.nih.gov/. [accessed: 10th december 2021]. [2] kurdistan regional government 2020. corona virus (covid-19) outbrak. available at https://coronavirus-covid-19-iraqatlasgis.hub.arcgis.com/ [accessed: 12th april 2022]. [3] lami f, rashak ha, khaleel ha, mahdi sg, adnan f, khader ys,. iraq experience in handling the covid-19 pandemic: implications of public health challenges and lessons learned for future epidemic preparedness planning. journal of public health. 2021. 43 (3):iii19-28. available from:https:// doi.org/10.1093/pubmed/fdab369 [accessed: 10 august 2022] [4] john calabres. iraq’s fragile state in the time of covid-19. mei. december 8, 2020. available at: https://www.mei.edu/ publications/iraqs-fragile-state-time-covid19#_ednref36 [ acceded: 12 august 2022] [5] sama sr, quinn mm, galligan cj. impacts of the covid-19 pandemic on home health and home care agency managers, clients, and aides: a cross-sectional survey, march to june, 2020. home health care management & practice. 2021;33(2):125-29. available at:doi:10.1177/1084822320980415 [ acceded: 08 august 2022] [6] world health organization (who) 2020. who announces covid-19 outbreak a pandemic. available at (http:// www.euro.who.int/en/health-topics/healthemergencies/coronavirus-covid-19/news/ news/2020/3/who-announces-covid-19outbreak-a-pandemic). [accessed 20-march 2022] [7] center for disease control and prevention. covid-19. available at https:// www.cdc.gov/coronavirus/2019-ncov/ index.html [accessed: 12 april 2022] [8] 21 who. covid-19 dynamic infographic dashboard for iraq [internet] iraq: world health organization, iraq country office, 2020[cited 6 august 2020] available from: https://app.powerbi.com/view? r=eyjrijoinjljmdhiymitztlhms00mdlhltg3m jitmdnmm2fhnze5nmm4iiwidci6imy2mtb jmgi3lwjkmjqtngizos04mtbiltnkyzi4mg fmyju5mcisimmiojh9. about the involvement of family member (s) in the care of the patients. second, unknown population prevalence led to small sample size recruitment which may be representative of the actual population size. third, lack of research on the subject led to lack of research support. finally, the study did not collect data about the challenges of looking after covid-19 patients at homesettings. the researcher suggests more comprehensive research that enhance generalization and comparison with the care provided to covid-19 patients at hospital setting. patients’ perspective on the care received at home setting should also be investigated. further studies are suggested to overcome the limitations and collect data on the aspect that did not include in the current study. depending on the data received from the nurses, covid-19 patients at home setting received holistic nursing care and patients were under close and constant monitoring. the holistic care provided to the patients included financial, physical, emotional, and spiritual care. most covid-19 patients decided to treated at home by someone they trust. the author reports no conflict of interests. the authors (s) report no funding support. 95 conflict of interest funding copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.10 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article doi.org/10.1016/j.rccl.2020.10.005. [accessed: 12 december 2021] [16] tharakan, s., nomoto, k., miyashita, s. kiyotake ishikawa. body temperature correlates with mortality in covid-19 patients. critical care. 2020; 24 (298). available from: https://doi.org/10.1186/s13054-02003045-8. [accessed: 12 january 2022] [17] liu x, yue x, liu f, wei l, chu y, bao h, et al. analysis of clinical features and early warning signs in patients with severe covid-19: a retrospective cohort study. plos one. 2020 jun 26;15(6):e0235459. available from: https://doi.org/10.1371/ journal.pone.0235459 . [accessed: 12 january 2022] [18] cabin w. pre-existing inequality: the impact of covid-19 on medicare home health beneficiaries. home health care management & practice. 2021 may;33(2):130-6. available at: https://doi.org/10.1177/1084822321992380 [accessed: 10 august 2022] [19] gök a. examination of home quarantine experiences of individuals diagnosed with covid-19 living in turkey. home health care management & practice. 2022; 34(3) 229-236. available at:https:// doi.org/10.1177/10848223211073896 [ acceded: 08 august 2022] [20] oppenauer, c., burghardt, j., kaiser, e., riffer, f., & sprung, m. psychological distress during the covid-19 pandemic in patients with mental or physical diseases. frontiers in psychology. 2021; 12 (703488). available from: https:// doi.org/10.3389/fpsyg.2021.703488. [accessed: 12 april 2022] [21] shah, m. m., abbas, s., khan, j. z., iftikhar, m., jamal, a., zeb khan, j., et al. psychological and clinical predictors of covid-19 severity and outcomes. cureus. 2021; 13(11), e19458. available from: https:// doi.org/10.7759/cureus.19458. [accessed: 12 january 2022] [22] li w, yang y, liu zh, zhao yj, zhang q, zhang l, et al. progression of mental health services during the covid-19 outbreak in china. international journal of biological sciences. 2020;16(10):1732. available from: doi: 10.7150/ijbs.45120. [accessed: 01 april 2022] [23] darweesh o, abdulrazzaq gm, al-zidan rn, bebane p, merkhan m, aldabbagh r, alomari n. evaluation of the pharmacologic treatment of covid-19 pandemic in iraq. [9] ahmad fb, cisewski ja, miniño a, anderson rn. provisional mortality data — united states, 2020. morbidity and mortality weekly report 2021;70:519–522. available from: doi: http://dx.doi.org/10.15585/ mmwr.mm7014e1. https://www.cdc.gov/ mmwr/volumes/70/wr/mm7014e1.htm? s_cid=mm7014e1_w [accessed: 02 january 2022]. [10] pennington af, kompaniyets l, summers ad, danielson ml, goodman ab, chevinsky jr, et al. risk of clinical severity by age and race/ ethnicity among adults hospitalized for covid-19—united states, march–september 2020, open forum infectious diseases. 2021; 8 (2). available from: https:// doi.org/10.1093/ofid/ofaa638external icon. [accessed: 12 march 2022] [11] azevedo rb, botelho bg, hollanda jvg, ferreira lvl, junqueira de andrade lz, oei ssml, et al. covid-19 and the cardiovascular system: a comprehensive review. journal of human hypertension. 2021 jan;35(1):4-11. available from doi: 10.1038/s41371-020-0387-4. epub 2020 jul 27. pmid: 32719447; pmcid: pmc7384729. [accessed: 01 january 2022] [12] kompaniyets l, pennington af, goodman ab, rosenblum hg, belay b, ko jy. underlying medical conditions and severe illness among 540,667 adults hospitalized with covid-19, march 2020–march 2021. preventing chronic disease. 2021; 18(123). available from: https://www.cdc.gov/pcd/ issues/2021/21_0123.htm. [accessed: 10 february 2022] [13] harrison sl, fazio-eynullayeva e, lane da, underhill p, lip gyh. comorbidities associated with mortality in 31,461 adults with covid-19 in the united states: a federated electronic medical record analysis. plos medicine. 2020; 17(9): e1003321. available from: https:// doi.org/10.1371/journal.pmed.1003321. [accessed: 13 february 2022] [14] gandhi rt, lynch jb, del rio c. mild or moderate covid-19. new england journal of medicine. 2020 oct 29;383(18):1757-66. available from: https://www.nejm.org/doi/ full/10.1056/nejmcp2009249 . [accessed: 12 december 2021] [15] [15]cordero a, garcía-gallego cs, bertomeugonzález v, fácila l, rodríguez-mañero m, escribano d, castellano jm, et al. mortality associated with cardiovascular disease in patients with covid-19. rec: cardio clinics. 2021 jan 1;56(1):30-8. available from: https:// 96 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.10 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article current pharmacology reports. 2021 sep;7 (4):171-8. available from: https:// doi.org/10.1007/s40495-021-00262-9. [accessed: 15 august 2022] [24] nicola m, o'neill n, sohrabi c, khan m, agha m, agha r. evidence based management guideline for the covid-19 pandemic-review article. international journal of surgery. 2020; 77(1) 206-16. avialable from: https:// doi.org/10.1016/j.ijsu.2020.04.001. [accessed: 01 april 2022] [25] labrague lj, de los santos ja, fronda dc. factors associated with missed nursing care and nurse‐assessed quality of care during the covid‐19 pandemic. journal of nursing management. 2022; 30(1):62-70. available from: https://doi.org/10.1111/jonm.13483. [accessed: 01 may 2022] [26] darweesh, o., abdulrazzaq, g.m., al-zidan, r.n. et al. evaluation of the pharmacologic treatment of covid-19 pandemic in iraq. curr pharmacol rep 7, 171–178 (2021). https:// doi.org/10.1007/s40495-021-00262-9 97 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2021.06 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article assessment and clinical outcomes of fall related injuries at emergency abstract introduction falls are a common cause of mortality in both sex and all age groups [1]. it is one of the common reasons for trauma care at emergency department (ed) visits among all age groups [2]. fall-related injuries increase the cost on the health care system [3]. about half of falls result in injuries, and about 10% of those injuries are serious injuries such as head injuries and fractures or injuries to the joint [4]. falls and resulting injuries are frequently need medical care [5].globally, falls are a major public health problem. each year about 646,000 fatal falls occur. it is the second leading cause of accidental injury death after road traffic injuries. in lowand middle-income countries, fatal falls occur over 80% [6]. it is one reason that leads to death and the background and objectives: falls are significant cause of mortality and morbidity with a considerable burden on societies, families and victims. the study aims to determine the interventions and outcomes of fall-related injuries, and the association between injury severity and fall height. methods: a descriptive cross-sectional study was conducted among 322 fall-related injured persons in west and east emergency hospitals in erbil city from september 2020 to february 2021. study sample demography, location of injury, place of affected body regions, outcome, and hospital stay were analyzed. results: of the 322 patients studied, 68.9% were males, and 31.1% were female. less than half of the samples (48.8%) were between the ages 18 to 36 years old. the most common location for fall-related injuries was residential facilities (44.1%) followed by the place of work (35.1%). according to the type of fall, fall from ground was 38.4%, and fall from a fall height of 1-3 meters was 48.8%. finally, according to the injury classification, more than half (56.5%) of the study sample had a significant degree of severity. the discharged status of disposition at the emergency room had the highest percentage (64.9%) of the study sample. there was a significant difference between the scores of the items of fall consequences and outcomes regarding to type of ground (soft or hard). there was a significant relationship between injury severity and fall height (p-value = 0.00). conclusion: fall-related injuries are the most common cases at emergency departments in erbil city. among ages 18 to 36, men are more frequently exposed to falls than women. the highest risk of fall is occupation with construction laborers at the greatest risk. fallrelated injury is a burden on the health care system, particularly on emergency services in developing countries like iraq in relations cost of care and resources. key words: fall, unintentional fall, injury severity, fall height, outcome. shawbo muhammad osman; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: shawbo.othman@hmu.edu.krd) vian afan naqshbandi; department of nursing, college of nursing, hawler medical university, erbil, iraq. 50 erbil journal of nursing & midwifery received: 17/03/2021 accepted: 10/05/2021 published: 30/05/2021 https://doi.org/10.15218/ejnm.2021.06 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article third. leading cause of non-fatal injuries [7]. although fall-related injuries are usually reported in older age groups, other studies have shown that younger people (15-49 years) have been recognized as the most vulnerable group affected by fall-related injuries. in addition, men are twice as likely to as women to be affected by falls [8]. two of the three significant causes of injury deaths – fall and road traffic injuries– are expected to increase in rank compared to other causes of death, with falls increasing to become the 17th leading cause of death. [9].in kurdistan, iraq, there is no current study about falls in all circumstances, including settings and injury-prone environments. the environmental, personal, and equipment risk factors for falls change in different communities. it is essential to know the severity of injuries and outcome of patients who sustain injuries by falls to be better prepared to manage these emergencies and to provide appropriate recommendations for prevention. this study will have a fundamental role in refining knowledge and will be recognized as a source of nurses and emergency staff. the finding of this study may help nurses and other healthcare professionals expand their knowledge and improve their practice related to fall-related injuries. this study aimed to explore the socio demographic characteristics, severity, interventions, and health outcomes associated with fallrelated injuries and determine the association between injury severity and fall height. a descriptive cross-sectional study of 322 fall-related injured persons in west and east emergency hospitals in erbil city was conducted from september 2020 to february 2021. the sample size was determined by z2 p q/d2, z = confident interval 95% (1.96), p= prevalence= (0.30), q = (1-p) = (0.70), d = sampling error (0.05) [10]. patients who died upon injury or those who died in the emergency rooms (9) were omitted because there was no complete data regarding the circumstances of death and to avoid potential bias due to outcome measurement. the researcher obtained an approval letter from the ethics committee at hawler medical university/college of nursing on september 2020 (number 833). the official approval was taken as well. the researcher prepared a questionnaire for collecting data based on the review literature. the questionnaire was reliable and accessible to the public. the questionnaire was checked by a panel of experts who have extensive experience from different specialties. based on their comments, the questionnaire was corrected and modified for appropriate data collection. a pilot study was conducted on 30 fall-related injured persons selected purposively from east and west emergency hospitals in september 2020. the pilot study was beneficial to determine the reliability, clarity, acceptability and time estimation for each participant to give full data which was 2030 minutes. reliability was determined using the spearman-brown formula. the following procedures were used in data analysis: descriptive statistical data analysis (frequency and percentage) and inferential statistical data analysis (independent sample t-test and chi-square test). data were analyzed using spss version 21. table 1 shows the socio demographic characteristics of the sample. nearly half of the sample (48.8%) were aged 18 – 36 years old, and a majority were male was (68.9%). 31.7% graduated from primary school, and 49.1% lived in urban areas. the majority of the sample (86% ) were iraqi, more than a third (37.9%) . 51 erbil journal of nursing & midwifery methods results https://doi.org/10.15218/ejnm.2021.06 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article reported a social income status of sufficient daily needs. identified their occupation as a worker, and more than half (57.1%) 52 erbil journal of nursing & midwifery table 1: distribution of socio demographic data of the study sample (n=322) the characteristics subgroups f. % age groups 1 – 18 years 91 (28.3) 18 -36 years 157 (48.7) 36-54 years 44 (13.7) > 54 years 30 (9.3) gender male 222 (68.9) female 100 (31.1) education level illiterate 57 (17.7) able to read and write 70 (21.7) primary school 85 (26.4) secondary school 33 (10.3) college or institute 22 (6.8) post graduate 11 (3.4) child (n. a.) 44 (13.7) residence urban 158 (49.1) rural 95 (29.5) suburban 69 (21.4) nationality iraqi 277 (86) others 45 (14) occupation manual employee 9 (2.8) office (government) employee 14 (4.3) unemployed (house wife) 75 (23.3) retired 10 (3.1) worker 122 (37.9) student 48 (14.9) child (n. a.) 44 (13.7) income exceeds daily needs 3 (0.9) sufficient for daily needs 184 (57.1) insufficient for daily needs 135 (42) https://doi.org/10.15218/ejnm.2021.06 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article table 2 shows information regarding fallrelated injuries. the primary mode of arrival was by none-ambulance mode (87%). nearly half of the samples (44.1%) were injured at a residential facility, followed by the workplace (35.1%). almost all falls (92.5%) were unintentional, and 89.1% of falls were falls to a hard ground. the most common mechanism of fall was fall from ground 38.4%, and the most common fall height was fall from 1-3 meters (48.8%). on the pain scale, 54.3% of the sample reported, and on the glasgow coma scale, 91.3% reported no head injury, and 79.2% received radiological investigation. 53 erbil journal of nursing & midwifery table 2: distribution of information regarding fall of the study sample (n= 322) the characteristics subgroups f. % mode of arrival ambulance 41 (12.7) none-ambulance mode 281 (87.3) location of fall occurrence residential facility 142 (44.1) sports facility 26 (8.1) work place 113 (35.1) public / commercial area 14 (12.7( intentionality of fall unintentional 298 (92.5) intentional 24 (7.5) ground of fall soft 35 (10.9) hard 287 (89.1) fall height < 1 meter 109 (33.8) 1 – 3 meters 157 (48.8) 3 – 6 meters 51 (15.8) > 6 meters 5 (1.6) level of consciousness conscious 299 (92.9) unconscious and or altered mental status 23 (7.1) pain scale mild pain 7 (2.2) moderate pain 132 (41) severe pain 175 (54.3) unconscious 8 (2.5) total of glasgow coma scale (gcs) no head injury gcs 15/15 294 (91.3) severe head injury gcs 3-8 8 (2.5) moderate head injury gcs 9--12 18 (5.6) miner head injury gcs 13 -15 2 (0.6) radiology investigation no 32 (9.9) x-ray 255 (79.2) x-ray with other radiology test 35 (10.9) mechanism of fall f % fall from ground 124 (38.4) fall from stairs and scaffold 111 (34.5) fall from building or structure 45 (14) sport activity 27 (8.4) others 15 (4.7) total 322 (100) https://doi.org/10.15218/ejnm.2021.06 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article was received back slab or cast for the affected area, 24.8% was received advice and giving medication, 22.4% was received open reduction and internal fixation, 15.6% was received wound dressing and suturing, 3.4% was received traction, others, craniotomy 2.8%, surgical debridement and external fixation2.5%, laparotomy 1.2%. 54 erbil journal of nursing & midwifery table 3 shows the characteristics of injuries. of the sample, 53.1% has no soft tissue injury, 41.3% had no fracture, 99.1% had no spinal cord injury, and 97.3% had no visceral injury. more than half (56.5%) of study sample had major degree of severity. table 4 shows the frequencies and percentages of the treatment type and in terventions of the study sample, 27.3% table 3: distribution of the injury characteristics among study sample (n= 322) the characteristics subgroups f. % soft tissue injury none 171 (53.1) yes 151 (46.9) site of fracture none 133 (41.3) skull and neck fracture 20 (6.2) upper limb fracture 57 (17.7) lower limb fracture 68 (21.1) back fracture 11 (3.4) chest fracture 5 (1.6) pelvis fracture 15 (4.7) multiple fracture 13 (4) spinal cord injury sci none 319 (99.1) yes 3 (0.9) visceral injury no 313 (97.3) yes 9 (2.7) injury severity classification none 0 (0.0) minor 104 (32.3) moderate 29 (9) major 183 (56.8) death 6 (1.9) table 4: distribution of interventions of fall among the study sample (n= 322) the outcomes subgroups f. % open reduction and internal fixation no 250 (77.6) yes 72 (22.4) laparotomy no 318 (98.8) yes 4 (1.2) surgical debridement and external fixation no 314 (97.5) yes 8 (2.5) craniotomy no 313 (97.2) yes 9 (2.8) wound dressing and suturing no 285 (88.5) yes 50 (15.6) back slab or cast for affected area no 234 (72.7) yes 88 (27.3) traction no 311 (96.6) yes 11 (3.4) advice and giving medication no 242 (75.2) yes 80 (24.8) https://doi.org/10.15218/ejnm.2021.06 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article table 5 shows the differences between the fall consequences and outcomes regarding the ground of fall (soft or hard). there was a significant difference between the scores of the fall consequences and outcomes regarding ground of fall. a high significance was reported for open reduction and internal fixation (p=0.00), advice and giving medication (p=0.00), and disposition at emergency hospitals (p=0.00) with back slab or cast for the affected area (p=0.01), traction (p=0.01) and significant association for open reduction and external fixation (p=0.04). there was no significance at the p ≤ 0.05 with craniotomy, laparotomy, wound dressing, and suturing. a significant relationship between injury severity and fall height was observed (p= 0.00). 55 erbil journal of nursing & midwifery table 5: distribution of the fall consequences and outcomes based on (ground of fall) of the study sample (n=322) fall outcomes ground of fall (f.) sig. p value sig. level at p. value ≤ 0.05 1open reduction and internal fixation soft (35) 0.000 h.s. hard (287) 2laparotomy soft (35) 0.156 n.s. hard (287) 3surgical debridement and external fixation soft (35) 0.041 s. hard (287) 4craniotomy soft (35) 0.963 n.s. hard (287) 5wound dressing and suturing soft (35) 0.289 n.s. hard (287) 6back slab or cast for affected area soft (35) 0.019 s. hard (287) 7traction soft (35) 0.015 s. hard (287) 8advice and giving medication soft (35) .0000 h.s. hard (287) 9disposition at emergency room soft (35) 0.000 h.s. hard (287) https://doi.org/10.15218/ejnm.2021.06 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article results [15]. residential facility was the most common place of fall followed by the workplace as reported in the same study [16]. a higher proportion of falls were unintentional, and majority of fall ground was hard. injuries from fall height of 1-3 meters were the highest which is similar to the results by i̇çer et al [17]. falls from the ground were highest among the sample which agrees with the study done by alfredsson [18]. the present study disagrees with the study by grivna et al., which showed more patients had fallen from higher heights compared to ground level [19].most of the sample population were conscious and had a glasgow coma score of 15. most of the patients were stabilized and after primary care discharged directly from the emergency department, similar to study results this study shows that majority of the sample as between 18 – 36 years old, which aligns with the lohanathan et al. retrospective study in south india [11]. the sample had a larger proportion of males than females, which aligns with the ahmad et al. study results of fatal falls [12]. usually, men are exposed to falls more frequently than women because boys are more active at early ages than girls, and men are more physical workers than women. based on the occupation, workers were more than a third of the study sample and aligns with dong et al., meena, and punia, which reported that the highest risk of fall was occupation with construction laborers as the largest occupation at risk [13] [14]. the primary mode of arrival was by none-ambulance mode, consistent with earlier studies by fayyaz et al. that demonstrated similar 56 erbil journal of nursing & midwifery table 6: association between injury severity and fall height among the study sample (n=322). sig. value at p. value 0.05 χ² value total fall height injury severity classification >6 m f. % >3-6 m f. % >1-3 m f. % less than one meter f. % 0.000 74.213 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 none 0 0.0 0 0.0 9 2.8 38 11.8 57 17.7 minor 0 0.0 0 0.0 0 0.0 11 3.4 18 5.6 moderate 3 0.9 0 0.0 38 11.8 60 18.6 82 25.5 major 2 0.6 4 1.2 0 0.0 0 0.0 0 0.0 death 5 1.6 4 1.2 47 14.6 109 33.8 157 48.8 total discussions https://doi.org/10.15218/ejnm.2021.06 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article observational data-based study by dickinson et al. which showed the same result [25]. fall-related injuries are the most common cases at emergency departments in erbil city. men are exposed to falls more frequently than women among ages 18 to 36 years old. the highest risk of fall is occupation with laborers of construction at the highest risk. fall-related injuries have serious implications on the burden of the health care system, particularly on emergency services in developing countries like iraq in relation to cost of care and resources. falls at work can be prevented by safety instruction to different groups, and proper regulation and legislation. environmental variation based on architectural design may prevent falls among susceptible risk groups. the author reports no conflict of interests. [1] turgut k, sarihan me, colak c, güven t, gür a, gürbüz s. falls from height: a retrospective analysis. world journal of emergency medicine. 2018;9(1):46. [2] murray et al. disability-adjusted life years (dalys) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the global burden of disease study 2010. the lancet. 2012 dec 15;380(9859):2197223. [3] tuma et al. epidemiology of workplacerelated fall from height and cost of trauma care in qatar. international journal of critical illness and injury science. 2013 jan;3(1):3. done in south india done by lohanathan et al [11]. x-ray investigation was done for majority of the cases like the study by dong et al [13]. nearly half of sample population had soft tissue injuries similar to the retrospective study by turgut et al. at the emergency department of inonu university which reported the most common traumatic lesion of fall was soft tissue injury [1].limbs were the commonly injured body part, similar to the study in india done by kumar and srivastava [20]. nearly one percent of the study sample had spinal cord injuries, agreeing with the oxley et al. study [21]. however, it disagrees with the kennedy et al. study reporting nearly a quarter percent of falls had spinal cord injury which may be attributed to the long duration of the study and differences in the heights of fall [22]. more than half of the sample has a major degree of severity which disagreed with luzia et al., which reported that most injuries were classified as mild. fall-related injuries involved specific medical and nursing interventions such as sutures, dressings, casting, orthopedic and neurologic surgical procedures. the percentage of injuries resulting in death was 1.9% of cases similar to that reported by luzia et al. [23]. in this study, nearly a quarter of the cases needed orthopedic surgery, which disagrees with the study by alizo et al., which showed that more than half of the sample population needed orthopedic surgery [24]. alizo et al. reported these findings among falls from height only and not all types of falls. the outcomes of patients falling on soft grounds compared to those falling on solid grounds were statistically significant, similar to a turkish study done by i̇çer et al. [17]. the present study showed a significant relationship between injury severity and fall height, similar to a retrospective 57 erbil journal of nursing & midwifery conclusion recommendation conflict of interest references https://doi.org/10.15218/ejnm.2021.06 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article cpwr quarterly data report; 3rd quarter. july 2019. [14] meena pc, punia rk. socio-demographic profile of fatal cases of fall from height-sms hospital, jaipur during the year 2015-16. indian journal of forensic medicine & toxicology. 2018 apr; 2:93-8. [15] fayyaz et al. pattern of fall injuries in pakistan: the pakistan national emergency department surveillance (pak-neds) study. bmc emergency medicine. 2015 dec;15(2):17. [16] haggag og, zamzam is, sharaf eldin aa, madboly ag, morad mm. pattern of fatal injuries of fall from height at great cairo: a retrospective analytical study (2009–2013). the egyptian journal of forensic sciences and applied toxicology. 2016 dec 1; 16 (2):97-116. [17] i̇çer m, güloğlu c, orak m, üstündağ m. factors affecting mortality in falls from height. turkish journal of trauma and emergency surgery. 2013 nov 1;19(6):529-35. [18] alfredsson m. fall injury patterns and injury severity at colombo south teaching hospital, sri lanka. university of gothenburg (doctoral dissertation). 2020. [19] grivna m, eid ho, abu-zidan fm. epidemiology, morbidity and mortality from fallrelated injuries in the united arab emirates. scandinavian journal of trauma, resuscitation and emergency medicine. 2014 dec;22 (1):1-7. [20] kumar jv, srivastava ak. pattern of injuries in fall from height. journal of indian academy of forensic medicine. 2013;35(1):47-50. [21] oxley j, o’hern s, burtt d, rossiter b. fallrelated injuries while walking in victoria. accident research centre. 2016 mar; 16(02). accessed on line from http://www. victoriawalks. org. au/assets/files/fall-relatedinjuries-while-walking. report. pdf [22] kennedy p, cox a, mariani a. spinal cord injuries as a consequence of falls: are there differential rehabilitation outcomes?. spinal cord. 2013 mar;51(3):209-13. [23] luzia md, prates cg, bombardelli cf, adorna jb, moura gm. characteristics of falls with damage to hospitalized patients. revista gaúcha de enfermagem. 2019;40(spe). [24] alizo et al. fall from heights: does height really matter?. european journal of trauma and emergency surgery. 2018 jun; 44(3):411 -6. [25] dickinson a, roberts m, kumar a, weaver a, [4] hill et al. fall rates in hospital rehabilitation units after individualized patient and staff education programmes: a pragmatic, stepped-wedge, cluster-randomised controlled trial. the lancet. 2015 jun 27;385 (9987):2592-9. [5] ersoye et al. analysis and injury patterns of walnut tree falls in central anatolia of turkey. world journal of emergency surgery. 2014 dec; 9(1):1-5. [6] word health organization. falls. fact sheets. 2017. available from https:// www.who.int/news-room/fact-sheets. [7] bunting j, branche c, trahan c, goldenhar l. a national safety stand-down to reduce construction worker falls. journal of safety research. 2017 feb 1; 60:103-11. [8] shrestha r, shrestha sk, kayastha sr, parajuli n, dhoju d, shrestha d. a comparative study on epidemiology, spectrum and outcome analysis of physical trauma cases presenting to emergency department of dhulikhel hospital, kathmandu university hospital and its outreach centers in rural area. kathmandu university medical journal. 2013;11(3):241-6. [9] world health organization. injuries and violence: the facts 2014. available from https://www.google.com/search? q=.+world+health+organization.+injuries+ and+violence3a+the+facts+2014.&rlz=1c1 chbd_eniq909iq910&oq=.09world+healt h+organization.+injuries+and+violence% 3a+the+facts+2014.+&aqs=chrome..69i57. 9943j0j15&sourceid=chrome&ie=utf-8 . [10] araoye, m.o.research methodology with statistics for health and social sciences. ilorin: nathadex publisher. 2003. 115 (9), pp.25-120. [11] lohanathan a, hazra d, jyothirmayi ca, kundavaram ap. an elucidation of pattern of injuries in patients with fall from height. indian journal of critical care medicine: peer-reviewed, official publication of indian society of critical care medicine. 2020 aug;24(8):683. [12] ahmad m, rahman fn, al-azad ma, majumder mr, chowdhury mh. pattern of fatal injury in fall from height cases-a medicolegal study. journal of armed forces medical college, bangladesh. 2014;10 (1):80-4. [13] dong xs, jackson r, varda d, betit e, bunting j. trends of fall injuries and prevention in the construction industry. 58 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2021.06 erbil j. nurs. midwifery, vol. 4, no. (1), may 2021 original article lockey dj. falls from height: injury and mortality. bmj military health. 2012 jun 1; 158(2):123-7. 59 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article mothers’ awareness regarding home care management of a preterm baby at the rapareen pediatric teaching hospital in erbil city. abstract world health organization (who) states that the preterm baby is a baby born alive before 37th week of pregnancy is completed, or an infant’s birth before the 37th week after the first day of the last menstrual period [1]. the preterm babies are divided into three sub-categories based on gestational age: an extremely preterm baby (<28 weeks), very preterm baby background and objectives: preterm birth is a global health issue that occurs in every country. every year, 15 million preterm infants are born worldwide, and one out of ten is a preterm infant. sixty percent of preterm infants are born in developing countries. this study aimed to assess mothers' awareness regarding home care management of a preterm baby at the rapareen pediatric teaching hospital in erbil in the kurdistan region of iraq. method: a quantitative, descriptive, cross-sectional study was carried out in the neonatal intensive care unit at the rapareen pediatric teaching hospital in erbil from the 7th of october 2018 to the 15th of october 2019. a purposive, non-probability sampling technique was used, and 130 mothers were respectively recruited to the study. a questionnaire was developed by the researcher and the research data were collected by direct, face-to-face interviews. descriptive statistics in the form of frequencies, percentages, and interferential chi-square test were used to analyze the data. results: more than half (53.8%) of the mothers were 25-33 years old and the majority (77.7%) of them were housewives. the main finding of the study is that most mothers had a neutral level of awareness regarding thermoregulation, breastfeeding, vaccinations, and recognizing danger signs. at the same time, most of the mothers were not aware of the infection prevention, and there was a very high, statistically significant association between mothers' awareness regarding thermoregulation and occupation and a type of family. furthermore, there was a statistically significant association between the mothers' awareness regarding breastfeeding and their residency and a type of delivery, and a statistically significant association between the mothers' awareness regarding infection prevention and their occupation and economic status. finally, there was a statistically significant association between the mothers' awareness of vaccinations and their age and the type of delivery, and there was a statistically significant association between the mothers' awareness about the danger signs and the economic status. conclusion: the study concluded that mothers who have a preterm baby at the rapareen pediatric teaching hospital in erbil have poor awareness regarding the care of their babies at home. keywords: preterm babies; mothers; homecare; awareness; rapareen; erbil chawarwan saleem abdullah; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: chawarwan.abdulla@gmail.com ) shukir saleem hassan; department of nursing, college of nursing, hawler medical university, erbil, iraq. 163 erbil journal of nursing & midwifery received: 2/8/2019 accepted: 13/10/2019 published: 30/11/2019 introduction mailto:chawarwan.abdulla@gmail.com https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article (28 to <32 weeks), and moderate to late preterm baby (32 to <37 weeks) [2]. every year 15 million babies are born prematurely and their possibility for life differs dramatically around the world. for example, in countries with high income, about 1.2 million preterm babies were registered [3]. in 2010, more than 60% of preterm babies were born in sub-saharan africa and south asia. the countries with the highest numbers of preterm births include brazil (9.2%), the united states of america (12%), india (13%) and nigeria (12.2%), demonstrating that the preterm birth is a global problem the rate of preterm births in iraq, iran, and turkey is 6.5%, 11.5,%, and 11.9% respectively [4].the cause of more than half of the preterm births is idiopathic, but some maternal health conditions like preeclampsia, gestational diabetes mellitus, polyhydramnios, and maternal chronic conditions like hypertension and diabetes are also related to preterm birth [5]. about 30– 35% of preterm births are related to medical or obstetric complications, 40–45% of them are due to spontaneous preterm labour, and 25–30% of preterm births are caused by a preterm pre-labour rupture of membranes (pprom) [6]. more than 85% of newborn deaths are related to the complications of prematurity, and neonatal infections and complications of prematurity are currently the second leading cause of death [7].complications of preterm labour are divided into two categories: short-term and long-term complications. the shortterm complications include breathing problems, brain problems, and premature immune system problems when babies are born too soon and are more susceptible to infection. the long-term complications of preterm labour include cerebral palsy, impaired cognitive skills, behavioural and psychological problems, and chronic health issues such as asthma and feeding problems [8]. several medical strategies based on the research evidence are used to prevent preterm birth such as progesterone supplementation, cervical cerclage and maternal education regarding avoiding cigarette smoking and alcohol [9].home care management refers to the care of children with simple or complex health problems and their families in their places of residence for the aims of promoting, maintaining, or restoring health, or for boosting the level of independence while decreasing disability and illness. some children with multiple health problems after discharge from a hospital need more specific care at home to prevent readmission [10]. although all babies need appropriate home care after birth, premature babies are especially susceptible to temperature irregularities, feeding difficulties, low blood sugar level, infections and breathing difficulties. mothers should be aware of and be able to provide care for their preterm babies at home such as thermal care by wrapping and drying baby, covering baby's head, providing skinto-skin care, giving breast milk, which is important for a preterm baby nutritionally, immunologically and developmentally. premature babies have a higher risk of bacterial sepsis, which is why mothers should be aware of and continually do basic hygienic practices such as hand washing, maintaining a clean environment and visiting restrictions, and assessing for general danger signs of illness [11]. this study aimed to assess mothers’ awareness regarding home care management of a preterm baby regarding thermoregulation, feeding, immunization, infection prevention, and danger signs at the neonatal intensive care (nicu) unit in erbil, and to find out the association between home care management, mothers’ awareness and selected socio demographic characteristics. 164 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article such as the age of the mother, marital status, occupation, level of education, religion, type of family, economic status, and type of delivery. the second part contained an assessment of maternal awareness regarding preterm baby home care. a three-point likert scale was used (0 for not awareness, 1 for neutral awareness, and 2 for awareness) and consisted of 31 items. the calculation of overall mothers’ awareness was categorized into three groups: poor awareness (0-20), fair awareness (21-41), and good awareness (42-62). the validity of the study instrument was determined through the panel of 15 experts of different specialities. the majority of the experts agreed upon the items of the study instrument. a pilot study was conducted on 15 mothers who were randomly selected. the pearson correlation(r) was 0.81. ethical approval was obtained from the scientific and ethical committees of the college of nursing of hawler medical university on 10th june 2019, the erbil directorate of health, ministry of health, and the director of rpth. the verbal permission was obtained from the mothers before starting the interview. the data were analyzed using ibm spss software for statistical analysis version 25, and descriptive statistics (frequency and percentage) were calculated. the inferential statistical analysis (chi-square and fisher's exact test)) was conducted to find out the association between variables. the p-value was considered statistically significant if it was ≤ 0.05, which indicated a rejection of the null hypothesis. a total of 130 mothers were interviewed. the majority, 70 (53.8%) of respondents were between 25-33 of age, and most, 101 (77.7%) were housewives, while 3 (2.3%) were private employees.43.1% of mothers were illiterate and only 1.5% a quantitative, cross-sectional, descriptive study was carried out to assess the awareness of mothers who attended the nicu at the rapareen pediatric teaching hospital (rpth) in erbil. the mothers were asked to participate in the study about the home care management of a preterm baby in terms of thermoregulation, feeding, immunization, infection prevention, and danger signs. the data collection lasted from the 7th of october 2018 to the 15th of october 2019. a non-probability purposive sample of 130 mothers was recruited to participate in the study using a formula which was developed by taro yamane in 1967 (, , n=115) [39]. in this formula, n = the sample size, n= the size of the population (rpth’s reported number of admissions of preterm infants every month was 40 so the estimated population for four months was 160), e= the alpha-error of 0.05. the target population consisted of mothers who delivered premature babies. preterm babies who received home care management by mothers at home were included in the study, while orphan children whose mother died, mothers with psychological problems, babies with congenital anomalies, or who were admitted to the nicu from the labour room were are excluded from the study. after the calculation of the sample size using the yamane formula, the researcher considered 115 cases of mothers as a sample size. in order to obtain reliable data, the researcher has increased the sample size to 130 cases. the data were gathered through a direct interview (faceto-face) using the questionnaire, which was prepared by the researcher. each interview session took approximately 30-45 minutes. the questionnaire contained two main parts. the first part, the sociodemographic characteristics, included the mother's demographic characteristics 165 erbil journal of nursing & midwifery methods results https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article had a postgraduate level of education. 43.8% of mothers lived in urban areas. the majority of participants (69.2%) were in a nuclear family. as for the economic status of participants, results showed that more than half (63.1%) had sufficient income for daily needs, and in 12.3% of cases, the income exceeded economic needs. over one third (46.2%) of mothers delivered their 166 erbil journal of nursing & midwifery babies by a cesarean section (c\s) (table1). according to the table 2, most (66.2%, 70%, 58.5%, and 66.9%) of mothers had neutral awareness regarding thermoregulation, breastfeeding, vaccinations, and danger signs respectively, while 67.7% of participants were completely not aware regarding infection prevention. table 1: socio-demographic characteristics of mothers. (n=130) mothers’ socio demographic characteristics no. (%) mother's age 16-24 24 (18.5) 25-33 70 (53.8) 34-42 36 (27.7) occupation housewife 101 (77.7) governmental employee 20 (15.4) private employee 3 (2.3) student 6 (4.6) level of education illiterate 56 (43.1) able to read and write 13 (10) primary school graduate 11 (8.5) secondary school graduate 21 (16.2) institute graduate 12 (9.2) college graduate 15 (11.5) postgraduate 2 (1.5) residency area rural 31 (23.8) urban 57 (43.8) suburban 42 (32.3) type of family nuclear 90 (69.2) joint 14 (10.8) extented 26 (20) economic status type of delivery sufficient for daily needs 82 (63.1) insufficient 32 (24.6) exceeds needs normal delivery cesarean section episiotomy 16 49 60 21 (12.3) (37.7) (46.2) (16.2) total 130 (100) https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article and a statistically highly significant association between awareness of infection prevention and their economic status (p-value = 0.004). our study demonstrated that there was a statistically significant association (p-value < 0.05) between mothers' vaccinations awareness and their age and a type of delivery. there was no significant association between mothers' awareness of vaccinations and other socio-demographic characteristics such as level of education, occupation, residency, type of family, and economic status (table 6). there was only a statistically significant association between mothers’ awareness regarding danger signs and their economic status (p-value = 0.013) (table7). 167 erbil journal of nursing & midwifery table 3 shows the association between mothers’ awareness regarding thermoregulation and selected socio-demographic characteristics and demonstrates that there was statistically a very highly significant association between occupation and a family type of mothers and their home care awareness regarding thermoregulation (p value=0.001). there was no statistically significant association between mothers’ thermoregulation awareness and other socio-demographic characteristics such as the age of mother, level of education, residency, economic status, and type of delivery. the current study found that there was a statistically significant association between an area of mother’s residency and a type of delivery and their home care awareness regarding breastfeeding with p-value = 0.037 and 0.050 respectively (table 4). table 5 shows the existence of a statistically significant association between mothers’ awareness of infection prevention and their occupation (p-value = 0.037), table 2: assessment of mothers’ awareness regarding preterm baby homecare. (n=130) assessment of mothers’ awareness regarding preterm baby homecare not aware neutral awareness f (%) f (%) f (%) mothers’ awareness regarding thermoregulation 38 (29.2) 86 (66.2) 6 (4.6) mothers’ awareness regarding breastfeeding 37 (28.5) 91 (70) 2 (1.5) mothers’ awareness regarding infection prevention 88 (67.7) 41 (31.5) 1 (0.8) mothers’ awareness regarding vaccination 51 (39.2) 76 (58.5) 3 (2.3) mothers’ awareness regarding danger signs 40 (30.8) 87 (66.9) 3 (2.3) https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article 168 erbil journal of nursing & midwifery table 3: association between mothers’ awareness regarding thermoregulation and selected socio-demographic characteristics. thermoregulation (scores) not aware neutral awareness p-value socio demographic characteristics no. (%) no. (%) no. (%) mother's age 16-24 8 (33.3) 13 (54.2) 3 (12.5) 0.213 ns 25-33 19 (27.1) 48 (68.6) 3 (4.3) 34-42 11 (30.6) 25 (69.4) 0 (0) occupation housewife 53 (40.8) 36 (27.7) 12 (9.2) 0.001 vhs governmental employee 11 (8.5) 6 (4.6) 3 (2.3) private employee 3 (2.3) 0 (0) 0 (0) student 6 (4.6) 0 (0) 0 (0) level of education illiterate 16 (28.6) 37 (66.1) 3 (5.4) 0.603 ns able to read and write 1 (7.7) 12 (92.3) 0 (0) primary school graduate 4 (36.4) 7 (63.6) 0 (0) secondary school graduate 6 (28.6) 13 (61.9) 2 (9.5) institute graduate 4 (33.3) 8 (66.7) 0 (0) college graduate 7 (46.7) 7 (46.7) 1 (6.7) post graduate 0 (0) 2 (100) 0 (0) residency rural 7 (22.6) 23 (74.2) 1 (3.2) 0.590 ns urban 15 (26.3) 39 (68.4) 3 (5.3) suburban 16 (38.1) 24 (57.1) 2 (4.8) type of family nuclear 27 (30) 63 (70) 0 (0) 0.001 vhs joint 5 (35.7) 8 (57.1) 1 (7.1) extend 6 (23.1) 15 (57.7) 5 (19.2) economic status sufficient for daily needs 22 (26.8) 57 (69.5) 3 (3.7) 0.202 ns insufficient 8 (25) 21 (65.6) 3 (9.4) exceeds needs 8 (50) 8 (50) 0 (0) type of delivery normal vaginal delivery 11 (22.4) 36 (73.5) 2 (4.1) 0.690 ns caesarean section 21 (35) 36 (60) 3 (5) episiotomy 6 (28.6) 14 (66.7) 1 (4.8) https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article 169 erbil journal of nursing & midwifery table 4:association between mothers’ awareness regarding breastfeeding and selected socio-demographic characteristics. breastfeeding (scores) not aware neutral awareness p-value socio demographic characteristics no. (%) no. (%) no. (%) mother's age 16-24 7 (29.2) 17 (70.8) 0 (0) 0.219 ns 25-33 24 (34.3) 44 (62.9) 2 (2.9) 34-42 6 (16.7) 30 (83.3) 0 (0) occupation housewife 29 (28.7) 71 (70.3) 1 (1) 0.331 ns governmental employee 3 (15) 16 (80) 1 (5) private employee 2 (66.7) 1 (33.3) 0 (0) student 3 (50) 3 (50) 0 (0) level of education illiterate 15 (26.8) 41 (73.2) 0 (0) 0.529 ns able to read and write 3 (23.1) 9 (69.2) 1 (7.7) primary school graduate 3 (27.3) 8 (72.7) 0 (0) secondary school graduate 9 (42.9) 12 (57.1) 0 (0) institute graduate 4 (33.3) 8 (66.7) 0 (0) college graduate 3 (20) 11 (73.3) 1 (6.7) post graduate 0 (0) 2 (100) 0 (0) residency rural 11 (8.5) 18 (13.8) 2 (1.5) 0.037 s urban 34 (26.2) 21 (16.2) 2 (1.5) suburban 21 (16.2) 17 (13.1) 4 (3.1) type of family nuclear 25 (27.8) 63 (70) 2 (2.2) 0.864 ns joint 5 (35.7) 9 (64.3) 0 (0) extend 7 (26.9) 19 (73.1) 0 (0) economic status sufficient for daily needs 21 (25.6) 60 (73.2) 1 (1.2) 0.340 ns insufficient 13 (40.6) 18 (56.3) 1 (3.1) exceeds needs 3 (18.8) 13 (81.3) 0 (0) type of delivery normal vaginal delivery 14 (28.6) 34 (69.4) 1 (2) 0.050 s caesarean section 16 (26.7) 43 (71.7) 1 (1.7) episiotomy 14 (66.7) 7 (33.3) 0 (0) https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article 170 erbil journal of nursing & midwifery table 5: association between mothers’ awareness regarding infection prevention and selected socio-demographic characteristics. infection prevention (scores) not aware neutral awareness p-value socio demographic characteristics no. (%) no. (%) no. (%) mother's age (years) 16-24 14 (58.3) 10 (41.7) 0 (0) 0.605 ns 25-33 47 (67.1) 22 (31.4) 1 (1.4) 34-42 27 (75) 9 (25) 0 (0) occupation housewife 72 (71.3) 29 (28.7) 0 (0) 0.037 s governmental employee 13 (65) 6 (30) 1 (5) private employee 2 (66.7) 1 (33.3) 0 (0) student 1 (16.7) 5 (83.3) 0 (0) level of education illiterate 41 (73.2) 15 (26.8) 0 (0) 0.281 ns able to read and write 8 (61.5) 5 (38.5) 0 (0) primary school graduate 7 (63.6) 4 (36.4) 0 (0) secondary school graduate 16 (76.2) 5 (23.8) 0 (0) institute graduate 5 (41.7) 6 (50) 1 (8.3) college graduate 10 (66.7) 5 (33.3) 0 (0) post graduate 1 (50) 1 (50) 0 (0) residency rural 24 (77.4) 7 (22.6) 0 (0) 0.386 ns urban 34 (59.6) 22 (38.6) 1 (1.8) suburban 30 (71.4) 12 (28.6) 0 (0) type of family nuclear 60 (66.7) 29 (32.2) 1 (1.1) 0.867 ns joint 11 (78.6) 3 (21.4) 0 (0) extend 17 (65.4) 9 (34.6) 0 (0) economic status sufficient for daily needs 55 (67.1) 26 (31.7) 1 (1.2) 0.004 hs insufficient 23 (71.9) 9 (28.1) 0 (0) exceeds needs 10 (62.5) 6 (37.5) 0 (0) type of delivery normal vaginal delivery 37 (75.5) 12 (24.5) 0 (0) 0.447 ns caesarean section 39 (65) 20 (33.3) 1 (1.7) episiotomy 12 (57.1) 9 (42.9) 0 (0) https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article 171 erbil journal of nursing & midwifery table 6: association between mothers’ awareness regarding vaccination and selected socio-demographic characteristics. vaccination (scores) not aware neutral awareness p-value socio demographic characteristics no. (%) no. (%) no. (%) mother's age (years) 16-24 18 (13.8) 5 (3.8) 1 (0.8) 0.047 s 25-33 49 (37.7) 20 (15) 1 (0.8) 34-42 30 (23.1) 6 (5) 0 (0) occupation housewife 37 (36.6) 61 (60.4) 3 (3) 0.320 ns governmental employee 7 (35) 13 (65) 0 (0) private employee 2 (66.7) 1 (33.3) 0 (0) student 5 (83.3) 1 (16.7) 0 (0) level of education illiterate 20 (35.7) 34 (60.7) 2 (3.6) 0.855 ns able to read and write 6 (46.2) 7 (53.8) 0 (0) primary school graduate 2 (18.2) 8 (72.7) 1 (9.1) secondary school graduate 9 (42.9) 12 (57.1) 0 (0) institute graduate 6 (50) 6 (50) 0 (0) college graduate 7 (46.7) 8 (53.3) 0 (0) post graduate 1 (50) 1 (50) 0 (0) residency rural 14 (45.2) 16 (51.6) 1 (3.2) 0.716 ns urban 24 (42.1) 32 (56.1) 1 (1.8) suburban 13 (31) 28 (66.7) 1 (2.4) type of family nuclear 33 (36.7) 56 (62.2) 1 (1.1) 0.392 ns joint 5 (35.7) 8 (57.1) 1 (7.1) extend 13 (50) 12 (46.2) 1 (3.8) economic status sufficient for daily needs 33 (40.2) 47 (57.3) 2 (2.4) 0.662 ns insufficient 14 (43.8) 17 (53.1) 1 (3.1) exceeds needs 4 (25) 12 (75) 0 (0) type of delivery normal vaginal delivery 21 (42.9) 25 (51) 3 (6.1) 0.02 s caesarean section 20 (33.3) 40 (66.7) 0 (0) episiotomy 10 (47.6) 11 (52.4) 0 (0) https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article 172 erbil journal of nursing & midwifery table 7: association between mothers’ awareness regarding danger signs and selected socio-demographic characteristics. danger signs (scores) not aware neutral awareness p-value socio demographic characteristics no. (%) no. (%) no. (%) mother's age (years) 16-24 6 (25) 17 (70.8) 1 (4.2) 0.680 ns 25-33 24 (34.3) 44 (62.9) 2 (2.9) 34-42 10 (27.8) 26 (72.2) 0 (0) occupation housewife 34 (33.7) 65 (64.3) 2 (2) 0.340 ns governmental employee 4 (20) 15 (75) 1 (5) private employee 2 (66.7) 1 (33.3) 0 (0) student 0 (0) 6 (100) 0 (0) level of education illiterate 20 (35.7) 36 (64.3) 0 (0) 0.061 ns able to read and write 2 (15.4) 11 (84.6) 0 (0) primary school graduate 2 (18.2) 9 (81.8) 0 (0) secondary school graduate 10 (47.6) 10 (47.6) 1 (4.8) institute graduate 1 (8.3) 11 (91.7) 0 (0) college graduate 4 (26.7) 9 (60) 2 (13.3) post graduate 1 (50) 1 (50) 0 (0) residency rural 14 (45.2) 16 (51.6) 1 (3.2) 0.227 ns urban 15 (26.3) 40 (70.2) 2 (3.5) suburban 11 (26.2) 31 (73.8) 0 (0) type of family nuclear 25 (27.8) 62 (68.9) 3 (3.3) 0.665 ns joint 5 (35.7) 9 (64.3) 0 (0) extend 10 (38.5) 16 (61.5) 0 (0) economical status sufficient for daily needs 29 (35.4) 52 (63.4) 1 (1.2) 0.013 s insufficient 10 (31.3) 22 (68.8) 0 (0) exceeds needs 1 (6.3) 13 (81.3) 2 (12.5) type of delivery normal vaginal delivery 17 (34.7) 31 (63.3) 1 (2) 0.785 ns caesarean section 18 (30) 40 (66.7) 2 (3.3) episiotomy 5 (23.8) 16 (76.2) 0 (0) https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article assessment of socio-demographic characteristics of mothers. more than half (53.8%) of the mothers in the present study were between 25-33 years of age. these results are similar to a study carried out by raffray et al (2014) in colombia, which revealed that 46.6% of participants were 25-30 years old [12], but are different from a study done by gul et al in the neonatology unit of khyber teaching hospital in peshawar in 2018, which stated that most of the mothers (62.7%) were in the age group of 21-31 years [13]. the current study showed that the highest percentages of the participants were housewives. this result agrees with the studies by abbasi-shavazi (2019) from iran and ahmed (2007) from egypt, in which the majority of mothers were also housewives [14, 15]. the results of the present study revealed that less than half of the research sample was illiterate. this result agrees with a study by roba et al in eastern ethiopia who mentioned that most mothers did not have any education [16]. however, the results are different from a study done by çelen and arsalan in turkey in 2017, which indicated that 38.25% of mothers had a primary school education [17]. in the current study, most participants lived in urban areas. this finding is in agreement with a study carried by abdel-latif et al in australia, which showed that the highest percentage of mothers lived in urban areas [18], and also similar to a study done by roba et al in eastern ethiopia, which indicated that more than half (55.87%) of mothers lived in urban areas [16]. nearly three-quarters of mothers in the current study lived in a nuclear family. this finding is similar to a conducted by nepal and thapa in 2017, which showed that more than half of mothers were living in a nuclear family [19]. our finding differs from a study of castalino et al from india who found that the majority 173 erbil journal of nursing & midwifery of mothers lived in a joint family [20].regarding the economic status, most participants of the current study indicated that their income was sufficient for daily needs. this result is consistent with the finding of a bangladeshi study by khatun and rahman from 2008, which mentioned that most of the mothers' economic status satisfied their daily needs [21].onethird of the participants of the current study delivered preterm babies by c\s. these finding is supported by a study of çelen and arsalan in turkey, which found that the majority of mothers had c\s delivery [17], and also by a randomized clinical trial study by akbarian et al (2017) in iran, which showed that 74% of mothers in the intervention group and 66% mothers in the control group delivered by a cesarean section [22]. assessment of mothers’ awareness regarding preterm baby home care. the high percentage (66.2%) of mothers in the current study had neutral awareness regarding thermoregulation of preterm babies at home. a similar study was conducted by malathi et al (2014) in india, which revealed that the majority of mothers had a neutral level of awareness about thermoregulation [23]. the majority (70%) of mothers in the current study had neutral awareness regarding breastfeeding. the results are the same as in a crosssectional survey conducted in bangalore on postnatal mothers, which reported that most of the mothers had neutral breastfeeding awareness [26]. most of the mothers in the current study had poor awareness regarding infection prevention. this finding disagrees with a study by khalesi et al (2015) in iran, which found that most parents were aware of regular hygiene to prevent infection [30]. the majority of mothers had neutral awareness regarding vaccinations. a similar study, which was done by meseka et al (2017) discussion https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article in south sudan found that most participants had gaps in awareness about vaccinations [24]. the high percentage (66.9%) of mothers in this study had neutral awareness regarding recognizing danger signs. this finding is not supported by anmut et al (2017) who conducted a study in ethiopia, which revealed that mothers had poor awareness about recognizing danger signs [34]. home care our study shows statistically a very highly significant association between mothers’ awareness of thermoregulation and their type of occupation with the p-value=0.001. this finding is consistent with a study done by meseka et al in soudan, which mentioned a highly significant statistical association between mothers’ awareness and their type of occupation [24]. the findings further show that there is statistically a very highly significant association between a type of family and their awareness regarding thermoregulation. this finding is supported by a study of panda et al in india, which found a statistically significant association between the type of family of mothers and their awareness regarding thermoregulation, with the p-value <0.001 [25]. the result of the current study shows that there was no statistically significant association between the age of participants and their awareness regarding thermoregulation. this finding is in agreement with a study of malathi (2015), which found that there was no statistically significant association between the age of the participants and their awareness regarding thermoregulation [23]. current results show that there is no statistically significant association between the level of education of mothers and their awareness regarding thermoregulation, which is supported by a study of malathi (2015) who found no statistically significant association between the level of education of mothers and their 174 erbil journal of nursing & midwifery awareness regarding thermoregulation [23]. the result of the current study also shows no statistically significant association between the area of living of mothers and their awareness regarding thermoregulation. this finding is not supported by a study, which was conducted by panda et al in india who found a statistically significant association between the area of living of mothers and their awareness regarding thermoregulation with the pvalue <0.001 [25]. there is also no statistically significant association between economic status and mothers’awareness of thermoregulation in the present study. this finding is in contrast with a study of malathi (2015) who found a statistically significant association between the economic status and thermoregulation awareness with the p-value=<0.05 [23]. our findings revealed no statistically significant association between the type of delivery and the mothers’ awareness of thermoregulation. it is the same result as in a study of çelen and arsalan in turkey (2017), which found there was no significant association between the type of delivery and their awareness regarding thermoregulation [17]. association between mothers’ awareness regarding breastfeeding and selected socio-demographic characteristics. our findings show that there is a statistically significant association between a residency of the mothers and their awareness of breastfeeding with p-value=0.037. vijayalakshmi et al (2015) conducted a cross-sectional survey in bangalore on postnatal mothers, which found a statistically significant association between the participants’ area of living and their awareness regarding breastfeeding with the p-value=0.012 [26]. a type of delivery was statistically significantly associated with mothers’ awareness regarding breastfeeding with the p-value = 0.050. https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article jamil et al (2018) in lahore found a significant association between the modes of delivery of participants and mothers’ awareness regarding breastfeeding with the pvalue=0.037 [27]. the present study indicates that there is no significant association between mother's awareness regarding breastfeeding and their age, occupation and educational level. abdel aziz et al (2018) in burkina faso conducted a descriptive study among mothers, which found no significant association between mothers’ awareness of breastfeeding and their age, occupation and educational level [28]. there was no significant association between mothers’ awareness regarding breastfeeding and their types of family and economic status. this finding agrees with a cross-sectional study by vijayalakshmi et al (2015) in bangalore who conducted a study on mothers of preterm babies, which found no significant association between mother's awareness regarding breastfeeding and their types of family and economic status [26]. association between mothers’ awareness regarding infection prevention and selected socio-demographic characteristics. the researcher found that there is a highly significant statistical association between mothers' awareness of infection prevention and their economic status. this result is not matched with a study, which was done in india and mentioned that economic status does not influence mothers' awareness of infection prevention [21]. our study reveals that there is a statistically significant association between mother's awareness regarding infection prevention and their occupation with the p-value = 0.037. this finding is supported by a crosssectional study of amolo et al (2017) in kenya, which showed that there was a statistically significant association between poor mothers' awareness and their occupation regarding infection prevention [29]. 175 erbil journal of nursing & midwifery table 4 shows that there is no statistically significant association between mothers' awareness regarding infection prevention and their age in the present study. this result disagrees with the research of khalesi et al (2015) in iran who conducted a descriptive, cross-sectional study and found that there was a statistically significant association between mothers' awareness and the age of participants [30]. regarding the level of education, the present study shows that there is no statistically significant association between mothers' awareness regarding infection prevention and their level of education. this result is in line with a study done in kenya, which found that there was a statistically significant association between mothers' poor awareness of infection prevention and their level of education [29]. the current study found that a residency area, types of family and a mode of delivery of participants hadn't influenced mothers' awareness regarding infection prevention. it correlates with a previous study, which was done in india and found no statistically significant association between residency areas, types of family and a mode of delivery with mothers' awareness of infection prevention [21]. association between mothers’ awareness regarding vaccinations and selected sociodemographic characteristics. our findings show that there is a statistically significant association between mothers' awareness regarding vaccinations and their age. as in research done by adefolalu et al (2019) who conducted a cross-sectional descriptive study in ikorodu local government area (lga) of lagos, which found that there was a statistical association between mothers' awareness regarding vaccinations and their age [31]. our study shows a statistically significant association between mothers' awareness regarding vaccination and their type https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article of delivery, which is different from a study of castalino et al (2014), which found no such association [21]. regarding mothers' occupation and residency, the current study demonstrates that there is no statistical association between mothers' awareness regarding vaccination and their occupation and residency area. bofarraj (2008) in libya conducted a cross-sectional survey of a non-randomized sample of 200 mothers and found that there was no statistical association between mothers' knowledge regarding vaccinations and their occupation and residency area (p-value=>0.05) [32]. according to the results of the present study, there is no statistical association between mothers' awareness of vaccinations and their level of education. a study by adefolalu et al (2019) in local government area (lga) of lagos also reported that there was no statistical association between mothers' awareness regarding vaccinations and their level of education [31]. regarding economic status and a type of family, the current study shows there was no statistical association between mothers' awareness regarding vaccinations and their economic status and a type of family. these findings are supported by a study of jose et al (2013) conducted a study in mangalore, which concluded that there was no statistical association between mothers' awareness of vaccinations and their economic status and a type of family [33]. association between mothers’ awareness regarding danger signs and selected sociodemographic characteristics. our study shows that there is a statistically significant association between mothers’ awareness regarding danger signs and economic status. this result is in line with a study of adem et al (2015), who conducted a cross-sectional study in ethiopia and found a statistically significant association between mothers' awareness regarding 176 erbil journal of nursing & midwifery danger signs and their economic status [35]. regarding the mothers' age, this study found no statistically significant association between mothers' awareness of danger signs and their age and level of education. these results agree with a study done by ekwochi et al (2015) in nigeria who stated that there was no statistically significant association between mothers' awareness regarding danger signs and their age and level of education [36]. furthermore, according to the current study, there is no statistically significant association between mothers' awareness of danger signs and their occupation and residency area. these results are different from the conclusions of a study by jemberia et al (2018) conducted in ethiopia, which described a statistically significant association between mothers' awareness of danger signs and their occupation and residency area [37]. additionally, this research found no statistically significant associations between mothers' awareness regarding danger signs and the type of family and the mode of delivery. these findings agree with findings of prabhakaran (2015) who conducted quantitative pre-experimental research in india and mentioned that there were no statistically significant associations between mothers' awareness regarding danger signs the type of family and the mode of delivery [38]. this study found that the majority of studied mothers were of childbearing age, the majority were illiterate, housewives and lived in an urban area. the results further indicate that most of the mothers had poor awareness regarding preterm baby home care, and occupation, type of family, residency, type of delivery, age of mothers, and economic status influenced the mothers’ awareness regarding conclusion https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article preterm baby home care. there is no actual or potential conflict of interest. [1] world health organization. preterm birth. who headquarters in geneva.2018. available from: http://www.who.int/news-room/ fact-sheets/detail/preterm-birth [2] blencowe h, cousens s, oestergaard mz, chou d, moller ab, narwalr, et al. national, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. the lancet. 2012. 379(9832), pp.2162-2172. available from https:// www.ncbi.nlm.nih.gov/pubmed/22682464 [3] lawn je, davidge r, paul vk, von xylander s, de graft johnson j, costello aet al. born too soon: care for the preterm baby. reproductive health. 2013; 10(1): s5. available from: http://www.reproductive-healt journal.com/ content/10/s1/s5 [4] world health organization. born too soon: the global action report on preterm birth. march of dimes, partnership for maternal, newborn, child health. save the children.2012. available from: http:// www.who.int/pmnch/media/ news/2012/201204_borntoosoon-report.pdf [5] mohsenzadeh a, saket s, karimi a. prevalence of preterm neonates and risk factors. iranian journal of neonatology. 2011; 2(2). available from: http://ijn.mums.ac.ir/ artcle_5152_11d974e9f6c4e334e442fcda7fb 5bbaa.pdf [6] offiah i, o’donoghue k, kenny l. clinical risk factors for preterm birth. preterm birthmother and child. 1st ed. intech. 2012:7394.availabl from:http:// www.intechopen.com/books/preterm-birthmother-and-child/clinical-risk-factors-forpreterm-birth [7] lawan je, kerber k, enweronu-laryea c, cousens s. 3.6 million neonatal deaths— what is progressing and what is not?. seminars in perinatology.2010; 34(6): 371-86. available from: https:// www.sciencedirect.com/science/article/pii/ s0146000510001175?via%3dihub 177 erbil journal of nursing & midwifery [8] shreena. the complications in premature deliveries. journal of nursing and health science. 2016;2(3). available from: http:// www.rroij.com/open-access/complicationin-premature-deliveries-.pdf [9] newnham jp, dickinson je, hart rj, pennell ce, arrese ca, keelan ja. strategies to prevent preterm birth. frontiers in immunology. 2014; 5(584). available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc4237124/pdf/fimmu-05-00584.pdf [10] hochenberry, mj and wilson d. wongs essential of pediatric nursing, 9th edition, united state of america, mosby.2013; p: 596-597 [11] lawn je, davidge r, paul vk, von xylander s, de graft johnson j, costello a, kinney mv, segre j, molyneux l. born too soon: care for the preterm baby. reproductive health. 2013 nov;10 (1): s5. available from: http://www.who.int/pmnch/media/ news/2012/borntoosoon_chapter5.pdf [12] raffray m, semenic s, osorio galeano s, ochoa marín sc. barriers and facilitators to preparing families with premature infants for discharge home from the neonatal unit. perceptions of health care providers. investigation education en enfermeria. 2014 dec;32(3):379-92. available from: http:// www.scielo.org.co/scielo.php? pid=s012053072014000300003&script=sci_ arttext&tlng=en [13] gul r, noreen s, memon ah, ullah a, ali hu, khan az. factors determining the consequences of prematurity in a teaching hospital. journal of khyber college of dentistry. 2018; 8(2). available from: http:// www.jkcd.kcd.edu.pk/issues/june-2018-82/jkcd-v8-no2-(4).pdf [14] abbasi-shavazi m, sadeghian h, noorishadkam m, askarishahi m. perceived benefits and barriers of mothers with premature infant to kangaroo mother care. international journal of pediatrics. 2019; 7(4), pp.9237-9248. available from: http://ijp.mums.ac.ir/ article_11738_adebf0d83cc38aaea0542bda60 4814f2.pdf [15] ahmed ah. breastfeeding preterm infants: an educational program to support mothers of preterm infants in cairo, egypt. pediatric nursing. 2007; 34(2), p.125. available from: https:// www.researchgate.net/profile/ conflict of interest references https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article azza_ahmed4/ publication/5313117_breastfeeding_preterm_infant s_an_educational_program_to_support_mo thers_of_preterm_infants_in_cairo_egypt/ links/00463537d1faa2b2a5000000/ breastfeeding-preterm-infants-aneducational-program-to-support-mothers-ofpreterm-infants-in-cairo-egypt.pdf [16] roba aa, binoy s, naganuri ma. knowledge, attitude and practice of kangaroo mother care by postnatal mothers who gave birth to preterm and low birth weight babies in public hospitals, eastern ethiopia. journal of neonatal biology. 2017; 6(3): 264. available from: https://www.omicsonline.org/openaccess/knowledge-attitude-and-practice-ofkangaroo-mother-care-by-postnatal-mothers -who-gave-birth-to-preterm-and-low-birthweight-babies-2167-0897-1000264.pdf [17] çelen r and arslan ft. the anxiety levels of the parents of premature infants and related factors. the journal of pediatric research. 2017; 4(2), p.68. available from: http:// cms.galenos.com.tr/uploads/ article_15972/68-74.pdf [18] abdel-latif, m.e, bajuk b, oei j, vincent t, sutton, lui k. does rural or urban residency make a difference to the neonatal outcome in premature birth? a regional study in australia. archives of disease in childhood-fetal and neonatal edition. 2006; 91(4), pp.f251f256.available from: https:// www.researchgate.netpublication/7345215_ does_rural_or_urban_residency_make_a_di fference_to_neonatal_outcome_in_prematu re_birth_a_regional_study_in_australia [19] nepal s and thapa s. knowledge and practice of newborn care among mothers of infants in kavrepalanchok district. international annals of medicine. 2017; 1(4). available from: https://pdfs.semanticscholar.org/ d4c7/ a3f38cf346704167397861713d223ee97766. pdf [20] castalino f, nayak bs and d'souza a. knowledge and practices of postnatal mothers on newborn care in tertiary care hospital of udupi district. nitte university journal of health science. 2014;4(2), p.98. available from: http://nitte.edu.in/journal/ june2014/98-101.pdf [21] khatun s and rahman m. socio-economic determinants of low birth weight x 178 erbil journal of nursing & midwifery in bangladesh: a multivariate approach. bangladesh medical research council bulletin. 2008; 34(3), pp.81-86. available from: https://www.banglajol.info/ index.php/bmrcb/article/view/1857 [22] akbarian, m., dashti, f. and baraz, s, the effect of phone counseling for mothers of premature infants discharged from the hospital on infants’ readmission. international journal of pediatrics. 2017; 5(8), pp.5441-5450.available from: http://ijp.mums.ac.ir/ article_3945_0.htmlhttp:/ijp.mums.ac.ir/ article_8890.html [23] malathi k. effectiveness of structured teaching programme on knowledge regarding measures of thermoregulation in newborn among postnatal mothers. american international journal of research in humanities, arts and social sciences. 2015; 11(1).64-68. available from: http:// iasir.net/aijrhasspapers/aijrhass15528.pdf [24] meseka, la, mungai, lw and musoke, r. mothers’ knowledge on essential newborn care at juba teaching hospital, south sudan. south sudan medical journal. 2017; 10 (3), pp.56-59. available http:// www.southsudanmedicaljournal.com/ assets/files/journals/vol_10_iss_3_aug. [25] panda s, majhi b, panda a. knowledge regarding prevention of hypothermia among mothers of lbw neonates in sncu of mkcg medical college hospital. journal of evidence-based medicine and health care. 2017;4(86):5054-7. available from: https:// www.jebmh.com/data_pdf/sadana% 20panda%20-%20final%20-%20(86).pdf [26] vijayalakshmi p, susheela t, mythili d. knowledge, attitudes, and breastfeeding practices of postnatal mothers: a crosssectional survey. international journal of health sciences, qassim university. 2015; 9 (4).available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc4682591/pdf/ijhs-9-4-364.pdf [27] jamil m, khanum a, omer mt, hamid mh. knowledge, attitude and breastfeeding practices of mothers of infants: an experience from a tertiary care hospital in lahore. proceedings szpgmi vol. 2018;32 (3):1-7. available from: https:// www.researchgate.net/ publication/329308882_knowledge_attitude_and_ https://doi.org/10.15218/ejnm.2019.20 erbil j. nurs. midwifery, vol. 2, no. (2), nov, 2019 original article breastfeing_practices_of_mothers_of_infant s_an_experience_from_a_tertiary_care_ho spital_in_lahore [28] abdel aziz sb, marcel b, franck g, zeynab k, soumaila c, joseph cd then et al. knowledge, opinions and attitudes of mothers about breastfeeding and child feeding in rural areas of burkina faso: a study in ouargaye’s district health facilities. journal of family medicine and health care. 2018; 4(3), pp.13-19. available from: http:// www.medicinehealthcare.org/ article/378/10.11648.j.jfmhc.20180403.11 [29] amolo l, irimug, njai d. knowledge of postnatal mothers on essential newborn care practices at the kenyatta national hospital: a cross-sectional study. pan african medical journal. 2017; 28(1), p.159. available from: https://www.ajol.info/index.php/pamj/ article/view/167377 [30] khalesi n, anjom, fs, rezaeiezadeh g, farahani z. evaluation of parents’ awareness and knowledge about problems and issues related to their premature infants in an iranian hospital. open journal of nursing. 2015; 5, 465-469. available from: https:// file.scirp.org/pdf/ ojn_2015051316281929.pdf [31] adefolalu oa, kanma-okafor oj, balogun mr. maternal knowledge, attitude and compliance regarding immunization of under-five children in primary health care centres in ikorodu local government area, lagos state. journal of clinical sciences. 2019; 16 (1), p.7. available from: http:// www.jcsjournal.org/temp/jclinsci16175342863_145028.pdf [32] bofarraj ma. knowledge, attitude and practices of mothers regarding immunization of infants and preschool children at al-beida city, libya 2008. egyptian journal of pediatric allergy and immunology .2011; 9(1). available from: http://www.jespai.org/cms/ upload/1386015612.pdf [33] jose mj, lobo mmr, nisha k, gs ms, umarani j. awareness on immunization among mothers of under-five children. international journal of innovative research and development (issn 2278–0211). 2013; 2(6).available from: https://pdfs.semanticscholar.org/ d247/22325c0c3d44599c16b45265ee5002d 3ad50.pdf [34] anmut w, fekecha b, demeke t. mother’s knowledge and practice about neonatal danger signs and associated factors 179 erbil journal of nursing & midwifery in wolkite town, gurage zone, snnpr, ethiopia, 2017. journal o biomedical sciences. 2017; 6(4), p.33. available from: http:// www.jbiomeds.com/biomedical-sciences/ mothers-knowledge-and-practice-aboutneonatal-danger-signs-andassociatedfactors-in-wolkite-town-guragezone-snnpr-ethiopia-2017.pdf [35] adem n, berhe kk, tesfay y. awareness and associated factors towards neonatal danger signs among mothers attending public health institutions of mekelle city, tigray, ethiopia, 2015. journal of child adolesc behav. 2017; 5(6). available from: https:// www.omicsonline.org/open-access/ awareness-and-associated-factors-towardsneonatal-danger-signs-amongmothersattending-public-health-institutions-ofmekelle-city-t-2375-4494-1000365.pdf [36] ekwochi u, ndu ik, osuorah cd, amadi of, okeke ib, obuoha e, et al. knowledge of danger signs in newborns and healthseeking practices of mothers and caregivers in enugu state, south-east nigeria. italian journal of pediatrics. 2015; 41(1), p.18. available from: https:// ijponline.biomedcentral.com/ articles/10.1186/s13052-015-0127-5 [37] jemberia mm, berhe et, mirkena hb, gishen dm, tegegneae, reta ma. low level of knowledge about neonatal danger signs and its associated factors among postnatal mothers attending at woldia general hospital, ethiopia. maternal health, neonatology and perinatology. 2018; 4(5), p.5. available from: https://link.springer.com/content/ pdf/10.1186%2fs40748-018-0073-5.pdf [38] prabhakaran h. enhancing maternal knowledge in improving the lives of low birth weight babies. journal of nursing and health science. 2015; 4(4).pp: 71-77. available from: http://www.iosrjournals.org/iosrjnhs/papers/vol4-issue4/version-7/ i04477177.pdf [39] yamane t (1967). statistics, an introductory analysis, 2nd ed. new york: harper and row. https://doi.org/10.15218/ejnm.2022.03 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article knowledge, attitudes, and practices related to covid-19 among people in kurdistan region of iraq: a cross-sectional survey abstract introduction covid-19 emerged as a respiratory disease caused by a new type of coronavirus family. it was detected for the first time in wuhan, china in december 2019 [1]. the disease was found to be highly infectious among humans, and the patients usually presented with respiratory symptoms such as shortness of breath, dry cough, and constitutional symptoms such as fever, fatigue, and myalgia [2-3].among the participants, 18.5% of the ill cases are found to progress to a severe stage that background and objective: covid-19 illness is a serious public health concern worldwide. the people in iraqi kurdistan have little knowledge about coronaviruses. it was noticed that in the kurdistan region, the covid-19 infection was not dealt with as required in terms of knowledge, attitudes, and practice. this study aimed to identify the level of knowledge and attitudes of kurdish people in addition to their practices concerning covid -19. methods: this study adopted an online cross-sectional survey design and was conducted from march 23 to april 2, 2020, to collect data from iraqi kurdistan region citizens who were asked about their knowledge, attitudes, and practices related to covid-19. results: the majority of the study participants were young and male (62.5%). most responders (92.9%) were optimistic that the government could take necessary procedures to reduce the risks of covid-19 infection. less than half of the participants wore masks and gloves when they left home (41.4%, 45.1% males and females respectively). most of the participants had good knowledge (74%), and good practice (64.6%), and the vast majority had a positive attitude (98.1%) concerning covid-19. conclusions: less than half of the participants who got engaged in this study wore masks and gloves whenever they went out. hereby, the participants are to be provided with an extensive health education program so they can increase their awareness of covid-19 infection. keywords: covid-19; knowledge; attitude; practice; kurdistan region shalaw faris ahmed; surgical specialist hospital-cardiac center, ministry of health, erbiliraq dara abdulla al-banna; department of nursing, tishk international university and hawler medical university, erbil, iraq. (correspondence: dara.abdulla@tiu.edu.iq) jamal kareem shakor;nursing department, darbandikhan technical institute, sulaimani polytechnic university, sulaimani, iraq sairan khurshed nariman; college of dentistry, hawler medical university, erbil, iraq ari ahmed taha; surgical specialist hospital-cardiac center, ministry of health, erbil, iraq 22 erbil journal of nursing & midwifery received: 16/02/2022 accepted: 18/04/2022 published: 30/05/2022 https://doi.org/10.15218/ejnm.2022.03 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article led to acute respiratory distress syndrome, septic shock, a severe form of metabolic acidosis, and coagulation dysfunction [1-4]. an active contagion that can be efficient via close contact with an infected person was identified as coronavirus disease 2019 [5-6]. empirical clinical data have shown that the overall mortality rate of the diseases was 8% in the world, which was lower than that of sars (9.5%), mers (34.4%), and h7n9 (39.0%) [1-7].world health organization (who) reported that the covid19 pandemic spread was very fast, and by june 28, 2020, the virus was present in 216 countries, areas, or territories with documented positive lab results and significant human deaths [9]. many aggressive measures were taken to control the spread of the disease to the whole world such as curfew and closing of many public places, with strict isolation of both confirmed and suspected cases of covid-19 [9-10]. by evaluating public understanding and knowledge of covid-19, it is possible to gain deeper insights into public knowledge and attitudes, and thus help to recognize characteristics that affect the public when implementing safe practices and sensitive activities [11]. adherence to the control measures by people is very important and is significantly affected by their knowledge, attitudes, and practices (kap) towards the disease according to the kap hypothesis [12-13]. to make the management of the covid-19 epidemic easier, there is an immediate need to understand the public's awareness of covid-19. in this study, we investigated the knowledge, attitudes, and practices toward covid-19 among the residents of the kurdistan region of iraq. this descriptive study was based on a cross -sectional survey conducted between march 23 to april 2, 2020, a sample size calculator (raosoft software) was used to measure the representative target sample size needed to achieve the study objectives and adequate statistical power [14]. the approximate sample size was calculated based on a 95% confidence level with a population = 2.00.000, an alpha-error of 0.05. online data collection has long been one of the safest and most popular data collection techniques in this period. the pre-test online questionnaire survey was adopted and used in both english and kurdish languages. to develop a covid-19 knowledge questionnaire, the authors depended on the guidelines for controlled and community management of covid-19 by the european centre for disease prevention and control (ecdc), the centers for disease control and prevention (cdc), and the world health organization (who) [15,16,17]. these questions were answered on a yes/no basis with an additional “i don't know” option. the cronbach’s alpha coefficient of the knowledge questionnaire was 0.76 in our sample indicating acceptable internal consistency [18]. the questionnaire was divided into three sections. the total number of questions on the questionnaire was limited to twentynine questions, comprising twelve questions on knowledge, three questions on attitudes, five questions on practices, and nine questions on demographics and health information. part one collected information about the socio-demographic background of the participants such as gender, age, marital status, family members, education levels, city, place of residence, and employment income. individual characteristics were collected in part two, which involved information on the role of social media in covid-19 and online meetings on the outbreak. the last section, part three, contained the details of the knowledge, attitudes, and practices related to covid-19, and it also included clinical presentations, communication routes, and 23 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2022.03 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article prevention and control of covid-19.an online questionnaire survey was posted/ reposted to groups via telecommunication and social networking. the respondents who voluntarily participated were informed about the purpose of the study. besides, the respondents were ensured that their answers would be kept confidential and would only be used for research purposes. the respondents completed the answers to the questions and submitted the questionnaires online. furthermore, the emails were arranged and kept in a single folder. data were analyzed by using the ibm statistical package of social sciences (spss) version 25. initially, the data were analyzed descriptively using frequency, and percentage. the responses to the participant's knowledge items included three answers (0 = i don't know, 1= incorrect, and 2= correct). the calculation of overall participant's knowledge (12 items) was categorized into three groups poor knowledge (0-8), fair knowledge (9-16), and good knowledge (17-24). the responses to the participant's practice items included three answers (0 = not done, 1= sometimes, and 2= done). the calculation of overall participant's practice (3 items) was categorized into three groups poor practice (0-2), fair practice (3-4), and good practice (5-6).the responses to the participant's attitude items included three answers (0 = i don't know, 1= disagree, and 2= agree). the calculation of the overall participant's attitude (5 items) was categorized into two groups negative attitude (0-5) and positive attitude (6-10). table 1 shows that the participants were mostly young; and male, 667 (62.5%) were aged less than 35 years, and 677 (62.6%) were male. the responders were mostly from families having less than 5 members 678 (62.7%), diploma and bachelor’s 24 erbil journal of nursing & midwifery results degree educated level 777 (72.9%), being governmentally employed 434 (40.1%), the middle income of economic status 1000 (92.5%), lived in urban 927 (85.8%) and in erbil 856 (79.2%). table 2 demonstrates that the responders had relatively positive awareness of covid-19 as 1038 responders (96%) believed in covid-19. almost 958 (88.6) % knew that the coronavirus virus spreads via respiratory droplets of infected individuals. meanwhile, beliefs about wearing gloves, masks, and the possibility of the product being contaminated were less than 45%. table 3 shows the participants' attitudes in terms of covid19. most participants 1004 (92.9%) agreed with the governmental measures to reduce the transmission risk, and some responders 278 (25.7%) felt worried about the infection. table 4 illustrates that for 956 (88.4%) of the respondents, the most frequent practice to protect from being infected was staying at home with all family members while less than 464 (43%) bought products from china and iran. table 5 shows that most participants (800, 74%) had good knowledge, positive attitude 1060 (98.1%), and good practice 694 (64.6%) concerning covid-19. https://doi.org/10.15218/ejnm.2022.03 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article 25 erbil journal of nursing & midwifery table 1: socio demographic characteristics of the study population socio-demographic characteristics (n=1081) n (%) age 15-24 358 (33.1) 25-34 469 (43.4) 35-44 197 (18.2) 45-54 47 (4.3) ≥ 55 10 (0.9) gender male 677 (62.6) female 404 (37.4) marital status single 542 (50.1) married 539 (49.9) family members < 5 678 (62.7) 6-10 376 (34.8) > 10 27 (2.5) education levels primary and secondary 153 (14.2) diploma and bachelor 777 (71.9) master’s degree and phd 151 (14) job student 280 (25.9) government employees 434 (40.1) not working 118 (10.9) private employee 183 (16.9) free job 66 (6.1) income low 58 (5.4) middle 1000 (92.5) upper middle 23 (2.1) city erbil 856 (79.2) sulaymaniyah 185 (17.1) duhok 32 (3) halabja 8 (0.7) place of residence urban 927 (85.8) rural 154 (14.2) https://doi.org/10.15218/ejnm.2022.03 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article 26 erbil journal of nursing & midwifery table 2: knowledge about covid-19 knowledge (n=1081) yes no i do not know n (%) n (%) n (%) do you believe in covid19? 1038 (96) 43 (4) 0 (0) do you know much about coronavirus disease (covid19)? 647 (59.9) 414 (38.3) 20 (1.9) do you know the main medical symptoms of covid-19 are fever, fatigue, dry cough, and myalgia? 751 (69.5) 123 (11.4) 207 (19.1) is coronavirus disease (covid-19) the same as the flu? 688 (63.6) 153 (14.2) 240 (22.2) is the covid-19 virus spread via respiratory droplets of infected individuals? 958 (88.6) 60 (5.6) 63 (5.8) am i at risk for covid-19 from a package or products shipping from china or other countries? 450 (41.6) 338 (31.3) 293 (27.1) should i wear a mask to protect myself? 448 (41.4) 573 (53) 60 (5.6) should i wash my hands frequently using soap and water to protect myself? 684 (63.3) 397 (36.7) 0 (0) should i wear gloves when i go shopping? 492 (45.5) 589 (54.5) 0 (0) should i avoid touching my face, nose, and eyes? 528 (48.8) 553 (51.2) 0 (0) should i avoid close contact with anyone who has cold flu -like symptoms to protect myself? 665 (61.5) 411 (38) 5 (0.5) should i avoid going to crowded places such as masjids and avoid taking public places? 719 (66.5) 362 (33.5) 0 (0) https://doi.org/10.15218/ejnm.2022.03 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article 27 erbil journal of nursing & midwifery table 3: attitude according to covid 19 protective measures attitude (n=1081) yes no i do not know n (%) n (%) n (%) do you agree that you are at risk from covid-19 due to taking products from outside of the kurdistan region? 450 (41.6) 337 (31.3) 293 (27.1) do you agree that government can win the conflict against the covid-19 virus? 991 (91.7) 64 (5.9) 26 (2.4) do you agree with the procedures the government achieved to decrease people's risk of being infected by/ with covid 19? 1004 (92.9) 54 (5) 23 (2.1) do you agree to help government to control this situation? 958 (88.6) 65 (6) 58 (5.4) do you agree with your worry feel about covid-19? 278 (25.7) 502 (46.4) 301 (27.8) table 4: practices to protect from covid 19 practice (n=1081) yes no i do not know n (%) n (%) n (%) during this period, have you bought products from china, iran, or other products that have been infected by covid19? 464 (42.9) 365 (33.8) 252 (23.3) during this quarantine, have you stayed at home? 843 (78) 238 (22) 0 (0) during this quarantine, have all family members stayed at home? 956 (88.4) 66..0 (6.1) 59.0 (5.5) table 5: the overall knowledge, attitude, and practice about covid-19 overall kap (n=1081) n (%) overall knowledge (n=1081) good 800 (74) fair 281 (26) poor 0 (0) overall practice (n=1081) good 698 (64.6) fair 378 (35) poor 5 (0.5) overall attitude (n=1081) positive attitude 1060 (98.1) negative attitude 21 (1.9) total 1081 (100) https://doi.org/10.15218/ejnm.2022.03 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article china, malaysia, and saudi arabia showed that the majority of the participants also held an optimistic attitude towards the epidemic: they believed that it would finally be successfully controlled, and they were confident that china, malaysia, and saudi arabia could win the battle against the virus [1,10-20]. this study also evaluated kap's characteristics in contradiction to covid-19 and described some related demographic variables to kap. remarkably, the kurdistan region's population practices were incautious: 41.4% wore masks when leaving home during the outbreak's rapid rise period and 66.5% avoided crowded places. in kurdish society, the use of facemasks is not common. it is rare for people in this area to wear a face mask during the disease period. in contrast to these findings, the chinese residents' practices were very cautious: nearly (96.4%) avoided crowded places, and (98.0%) wore masks when leaving home during the covid-19 outbreak [1]. based on the results, this study calls for providing the residents with an extensive health education program to increase their awareness of covid-19. the limitation of the sample representation requires further studies to check the kap to covid-19 among people living in low socio-economic conditions in the kurdistan region of iraq. [1] zhong b, luo w, li h, zhong q, liu x, li w, et al. knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online cross-sectional survey. international journal of biological sciences. 2020;16(10):1745-52 [2] riou j, althaus cl. the pattern of early human-to-human transmission of wuhan 2019 novel coronavirus (2019-ncov) from december 2019 to january 2020. euro surveill. 2020:25(4):1-5. to our knowledge, the present study is the first of its kind focusing on studying kap among the general population of iraqi kurdistan regarding the covid-19 outbreak. the regular number of local cases dropped substantially to nearly zero in areas since late april 2021. nevertheless, the direct link of transmission started since the viral return because many people came back from outside of the kurdistan region, and positive cases were exponentially increasing since june 2020 [19]. observing the instantaneous effective number of reproductions and realtime tuning of policy interventions to ensure a controllable second wave, the overriding public health priority remained close. the availability of data on population knowledge, attitudes, and practices about covid-19 or other related viruses, particularly in the kurdistan region is limited. along with its uncertainties, the novelty of this disease makes it essential for health authorities to plan appropriate strategies to prepare and manage the public. therefore, it is important to study the knowledge, attitudes, and practices of the population to manage these efforts. another study showed that those with low monthly income had the lowest knowledge scores [10-20]. this may indicate limited access to credible and timely information about the virus. the difference in the level of knowledge probably reflects the existing covid-19 figures background in the area [10]. the majority of the participants demonstrated that they had relatively positive awareness of covid-19. almost 92.9% agreed about the governmental measures to reduce transmission, and 88.6% agreed with controlling the covid19 risks during the first wave. likewise, research similar to the current study, in 28 erbil journal of nursing & midwifery discussion conclusion references https://doi.org/10.15218/ejnm.2022.03 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article [12] kurdistan regional government. what you should know coronavirus (covid19). 2020. available from: https://gov.krd/coronavirusen/situation-update/ [13] chirwa gc. “who knows more, and why?” explaining socioeconomic-related inequality in knowledge about hiv in malawi. scientific african. 2020; 7(e00213)1-15. [14] raosoft. sample size calculator 2020. internet. the software; 2020, available from: http://www.raosoft.com/samplesize.html. [15] european center for disease prevention and control (covid-19). questions and answers on covid-19. 2020. available from: https:// www.ecdc.europa.eu/en/covid-19/ questions-answers [16] center for disease control and prevention. coronavirus (covid-19). 2020. available from: https://www.cdc.gov/ coronavirus/2019-ncov/index.html. [17] world health organization. coronavirus disease (covid-19). 2020. [cited 2020 march 16]; available from: https://www.who.int/ emergencies/diseases/novel-coronavirus2019/question-and-answers-hub/q-a-detail/ q-a-coronaviruses [18] cronbach’s alpha. statistics solution advancement through clarity. the scale; 2020. available from: https:// www.statisticssolutions.com/cronbachsalpha/#:~:text=the%20general%20rule% 20of%20thumb,90%20and%20above%20is% 20best [19] kurdistan region government. covid-19 in the kurdistan region. 2020. available from: https://gov.krd/coronavirus-en/dashboard/ [20] al-hanawi mk, angawi kh, alshareef n, qattan am, helmy hz, abudawood y, et al. knowledge, attitude and practice toward covid-19 among the public in the kingdom of saudi arabia: a cross-sectional study. front public health. 2020;8(217)1-10. [3] chan jf, yuan sh, kok kh, to k, chu h, yang j, et al. a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. lancet. 2020; 395(10223):514-23. [4] chen n, zhou m, dong x, qu j, gong f, han y, et al. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. lancet. 2020; 395 (10223):507-13. [5] world health organization. country and technical guidance coronavirus disease (covid-19). 2020. available from: https:// www.who.int/emergencies/diseases/ novel-coronavirus-2019/technicalguidance [6] phan lt, nguyen tv, luong qc, nguyen tv, nguyen ht. importation and human-to -human transmission of a novel coronavirus in vietnam. the new england journal of medicine. 2020; 382(9):872-4. [7] cao j, hu x, cheng w, yu l, tu wj, liu q. clinical features and short-term outcomes of 18 patients with coronavirus disease 2019 in the intensive care unit. intensive care medicine. 2020: 98(2):1-3. [8] world health organization. coronavirus disease (covid-2019) situation reports. 2020. available from: https:// www.who.int/emergencies/diseases/ novel-coronavirus-2019? gclid=cjwkcajw_d3brbieiwajvmy7htm_p 8xklbmre_easnfo6dxrewvikstkq6uuxp 1ujb0b7pl7z-s5hocywkqavd_bwe [9] leung k, wu jt, liu d, leung gm. firstwave covid-19 transmissibility and severity in china outside hubei after control measures, and second-wave scenario planning: a modelling impact assessment. lancet. 2020; 395(10233):1382-93. [10] azlan aa, hamzah mr, sern tj, ayub sh, mohamad e. public knowledge, attitudes and practices towards covid-19: a crosssectional study in malaysia. plos one. 2020; 15(5):1-15. [11] podder d, paul b, dasgupta a, bandyopadhyay l, pal a, roy s. community perception and risk reduction practices toward malaria and dengue: a mixedmethod study in slums of chetla, kolkata. indian journal of public health. 2019; 63 (3):178-85. 29 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2022.04 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article challenges of implementing nurse educator core competencies as perceived by clinical instructors in erbil city, kurdistan region, iraq. abstract introduction clinical education is a vital component of nursing education [1]. the quality of nursing education at the clinic is based solely on the clinical instructors’ (cis) ability to provide and creating the most productive clinical environment possible. the terms clinical nurse instructor and clinical nurse educator are used interchangeably in the field of nursing education. cis teach mainly at clinical placements and support nursing students in gaining theoretical knowledge, practical skills, and background and objective: the quality of nursing education in the clinical setting in nursing colleges, especially in the middle east, is based solely on the clinical instructors’ ability to provide and creating the most productive clinical environment possible. the world health organization (who) identified eight domains as core competencies for clinical nurse educators. however, studies on contemporary clinical education and educators’ role indicate that clinical instructors continuously face challenges in adopting the competencies recognized by the who. therefore, this study aimed to explore the challenges of implementing the nurse educator core competencies as perceived by the clinical instructors in erbil in the kurdistan region of iraq. method: the interpretive phenomenological approach of the qualitative study and swot analysis was adopted to explore the clinical instructors’ experience of clinical education’s challenges. result: the main challenges of the academic institutions were shortages of qualified clinical instructors, lack of confidence among instructors, and difficulty in achieving learning outcomes. challenges reported among health institutions include inappropriate selection for managerial roles, poor recognition of clinical education, and poor teaching environments. conclusion: the study results highlighted challenges for clinical instructors to carry out their role in a safe and less stressful environment, including inadequate strategic plans for clinical teaching from academic institutions and stakeholder involvement in health institutions. keywords: clinical instructors, clinical educators, clinical education, challenges, competencies newroz ghazi aziz; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: newroz.aziz@hmu.edu.krd) vian affan naqshbandi; department of nursing, college of nursing, hawler medical university, erbil, iraq. halmat authman rasheed; department of nursing, college of nursing, hawler medical university, erbil, iraq. 30 erbil journal of nursing & midwifery received: 02/12/2021 accepted: 01/02/2022 published: 30/05/2022 mailto:newroz.aziz%20@hmu.edu.krd https://doi.org/10.15218/ejnm.2022.04 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article understanding of the nursing roles and responsibilities [2]. the world health organization (who) identified eight domains as core competencies for clinical nurse educators [3]: • integrate contemporary teaching theories, principles, and models in teaching nursing adult learners • design, implement, monitor, and manage nursing curriculum based on sound, contemporary educational models, principles, and best evidence • teaching contemporary nursing practice based on the best available evidence • conduct research and utilize the finding to solve educational and practical problems • communicate, collaborate, and partner with other health professionals • develop policies, procedures and decision making based on the legal, ethical, and professional values • utilize effective strategies to monitor and evaluate, nursing programs, curricula, and students’ learning outcomes • demonstrate the skills of system management and leadership to create, maintain, and shape the future of educational institutions the purpose of developing nurse educator core competencies was ‘to enable educators to effectively contribute to the attainment of high-quality education, and the production of effective, efficient and skilled nurses who can respond to the health needs of the populations they serve’ (who, p.5) ³. the ability to master these domains enables cis to utilize the most updated clinical teaching strategies to promote undergraduate nursing students’ competencies and help them to be lifelong learners [3]. previous studies have revealed that supervised clinical practice by competent cis enhances the professional growth of the students, thereby ensuring patient safety and reducing medical errors. however, studies on contemporary clinical education and educators’ role indicated that cis continuously face challenges in adopting the competencies recognized by the who while teaching in clinical settings [4].positive clinical teaching could be encouraged by empowering cis [5, 4]. power is the ability to activate resources to achieve organizational goals. cis could be empowered to face challenges when support is received from health care institutions and academic institutions. enhancing the practical environment by providing learning opportunities is a crucial role of health care institutions. it empowers cis to utilize the most effective learning strategies. additionally, the academic institutions could be better involved in clinical education by letting cis access educational materials, organizational clinical guidance, providing access to continuous training courses, financial support, and rewards. on the contrary, less involvement of academic and health care institutions in the clinical education program causes cis to be confronted by various challenges, including relying on personal knowledge and clinical experience to plan clinical education programs rather than on an institutional strategic program [5]. in such cases, the clinical learning objectives are short and less dependable, compromising and hindering academic institutional goals and vision. the need to achieve a higher level of education and develop skills needed to meet the health organizations’ demands and diversity of patient care made more students enroll in nursing colleges in recent years. the record number of enrollments calls for more competent nurse instructors clinical nursing education. the critical shortage of cis causes various challenges to appear. therefore, this qualitative study was conducted to explore the significant 31 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2022.04 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article based on the who competencies for nurse educators. the interview guide included questions related to challenges in meeting competencies. due to the covid-19 pandemic and the participants' safety, the research team decided to interview using a digital program (zoom). permission was obtained from the participants, and the informed consent was signed and sent back through email and viber application. the interviews lasted between 60 to 80 minutes and were digitally recorded. the researcher reassured participants about the confidentiality of the interview records and the anonymity of participants’ names. anonymity in qualitative research is the key to assisting participants in unveiling sensitive information [7, 8]. the participants chose the kurdish language in the interview to express themselves because they felt more comfortable and confident with their mother tongue. the quotations used in the study were translated to english by an independent professional translator. ethical considerations ethical approval was obtained from the ethical committee of the college of nursing of hawler medical university no. (4) on 29 january 2020. before data collection, written informed consent was obtained digitally. the participants were informed about the study's purpose, benefits, and risks, and they were permitted to withdraw at any point if they felt insecure or uncomfortable. data analysis this study used thematic analysis as the method of data analysis. thematic analysis is widely used in a phenomenological study for compatibility [9]. the swot analysis was written in english and did not need to be translated, only anonymized. the data analysis process was done manually after the digital records of the second phase interviews were anonymized and transcribed. braun and clarke's six phases of thematic analysis [ 10] was applied in the challenges in attempting to implement the core competencies developed by the who [3]. study design: swot and the interpretive phenomenological approach were used. a swot analysis is a “methodology to identify a department’s strengths, weaknesses, opportunities, and threats” [6].time of the study: the study was conducted from january to may 2020. the setting of the study: college of nursing of hawler medical university sample size and data collection: the data were collected in two phases: the first phase was a workshop held 30 january 2020 on that focused mainly on clinical practice. forty faculty clinical educators of the college were invited to a semistructured focus group discussion to talk about their experiences and challenges at the clinics. the clinical educators were divided into several groups based on their specialty. after oral discussion, a group swot analysis was conducted to obtain reliable and written data. the second phase used the interpretive phenomenological approach to explore the cis’ experience of clinical education challenges. a convenient sample of nine academic educators at the college was recruited to participate in individual interviews. the participants have taught clinical practice at the college in different specialties, including adult nursing, pediatric nursing, and maternity care, for more than two years. the eligible criteria for recruitment of both genders included two or more years of clinical teaching experience, completion of a master’s or ph.d. degree, and full-time employment. with the help of the interview guide (see table 1, appendix 1), the in-depth semi-structured interviews were conducted to obtain data from the participants over six weeks starting from march 2020. the original interview guide was developed 32 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2022.04 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article analysis process: 1listening and relistening to the recorded data for familiarization; the swot analysis were read several times by the researchers and one independent coder 2-extracting initial codes by allocating interesting features relevant to the research question: “challenges of teaching undergraduate nursing students at teaching hospitals” 3-generating initial themes by analyzing and combining potential codes; the codes were clustered and labelled based on their similarities and differences to generate main themes and sub-themes 4-reviewing initial themes in relation to the research question 5-naming and defining themes and subthemes in a few sentences to explain what they are consisted of 6-producing the final report with the final themes and subthemes written and presented with dialogues extracted from the interviews and swot analysis table 2 shows the demographic characteristics of the participants in the second phase of data collection. out of nine participants, most were male and from adult nursing specialty (n= 6). the highest age of the participant was 38 years, who also had the highest years of experience in clinical education. the demographic characteristics of the participants in the first phase were not collected since they were divided into subgroups for data collection. the analysis of the overall study data revealed the following themes: academic institutional challenge and health institutions. the three principal subthemes under academic institutional challenge were the shortage of qualified cis, cis' lack of confidence, and lack of clarity in the learning outcomes. inappropriate selection for managerial roles, poor recognition of clinical education importance, and poor teaching environment were the subthemes under health institutions. academic institutional challenges a) qualified cis shortage the nursing profession is in demand in erbil city, the capital city of the kurdistan region of iraq. in recent years the number of private government hospitals have dramatically increased, positively affecting the recruitment of nurses holding baccalaureate degrees. the fast-growing number of nursing students has put a lot of pressure on the college, requiring cis to fill all the gaps present in the clinical schedule. “some of the time i have to cover two areas, helping nearly 25 students with the simple and short task without focusing on the actual learning objectives… i prefer to look after six students as a maximum number, otherwise, it is hard to set clear learning outcomes” (participant #1). the study participants reported that their lack of ability to cover all of the clinical areas caused the college to recruit some clinical educators that have no expertise in supervising nursing students. “it is common to hear from students complaining about wasting their time in the areas where they are supervised by unqualified clinical teachers” (participant #2). b) cis lack of confidence assigning the cis to a clinical placement without the appropriate training course or previous clinical experience in the area is stressful and puts cis in a risky and unsafe environment. some cis disclosed their lack of expertise in the clinical area they are assigned to in terms of skills and finding learning opportunities. the interviews with participants revealed that cis are more 33 erbil journal of nursing & midwifery results https://doi.org/10.15218/ejnm.2022.04 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article procedures, and this affected learning outcomes” (participant #4). changing clinical areas in the middle of the semester is challenging and requires extra hard work as reported by participants. “when i arrive at the clinic, either i ask the staff for activities that can be done by the students or i search by myself to see what procedures are available. finding learning opportunities by myself is difficult and i do not feel comfortable going to clinical placement without appropriate, previously planned activity” (participant #5). moreover, none of the students has a portfolio. students’ learning progress is not documented or shared between cis when the clinical area changes. some procedures and skills might be repeated several times in one clinical area. students never get the chance to practice some activities. most practical activity is planned daily when the students arrive at the clinic which does not necessarily fulfil the desired learning outcomes. “when students’ group changes, i call their cis to see what activities i should focus on, and what students are lacking in so time is not wasted on repeated procedures and skills” (participant #3). health institution challenges a. inappropriate selection for managerial positions the first sub-theme identified under health institution challenges is the ci’s weak authority in clinical settings. most of the cis are holding a master’s degree, or higher, in nursing science, whereas the managerial and administrative positions in the health service are filled by doctors or by nurses holding diploma degrees or lower. unfortunately, promoting staff to a higher 34 erbil journal of nursing & midwifery textbook oriented and avoid being clinically oriented to stay safe and make fewer errors in the practice. “i was assigned to teach at the urology unit, which i never did before. i struggled a lot. i had to familiarize myself with the area while teaching undergraduate students. a lot of learning objectives could be achieved if i had previous experience at urology unit” (participant #3). the college administrators announced the clinical schedule shortly before students started their clinical placements. most cis were relocated to a new clinical area they had never taught before.“teaching in a new clinical setting is hard work. i would prefer to be informed early to familiarize myself with the staff, cases, and learning opportunities” (participant # 1). concerning the problems of clinical settings, participants who spent more than one year in the same clinical setting complained less. “if i compare my clinical objectives now to the first time, i can say it is more productive and clinically oriented. now, i am more familiar with the environment, cases and staff” (participant # 9). c) difficulty achieving learning outcomes there are a limited number of teaching hospitals (government hospitals) in erbil city where students can practice their clinical teaching. furthermore, the inadequacy of the health service at public hospitals results in more patients using nonteaching private hospitals rather than public health care institutions. these barriers forced the clinical committee of the college to distribute students to teaching hospitals based on the availability of the patients rather than learning objectives causing, a huge gap in applying theory to practice. “the area i used to teach in, which was related to my specialty, no longer received patients. therefore, i had to distribute students in the areas that had patients so that students could practice required https://doi.org/10.15218/ejnm.2022.04 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article position in government organizations usually happens based on staff loyalty to a political party, not professional capability. as a result, a vacant position might be filled by staff that has no experience or qualification relevant to that position. this lack of professionalization causes a significant misunderstanding regarding the importance of nursing education, which sometimes means that nursing students are seen as a future threat to the way authority is distributed among health care staff. “most clinical areas where i used to teach had a team leader with a very low qualification in nursing. it was difficult to explain the role and purpose of good quality clinical education” (participant #5).according to the participants, lack of authority forces cis to use the personal relationships with the staff to be allowed into the clinical placement and find learning opportunities. “i try to teach in the clinical settings where i used to work or have friends, so that i can have freedom in using clinical equipment and find the best learning opportunities for students” (participant # 6).in addition, hospital staff distance themselves from academic faculty, staff, and students, by creating an environment where no students are welcomed. “i always advise my students and myself to avoid any argument or criticism with the staff, in fear of losing permission to practice teaching nursing care” (participant #4). b. poor recognition of clinical education importance the participants reported that the health institutions do not see students as their future employees. the quality of clinical education is of least concern of teaching hospitals. they believe that the students will ultimately learn the role of nursing even in the absence of supervisors. “lack of knowledge about nursing role and importance of having mentor, preceptor or supervisor forced us to look after students alone, which i am positive, they would the learn more if hospital staff were involved inclinical education” (participant #5).additionally, the teaching hospital staff perceive cis and nursing students as a burden. they demand that the college should have it is own teaching hospitals. some participants mentioned that teaching hospitals have no rules or regulations concerning teaching students, which is a sign that clinical education is not welcomed at the teaching hospitals as indicated at the beginning. “last year in the first week, with my students we had to wait more than one hour outside of emergency department because we were not allowed to enter the department that claimed that we did not have a permission” (participant #7).“not acknowledging the importance to practice clinical education at teaching hospitals was discussed with the director at the ministry of health, who claimed that the best solution is to have a private hospital belong to the college of nursing” (participant #8).cis and nursing students, during clinical days, have, however, solved some of the problems of nursing shortages by putting a lot of effort into looking after admitted patients and their relatives. during the interviews, only one participant said that she got a letter of appreciation from the hospital while others are still in a continuous argument with the hospital administration and staff over clarifying their role in improving the health care services. “hospital staff leave them alone to look after the patients, while it is illegal, but students under our supervision carry out their duties professionally” (participant # 9). c. poor teaching environment: one of the main challenges that cis face at the clinic is the lack of standardization. at the college, the most updated version of nursing books is used in the theory lectures and clinical simulation laboratory sessions. students are familiar with various equipment and techniques used in nursing 35 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2022.04 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article procedures. on the contrary, clinical placements are not equipped with the necessary equipment. cis must involve students in clinical skills with minimal or sometimes old versions of medical equipment. in this way, students get confused between what they studied and what they are experiencing in the clinical settings. cis are the first people to be criticized and blamed for these differences. “so many times, we did not have waterproof pad or sheet to create a sterilized filed. i had to teach my students using gloves paper or gauze to put under the equipment during procedures” (participant # 9).procedures are a daily challenge for cis. some nursing cares are such as foley catheter insertion, ng tube insertion, and dressing of wounds are no longer done by nurses, are being claimed as doctors’ jobs, and have been banned by the ministry of health to undertake. of course, it is not the same in all areas and there are differences between hospitals. “one of the relatives did not permit my students to participate in the dressing of her mother’s wound. she said: ‘i prefer it to be done by a doctor like yesterday.’” (participant #3). other issues with the teaching environment are lack of libraries, conference rooms, and most importantly locker rooms. most of the clinical discussions, according to the study participants, are taking place in the corridors or empty patient rooms. “some hospitals have conference room, but the priority is given to medical students, on one occasion we were even asked to leave the room because medical students’ lecture started” (participant #2). 36 erbil journal of nursing & midwifery table 1: please describe any challenges in implementing the core competencies developed by who (3)by answering the following questions: interview questions how many years of clinical experience do you have? in how many clinical areas you have taught so far? were they related to your specialty? please explain the challenges of teaching in a new clinical setting. please explain any challenges that would prevent you from adapting theoretical nursing expertise to clinical teaching practice. please explain any challenges you may face in defining teaching objectives and integrating them for teaching students. please explain any challenges you may face in teaching nursing practice to nursing students. please explain any challenges you may face when undertaking research and applying results in the field of clinical teaching. please explain any challenges you may face in including health care providers in the process of teaching. please explain any legal and ethical challenges that may prohibit you from delivering professional nursing education. please explain any challenges you may face when assessing students’ performance and the effectiveness of the curricula. do you assist in developing policies and protocols for nursing students at your institution? if yes, please explain any challenges in developing them. https://doi.org/10.15218/ejnm.2022.04 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article novice instructors requires an extensive orientation program. the importance of training cis before assigning them to clinical placement is paramount [15]. cis play a crucial role in developing students’ competency and shaping the future of the health care system. clinical practice skills and knowledge are the two most important components of cis’ role, and they have a strong effect on the confidence level. in addition, conducting research, improving curriculum based on contemporary educational models and theories, monitoring and evaluating students’ learning outcomes, demonstrating effective communication skills with other health care professionals, and professionally enhancing nursing education policies, procedures, and decisionmaking as requested by who [3] are other components that every cis musthave. although competency is developed by practice, novice cis should go through a relevant and recognized training program to acquire basic information on how to master the role of qualified ci. nonetheless, the clinical environment is complex and each practical situation requires a unique learning experience [4]. although the unavailability of dependable resources is a major challenge in adopting core competencies mentioned by many who experts [16], many strategic methods could the findings of the present study revealed that cis face various challenges in implementing core competencies for nurse educators identified by who [3]. the challenges related to the academic institutions were the first theme identified by the study participants and included three sub-themes: the shortage of cis, cis’ lack of confidence, and difficulty achieving learning outcomes. interviews with the participants revealed that the college had been running clinical education with a short-term plan instead of having a long-term plan that can tackle minor and major issues more efficiently. the fast-growing population and developing nursing services have made a larger number of students pursue nursing as a career. however, the college of nursing/ hmu still works according to the plan that has been in situ since 2001. many full-time and part-time cis have been recruited and given the role of ci without previous preparation. the only requirement was holding a bachelor’s degree in nursing science and at least one year of clinical experience. the shortage of cis is universal [11,12]. many studies document the urgent need of nurse educators [13, 14]. filling the shortage gap in the teaching faculty staff is challenging and transitioning nurses to 37 erbil journal of nursing & midwifery table 2: demographic characteristic of the study participants (second phase) no sex age educational level speciality work experience/years 1 male 38 master degree adult nursing 11 2 female 36 master degree pediatric nursing 10 3 male 35 master degree adult nursing 7 4 male 32 master degree adult nursing 9 5 male 32 master degree pediatric nursing 9 6 male 32 master degree adult nursing 8 7 female 32 master degree adult nursing 7 8 female 30 master degree maternity nursing 5 9 male 29 master student adult nursing 4 discussion https://doi.org/10.15218/ejnm.2022.04 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article edgement and poor teaching environmentthe role of the manager in hospital settings in most countries is practiced by registered nurses who hold a bsc or higher degree in nursing science. contrary to this, in erbil city’s teaching hospitals, this role is practiced by nurses who often have a lower degree and are loyal to a particular political party. due to the lower number of graduated nurses who hold a bsc this problem has not been resolved yet. the presence of a nurse manager is most important for preparing hospitals to receive nursing students [19]. cis find that dealing with someone who understands the purpose of the clinical practice is much easier [2] and that learning opportunities and learning outcomes could be designed more effectively through stronger collaboration between cis and nurse managers [18]. planning clinical teaching in public sector academic health institutions across all of erbil city is authorized by the government, namely the ministry of health, under specific rules and regulations. nursing students like other medical students should be given the chance to experience practice in the most supportive environment. however, not valuing the importance of clinical nursing training by health staff is a huge challenge as experienced by the study participants. the exact role of nurses or what nurses can and should do at the hospital is still vague. presently nurses are not involved in providing holistic care, and the services they provide are simple and can be learned within a couple of weeks. this mentality leads the hospital staff to think that the students do not need extensive clinical practice or supervision. there is no doubt that the success of clinical training in nursing education depends largely on strong, structured, collaboration and relationships between health care services and academic institutions [12, 20]. not having this strong bond forces cis to practice the be applied to achieve this task. an innovative approach implemented by nurse educators in canada is through a project using open education resources (oers), where all necessary materials are made freely accessible online for novice nurse educators and the progress of learning monitored and supported by volunteered educators. the developers of the oers are confident that faculty members and higher education institutes that lack organizational and financial support would benefit from such a program [17]. lack of clarity regarding the learning outcomes was another challenge identified by the participants. continuous political conflicts and economic crises negatively influence education systems worldwide. unfortunately, the kurdistan region of iraq has seen various conflicts, which have not given the region the chance to build a well-organized structure in the education system and learning process across all levels. participants disclosed their concern with the lack of viable educational clinical settings and lack of learning opportunities. inability to fulfil health staff demand by the government resulted in providing low-quality service in the teaching hospitals. in the search to find better services, patients use private hospitals if possible. simply expressed, no patients mean no learning opportunities. well clarified and articulated learning objectives are the key to achieving learning outcomes [18]. however, even consistent learning objectives cannot be accomplished when the clinical setting continuously changes based on the availability of patients. this issue challenges the cis to choose learning outcomes that are realistic and achievable. the second theme identified by this study was concerned with the challenges related to the health institutions included three subthemes: weak authority, lack of acknowl. 38 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2022.04 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article still not ready or able to provide the learning environment requested by the academic institutions. the perceived challenges of clinical instructors while teaching undergraduate nursing students have been scrutinized in the current study. the shortage of qualified cis, cis’ lack of confidence and lack of clarity in the learning outcomes are the three principal issues under the main theme of the academic institutional challenge. inappropriate selection for managerial roles, poor recognition of clinical education importance and poor teaching environments were recognized as the most difficult challenges under the theme of the health institutions as perceived by the study participants. the outcome of the study reasserted and supported the premise that inadequate strategic plans for clinical teaching from the academic institution and the lack of more positive involvement of the health institutions in the clinical study made it much more difficult for cis to carry out their role in a safe and less stressful environment. relevance to clinical practice: the findings of this study can be used to reform clinical education and to empower cis based on the core competencies developed by who [3] for nurse educators to achieve a more productive clinical teaching and learning. the study also recommends the following points: 1-reforming the policy and mechanism of supervising students at the clinic, most importantly involving health staff as mentors or preceptors in the process of education. 2-addressing cis challenges and empowering cis with basic needs and opportunities to practice the role more productively. 3-developing a strategic plan to tackle the issue of the fast-growing number of role alone and in an extremely unsupportive environment. worldwide, clinical education is a shared task. mentors and preceptors who are experienced clinicians and have skills take part in educating nursing students [20]. however, clinicians in many studies reported that other challenges come with adopting these roles, mainly student’s assessment and the amount of time each student needs to achieve a specific task [18, 20]. students need constant attention, which means that the supervisor should not be distracted with other duties in clinical settings [21]. on the other hand, faculty cis can focus only on the students’ need, but has the least amount of clinical experience, which ultimately affects the learning opportunities they provide [22]. therefore, achieving the best learning outcomes requires the involvement of both sides and all supervisor’s contributions at the clinic should be acknowledged regardless of their background or position. the clinical environment is the real world where students finally get the chance to apply what they have learned at college to the real practice situation [23]. students must find similarities between textbooks, simulation laboratories, and clinical settings. students expect to see role models and advanced techniques used in nursing care [19, 23]. teaching in a poor environment that is far from students’ expectations, make cis struggle to keep students motivated and not lose interest. when the differences are huge students feel doubt and accuse cis of putting unnecessary pressure on them at the college to master the role of a qualified nurse. study participants pointed out that teaching in a pedagogical atmosphere would be more productive. however, as has been mentioned, due to continuous political problems and economic crises, teaching hospitals are 39 erbil journal of nursing & midwifery conclusion https://doi.org/10.15218/ejnm.2022.04 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article no conflict of interest has been declared by the authors. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. [1] creswell jw, poth cn. qualitative inquiry and research design: choosing among five approaches. sage publications, social science; 2016. 76 p. availablefrom:https:// books.google.com/ bookshl=en&lr=&id=dlbbdqaaqbaj&oi=fn d&pg=pp1&dq=qualitative+inquiry+26+rese arch+design:+choosing+among+the+five+a pproaches&ots=gw777hopb&sig=ufsjdmi42wx4jk9swscva km3dke. accessed [10-11-2019] [2] younas a, zeb h, aziz sb, sana s, albert js, khan iu, et al. perceived challenges of nurse educators while teaching undergraduate nursing students in pakistan: an exploratory mixed-methods study. nurse education today. 2019;81(7):39–48. available from: https://doi.org/10.1016/j.nedt.2019.07.002. accessed [10-01-2020] [3] world health organization. nurse educator core competencies. who [internet]. 2016;1 –36. available from: http://apps.who.int/ iris/bitstream/ handle/10665/258713/9789241549622eng.pdf;jsessionid=8dcad822f36d10f1b82 9697b0637542d?sequence=1. accessed [1011-2019] [4] van wyngaarden a, leech r, coetzee i. challenges nurse educators experience with development of student nurses’ clinical reasoning skills. nurse education in practice [internet]. 2019;40(october):102623. available from: https://doi.org/10.1016/ j.nepr.2019.102623. accessed [11-02-2020] [5] thuss m, babenko-mould y, andrusyszyn ma, laschinger hks. nursing clinical instructor experiences of empowerment in rwanda: applying kanter’s and spreitzer’s theories. international journal of nursing education. 2016;13(1):1–9. accessed [04-02-2020] nursing students’ enrollment. 4-adopting a well-prepared program based on the core competencies³ recommended for transitioning expert nurses to expert educators. 5-designing well-structured collaborations and partnerships with the health care institutions. limitations the interviews with the participants disclosed various issues related to clinical education, most of which have been discussed in this paper. however, the challenges of teaching nursing students in the kurdistan region have not been highlighted in the study. the teaching style in high schools when compared to the universities is different, with universities having a more modern approach, which affects the academic ability of the new student cohorts. the researchers would like to undertake a research study focusing only on this subject. the participants did not adequately describe the challenges of conducting educational research itself. therefore, further research is also needed in this arena. 1.1 rigor the research question and the interview guide were discussed with multiple researchers who had expertise in qualitative research. to ensure dependability and transparency of the study results, the transcribed data from the video records and swot were analyzed, coded, and categorized by an independent reviewer and the researchers separately. the researchers compared and verified their analysis with the reviewer’s conclusions. 40 erbil journal of nursing & midwifery conflicts of interest funding references https://doi.org/10.15218/ejnm.2022.04 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article [13] scammell j. the implications of nurse shortages. british journal of nursing. 2019;28(3). available from: https:// www.magonlinelibrary.com/doi/ full/10.12968/bjon.2019.28.3.208 accessed [21-07-2020] [14] berland a, capone k, etcher l, ewing h, keating s, chickering m. open education resources to support the who nurse educator core competencies. international nursing review. 2020;67(2):282–7. available from: https://onlinelibrary.wiley.com/doi/ abs/10.1111/inr.12583. accessed [21-072020] [15] levett-jones t, fahy k, parsons k, mitchell a. enhancing nursing students’ clinical placement experiences: a quality improvement project. contemporary nurse. 2006 oct 1;23 (1):58-71. available from: https:// www.tandfonline.com/doi/abs/10.5172/ conu.2006.23.1.58. accessed [15-03-2020] [16] hee kc, yee kj. influence of nursing students’ clinical practice learning environment, self-leadership, and clinical practice belonging on nursing professionalism. journal korean academic society of nursing education. 2019 feb 28;25(1):5–16. available from: https://doi.org/10.5977/jkasne. accessed [17-03-2020] [17] ekstedt m, lindblad m, löfmark a. nursing students’ perception of the clinical learning environment and supervision in relation to two different supervision models – a comparative cross-sectional study. bmc nursing. 2019;18(1):1–12. available from: https:// bmcnurs.biomedcentral.com/ articles/10.1186/s12912-019-0375-6. accessed [20-08-2020] [18] manninen k, henriksson ew, scheja m, silén c. supervisors’ pedagogical role at a clinical education ward an ethnographic study. bmc nursing. 2015;14(1):1–8. available from: http://dx.doi.org/10.1186/s12912-015 -0106-6. accessed [17-03-2020] [19] pront l, mcneill l. nursing students’ perceptions of a clinical learning assessment activity: ‘linking the puzzle pieces of theory to practice.’ nurse education in practice [internet]. 2019;36:85–90. available from: http://www.sciencedirect.com/science/ article/pii/s1471595318300489. accessed [01-11-2020] [6] desilets ld, desilets ld. swot is useful in your tool kit. journal of continuing education in nursing [internet]. 2008;39(5):196– 7. available from: https:// pubmed.ncbi.nlm.nih.gov/ pubmed/18512578. accessed [03-082020] [7] given lm. the sage encyclopedia of qualitative research methods: a-l ; vol. 2, m-z index. in the usa: sage reference publisher; 2008. p. 10. available from: https:// books.google.iq/books? id=byh1awaaqbaj&lpg=pp1&ots=loy1k o3m0r&dq=the sage encyclopedia of qualitative research methods&lr&pg=pp1#v=onepage&q=the sage encyclopedia of qualitative research methods&f=false. accessed [05-11-2020] [8] kallio h, pietilä am, johnson m, kangasniemi m. systematic methodological review: developing a framework for a qualitative semi-structured interview guide. journal of advanced nursing. 2016;72 (12):2954–65. accessed [20-07-2020] [9] braun v, clarke v, hayfield n, terry g. thematic analysis. in: liamputtong p, editor. handbook of research methods in health social sciences. singapore: springer singapore; 2019. p. 843–60. available from: https://doi.org/10.1007/978-981-10 -5251-4_103. accessed [30-08-2020] [10] guest g, macqueen km, namey ee. applied thematic analysis. thousand oaks, california: sage; 2011. 11 p. available from: https://books.google.com/books? hl=en&lr=&id=hr11dwaaqbaj&oi=fnd&p g=pp1&dq=applied+thematic+analysis&ot s=xi5dylzgqd&sig=zlpt0ky3ztisc64hick5 tvx3yug. accessed [01-06-2020] [11] rosseter r. fact sheet: nursing faculty shortage. american association of colleges of nursing. 2019;(202):1–4. available from: https://www.aacnnursing.org/ portals/42/news/factsheets/facultyshortage-factsheet.pdf. accessed [21-072020] [12] stamps a, cockerell k, opton l. a modern take on facilitating transition into the academic nurse educator role. teaching and learning in nursing. 2021 jan 1;16(1):92-4. available from: https:// www.sciencedirect.com/science/article/ pii/s1557308720300421. accessed [30-012021] 41 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2022.04 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article [20] kalyani mn, jamshidi n, molazem z, torabizadeh c, sharif f. how do nursing students experience the clinical learning environment and respond to their experiences? a qualitative study. bmj open. 2019;9 (7):1–8. available from: https:// bmjopen.bmj.com/content/9/7/ e028052.abstract.accessed [17-03-2020] [21] green j, thorogood n. qualitative methods for health research. 4edition ed. sage. 2018. 116–117 p. available from: https:// books.google.iq/books? hl=en&lr=&id=huhldwaaqbaj&oi=fnd&p g=pp1&dq=qualitative+methods+in+healt h+research&ots=quk9zmkjxj&sig=rnko1k 6qegmtzhqy7kdbb_mnqoy&redir_esc=y #v=onepage&q=qualitative methods in health research&f=false. accessed [15-112020] [22] malterud k, siersma vd, guassora ad. sample size in qualitative interview studies: guided by information power. quality health research. 2016;26(13):1753–60. available from: https:// doi.org/10.1177/1049732315617444. accessed [10-12-2020] [23] mcgrath c, palmgren pj, liljedahl m. twelve tips for conducting qualitative research interviews. medical teacher. 2019 sep 2;41(9):1002–6. available from: https:// doi.org/10.1080/0142159x.2018.1497149. accessed [02-11-2019] 42 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2025.06 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article patient’s satisfaction with coronary artery disease concerning medical care services at teaching hospitals in erbil city abstract background and objectives: coronary artery disease is now broadly recognized as a major global health issue. patient’s satisfaction with medical care services is an important health outcome. the study was to assess the satisfaction level of patients with coronary artery disease concerning medical care services and to find out the difference between patients’ satisfaction and the socio-demographic characteristics of the patients. methods: a descriptive cross-sectional study design was conducted from february 2022 to may 2022. to find out the satisfaction level of patients with coronary artery disease concerning medical care services. researchers used a non-probability purposive sampling technique among 205 patients diagnosed with coronary artery disease. data were analyzed using statistical package for the social sciences version 25. results: the result shows that half of the sample (50.7%) was among the age group 61 years and older. more than half of them (51.2%) were females. about (58%) of the participants were illiterate. the majority (79%) of the samples were married. however, (46.8%) of the study samples were housewives and living in an urban area (47.8%). the highest percentage of the samples (64.9%) had satisfied with medical care. there was a significant difference among patients’ medical care satisfaction: age, gender, marital status, and occupational status. conclusion: a substantial proportion of patients were satisfied with medical care, and there was a significant difference between patients' medical care satisfaction and age, gender, marital status, and occupational status. keywords: patient’s satisfaction; coronary artery disease; medical care services; erbil city. srusht dhahier ismael; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. (correspondence: srusht.ismael@hmu.edu.krd) yousif mohammad younis; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. 49 received: 26/08/2022 accepted: 30/09/2022 published: 30/05/2025 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:(correspondence:%20dara.albanna@hmu.edu.krd) mailto:srusht.ismael@hmu.edu.krd?subject=srusht.ismael@hmu.edu.krd%20%20%20%20 mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.06 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article the lining of arterial blood vessels develops an abnormal buildup of lipid, or fatty substances and fibrous tissue, known as coronary artery disease (cad). these substances cause the arterial lumen to narrow and block, which lowers blood flow to the myocardium [1] it has remained the world's leading killer and the source of public health issues, as well as one of the most prevalent causes of morbidity and mortality in many communities [2].according to health data from the american heart association (aha), coronary artery disease remained the leading cause of mortality in more than 190 countries, with 17.3 million deaths per year. by 2030, the number is estimated to rise up to 23.6 million(3). in united states of america, cad is the most common type of heart disease, killing 365,914 people in 2017. about 18.2 million adults age 20 and older have cad (about 6.7%) and 2 in 10 deaths from cad happen in adults less than 65 years old(4).the prevalence of cad has been found to range from 5.4 percent to 13.4 percent in the middle east [5,6]. according to a study conducted in tehran, the prevalence of cad among the tehranian population was 15.81% (8.62% for men and 7.19% for women respectively) [7].patient satisfaction is an essential component in evaluating the quality of healthcare services because it shows how well the staff is achieving the patients' goals. it has a significant impact on patients' expectations [8]. it was initially expressed by risser in 1975 as the grade of agreement between patients' expectations of the optimal level of treatment and their perceptions of the care they receive [9].medical care is an essential hospital service or technical quality. it refers to "what" treatment the patient receives from the physician and is established on the precision of medical diagnosis, treatment, and adherence to professional principles. patients may not believe they are getting high-quality care when a hospital falls short in this area [10]. successfulphysician-patientcommunication has been indicated to improve health outcomes by raising patient satisfaction, enhancing patient comprehension of health issues and available treatments, promoting better adherence to treatment regimens, and offering patients support and assurance [11]. effective collaboration of health care professionals in care of patients with heart disease will usually result in good quality care for the patient [12]. the record from erbil general directorate of health showed that in erbil government, there were about 8853 patients diagnosed with cad during 20192020. because heart disease develops gradually and not easily detected, and morbidity and mortality with the disease increase day by day. therefore, this study was aimed at assessing the socio demographic characteristics, evaluating satisfaction level of patients with cad related to medical care from the patient’s point of view as a determinant of whether there is improvement in patient’s satisfaction of care or not, and determining the difference between some of the sociodemographic characteristics of the sample and over all medical care satisfaction levels. a descriptive cross-sectional study was conducted from february 2022 to may 2022 among 205 cad patients at rizgary and hawler teaching hospitals in erbil city. the sample size was determined by z2 p q/ d2, z = confidence interval 95% (1.96), p= prevalence= (0.1581), q = (1-p) = (0.8419), d = sampling error (0.05) [13]. the samplesof the study were adult patients 50 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.06 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article were analyzed using statistical package for social science (spss) version 25 for calculating descriptive statistical data analysis (frequency and percentage) and inferential statistical data analysis (independent sample t-test and anova test). table 1 showed the distribution of sociodemographic characteristics of 205 study samples with cad. half (50.7%) of the sample were in the age group 61 years and more, followed by 4760 years (36.1%), 33 46 years (11.2%), while the lowest percentage (2%) were in the age group 19 32 years . more than half of them (51.2%) were females, and higher than the percentage of males (48.8%). in addition, the table showed that the highest percentage (58%) of the participants were illiterate, followed those who could read and write (12.2%), primary school (11.2%), institute (7.8%), secondary school (6.8%), and college (3.9%) respectively. it was also revealed that the majority of the samples were married and accounted for (79%).regarding occupational status, housewives were the highest percentage among all occupational statuses (46.8%), followed by employed (34.6%), unemployed (10.2%), and retired (8.3%) respectively. meanwhile, most of them were living in an urban area (47.8%). table 2 revealed the frequency and percentage of items about medical care satisfaction. item (the doctor treats you friendly and in a courteous manner) ranked first with a rate of 98.8%, and item (the doctor did not ignore what you told him/or her) ranked second with 93.7%. furthermore, item (the doctor spends plenty of time with you) ranked third with 91.2%. diagnosed with coronary artery disease. non-probability, purposive sampling techniques were used to collect the relevant study data. the inclusion criteria include adult patients who had coronary artery disease and (were older than18 years old) as well as both genders. the exclusion criteria included patients who had psychiatric or mental problems and patients with communication problem. the researcher obtained an approval letter from the ethics committee at hawler medical university/ college of nursing (code no.111, date 7/10/2021). the official approval was taken from general directorate of health, rizgary and hawler teaching hospitals in erbil city. oral informed consent was obtained from patients after a detailed explanation about the aim of the study before starting the interview. each patient's form was coded with a specific number. the researcher prepared a questionnaire for collecting data based on the review literature and exploring questionnaires used in similar studies. the face-to-face interview technique was used to collect data about socio-demographics and patients satisfaction with medical care services. the questionnaire was checked by a panel of experts of different specialties related to the fields of the present study. based on their comments, the questionnaire was corrected and changed for suitable data collection .the reliability of the study done by using a pilot study on a purposive sample of 15 cad patients in january 2022.the researcher spent with each patient approximately 20-30 minutes to respond to questionnaire. the researcher assessed the sociodemographics characteristics, including age, gender, educational level, marital status, occupational status and residential area. patient satisfaction regarding medical care services consists of 12 questions and includes three answers or options (1=disagree, 2= neutral, 3= agree). data 51 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.06 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article 52 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: socio-demographic characteristic of the study sample (n=205) socio-demographic characteristics f (%) age 19-32 4 (2) 33-46 23(11.2) 47-60 74 (36.1) 61 and more 104 (50.7) gender male 100 (48.8) female 105 (51.2) educational level illiterate 119 (58) reading and writing 25 (12.2) primary school 23 (11.2) secondary school 14 (6.8) institute graduate 16 (7.8) college graduate 8 (3.9) marital status single 10 (4.9) married 162 (79) widowed 33 (16.1) occupational statues employed 71 (34.6) unemployed 21(10.2) housewife 96 (46.8) retired 17 (8.3) residential area urban 98 (47.8) sub-urban 93 (45.4) rural 14 (6.8) table 2: patient’s satisfaction related to medical care services (n=205) items disagree f (%) neutral f (%) agree f (%) the doctor spends plenty of time with you. 3 (1.5) 15 (7.3) 187 (91.2) the doctor treats you friendly and in a courteous manner. 3(1.50) 0 (0) 202 (98.5) the doctor always gives you instructions. i02 (49.8) 33 (16.1) 70 (34.1) it has easy to access the medical specialist when you need it. 36 (17.6) 35 (17.1) 134 (65.5) the doctor understands your health need. 5 (2.4) 24 (11.7) 175 (85.5) the doctor gave you information about your health condition. 80 (39) 21 (10.2) 104 (50.7) the doctor gave you information about the present treatment. 66 (32.2) 29 (14.1) 110 (53.7) the doctor sometimes hurries too much when they treat you. 176 (85.9) 13 (6.3) 16 (7.8) the doctor explains to you the reason for doing tests. 74 (36.1) 31 (15.1) 100 (48.8) the doctor gives you information about the test results. 59 (28.8) 30 (14.6) 116 (59.6) the doctor did not ignores what you tell him/or her. 6 (2.9) 7 (3.4) 192 (93.7) sometimes you have doubt about the ability of the doctor who treats you. 175 (85.4) 13 (6.3) 17 (8.3) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.06 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article 53 (64.9%) of the samples had agreed with medical care, followed by neutral (34.1%) and disagree (1%) respectively. a significant difference was reported for age group (p=0.006), gender (p=0.004), marital status (p=0.039) and occupational status (p=0.004) ≤ 0.05.while there was no significant correlation with educational level and residential area at p 0.05. table 3 showed the overall levels of patient satisfaction with cad regarding medical care services. the highest percentage table 4 showed the difference between socio demographics characteristics the study sample with medical care satisfaction. there was a significant difference between the mean of age group, gender, marital status, occupational status and quality of medical care. copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: overall levels of satisfaction with medical services among patients with cad (n=205) table 4: difference between socio-demographics characteristics of study sample and medical care satisfaction (n=205) overall level of satisfaction f (%) disagree 2 (1) neutral 70 (34.1) agree 133 (64.9) socio-demographic characteristic f mean± sd p-value age 19-32 4 30.250±0.957 f=4.23 p-value= 0.006(s) 33-46 23 29.739±2.750 47-60 74 29.257±2.659 61 and more 104 27.971±3.263 gender male 100 29.300±3.215 t=2.903 female 105 28.086±2.767 educational level illiterate 119 28.437±2.845 f=1.663 p-value= 0.145(ns) read and write 25 28.560±3.927 primary school 23 28.261±2.734 secondarey school 14 30.000±3.038 institute graduate 16 30.250±2.295 college graduate 8 28.375±4.307 marital status single 10 29.700±3.128 t=3.301 p-value= 0.039(s) married 162 28.851±3.046 widowed 33 27.515±2.807 occupational statues employed 71 29.718±2.948 f=4.497 p-value= 0.004(s) unemployed 21 28.381±3.138 housewife 96 28.072±2.753 retired 17 28.117±3.950 residencal area urban 98 29.091±2.970 f=1.765 p-value= 0.174(ns) sub-urban 93 28.322±3.029 rural 14 28.142±3.526 f= one way anova test, t= independent sample t-test https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.06 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article not ignore what they told him/or her” (93.7%) and (time spend with the doctor) (91.2%). likewise, research carried out in nepal in 2021 had a similar result [22]. on the subject of overall satisfaction with medical care services, most of the samples were satisfied with the care provided by doctors. this agrees with a crosssectional study finding that was performed in south saudi arabia in 2022 among 423 patients, which displayed that the overall satisfaction level related to doctor services was 81% [23]. however, in contrast to the study carried out in iraq/baquba, they found that the patients with cad were not satisfied with the care provided by doctors [24]. the present study illustrated a significant difference among overall satisfaction , age, gender, marital status and occupational status. it was supported by a study conducted in turkey in 2013, which demonstrated significant differences among patients’ gender, marital status, and occupational status as well as overall medical care services[25]. additionally, it was in line with a research in australia which revealed that age and gender were significant with overall satisfaction[26]. conversely, it disagreed with a study performed in iraq in 2014 that clarified no significant differences between patients' sociodemographic characteristics and overall medical care services[24]. 54 discussion the result of this study illustrated that the majority of samples were within the age group (61 years and more); this is comparable to the studies conducted in india and tanzania that showed most of the samples were older than 60 years [14,15]. this finding indicates that in comparison to young people, aging has a significant impact on the development of heart disease. the current study result found that more than half of the study samples were female. that may be due to hormonal changes that occur in females after the age of 45 years, and in addition, females are often overloaded, especially after having several children, which impact on the body's whole function. correspond to the studies done in kuwait and nepal that revealed the majority of samples were females [16,17]. regarding educational level more than half of the present study samples were illiterate. a similar result was found in the research performed in maysan/iraq, among 100 patients in 2015, representing that most of the study samples were illiterate [18]. the present study found that the majority of samples were married. this result is supported by a study conducted in india in 2015 that found that most of study the samples, 68% were married [19]. most of the samples were housewives. the result is supported by finding from a crosssectional study in iran in 2015;which clarified that the majority of study samples were housewives [20]. about residential area, the majority of present study samples were from urban areas. this is consistent with a study done in iraqi kurdistan, which concluded that most of the study sample were from urban areas[21]. the result showed the majority of samples satisfied with the items “the doctor treats them friendly and courteously” (98.5), followed by “the doctor did copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.06 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article correlates of coronary heart disease: first population-based study in lebanon. vascular health and risk management [internet]. 2016;12:75–84. availablefrom:https:/ www.ncbi.nlm.nih.govpmcarticles/ pmc4803334/ [7] moazzeni ss, ghafelehbashi h, hasheminia m, parizadeh d, ghanbarian a, azizi f, et al. sex-specific prevalence of coronary heart disease among tehranian adult population across different glycemic status: tehran lipid and glucose study, 2008–2011 biomed central public health [internet]. 2020;20(1):1510. available from: https:// doi.org/10.1186/s12889-020-09595-4 [8] xesfingi s, vozikis a. patient satisfaction with the healthcare system: assessing the impactofsocioeconomic and healthcare provisi on factors. biomed central health services research [internet]. 2016;16 (1):94. available from: https:// doi.org/10.1186/s12913-016-132 [9] emmanuel k, chastonay p. patient satisfaction studies and the monitoring of the right to health: some thoughts based on a review of the literature. global journal of health science.2011;3(1). [10] mohamed b, mohamad m, azizan n. technical quality and patient perception of hospital care quality. journal of service science and management research.. 2017;1:63–91. [11] birkhäuer j, gaab j, kossowsky j, hasler s, krummenacher p, werner c, et al. trust in the health care professional and health outcome: a meta-analysis. public library of science one [internet]. 2017;12 (2):e0170988. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc5295692/ [12] odunaiya na, akinpelu ao, ogwu s, aje a. healthcare professionals’ perception of quality of care of patients with cardiac disease in nigeria: implication for clinical guideline, inter-professional education and team work.malawi medical journal [ [internet]. 20 19;31(1):31–8. available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc6526338/ [13] araoye mo. research methodology with statistics for health and social sciences. nathadex publisher irion. 2003;115(9):25– 120. [14] tanna n, srivastava r, tanna v. age wise distribution of coronary artery disease risk the study illustrated that half of the sample (50.7%) was among the age group 61 years and older. more than half of them (51.2%) were females. about (58%) of the participants were illiterate. the majority of the samples were married (79%). however, most of the study samples were housewives (46.8%) and living in an urban area (47.8%). in conclusion, a substantial proportion of patients were satisfied with medical care, and there was a significant difference between patients' medical care satisfaction and age, gender, marital status, and occupational status. the author reports no conflict of interest. [1] smeltzer s, bare b. smeltzer & bare’s textbook of medical-surgical nursing. fourth australian and new zealand edition. vol. 1. philadelphia: lippincott williams & wilkins; 2017. 680 p. [2] ahmadi a, mobasheri m, soori h. prevalence of major coronary heart disease risk factors in iran. international journal of epidemiologic research [internet]. 2014;1(1):3– 8. available from: http://ijer.skums.ac.ir/ article_8662.html [3] american heart association (aha). american heart association statistical report tracksgloal figures for first time [internet]. 2 014. available from: https://www.heart.org/ en/news/2018/05/01/american-heartassociation-statistical-report-tracks-globalfigures-for-first-time [4] centers for disease control and prevention (cdc). heart disease facts [internet]. 2020. available from: https://www.cdc.gov/ heartdisease/facts.htm [5] mohannad n, mahfoud z, kanaan mn, balbeissi a. prevalence and predictors of non fatal myocardial infarction in jordan. eastern mediterranean health journal.. 2008;14 (4):13. [6] zeidan rk, farah r, chahine mn, asmar r, hosseini h, salameh p, et al. prevalence and 55 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion conflicts of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.06 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article bio med central health services research [internet]. 2021;21 (1):135. available from: https:// doi.org/10.1186/s12913-021-06155-3 https://doi.org/10.1186/s12913-021-061553 [23] elias a, abdalkarim s, m wm, ali gy, ahmed mm, khan my, et al. patient satisfaction and its predictors in the general hospitals of southwest saudi arabia: a cross-sectional survey. sudan journal of medical sciences [internet]. 2022;17(1):15–27. available from: https://www.ajol.info/index.php/sjms/ article/view/225316 [24] al-shammary y, al-gersha k. satisfaction of patients, coronary arteries in related to nursing and medical care. iraqi national journal of nursing specialties [internet]. 2014;2(27):74–83. available from: https:// injns.uobaghdad.edu.iq/index.php/injns/ article/view/211. [25] baltaci d, eröz r, ankaralı h, erdem ö, celer a, korkut y. association between patients’ sociodemographic characteristics and their satisfaction with primary health care services in turkey. kuwait medical journal. 2013 dec 1;45:291–9. [26] chandra s, ward p, mohammadnezhad m. factors associated with patient satisfaction in outpatient department of suva subdivisional health center, fiji, 2018: a mixed method study. frontiers in public health [internet]. 2019;7:183. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc6614334/ factors. international journal of medical science and public health [internet]. 2013;2 (4):954. available from: http:// www.scopemed.org/fulltextpdf.php? mno=41325 [15] kisenge pr. pattern of cardiovascular diseases among elderly patients admitted in medical wards at muhimbili national hospital dar es salaam tanzania [internet] [thesis]. muhimbili university of health and allied sciences; 2011. available from: http:// dspace.muhas.ac.tz:8080/xmlui/ handle/123456789/43 [16] awad a, al-nafisi h. public knowledge of cardiovascular disease and its risk factors in kwait:acrosssectional survey. biomed centra l public health[internet]. 2014;14(1):1131. available from: https:// doi.org/10.1186/1471-2458-14-1131 [17] shrestha m, pyakurel p, yadav kp, singh s, priyadarshini s, rajak b, et al. knowledge, attitude and practices regarding cardiovascular diseases among people of pakhribas municipalty of eastern nepal. nepal heart journal [internet]. 2020;17(1):33–9. available from: https://www.nepjol.info/ index.php/nhj/article/view/28806 [18] khafel mal, abass ad. patients’ satisfaction concerning hospital care post-acute myocardial infarction at maysan governorate hospitals. kufa journal for nursing sciences [internet]. 2015;5 (3). available from: https://www.iasj.net/ iasj/article/106928 [19] suresh s, d’cunha sweeta, kodikal r. patient satisfaction: a study in general and private wards of a multispecialty hospital. journal of medical science and clinical research. 2015;3:6162. [20] rahnavard z, hosseini nodeh z, hatamipour k. congestive heart failure: predictors of health-related quality of life in iranian women. contemporary nurse [internet]. 2014;47 (1–2):159–67. available from: https:// doi.org/10.1080/10376178.2014.11081917 [21] khalil h. risk factors associates with coronary artery disease among patients attending surgical specialty hospital-cardiac center in erbil city a case-control study [thesis]. 2019. [22] adhikari m, paudel nr, mishra sr, shrestha a, upadhyaya dp. patient satisfaction and its socio-demographic correlates in a tertiary public hospital in nepal: a cross-sectional study. 56 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.10 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article knowledge of high school teachers regarding healthful school environment in erbil city abstract background and objectives: a healthy school environment focuses on providing a suitable setting for learning and healthy behaviors because the school environment represents an important setting for many children’s social habits and behaviors that are learned at school. the purpose of this study was to assess the high school teachers in erbil city's public and private schools' knowledge of a healthy learning environment. method: an across-sectional survey was conducted to determine teachers' knowledge regarding a healthful school environment. the study included 360 teachers in erbil city, 260 from public schools and 100 from private schools. a questionnaire was constructed for the purpose of data gathering. results: more than half (64.6%) of teachers of the public schools were aged 38-50 compared with 21% of teachers of the private schools; 51.2% of the teachers of the public schools were male compared with 64% of the private teachers; 81.9% of the teachers in the public schools were married compared with 69% of the private school teachers; and the majority (86%) of the private teachers had bachelor degrees compared with 95.8% of teachers of the public schools. the highest percentage (74.6%) of the public teachers had a fair level of knowledge compared with 56% of teachers of the private schools. conclusion: based on the study findings of the present study, it was concluded that the highest percentage of the teachers had a fair level of knowledge regarding school health policies. keywords: school health policy; knowledge; teachers. bakhtiyar fattah saleh; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. (correspondence: bakhtiarfattah8@gmail.com) salih ahmed abdulla; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. 103 received: 10/09/2022 accepted: 12/12/2022 published: 30/05/2024 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:bakhtiarfattah8@gmail.com mailto:bakhtiarfattah8@gmail.com mailto:bakhtiarfattah8@gmail.com?subject=bakhtiarfattah8@gmail.com%20%20 mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.10 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article a healthy school environment focuses on providing a suitable setting for learning and healthy behaviors, which is insufficient in the majority of schools and exposes staff members and children to different health risks. to improve health among staff members and children in schools, adequate understanding of and adherence to healthy school environments are required [1].according to the world health organization (who, 2010), a healthy school environment includes the school's physical structure, infrastructure, furniture, use of chemicals, and biological agents, as well as the site where the school is located and the immediate environment, including the air, water, and materials that kids may come into contact with[2].because many of a child's social norms and behaviors are learned in the classroom, the school environment is a crucial context [3]. the school is the children's second-most-important learning environment after the home, and it plays a significant role in the community [4].the implementation of a healthy school environment was assessed putting into consideration the availability or presence of facilities that are basic to its implementation and that are conducive to optimal physical, mental and emotional health, safety of the pupils amongst all members of staff and students [5]. a key component of the school health program is a healthy school environment. the term "healthy school environment" refers to any carefully planned, organized, and carried out actions to guarantee safety and wholesome living conditions for all members of the school community. the level of intellectual growth and development of a person is significantly influenced by their school environment, which includes physical, biological, and sociocultural factors. the goals of a healthy school environment are to establish a secure and healthy learning environment as well as adequate safe water supplies and restrooms for use in classrooms [6].health is essential to everyone's life. everyone has to be in good health. even though, everyone is in good health that needs to be maintained constantly. this knowledge will cause schools to adjust in order to care for children's health issues. a country's overall system for delivering healthcare should include a school health program [7]. a healthy school environment includes everything surrounding a school that has an impact on students' physical, mental, and emotional health [8].additionally, it presents an opportunity to guarantee the life cycle approach required for a kid's development as in addition to services for maternal and child health [9].according to ezeonu et al, the national school health policy was passed and accepted in nigeria in 2006 as a manual for carrying out the school health programme to maintain and enhance the health of students[10].as a result, it serves as both a legal foundation and a declaration of the government's commitment to protecting students' health at school. future health may be contributed to and wisely ensured by making investments in children's health today. through the ongoing execution of the sustainable development objective of "ensuring an inclusive and excellent education for all and encouraging lifelong learning" as the cornerstone to improve people's lives and sustainable development, the school provides a great chance to reach many youngsters [11]. an across-sectional was conducted to determine teachers' knowledge regarding ahealthy school environment. 360 teachers were recruited for the study (260 teachers from public schools and 100 teachers from private schools) in erbil city/ kurdistan 104 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.10 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article of overall teachers’ knowledge about school health policy documents (14 items) was categorized into three groups' poor knowledge (0-4.8), fair knowledge (4.99.7), and good knowledge (9.8-14). the data were analyzed by using statistical package for social sciences (spss) software for statistical analysis version 26, for calculating descriptive statistical analysis (frequency and percentage). inferential statistical analysis (chi-square test, fisher’s exact test, and independent sample t-test) was used to determine the association between variables. the p-value is considered statistically significant if it's ≤ 0.05 which rejects the null hypothesis. the scientific and ethics committee of the college of nursing at hawler medical university gave its approval to the study (code 112) on 7/10/2021 before starting the research. the formal consent form was taken from the ministry of education in erbil. the respondents' rights and confidentiality were protected throughout the study. they were informed and explained the goal of the study as well as the confidentiality of the information through a verbal permission process. three hundred and sixty teachers were included in the study. their mean age (sd) was 39.8 (8.3) years, ranging from 25 to 63 years; the median was 40 years. table 1 shows that the majority (74%) of private school teachers were aged (25-37), younger than public schools (64.6%) were aged between (38-50) years (p < 0.001).the percentage of male in private school teachers was (64%), which was higher than male in public school teachers from 51.2% (p = 0.028).the majority (81.9%) of the teachers in the public schools were married compared with 69% of the private school teachers (p = 0.046).the highest (95.8%) of the public teachers had bachelor degrees region, from 1st november 2021 to 1st november 2022. a non-probability/ convenience sampling technique was used to collect the data. the scientific and ethics committee of the college of nursing at hawler medical university gave its approval to the study (code 112) on 7/10/2021 before starting the research. the formal consent form was taken from the general directorate of education in erbil, in both public and private schools to conduct the study. the inclusion criteria are composed of (high schools located in erbil city, teachers of both genders who are willing to participate in the study and are available during the study). exclusion criteria included (students, non-teaching staff, crop members, students participating in teaching practice, and teachers who refused to participate in the study were all excluded from the study. the high schools not located within the erbil city, non-teaching staff, teachers that experience less than 2 years and teachers that refuse to take part in the study). a semi-structured instrument was designed after reviewing related literature on school health policy documents and perceived knowledge that related to healthy school environments. two parts were used for data collection. part one includes socio-demographic characteristics and the professional background of the teachers. this part contains information such as age, gender, marital status, level of education, years in service, subject taught, monthly income, house ownership and car ownership. part two: knowledge of school health policies. the inquiries are openended. respondents to the open-ended questions were required to provide a "yes," "no," or i don't know" response. regarding the rating and scoring of the scales, the responses to the teachers’ knowledge about school health policy document items included two answers (0 = incorrect and 1= correct). the calculation 105 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.10 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article compared with 86% of teachers in the private schools (p = 0.001).around onequarters(14%) of the private teachers had postgraduate degrees compared with 4.2% of teachers in the public schools (p = 0.001).regarding the duration of service, around two-thirds (65%) of the private teachers served less than 10 years in teaching compared with 10.4% of teachers in public schools. on the other hand, 35.4% of the public teachers had served 20 years or more as teachers compared with 11% of the private teachers (p < 0.001). there was no significant difference between public and private teachers in the subjects they taught (p = 0.643). no significant difference was noticed in the income of teachers of the two groups (p = 0.105). regarding house ownership, 61.2% of the teachers in the public schools owned a house compared with 47% of teachers in the private schools (p = 0.016). finally, 85.8% of teachers of the public schools owned a car compared with 77% of the private teachers (p = 0.046). 106 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: characteristics of study samples of high school teachers. socio-demographic characteristics school p-value public private f. (%) f.(%) age group (years) 25-37 60 ( 23.1 ) 74 (74) < 0.001 vhs 38-50 168 (64.6) 21 (21) 51-63 32 (12.3 ) 5 (5) gender male 133 (51.2) 64 (64) 0.028 s female 127 (48.8) 36 (36) marital single 44 (16.9) 30 (30) 0.046 s married 213 (81.9) 69 (69) divorced 2 ( 0.8 ) 1 (1) widowed 1 (0.4) 0 (0) education bachelor degree 249 (95.8) 86 (86) 0.001 vhs postgraduate 11(4.2 ) 14 (14) service duration < 10 27 (10.4) 65 (65) < 0.001 vhs 10-19 141 (54.2) 24 (24) 20+ 92 (35.4) 11 (11) subject taught english 33 (12.7) 16 (16) 0.643 ns kurdish 23 (8.8 ) 13 (13) arabic 32 (12.3) 12(12) mathematic 28 (10.8) 14(14) physic 21 (8.1 ) 7 (7) chemistry 28 (10.8) 12 (12) biology 32 (12.3) 8 (8) others 63 (24.2) 18 (18) income sufficient for daily needs 136 (52.3) 64 (64) 0.105 ns insufficient for daily needs 122 (46.9) 36 (36) exceeds ne 2 (0.8 ) 0 (0) house owned 159 (61.2) 47 (47) 0.016 s partially owned 41 (15.8) 15 (15) rented 45 (17.3) 24 (24) others 15 (5.8 ) 14 (14) car yes 223 (85.8) 77 (77) 0.046 s no 37 (14.2 ) 23 (23) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.10 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 107 teachers knew that a safe physical, biological, and socio-emotional climate in the school is one of the components of the school health program, and there was no significant difference between the two groups (p = 0.468). the majority of the teachers (88.6%) were aware that a school might be considered healthy if it promotes intimate relationships between the school, home, and community and there was no significant difference between the two groups (p = 0.339). the table shows that only 16.7% (27% of the private and 12.7% of the public) of the teachers have a copy of the national school health policy in their school (p = 0.001). more than one-third (37.5%) of the teachers mentioned that their school has written health-related guidelines or policies for use (51% of the private teachers compared to 32.3% of the public teachers, p = 0.001). more than one-third (35.8%) of the teachers mentioned that there is a procedure in place to monitor and enforce proper implementation of the mentioned policies in their school (56% of the private compared to 28.1% of the public teachers, p < 0.001). the majority (85.8%) of teachers consider that the school health policy encourages skill-based health education (89.2% of the public teachers compared to 77% of the private teachers, p = 0.001). table 2 shows that more than half (52.3% of public and 58% of private) of the teachers have information about school health policy, but there was no significant difference between both groups of teachers (p = 0.398). more than two-thirds (68.1%) of public school teachers compared to 74% of private school teachers knew the school health policy is a written guideline which helps in the effective monitoring and evaluation of the school health program, and no significant difference was detected between the two groups of teachers (p = 0.403). more than three-quarters of (79.2) public school and (81%) private school teachers knew the school health program helps in the promotion of health and development of the school community(p = 0.398). only 19.7% of teachers knew that the school health policy was formulated by the ministry of education, one-quarter of private teachers knew about that, compared with 17.7% of public teachers (p = 0.001). around three-quarters of (72.3%) public school and (75%) private school teachers knew that the school health policy is a structure that successfully monitors the duties of participants in the school. no significant difference was perceived between the two groups of teachers (p = 0.795). around two-thirds (63.8%) of public school teachers and (58%) private school teachers knew that the school health policy was formulated in joint conjunction with the ministry of health and education. no significant difference was noted between the private and public school teachers (p = 0.583). more than three-quarters (77.2%) of the teachers knew that the school health programs enhanced the comprehension and learning abilities of the students (76.9%) public school teachers and(78%) private school teachers. the difference between the two groups was not significant (p = 0.794). the majority (85%) of public school teachers and (87%) of private school copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.10 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 108 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. knowledge on school health policy document school public private incorrect correct incorrect correct f. (%) f. (%) f. (%) f. (%) policies are written document formulated by law makers or recognized health institution to help coordinate a particular program or activities for the benefit of the population 124 (47.7) 136 (52.3) 42 (42) 58 (58) school health policy is a written guideline which helps in the effective monitoring and evaluation of the school health program 83 (31.9) 177 (68.1) 26 (26) 74 (74) the school health program helps in the promotion of health and development of the school community 54 (20.8) 206 (79.2) 19 (19) 81 (81) the school health policy document was formulated by the ministry of education 214 (82.3) 46 (17.7) 75 (75) 25 (25) the school health policy is a framework that effectively monitor the roles of stakeholders in the school 72 (27.7) 188 (72.3) 25 (25) 75 (75) the school health policy was formulated by the joint conjunction of the ministry of health and education 94 (36.2) 166 (63.8) 42 (42) 58 (58) school health programs enhance the comprehension and learning abilities of the students 60 (23.1) 200 (76.9) 22 (22) 78 (78) do you know in which year the school health policy was formulated and adopted for use 253 (97.3) 7 (2.7) 95 (95) 5 (5) the provision of a safe physical, biological and socio emotional climate in the school is one of the components of the school health program 39 (15) 221 (85) 13 (13) 87 (87) school that enhances a close relationship between the school, home and the community can be considered healthy 33 (12.7) 227 (87.3) 8 (8) 92 (92) do you have a copy of the national school health policy in your school 227 (87.3) 33 (12.7) 73 (73) 27 (27) does this school has any written health related guideline or policy for use 176 (67.7) 84 (32.3) 49 (49) 51 (51) is there any procedure in place to monitor and enforce proper implementation of this policy in this school 187 (71.9) 73 (28.1) 44 (44) 56 (56) school health policy encourage skill-based health education 28 (10.8) 232 (89.2) 23 (23) 77 (77) table 2: distribution of the study sample according answers. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.10 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article is a very highly statistically significant difference between public and private schools in regard to the level of knowledge. 13.9% among those with 10-19 years of service, and 21.4% among those with ≥ 20 years of service (p = 0.019). also, table4 shows that no significant association was noted between knowledge of the national school health policy document and the following socio-demographic variables: marital status (p = 0.503), income (p = 0.794), and house ownership (p = 0.440). and also the association with subject taught: no significant association was noted between knowledge on the national school health policy document and subject taught (p = 0.229). table3 shows that the highest (74.6% of public and 56 of private) of the teachers had fair knowledge about a national school health policy (p < 0.001). and there table4 shows that the relationship with car ownership was also highly significant (p = 0.004), that 35% of people without cars had a high degree of knowledge compared to 17.7% of those who had cars. also shows that a significant was noted between knowledge on national school health policy document with age (p = 0.031) and educational level (p = 0.053).the highest percentage (71.8%) of female teachers had fair knowledge, compared with 67.5% among males (p = 0.011).around one third (31.5%) of teachers with less than 10 years of service had a high level of knowledge, compared with 109 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table3: distribution of the study sample according to the levels of overall knowledge. overall knowledge on school health policy document school public private poor 28 (10.8) 8 (8) fair 194 (74.6) 56 (56) good 38 (14.6) 36 (36) total 260 (100) 100 (100) p-value of independent sample t-test < 0.001 vhs https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.10 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 110 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: distribution of the study sample according to association between sociodemographic characteristics and levels of knowledge. socio-demographic characteristics overall knowledge on school health policy document p-value chi-square test poor fair good f. (%) f. (%) f. (%) age group (years) 25-37 15 (11.2) 82 (61.2) 37 (27.6) 0.031 s 38-50 18 (9.5) 144 (76.2) 27 (14.3) 51-63 3 (8.1) 24(64.9) 10 (27) gender male 28 (14.2) 133 (67.5) 36 (18.3) 0.011 s female 8 (4.9) 117 (71.8) 38 (23.3) marital single 10 (13.5) 44 (59.5) 20 (27) 0.503 ns married 26 (9.2) 203 (72) 53 (18.8) divorced 0 (0) 2 (66.7) 1 (33.3) widowed 0 (0) 1 (100) 0 (0) education bachelor degree 30 (9) 235 (70.1) 70 (20.9) 0.053 s postgraduate 6 (24) 15 (60) 4 (16) service duration < 10 8 (8.7) 55 (59.8) 29 (31.5) 0.019 s 10-19 16 (9.7) 126 (76.4) 23 (13.9) 20+ 12 (11.7) 69 (67) 22 (21.4) subject taught english 5 (10.2) 39 (79.6) 5 (10.2) 0.229 ns kurdish 4 (11.1) 24 (66.7) 8(22.2) arabic 4 (9.1) 29 (65.9) 11 (25) mathematic 8 (19) 24 (57.1) 10 (23.8) physic 0 (0) 23 (82.1) 5 (17.9) chemistry 1 (2.5) 29 (72.5) 10 (25) biology 3 (7.5) 26 (65) 11 (27.5) others 11 (13.6) 56 (69.1) 14 (17.3) income sufficient for daily needs 18 (9) 142 (71) 40 (20) 0.794 ns insufficient for daily needs 18 (11.4) 106 (67.1) 34 (21.5) exceeds need 0 (0) 2 (100) 0 (0) house owned 21 (10.2) 138 (67) 47 (22.8) 0.440 ns partially owned 2 (3.6) 45 (80.4) 9 (16.1) rented 9 (13) 47 (68.1) 13 (18.8) others 4 (13.8) 20 (69) 5 (17.2) car yes 34 (11.3) 213 (71) 53 (17.7) 0.004 hs no 2 (3.3) 37 (61.7) 21 (35) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.10 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article in table 3 that more than half of public and private school teachers knew the definition of a policy, but there was no significant difference between both groups of teachers. a similar finding was also reported by abubakar au et al, conducted in nigeria, which found that a higher percentage of respondents had good knowledge of school health program[13]. more than two -thirds of the teachers knew the definition of school health policy, and no significant difference was detected between the two groups of teachers. the findings of the present study disagree with a study done in nigeria by obembe ta who found that only a few of the respondents (35.5%) knew the national school health policy[12].the school health policy was created by the ministry of education, although only a little more than a quarter of teachers were aware of this. one-quarter of private teachers had knowledge about that, compared with one-quarters of the public teachers. this result was supported by the result of the study conducted in ibadan local government by omakinwa so, who found that the ministry of education does not create school health policy, according to more than half of the respondents [1]. around three-quarters of teachers knew that the school health policy is a framework for efficiently observing the functions of school stakeholders. no significant difference was detected between the two groups of them. it can be compared to a study done by ademokun om et al, in ibadan, which reveals that teachers are not well-aware of the presence of national school health policy [5].most of the schools that were visited—more than 75 percent—do not have a copy of any written document guidelines to assist in enhancing the state of staff and student health, which supports how little knowledge there is of the school health document. the school health policy was three hundred and sixty teachers were included in the study. their mean age (sd) was 39.8 (8.3) years, ranging from 25 to 63 years. the median was 40 years. these results are almost similar to previous studies, such as a study done by omakinwa, in which the age range of the respondents was between 23– 62 years of age with a mean age of 38.3± 7.7. [1]. the finding of the present study shows that the majority of (74%) private school teachers were aged (25-37), younger than in public schools 64.4% were aged between (38 to 50) years. because the employment of teachers in public schools has stopped only in private schools, the age of private school teachers is younger than that of public teachers. it is evident in table1 that around half of the teachers of the public schools were females compared with less than half of the private teachers. the current study results were similar to a study done by obembe ta et al, conducted in ibadan, which found that most of the respondents were males (51.9%) [12].the majority of the teachers in the public schools were married, compared with more than half of the private school teachers. the current study results were similar to a study by abubakar au, which found that the majority of respondents were married[13].it is evident that one quarter of the private teachers had postgraduate degrees compared with less than one quarter of teachers of the public schools. similar findings were also reported by omakinwa so, who found that more than one quarter have a postgraduate degree[1].no significant difference was noticed in the income of teachers of the two groups. a similar finding revealed in a study in the philippines by gregorio jr er, which found that there was no significant association between the school teacher’s monthly income[14].it is evident 111 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.10 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article a healthy school environment includes a safe physical environment, a biological environment, and a socio-emotional environment, and there was no significant difference between the two groups. a similar finding revealed in a study in ibadan by omakinwa so, who found that more than half of the respondents concurred that a safe physical, biological, and socioemotional environment is a crucial component of the school health program[1]. this could be as a result of the increased attendance and concentration of students in the classroom, further elucidating respondents knowledge of national school health policy. the majority of the teachers (88.6%) knew that a school that enhances a close relationship between the school, home, and community can be considered healthy, and there was no significant difference between the two groups (p = 0.339). a similar finding revealed in a study in ibadan by obembe ta, who found that the majority of respondents, 340 (80%), agreed that parents should be informed of their children's health requirements in terms of "school, home, and community relationship[12].no significant association was detected between knowledge on the national school health policy document and the following socio-demographic variables: marital status, income, and house ownership. a similar finding revealed in a study in nigeria by abubakar au, who found that there was no statistically significant relation between gender and knowledge[16]. significant association was detected between knowledge on the national school health policy document with the following socio-demographic variables: age and educational level. it was in contrast to the study carried out by abubakar au, who found that there was no statistically significant relation between age and level of education[16]. around more than one quarter of female teachers had high developed in partnership with the ministry of health and education, according to about two-thirds of the instructors. no significant difference was detected between the private and public-school teachers. similar findings were in a study in ibadan[1]. more than two-thirds of respondents agreed that the national school health policy was developed by the ministry of health and education, and more than three-quarters believed that it aids in promoting the health and development of the school community, according to the data. this demonstrates that although the respondents were well-informed on the national school health policy content, they had little awareness about the year it was created. more than 75% of the teachers were aware that the understanding and learning skills were improved by the school health programs. the difference between the two groups was not significant. it also disagrees with the result of the study by saadia ag concerning the awareness of national school health policy that only a few of the respondents had ever heard of the term national school health policy [15].the table also shows that only less than one-quarters of the teachers knew the year at which the school health policy was formulated and adopted for use, and there was no significant difference between the two groups. similar findings in a study in ibadan [1]. more than half of respondents do not know when the national school health policy was created or whether it is available in their schools. this could be due to the government not properly informing stakeholders in the education system about the policy creation and availability and another study supported by ademokun om, in ibadan, which supports the fact that few teachers are aware of the existence of national school health policy [5].most teachers—more than 75%—were aware that 112 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.10 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article outcomes for learners with emotional and behavioral disabilities. european journal of business and social sciences. 2012 aug;1 (5):54-69. [4] masten as, obradovic j. disaster preparation and recovery: lessons from research on resilience in human development. ecology and society. 2008 jun 1;13(1). [5] ademokun om, osungbade ko, obembe ta. a qualitative study on status of implementation of school health programme in south western nigeria: implications for healthy living of school age children in developing countries. american journal of educational research. 2014 nov 17;2(11):1076-87. [6] amoran oe, kupoluyi ot, salako aa. healthful school environment: a comparative study of public and private primary schools in ogun state, nigeria. archives of community medicine and public health. 2017 aug 24;3 (2):062-70. [7] gowri ma, missiriya s. knowledge and practice of school teachers on health care of school children. international journal of pharma and bio sciences. 2017 jan;8(1):22731. [8] bisi‑onyemaechi ai, akani na, ikefuna an, tagbo bn, chinawa jm. evaluation of the school environment of public and private schools in enugu to ensure child health promotion. nigerian journal of clinical practice. 2018 feb 26;21(2):195-200. [9] bundy d. rethinking school health: a key component of education for all. directions in development; human development washington, d.c. world bank publications; 2011. [10] ezeonu ct, asiegbu uv, arua ce, edafioghor lo, una af, anyansi mn, onwe oe. national school health policy in nigeria; survey of teachers’ perception and implementation in public schools in ebonyi state. nigerian journal of paediatrics. 2022 may 3;49(1):83-9. [11] united nations. sustainable development goals17 goals to transform the world. accessed at https://www.un.org/ sustainabledevelopment/ sustainable-developmentgoals november date 2018 [12] obembe ta, osungbade ko, ademokun om. awareness and knowledge of national school health policy and school health programme among public secondary school teachers in ibadan metropolis. nigerian medical journal. 2016 jul;57(4):217. knowledge, compared with one quarter among males. it was in contrast to the study carried out by saadia ag, who found that more than half males demonstrated a good knowledge of the school health policy [15]. the association with car ownership was also significant, where it is evident that 35% of those who don’t possess a car had a high level of knowledge compared with more than one quarter of the car owners, because in our country, whoever has a car goes to picnic and walk with his friends, so it will be short of time to read and get to the information. and no significant association was detected between knowledge on the national school health policy document and the sociodemographic variables in both public and private schools in erbil city. in the present study's findings, it was concluded that the highest percentage of the teachers had a fair level of knowledge on national school health policy documents. there was a statistically significant association between teachers’ knowledge on the national school health policy document with age, gender, level of education and service duration. there was a highly significant association between the teachers’ knowledge on the national school health policy document and car ownership. [1] omakinwa so. knowledge and practice of healthful school environment among public and private secondary school teachers in ibadan north local government area, oyo state(doctoral dissertation). [2] world health organization. regional office for the eastern mediterranean. a practical guide to developing and implementing school policy on diet and physical activity. world health organization; 2010. [3] lamport ma, graves l, ward a. special needs students in inclusive classrooms: the impact of social interaction on educational 113 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.10 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 114 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [13] abubakar au, awosan kj, ibrahim mt, ibitoye kp. knowledge and practice of school health program in primary and secondary schools in sokoto metropolis, nigeria. international archives of medicine and medical sciences. 2019;1:23-8. [14] gregorio jr er, medina jr, lomboy mf, talaga ad, hernandez pm, kodama m, kobayashi j. knowledge, attitudes, and practices of public secondary school teachers on zika virus disease: a basis for the development of evidence-based zika educational materials for schools in the philippines. plos one. 2019 mar 28;14(3):e0214515. [15] saadia ag. knowledge and view of teacher regarding school health program in two localities khartoum, sudan 2019. international journal of sciences: basic and applied research. 2019;45:181-6. [16] abubakar au, abubakar aa, balogun ms, awosan kj, raji ia, usman ab, abdullahi am, njidda am, bala ha, kaoje au, nguku pm. knowledge of health effects and determinants of psychoactive substance use among secondary school students in sokoto metropolis, nigeria. the pan african medical journal. 2021;40. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article prevalence and associated factors with attending antenatal care in akre city, iraq abstract background and objectives: antenatal care is essential for protecting the health of women and their unborn children. antenatal care utilization is a key intervention in problem detection and treatment, promoting health-seeking behavior, and preparing pregnant women for birth. the present study aimed to investigate the prevalence and associated factors that affect attending and utilizing antenatal care in primary health care centers among pregnant women in akre city. methods: a cross-sectional study was conducted in the maternity hospital of akre city from november 21 to february 21, 2022. data were collected through interviews with 400 women who attended the hospital for delivery and via a questionnaire constructed for the study. the questionnaire included women's socio-demographic characteristics, socio-economic status, obstetrical and reproductive history, and factors affecting antenatal care. frequency, percentage, and chi-square tests were used to analyze the data. result: the rate of attending antennal care was 20%. the study findings showed a statistically significant association between attending antenatal care in the last pregnancy with residency, type of family, parity, and previous mode of delivery. conclusion: the prevalence of women who attend antenatal care is few. effective media and providing special health care in primary health care centers and services are required to improve the level of awareness of pregnant women for utilizing antenatal care. keywords: antenatal care; prevalence; factors; iraq. bnar mustafa ahmed; department of nursing, college of nursing, university of duhok , duhok, kurdistan region, iraq (correspondence:bnar27akre@gmail.com) hamdia mirkhan ahmed; department of nursing, college of nursing , hawler medical university, erbil, kurdistan region, iraq. 84 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 14/07/2022 accepted: 12/09/2022 published: 30/5/2023 mailto:bnar27akre@gmail.com mailto:@gmail .com mailto:bnar27akre@gmail.com https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article pregnancy is necessary to promote good health psychologically and emotionally and prepare women and their families for parenthood. antenatal care (anc) is given to pregnant women and adolescent girls by skilled healthcare providers to ensure the best health conditions for both mother and baby during pregnancy [1]. antenatal care is one of the "four pillars" of safe motherhood initiatives to promote and establish good health during pregnancy and early postpartum [2]. antenatal care also allows women to communicate with their healthcare providers and increases the likelihood of using a skilled birth attendant [3]. approximately 303,000 women and adolescent girls died from pregnancy and childbirth-related complications in 2015; 2.6 million babies were stillborn [4]. maternal mortality is much too high. in 2017, approximately 295,000 women died during and after pregnancy and childbirth. the vast majority of these deaths (94%) occurred in low-resource settings, which could have been avoided [5].the world health organization (who) envisions a world where every pregnant woman and newborn is provided with high-quality care throughout their pregnancy, delivery, and postpartum. antenatal care (anc) is an essential component of the reproductive healthcare continuum because it serves as a platform for crucial healthcare tasks such as disease prevention, screening and diagnosis, and health promotion. it has been demonstrated that anc can save lives by implementing timely and appropriate evidence-based practices. notably, developing these anc recommendations has emphasized the importance of providing pregnant women with respectful communication about physiological, biomedical, behavioral, and sociocultural issues and practical support, including social, cultural, emotional, and psychological support [6]. the who’s new recommendation declares that pregnant women should have at least eight visits to healthcare professionals [7]. the first visit between these should occur within the first 12 weeks of gestation, and the following visits occur repeatedly at weeks 20, 26, 30, 34, 36, 38, and 40 [4]. maternal mortality rates in maternity teaching hospital in erbil city were found to be 44/per 100,000 live births. because not all childbirths occur in hospitals, death in the hospital is a good predictor of death in the community [8]. the advantages of prenatal care were more readily available, particularly regarding gestational diabetes, hemoglobinopathy, and ultrasonography, and the update was started. this update has also given us a chance to look at a number of antenatal care-related issues, such as the creation of a tool to identify women who need additional care (the "antenatal assessment tool"), the distribution of information to women, lifestyle (vitamin d supplementation, alcohol consumption), and fetal screening (using ultrasound for assessing gestational age and screening for fetal abnormalities, methods for determining normal fetal growth, and plausibility tests) (hemoglobinopathy screening, gestational diabetes, preeclampsia and preterm labor) [9].the researcher was interested in the use of antenatal care centers among pregnant women. this study aimed to assess the prevalence of antenatal care attendance and its associated characteristics among women in akre city. a cross-sectional study was conducted among 400 women in the maternity hospital in akre city in the kurdistan region of iraq. this hospital is a public site. akre is a small city with many villages comprising four primary healthcare centers. four hundred women attending the mentioned 85 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 15-43 years old. the highest percentage (36.75%) of women aged 30 years or more, and the majority (97.25%) of them were housewives. regarding residency, most of the study sample (69.50%) were living outside akre (rural). more than half of the study sample were passive smokers (50.63) and lived in an extended family (52.00%). hospital were interviewed by reviewing their records.inclusions criteria included women who were attending the maternity hhospital for delivery at the time of collecting data, willingness to participate in the study, ability to speak clear kurdish or arabic. exclusion criteria included women who disagreed to participate in the study. a questionnaire was developed for data collection and included (sociodemographic, socio-economic status, and obstetrical history of women and questions regarding the rate of attending antenatal care). all the women in the sample completed the questionnaire using face-to -face interview techniques. the questionnaire form filled out the questionnaire took approximately 10 to 15 minutes. before data collection, permission to conduct the study was obtained from the scientific and ethics committee of the university of dohok /college of nursing, the code of ethical approval 42001. each question in the questionnaire was coded, and the data were entered and analyzed by jmp pro 14.3.0. the patients' general information was presented in mean, standard deviation (sd), or number (no.). the prevalence utilization of anc services and satisfaction with the anc services were determined in number and percentage. the level of anc quality was determined by mean and standard deviation (sd). a point was given for each item done by the medical staff during each anc session. the total items were added together to obtain the total quality of anc services. before data collection, informed consent was taken from the study sample, and they had the right to withdraw from the study at any time. table 1 shows the socio-demographic characteristics of the study sample. regarding age groups, they ranged between 86 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results table 1: socio-demographic characteristics of the study sample variable no. (%) age (years) 15-43 27.16 (5.66) < 20 30 (7.5) 20-24 110 (27.5) 25-29 113 (28.25) 30 and older 147 (36.75) occupation contract temporary employee 5 (1.25) governmental employee 5 (1.25) house wife 389 (97.25) self-employed 1 (0.25) residency akre 122 (30.5) outside 278 (69.5) smoking active 1 (0.25) passive 202 (50.63) non 196 (49.12) type of family extended 208 (52.00) nuclear 192 (48.00) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article table 2 shows the socio-economic status of the study sample, which was calculated according to women and husbands' education , crowding index , possession of care, type of housing, and cost of electrical machines. overall socio-economic status divided into three groups, in which 67.5% of the study sample had medium status. 87 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: distribution of socio-economic status of the study sample n=400 socio-economic criteria category no. (%) women education illiterate 144 (36) read and write 73 (18.25) primary 106 (29.5) intermediate and secondary 30 (7.5) diploma, university and high education 47 (11.75) husband education illiterate 85 (21.25) read and write 94 (23.5) primary 100 (25) intermediate and secondary 39 (9.75) diploma, university and high education 82 (20.5) crowding index <1.2 201 (50.25) 1.5-2.9 196 (49) ≥3 3 (0.75) possession of car yes 191 (47.75) no 209 (52.25) type of housing owned 163 (40-5) partially owned 195 (48.75) rented 43 (10.75) cost of electrical machines < 1500$ 222 (55.5) 1500 – 3000 $ 175 (43.75) > 3000 $ 3 (0.75) overall socio-economic status low ses medium ses high ses 67 270 63 (16.75) (67.5) (15.75) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 88 had no abortion (76.50), and stillbirth (52%). most of the study sample (74.50%) did not attend antenatal care in the previous pregnancy. the majority (80%) of women did not attend antenatal care. the rate of attending to antenatal care was 20%. copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3 shows the obstetrical and reproductive history of the study sample. the highest percentage of them were multipara (47.25%), figure 1 shows the prevalence and rate of attending and utilizing antenatal care in the last pregnancy. table 3:disrtibution of the study according obstetrical and reproductive history variable no. (%) gravida category prime gravida 131 (32.75) multi-gravida 169 (42.25) grand multigravida 100 (25) parity null parity 1 (0.25) prime para 150 (37.5) multi para 189 (47,25) grant multi para 60 (15) abortion 0 306 (76.5) 1 50 (12.5) 2-4 44 (11) still birth 0 352 (88) 1 35 (8.75) 2-4 13 (3.25) delivery mode c/s 192 (48) normal delivery 208 (52) attending anc during previous pregnancies no 298 (74.5) yes 102 (25.5) figure 1: prevalence and rate of attending and utilizing antenatal cate in last pregnancy https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 89 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4 shows the association between attending anc in the last pregnancy with women's socio-demographic characteristics and socio-economic status. there was no significant association between attending antenatal care in the last pregnancy, women's age (p=0.0805) , occupation (p=0.0893), and smoking (p=0.3295). in contrast, there was a significant association between attending antenatal care in the last pregnancy with residency (p=0.0020), and type of family (p=0.0043). table 4: : association between attending anc in last pregnancy with socio-demographic characteristic and socio-economic status of women characteristics (n=400) no (n=320) no. (%) yes (n=80) no. (%) p-value age < 20 20-24 25-29 22 (73.33) 82 (74.55) 89 (78.76) 8 (26.67) 28 (25.45) 24 (21.24) 0.0805 occupation contract/temporary employee governmental employee house wife self-employed 2 (40) 5 (100) 312 (80.21) 1 (100) 3 (60) 0 (0) 77 (19.79) 0 (0) 0.0893 residency akre outside 109 (89.34) 13 (10.66) 0.0020 type of family extended nuclear 155 (74.52) 165 (85.94) 53 (25.48) 27 (14.06) 0.0043 smoking active passive none socio economic status low ses medium ses high ses 1 (100) 167(82.67) 151 (77.04) 57(85.07) 213(78.89) 50(79.37) 0 (0) 35 (17.33) 45 (22.96) 10(14.93) 57(21.11) 13(20.63) 0.3295 0.5214 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article (p=0.0356) have a significant association with attending antenatal care, while gravida (p=0.0928) and having stillbirth (p=0.4655) do not. table 5 describes the association between attending antenatal care in the last pregnancy and women's obstetrical and reproductive history. in this study, parity (p=0.0200) and previous mode of delivery 90 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table5: association between attending antenatal care in last pregnancy with obstetrical and reproductive history of pregnant women variables=400 no (n=320) no. (%) yes (n=80) n0. (%) p-value gravida category prime 2-4 ≥ 5 97 (74.05) 138 (81.66) 85 (85) 34 (25.95) 31 (18.34) 15 (15) 0.0928 parity null parity prime multipara grant multipara 1 (100) 108 (72) 161 (85.19) 50 (83.33) 0 (0) 42 (28) 28 (14.81) 10 (16.67) 0.0200 abortion 0 1 2-4 244 (79.74) 36 (72) 40 (90.91) 62 (20.26) 14 (28) 4 (9.09) 0.0712 still birth 0 1 2-4 279 (79.26) 29 (82.86) 12 (92.31) 73 (20.74) 6 (17.14) 1 (7.69) 0.4655 previous mode of delivery c/s normal delivery 162 (84.38) 158 (75.96) 30 (15.63) 50 (24.04) 0.0356 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article finding, a high percentage (89.5%) of women were living in urban areas attending anc; the result of this study is different result with the study done in akre, that residency is significantly associated with antenatal care utilization [16,17]. women in nigeria [18] attended (82%) more anc visits than rural women (45%); according to the report, a study conducted in nigeria found that living in an urban setting increases the likelihood of using antenatal care services by more than twofold [19]. this contradicts research is done in eastern sudan, which found no link between residency and antenatal care utilization [20]. the discrepancy could be because women in urban areas have better access to health facilities and information and hence receive services from nearby health facilities. there is no study that is similar to this study regarding residency. regarding socio -economic status, the high percentage of socio-economic classes in this study was reported as a medium class (67.50%), which is similar to the results of a study done in erbil city in which the rate of attending anc (80.5%) [21]. higher than this finding was reported by the study [22] in ethiopia, they found (1.41%)low percentage of women were in the middle class of ses. the current study revealed that the use of anc was higher (92.2%) among women with a high ses. this finding was similar to previous studies done in turkey [23]. these findings are similar to those of previous studies indicating that family income and the cost of accessing care played a very important role in the utilization of anc services and in encouraging pregnant women to visit anc [24,25]. in a recent review conducted in low and middle-income countries, the mother's and her partner's education were the most significant factors that influence the utilization of maternal healthcare services [26]. a study in sub-saharan african countries the prevalence and rate of attending antenatal care in the last pregnancy in akre city was low (20%). compared to another study, a high proportion of women in the syrian refugee camps in erbil attended antenatal care services during the last pregnancy (99.6%), with different results [10]. according to this study, egyptian women in 2000-2014 utilizing anc was low; its similar result [11] about (28.5%) of women's attending anc women's education and quality of health services play significant roles in increasing accessibility of antenatal health care services. on the other hand, women's empowerment has shown a positive effect; another study shows the utilization of anc service is very low even for women who have access to the service in ethiopia in general (49.8%) of the study sample attending anc in the last delivery, in a study conducted in north maharashtra utilization of antenatal care (anc) services is poor in the tribal areas, causing increased maternal morbidity and mortality [12]. (64.2 %) its different result [13, 14]. the study participants might be in similar sociodemographic status, understanding of antenatal care options, and common traditional practices encouraging home treatment, which could explain the consistency. however, this figure is higher than the (34%) attendance rate reported in the ethiopia demographic health survey 2011 its similar result [15]. the analysis was done on any women who received antenatal care follow-up by any health professional, more awareness, and better access to service, which could be the main component that boosted antenatal care service use in this study. regarding residency, the highest percentage (69.50 %) of women were living outside akre (rural) and attending antenatal care, while in this 91 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 018-2014-8 [accessed: 20th aug 2022]. [3] world health organization. who recommended interventions for improving maternal and newborn health: integrated management of pregnancy and childbirth. world health organization; 2007. [4] tunçalp ӧzge, pena-rosas jp, lawrie t, bucagu m, oladapo ot, portela a, et al. who recommendations on antenatal care for a positive pregnancy experience-going beyond survival. an international journal of obstetrics and gynaecology. 2017;124 (6):860–862. [5] world health organization. trends in maternal mortality 2000 to 2017: estimates by who, unicef, unfpa, world bank group and the united nations population division; 2019; [6] world health organization. who recommendations on antenatal care for a positive pregnancy experience: summary: highlights and key messages from the world health organization’s 2016 global recommendations for routine antenatal care. world health organization; 2018. [7] world health organization. who recommendations on antenatal care for a positive pregnancy experience; world health organization. 2016b. [8] ali ms, jawad ak, jawad rk. maternal mortality at the maternity teaching hospital in erbil, kurdistan: a hospital-based data 20112013. zanco journal of medical sciences. 2015;19(3):1116–22. [9] guıa ni. national collaborating centre for women’s and children’s health (uk) and national institute for health and care excellence (uk). bronchiolitis. diagnosis and management of bronchiolitis in children. 2015. [10] fareed sm, ismail kh. utilization of antenatal care services in syrian refugee camps in erbil, iraq. zanco journal of medical sciences. 2019;23(2):250–6. [11] zaky hh, armanious dm, hussein ma. determinants of antenatal health care utilization in egypt (2000-2014) using binary and count outcomes. health (n y). 2019;11 (01):25. [12] tura g. antenatal care service utilization and associated factors in metekel zone, northwest ethiopia. ethiopian journal of health sciences. 2009;19(2). [13] mumbare ss, rege r. ante natal care services utilization, delivery practices and factors affecting them in tribal area of north revealed that use of antenatal care was associated with mother’s age, parity, interaction with healthcare provider and cost of antenatal care [27]. another study in urban slum areas in islamabad found that family income was not significantly associated with antenatal care utilization women's education and husband’s education were significantly associated with the utilization of antenatal care facilities in this study [28]. the results show the majority of women have not attended and utilized anc during pregnancy. there were statistically significant associations between attending antenatal care with residency, type of family, parity, and previous mode of delivery. it is recommended that effective media and health education can be used to raise pregnant women's awareness and that professional staff in primary health care centers. pregnant women should encourage to attend antenatal care to ensure the best health conditions for both mother and baby during pregnancy. there is no conflict of interest. [1] organization wh. who antenatal care recommendations for a positive pregnancy experience: nutritional interventions update: vitamin d supplements during pregnancy. 2020. [2] konje et, magoma mt, hatfield j, kuhn s, sauve rs, dewey dm. missed opportunities in antenatal care for improving the health of pregnant women and newborns in geita district, northwest tanzania. bmc pregnancy and childbirth. 2018 dec;18(1):1-13. available from: https://doi.org/10.1186/s12884 92 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article maharashtra. indian journal of community medicine. 2011;36(4):287. [14] kushwaha p, mehnaz s, ansari ma, khalil s. utilization of antenatal care services in periurban area of aligarh. international journal of medical science and public health. 2016;5(10):2004–8. [15] tarekegn sm, lieberman ls, giedraitis v. determinants of maternal health service utilization in ethiopia: analysis of the 2011 ethiopian demographic and health survey. bmc pregnancy childbirth. 2014;14(1):1– 13. [16] ali sa, dero aa, ali sa, ali gb. factors affecting the utilization of antenatal care among pregnant women: a literature review. journal of pregnancy and neonatal medicine. 2018;2(2): 41-45. [17] rafaeli t, hutchinson g. the secondary impacts of covid-19 on women and girls in sub-saharan africa. brighton, uk: institute of development studies; 2020. [18] doctor hv. intergenerational differences in antenatal care and supervised deliveries in nigeria. health place. 2011;17(2):480–9. [19] babalola s, fatusi a. determinants of use of maternal health services in nigeria-looking beyond individual and household factors. bmc pregnancy childbirth. 2009;9(1):1–13. [20] ali aaa, osman mm, abbaker ao, adam i. use of antenatal care services in kassala, eastern sudan. bmc pregnancy childbirth. 2010;10(1):1–4. [21] dhahir aa, zangana jm. determinants of utilization of antenatal care services in erbil city. zanco journal of medical sciences. 2015;19(2):984–90. [22] acharya d, khanal v, singh jk, adhikari m, gautam s. impact of mass media on the utilization of antenatal care services among women of rural community in nepal. bmc research notes. 2015;8(1):1–6. [23] celik y, hotchkiss dr. the socio-economic determinants of maternal health care utilization in turkey. social science & medicine. 2000;50(12):1797–806. 93 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [24] simkhada b, teijlingen er van, porter m, simkhada p. factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. journal of advanced nursing. 2008;61(3):244–60. [25] alam ay, qureshi aa, adil mm, ali h. factors affecting utilization of antenatal care among women in urban slum areas of islamabad. rawal medical journal. 2004;29(2):71–5. [26] banke-thomas oe, banke-thomas ao, ameh ca. factors influencing utilisation of maternal health services by adolescent mothers in low-and middle-income countries: a systematic review. bmc pregnancy childbirth. 2017;17(1):1–14. [27] pell c, meñaca a, were f, afrah na, chatio s, manda-taylor l, et al. factors affecting antenatal care attendance: results from qualitative studies in ghana, kenya and malawi. plos one. 2013;8(1):e53747. [28] erbaydar t. utilization of prenatal care in poorer and wealthier urban neighbourhoods in turkey. the european journal of public health. 2003 dec 1;13(4):320-6. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.13 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article prevalence and persistent fatigue among patients post covid-19 in erbil city abstract background and objectives: fatigue is one of the most common symptoms, affecting more than 75% of people. it is a subjective lack of physical or mental energy. the goal of the study was to assess persistent fatigue among patients post-covid-19 in erbil city. methods: a quantitative, descriptive cross-sectional study was conducted at a private clinic and home for patients in erbil city. a nonprobability-purposive sample was selected for 300 post-covid patients. data was collected through interviews using a questionnaire and a modified fatigue impact scale was used to assess patients’ fatigue in postcovid-19. results: the results show that one third (31.7%) of the study samples were older than 50 years, and more than half (52.3%) were males, less than one third (28.3%) graduated from an institute, and more than one third (32.3%) were housewives. the majority of the samples (84.7%) lived in areas, and almost all the samples (81.7%) were married. most of the samples (73.0%) without comorbidity disease about 75.3 were overweight, and the samples (83.0%) were not hospitalized during covid-19, about more than half (67.0%) were not received oxygen. less than half (46.3%) of the samples have physical fatigue, and more than half (63.7%) have mild mental fatigue. there was a significant association between fatigue and gender, hospitalization, and receiving oxygen during covid-19 at p-value ≤ 0.05. conclusion: the study concluded that the participants have physical and mental fatigue and physical and mental fatigues are decreasing by increasing the duration of illness from the first to the sixth month. a significant difference was found between fatigue and the female gender. keywords: post covid-19 fatigue; covid-19; chronic fatigue syndrome. shagul hasan hussein;department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: shagul.00073154@gmail.com) ronak nihmatala hussain; department of nursing, college of nursing, hawler medical university, erbil, iraq. 116 received: 31/07/2022 accepted: 13/09/2022 published: 30/11/2023 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:shagul.00073154@gmail.com?subject=shagul.00073154@gmail.com mailto:shagul.00073154@gmail.com?subject=shagul.00073154@gmail.com https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.13 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article the coronavirus disease (covid-19) outbreak of 2019 was originally detected in wuhan, china, and is now spreading domestically and worldwide. covid-19 is a viral illness induced by sars-cov-2 that mostly affects the pulmonary system, according to rothan and byrareddy [1]. on march 12, 2020, the world health organization declared the covid-19 outbreak a pandemic. since then, the virus has spread swiftly throughout china and around the world, affecting about 12,000,000 confirmed patients and 500,000 deaths in over 200 nations, areas, or territories with confirmed cases by july 2020, resulting in a catastrophic global health disaster [2].long term covid is used to describe illness in persons who have either healed from covid-19 but still have long-term sequelae from the infection or who have experienced the regular symptoms for far longer than expected [3]. in spring 2020, when covid-19 patients still had symptoms several weeks after their acute infection and soon after the first cases emerged, postcovid syndrome, also known as longcovid, was first described as a clinical entity; in particular, relevant information emerged from the first detailed patient survey of post-covid syndrome [4]. even after a very minor acute illness, post-covid syndrome appears to be a multisystem disease [5].chronic fatigue syndrome (cfs) is characterized by extreme mental and physical exhaustion, sleep disturbances, and persistent discomfort. fatigue is one of the most prevalent symptoms in people infected with sars-cov-2, the virus that is causing the current covid-19 pandemic [6]. chronic fatigue syndrome (cf) affects 2.5 million americans, according to the centres for disease control and prevention (cdc) [7]. it is a multisystem condition that causes devastating symptoms such as extreme fatigue, post-exercise malaise, restless sleep, cognitive impairments, and orthostatic intolerance. in the united states alone, the centers for disease control and prevention and the national academy of medicine estimate that 836,000 to 2.5 million people have me/cfs [8].according to recent findings, weariness has been noted in about one-third of covid-19 patients, where it has been linked to a worse prognosis and can last for at least six months following infection. according to studies on the prevalence of fatigue following covid-19, between 9 and 49% of patients exhibit fatigue 4 weeks after the onset of symptoms and between 30 and 16 weeks later. according to a recent study, at least one-third of covid19 patients may experience fatigue for up to a year after [9]. coronavirus causes several complications or several of symptoms after the patient recovers from the virus. fatigue is a more common symptom after recovery from the coronavirus and many people have been diagnosed with post-covid fatigue, limited studies in the kurdstan region assess fatigue among patients in post-covid-19 in erbil city. the aim of the study was to assess the prevalence persistent fatigue among patients post-covid-19. adescriptive crosssectional study was conducted in erbil city, kurdistan region. non-probability (purposive sample) of 300 post-covid-19 patients in six months at a private clinic and home visit from 1st september 2021 to 1st september 2022, data were collected through direct interviews (face to face). info software program version 8 was used for sample size estimation. the expected frequency (26.5) based on the proportion covid-19 patients in erbil city because the number of patients infected with covid-19 about 117 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.13 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article percentage). an independent sample ttest is used to compare two independent variables; one-way anova analysis of variance is used to test the claim that there are three or more variables, correlation and simple regression analysis was used to determine the relationship between independent variables and dependent variables. a p-value statistically significant level of ≤ 0.05. the results show that (31.7%) of the patient were older 50 years, males (52.3%) were higher than females; high percentage of them graduated from institute (28.3) and housewife (32.3), the majority of the patients lived in urban(84.7), and married (81.7), as shown in the table 1. 95%. the population size is 57000 number of recovered covid19 patients in erbil city from june 2021 to december 2021[10]. accordingly, 300 samples were estimated for the study. they were chosen according to the criteria of the study, more than 18 years old, female and male 6 months of recovery after infected covid-19 and all hospitalization and non-hospitalization patients. the instruments used for data collection consist of three parts based on the objectives of the study. part one sociodemographic about patients such as (age, gender, level of education, occupation status, residence and marital status). part two medical data consisted of different items about patients such as (body mass index ‘bmi’, chronic disease, hospitalization during covid-19, and receiving oxygen during covid-19). part three was fatigue impact. fatigue prevalence items include 21 (11 ‘’physical’’ items and 10 ‘’mental’’ items); the total score of the mfis ranges from 0 to 84. the mfis-5 scores each item on a five-point likert scale from 0 to 4. it means never (0), rarely (1), sometimes (2), often (3), always (4). fatigue level was split into three categories: ‘mild fatigue,’ moderate fatigue,’ severe fatigue’. the score for mild fatigue ranged from (0 to 1), moderate fatigue ranged from (2), severe fatigue ranged from (3 to 4) [11].the study protocol was approved by the ethical committee of the college of nursing at hawler medical university code number is 97 on 7th october 2021 and the official permission was obtained from the ministry of health in erbil, director of health to take the number of recovery patients in erbil city. the permission was obtained from each participant; they were informed and explained the purpose of the study and the confidentiality of the information. data were analysed using the statistical package for social sciences (spss, version 28) to calculate descriptive statistical analysis (frequency and 118 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result table 1: socio demographic data of 300 covid19 patients variables n. (%) age 20 29 51 (17) 30 39 93 (31) 40 49 61 (20.3) ≥50 95 (31.7) gender male 157 (52.3) female 143 (47.7) level education illiterate 32 (10.7) primary school 70 (23.3) secondary school 52 (17.3) institute 85 (28.3) university and above 61 (20.3) occupation employee 91 (30.3) unemployed 88 (29.3) retired 12 (4) house wife 97 (32.3) student 12 (4) residence urban 254 (84.7) suburban 46 (15.3) marital status married 245 (81.7) unmarried 55 (18.3) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.13 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article (75.3%) of patient were overweight, a high percentage of them did not have any comorbidity disease (73%), since most of them (60.5%) have diabetic disease, the majority of the patients have not been admitted at hospital during their covid-19 (83%)since the range of their remained to the hospital was 4-6 days and more than half of the samples (67%) did not receive oxygen while the range of using oxygen was 6-10 days, as shown in the table 2. the prevalence of fatigue post-covid-19 of the study samples was less than half (46.3%) of the study samples had severe physical fatigue and more than half (63.7%) of the study samples had mild mental fatigue. the mean of physical fatigue in general (26.657) is higher than the mean of mental fatigue (11.667), which means the patients post covid-19 had a physical fatigue compared with mental fatigue. as shown in the figure 1. the results show a very strong negative correlation between the independent variable (duration of illness) and the dependent variable (physical problem) (-0.75) while there is a strong negative correlation between the independent variable (duration of illness) and the dependent variable (mental problem) (-0.66). 119 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: medical data of 300 post covid 19 patients variables n. (%) body mass index normal 37 (12.3) overweight 226 (75.3) obese 37 (12.3) do you have any chronic disease? yes 81 (27) no 219 (73) what is it? asthma 1 (1.2) diabetic 49 (60.5) hypertension 28 (34.6) thalassemia 3 (3.7) did you hospitalize during covid-19 yes 51 (17) no 249 (83) how many days 1-3 11 (21.6) 4-6 21 (41.2) ≥7 19 (37.3) did you receive oxygen therapy yes 99 (33) no 201 (67) received oxygen/ days 1-5 46 (46.5) 6-10 22 (22.2) 11-15 15 (15.2) ≥15 16 (16.2) figure1: prevalence and incidence percentage for physical and mental https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.13 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 120 duration of illness is -0.084, which means, that increasing one unit for duration of illness will decrease the mental problem by 0.084. as shown in table 3. p-values were less than the significant level of α=0.05. patients who lived in areas and married perceived non-significant with physical and mental fatigue compared to those who lived in suburban and single patients because their p-values were higher than the significant level of α=0.05, as shown in able 4. copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: prediction of the duration of covid-19 recovery on physical and mental fatigue simple regression coefficient (b) for duration of illness is -0.144, which means, that increasing one unit for duration of illness will decrease the physical problem by 0.144. regression coefficient (b) for female patients perceived significantly more physical and mental fatigue than male patients with comorbidity disease, hospitalization and received oxygen during covid-19, perceived significantly more physical and mental fatigue than noncomorbidity disease, non-hospitalization and received oxygen because their model b t p-value corr. r2 f p-value physical (constant) 41.704 48.077 0.001 -0.75 0.556 372.6 0.001 how long your illness recovered completely -0.144 -19.313 0.001 mental (constant) 20.450 31.644 0.001 -0.66 0.434 228.3 0.001 how long your illness recovered completely -0.084 -15.131 0.001 table 4: comparison between characteristic and physical and mental fatigue p-value t std. deviation mean n variables 0.002 3.058 9.778 25.013 157 male physical gender 9.735 28.462 143 female 0.039 2.078 6.598 10.924 157 male mental 6.381 12.483 143 female 0.585 0.547 9.737 26.524 254 urban physical residence 10.796 27.391 46 suburban 0.596 0.531 6.689 11.752 254 urban mental 5.620 11.196 46 suburban 0.127 1.529 9.679 27.069 245 married physical marital status 10.695 24.818 55 unmarried 0.727 0.35 6.191 11.604 245 married mental 7.931 11.945 55 unmarried 0.002 3.049 9.022 29.481 81 yes physical chronic disease 10.015 25.612 219 no 0.012 2.531 6.582 13.222 81 yes mental 6.432 11.091 219 no 0.001 5.298 8.177 33.059 51 yes physical hospitalize during covid 9.714 25.345 249 no 0.001 4.285 6.561 15.137 51 yes mental 6.306 10956 249 no 0.001 4.303 9.658 30.061 99 yes physical receiving oxygen during covid 19 9.594 24.980 201 no 0.001 3.385 6.484 13.455 99 yes mental 6.388 10.786 201 no 0.041 2.128 9.990 26.974 274 one time physical infected with covid 19 8.240 23.308 26 two times 0.025 2.257 6.577 11.927 274 one tie mental 5.411 8.923 26 two times https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.13 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article the results of this study show that the mean of physical fatigue (26.65) higher than the mean of mental fatigue (11.66). this result is supported by the study done at dublin, ireland, st james’s hospital (sjh) about 128 post-recovery patients by using the chalder fatigue scale (cfq-11), that results illustrate that mean physical (11.38) higher than the mean mental (4.72) [32]. moreover; it was agreed with the study conducted in el minya / egypt about 81 patents. by using mfis (21 items), this study shows that the mean physical (24.62) is higher than the mean mental (17.68) [31].on other hand the results of the current study disagree with the finding of the other two studies. a cross-sectional survey was conducted in china about 2614 post recovery patients using fatigue selfassessment scale (fsas) 23 items, the results of this study show that the mean of physical (20.1) is less than the mean of mental (23.6) [23]. another study was done in barcelona (spain) about 136 patients using mfis (21 items). the study found that the mean of physical (52.5) less than the mean of mental (57.9) [33].the current study illustrates the prevalence of fatigue in the first month post-covid higher than other months and decreasing physical and mental fatigue month by month until complete recovery. this result consistent with many of the results of the study. some studies done by tenforde mw et al (2020), townsend l et al (2020), tomar bs et al (2021), tosato m et al (2021), ganesh r et al (2021), diem l et al (2022) display that most of the study samples had fatigue at the first month after recovery [26, 34-38]. however other studies conducted in the united kingdom, china, and egypt show that the majority of the study participants had fatigue in the second month [16, 23, 25]. a crosssectional survey in egypt, cohort study in mexico, and a cross-sectional in denmark 121 the highest percent age of the present study is 31.7 which is similar to the result of observational study at king abdulaziz medical city, jeddah, saudi arabia and prospective study was conducted in ankara city the percent of age was (41.3, 39.9), the age ≥ 50 years [12,13]. more than half of the participants in this study were a male which agrees with the results of some studies [12-18]. the current study findings illustrate that the highest percentage (28.3) of participants graduated from the institute this result disagrees with some study results [19-21]. in this study one-third of the study samples were housewives as consent by a crosssectional study conducted in istanbul, turkey [22]. most of the participants were lived in urban areas this result corroborates some studies [20, 23, 24]. current study shows that most of the participants were married, as supported by the results of the studies [19, 23, 24]. results illustrate that a high percentage of the study samples were overweigh which agrees with the results of more than the studies [16, 25]. the majority of this study’s samples don’t have any chronic disease which is similar to the results of many studies [23, 25, 26]. the present study results show that more than half of the participants have diabetes which agrees with the results of the studies [15, 27-29]. most of the study samples this study were not hospitalized during covid-19 this result is supported by some studies [12, 30, 31]. current study results show that 67 percent of the participants did not receive oxygen during covid 19 which agrees with the results of the previous study [25]. in this study, all the participants were fatigued 46.3 % had severe physical fatigue and 63.7 % had mild mental fatigue; which means participants had physical fatigue more than mental fatigue. copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.13 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article there are no conflicts of interest or sources of financial support for any of the authors. [1] rothan ha, byrareddy sn. the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak. journal of autoimmunity. 2020 may 1;109:102433. [2] qian q, asinger pa, lee mj, han g, mizrahi rodriguez k, lin s, et al. mof-based membranes for gas separations. chemical reviews. 2020 jul 1;120(16):8161-266. [3] mahase e. china coronavirus: who declares international emergency as death toll exceeds 200. bmj: british medical journal (online). 2020 jan 31;368. [4] li r, wang w, el-sayed es, su k, he p, yuan d. ratiometric fluorescence detection of tetracycline antibiotic based on a polynuclear lanthanide metal–organic framework. sensors and actuators b: chemical refining laboratory. 2021 mar 1;330:129314. [5] pavli a, theodoridou m, maltezou hc. postcovid syndrome: incidence, clinical spectrum, and challenges for primary healthcare professionals. archives of medical research. 2021 aug 1;52(6):575-81. [6] gunnell d, appleby l, arensman e, hawton k, john a, kapur n, et al. suicide risk and prevention during the covid-19 pandemic. the lancet psychiatry. 2020 jun 1;7(6):46871. [7] mardani r, vasmehjani aa, zali f, gholami a, nasab sd, kaghazian h, et al. laboratory parameters in detection of covid-19 patients with positive rt-pcr; a diagnostic accuracy study. archives of academic emergency medicine. 2020;8(1). [8] galloway se, paul p, maccannell dr, johansson ma, brooks jt, macneil a, et al. emergence of sars-cov-2 b. 1.1. 7 lineage— united states, december 29, 2020–january 12, 2021. morbidity and mortality weekly report. 2021 jan 1;70(3):95. available from https://doi.org/10.15585% 2fmmwr.mm7003e2. [9] [9] calabria m, garcía-sánchez c, grunden n, pons c, arroyo ja, gómez-anson b, et al. post-covid-19 fatigue: the contribution of cognitive and neuropsychiatric symptoms. journal of neurology. 2022 apr 30:1-0. illustrate that more than half of the survivors had fatigue at the third month [20, 27, 39]. according to a couple of the studies in the 4th months half of the samples had fatigue. the studies were conducted in france and norway [29, 40]. augustin m et al (2021) conducted a cohort study in norway and khatib s et al (2022) did a cross-sectional study in missouri. both studies show that less than half of the samples had fatigue in the 5th month [30, 41]. about 6th month in mexico the study was conducted by gonzález-hermosillo ja et al (2021), and in saudi arabia, the study was done by garout ma et al (2022) both studies indicate that one-third of the study survivors had fatigue [27, 42].the present study findings illustrate that female gender is significantly associated with fatigue, which agrees with the results of some studies [15, 30, 40,], but it disagrees with other studies [41]. in this study, fatigue was perceived significantly in patients with comorbidity disease; this result is supported by some studies [12, 25, 39, 41]. the current study shows that fatigue difference is significant with hospitalized during the disease or covid-19 which agrees with the results of the three studies [12, 16, 17]. the study finding display that there is a significant difference between fatigue and receiving oxygen during covid-19 which is similar to the results of the study [36]. the present study shows no difference between fatigue with residence and marital status; this result is corroborated by two studies [20]. the study concluded that less than half of the participants had severe physical fatigue and more than half had mild mental fatigue. statistical difference is significant between fatigue in females, patients with comorbidity diseases, hospitalization, and receiving oxygen during covid19. 122 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.13 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article the united states. journal of clinical nursing. 2020 nov 20. [20] abdelhafiz as, ali a, maaly am, mahgoub ma, ziady hh, sultan ea. predictors of postcovid symptoms in egyptian patients: drugs used in covid-19 treatment are incriminated. plos one. 2022 mar 31;17(3):e0266175. [21] munblit d, bobkova p, spiridonova e, shikhaleva a, gamirova a, blyuss o, et al. incidence and risk factors for persistent symptoms in adults previously hospitalized for covid‐19. clinical & experimental allergy. 2021 sep;51(9):1107-20. [22] morgul e, bener a, atak m, akyel s, aktaş s, bhugra d, et al. covid-19 pandemic and psychological fatigue in turkey. international journal of social psychiatry. 2021 mar;67 (2):128-35. [23] teng z, wei z, qiu y, tan y, chen j, tang h, et al. psychological status and fatigue of frontline staff two months after the covid19 pandemic outbreak in china: a crosssectional study. journal of affective disorders. 2020 oct 10;275:247. [24] el sayed s, shokry d, gomaa sm. post‐ covid‐19 fatigue and anhedonia: a cross‐ sectional study and their correlation to post‐ recovery period. neuropsychopharmacology reports. 2021 mar;41(1):50-5. available from https://doi.org/10.1002/npr2.12154. [25] kamal m, abo omirah m, hussein a, saeed h. assessment and characterisation of post‐ covid‐19 manifestations. international journal of clinical practice. 2021 mar;75 (3):e13746. [26] tenforde mw, kim ss, lindsell cj, rose eb, shapiro ni, files dc, et al. symptom duration and risk factors for delayed return to usual health among outpatients with covid-19 in a multistate health care systems network— united states, march–june 2020. morbidity and mortality weekly report. 2020 jul 7;69 (30):993. [27] gonzález-hermosillo ja, martínez-lópez jp, carrillo-lampón sa, ruiz-ojeda d, herreraramírez s, amezcua-guerra lm, et al. postacute covid-19 symptoms, a potential link with myalgic encephalomyelitis/chronic fatigue syndrome: a 6-month survey in a mexican cohort. brain sciences. 2021 jun;11 (6):760. [28] myall kj, mukherjee b, castanheira am, lam jl, benedetti g, mak sm, et al. persistent post–covid-19 interstitial lung disease. an observational study of corticosteroid [10] covid-19: dashboardgov.krd [internet]. kurdistan regional government. [cited 2021 dec 11]. available from: https://gov.krd/coronavirus/dashboard [11] larson rd. psychometric properties of the modified fatigue impact scale. international journal of multiple sclerosis care. 2013;15(1):15-20. [12] kayaaslan b, eser f, kalem ak, kaya g, kaplan b, kacar d, et al. post‐covid syndrome: a single‐center questionnaire study on 1007 participants recovered from covid‐19. journal of medical virology. 2021 dec;93(12):6566-74. [13] jabali ma, alsabban as, bahakeem lm, zwawy ma, bagasi at, bagasi ht, et al. persistent symptoms post-covid-19: an observational study at king abdulaziz medical city, jeddah, saudi arabia. cureus. 2022 apr 21;14(4). [14] mizrahi b, shilo s, rossman h, kalkstein n, marcus k, barer y, et al. longitudinal symptom dynamics of covid-19 infection. nature communications. 2020 dec 4;11(1):10. [15] simani l, ramezani m, darazam ia, sagharichi m, aalipour ma, ghorbani f, et al. prevalence and correlates of chronic fatigue syndrome and post-traumatic stress disorder after the outbreak of the covid19. journal of neurovirology. 2021 feb;27 (1):154-9. [16] halpin sj, mcivor c, whyatt g, adams a, harvey o, mclean l, et al. postdischarge symptoms and rehabilitation needs in survivors of covid‐19 infection: a cross‐ sectional evaluation. journal of medical virology. 2021 feb;93(2):1013-22. [17] righi e, mirandola m, mazzaferri f, dossi g, razzaboni e, zaffagnini a, et al. determinants of persistence of symptoms and impact on physical and mental wellbeing in long covid: a prospective cohort study. journal of infection. 2022 apr 1;84(4):56672. [18] wang d, hu b, hu c, zhu f, liu x, zhang j, et al. clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in wuhan, china. jama internal medicine. 2020 mar 17;323(11):1061-9. [19] [19] sagherian k, steege lm, cobb sj, cho h. insomnia, fatigue and psychosocial well‐ being during covid‐19 pandemic: a cross‐ sectional survey of hospital nursing staff in 123 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.13 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article american medical directors association. 2021 sep 1;22(9):1840-4. [38] ganesh r, ghosh ak, nyman ma, croghan it, grach sl, anstine cv, et al. promis scales for assessment of persistent post-covid symptoms: a cross sectional study. journal of primary care & community health. 2021 jul;12:21501327211030413. [39] leth s, gunst jd, mathiasen v, hansen k, søgaard o, østergaard l, et al. persistent symptoms in patients recovering from covid-19 in denmark. in open forum infectious diseases 2021 apr (vol. 8, no. 4, p. ofab042). available from https:// doi.org/10.1093/ofid/ofab042 [40] stavem k, ghanima w, olsen mk, gilboe hm, einvik g. prevalence and determinants of fatigue after covid-19 in non-hospitalized subjects: a population-based study. international journal of environmental research and public health. 2021 feb;18(4):2030. [41] augustin m, schommers p, stecher m, dewald f, gieselmann l, gruell h, et al. postcovid syndrome in non-hospitalised patients with covid-19: a longitudinal prospective cohort study. the lancet regional health-europe. 2021 jul 1;6:100122. [42] garout ma, saleh sa, adly hm, abdulkhaliq aa, khafagy aa, abdeltawab mr, et al. post‐ covid-19 syndrome: assessment of shortand long-term post-recovery symptoms in recovered cases in saudi arabia. infection. 2022 mar 16:1-9. treatment. annals of the american thoracic society. 2021 may;18(5):799-806. [29] morin l, savale l, pham t, colle r, figueiredo s, harrois a, et al. four-month clinical status of a cohort of patients after hospitalization for covid-19. jama. 2021 apr 20;325 (15):1525-34. available at https:// jamanetwork.com/journals/jama/articleabstract/2777787 [30] khatib s, sabobeh t, habib a, john s, gomez r, sivasankar s, et al. post-covid-19 fatigue as a major health problem: a cross-sectional study from missouri, usa. irish journal of medical science (1971-). 2022 apr 18:1-7. [31] ezzat mm, elsherif aa. prevalence of fatigue in patients post covid-19. european journal of molecular & clinical medicine. 2021 mar 21;8(3):1330-40. [32] townsend l, dyer ah, jones k, dunne j, mooney a, gaffney f, et al. persistent fatigue following sars-cov-2 infection is common and independent of severity of initial infection. plos one. 2020 nov 9;15 (11):e0240784. [33] calabria m, garcía-sánchez c, grunden n, pons c, arroyo ja, gómez-anson b, et al. post-covid-19 fatigue: the contribution of cognitive and neuropsychiatric symptoms. journal of neurology. 2022 apr 30:1-0. [34] tabacof l, tosto-mancuso j, wood j, cortes m, kontorovich a, mccarthy d, et al. postacute covid-19 syndrome negatively impacts physical function, cognitive function, health-related quality of life, and participation. american journal of physical medicine & rehabilitation. 2022 jan;101(1):48. [35] diem l, fregolente-gomes l, warncke jd, hammer h, friedli c, kamber n, et al. fatigue in post-covid-19 syndrome: clinical phenomenology, comorbidities and association with initial course of covid-19. journal of central nervous system disease. 2022 may 21;14:11795735221102727. [36] tomar bs, singh m, nathiya d, sharma a, sharma e, bareth h, et al. prevalence of symptoms in patients discharged from covid care facility of nims hospital: is rt pcr negativity truly reflecting recovery? a single-centre observational study. international journal of general medicine. 2021;14:1069. [37] tosato m, carfì a, martis i, pais c, ciciarello f, rota e, et al. prevalence and predictors of persistence of covid-19 symptoms in older adults: a single-center study. journal of the 124 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.17 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article assessment of mother’s information and practice, and factors associated infantile colic in erbil city abstract background and objectives: an excessive crying of unknown cause, the most common presentation to the primary health sector in early life, known as infantile colic, affects more than 20% of infants. parents must deal with the terrible situation to resolve it spontaneously after the first three to four months of life. the study aimed to assess the mothers’ information and practices about infantile colic in erbil city. methodology: this descriptive cross-sectional study was conducted on 60 mothers who attended treatment and routine follow-ups in the outpatients of primary health care centers in erbil city. the data was collected from the 1st of june to the 30th of november 2022, through direct interviews (face-to-face) using a questioner checklist. the data were analyzed by using spss (24 version) to analyze the data inferentially (frequency and percentage) and to find out the association between dependent and independent variables, the chi-square was used to identify the factors behind their practice and knowledge of the linear regression test was used. results: according to the study's findings, the majority (70%) of the sample were within average gestational ages (37 or more weeks). the highest percentages (70%) were within 2 months of age. there was a very highly significant association between the infant’s ages, period of crying, residency, and mother’s levels of information about the baby’s crying; also, there was a significant association between the mode of feeding and levels of the mother’s practice about infantile colic. linear regression found that demographic variables explain a significant amount of the variance in the mothers` information. the analysis shows that infant age and period of crying were significantly associated with the mothers` information; it was found that demographic variables explain a significant amount of the variance in the mothers` practice. the analysis shows that the mode of feeding did significantly predict the mothers` practice. conclusion: the majority of mothers had poor information about the signs and symptoms, etiology, and management of infantile colic, as well as poor practice about infantile colic management. key words: infant; newborn; infantile colic; information; practice; factors; mothers. gulala kareem azeez; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. (correspondence: gulala.azeez@hmu.edu.krd) abbas abdulqader ahmed rabaty; department of pediatric, college of medicine, hawler medical university, erbil, kurdistan region, iraq. shukir saleem hasan; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. 181 received: 26/11/2022 accepted: 07/01/2023 published: 30/11/2024 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:gulala.azeez@hmu.edu.krd?subject=gulala.azeez@hmu.edu.krd%20 mailto:azeez@hmu.edu.krd mailto:gulala.azeez@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.17 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article in the first few months of a baby's existence, the parents must deal with the terrible situation of infantile colic. infantile colic describes excessive crying of unknown cause in otherwise well infants. colic affects up to 20% of infants and is one of the most common presentations to the primary health sector in early life [1]. this disorder is thought to afflict 10% to 30% of infants worldwide [ 2]. despite the significant occurrence of this condition, there are currently no standardized treatment options available because the precise underlying cause of it is unknown. continuous baby screaming and maternal distress can create a vicious cycle that can have negative psychosocial effects on the family, including child maltreatment. according to recent research, parents and family members may experience worry and panic if this disease persists for an extended period of time in infants [2,3]. colic pain is one of the main reasons for stress and anxiety in infants' parents, especially mothers, and there is still no specific treatment. thus, mothers always try their best to relieve their infants' pain [4]. infant colic occurs in 3% to 40% of all infants and has multiple etiologies. it may initiate within 3 to 6 weeks of infant age and can persist up to 36 months of age [5]. it resolves spontaneously after the first three to four months of life [1].infantile colic is described as periods of uncontrollable crying and sporadic irritability in healthy babies between the ages of two and four weeks old that last longer than three hours per day, more than three days per week, and last for at least three weeks. rome iv clinical diagnostic criteria were established in 2016 and the rome criteria were modified. [6,7]. living with a colicky child for mothers is difficult and they are physically, emotionally and nutritionally affected by their infant's sensitive behavior and inadequate weight gain [5]. colic is typically seen as a clinical symptom that is equivalent to sudden, severe abdominal pain. it is a behavioral syndrome that typically manifests as self-limited pain in the first three months of an infant's life. colic, which is associated with excruciating intestinal discomfort, is thought to be due to an underlying condition of the digestive tract. [8]. the study aimed to assess and find out the factors associated with mothers’ information and practice regarding infantile colic care in erbil city a descriptive cross-sectional study was carried out in four primary health care centers (phcc) (kurdistan, nafh akray, mala afandy, and birth registration) in erbil city /kurdistan region of iraq. a nonportability (purposive) sample of 60 mothers who attended the phcc for management and treatment for their infantile colic was recruited. the sample has been estimated through the following criteria = . whereas : sample size. in natural logarithm. y:it is the confidence that is able to detect the existing problem (0.95). : it is a probability of a problem in order to be detected (0.05). [9]. = 0.05, including n = ln (10.95)/ ln (10.05) = 59. in addition to that, the researchers increased to 60 participants. a special tool (questionnaire checklist) was constructed after a review of extensive related previous studies. the questionnaire format included 153 items and consisted of five parts: part one: baby’s demographic information, consists of six items of general information about gestational age, newborn weight, sex, infant age, mode of feeding, and period of crying. part two: includes the mother’s demographic information; it consists of seven items of general information such as age of mother, level of education, residency, religion, 182 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.17 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article than half (68.3) of them had a period of crying 3 hours per day. the majority (68.3%) of participant mothers were within the age group of 20-30 years old. table 2 revealed the association between demographic overall variables and levels of information about the baby crying. there was a very significant association between the infant’s age, period of crying and residency, and levels of mother’s information about baby crying (p-value < 0.001). on the other hand, there was no significant smoking, husband smoke, and a special scale for socioeconomic status. phase three: assessment of the mother’s information about baby crying, it consists of nine items: focused on crying history, duration, period, and the time. part four: assessment of mother’s information about infantile colic: it consists of 56 items, three likert scales, and scored 0 for don’t know, 1 for poor information, and 2 for good information. the total scores between 0 and 37.2 indicated don’t know, the scores between 37.3 and 74 for poor, and the scores between 74.1and 112 indicated good answers. regarding the mother’s practice about infantile colic: it consists of (71 items), three likert were used, and scored 0 not applicable, one (1) for some time done and two (2) for applicable. the scores ranged between 0 and 47.2 not applicable, 47.3 and 94.6 sometime done, and 94.7 to 142 applicable. reliability (stability) was determined and measured through cronbach’s alpha for all three subscales, and it was 0.85. data processing and statistical analysis were performed using spss, version 24, a statistical package for social sciences; a p-value of 0.05 is considered significant association (frequency and percentage, mean and standard deviation) and inferential statistical analysis (chisquare test to find out the association and liner regression test to predict the factors behind mothers’ information and practices). data were collected in four healthcare centers from 60 mothers who had babies with infantile colic; table 1 shows that the majority (86.7%) of the sample were within the normal gestational age (37 weeks). the most (70.0%) of infants were within 2 months of age, less than half (31%) of the mothers used mixed feeding patterns, and regarding infant crying duration, more 183 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results table 1: assessment of mother’s and baby demographic characteristics items *n. **(%) gestational age at birth newborn weight gender of infant infant age mode of feeding period of crying age of mother >37 /weeks <37 /weeks 2-2.5 kg 2.5-3 kg 3-3.5 kg <3.5 kg boy girl 2months 3months 4months exclusive breastfeeding bottle feeding mixed breastfed 1houre 2hours 3hours 4hours 5hours >20 20-30 30-40 8 52 10 21 24 5 32 28 42 10 8 20 9 31 7 3 41 8 1 1 41 18 (13.3) (86.7) (16.7) (35) (40) (8.3) (53.3) (46.7) (70) (16.7) (13.3) (33.3) (15) (51.7) (11.7) (5) (68.3) (13.3) (1.7) (1.7) (68.3) (30) total 60 100 *number **%=percentage https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.17 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article association between other sociodemographic variables and the levels of information about baby crying (p-value > 0.05). 184 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: association between demographic characteristics variables and overall levels of information about baby crying mothers’ information about baby crying demographical characteristics poor level f(%) fair level f(%) good level f(%) *p-value gestational age at birth newborn weight infant age mode of feeding period of crying age of mother level of education residency >37 /weeks <37 /weeks 2-2.5 /kg 2.5-3 /kg 3-3.5 /kg <3.5 /kg 2/months 3/months 4/months exclusive breastfeeding bottle feeding mixed breastfed 1/hour 2/hours 3/hours 4/hours 5/hours >20 20-30 31-41 < 41 years’ old illiterate primary school intermediate school secondary diploma university urban rural suburban 0 (0) 10 (100) 2 (20) 2 (20) 5 (50) 1 (10) 2 (20) 2 (20) 6 (60) 1 (10) 1 (10) 8 (80) 7 (70) 3 (30) 0 (0) 0 (0) 0 (0) 0 (0) 8 (80) 2 (20) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (10) 2 (20) 5 (50) 2 (20) 10 (100) 0 (0) 0 (0) 0 (0) 2 (100) 0 (0) 1 (50) 0 (0) 1 (50) 1 (50) 0 (0) 1 (50) 2 (100) 0 (0) 0 (0) 0 (0) 0 (0) 2 (100) 0 (0) 0 (0) 0 (0) 2 (100) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (100) 0 (0) 0 (0) 1 (50) 0 (0) 1 (50) 8 (16.7) 4 (83.3) 8 (16.7) 18 (37.5) 19 (39.6) 3 (6.3) 39 (81.3) 8 (16.7) 1 (2.1) 17 (35.4 %) 8 (16.7) 23 (47.9) 0 (0) 0 (0) 39 (81.3) 8 (16.7) 1 (2.1) 1 (2.1) 31 (64.6) 16 (33.3) 0 (0) 0 (0) 0 (0) 1 (2.1) 2 (4.2) 8 (16.7) 7 (14.6) 18 ((37.5) 12 (25.0) 47 (97.9) 1 (2.1) 0 (0) 0.32 0.34 0.001 0.11 0.001 0.74 0.93 0.001 total 100 100 100 * p-value < 0.05 significant while 0.01is high significant https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.17 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article 185 association between the mode of feeding and levels of the mother’s practice about infantile colic with (p-value > 0.005). table 3 reveals the association between demographic overall variables and levels of practice. there was a significant copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: association between demographic characteristics variables and overall levels of practice. items mother’s practice about infantile colic, n = 60 poor level f(%) fair level f(%) good level f(%) p-value gestational age at birth newborn weight infant age mode of feeding period of crying age of mother level of education >37 /weeks <37 /weeks 2-2.5 /kg 2.5-3 /kg 3-3.5 /kg <3.5 /kg 2/months 3/months 4/months exclusive breastfeeding bottle feeding mixed breastfed 1houre 2hours 3hours 4hours 5hours >20 20-30 31-41 <41 illiterate primary school intermediate school secondary diploma university 3 (16.7) 15 (83.3) 4 (22.2) 7 (38.9) 6 (33.3) 1 (5.6) 13 (72.2) 4 (22.2) 1 (5.6) 12 (66.7) 1 (5.6) 5 (27.8) 1 (5.6) 0 (0) 14 (77.8) 3 (16.7) 0 (0) 1 (5.6) 13 (72.2) 4 (22.2) 0 (0) 1 (5.6) 0 (0) 4 (22.2) 4 (22.2) 6 (33.3) 3 (16.7) 3 (9.1) 30(90.9) 4 (12.1) 10(30.3) 15(45.5) 4 (12.1) 23(69.7) 5 (15.2) 5 (15.2) 0 (0) 1 (3.0) 5 (15.2) 5 (15.2) 13(39.4) 9 (27.3) 0 (0) 0 (0) 22(66.7) 11(33.3) 0 (0) 0 (0) 1 (3.0) 5 (15.2) 5 (15.2) 13(39.4) 9 (27.3) 2 (22.2) 7 (77.8) 2 (22.2) 4 (44.4) 3 (33.3) 0 (0) 6(66.7) 1 (11.1) 2 (22.2) 0 (0) 2 (22.2) 7 7(7.8) 1 1(1.1) 2 2(2.2) 4 4(4.4) 2 2(2.2) 0 (0) 0 (0) 6 (66.7) 3 (33.3) 0 (0) 0 (0) 1 (11.1) 0 (0) 0 0) 6 (66.7) 2 (22.2) 0.52 0.75 0.73 0.005 0.24 0.57 0.37 total 100 100 100 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.17 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article (beta = .265, t (59) = 2.804, p < .05, r2= 0.37), and (beta = .687, t (59) = 7.516.53, p < .05, r2= 0.72) respectively. the value of r2 of infant age and period of crying, which are 0.37 and 0.72, respectively, shows that 37 % and 72 % of the change in mothers` total information regarding infantile colic is caused by a change in infant age and period of crying, respectively. the analysis shows that only mode of feeding did significantly predict the mothers` practice (beta = 0.456, t (59) = 3.44, p < .05, r2= 0.15. the value of r2 of the mode of feeding, which is 0.15, displays that 15 % of the change in mothers` total practice regarding infantile colic is caused by a change in mode of feeding. 186 table 4 a linear regression was illustrated to predict the factors behind the mothers’ information and practice regarding infantile colic care. a significant amount of the variance in the mothers` information (f11, 48) = 15.98, p < .00, r2 = .78). the analysis shows that only infant age and period of crying did significantly predict the mothers` information table 5 a linear regression was conducted to see if demographic variables predicted the mothers` total practice regarding infantile colic. using the enter method, it was found that demographic variables explain a significant amount of the variance in the mothers` practice (f11, 48) = 2.56, p < 0.05, r2 = .37). copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: factors associated with mothers` information regarding infantile colic variables b ci 95% β t-value p-value gestational age at birth newborn weight gender of infant infant age mode of feeding period of crying age of mother level of education mother`s occupation residency religion -0.155 0.002 -0.066 -0.278 0.003 0.616 0.088 0.022 0.013 -0.059 0.089 [-0.544,0.233] [-0.148,0.152] [-0.300,0.167] [-0.477, -0.079] [-0.131,0.136] [0.451,0.781] [-0.154,0.330] [-0.083,0.127] [-0.225,0.250] [-0.473,0.354] [-0.860,1.039] -0.070 0.002 -0.044 -0.265 0.003 0.687 0.057 0.035 0.008 -0.022 0.015 -0.804 0.023 -0.570 -2.804 0.039 7.516 0.732 0.421 0.107 -0.289 0.189 0.425 0.981 0.572 0.007 0.969 <0.01 0.468 0.675 0.915 0.774 0.851 *infant age r2= 0.37; period of crying r2= 0.72 table 5: factors affecting mothers practice regarding home care of infantile colic baby variables b ci 95% β t-value p-value gestational age at birth newborn weight gender of infant infant age mode of feeding period of crying age of mother level of education mother`s occupation residency religion -0.214 0.046 -0.213 -0.047 0.330 -0.037 0.068 0.075 0.262 0.522 -0.604 [0.775,0.346] [0.170,0.263] [0.550,0.125] [0.335,0.240] [0.137,0.522] [0.275,0.200] [0.281,0.417] [0.076,0.226] [0.081,0.605] [0.074,1.119] [-10.975,0.767] -0.112 0.061 -0.162 -0.052 0.456 -0.048 0.051 0.136 0.200 0.227 -0.118 -0.769 0.428 -1.268 -0.332 3.445 -0.315 0.392 0.999 1.537 1.761 -0.886 0.446 0.671 0.211 0.742 0.001 0.754 0.697 0.323 0.131 0.085 0.380 mode of feeding r2= 0.15 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.17 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article crying; the result is in agreement with a study done by didişen and his colleagues, who found a statistically significant association with the infants crying persistently for more than 3 hours per day [15].there was no significant association between other demographic variables and levels of information about the baby’s crying. the finding of this study shows that there is no significant association between mother’s information and excessive crying. this result was supported by wal and his colleagues, who reported that there was no significant difference between poorly educated mothers and highly educated mothers regarding information about infantile colic [16].there was a highly significant association between the mode of feeding and the levels of mother’s practice about infantile colic; this result is supported by al -shehri and colleagues, who discovered that 36% of participants thought milk allergy to be the contributing cause of infantile colic, whereas 42.6% of mothers thought the reasons for infantile colic were unknown and may involve numerous variables [2]. also, their result is disagreement with trunur and his friend found that the mother's diet has a direct effect on the composition of her breast milk; these foods can occasionally cause food reactions and digestive problems such as abdominal pain [14]. there was no significant association between the mother’s practice and gestational age, infant weight, mother’s age, and mother’s education. despriee and the colleagues reported that there was no relation between caregiver’s practices and gestational age or weight [17].a linear regression was illustrated to see if demographic variables mothers practice total information regarding infantile colic. using the enter method, it was found that demographic variables explain a significant amount of the variance in the mothers` information. the analysis shows that the analysis of the demographic characteristics revealed that most of the baby’s gestational age is more than 37 weeks. this result is in disagreement with a study done by talachian and his colleagues in iran about incidence and risk factors for infantile colic among iranian infants; they found that more than three-quarters of infant gestational ages were less than 37 weeks [10].the highest percentage of newborns’ weight is 3-3.5 kg; also, most of them were about 2 months of age, and one quarter were in a mixed mood of feeding. nearly half of them were crying for 3 hours; this result is supported by khajeh and her friends, who reported that almost all of the infant participants cry more than three hours a day [11]. the majority of the participant’s gender was boy babies; this result is similar to a study reported that babies were in excessive crying beyond 3 months and found that more than half of babies were boys in gender [12].concerning the age of mothers shows that most of the participants were within 20-30 years old; nearly the result was supported by a study done by saeidi and friends, who conducted a study in iran on the effectiveness of mother-infant interaction on infantile colic and found that the majority of mothers participating were within age 20 to 35 years old [13]. the study found a highly significant association between levels of information about baby’s crying; this result is similar to a study that reported the patient education concerning colic (excessive crying) in infants (beyond the basics) was association with the infant age levels of mother’s information about baby crying [14]. concerning the period of crying, the current result shows a very high significant association between the period of crying and levels of mother’s information about the baby’s 187 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.17 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article in four primary healthcare clinics in erbil city, the majority of mothers in this study were found to be less knowledgeable about the signs and symptoms, etiology, and management of infantile colic. increased newborn discomfort as well as moms' psychological suffering could result from this, as could poor practice about infantile colic management. researchers recommended developing a health education and training program that should be made available to women in outpatient clinics, beginning with their customary prenatal well baby clinic consultations and continuing through their customary postnatal well baby clinic visits. [1] sung v. infantile colic. australian prescriber journal. 2018 aug; 41(4): 105–110. published online 2018 aug 1. doi: 10.18773/ austprescr.2018.033: pmcid: pmc6091773. [2] al-shehri h, al-mogheer b.h, al-sawyan t.h, abualalaa a.b, jarrah o.a, jabari m et al . assessment of maternal information about infantile colic in saudi arabia. electron physician. december 2016, volume: 8, issue: 12, pages: 3313-3317, doi: http:// dx.doi.org/10.19082/3313. (issn: 20085842). [3] dobson d, lucassen pl, miller jj, vlieger am, prescott p, lewith g. manipulative therapies for infantile colic. cochrane database system rev. 2012; 12: cd004796. doi: 10.1002/14651858.cd004796.pub2. pmid:23235617. [4] bagherian b, mehdipour-rabori r, nematollahi m. how do mothers take care of their infants with colic pain? a mixed-method study. ethiopian journal health scince. 2021;31 (4):761. doi:http:// dx.doi.org/10.4314/ejhs.v31i4.10. [5] mansourzadeh ar, sirati nir m, najafi mehri s. living with a colicky infant: meta synthesis of qualitative studies. intentional journal of pediatric 2016; 4(8): 2311-16. http:// ijp.mums.ac.ir. period of crying did significantly predict the mothers` information, whereas the result was supported by others who found that most colic babies have crying for longer duration and mainly at night with decreased daily sleep compared to the control group [18]. the period of crying problems was seen less often if the mother had other children, while the other examined factors showed no statistically significant relationships [19].the analysis shows that infant age did significantly predict the mothers` information, this result is supported by didişen and his friends finding statistically significant differences with “the infants generally started to cry when they were between 3 weeks and 3 months’ old. the value of r2 of infant age and period of crying, which are 0.37and 0.72, respectively, shows that 37 % and 72 % of the change in mothers` total information regarding infantile colic is caused by a change in infant age and period of crying, respectively [1]. regarding factors affecting mothers practice of infantile colic baby’s care, a linear regression was conducted to see if demographic variables predicted the mothers` total practice regarding infantile colic. it was found that demographic variables explain a significant amount of the variance in the mothers` practice. the analysis shows that only mode of feeding did significantly predict the mothers` practice. this result is similar to critch (2011) finding a statistically significant association between feeding difficulties and colic, who suggested the potential for ongoing regulatory problems in infants presenting with clinically significant colic symptoms, and also regression analyses that examine the relation between colic, feeding difficulties, and the outcomes of infant responsiveness and parenting stress [20]. 188 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion recommended references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.17 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article practices of mothers for colic. journal pediatrics research. 2020;7(3):223-9. doi: 10.4274/jpr.galenos.2019.72687. [16] wal d.v, boomb d.v, h pauw-plomp h ,g a de jonge d.ga. mothers’ reports of infant crying and soothing in a multicultural population.1998, v 79, issue 4 :issn 14682044print: issn 0003-9888. [17] despriee w.a, mägi c.a, småstuen m.c, glavin k, nordhagen l, jonassen ch.m, et al (2021). prevalence and perinatal risk factors of parent-reported colic, abdominal pain and other pain or discomforts in infants until 3 months of age a prospective cohort study in prevent adall. journal of clinical nursing. pub date: 2021-10-26, doi: 10.1111/ jocn.16097.http:// dx.doi.org/10.19082/3313. (issn: 20085842). [18] chalabi d.k, omer k, al-taweel n. risk factors for infantile colic: a case-control study. journal of the arab board of health specializations (2016). vol.17, no.2, 2016 https:// www.researchgate.net/ publication/315722616 [19] ölmestig t.k, siersma v, birkmose a.r, kragstrup j, ertmann r.k . infant crying problems related to maternal depressive and anxiety symptoms during pregnancy: a prospective cohort study. bmc pregnancy and childbirth 2021,21:777. https:// doi.org/10.1186/s12884-021-0425. [20] jn critch. infantile colic: is there a role for dietary interventions? pediatrics & child health journal (2011). 16(1): 47–49. pmcid: pmc3043028 [6] benninga ma, faure c, hyman pe, st james roberts i, schechter nl, nurko s. childhood functional gastrointestinal disorders: neonate and toddler. gastroenterology journal:2016, s00165085(16)00182–7. 15; s0016-5085(16)00182-7. doi: 10.1053/ j.gastro.2016.02.016. [7] ünal e.t,bülbül a, elitok g.k, avşar h, uslu s . evaluation of the information level and attitude of mothers about infantile colic. haydarpasa numune medical journal. doi: 10.14744/hnhj.2020.47135 2021;61(1):38– 44. [8] rad z.a , mojaveri m.h, pasha y.z, kacho m.a, kamkar a, khafri s et al .the effects of kangaroo mother care (kmc) on the fuss and crying time of colicky infants. iranian journal of neonatology; (2015). 6(1). 10.22038/ijn.2015.4152 [9] viechtbauer w., smits l., kotz d., budé l., spigt m. and serroyen j, et al. r. a simple formula for the calculation of sample size in pilot studies. journal of clinical epidemiology, (2015). 68, 1375-1379. [10] talachian e, bidari a, rezaie mh. incidence and risk factors for infantile colic in iranian infants. world journal gastroenterol 2008; 14(29): 4662-4666 [pmid: 18698680 doi: 10.3748/wjg.14.4662]. [11] khajeh m, sadeghi t, ramezani m, derafshi d . effect of mothers' educational supportive care program on the pain intensity and crying caused by colic in infants aged 1-5 months. evidence based care journal, 2019, 9(1): 7-15. downloaded from http:// ebcj.mums.ac.ir/. [12] kries r.v, kalies h, papoušek m (2006). excessive crying beyond 3 months may herald other features of multiple regulatory problems. archives of pediatrics & adolescent medicine journal. 2006;160(5):508-511. doi:10.1001/archpedi.160.5.508. [13] saeidi r, abadi m.z , saeidi a, robatsangi m.gh (2014). the effectiveness of mother infant interaction on infantile colic. iranian journal of neonatology 2014; 38. 1997; 71 (4):862–77. 22. [14] turner t.l, palamountain sh, augustyn m, torchia m.m . patient education: colic (excessive crying) in infants (beyond the basics). journal of clinical nursing .2021, topic 1205 version 16.0. doi: 10.1111/jocn.16097. [15] didişen n.a, yavuz b, gerçekero.g, albayrak t, meryem atak m, başbakkal d.z. infantile colic in infants aged one-six months and the 189 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.09 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article knowledge, attitude, and practice of nurses concerning hospital acquired infections in surgical specialty hospital erbil cardiac center abstract background and objectives: hospital-acquired infections also called nosocomial infections refer to infections acquired by patients during their period in the hospital, in which they were not infected before entering the hospital, and the patient is admitted for a reason other than that infection, and whose symptoms appear only 48 hours or more after entering the hospital. this study assessed the nurses’ knowledge, attitude, and practices regarding hospital-acquired infections. methods: a descriptive cross-sectional study was conducted from september 2021 to september 2022. a non-probability convenience sampling technique was used among 170 nurses who worked in the surgical specialty hospital erbilcardiac center in erbil city. data collected through a self-report questionnaire composed of three parts: part 1, sociodemographic characteristics, part 2 knowledge and part 3, attitude of participating nurses. the nurses’ practice was observed through a checklist. data were analyzed using spss26. results: most of the participants (59.4%) were aged 31 to 40 years old and more than half of them (56.5%) were male. about 66% of the participants had a diploma degree in nursing. approximately (69%) of the nurses had 5.1 to 14 years of clinical experience. less than half of nurses had good overall knowledge and practice, (43.5%) and (38.2%) respectively. while the majority of them (87.6%) had a positive attitude. conclusion: a remarkable number of nurses had good knowledge and the majority of them had a positive attitude about hais. also, the nurses had acceptable practice scores. formulation and administration of an extensive program for infection control in hospitals is recommended to facilitate healthcare professionals to follow written instructions for using safety procedures against hais. keywords: nosocomial infection; knowledge; attitudes; nurses. niyan anwar omar; ataya emarati maternity and childhood hospital, erbil directorate of health, ministry of health, kurdistan region, iraq. (correspondence: niyananwar1990@gmail.com) karwan mohammed m-amen; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. 77 received: 23/11/2022 accepted: 08/02/2023 published: 30/05/2025 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:(correspondence:%20dara.albanna@hmu.edu.krd) mailto:niyananwar1990@gmail.com?subject=niyananwar1990@gmail.com%20%20%20%20%20%20%20%20%20%20 mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.09 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article hospital acquired infections (hais) refer to infections acquired by patients during their period in the hospital, in which they were not infected before entering the hospital and the patient admitted for a reason other than that infection, and whose symptoms appear only 48 hours or more after entering the hospital [1]. the incidence of hais is approximately 5–8% of admitted patients in the world and one-third of these infections are preventable [2]. hais occur worldwide and affect all countries [3]. hais are present in both developed and developing countries, but 75% of this burden occurs in developing countries [4]. several epidemiological types of research have described the causes of hais and mentioned that hais are caused by pathogens which are existing in all places, for example, viruses, bacteria, and fungi [5]. the pathogens are not present or incubated before the patient's admission into the healthcare facility and are most likely transmitted by direct person-to-person contact during invasive medical procedures [6]. within the hospital, transmission happens by cross-contamination of patients, infected hands of healthcare personnel who have regular interaction with patients, or contaminated objects [7]. hais are disease forms that may be transmitted from the healthcare staff to the patients or from patients to healthcare staff. in addition, the infection might have occurred due to the spread of infection from one patient to another patient [8]. some of the pathogens are highly resistant to antimicrobial agents, and this necessitates the prescription of more potent and costly antimicrobial agents [9].hais led to slow patient recovery and increased patient relatives suffering due to the difficulties related to hais [10]. the hais can lead to an over consideration of the additional duration of hospital admission between 2-28 days, according to the type of infection, the duration of hospitalization differs [11]. hais are generally attributable to pathogens including bacteria, fungi, viruses, and parasites spread from one patient to another via direct or indirect contact [12].nurses’ or healthcare team members' knowledge regarding hais is the indicator for the spread of the hais at hospital and health care facilities. inappropriate information about infection control measures performance by healthcare professionals reduces the submission of infection control practices appropriately, and this leads to continuous risk from hais as health workers do not follow infection control measures completely [13]. despite instituted infection control guidelines, till now hais cannot be avoided due to a shortage of regulations on the application of these guidelines [1]. various research has correspondingly recommended that appropriate knowledge and attitude could be vital aspects of a suitable prevention strategy and infection control [8].to the researcher’s best knowledge, there have been few studies conducted to explore the nurses’ knowledge, attitude, and practices regarding hais globally, and no studies in the kurdistan region-iraq, particularly. therefore, conducting this study is deemed essential. this study was conducted to assess the nurses’ knowledge, attitude, and practices regarding hospital-acquired infections. 78 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.09 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article (0=disagree, 1= neutral, and 2= agree). the calculation of the overall nurses’ attitude concerning hospital-acquired infections was categorized into three groups: poor attitude if the score is between (0 – 0.66), fair attitude if between (0.67 – 1.33), and good attitude if between (1.34 -2). furthermore, nurses’ practice was observed and scored as (0=never, 1= sometimes, and 2= always). the calculation of the overall nurses’ practice concerning hospital-acquired infections (10 items) was categorized into three groups: poor practice if the score is between (0 – 0.66), fair practice if between (0.67 1.33), and good practice if between (1.34 -2). a panel of experts in various fields examined the questionnaire's content for its clarity, appropriateness, and relevancy and validated the study tool. the modification in the study tool was typically in the attitude and practice section, where the experts removed and changed some questions. the reliability of the study was assessed by using a pilot study on a purposive sample of eleven nurses who worked at different units in the surgical specialty hospital erbil cardiac center. the pilot study was conducted from 5th january to 21st january/2022, and as a result, some questions from the questionnaire were added and others were removed from the questionnaire form. the data were collected using non-probability, convenience sampling techniques. for each questionnaire form, a different code with a specific number was used. the data about nurses’ knowledge and attitude were collected through a questionnaire form, and each nurse was observed for evaluation of his/her practice daily between 7:30 am and 4:00 pm during their working shifts at the hospital. the researcher obtained an approval letter from the ethics committee at hawler medical university/college of nursing (code no.107, date 7/10/2021). permission was a descriptive cross-sectional study was conducted from september 2021 to september 2022 among 170 nurses working at the surgical specialty hospital erbilcardiac center in erbil city. the population size was 300 nurses working at surgical specialty hospital erbilcardiac center. therefore, the calculated sample size was 169, but the researcher decided to select 170 nurses as a sample size to be a more accurate representative sample. the epi info version 7 program (issued by cdc and who) was used for sample size estimation. the expected frequency (50%) based on a study conducted in india and a 95% confidence interval [14]. the inclusion criteria included nurses (both genders) who provide direct care to patients in the hospital, as well as having more than one year of experience. nurses who were not available during the period of the study were excluded. the researcher constructed the questionnaire after an extensive review of the relevant literature. the sociodemographic characteristics of nurses involved age, sex, marital status, educational status, monthly income, employment years in the hospital, employment status, nurses’ current specialty unit, participation in training courses on prevention and control of hospital-acquired infections, and their source of information. nurses’ knowledge concerning hospital-acquired infections consisted of 10 questions and included two options (1= incorrect and 2=correct). the calculation of the overall nurses’ knowledge concerning hais (ten items) was categorized into three groups: poor knowledge if the score is between (0– 3), fair knowledge if between (4-6), and good knowledge if between (7-10). in addition, nurses’ attitudes concerning hospitalacquired infections consisted of 10 statements and included three options 79 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.09 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article also obtained from the general directorate of health/erbil as well as the administration of surgical specialty hospital erbil cardiac center. before the definite start of data collection, the potential participants were asked to give a verbal consent showing their readiness to be included in the study. the data analysis was performed through the application of a statistical package for social sciences (spss) version 26 for calculating descriptive statistical data analysis (frequency and percentage). in this study, 170 nurses were recruited, most of the nurses (59.4%) were aged between 31 and 40 years old, ranging from 22 to 55 years, and more than half of them (56.5%) were male. approximately (67%) of the participants had a diploma degree in nursing. moreover, out of the total 170 nurses, more than half of them (54.7%) were full-time nurses, and 68.8% of the nurses had clinical experience between 5.1 14 years. most of the nurses (66.5%) reported that they have sufficient monthly income. more than half (57.1%) of the nurses have not received any training courses. the internet was the main reported source of information, as shown in table 1. 80 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results table 1: sociodemographic characteristics of the study participants variables no. (%) age (years) 21 – 30 )33.5 (57 3140 )59.4 (101 41 + )7.1 (12 gender male )56.5 (96 female )43.5 (74 marital status single )22.4 (38 married )77.6(132 level of education high school diploma/nursing )1.1 (2 diploma )66.5 (113 bachelor )30 (51 master and phd )2.4 (4 =<5.0 )21.2 (36 employment years in hospital 5.1 14.0 )68.8 (117 14.1 + )10 (17 employment status full time )54.7 (93 contract )45.3 (77 have you participated in training courses on the prevention and control of hospitalno )57.1 (97 yes )42.9 (73 if yes, how long ago? (months) if yes, what was the duration of the course? (months) what is your source of information? self-reading )20 (34 training courses and workshops )11.1 (19 departmental seminars )11.7 (20 internet )42.3 (72 self-reading and internet )14.7 (25 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.09 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article 81 precaution of infection control applied to all patients all of the time was ranked second (72.4%). furthermore, the item concerning wearing the same pair of gloves for multiple patients was ranked third with (71.8%) (see table 2). of hais’ (83.5%). the majority (84.7%) of the nurses disagreed with the statement ‘it is not my responsibility to comply with the hais control guidelines’ as shown in table 3. regarding the nurses’ knowledge about hais, the data depicts that the nurses answered most of the knowledge questions correctly, 6 out of 10. the item involving factors that influence hais was ranked first (77.1%) (i.e., the most correctly answered question), and the item related to standard regarding the attitude of the nurses towards hais, the highest percentage (94.1%) agreed with the statement ‘use of antiseptic is necessary to prevent hais, followed by ‘i believe the infection control policies and guidelines will reduce rates copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: knowledge of nurses regarding hais items correct answer no. (%) incorrect answer no. (%) hospital-acquired infections definition? (44.7) 76 94 (55.3) factors influencing the hospital-acquired infections )77.1( 131 39 (22.9) the most common way of hospital-acquired infections transmission )52.4( 89 81 (47.6) standard precautions for infection control applied to all patients all of the time )72.4( 123 47 (27.6) the most effective way to stop the transmission of hospital-acquired infections is washing hands )42.4( 72 98 (57.6) hand hygiene should be performed before and after direct patient contact. 116 (68.2) 54 (31.8) washing hands with soap or an alcohol-based antiseptic decreases the risk transmission of hais. 104 (61.2) 66 (38.8) wearing gloves decrease your chance of getting hais. 66 (38.8) 104 (61.2) when there is a risk of a splash of blood or body fluid the nurse should wear gloves, mask, goggle, and gown. 60 (35.3) 110 (64.7) i can’t wear the same pair of gloves for multiple patients as long as there is no visible contamination on the gloves. 122 (71.8) 48 (28.2) table 3: attitude of nurses regarding hais items disagree no. (%) neutral no. (%) agree no. (%) health worker’s hands are a vehicle for the transmission of the hospital-acquired pathogen 31 (18.2) 40 (23.5) 99 (58.2) i don’t have to wash my hand if used gloves. 112 (65.9) 14 (8.2) 44 (25.9) hand hygiene after removing gloves is a hospital-acquired infection control measure. 26 (15.3) 15 (8.8) 129 (75.9) the use of antiseptic is necessary to prevent hospital-acquired infections 3 (1.8) 7 (4.1) 160 (94.1) i believe invasive procedures are not a risk factor for infectious organisms 131 (77.1) 18 (10.6) 21 (12.4) i feel needles should not be recapped after use and before disposal. 126 (74.1) 3 (1.8) 41 (24.1) i believe the infection control policies and guidelines will reduce rates of hospital-acquired infections 9 (5.3) 19 (11.2) 142 (83.5) it is not my responsibility to comply with the hospital-acquired infection control guidelines. 144 (84.7) 15 (8.8) 11 (6.5) changing mask before going to another patient is a hospital-acquired infections control measure 42 (24.7) 46 (27.1) 82 (48.2) i should attend in-service training/workshops related to infection prevention and control regularly. 9 (5.3) 36 (21.2) 125 (73.5) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.09 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article sixty percent of participants never discarded infectious materials and leftover samples according to the guideline as shown in table 4. besides, about half of the participants (50.6%) had fair overall practice regarding hais (see table 5). 82 regarding the nurses' practice concerning hais, the majority (91.2%) received the covid-19 vaccine. besides, it is just under three-quarters (73.5%) of the sample washed their uniform/white coat weekly. less than half of nurses had good overall knowledge regarding hais (43.5%). while the majority of them (87.6%) had a fair attitude overall regarding hais. copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: practice of nurses regarding hais table 5: overall knowledge, attitude, and practice of nurses regarding hais items never no. (%) sometimes no. (%) always no. (%) i wash my hands before and after direct contact with the patient. 39 (22.9) 63 (37.1) 68 (40) i put on a mask and glasses when performing invasive and body fluid procedures. 57 (33.5) 62 (36.5) 51 (30) i change my gloves before starting to handle a new patient 11 (6.5) 55 (32.4) 104 (61.2) surgical operation sites are shaved with razors. 26 (15.3) 54 (31.8) 90 (52.9) i wash my uniform/ white coat weekly 0 (0) 45 (26.5) 125 (73.5) i discard infectious materials and left-over samples according to the guideline 102 (60) 43 (25.3) 25 (14.7) i received the covid-19 vaccine. 15 (8.8) 0 (0) 155 (91.2) i clean my stethoscope/ equipment with antiseptic (e.g., 70% alcohol). 58 (34.1) 37 (21.8) 75 (44.1) i clean my mobile phone with antiseptic (e.g., 70% alcohol). 93 (54.7) 44 (25.9) 33 (19.4) i attend in-service training/workshops related to infection prevention and control yearly. 60 (35.5) 67 (39.6) 42 (24.9) overall score f. (%) overall knowledge poor knowledge 40 (23.5) fair knowledge 56 (32.9) good knowledge 74 (43.5) overall attitude positive attitude 149 (87.6) negative attitude 21 (12.4) overall practice poor practice 19 (11.2) fair practice 86 (50.6) good practice 65 (38.2) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.09 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article out . on 172 healthcare providers in india [16]. however, these results are higher than the results of an interventional study conducted in malaysia [19]. most of the nurses achieved a fair to good overall score in practice concerning hais. the results of the present study are lower than a study conducted in egypt, which was conducted among 77 nurses working at the icu [20]. nevertheless, current study findings are more assuring than a study conducted in ethiopia on 191 healthcare providers [21]. in addition, it is more assuring than a study conducted in saudi arabia (226 healthcare providers) [2]. only 40% of nurses always washed their hands before and after direct contact with the patient. the figure of the present study is higher than a study done in ethiopia, which showed only 18.2% and 27.8% washed their hands preand postinteraction with the patient [22]. nevertheless, the findings of the current study are lower than a study done in ogun state, nigeria that showed the majority of participants (99.6%) performed hand-washing techniques before and after dealing with patients [23]. it is worth mentioning that the current data were collected during the covid-19 outbreak and eventually the staff’s practice may have been affected by it due to the fact that precautionary measures such as hand washing and wearing face masks were made essential to mitigate the spread of the infection the results of this study suggest that hais practice should be improved on a broader scale. in order to improve the quality of healthcare with relation to infection prevention, the healthcare system and policymakers should make an effort. even though the majority of healthcare providers have gained positive attitudes and good knowledge about hals, the management system still needs to be improved. as a result, the health system and policymakers the present study assessed the nurses’ knowledge, attitude, and practices regarding hospital-acquired infections. the finding of the present study showed that most of the nurses had good overall knowledge about hais. the results of the present study are in accordance with a study conducted in india [13]. however, these results are higher than the results of a study conducted in yemen [15]. although most of the nurses obtained a good knowledge score, continuous and regular scientific seminars and workshops incorporating evidence-based practice regarding hais need to be undertaken to consolidate the knowledge and improve the practice. the findings showed that the majority of nurses were knowledgeable about “factors that influence hais” (77.1), followed by “standard precautions for infection” (72.4%). likewise, a research study conducted in india in 2016 had a similar outcome [16]. however, this disagrees with the results of a study done in nigeria [17]. regarding nurses’ source of information, less than half of nurses (42.4%) got their information from the internet. this is in disagreement with a study done in india that found nurses' common source of information about hais was seminars (39.7%) [18]. this suggests that the nurses rely highly on different online resources to obtain information concerning the hais. it is critical to state that this is of considerable concern, due to the fact that some information obtained from the internet might contain unreliable information from unreliable sources, and this may be as a result mislead the nurses’ responses towards the hais. concerning the overall nurses’ attitude concerning hais, the majority of nurses had a positive attitude towards hais. the results of the present study are supported by a study carried 83 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.09 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article [4] obiero cw, seale ac, berkley ja. empiric treatment of neonatal sepsis in developing countries. the pediatric infectious disease journal. 2015 jun;34(6):659–61. doi:10.1097/inf.0000000000000692. [5] gruda a, sopjani i. the knowledge, attitudes and practices of nurses toward management of hospital-acquired infections in the university clinical center of kosovo. materia socio-medica. 2017 jun;29(2):84–7. doi: 10.5455/msm.2017.29.84-87. [6] tolera m, abate d, dheresa m, marami d. bacterial nosocomial infections and antimicrobial susceptibility pattern among patients admitted at hiwot fana specialized university hospital, eastern ethiopia. advances in medicine. 2018 dec 4;2018: e2127814. available from: https:// doi.org/10.1155/2018/2127814. [7] simindokht s, shahnaz s, hooman y. incidence and resistance patterns of nosocomial infections in labbafi nejad hospital admitted patients during 2012-2014. i infection epidemiology and microbiology. 2017 jan 1;3(3):78–81. doi: 10.18869/ modares.iem.3.3.78. [8] nag k, datta a, karmakar n, chakraborty t. knowledge, attitude and practice about hospital acquired infection among health care personnel in a tertiary care hospital of tripura. international journal of research in medical sciences. 2018 sep 25;6(10):3303–8. doi: http://dx.doi.org/10.18203/23206012.ijrms20184037. [9] stanton ic, bethel a, leonard afc, gaze wh, garside r. what is the research evidence for antibiotic resistance exposure and transmission to humans from the environment? a systematic map protocol. environmental evidence. 2020 dec;9(1):12. (2020) 9:12. available from: https://doi.org/10.1186/ s13750-020-00197-6. [10] sousa afl de, matos mcb, matos jgnf de, sousa lrm, moura meb, andrade d de. prevention and control of infection in professional nursing training: a descriptive study. online brazilian journal of nursing. 2017 may 1;16(2):199–209. available from: https://doi.org/10.17665/16764285.20175560 [11] benenson s, cohen mj, schwartz c, revva m, moses ae, levin pd. is it financially beneficial for hospitals to prevent nosocomial infections? bmc health services research. 2020 jul 14;20(1):653. available from: should take action to raise the knowledge, attitude, and practice of the medical staff towards hais. training programs about hais should be provided by the hospital specifically for newly hired healthcare professionals. a large proportion of nurses working in surgical specialty hospital erbilcardiac center had good knowledge and attitude about hais. in addition, they had acceptable practice scores. formulation and administration of an extensive program for infection control in hospitals to assist healthcare professionals to follow written instructions for using safety procedures against hais. further research might be necessary as researchers should also continue discovering the aspects that may suggestively impact the knowledge of nurses concerning the prevention of hais using well-designed research. the authors report no conflicts of interest. [1] revelas a. healthcare – associated infections: a public health problem. nigerian medical journal. 2012;53(2):59–64. doi: 10.4103/0300-1652.103543. [2] hamid ha, mustafa mm, al-rasheedi m, balkhi b, suliman n, alshaafee w, et al. assessment of hospital staff knowledge, attitudes and practices (kaps) on activities related to prevention and control of hospital acquired infections. international journal of prevention and treatment. 2019;8(1):1–7. doi: 10.5923/j.ijpt.20190801.01. [3] paul e, alzaydani asiri ia, al-hakami a, chandramoorthy hc, alshehri s, beynon cm, et al. healthcare workers’ perspectives on healthcare-associated infections and infection control practices: a video-reflexive ethnography study in the asir region of saudi arabia. antimicrobial resistance and infection control. 2020 jul 16;9(1):110. available from: https://doi.org/10.1186/s13756-02000756-z 84 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.09 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article professionals. bmc medical education. 2021 sep 9;21(1):482. available from: https:// doi.org/10.1186/s12909-021-02907-1. [20] eskander hg, youssef w, morsy m, ali h, elfeky a. intensive care nurses ’ knowledge & practices regarding infection control standard precautions at a selected egyptian cancer hospital. journal of education and practice. 2013;4(19). available from: issn 2222-288x (online). [21] gezie h, leta e, admasu f, gedamu s, dires a, goshiye d. health care workers knowledge, attitude and practice towards hospital acquired infection prevention at dessie referral hospital, northeast ethiopia. clinical journal of nursing care and practice. 2019 dec 5;3(1):059–63. doi: dx.doi.org/10.29328/journal.cjncp.1001019. [22] haile, t.g., engeda, e.h., abdo, a.a. compliance with standard precautions and associated factors among healthcare workers in gondar university comprehensive specialized hospital, northwest ethiopia. journal of environmental and public health. 2017 jan 16;2017. available from: https:// doi.org/10.1155/2017/2050635. [23] olatade, m.j., ifeoluwa, a. knowledge and preventive practices of nosocomial infections among health workers in two selected tertiary hospitals in ogun state. international journal of caring sciences. 2021 jan;14 (1):174. available from: http:// www.internationaljournalofcaringsciences.o rg/docs/19_maitanmioriginal_14_1.pdf. https://doi.org/10.1186/s12913-020-05428-7. [12] nimer na. nosocomial infection and antibiotic-resistant threat in the middle east. infection and drug resistance. 2022 feb 25;15:631–9. available from: https:// doi.org/10.2147/idr.s351755. [13] sodhi k, shrivastava a, arya m, kumar m. knowledge of infection control practices among intensive care nurses in a tertiary care hospital. journal of infection and public health. 2013 aug 1;6(4):269–75. available from: http://dx.doi.org/10.1016/ j.jiph.2013.02.004. [14] sheth am, jani ds, rangoonwala m, kadri a. assessing the awareness and practice of hospital acquired infections (hais) among nursing staff of civil hospital, rajkot, gujarat, india. international journal of research in medical sciences. 2015 aug;3(8):18441850. doi: http://dx.doi.org/10.18203/23206012.ijrms20150283. [15] alrubaiee g, baharom a, shahar hk, daud sm, basaleem ho. knowledge and practices of nurses regarding nosocomial infection control measures in private hospitals in sana’a city, yemen. safety in health. 2017 dec;3(1):16. doi 10.1186/s40886-017-00674. [16] thankam t, goswami yp. knowledge attitude and practice of health care workers towards hospital acquired infection prevention in joseph hospital, tamil nadu, india. international journal of life sciences [internet]. 2021;10(2). available from: http://www.crdeepjournal.org/wp-content/ uploads/2021/04/vol-10-2-1-ijls-.pdf. [17] balarabe sa, joshua i, aliyu d, dauda m, omoniyi s, yusuf h. knowledge of healthcare workers on nosocomial infection in selected secondary health institutions in zaria, nigeria. journal of preventive medicine. 2015 feb 8;3:1–6. available online at: http://pubs.sciepub.com/jpm/3/1/1. [18] giri p, kamble m, kasat v, phalke d. knowledge about hospital-acquired infections amongst nursing staff of tertiary care teaching hospital in rural western maharashtra, india. international journal of medical science and public health. 2016 jan 1;5:1. doi: 10.5455/ijmsph.2016.21082015134. [19] saraswathy t, nalliah s, rosliza am, ramasamy s, jalina k, shahar hk, et al. applying interprofessional simulation to improve knowledge, attitude and practice in hospital acquired infection control among health 85 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article association of belief and experience of insufficient breast milk supply with mothers’ knowledge regarding breast feeding abstract background and objectives: belief and experience of insufficient milk supply (ibms) are important and modifiable factors for optimal breastfeeding. however, very few people know about maternal belief, experience about breast milk supply, and how it impacts breastfeeding practice. the aim of the study is to identify the prevalence and association between mothers’ belief and experience of insufficient breast milk supply with mother’s knowledge regarding breast feeding. methods: this descriptive cross-sectional study was conducted on (1,000) participants who took six months postpartum in the primary health care centers (phcc) and raparin teaching hospital for children (rthc) in erbil city /iraq. data were collected via direct interview. the question used in the interview were developed after a review of the relevant literature. frequency, percentage, and chi-square were used for the purpose of data analysis. results: in general, the study showed the prevalence of mothers' belief regarding insufficient breast milk supply was 59.8%. also, the prevalence of a mother’s experience was 78.6%. mothers who had a poor level of knowledge regarding breastfeeding got the highest percentage, 62.2%. however, it showed the highly significant association between mothers’ knowledge and mode of the last delivery with mothers’ belief of insufficient breast milk supply. moreover, there was a highly significant association between mother’s experience with socio economic status. conclusion: the majority of the mothers had belief and experience of insufficient breast milk supply (ibms). the current study showed a significant association between mothers’ belief with mother’s knowledge regarding the benefits of breastfeeding. keyword: belief; experience; insufficient breast milk supply; breastfeeding; knowledge. nazeera tahseen kareem; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq (correspondence: nazeera.tahsen@gmail.com) hamdia merkhan ahmad; department of midwifery, college of nursing, hawler medical university, erbil, kurdistan region, iraq. 135 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 05/07/2022 accepted: 09/09/2022 published: 30/11/2023 mailto:nazeera.tahsen@gmail.com https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article breast milk is a primary source of nutrition for infants during the first year of life. in the first month, breast milk serves as the newborn's main source of sustenance. infants mostly get their nutrition from breast milk, especially during the first six months of life. it has a nutritional composition that closely resembles what a baby needs for growth, immune system health, and brain development. although human milk has a variety of nutritional compositions, its main components are water, lipids, carbohydrates, and proteins, each of which plays a significant role in the growth and development of the infant [1, 2].the american academy of pediatrics (aap) and major organizations like the united nations children's fund (unicef) and world health organization (who) advise that infants should only be fed breast milk for the first six months. and this should be continued for the second half of the first year or longer with an overview of complementary foods, as this is what both the infant and mother prefer from the age of six months to the age of two years [3, 4].one of the significant causes of newborn formula supplementation and early breastfeeding termination is insufficient breast milk supply [5].the term "insufficient milk supply (ibms)” refers to a mother's perception that the amount of breast milk she produces is insufficient for her child's requirements. instead of counting the baby's wet diapers and feces, mothers frequently use certain inaccurate signals, including infant satiety cues or newborn screaming, as the main indicator of inadequate milk supply. after birth, mothers who believe their breast milk supply is insufficient have a tendency to put off starting to breastfeed until they feel it is sufficient. they may also start adding needless formula supplementation early [6,7,8,9].the main cause of low breast milk production is aberrant hormonal lactation that takes place during the final week of pregnancy and after the birth of the baby, which leads to insufficient milk production. this can happen if aberrant hormone levels disturb breastfeeding's endocrine balance [9].several aspects, such as stress, anxiety, depression, alcohol, smoking, obesity, and heredity, can lead to hormonal imbalances. unknown factors like, nipple or breast massages that stimulate the oxytocin hormone may also alter how much breast milk a woman produces. however, autocrine control may interfere with milk production [5]. mothers with a low milk production might think it is impossible to continue breastfeeding [10].the mother may prematurely stop nursing for a number of reasons, including: demographic, physical, social, psychological, and biological variables that influence mothers' adherence to inadequate breast milk production. the degree of breastfeeding success, sleep, nutrition, family support, family income, and a mother's ability and self-efficacy can all contribute to her decision to continue exclusively nursing [11].the prevalence of insufficient breast milk supply in the usa over the first year of life was between 43% and 55% [12], 54% in iran [14], 56% in poland [15], 58% in australia [16], 47% in new zealand [5], and 36% in madrid [13].many studies result on mothers' notion and attitudes toward breast feeding, but few discuss ibms beliefs and experiences. but there was not any specific study in regard to the belief in insufficient breast milk supply in kurdistan. the objectives of the study were to:1) determine the prevalence of belief and experience insufficient breast milk supply. 2) find associations between ibms with knowledge of the mother regarding breast feeding, parity, mode of last delivery, and socio-economic status. 136 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article or more. for measuring family income, the socio-economic status scale (ses) was used, which was composed of the following variables. it was determined by the mother's age, education level, and occupation, as well as her husband's occupation and possession of a car and a house [35]. part ‘two’obestrical history of women includes: parity ( 1primiparous, 2-4 multiparous, ≥ 5 grand multiporous ), abortion, mode of last delivery ,vagianal and ceserean delivery. part ‘three’ includes the mother's belief and seven items about the reasons and factors that affected insufficient breast milk supply.part ‘four’ includes the mother’s experiance of ibms with 6 itimes. part ‘five’ of the questionnaire( the questionnaire was via direct interview ) was regarding the mothers' knowledge toward breast feeding (bf) consisted of 16 items that were divided into two sections. items were scored as one when answered correctly or zero when answered incorrectly. the total score for the scale ranged from zero to 16 points, with a higher score indicating a higher degree of maternal bf knowledge. the first section had eight question items relating to the benefits of breastfeeding for the infant. the second section consisted of eight question items about the benefits of bf for the mother. the level of knowledge regarding breastfeeding was categorized into three levels as follows: 1) poor level of knowledge (0–5); 2) fair level of knowledge (6–10); and 3) good level of knowledge (11–16). the data were entered and analyzed via using the statistics package for social science (spss, version 26), to find out the descriptive statistics (frequency and percentage) and chisquare test. a descriptive cross-sectional study was conducted from september 1st 2020 to september 1st 2022, with data collected during the postpartum period in eight primary health care centers (phcc) and raparin teaching hospital (rth) in erbil city from october 1, 2021 to may 25, 2022. the phcc was chosen randomly from the following geographical areas: nazdar bamarny and zhiyan (north), azadi and rasty (south), nawras and mahammad bajalan (west), and kurdistan and mala fandi (east). the approval was obtained from the ethical and scientific committee of the college of nursing at hawler medical university (n.103, on october 7th ,2021). the formal agreement was reserved from directorate of health and phcc and rth. verbal consent was obtained from all participants before starting interview.data were gathered directly from 1,000 mothers who participated in the study during the postpartum period through a questionnaire. and the calculated net had been used to estimate the sample size of the study, according to the following values: the confidence interval was 95%, the margin of error showed 1%, and the population proportion was 50%. in terms of inclusion criteria (prime and multiparous women, women with a healthy newborn baby capable of breast milk sucking, and mothers at 6 months postpartum), and in regard to exclusion criteria: mothers who refused to participate in the study; mothers who have breast diseases such as breast cancer, breasts mass, or breast surgery. the questionnaire consisted of five parts: part one: socio-demographic information, including age, education level, employment, and residence location; types of family, and body mass index: underweight: under 18.5, normal weight: 18.5-24.99, over weight, 25-29.99, and obese, had got 30 137 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article table 1focuses on the sociodemographic characteristics of the study sample, which were estimated based on participants age, level of education, occupation status, and their residential location, economic status, family type, and bmi. the highest percentage (51.8%) of the study sample was between 21-30 years old, while the lowest percentage (3.1%) was between ≥ 40 years old. according to the mother's level of education, it shows that intermediate levels had the highest percentage 27.6% while msc holders had got 1.4% that was the lowest percentage. in terms of occupation, mothers who had semiskilled manual occupations got 50.8%, which was the highest percentage, and highly skilled professional mothers scored the lowest percentage, which is 1.2% the study shows residential place, urban mothers had got the highest percentage 69.5% while ‘rural’ had got the lowest percentage 2.9%. the study, also, shows that the majority of the participants, 76%, had their own car, and the minority, 24%, didn't have it. furthermore, it shows the percentage of having house, the highest percentage 53.4% didn't have it and the lowest percentage 46.6% had it. in addition, it shows the percentage of the mother’s body mass index. mothers who were overweight got the highest percentage 46.8% and underweight mothers the lowest percentage 0.3%. according to their family types, mothers who had unclear family type were the majority with the highest percentage (73.3%), and extended family mothers were the minority with the lowest percentage (26.7%). the results also indicate the socioeconomic levels of mothers; it shows that middle socioeconomic level mothers had the highest percentage (52.2%), while mothers who had a high socioeconomic level had the lowest percentage (only 3.6%).table 2 indicates the obstetrical data of the study samples, in . terms of parity, the highest percentage 65.5% of the study sample were multiparous, while the lowest percentage 9.3% of them were grant mute parous. the highest percentage, 65.5%, of the study samples had no abortions, while the lowest percentage, 1.0% of them had more than three abortions. the high percentage, 89.7%, had no neonatal deaths, while the lowest percentage, 0.4%, had >3 neonatal deaths. regarding mode of last delivery, the highest percentage, 63.2%, was a cesarean section, while vaginal delivery gave the lower percentage, 36.8%.the prevalence of belief was 59.8% regarding insufficient breast milk supply. and the mothers experience was 78.6% regarding insufficient breast milk supply. table 3 highlights, the mothers’ knowledge towards all items of breastfeeding and the benefits for infants and the mothers were showed. regarding the benefits of breastfeeding for the baby, protects against infection and illnesses had the highest percentage (54.9%). also, it showed that breastfeeding leads to uterine involution had the highest percentage (37.8%), regarding the benefits of breastfeeding for the mother. the overall level of perceptions among participants showed that 62.2% of the mothers had poor level of knowledge. table 4 shows that there was a highly significant association between mode of the last delivery and mothers' knowledge with belief because of their pvalue rates (0.01). it shows that there is not a significant association between parity and socioeconomic status with belief because of their pvalue rates (0.869) and (0.986).table 5 shows that there was a highly significant association between socioeconomic status with mother’s experience because of its p-value rate (0.01), also mother’s knowledge is nearby significant, it shows that there's not any significant association between experience and the other factors 138 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 139 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: socio-demographic characteristic of the study sample (n=1000). variables f (%) age groups (years) ≤20 21-30 31-40 >40 52 518 399 31 (5.2) (51.8) (39.9) (3.1) mother education illiterate primary (or read and write) intermediate high school or vocational institute (2years) college (bachelor degree) college (msc degree) 144 112 276 146 131 177 14 (14.4) (11.2) (27.6) (14.6) (13.1) (17.7) (1.4) occupation status unskilled manual semi-skilled manual skilled manual and manual associated professional skilled professional or senior managerial highly skilled professional residential place urban sub urban rural possession of car 91 508 239 108 42 12 695 276 29 (9.1) (50.8) (23.9) (10.8) (4.2) (1.2) (69.5) (27.6) (2.9) yes no possession of house yes no socio economic status low economic level middle economic level high economic level type of family nuclear extended bmi under weight normal weight over weight obese 760 240 466 534 442 522 36 733 267 3 314 469 215 (76) (24) (46.6) (53.4) (44.2) (52.2) (3.6) (73.3) (26.7) (0.3) (31.4) (46.9) (21.5) economic status: it was depending on the mother’s age, level of education, mother’s occupation, also husbands occupation, car, house [35]. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 140 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: mothers obstetrical history sample size (n=1000) variable f (%) parity primiparous multiparous grant multiparous 252 655 93 (25.2) (65.5) (9.3) abortion none 1-3 >3 655 335 10 (65.5) (33.5) (1) neonatal death none 897 (89.7 1-3 >3 mode of last delivery 109 4 (10.9) (0.4) vaginal delivery cesarean delivery mothers believed of insufficient breast milk supply yes no mothers experienced of insufficient breast milk supply yes no 368 632 598 402 786 214 (36.8) (63.2) (59.8) (40.2) (78.6) (21.4) table 3: mother’s knowledge regarding breast feeding benefits of breast feeding correct (%) incorrect (%) benefit of breast feeding for infant 1protects against infection and illnesses 2promotes bonding between mother and child 3baby is rarely constipate 4strengthen child’s bones 5enhances development 6enhances intelligent 7is at the right temperature 8it is always clean benefit of breastfeeding for mother 549 (54.9) 152 (15.2) 154 (15.4) 350 (35) 494 (49.4) 490 (49) 198 (19.8) 167 (16.7) 451 (45.1) 848 (84.8) 855 (85.5) 650 (65) 506 (50.6) 510 (51) 802 (80.2) 833 (83.3) 1-leads to uterine involution 378 (37.8) 622 (62.2) 2-decrease incidence of breast disease 365(36.5) 635(63.5) 3-decrease incidence ovarian cancer 363 (36.3) 637 (63.7) 4helps mother's body to return to normal 239 (23.9) 761 (76.1) 5provides emotional satisfaction to the mother 153 (15.3) 847 (84.7) 6save money 159 (15.9) 841 (84.1) 7lose weight faster after birth 247 (24.7) 753 (75.3) 8spacing birth. 101 (10.1) 899 (89.9) overall mother’s knowledge f (%) poor knowledge 622 (62.2) fair knowledge 368 (36.8) high knowledge 10 (1) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 141 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: associated factors with belief of insufficient breast milk supply factors believed not believed p -value f (%) f ( %) parity primiparous 150 (59.5) 102 (40.5) 0.869ns multiparous 390 (59.5) 265 (40.5) grant multiparous 58 (62.4) 35 (37.6) mode of last delivery vaginal delivery 79 (21.5) 289 (78.5) 0.017hs cesarean delivery 98 (15.5) 534 (84.5) mothers’ knowledge poor knowledge 369 (59.3) 253 (40.7) 0.015*hs fair knowledge 223 (60.6) 145 (39.4) good knowledge 6 (60) 4 (40) socio-economic status low socioeconomic level 266 (60.2) 176 (39.8) 0.986ns middle socio-economic level 310 (59.4) 212 (40.6) high socio-economic level 22 (61.1) 14 (38.9) *fisher’s exacted test was applied. ns: non significant hs: highly significant table 5: associated factors with mother’s experience about insufficient breast milk supply factors experienced not experience p -value f (%) f ( %) parity primiparous multiparous 525 (80.2) 130 (19.8) 0.064 ns grant multiparous 76 (81.7) 17 (18.3) mode of last delivery vaginal delivery 299(81.3) 69 (18.8) 0.119 ns cesareansection 487(77.1) 145(22.9) mothers’ knowledge poor knowledge 474 (76.2) 148 (23.8) 0.051*ns fair knowledge 303 (82.3) 65 (17.7) good knowledge 9 (90) 1 (10.0) socio-economic status low economic level 329 (74.4) 113 (25.6) 0.014s middle economic level 426 (81.6) 96 (18.4) high economic level 31 (86.1) 5 (13.9) ns: non significant s: significant. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article discussion 142 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. promoting positive beliefs about breast milk in women during postpartum is an important precursor to future breastfeeding. the study showed that knowledge about the benefits of breastfeeding and perceived social influences were important for individuals with positive breastfeeding belief. the study included 1,000 healthy women who were six months postpartum, and the results revealed that the majority of the participants were between the ages of 21-30 years old. this finding is consistent with the findings of sultania et al. (2019), who conducted a cross-sectional study of 1000 healthy women in india [18], and discovered that the majority of them were between the ages of 20 and 30. and topothai, (2021) conducted a crosssectional study on 676 mothers, of whom a high percentage were 17-35 years old, in bangkok [19].the current study found that, the majority of residential places were in urban areas; this finding is similar to that of huang (2022), who conducted a longitudinal cohort study in china; 628 of the 1520 mothers recruited into the study were from urban areas [20]. the result of the present study indicates that overweight mothers had the highest percentage of 46.9% in regard to bmi; this result agrees with the result of two studies preusting's (2017) descriptive cohort study, which included 216 women, showed that the majority of participants had become overweight [21]. nommsen et al. (2010) also conducted a cohort study with 431 postpartum women. showed the high percentage of overweight people (44.8% in california) [22].the current study found that intermediate level education received the highest percentage of 27.6% in terms of mother's education, which agrees with the findings of abdallah (2018), who conducted a cross-sectional study with 384 women and found that intermediate level education received the highest percentage of 58.6%, which is higher than the current study in zagazig [23]. but in another study in india by sultania et al. (2019), it showed that the illiterate had the highest percentage [18].regarding types of families, the result showed that the highest percentage was the nuclear type (73.3%). this is consistent with a study by menekse, (2021) a descriptive a cross-sectional study that included 429 mothers in turkey, where the highest percentage, 83.4%, were living in a nuclear family [24].in the present study, the highest percentage in ses (socioeconomic status) (52.2%) was middle economic level. this result is compatible with the finding of nukpezah, (2017), who conducted a study on 393 mothers in ghana [25], which showed the highest percentage (53.1%) were in the middle economic level, while these results are in contrast with the finding of sultania et al. (2019), who showed that 49% belonged to the low socio-economic level in india [18]. habibi (2018) discovered a 44% low economic level in a cross-sectional study of 297 mothers in casablanca [26]. the current study showed that there was a highly significant association between socioeconomic status with mother’s experience regarding insufficient breast milk supply. but there was not significant between mothers’ belief with socio economic status. the results of the present study showed that the highest percentage in the study, 65.5%, were multiparous, respectively, which is consistent with a previous study done by topothai (2021) [19]. sandhi et al. (2020) conducted a crosssectional study and included 237 participants in yogyakarta city more than half of the mothers were multiparous [9].however, primiparous was 25.2% that was similar to the previous study sultania et al (2019) that 25.5% was https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article conclusion 143 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. in erbil, iraq. the highest percentage of mother's experiences was 72% in the study by gewa (2016) [31], which conducted a cross-sectional study on 400 mothers, which is in contrast with another study by gatti et al. (2018) [17].the study showed that the mothers with poor knowledge were the majority in regards to the benefits of breastfeeding for the baby and the mother; this result is almost similar to the previous studies by ahmed and piro (2019) that conducted a crosssectional study in erbil, iraq; sultania et al. (2019) in india; cardoso (2017) in portugal; and qarabi (2017) in saudi arabia [32, 18, 33, 34, 35].the study indicated that there was a highly significant association between the mother's belief and knowledge with insufficient breast milk supply, which was similar to the previous study's result by menekse (2021) [24]. but in the longitudinal design study that applied to 61 participants in new zealand by hintz (2019) [5], there was not a significant association between a mother's knowledge and the perception of insufficient milk supply. the study shows a near -significant association between mothers' experience with insufficient breast milk supply, which is similar to the previous studies by gewa (2016) [31] and hintz (2019). the results of the present study indicate that there is an association between mother's belief of insufficient breast milk supply with mothers’ knowledge about breastfeeding. also, there is an association between the mother's belief with mode of last delivery. besides, there is an association between a mother's experience with socio-economic status regarding insufficient breast milk supply. primiparous [18].the current study showed that the most percentage in the mode of the last delivery was cesarean section, that agree with previous studies by menekse (2021) and segura (2022) systematic review showed that the majority was caesarean sections [24, 27]. yet, it disagrees with two previous studies that the high percentage in vaginal delivery by topothai (2021) [19] and sandhi et al (2020) [9].the present study, also, showed that there was a significant association between the mode of last delivery and beliefs. yet, there was not a significant association between parity, belief, and experience with insufficient breast milk supply. the result of parity is similar in two studies, mccarter-spaulding and kearney (2001), which concluded a cross-sectional study of 60 mothers in the northern united states [28]. and previous study, sandhi et al. (2020) [9].moreover, the result shows that beliefs and experiences are highly significant along with mothers’ concepts regarding insufficient breast milk supply and breast feeding. this finding is consistent with previous studies camurdan (2008) descriptive cross-sectional study included 1230 mothers in turkey [29]. sacco (2006) conducted a qualitative study using semistructured interviews with 200 mothers in mexico [30], which found that postpartum mothers who did not practice exclusive breastfeeding had a perception of insufficient milk supply. the current study found the prevalence of mothers' belief about insufficient milk supply to be 59.8%; that was the most prevalent reason for stopping breast feeding during the first six months. however, in a study conducted by sultania et al. (2019) in india, insufficient breast milk supply was cited by 41% of respondents as the most common reason for discontinuing breastfeeding [18].the prevalence of a mother’s experience with insufficient breast milk supply was 78.6% https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article references 144 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [1] gruca ma. breast milk macronutrient composition and infant growth in rural west africa. breast. 2017 jan 1.a thesis submitted to the faculty of the graduate school of the university of colorado in partial fulfillment of the requirement for the degree of master of arts. department of anthropology. [2] jarosh w, phelan g, dwyer jt, ziegler pj, hendricks k. menus for infants and toddlers to explore the dietary world. nutrition today. 2006 jul 1;41(4):144-52. [3] karacam z. factors affecting exclusive breastfeeding of healthy babies aged zero to four months: a community‐based study of turkish women. journal of clinical nursing. 2008 feb;17(3):341-9. [4] aljawadi hf, ali ea, altimimi ha. exclusive breast-feeding incidence in the first six months of life and its associated factors. mustansiriya medical journal. 2017 dec;16 (3):62. [5] hintz m. perceived insufficient milk supply in new zealand mothers during the first-year postpartum: this thesis presented in partial fulfilment of the requirements for the degree of master of science in nutrition and dietetics at massey university, albany, new zealand 2019 (doctoral dissertation, massey university). [6] sharma ik, byrne a. early initiation of breastfeeding: a systematic literature review of factors and barriers in south asia. international breastfeeding journal. 2016 dec;11 (1):1-2. [7] mohseni h, jahanbin i, sekhavati e, tabrizi r, kaviani m, ghodsbin f. an investigation into the effects of prenatal care instruction at home on breast-feeding self-efficacy of firsttime pregnant women referred to shiraz clinics, iran. international journal of women's health and reproduction sciences. 2018;6(1):41-6. [8] victora cg, bahl r, barros aj, franca gv, horton s, krasevec j, et al. breastfeeding in the21st century: epidemiology, mechanisms, and lifelong effect. the lancet. 2016;387 (10017):475–90. [9] sandhi a, lee gt, chipojola r, huda mh, kuo sy. the relationship between perceived milk supply and exclusive breastfeeding during the first six months postpartum: a crosssectional study. international breastfeeding journal. 2020 dec;15(1):1-1. [10] grzeskowiak le, amir lh. pharmacological management of low milk supply with domperidone: separating fact from fiction. the medical journal of australia 2014 sep 1;201(5):257-8. [11] lou z, zeng g, huang l, wang y, zhou l, kavanagh kf. maternal reported indicators and causes of insufficient milk supply. journal of human lactation. 2014 nov;30 (4):466-73. [12] whipps md, demirci jr. the sleeper effect of perceived insufficient milk supply in us mothers. public health nutrition. 2021 apr;24(5):935-41. [13] gonzález md, marrón ho, cañedoargüelles ca, olcina mj, rico oc, claramonte mt, et al. prevalence of breastfeeding and factors associated with the start and duration of exclusive breastfeeding in the community of madrid among participants in the eloin. anales de pediatría (english edition). 2018 jul 1;89(1):32-43. [14] olang b, heidarzadeh a, strandvik b, yngve a. reasons given by mothers for discontinuing breastfeeding in iran. international breastfeeding journal. 2012 may;7(1):1-7. [15] krolak-olejnik b, błasiak i, szczygieł a. promotion of breastfeeding in poland: the current situation. journal of international medical research. 2017 dec;45(6):1976-84. [16] anggraeni md, latifah l, rismawati i. the effect of “insufficient milk supply” concept intervention on mother's perception of breast milk production. indonesian nursing journal of education and clinic (injec). 2016 sep 24;1(1):71-4. [17] gatti l. maternal perceptions of insufficient milk supply in breastfeeding. journal of nursing scholarship. 2008 dec;40(4):355-63. [18] sultania p, agrawal nr, rani a, dharel d, charles r, dudani r. breastfeeding knowledge and behavior among women visiting a tertiary care center in india: a cross-sectional survey. annals of global health. 2019;85(1). [19] topothai c, topothai t, suphanchaimat r, patcharanarumol w, putthasri w, hangchaowanich y, et, al. breastfeeding practice and association between characteristics and experiences of mothers living in bangkok. international journal of environmental research and public health. 2021 jul 26;18 (15):7889.https://doi.org/10.3390/ ijerph18157889 2021 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.15 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 145 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [20] qiu l. factors that influence breastfeeding initiation and duration in urban, suburban and rural areas of zhejiang province, peoples republic of china (doctoral dissertation, curtin university). 2008 [cited 2021 dec 19]. availablefrom: https://espace.curtin.edu.au/ handle/20.500.11937/1242. [21] preusting i, brumley j, odibo l, spatz dl, louis jm. obesity as a predictor of delayed lactogenesis ii. journal of human lactation. 2017 nov;33(4):684-91. [22] nommsen-rivers la, chantry cj, peerson jm, cohen rj, dewey kg. delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding. the american journal of clinical nutrition. 2010 sep 1;92(3):574-84. [23] abdallah nm, eldin sa, gad ah. breast and nipple problems encountered among puerperal primipara women in zagazig. international journal of pharmaceutical research &allied sciences. 2018;7(1):183-95. [24] menekse d, tiryaki ö, karakaya suzan ö, cinar n. an investigation of the relationship between mother’s personality traits, breastfeeding self-efficacy, and perception of insufficient milk supply. health care for women international. 2021 jul 1;42(4-6):925 -41. [25] nukpezah rn, nuvor sv, ninnoni j. knowledge and practice of exclusive breastfeeding among mothers in the tamale metropolis of ghana. reproductive health. 2018 dec;15(1):1-9. [26] habibi m, laamiri fz, aguenaou h, doukkali l, mrabet m, barkat a. the impact of maternal socio-demographic characteristics on breastfeeding knowledge and practices: an experience from casablanca, morocco. international journal of pediatrics and adolescent medicine. 2018 jun 1;5(2):39-48. [27] segura‐pérez s, richter l, rhodes ec, hromi‐ fiedler a, vilar‐compte m, adnew m, et, al. risk factors for self‐reported insufficient milk during the first 6 months of life: a systematic review. maternal & child nutrition. 2022 mar 28: e13353. [28] mccarter‐spaulding de, kearney mh. parenting self‐efficacy and perception of insufficient breast milk. journal of obstetric, gynecologic, & neonatal nursing. 2001 sep;30 (5):515-22. [29] camurdan ad, ilhan mn, beyazova u, sahin f, vatandas n, eminoglu s. how to achieve long-term breast-feeding: factors associated with early discontinuation. public health nutrition. 2008 nov;11(11):1173-9. [30] sacco lm, caulfield le, gittelsohn j, martínez h. the conceptualization of perceived insufficient milk among mexican mothers. journal of human lactation. 2006 aug;22 (3):277-86. [31] gewa ca, chepkemboi j. maternal knowledge, outcome expectancies and normative beliefs as determinants of cessation of exclusive breastfeeding: a cross-sectional study in rural kenya. bmc public health. 2016 dec;16(1):1-9. [32] ahmed hm, piro ss. knowledge and attitudes of pregnant women regarding breastfeeding. polytechnic journal. 2019 dec 1;9(2):55-62. [33] cardoso a, e silva ap, marín h. pregnant women’s knowledge gaps about breastfeeding in northern portugal. open journal of obstetrics and gynecology. 2017 mar 15;7(3):376-85. [34] orabi a, al-sayad r, alharthi k. investigating the knowledge, attitudes, practice and perceived barriers of breastfeeding among saudi women in the national guard hospital jeddah. athens journal of health. 2017;257. [35] omer w, al-hadithi t. developing a socioeconomic index for health research in iraq. east mediterr health j. 2017 oct 1;23 (10):670-7. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.04 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article teacher’s practice regarding cardiopulmonary resuscitation at basic schools in erbil city abstract background and objectives: every day, either by accident or illness, there are numerous situations in which the safety of individuals, families or communities is endangered. >2000 children worldwide die every day as a result of unintentional injuries. the majority of risks influencing a cardiac arrest in a school are related to physical activity, such as participating in sports or having an airway obstruction or trauma event. in the united states and europe, one million people experience cardiac arrests annually. the aim of this study was to assess the basic school teachers’ practices regarding cardiopulmonary resuscitation at basic schools in erbil city. methods: a cross suctional study was carried out. to assess the practices of basic school teachers regarding cardiopulmonary resuscitation. the study was conducted from january 20,2021 to may 15, 2022. this study was conducted in basic schools in erbil city according to six municipalities. the sample size was 470 teachers. the observational check list technique was used to assess cardiopulmonary resuscitation performance. results: the majority of them were female (74%), more than half of them have a diploma (52.3%), the majority of age group were between 37-48 years old which represents 51%, the mean age was (43.85±8.27), most of the teachers were married (86.4%), the majority of them did not a training course (86.4%). several teachers use tradition at media (9.6%) and social media (44.7). a lot of barriers were faced teachers to prevent participation in training courses were not found in professional training course the majority of the schoolteachers had poor levels of practice (51.1%) regarding the performance of cardiopulmonary resuscitation. conclusion: the majority of schoolteachers had poor levels of practice regarding cardiopulmonary resuscitation. there was a significant association between the performance of cpr and some socio-demographic variables like age group, gender, years of experience, and desire to attend cpr training course. keywords: cardiopulmonary resuscitation; practices; basic school teacher. jawdat mamand akhagbaker; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: jawdat.baker@hmu.edu.krd) kareem fattah aziz; department of nursing, college of nursing, hawler medical university, erbil, iraq. 31 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 17/09/2022 accepted: 06/11/2022 published: 30/05/2024 mailto:jawdat.baker@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.04 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article every day, either by accident or illness, there are numerous situations in which the safety of individuals, families or communities is endangered. >2000 children worldwide die every day as a result of unintentional injuries [5]. to date, an estimated 17.5 million people have died each year from cardiovascular diseases (cvd) such as stroke and heart attack, known to be the world's leading cause of death [4]. cardiac arrests in schools are linked to physical activity, sports, aerobic fitness participation, or other traumaor airway-related occluded. although there are about one million cardiac arrests annually in the united states and europe, cardiac arrest is still a clinical illness with a dismal prognosis [1]. basic life support (bls): is defined as “maintaining airway patency and supporting breathing and circulations without the use of equipment other than a protective device” [2]. basic life support (bls) is a set of emergency procedures applied to a patient, it comprises a number of techniques, like cardiopulmonary resuscitation (cpr to sustain patient’s life until the hospital facility arrives or the person reaches the hospital [3] the american academy of pediatrics and the american heart association (aha) have issued guidelines that stress the need for school teachers to be knowledgeable about emergency response measures to address life-threating emergency. thus, in this regard, the training of school teachers will facilitate the learning process for students [4]. considering that school instructors have the time to demonstrate bls to pupils and should be certified in cpr, the european resuscitation council recommended that cpr be included in the school curriculum [1]. the study is important because it illustrate practices of cardiopulmonary resuscitation among teachers in basic school. it motivates teachers, how to take care of the school, to make good scientific intervention, the lives of students in cases of cardiac arrest. the study contributes to the awareness of emergency in the school among the school teachers and staff of school administration to decrease emergency problems by increasing suitable intervention for the purpose of saving lives students and staff in school. basic life support is of high importance when an individual is at risk. learning basic life support skills is of great importance in resuscitation, life-saving and is prevention of complications in emergency situations in both the school environment and the community [6]. the aim of this study was to assess teachers, practices regarding cardiopulmonary resuscitation at basic schools in erbil city. the objectives of the study are to assess the level of teachers’ practices in cardiopulmonary resuscitation and, find out the association between level of performance and sociodemographic variables like age, gender, qualification, marital status, number of children, previous in educational program and source of information. the current cross-sectional study was carried out to assess the practices of school teachers regarding cardiopulmonary resuscitation. the study was carried out over a four-month period, from january 20 to may 15, 2021. this study was conducted in basic schools in erbil city north-central of iraq which contents 6 municipality, the sample to six municipality 1 municipality located in the center of the city around a street 60 meters, 2 located from the roadway of erbil-mosel to the roadway of erbilshaqlawa, 3 located from the roadway of erbil-saqlawa to the roadway of erbil-koya, 4 located from the roadway of eskan to the roadway of erbil-mahmur, fifth located from the roadway of erbil-koya to the roadway of eskan street, sixth located 32 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.04 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article of education in erbil city, for each cluster, teachers were selected, in 6 municipality there were 470 teachers for a total sample size of 10445 basic school teachers in erbil city. approximately, the samples of teachers from each school were enrolled in the study. the number of teachers needed from each school was calculated proportionally to the total sample size. the teacher signed the consent form and then completed the questionnaire using paper and pencil. the samples of teachers from each school are dependent on the total number of teachers in schools. according to the formula of teachers (each school) is multiplied by the sample size (470) and divided by the total of teachers in the whole school (1189). if a teacher did not agree to participate, another one from the same school was randomly replaced. the data collection took place through assessment of cardiopulmonary resuscitation practices using observational checklist technique. after cooperating with the school manager after teachers were accepted to share in the study, assessment tests were used in teachers' rooms in the school to evaluate teachers one by one used. the researcher used an observational checklist for evaluation. the data were collected during the morning shift on school duty, from 8:00 am to 12:00 pm, and during the shift from 1:00pm to 4:00 pm. the period of data collection depends on three times in the school. firstly, some of the teachers participated when there was no have class for 45 minutes. secondly, some of the teacher participated in coffee break. thirdly, some of the teachers participated at the end of class or according to teacher free time. the data was collected for 8–10 minutes for each sample. they were completed, the researcher gathered all the checklist data, the tool was developed by the researchers after reviewing the related literature, for cardiopulmonary resuscitation dependent from the roadway of erbil-mahmur to the roadway of erbil-mosel. the basic schools were selected randomly utilizing simple random sampling according to six municipalities as a geographical distribution area in erbil city, all municipality were included in the study, 5 basic schools in each municipality were selected, according to the list of all basic schools affiliated to center for the direct education in erbil city. a total of 30 different basic schools were chosen out of 242 schools in erbil city. the sample size estimation is distributed according to the number of teachers in erbil city based on the proportion of school teachers. 385 teachers were selected from the total number of basic school teachers (10445) for this study. the sample was calculated using taro yamane formula and it comprised 385 participants. a sample of 385 teachers was estimated to be enough for this study. however, to improve the representativeness of the sample, increase the power of the study and accuracy 470 teachers were recruited for this study. the sample size needed to reflect the target p taro yamane formula n = n / (1 + ne^2) n= 10445/ (1+10445* (0.052 )2. n= 10445 / (1+10445*0.0025) n= 10445 / 27.1125 n=385 n= corrected sample size, 385 n = population size, 10445 e = margin of error (moe), e = 0.05 based on the research condition, population with a 5% of error at a 95% confidence [7]. a sample is a portion picked from the representative population for the purpose of reaching inferences. all the school teachers who participated in the study were entirely voluntary and their identities were maintained and any feeling of commitment to share in the present study was reduced by satisfying the basic teachers that sharing was optional and that they had the right to drop out at any time they wanted. probability cluster sampling was carried out, the list of basic schools was obtained from the general directorate 33 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.04 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article who teachers disagree to participate and complete the questionnaire. a questionnaire of teachers’ socio-demographic characteristics and practices consisted of 4 parts. part 1: socio-demographic characteristic questions include the following: age, gender, qualification, marital status, number of children, years of experience and previous participation in an educational program about cardiopulmonary resuscitation. part 2: questions about respondents' experience with educational programs and surveys in have you, attended a previous training course of cpr. part 3: questions regarding sources of information which consist of 1. formal learning which includes study in a formal university education or college). 2. informal learning (seminar, webinar, workshop, training course). 3. social media (facebook, instagram. snap chat. whats-up. telegram. youtube) 4. traditional media (tv. program, reading book, magazines, newspaper, listen to the radio) part 4: assessment of cpr practices used the observational checklist, and one of these manikins or learning cpr procedure, the personal resuscitation named. trauma. the serial number of manikins is tm1172a150213m. this personal training manikin has a cpr mode that shows the depth of chest pressure through a fixed light point on a 1–7-point device. each light point is equal to 1cm. it is noticed during training that if the chest compression is incorrect, it appears through the light point; and changes color from green to red. if it is correct, the light point will stay in the green color assessment of basic life support practices consists of an observational check list for cpr procedures consisting of 13 steps, checking for safety, checking responsiveness, shouting for help activating emergency response system, calling an emergency number 066122 ,from a mobile phone, moving the child to a firm at surface, if the child is face-down, roll him or her face-up, keeping the head, neck and back in a straight line. airway opened by tilting the head slightly and lifting the chin checks breathing by listening for breaths, feeling the breaths against the skin and watching the chest movements, checks pulse, performs high-quality compressions, and places hands on the lower half of the sternum 30 compressions at a rate of at least 100 compressions per minute, located the correct hand position by placing the heel of one hand on the child’s sternum at the center of his or her chest, compressed at least 2 inches (5 cm), completed recoil after each compression, gives 2 breaths with a barrier device, each breath given over 1 second (pinched nose, made a complete seal over child’s mouth) visible chest rise with each breath, resumes compressions in less than 10 seconds, continued cycles of chest compressions and rescue breaths (30:2), (2 cycles for examination purposes. the observational checklist of cpr consists of 13 steps in the worksheet, it was filled out by the researcher for evaluation for each step using 6 categorize likert skills, got zero for not performance, 5 for excellent 4 for very good performance, 3 for good performance, 2 for moderate performance, and 1 for poor performance. the system scores, forever. cpr evaluation practice starts from 0 minimum to 65 maximum and is categorized into 6 levels, which consist of excellent performance (53 -65), very good performance (40-52), good performance (27-39), moderate performance (14-26), poor performance (1-13) and non-performance (0). the initial study was approve by the ethics committee, faculty nursing, hawler medical university with registration no 96 on 13 december 2020. official permission was sought from the .general directorate of erbil education directorate center education of erbil city, then permission was obtained from the manager of the school, following which 34 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.04 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article 35 frequent years of experience among teachers were between 15-26 years which reported 54%. the highest sample (86.4%) in the study were married. 65.1% of respondents reported having 1-3 children, with a mean of 19.09±8.53. copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. consent was taken orally from each school teacher .they signed the written informed consent attached to the study questionnaire after explaining the purpose of the participants were assured that all information was confidential and their participation in the study was voluntary without any costs and they had the right to refuse to participate in the study. the data was collected and entered into the personal computer. statistical analysis was done using the statistical package for social science (spss/version 26) analysis including frequencies and percentages. they were used to describe the items and the stud variables. a chi-squire test was used to find out the association between sociodemographic variables like age, sex, qualification, years of experience, and source f information. all statistical test had a significance p -value ≤ 0.05 with a 5% confidence level. during the data collection, a total of 500 questionnaires were distributed among school teachers. finally, 30 questionnaires by the teachers were not completed, related to school issues. in the end, only 470 questionnaires were completed and returned; it was considered in the study that the response rate in the current study is 94%. table 1: it was reported that the majority of teachers lived in municipality 6, which represented 20.2% while the lowest in musicality 4, which represented 12.6%. the highest age groups among participants were between 37-48 years which represented 53%. the mean age was 43.85±8.283. the majority of the samples were female (74%). 52.3% of participants in the study graduated from an institute while 47.7 % graduated from a college. the majority of class subjects were teaching language (42.1%), while the lowest were exercise (3.4%). the most results table 1: socio-demographic date of participants socio-demographic characteristic f (%) municipality municipality 1 76 (16.2) municipality 2 75 (16) municipality 3 83 (17.7) municipality 4 59 (12,6) municipality 5 82 (17.4) municipality 6 95 (20.2) age group years 25-36 85 (18.1) 37-48 249 (53) 49-60 136 (28.9) mean and standard deviation gender male 122 (26) female 348 (74) education college 224 (47.7) institute 246 (52.3) class subject science 97 (20.6) language ( kurdish, arabic and english) 198 (42.1) math 68 (14.5) sociality 68 (14.5) exercise 16 (3.4) art 23 (4.9) years of experience 3-14 130 (27.7) 15-26 254 (54) 27-38 86 (18.3) mean and standard deviation marital status married 406 (86.4) single 56 (11.9) divorced 5 (1.1) widowed 3 (0.6) number of child 1-3 252 (65.1) 4-6 125 (32.3) 7-9 10 (2.6) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.04 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article represented 76.6%. 86.8% of school teachers do not have the opportunity to attend any a previous training courses. by formal learning (62.6%) and social media (44.7), while the minority comes from formal learning (13.4 %). 36 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2 shows that the majority of study samples have a desire to participate in a basic life support training courses which table 3 demonstrated that the majority of sources of information among teachers come from traditional media (79.6%),followed table 2: basic life support training course f % do you have a desire to participate in basic life support (bls) training course no 110 (23.4) yes 360 (76.6) do you have attended a previous course of basic life support? no 408 (86.8) yes 62 (13.2) how many course not participation 387 (82.3) one course 36 (7.7) two course 22 (4.7) three course 25 (5.3) type of training course not participation 387 (82.3) theory course 29 (6.2) practices course 15 (3.2) both theory and practices 39 (8.3) table 3: source of information no. source of information yes f (%) 1 formal learning (study in formal university education ) 63 (13.4) 2 in formal learning (seminar, webinar, workshop, training course) 294 (62.6) 3 social media (facebook, insata-gram, snap-chat, whats-up, tell-gram, you-tub) 210 (44.7) 4 traditional media (tv-program , reading book, magazine, newspaper and listen to the radio) 374 (79.6) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.04 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article of them had good performance and none of the teachers had very good or excellent performance. using the same data in table4 socio-demographic variables like age group, gender, years of experience, and desire to attended cpr training course. table 4 illustrates that the highest percentage of study samples had poor practice performance in cpr, 51.1%, only 0.4 % figu1 demonstrates levels of performance table 5 shows that the assessment of cpr procedure was done in 13 steps, most of the school teachers had poor performance. table 6 indicated that there was a significant association between the performance of cpr and some 37 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. figure 1:over all cpr performance table 4: over all cpr performance levels of cardiopulmonary resuscitation performance f (%) excellent performance 0 (0) very good performance 0 (0) good performance 2 (0.4) moderate performance 38 (8.1) poor performance 240 (51.1) non performance 190 (40.4) total 470 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.04 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article 38 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 5: assessment of practices of cpr cardiopulmonary resuscitation steps not performance poor performance moderate performanc e good performance very good performance excellent performance f (%) f (%) f (%) f (%) f (%) f (%) 1. check for safety 376 (80) 80 (17) 2 (0.4) 1 (0.2) 2 (0.4) 9 (1.9) 2.checks responsiveness 404 (86) 64 (13.6) 1 (0.2) 1 (0.2) 0 (0) 0 (0) 3.shouts for help activates emergency called an emergency number 066122 398 (84.7) 67 (14.3) 2 (0.4) 3 (0.6) 0 (0) 0 (0) 4.moved the child to the firm flat surface. keeping the head, neck and back in a straight line 369 (78.5) 86 (18.3) 8 (1.7) 5 (1.1) 1 (0.2) 1 (0.2) 5. opened the airway by tilting head slightly and lifting chin. 317 (67.4) 118 (25.1) 16 (3.4) 15 (3.2) 3 (0.6) 1 (0.2) 6. check for pulse 1 (0.2) 156 (33.2) 21 (4.5) 14 (3) 3 0 (0) 7.hand placement on lower half of sternum 244 (51.9) 174 (37) 27 (5.7) 22 (4.7) 3 (0.6) 0 (0) compressions a rate of at least 100 compressions per minute. 225 (47.9) 200 (42.6) 30 (6.4) 13 (2.8) 2 (0.4) 0 (0) 9. located the correct hand position by placing the heel of one hand on the child’s sternum at the center of his or her chest, compresses at least 2 inches (5 cm) depth 234 (49.8) 203 (43.2) 19 (4) 11 (2.3) 3 (0.6) 0 (0) 10.complete chest recoil after each compression 252 (53.6) 192 (40.9) 16 (3.4) 9 (1.9) 1 (0.2) 0 (0) 11.gives 2 breaths with a barrier device each breath given over 1 second(pinched nose, made a complete seal over child’s mouth) 245 (52.1) 209 (44.5) 11 (2.3) 5 (1.1) 0 (0) 0 (0) 12. visible chest rise with each breath 252 (53.6) 205 (43.6) 12 (2.6) 1 (0.2) 0 (0) 0 (0) 13. continued cycles of chest compressions and rescue breaths (30:2). (2 cycles for examination purposes 270 (57.4) 192 (40.9) 8 (1.7) 0 (0) 0 (0) 0 (0) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.04 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article 39 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 6: relationship between overall and socio-demographic characteristics practices of cpr socio-demographic variables good moderate poor non chisquare p value f f f f 109.627 0.001 municipality 1 0 6 54 16 2 1 16 27 31 3 1 11 45 26 4 0 3 37 19 5 0 1 15 66 6 0 1 62 32 age group 25-36 0 10 43 32 13.18 0.04 37-48 0 22 135 92 49-60 2 6 62 66 gender male 2 20 61 39 22.725 0.001 female 0 18 179 151 education college 2 24 114 84 6.764 0.08 institute 0 14 126 106 class subject science 0 6 51 40 7.899 0.928 language 2 22 99 75 math 0 3 35 30 sociality 0 4 36 28 exercise 0 1 8 7 art 0 2 11 10 years of experience 3-14 years 0 15 72 43 16.581 0.011 15-26 years 0 18 131 105 27-38 years 2 5 37 42 marital status married 2 36 202 166 8.323 0.502 single 0 2 32 22 divorced 0 0 5 0 widowed 0 0 1 2 number of children no children 1 5 41 36 3.977 0.913 1-3 child 0 21 130 101 4-6 child 1 11 63 50 7-9 child 0 1 6 3 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.04 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article 40 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. continue of table 6: relationship between overall and socio-demographic characteristics practices of cpr socio-demographic variables good moderate poor non chisquare p value f f f f do you have a desire to participate in training course no 0 2 53 55 11.077 0.011 yes 2 36 187 135 do you have attended a previous training course no 2 33 199 153 1.443 0.695 yes 0 5 41 37 how many course 0 2 33 199 153 6.595 0.679 one course 0 2 21 13 two course 0 3 8 11 three course 0 0 12 13 type of training course 0 2 33 198 154 9.908 0.358 theory course 0 5 15 9 practices course 0 0 8 7 theory and practices 0 0 19 20 formal learning no 2 32 208 165 0.507 0.917 yes 0 6 32 25 tradition media no 1 16 126 106 3.421 0.754 yes 1 16 91 65 social media no 1 22 124 113 2.747 0.432 yes 1 16 116 77 informal learning no 0 10 88 78 4.324 0.229 yes 2 28 152 112 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.04 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article course (70%) [10]. the finding of the present study was consistent with the study done in turkey anatolia province that shows more than half of school teachers were female; most of them were married and had children while there was inconsistency with participation in a previous training course in which the majority of study samples participated [11]. the difference could be due to the mandatory requirement among school teachers to participate in training courses. this rule effected improved teachers’ knowledge and practice regarding basic life support. the result of the current study is in agreement with the study done in malaysia regarding sources of information that come from social media and tv. program while disagreeing with participating in the training course, more than half of school teachers in malaysia shared in the training course regarding basic life support [12]. the result of the present study is in agreement with the study done by alhejaili as et al, in saudi arabia, which shows that in the majority age group (41-50), most of the school teachers have the desire to participate in a training course [13]. also, our result strongly agrees with the study done in saudi arabia-hail city by alshammari ko, (2021) which demonstrates that the mean age is 39±7.8 the majority of teachers were married, more than half of them have not participated in training course, the majority of samples have a desire to participate in training course (87%), and most teachers use social media as sources of information [4]. the average of teachers who received basic life support training sessions in the present study was found to be very low because most of the teachers had not attended any training course. this finding is consistent with studies that shows that lowest percentage of teachers 41 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. the performance of cpr among school teachers in the current research study was found to be inadequate, and this finding was investigated in another country from a neighboring country. basic life support practices among teachers are weak and inadequate the public administration of education makes compulsory participation in basic life support training courses among school teachers, this can be e improved and promoted by opening mandatory training courses or teachers annually. all the factors contributing the low level of performance in cardiopulmonary resuscitation are related to a lack of training courses or educational programs in a school, no present instructors or guide posters and postcards for basic emergency first aid, and no films on health-applied tv programs in order to show how to provide basic life support and immediate care for sudden cardiac arrest. it is an outstanding role of teachers when dealing with injuries and accidents that happened in the school. after dealing with them using appropriate first aid techniques, the morbidity and death rate of these accidents decreased. community health nurses or other health care providers are not present in schools for the purpose of performing immediate emergency health care services. in the present, study out of 470 school teachers, 26 % were males and 47.7% graduated from college; most of them had not attended a previous training course in school. this finding is in agreement with the study done in south india (2015) shows the majority of school teachers do not know how to perform cpr. out of 146 participants, only 8 teachers can perform cpr correctly. the present result is similar with a mean age (39.3±10). most of the teachers were female (82%) and the majority of school teachers do not attend a previous training discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.04 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article sometimes lead you to situations that are dependent on teachers' personalities or school situations; on the other hand, the responsibility is related to the general directorate of education. all those factor cause school teachers to have poor knowledge and practices regarding basic life support. most teacher do not attend any training courses in the school, and the educational program content in the school curriculum does not present any subject of basic first aid. a lack of training in teachers may also contribute to the curriculum of higher education (university degrees) that does not contain basic support, even in the colleges of science and physical activity. for this reason, our school teachers have poor skills. most teachers agree that training most teachers agree that basic life support should be mandatory teachers in school. some of responders fear causing harm to victims and fear transferring communicable diseases like corona virus during mouth-to-mouth breathing [3]. the majority of the present investigation reported that the levels of practices among school teachers were very low. this finding is compatible with a study done in palestine, hebron city by ghraib fa, et al. in 2017 that showed a low level of practices toward basic life support [18] . the current study findings regarding basic life support practices were similar to those of the study done in south delhi by jacob om et al, (2018) that showed a low score percentage in cpr (15%), and choking (10%) [20] because the majority of school teachers had not attended training courses. a similar outcome was investigated in egypt by abuelenen nrm, which showed that the majority of basic life support poor performance [21] our finding, regarding cpr practices is in agreement with a study done in iraqbaghdad (2016) that shows 42 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. having attended training courses in the school, 40% in greece [14], % 30% in saudi arabia [13]. 50% in spain [15], 8.9% in south africa [16] 3 % in ethiopia [17], 42% in palestine [18], 24.2 % in indonesia [19]. in the current finding, there was no significant difference between teachers who attend training courses with those attend training courses. this result is in is agreement with the study in greece that found that those teachers had a higher level of knowledge than their non-trained counterparts [14]. variety among countries regarding rules and regulations could be one of the factors the affects the difference between the two results of the study. the educational program regarding basic life support does not involve a school curriculum, and is not mandatory, among school teachers in our country when compared to other countries. regarding sources of information, the present study found that most teachers got information from formal learning like seminars, webinars, workshops and training courses. in addition, the next source comes from social media. this finding is in disagreement with a study done in saudi arabia by. sara a. alzherei, et al20. most school teachers, sources of information come from social media while the lowest come from informal learning. the present studies demonstrate the signaled low scores in overall levels of cpr among school teachers because most of them do not participate in any educational program or training course and do not have the opportunity to participate in workshops and seminars. in addition, no extra supports are present to improve the knowledge and skill of teachers regarding basic life support in school. the school teachers faced many barriers in their lives that did not allow them to participate in educational programs or training courses regarding basic life support. these issues https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.04 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article [4] alshammari ko. assessment of knowledge, attitude, and practice about first aid among male school teachers in hail city. journal of family medicine and primary care. 2021 jan;10(1):138 https:// www.ncbi.nlm.nih.gov/pmc/articles/ pmc6436304/ [5] míguez-navarro c. the knowledge of and attitudes toward first aid and cardiopulmonary resuscitation among parents. journal of pediatric nursing. 2018. 42, pp.e91-e96. https:// www.pediatricnursing.org/article/s08825963(17)30362-7/fulltext\ [6] charalambous c. investigation of the teacher's knowledge and attitude towards providing first aid in the school environment. international journal of caring sciences. 2021 may 1;14(2):1468-72. https://www.researchgate.net/profile/ dimos-mastrogiannis/ publication/357535074_investigation_of_the_te acher's_knowledge_and_attitude_toward s_providing_first_aid_in_the_school_env ironment/ links/61d2fea0e669ee0f5c8368a1/ investigation-of-the-teachers-knowledgeand-attitude-towards-providing-first-aidin-the-school-environment.pdf [7] kayumba jd. effectiveness of video teaching on basic life support knowledge, attitude among non-health professional students at the university of rwanda (doctoral dissertation, university of rwanda). http://dr.ur.ac.rw/bitstream/ handle/123456789/999/kayumba% 20jean%20de%20dieu.pdf?sequence=1 [8] american heart association (2016) basic life support provide manual, isbn 978-161669-407-4 printed in the united states of america available at file:///c:/users/ hc/downloads/(1)%20american% 20heart%20association%20-%20bls% 20provider%20manual%20(2016).pdf [9] merchant rm. adult basic and advanced life support, pediatric basic and advanced life support, neonatal life support, resuscitation education science, and systems of care writing groups. part 1: executive summary: 2020 american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. circulation. 2020 oct 20;142(16_suppl_2):s337-57. 43 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. most school teachers have very weak cpr practices[22]. the majority of school teachers in basic school have poor performance about cpr, the majority of them have not attended previous training course. there was a significant association between performance in cpr and some socio-demographic variables like age group, gender, years of experience, and desire attend cpr training courses. there was no conflict of interest during the conducted study. [1] abelairas-gómez c, carballo-fazanes a, martínez-isasi s, lópez-garcía s, rico-díaz j, rodríguez-núnez a. knowledge and attitudes on first aid and basic life support of pre-and elementary school teachers and parents. journal of anales de pediatría (english edition). 2020 may 1;92(5):268-76. https://reader.elsevier.com/reader/sd/pii/ s2341287920300594? tken=5eb3861193c8824c004b0166e2dd0b 765b7dc1b2789a4da7b295d52bbfd506c 49fb9c416543a2d745e5af2ccf0d32c0c& originregion=eu-west1&origincreation=20220909080025. [2] pishgooie ah, abdi a, mazhari ms, nazari mr. comparing two teaching methods based on concept map and lecture on the level of learning in basic life support. journal of nurse education in practice. 2019 jul 1;38:40-4 https://www.sciencedirect.com/ science/article/abs/pii/ s1471595317307254 . [3] kayumba jd. effectiveness of video teaching on basic life support knowledge, attitude among non-health proffessional students at the university of rwanda (doctoral dissertation, university of rwanda). http://dr.ur.ac.rw/bitstream/ handle/123456789/999/kayumba% 20jean%20de%20dieu.pdf?sequence=1 conclusion conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.04 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article s2341287920300594? tken=5eb3861193c8824c004b0166e2dd 0b765b7dc1b2789a4da7b295d52bbfd5 06c49fb9c416543a2d745e5af2ccf0d32 c0c&originregion=eu-west1&origincreation=20220909080025 [16] ojifinni k, motara f, laher ae. knowledge, attitudes and perceptions regarding basic life support among teachers in training. cureus. 2019 dec 6;11(12). https:// www.cureus.com/articles/25582knowledge-attitudes-and-perceptionsregarding-basic-life-support-amongteachers-in-training [17] ganfure g, ameya g, tamirat a, lencha b, bikila d. first aid knowledge, attitude, practice, and associated factors among kindergarten teachers of lideta sub-city addis ababa, ethiopia. plos one. 2018 mar 13;13(3):e0194263. https:// journals.plos.org/plosone/article? id=10.1371/journal.pone.0194263 [18] ghrayeb fa, amro nr, rahseed o, yagi h, amro r, amro b. knowledge and attitude of basic life support (bls) among school teachers in hebron, palestine. international journal of research in medical sciences. 2017 jun;5(6):2477-82. https:// www.researchgate.net/profile/faridghrayeb-3/ publication/317178894_knowledge_and_attitud e_of_basic_life_support_bls_among_sch ool_teachers_in_hebron_palestine/ links/59d3ec32a6fdcc181ad94a44/ knowledge-and-attitude-of-basic-lifesupport-bls-among-school-teachers-inhebron-palestine.pdf [19] mirwanti r. attitude and knowledge of elementary school teachers towards first aid on emergency condition in children. in international conference on disaster management & infection control 2017 oct 14 (vol. 1, no. 1, p. 1http://conference.stikep -ppnijabar.ac.id/index.php/icdmic/article/ view/11/11 [20] jacob om, goswami a, ahamed f, dubey m, goswami k, gupta n. a training program on first aid and basic life support skills among teachers of a school in south delhi: a feasibility assessment. international journal of community medicine and public health. 2018 oct;5(10):4345. https:// d1wqtxts1xzle7.cloudfront.net/71140070 /2447-with-cover-page-v2.pdf? 44 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [10] joseph n. gopakumar kg. awareness, attitudes and practices of first aid among school teachers in mangalore, south india. journal of primary health care. 2015;7 (4):274-81. https://www.publish.csiro.au/ hc/pdf/hc15274 [11] faydali s, küçük s, yeşilyurt m. incidents that require first aid in schools: can teachers give first aid. journal of disaster medicine and public health preparedness. 2019 jun;13 (3):456-62. https:// www.cambridge.org/core/journals/disaster -medicine-and-public-health-preparedness/ article/abs/incidents-that-require-first-aidin-schools-can-teachers-give-firstaid/98b50f0d98fc4c08cd13a6367ee8daf 3#access-block [12] fariduddina mn, siau cs. knowledge, attitude and perceptions towards basic life support training among student teachers in a malaysian university. the european journal of social & behavioral sciences. 2021 apr 30. https:// www.europeanpublisher.com/ru/ article/10.15405/ejsbs.295 [13] alhejaili as, alghamdi ra, al-dubai sa. knowledge and attitude of basic life support skills among female school teacher in al-madinah, saudi arabia. journal of family medicine and primary care. 2020 may;9 (5):2281. https://www.ncbi.nlm.nih.gov/ pmc/articles/pmc7380791/ [14] charalambous c. investigation of the teacher's knowledge and attitude towards providing first aid in the school environment. international journal of caring sciences. 2021 may 1;14(2):1468-72. https:// www.researchgate.net/profile/dimosmastrogiannis/ publication/357535074_investigation_of_the_teac her's_knowledge_and_attitude_towards_p roviding_first_aid_in_the_school_environ ment/links/61d2fea0e669ee0f5c8368a1/ investigation-of-the-teachers-knowledgeand-attitude-towards-providing-first-aid-in -the-school-environment.pdf [15] abelairas-gómez c, carballo-fazanes a, martínez-isasi s, lópez-garcía s, rico-díaz j, rodríguez-núnez a. knowledge and attitudes on first aid and basic life support of pre-and elementary school teachers and parents. journal of anales de pediatría (english edition). 2020 may 1;92(5):268-76. https://reader.elsevier.com/reader/sd/pii/ https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.04 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article 45 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. expires=1662567095&signature=fbgxlqwpxc aafxpyov0vcqaaa5jqzylxx00wp5a4eill82 mx0aqub3iiaggrbicddyl0phl9tkc5ucoavy 6ckoqrfhu5vlj5rwjxmf3o1ep50fpxwnkw0amj9c3npqz8iva97znlzis00e3l8f7rxtoxfp0fu82tawhtifzbetz7cmrgnf1wqwrlt5jek4y0rskjwxj0cmhscdsmeaoyrsbgz0b5t9le5f2plkwupjhkty~q9htcjnh6wcr2t7q6ctwbsuby8pzt3xv qj9mzxbz1l6nub-3caaxf0pfkhtnyenypituv5iwhuzslfup6mexectovrkda~wuza__&key-pairid=apkajlohf5ggslrbv4za [21] abdella nh, abu-elenen nr, elkazaz rh, moussa mm. intervention program for the kindergarten teachers about pediatrics first aids. american journal of research communication. 2015;3(5):178-94. http://www.usa -journals.com/wp-content/ uploads/2015/04/abdella_vol35.pdf [22] razzaqj. khalaf arkanb. n.phd , maan h. i. impact of an educational program on secondary schools teachers' skills about cardiopulmonary resuscitation (cpr) in baghdad city. international journal of scientific and research publications, issn 22503153volume 6, issue 10, october 2016. https://www.ijsrp.org/research-paper1016/ijsrp-p5816.pdf https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article physical factors of spontaneous abortion in maternity teaching hospital in erbil city abstract background and objectives: abortion is considered a major reproductive health issue that acts as a health risk factor for mothers' well-being and threatens their lives and comfort. this study will contribute to recognize and be a better understanding of the physical risk factors for spontaneous abortion. the aim of the study was to find out the physical factors, which include previous and current medical factors of different types of spontaneous abortion by comparing the case and control groups among women in the maternity teaching hospital in erbil city. methods: a quantitative case-control study was conducted on 850 women with spontaneous abortions and pregnant women (each group was 425) pregnant women. however, the sample size of the study was 770 for both groups (each group was 385), however, 850 women were chosen who were admitted to maternity teaching hospital and were selected through non-probability purposive sampling. a questionnaire was developed for the purpose of data collection, which included socio-demographic characteristics of the study sample and questions about physical characteristics. frequency, percentage, the inferential statistical analysis of the chi-square test (fissure exact test), and binary logistic regression were used for data analysis. results: there was a significant difference between spontaneous abortion and physical factors which included medical conditions such as cardiovascular, urinary tract, neurological, and immune diseases. additionally, medical history such as obstetrical and gynecology surgery, gynecology disease, family history of chronic disease, and family history of spontaneous abortion. cardiovascular diseases (or:2.710; ci:1.636-4.483), immune diseases (or:0.230; ci:0.113-0.466), history of obstetrics and gynecology surgeries (or:0.599; ci:0.436-0.824), family history of chronic diseases (or:1.834; ci:1.336-2.518), family history of spontaneous abortion (or:0.098; ci:0.050-0.193) were predictors of the spontaneous abortion. conclusion: some physical factors are risk factors for spontaneous abortion. keywords: spontaneous abortion; physical factors; pregnant women. jwan kareem salh; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: jwan.salh@hmu.edu.krd). hamdia mirkhan ahmed; college of health sciences , hawler medical university, erbil, iraq. 01 received: 19/07/2022 accepted: 29/09/2022 published: 30/05/2024 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:jwan.salh@hmu.edu.krd?subject=jwan.salh@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article abortion is considered a major reproductive health issue and acts as a health risk factor for mothers' well-being and threatens their lives and comfort [1]. abortion is defined as the induced termination of a spontaneous pregnancy before fetal viability [2]. spontaneous abortion is another term for miscarriage, which refers to a pregnancy loss that happens before the 20th week of gestation or the expulsion of a fetus weighing 500 grams or less [3]. according to the clinical features and different stages of development, spontaneous abortion can be divided into threatened abortion, inevitable abortion, incomplete abortion, complete abortion, missed abortion, recurrent abortion, and infection abortion [4]. a study was done in kurdistan by azo and akbay reported that the total prevalence of abortion among kurdish married women was 27.7% [5]. another study was done in kermanshah provenance in iran by moradinazar et al, which found that about 25.7% of women had a history of spontaneous abortion [6]. it is the most common complication during pregnancy, affecting thousands of couples in the united kingdom every year. the average risk of spontaneous abortion has been calculated to be 15.3% of all recognized pregnancies [7].risk factors for spontaneous abortion include maternal age of more than 35 years, less education, women who had up to eight years of study, lower family income, and health conditions such as hypertension, heart disease, overweight, and obesity. additionally, there were infectious factors, which include infection by cytomegalovirus, rubella, toxoplasmosis, and bacterial vaginosis. hormonal changes include progesterone, hyperinsulinemia, and hyperandrogenism [8]. the research on the effects of viral respiratory infections on pregnancy, particularly during the first half of pregnancy, has been inconsistent. at the beginning of the covid-19 pandemic, there were risks that sars-cov2 infection could increase the risk of spontaneous abortion [9]. prevention of spontaneous abortion can occasionally be accomplished by reducing risk factors. this may include good antenatal care, avoiding medications and alcohol, preventing infectious diseases, and avoiding x-rays. detecting the reason for the spontaneous abortion may help prevent future pregnancy losses, specifically in cases of recurrent abortion [10]. this study will contribute to recognize and be better understanding of the physical risk factors for spontaneous abortion. the study aimed to find out the physical factors which include previous and current medical factors of different types of spontaneous abortion by comparing the case and control groups among women in the maternity teaching hospital in erbil city. a quantitative case-control study of a nonprobability purposive sample was conducted on 850 women with spontaneous abortion and pregnant women (each group 425) who were admitted to maternity teaching hospital and were available during data collection. however, the sample size of the study was 770 for both groups (each group 385), but i took 850 women with spontaneous abortions and pregnant women. by using calculator.net (sample size calculator) following values were entered confidence interval was 95 %, the margin of error was 5 % and the population proportion was 50%. the inclusion criteria for the case group included women who agreed to participate in the study, women with spontaneous abortions, and the control group included pregnant women at the end of the second and third trimesters of pregnancy and women who progressed 02 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article utilizing descriptive and inferential statistics. descriptive statistical analyses include frequency and percentage, the inferential statistical analysis of the chi-square test (fissure exact test), and logistic regression analysis. table 1 shows the differences between women with spontaneous abortions and pregnant women regarding sociodemographic characteristics. there were significant to highly significant differences between the scores of the items of the woman with spontaneous abortion and the pregnant woman with regards to socio -demographic characteristics except for the items ;( level of education, possession of a car, and socioeconomic status) which represented no significant difference at p≥0.05. table 2-1 illustrates the differences between women with spontaneous abortions and pregnant women regarding physical factors. there were significant to highly significant differences between the scores of the items of the women with spontaneous abortions and pregnant women with regards to physical factors, which including medical conditions, except for the items ; ( respiratory diseases, gastrointestinal diseases, endocrine diseases, hematological diseases, reproductive diseases, and musculoskeletal diseases) which represented no significant difference at p≥0.05. to labor . the exclusion criteria for the case group included those who refused to be interviewed, women with induced abortions and women who were not talking in the kurdish language. also, the control group was the pregnant women in the first, and beginning of the second trimester of pregnancy, and not talk in the kurdish language. data was collected in the period from october 25th 2021to may 25th, 2022. the sample was selected from the emergency department, delivery room, postpartum unit, high-risk department, and outpatient unit. a questionnaire was developed for the data collection for the study. in the first part socio-demographic characteristics included women’s age, level of education, occupation, residential status, type of family, possession of a car, and possession of a house. the socioeconomic status index was constructed using the index, it was depending on the patient's age, level of education, patient occupation and also the husband’s occupation, car, and house. the socioeconomic status index is divided into three levels: low, middle, and high economic level. physical characteristics included medical conditions and medical history.23 experts in the field reviewed the questionnaire and checklist and suggested some modifications to improve the internal validity of the tool. this study was approved by the scientific and ethical committee at hawler medical university / college of nursing. the code number was 102 and the date was 7 / 10/ 2021. formal permission was given by the administration of the hospital. before data collection, all study participants were informed about the aims and characteristics of the study. informed consent was obtained after confirmation of confidentiality and was collected through a face-to-face interview technique, and analyses were assessed using the statistical package for social science (version 26).variables were analyzed 03 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 04 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: difference between case and control groups regarding socio-demographic characteristics. socio-demographic characteristics case f (%) control f (%) age group ≤ 19 years old 34 (44.2) 43 (55.8) 20-29 years old 169 (45.1) 206 (54.9) 30-39 years old 181 (53.7) 156 (46.3) 40-49 years old 41 (67.2) 20 (32.8) level of education illiterate 100 (51.5) 94 (48.5) primary (or read and write) 149 (52.3) 136 (47.7) intermediate 78 (54.2) 66 (45.8) high school or vocational 45 (45.5) 54 (54.5) institute (2 years) 28 (39.4) 43 (60.6) college (bachelor degree) 23 (41.8) 32 (58.2) college (master degree) 2 (100) 0 (0) occupation status unskilled manual 23 (60.5) 15 (39.5) semi-skilled manual 322 (47.6) 354 (52.4) skilled manual and non-manual 40 (62.5) 24 (37.5) associate professional 30 (51.7) 28 (48.3) skilled professional or senior managerial 10 (71.4) 4 (28.6) residential area urban 210 (55) 172 (45) rural 46 (48.4) 49 (51.6) sub-urban 169 (45.3) 204 (54.7) type of family nuclear 327 (55.1) 266 (44.9) extended 98 (38.1) 159 (61.9) possession of car no 162 (46.4) 187 (53.6) yes 263 (52.5) 238 (47.5) possession of house no 218 (46.8) 248 (53.2) yes 207 (53.9) 177 (46.1) economic status low economic level 310 (51.1) 297 (48.9) middle economic level 113 (46.9) 128 (53.1) high economic level 2 (100) 0 (0) total 425 (50) 425 (50) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 05 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2-1: difference between case and control groups regarding physical factors (medical condition) medical conditions case f (%) control f (%) cardiovascular diseases no 394 (53.1) 348 (46.9) yes 31 (28.7) 77 (71.3) respiratory diseases no 422 (49.9) 423 (50.1) yes 3 (60) 2 (40) gastrointestinal disease no 414 (50.2) 411 (49.8) yes 11 (44) 14 (56) endocrine diseases no 384 (50.1) 383(49.9) yes 41 (49.4) 42 (50.6) hematological diseases no 343 (50.3) 339 (49.7) yes 82 (48.8) 86 (51.2) urinary tract disease no 386 (51.3) 366 (48.7) yes 39 (39.8) 59 (60.2) neurological disease no 411 (49.3) 422 (50.7) yes 14 (82.4) 3 (17.6) reproductive disease no 363 (50.1) 361 (49.9) yes 62 (49.2) 64 (50.8) immune disease no 375 (47.5) 414 (52.5) yes 50 (82) 11 (18) musculoskeletal disease no 419 (49.7) 424 (50.3) yes 6 (85.7) 1 (14.3) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article regards to physical factors, which including medical history, except for the items ; ( coronavirus disease, receiving coronavirus vaccine, history of surgical operation, drug history and drug allergy) which represented no significant difference at p≥0.05. 06 table 2-2 2 illustrates the differences between women with spontaneous abortions and pregnant women regarding medical history. there were significant to highly significant differences between the scores of the items of the woman with abortion and the pregnant woman with copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2-2: difference between case and control groups regarding physical factors (medical history) medical history case f (%) control f (%) coronavirus no 340 (51.8) 316 (48.2) yes 85 (43.8) 109 (56.2) receive corona virus vaccine no 414 (49.6) 421 (50.4) yes 11 (73.3) 4 (26.7) history of surgical operation no 360 (50.6) 352 (49.4) yes 65 (47.1) 73 (52.9) history obstetrical and gynecological surgeries no 235 (45.2) 285 (54.8) yes 190 (57.6) 140 (42.4) history of past gynecological diseases no 360 (48.5) 382 (51.5) yes 65 (60.2) 43 (39.8) drug history no 400 (49.7) 405(50.3) yes 25 (55.6) 20 (44.4) drug allergies no 414 (49.8) 418 (50.2) yes 11 (61.1) 7 (38.9) family history of chronic diseases no 268 (54.7) 222 (45.3) yes 157 (43.6) 203 (56.4) family history of spontaneous abortion (mother, sister) no 342 (45.3) 413 (54.7) yes 83 (87.4) 12 (12.6) *fissures exact test was used https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article women who had not disease, history of obstetrics and gynecology surgeries (p= 0.002 ;or:0.599; ci:0.436-0.824) times more likely expose to be spontaneous abortion, compare with women who had not history, family history of chronic diseases (p= <0.001 ;or:1.834;ci:1.336-2.518) times more likely expose to be spontaneous abortion, compare with women who had not history, family history of spontaneous abortion (p= <0.001 ;or:0.098; ci:0.050-0.193) times more likely expose to be spontaneous abortion, compare with women who had not history the predictors for spontaneous abortion. table 3 indicates that woman from suburban (p= 0.015 ;or:1.465; ci:1.077-1.992) times more likely expose to be spontaneous abortion, compare with women who had from urban, woman having extended family (p= 0.003 ;or:1.766; ci:1.2172.564) times more likely expose to be spontaneous abortion, compare with women who having nuclear family, cardiovascular diseases (p= <0.001 ;or:2.710; ci:1.636-4.483) times more likely expose to be spontaneous abortion, compare with women who had not disease, immune diseases (p= <0.001;or:0.230; ci:0.1130.466) times more likely expose to be spontaneous abortion, compare with 07 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: logistic regression analysis of spontaneous abortion with some variables variables odds ratio 95% ci p-value residential area urban reference category sub-urban 1.465 1.077-1.992 0.015 type of family nuclear reference category extended 1.766 1.217-2.564 0.003 cardiovascular diseases no reference category yes 2.710 1.636-4.483 <0.001 immune disease no reference category yes 0.230 0.113-0.466 <0.001 history obstetrical and gynecological surgeries no reference category yes 0.599 0.436-0.824 0.002 family history of chronic diseases no reference category yes 1.834 1.336-2.518 <0.001 family history of spontaneous abortion (mother, sister) no reference category yes 0.098 0.050-0.193 <0.001 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article medical conditions such as cardiovascular, urinary tract, neurological, and immune diseases. medical history such as obstetrical and gynecology surgery, gynecology disease, family history with chronic disease, and family history of spontaneous abortion are risk factors for spontaneous abortion. [1] umar nj, olubiyi sk, aliyu u, aminat gu, imam aa, ibraheem ma et al.spontaneous abortion among women admitted into gynaecology wards of three selected hospitals in maiduguri, nigeria. international journal of nursing and midwifery. 2014 apr 30;6 (2):24-31. [2] cunningham fg, leveno kj, bloom sl, spong cy, dashe js. williams obstetrics, 24e. new york, ny, usa: mcgraw-hill.2014:pp 350. [3] buzad p, mccoy tw, mularz a, dalati s, pedigo r. spontaneous abortion and recurrent pregnancy loss. ob/gyn secrets,4e. usa: elsevier.2016:pp 113. available from:https:// books.google.iq/books? hl=en&lr=&id=j8vdaaaqbaj&oi=fnd&pg=p a113&dq=buzad+p,+mccoy+tw.+spontane ous+abortion+and+recurrent+pregnancy+los s.&ots=5vgvsxp8w3&sig=mxttzevg2q0uuj vl8ghq6dwmimc&redir_esc=y#v=onepage &q&f=false [4] hu x, miao m, bai y, cheng n, ren x. reproductive factors and risk of spontaneous abortion in the jinchang cohort. international journal of environmental research and public health. 2018 nov;15(11):2444. [5] azo fm, akbay ca. prevalence and risk factors of abortion among a sample of married women in kurdistan region of iraq. zanco journal of medical sciences. 2016 dec 15;20 (3):1424_1432-. [6] moradinazar m, najafi f, nazar zm, hamzeh b, pasdar y, shakiba e. lifetime prevalence of abortion and risk factors in women: evidence from a cohort study. journal of pregnancy. 2020;2020 (4871494). [7] quenby s, gallos id, dhillon-smith rk, podesek m, stephenson md, fisher j, et al. miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. the lancet. 2021 may 1;397(10285):1658-67. the present study shows that there is a significant difference between case and control regarding medical conditions such as cardiovascular, urinary, neurological, and immune diseases and medical histories such as obstetrics diseases, gynecological surgery, gynecological diseases, family history with chronic diseases, and family history with spontaneous abortion. regarding another study, the results of the study were done by makharadze et al. (2019) disagree with our study, their study concluded that there was no difference between spontaneous abortion and medical conditions [11].regarding logistic regression in the present study sub-urban (or:1.465; ci:1.077-1.992) is the predictor for spontaneous abortion and, also having an extended family (or:1.766; ci:1.2172.564) .the study was done by zheng et al. (2017) their results disagree with our study. in their study, increased risk of spontaneous abortion in rural areas was 1.68 times greater than in urban areas (or = 1.68 ;ci: 1.54–1.84) [12].cardiovascular diseases(or:2.710;ci:1.636-4.483), immune diseases (or:0.230; ci:0.1130.466),history of obstetrics and gynecology surgeries (or:0.599; ci:0.4360.824),family history of chronic diseases (or:1.834;ci:1.336-2.518), family history of spontaneous abortion (or:0.098; ci:0.050-0.193) are the predictors for spontaneous abortion. also, a study was done by magnus et al. (2021) their results agree with our study. in their study, observed an increased risk of spontaneous abortion among women with cardiometabolic diseases (or 1.25, ci 1.20 to 1.31) [13]. the study was conducted by sunil and valsan (2020) their results disagree with our study, in their study in the family history of abortion (or:0. 79; ci 0.31-2.03) had risks for spontaneous abortion [14]. 08 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. references conclusion discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.01 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article [8] bellieni cv, buonocore g. abortion and subsequent mental health: review of the literature. psychiatry and clinical neurosciences journal. 2013 jul;67(5):301-10. [9] favre g, pomar l, musso d, baud d. 2019ncov epidemic: what about pregnancies? lancet .2020 feb 22;395(10224): e40. [10] lassi zs, imam am, dean sv, bhutta za. preconception care: caffeine, smoking, alcohol, drugs and other environmental chemical/radiation exposure. reproductive health. 2014 dec;11(3):1-2. [11] makharadze m, sulukhia r, tsiklauri m, melia l and taboridze i.risk factors for spontaneous abortion in georgian population.european scientific journal.2019;15 (33): e 18577431. [12] zheng d, li c, wu t, tang k. factors associated with spontaneous abortion: a crosssectional study of chinese populations. reproductive health. 2017 dec;14(1):1-9. [13] magnus mc, morken nh, wensaas ka, wilcox aj, håberg se. risk of miscarriage in women with chronic diseases in norway: a registry linkage study. plos medicine. 2021 may 10;18(5):e1003603. [14] sunil v, valsan sm. a study on risk factors of abortion in a tertiary care hospital in thrissur district, kerala. international journal of reproduction, contraception, obstetrics and gynecology. 2020 oct 1;9(10):4118-23. 09 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article knowledge and attitude of people about vaccination of corona virus disease in erbil city abstract background and objective: vaccine are an effective way to protect people against many infectious diseases. a variety of vaccines have been accepted against coronavirus disease (covid-19) and offered all over the world. having a good level of knowledge and individual attitude regarding vaccination can have an impact on vaccinating against covid-19. therefore, the study aimed to investigate the knowledge and attitudes about covid-19 vaccinations in erbil city. methods: community-based cross-sectional study was conducted in different areas in erbil city. a non-probability (convenience) sample was selected for 400 participants from november 1, 2021 to november 1, 2022. the survey was conducted using a structured questionnaire containing informed consent along with three sections (socio-demographic, knowledge, and attitude). data were analyzed by using descriptive statistics and chisquire to determine the level of knowledge and attitude regarding covid-19 vaccination. results: 60.8% of participants had an excellent knowledge regarding the covid-19 vaccine; education level, income status, and previously being infected with covid-19 were significantly associated with a high level of knowledge. the majority (58.5%) of participants had a positive attitude toward the covid-19 vaccine. having a history of covid-19 and income status were significantly associated with a positive attitude regarding the covid-19 vaccine. conclusion: despite the high level of knowledge and positive attitude regarding covid-19 vaccination, there is still misunderstanding and hesitancy about the covid-19 vaccine, the ministry of health must distribute and promote more health education and programs regarding covid-19 vaccination. keywords: knowledge; attitude; covid-19 vaccine, vaccination. shivan hamko rasool; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq (correspondence: shvanhawlere472@gmail.com) ibrahum hassan mustafa; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. 200 received: 11/12/2022 accepted: 08/02/2023 published: 30/11/2024 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:shvanhawlere472@gmail.com mailto:shvanhawlere472@gmail.com mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article in january 2020, who declared covid-19 a worldwide health emergency, and on 11 march 2020, this disease was characterized as a pandemic [1]. it brought billions of people into a state of quarantine during national lockdowns, especially those with mental or physical health issues, and negatively affected a range of aspects of life [2]. newly discovered covid-19 spreads mostly through contact of respiratory droplets with mucus membranes. it was also found that the virus was able to transmit via direct contact with contaminated surfaces up to 5 days after incubation and that it could stay on materials for up to 5 days depending on the type of contaminated material [3]. according to epidemiological studies, sars-cov-2 incubation lasts between 1-14 days, and the virus is also infectious in asymptomatic patients [4]. as a result of infection, some people experience kidney failure, severe pneumonia, acute respiratory syndrome, and even death [5]. there is no approved therapeutic for treating sars-cov-2 infection at this time. existing treatments usually target relieving symptoms or inhibiting the immune response. existing drugs that are known to be effective against sars-cov-2, ebola, and hiv infections are also being repurposed, but their use is being restricted to patients with severe infections [6]. various efforts are being made to suppress covid-19's transmission rate. it involves the practice of social distancing in public to discourage close contact, followed by educated hand washing to help destroy the lipid bilayer of the virus using soap, water, and 62–71% ethanol so that the virus will be less contagious. in addition to staying home, refraining from using public transportation, wearing masks, keeping a safe distance from people when in crowds, and avoiding areas with a high number of covid -19 infections, various media outlets are socializing these actions [7].a vaccine is a life-saving invention that has played a crucial role in eliminating and controlling many infectious diseases all over the world [8]. vaccination against coronavirus is considered to be the ultimate solution to controlling this disease [9]. a vaccine with high effectiveness, a long period of protection, and low adverse reactions was easily accepted by the population [10].however, this study was conducted to assess the knowledge and attitude of people regarding covid-19 vaccination. a community-based cross-sectional study was used to assess knowledge and attitude of people about covid-19 vaccination in erbil city during the period (1st november 2021 to 1st november 2022). a nonprobability (convenience) sampling technique was used to collect the data; the sample size was 400 using epiinfotm version 7 statcalc function of a population survey, with the assumption of a 95 % confidence interval, the margin of error was 5 % and the population proportion was 50%.a questionnaire was structured by researchers through a review of literature related to the subject. this questionnaire involved the following parts: part i consisted of primary data about participants, including involved sociodemographic characteristics (age, sex, residential status, educational level, occupation, marital status and economic status), family size, number of bedrooms, having a chronic disease, source of knowledge regarding covid-19 disease, history of covid-19 disease, and history of death of a member of family due to covid19 .part ii was related to assessment of the knowledge of study participants regarding covid-19 vaccinations, this part was composed of 12 201 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article the sum of knowledge assessment questions were thought of as having a positive attitude. both (males and females) aged 18 years and above were included in the study. the study proposal was formally approved by scientific and ethical committees in the college of nursing/hawler medical university code number 97 on 7th october 2021. prior to initiation of the present study, the approval from erbil governorate was secured. and the permission was taken from each participant and they were informed and explained the purpose of the study and the confidentiality of the information. data were prepared, organized and entered into a computer file; the statistical package for social science (spss, version 25) was used for data analysis to calculate the descriptive statistical analysis (frequency and percentage) and inferential statistical analysis was used to indicate the significance relationship between the participant’s demographical data (variable) with the level of knowledge and attitudes regarding preventive measures and covid19 vaccination. a p-value is a statistically significant level of ≤ 0.05. the mean age (± sd) of participants was 32.23 ± 11.74. the male: female ratio was 0.96:1 table 1 shows that the highest percentage of the study sample was 38.5% aged 18-25, followed by nearly a quarter (24.7%) aged 26-33, and only 9.3% of the study were aged 50 and more. table 1 also shows that the majority (89.2%) of the study sample was from urban areas. regarding educational level, the table shows that the highest percentage (58.3%), of the study sample graduated from institutes and colleges, followed by 26.2% who graduated from intermediate and secondary. the highest percentage of the sample (38.5%) was unemployed, followed by (26.3%) were unskilled manual workers, questions. comprehensive knowledge of the covid-19 vaccine was computed from summing up all relevant 12 knowledgerelated positive and negative question in the form of “yes” and “no” questions. respondents were asked, “vaccines are all designed to teach the body’s immune system to safely recognize and block the virus that causes the disease”. respondents who respond “yes” will score 1 and “no” responses will earn zero scores. for a negative question like (only elders should vaccinate themselves) the respondent who responds with no will score 1 and yes will score 0. the correct answer for each item was scored “1” and the incorrect answer was scored “0.” the same pattern of questioning and scoring was made for the rest of the 10 knowledge-related items. accordingly, respondents who scored less than 4 on the sum of knowledge assessment questions were thought to have poor knowledge, and respondents who scored 5 -8 on the sum of knowledge assessment questions were thought to have good knowledge. and respondents who scored above 8 on the sum of knowledge assessment questions were thought to have excellent knowledge. part iii: was related to assessing the attitudes of participants about vaccinations of covid-19.the attitude of covid-19 vaccine was computed from summing up all relevant six attituderelated ‘agree, “not certain and disagree” questions. respondents were asked, “it is necessary to encourage your relatives to get vaccine”. respondents who responded “agree” will score 2 and not certain will score 1, and a disagree response will earn zero scores. the same pattern of questioning and scoring was made for the rest of the five attitude-related items. accordingly, respondents who scored 1-6 value of the sum of attitude-related questions were thought of as having a negative attitude, and respondents who scored 7-12 value of 202 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article and only (3%) were retired. the same table shows that (58%) of the sample were married and only 3(0.7%) of the sample were divorced, as shown in table 1. table 1 also illustrated that close to two-third (66.5%) of the sample have enough income to meet their daily needs, followed by (19.5%) have enough income for daily needs. regarding family size, results show that the highest percentage (54.8%) of the sample was families consisting of 4 to 6 members, followed by close to a quarter (24.7%) of families with 7 to 9 members. table 1 shows that the majority (78.5%) of the sample live in houses with 1 to 3 bedrooms, followed by (20.2%) with 4 to 6 bedrooms in their houses. the table shows that the majority (76.5%) of the sample owned houses, and (21.3%) were rented. considering car ownership, results show that (77.2%) of the study sample owned a car. 203 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: distribution study sample according socio-demographic characteristics. variables f (%) age 18-25 154 (38.5) 26-33 99 (24.7) 34-41 65 (16.3) 42-49 45 (11.2) 50 and above total 37 (9.3) 400(100) sex male 196 (49.0) female 204(51.0) total 400 (100) residence rural 9 (2.3) urban 357 (89.2) suburban total 34 (8.5) 400 (100) education level illiterate 20 (5) primary 37 (9.2) intermediate and secondary 105 (26.2) institute and college 233 (58.3) post graduate 5 (1.3) total 400 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article 204 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: distribution study sample according socio-demographic characteristics. variables f (%) occupation unemployment 154 (38.5) retired 12 (3) unskilled manual worker 105 (26.3) skilled manual worker 89 (22.2) professional occupation total 40 (10) 400(100) marital status single 160 (40) married 232 (58) widowed divorced total 5 (1.3) 3 (0.7) 400 (100) income status inadequate for daily needs 78 (19.5) enough for daily needs 266 (66.5) extra saving total 56 (14.0) 400 (100.0) family number 1-3 70 (17.5) 4-6 219 (54.8) 7-9 99 (24.7) 10-12 12 (3) total 400 (100) number of bed room zero 1 (0.3) 1-3 314 (78.5) 4-6 81(20.2) 7-9 total 4(1) 400 (100) house ownership rented 82 (20.5) partial owned 12 (3) owned total 306 (76.5) 400 (100) car ownership rented 85 (21.3) partial owned 6 (1.5) owned total 309 (77.2) 400 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article percentage (29.3%) was hypertension, followed by 24.4% diabetes mellitus. sample who mentioned that the tv is the main source of their information, and the lowest percentage, 0.8% is from journal and newspapers. table 2 shows only (10.3%) of the study sample mentioned that they have chronic diseases; among them, the highest table 3 shows that nearly half (48.7%) of the study sample mentioned that social media is the main source of their information, followed by (28.5%) of the study 206 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: distribution of the study sample according to past medical history variables f (%) do you have any chronic disease? no 359 (89.8) yes 41 (10.2) total 400 (100) those who answered yes to have chronic disease thyroid disease 5 (12.2) dm 10 (24.4) htn 12 (29.3) htn+dm 7 (17.1) valvular heart disease 1 (2.4) psychiatric disorder receive drug 2 (4.9) asthma 3 (7.3) peptic ulcer 1 (2.4) total 41 (100) table 3: distribution the study sample according sources of knowledge variables f (%) the key source of knowledge tv 114 (28.5) medical staff 72 (18) social media 195 (48.7) relatives 16 (4) journal/newspaper 3 (0.8) total 400 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article mentioned there were died cases in their peers or families caused by covid-19. the side effects of vaccines. results show that (81% )of the sample answered false about vaccine causes infertility, and only (15.2%) of the study sample answered true for the question of whether one dose of vaccine is enough to keep prevent disease, complication, and death. table 4, illustrated that (52.3%) of the study sample had been infected by covid19, and (26.7%) of the study sample table 5 shows that the majority (89.3%) of the study sample selected the false in answering the question, which is related to only the elderly exclusively must vaccinate. the table shows that (80%) of the study sample selected a truth when they answered the question, which is related to 207 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: distribution of the study sample according to history of infection by covid-19, and family deaths by covid-19. variables f(%) have you infected with covid-19? no 191 (47.7) yes 209 (52.3) has anyone died in your family caused by covid-19? no 293 (73.3) yes 107 (26.7) total 400 (100) table 5: distribution study sample according to frequency, percentage, of knowledge in study sample n items responses f(%) 1 vaccines are all designed to teach the body’s immune system to safely recognize and block the virus that causes the disease. false 121(30.2) true 279(69.8) 2 only elders should vaccinate themselves false 357(89.3) true 43(10.8) 3 side effects from a vaccine such as a sore arm or mild fever are usually minor and temporary false 78(19.5) true 322(80.5) 4 covid-19 vaccines are weapon and could kill more people than covid-19 disease false 292(73) true 108(27) 5 covid-19 vaccines are safe for most people of 18 years and older false 179(44.8) true 221(55.2) 6 the only effective vaccine against covid-19 is pfizer vaccine false 268(67) true 132(33) 7 getting vaccinated even if you have had covid-19 means you are more likely to be protected for longer false 157(39.3) true 243(60.7) 8 vaccination increases transmission of covid-19. false 323(80.8) true 77(19.2) 9 the covid-19 vaccines are very effective at preventing serious illness, hospitalization and death false 130(32.5) true 270(67.5) 10 getting covid-19 vaccine, causes infertility false 324(81) true 76(19) 11 even if you have already had covid-19, you should be vaccinated false 157(39.2) true 243(60.8) 12 only one dose of vaccine is enough to be taken by people preventing serious illness, hospitalization and death false 339(84.8) true 61(15.2) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article knowledge related to the covid-19 vaccine. significant differences between educational levels, income status, house ownership, car ownership, have you infected with covid-19 and knowledge (p=0.024, < 0.001, 0.007, 0.007 and 0.008). table 6 shows that (60.8%) of the study sample expressed excellent overall table 7 shows that (40.25%) of participants who have an educational level between 13 to 18 years expressed excellent level, and (12.75%) of people who have between 7 to 12 years of education expressed excellent level. statistically 208 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 6: overall knowledge regarding covid-19 vaccine levels f (%) poor 59 (14.8) good 8 (24.5) excellent 243 (60.8) total 400 (100) table 7: significant association between socio-demographic characteristics and knowledge regarding covid19 vaccine in the study sample variables overall knowledge p. value poor (%) good (%) excellent (%) education level 1-6 7 (1.75) 12 (3) 18 (4.5) 0.024 s 7-12 26 (6.5) 28 (7) 51 (12.75) 13-18 22 (5.5) 50 (12.5) 161 (40.25) 19-24 0 (0) 1 (0.25) 4 (1) total 55 (13.75) 91 (22.75) 234 (58.5) income status inadequate for daily needs 22 (5.5) 23 (5.75) 33 (8.25) <0.001 vhs enough for daily needs 35 (8.75) 65 (16.25) 166 (41.5) extra saving 2 (0.5) 10 (2.5) 44 (11) total 59 (14.75) 98 (24.5) 243 (60.75) house ownership rented 22 (5.5) 22 (5.5) 38 (9.5) 0.007 s partial owned 2 (0.5) 3 (0.75) 7 (1.75) owned 35 (8.75) 73 (18.25) 198 (49.5) total 59 (14.75) 98 (24.5) 243 (60.75) car ownership rented 22 (5.5) 22 (5.5) 41 (10.25) 0.007 s partial owned 2 (0.5) 1 (0.25) 3 (0.75) owned 35 (8.75) 75 (18.75) 199 (49.75) total 59 (14.75) 98 (24.5) 243 (60.75) have you infected with covid-19? no 35 (8.75) 55 (13.75) 101 (25.25) 0.008 s yes 24 (6) 43 (10.75) 142 (35.5) total 59 (14.75) 98 (24.5) 243 (60.75) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article about the intention to get a vaccine. results show that 34.2% of the study sample disagreed about encouraging relatives to get the vaccine, and 38.2% of the study sample disagreed for the question related to the danger of the covid-19 vaccine. attitude regarding the covid-19 vaccine. table 8 shows that the highest percentage, 54.4% of the sample selected agree when they expressed their attitude in question, which is related to the covid-19 vaccine as social responsibility. the table shows that 53% of the sample agreed table 9 indicated that (58.5%) of participants have a positive 209 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 8: distribution of the study sample according to their attitudes regarding covid19 vaccine n items responses f(%) 1 it is dangerous to use covid-19 vaccine disagree 153(38.2) not certain 131(32.8) agree 116(29.0) total 400(100) 2 it is necessary to encourage your relatives to get vaccine disagree 137(34.2) not certain 129(32.3) agree 134(33.5) total 400(100) 3 it is not possible to reduce the incidence of covid-19 without vaccination. disagree 118(29.5) not certain 149(37.2) agree 133(33.3) total 400(100) 4 people being vaccinated against covid-19 will be helpful in controlling the pandemic. disagree 96(24.0) not certain 96(24.0) agree 208(52.0) total 400(100) 5 i believe that taking covid-19 vaccine is social responsibility disagree 77(19.3) not certain 105(26.3) agree 218(54.4) total 400(100) 6 i have intention to get vaccine // or i am vaccinated. disagree 135(34.7) not certain 53(13.3) agree 212(53.0) total 400(100) table 9: overall attitudes regarding covid-19 vaccine overall attitude f (%) negative 166 (41.5) positive 234 (58.5) total 400 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article have infected with covid-19 and attitudes (p=0.002, < 0.001, 0.013 and 0.001). educational level of participants, vaccine campaigns, and differences in socioeconomic, governmental and political differences. results of the present study showed that participants with higher educational levels, having cars, house ownership and have been infected with covid-19 previously were significantly more knowledgeable regarding covid-19 vaccine than other participants. likewise, a study in bangladesh [11] conducted as an online cross-sectional study to evaluate knowledge, attitude and perception table 10 shows that statistically significant differences between income status, house ownership, car ownership, knowledge regarding covid-19 vaccine results of the present study showed that the majority, 60.8% of participants had excellent information regarding the covid-19 vaccine. this finding was higher than the studies in bangladesh, ethiopia and malaysia, which were 57%, 40.8%, and 38% of their study participants who had good knowledge regarding the covid-19 vaccine [11] , [12] , [13].however, this high percentage of knowledge regarding the covid19 vaccine could be due to differences in sample size, time of the study, higher 210 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 10: significant association between socio-demographic characteristics and attitudes regarding covid19 vaccine in the study sample variables overall attitudes p. value negative (%) positive (%) income status inadequate for daily needs 45 (11.25) 33 (8.25) 0.002 s enough for daily needs 105 (26.25) 161 (40.25) extra saving 16 (4) 40 (10) total 166 (41.5) 234 (58.5) house ownership rented 50 (12.5) 32 (8) <0.001 vhs partial owned 7 (1.75) 5 (1.25) owned 109 (27.25) 197 (49.25) total 166 (41.5) 234 (58.5) car ownership rented 43 (10.75) 42 (10.5) 0.013 s partial owned 5 (1.25) 1 (0.25) owned 118 (29.5) 191 (47.75) total 166 (41.5) 234 (58.5) have you infected with covid-19? no 95 (23.75) 96 (24) 0.001 s yes 71 (17.75) 138 (34.5) total 166 (41.5) 234 (58.5) discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article participants to examine the knowledge, attitude and perception regarding covid19 vaccine, showing that the majority, 78% of participants had a positive attitude toward the covid-19 vaccine. the finding of the present study was higher than the study in ethiopia,[12] conducted an online cross-sectional study to measure awareness and attitude toward the covid-19 vaccine on 425 ethiopian people, showing that the overall score of positive attitude toward the covid-19 vaccine was 24.2% . however, the present study showed that participants with higher income status who were infected with covid-19 previously, had a significantly positive attitude toward covid-19 vaccine. this result was similar to the study in turkey,[17] which conducted a cross-sectional study among adults to find out knowledge and attitude and perception regarding the covid-19 vaccine, showing that having a previous history with covid-19 disease was significantly associated with a positive attitude regarding the covid-19 vaccine. on the contrary, [18] conducted a cross-sectional study in oman including 3000 participants to examine the knowledge and attitude regarding the covid-19 vaccine and reported that gender (being male) and people with chronic diseases were more likely to get the covid-19 vaccine than others. another study in syria,[19] conducted an online cross-sectional study on 3402 participants to examine the factors associated with intention to accept the covid-19 vaccine, showed that males were more likely to get the covid-19 vaccine that female, income status had an impact on the acceptance of the vaccine. the study also showed that younger people were more likely to accept the vaccine than older people.in india [20] conducted a webbased cross-sectional study among 3145 participants to examine the attitude toward covid-19 vaccine and showed that regarding the covid-19 vaccine showed that the level of knowledge was significantly higher among participants who stated having university/ higher levels of education. this finding is also supported by [12] which conducted a cross-sectional survey to find out awareness and attitude regarding the covid-19 vaccine showed that the mean score of knowledge regarding the vaccine was high among participants who described having college/ higher educational level. this could be due to people with a high level of education having more access to get the information and more understanding abilities will help them to know and react toward the covid19 vaccine [14],[15]. while the present study did not find a relationship between knowledge regarding the covid-19 vaccine with age or gender in palestine [16] showed that (being female, being in a younger age group, having a higher educational level and being infected with covid-19 previously were statistically significant. another study in malaysia supported the finding of the current study [13] showed that higher education level and higher income status were significantly associated with higher knowledge regarding the covid-19 vaccine. attitude regarding covid-19 vaccine the finding of the current study mentioned that 58.5% of participants had a positive attitude toward the covid-19 vaccine; this finding was in line with and slightly higher than the study in palestine,[16] which conducted a crosssectional study among 6226 participants to measure knowledge, attitude, and acceptance toward the covid-19 vaccine and reported that 55.1 of participants had a positive attitude toward the covid-19 vaccine. the result of the current study regarding attitude toward the covid-19 vaccine was lower than the study in bangladesh,[11] which conducted a web-based cross-sectional study including 1658 211 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article [1] ahmed nj, alkhawaja fz, alrawili as, almalki zs. public knowledge and attitudes toward covid-19 vaccination: a cross-sectional study. medical science. 2021;25(108):279-84. [2] rzymski p, zeyland j, poniedziałek b, małecka i, wysocki j. the perception and attitudes toward covid-19 vaccines: a cross-sectional study in poland. journal of vaccines 2021;9:382. https:// doi.org/10.3390/vaccines9040382. [3] hershan aa. awareness of covid-19, protective measures and attitude towards vaccination among university of jeddah health field community: a questionnaire-based study. journal of pure and applied microbiology 2021;15:604–12. https:// doi.org/10.22207/jpam.15.2.02. [4] olayemi l, alexabraham j, yemoh v, samuelu-matthes m. knowledge, risk perception, and preventive measures of covid-19 among medical and nursing students in samoa: a cross-sectional analysis. pacific health dialog 2021;21. https://doi.org/10.26635/ phd.2021.107. [5] nwagbara ui, osual ec, chireshe r, bolarinwa oa, saeed bq, khuzwayo n, et al. knowledge, attitude, perception, and preventative practices towards covid19 in sub-saharan africa: a scoping review. public library of science 2021;16:e0249853. https:// doi.org/10.1371/journal.pone.0249853. [6] kumar v, doshi ku, khan wh, rathore as. covid‐19 pandemic: mechanism, diagnosis, and treatment. journal of chemical technology & biotechnology 2021;96:299–308. https:// doi.org/10.1002/jctb.6641. [7] sari dk, amelia r, dharmajaya r, sari lm, fitri nk. positive correlation between general public knowledge and attitudes regarding covid-19 outbreak 1 month after first cases reported in indonesia. journal of community health 2021;46:182–9. https:// doi.org/10.1007/s10900-020-00866-0. the religion, occupation, and monthly income were the factors that affect the attitude toward intention toward the covid19 vaccine. these disparities might be attributed to the nature of the population and varying questionnaire design. limitations :the survey was conducted during the mass vaccination period in erbil city, so this may affect the results of the study. depending on the results of the present study, despite the high percentage of knowledge and positive attitude regarding covid-19 vaccination; there is still misunderstanding and less information regarding covid-19 vaccination, thirty point two percent of participants did not know about the vaccine. the present study found a significant association between participants' knowledge and their educational level, income, house ownership, and history of being infected by covid-19. the study also concluded that there was a significant association between participants’ attitudes and their income status, house ownership, car ownership, and history of being infected by covid 19. 1it is recommended that health authorities distribute and promote more accurate health education programs and information. 2by confirming adequate knowledge and positive attitudes toward covid-19 vaccinations, policy-makers can reduce vaccine hesitancy facilitated and encouraged by misinformation. there are no conflicts of interest or sources of financial support for any of the authors. 212 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion recommendations conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article a web-based cross-sectional study. journal of ideas in health 2020;3:258– 65. https://doi.org/10.47108/ jidhealth.vol3.issspecial2.59. [15] juin jcy, ern sls, min cehs, jing nk, qi mnm, hoe rcc, et al. knowledge, attitudes, and practices of covid-19 vaccination among adults in singapore: a cross-sectional study. the american journal of tropical medicine and hygiene 2022:tpmd211259. https:// doi.org/10.4269/ajtmh.21-1259. [16] al-kafarna m, matar sg, almadhoon hw, almaghary bk, zaazouee ms, elrashedy aa, et al. public knowledge, attitude, and acceptance toward covid -19 vaccines in palestine: a crosssectional study. bmc public health 2022;22:529. https://doi.org/10.1186/ s12889-022-12932-4. [17] sonmezer mc, sahin tk, erul e, ceylan fs, hamurcu my, morova n, et al. knowledge, attitudes, and perception towards covid-19 vaccination among the adult population: a cross-sectional study in turkey. journal of vaccines 2022;10:278. https://doi.org/10.3390/ vaccines10020278. [18] al-marshoudi s, al-balushi h, al-wahaibi a, al-khalili s, al-maani a, al-farsi n, et al. knowledge, attitudes, and practices (kap) toward the covid19 vaccine in oman: a pre-campaign cross-sectional study. journal of vaccines 2021;9:602. https:// doi.org/10.3390/vaccines9060602. [19] mohamad o, zamlout a, alkhoury n, mazloum aa, alsalkini m, shaaban r. factors associated with the intention of syrian adult population to accept covid19 vaccination: a cross-sectional study. bmc public health 2021;21:1310. https://doi.org/10.1186/s12889-02111361-z. [8] alle yf, oumer ke. attitude and associated factors of covid-19 vaccine acceptance among health professionals in debre tabor comprehensive specialized hospital, north central ethiopia; 2021: cross-sectional study. virus disease 2021;32:272–8. https:// doi.org/10.1007/s13337-021-00708-0. [9] usman, j., arshad, i., fatima, a., ahsan, m., minal, n. knowledge and attitude pertinent to covid-19 and willingness to covid vaccination among medical students of university college of medicine & dentistry lahore. journal of rawalpindi medical college. 31 aug. 2021; 25 covid-19 supplement-1, 61-66. doi: https://doi.org/10.37939/ jrmc.v25i1.1643. [10] jiang n, baojian wei, lin, wang, chai, liu. nursing students’ attitudes, knowledge and willingness of to receive the coronavirus disease vaccine: a cross -sectional study. nurse education in practice 2021;55:103148. https:// doi.org/10.1016/j.nepr.2021.103148. [11] islam ms, siddique ab, akter r, tasnim r, sujan msh, ward pr, et al. knowledge, attitudes and perceptions towards covid-19 vaccinations: a crosssectional community survey in bangladesh. medrxiv 2021:2021.02.16.21251802. https:// doi.org/10.1101/2021.02.16.21251802. [12] mesesle m. awareness and attitude towards covid-19 vaccination and associated factors in ethiopia: crosssectional study. infection and drug resistance 2021;volume 14:2193–9. https://doi.org/10.2147/idr.s316461. [13] mohamed na, solehan hm, mohd rani md, ithnin m, che isahak ci. knowledge, acceptance and perception on covid-19 vaccine among malaysians: a web-based survey. public library of science 2021;16:e0256110. https:// doi.org/10.1371/journal.pone.0256110. [14] jadoo saa, alhusseiny ah, yaseen sm, al-samarrai mam, al-rawi ra, aldelaimy ak, et al. knowledge, attitude, and practice toward covid-19 among 213 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article [20] leelavathy m, messaline s, ramachandran d, sukumaran a, jose r, noufel an. attitude towards covid-19 vaccination among the public in kerala: a cross sectional study. journal of family medicine and primary care 2021;10:4147– 52. https://doi.org/10.4103/ jfmpc.jfmpc_583_21. 214 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.07 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article risk factors associated with premature births in erbil city: a case-control study abstract background: premature birth is one of the major causes of mortality and morbidity among newborn babies. there are many factors that induce prematurity. this study aims to investigate the common risk factors associated with premature births in erbil city. methods: quantitative design, descriptive-analytic analysis and a retrospective study were used. the study was conducted at raparin teaching hospital for children (rthc) in erbil city from september 1st, 2021 to september 1st, 2022. to engage in the study, non -probability purposive sample of 510 mother-newborn pairs admitted to a premature intensive care unit (255 as case group, 255 as a control group) was taken. the statistical analysis program statistical package for the social sciences (spss) version 25 was used to analyze the data. results: the study reveals that the educational level, economic status, body mass index of the mother and types of delivery have a highly significant association with the mother’s socio-demographic characteristics at a p-value of 0.008, < 0.001, 0.019 and < 0.001respectively. the study found a highly differences between: risk factors during pregnancy among study and control groups, including gestational hypertension, gestational diabetes mellitus, urinary tract infection (utis), anemia, vaginal bleeding, preterm premature rupture of membranes, thyroid disease, psychological problems, infection with covid-19, polyhydramnios and oligohydramnios, at p-value of < 0.001 respectively. conclusion: the study concluded that gestational hypertension, gestational diabetes, thyroid diseases, psychological problems, covid-19, premature rapture of the membrane, polyhydramnios and oligohydramnios are the main factors behind premature births in erbil city. keywords: risk factors; premature birth; uterine hemorrhage; urinary tract infection. kurdistan hamadamin rasul; ranya general hospital, sulaymaniyah, kurdistan region, iraq. (correspondence: kurdistan.hamadamin@gmail.com) shukir saleem hasan; department of nursing, college of nursing, hawler medical university and tishk international university, erbil, kurdistan region, iraq. 68 received: 24/08/2022 accepted: 14/11/2022 published: 30/05/2024 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:kurdistan.hamadamin@gmail.com?subject=kurdistan.hamadamin@gmail.com%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.07 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article approximately 15 million babies are born preterm annually worldwide. preterm birth is the leading cause of death among children, accounting for 18% of all deaths among children aged under 5 years. 35% of all deaths among newborns ≤ 28 days [1]. south asia accounts for over 60% of preterm births worldwide, in india, 3,341,000 babies are born too early for the expected date. europe rates between (%5-%11) in unite status american %11,9 and australia %7. despite different developments, developing countries still know to have a high rate of premature birth in south africa with %15 rates of premature births, india % with 30, sudan with %31, malaysia with %10 and indonesia ranks as the fifth country with the highest preterm birth rate in the world after india, china, nigeria and pakistan[4,5].if the baby is born in the 37th week of pregnancy, the birth is regarded as early term, much like this pregnancy period categorization. and if the birth occurs between (37-39 weeks), it is regarded as a full -term pregnancy. preterm births are those that happen before the 37th week of pregnancy. it was who divided the stages of a child's birth into them [1]. world health organization for a premature baby of 37 weeks and this baby can be known by its weight that differs from the normal or normal weight of the baby and its normal weight is often (2300-2500) kg [ 1,2,3]. these studies stated that in egypt the prevalence was estimated at 4.1%, with a global prevalence of between 5% and 15%.3 the impact of the prevalence of preterm birth is greater in lowand middle-income countries, where the majority of preterm infant deaths occur [2].over 84% of preterm births occur at 32–36 weeks of gestation. only about 5% fall into the extremely preterm range of <28 weeks. the other 10% are born at 28 -32 weeks of gestation. six countries india, china, nigeria, pakistan, indonesia and the united states account for %50 (7.4 million) of the total preterm births in the world [3].the causes of premature birth include factors such as the mother's pregnancy in adolescence or older than 35 years of pregnancy[2,6]. maternal age under 20, utis, over 34 causes of preterm birth [7]. another study says young mothers (under 19 years of age) are more likely to give birth prematurely [5].the short period between one pregnancy and another, multiple pregnancies, elective cesarean section induction of labour and socioeconomic and nutritional conditions, all have an effect as those associated with the fetus such as genetic diseases, placental hemorrhage, uterine distension (twins), previous miscarriages, chronic disease such as high blood pressure, diabetes mellitus, black race and, smoking and alcohol and substance abuse during pregnancy infection and a history of placental abruption.[6]level of education, preterm birth history, premature rupture of membranes (prom), prenatal bleeding and prenatal care, maternal care, utis, anemia and iron deficiency[5,8]. some risk factors such as gender babies especially among males [9]. anemia during pregnancy, socioeconomic status, housing condition, sanitation, number of siblings, quality of medical care, immune system, urinary tract infection (utis), low birth weight and prematurity .[10] the social environment, abnormal structure of the uterus especially cervical insufficiency, lifestyle conditions, such as stress, hard work, smoking, short interval between pregnancy, low maternal weight, or low bmi, uterine overdistention with pregnancies increased risk of preterm birth approximately %25, more than half are related to preeclampsia, chronic fetal distress, abruption placenta and placenta insufficiency [11]. vaginal bleeding, 69 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.07 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article population, e= the alpha-error of 0.05. mothers who admitted the hospital with both premature and full-term babies, mothers who are willing to participate in the study, babies aged less than 28 days of life are admitted to the hospital (case and control), premature neonates who are admitted to the hospital and give birth before 37 weeks of gestational age, full-term neonates who are admitted to the hospital and labor for 37 weeks of gestational age, were included. verbal permission was obtained from the mothers before starting the interview. the tool did not consisting of personal information such as personal phone numbers, addresses, or other personal information and the researcher promised to keep the data for confidentiality and anonymity. the questionnaire included the following parts: part one: the socio-demographic data related to premature births. part two: sociodemographic characteristic of the mother: part three: assessment of risk factors during pregnancy. to assess the risk factors during pregnancy, 14 risk factors had been raised. the ratings included 1 for yes (have) and 2 for no (haven’t). the validity of the questionnaire was evaluated by the experts. internal consistency reliability was determined and measured by applying pearson correlation (r) and this was 0.81. the pilot study was conducted on 10 mothers. the data were analyzed using statistical package for the social sciences (spss) software for statistical analysis, version 25, for calculating descriptive statistical analysis (frequency and percentage). inferential statistical analysis (chi-square), (fisher's exact test) were used to identify the association between dependent and independent variables, mann-whitney u was used because the data was not normally distributed, to find out the differences between case and control groups, and regression was used to determine the history of previous preterm birth, previous or premature rupture membrane, history of chronic disease (e.g., neonate disease), lifestyle behavior and marital status [3]. the complications of premature birth that leads to maternal death and fetal death complications are major causes of morbidity and mortality including infection and fetal distress, hemorrhages such as intravascular, respiratory problems such as chronic lung disease, growth and development retardation.[2] a neurological problem such as visual and hearing problems retinopathy (deafness, blindness), severe cerebral palsy, mental retardation, sensory disturbances, hydrocephalus, learning difficulties, language, motor disabilities, cognitive delay and behavioral problem [5]. according to the official census, which has been recorded in raparin teaching hospital for children in erbil city/ iraqi kurdistan region, more than 4320 cases were admitted to nicu and around 700 were preterm babies official census during the first seven months of 2021 (raparin teaching hospital for children census erbil city iraqi kurdistan region between 1st of jan. to 1st of july 2021). the aim of the study was to explore the prevalence and risk factors associated premature babies admitted to raparin teaching hospital or pediatric. a case-control study design was conducted at the neonatal intensive care unit in raparin teaching hospital for children (rthc) in erbil city. starting on the 1st of september 2021 and ended to the 1st of september 2022. a convenience non -probability (purposive) sample of 510 mothers and their admitted premature births (255 as a case group, 255 as a control group) were recruited to participate in the study. the sample size has been estimated and determined using the yamane formula . where as: n= the sample size. n= the size of the 70 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.07 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article main factors associated with premature births. the p-value is considered statistically significant if it's ≤ 0.05 which rejects the null hypothesis. it shows that more than half (74.5%) of babies in the study group were less than 2500gm, while 74.11% in the control group were between 2500-4500 gm. a highest percentage (88.6% vs 94.1%) of premature babies in the control group and the control were singleton. concerning the gestational age, the study shows that more than half (59.2%) of the participants in the study group were between 32-36 weeks and all of the participants in the control group were between 37-42 weeks. half (51.0%) of the study group had a birth in public hospitals vs. 63.5% in (the control group) 63.5% had a birth in a privet hospital and also only (3.5%) of the study groups had a birth at home. concerning the gender of neonates, the study shows more than half (54.9%) of premature babies were male, while half (53.7%) of the control group were female. regarding the birth order, the study shows that one-third (38.0% and 45.1%) of the groups’ babies were between 1-2 birth order groups (table1). 71 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result table 1: demographical characteristics of the babies in the study group and control groups. case and control groups biographical characteristics of the babies case f. (%) control f. (%) weight at birth (gram) < 2500 190(74.5) 0(0) 2500-4500 65 (25.4) 189(74.1) > 4500 0(0) 66(25.8) type of pregnancy singleton 226(88.6) 240(94.1) twin and more 29(11.4) 15(5.9) gestational age (weeks) < 28 18(7.1) 0(0) 28-32 86(33.7) 0(0) 32-36 151(59.2) 0(0) 37-42 0(0) 255(100) place childbirth public hospital 130(51.0) 93(36.5) privet hospital 116(45.5) 162(63.5) home 9(3.5) 0(0) gender male 140(54.9) 118(46.3) female 115(45.1) 137(53.7) birth order (groups) 1 – 2 97(38.0) 115(45.1) 3 – 4 92(36.1) 89(34.9) < 4 66(25.9) 51(20) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.07 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 72 lives between urban and rural areas. more than two-thirds (78.4% and 89.8%) of both groups live in the middle-income economic status. concerning the body mass index (bmi) of mothers, the study shows that one-third 38.4% in the study group were overweight, while less than half (43.5%) in the control group had a healthy weight. in both groups, more than half (53.7% and 54.1%) delivered their baby by c/s respectively (table 2). the current study found that less than half (38% and 41.2%) in both groups were between 20 and 30 years old. around onethird; (33.7%) of participants in the study were illiterate, while 29% in the control group were able to read and write. a majority (89.8% vs. 84.3%) in both groups were housewives. half (56.9%) of the study group participants lived in rural areas, while half (49.4% and 50.6%) of participants in the control group shared their copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: socio-demographical characteristics of the mothers (study and control) n= 510 mother’s socio-demographical characteristics case f (%) control f (%) age of mother < 20 14(5.5) 7(2.7) 20-30 97(38) 105(41.2) 31-40 87(34.1) 93(36.5) 41-50 57(22.4) 50(19.6) educational status illiterate 86(33.7) 56(22) able to read and write 67(26.3) 74(29) primary school 34(13.3) 59(23.1) secondary school 28(11) 23(9) institute 15(5.9) 19(7.5) college 22(8.6) 24(9.4) postgraduate 3(1.2) 0(0) occupational status government employee 20(7.8) 29(11.4) privet employee 5(2.0) 10(3.9) self-employee 0(0) 0(0) student 1(0.4) 1(0.4) housewife 229(89.8) 215(84.3) economic status low 53(20.8) 26(10.2) middle 200(78.4) 229(89.8) high 2(0.8) 0(0) residency area urban 110(43.1) 126(49.4) rural 145(56.9) 129(50.6) bmi of mother underweight below 18.5 6 (2.4) 2(0.8) healthy weight 18.5-24.9 83 (32.5) 111(43.5) overweight 25-29.9 98 (38.4) 95(37.3) obese 30 and above 68 (26.7) 47(18.4) type of delivery vaginal delivery with episiotomy 118(46.3) 117(45.9) cesarian section 137(53.7) 138(54.1) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.07 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article economic status, bmi of the mother and types of delivery at a p-value of 0.008, < 0.001, 0.019 and < 0.001respectively (table 3). 73 the results shows that there is a highly significant association between case and control concerning educational level, copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: association between mothers’ socio-demographical characteristics and both case and control groups. case and control mother’s socio demographical characteristics case f (%) control f (%) test value p-value (chi-square) age of mother < 20 14(5.5) 7(2.7) 3.308 0.347 (ns) 20-30 97(38.0) 105(41.2) 31-40 87(34.1) 93(36.5) 41-50 57(22.4) 50(19.6) educational status illiterate 86(33.7) 56(22) 17.454 0.008 (hs) able to read and write 67(26.3) 74(29) primary school 34(13.3) 59(23.1) secondary school 28(11) 23(9) institute 15(5.9) 19(7.5) college 22(8.6) 24(9.4) postgraduate 3(1.2) 0(0) economic status low 53(20.8) 26(10.2) 14.151 0.001 (hs) middle 200(78.4) 229(89.8) high 2(0.8) 0(0) residency area urban 110(43.1) 126(49.4) 2.019 0.155 (ns) rural 145(56.9) 129(50.6) bmi of mother underweight below 18.5 6 (2.4) 2(0.8) 9.923 0.019 (s) healthy 18.5-24.9 83 (32.5) 111(43.5) overweight 25-29.9 98 (38.4) 95(37.3) obese 30 and above 68 (26.7) 47(18.4) type of delivery vaginal delivery (with episiotomy) 118(46.3) 117(45.9) 0.008 0.001 (hs) c/s 137(53.7) 138(54.1) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.07 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article (2% vs < 0.001), utis (98% vs 51.4%), anemia (37% vs < 0.001), vaginal bleeding (52.5% vs 8.2%), premature rupture of membrane (prom) (14.5% vs < 0.001), psychological problems (13.3% vs 4.7%), covid-19 (45.5% vs 7.8%), polyhydramnios (31% vs 1.6%) (table 4). bleeding (0.53 vs 0.05), prom 0.15 vs < 0.001), psychological problems ( 0.13 vs 0.05), infection with covid-19 (0.45 vs 0.08), polyhydramnios (0.15 vs 0.02), oligohydramnios (0.31 vs 0.02), placenta previa (0.01% vs < 0.001) at a p-value of 0.000, 0.025, 0.002 respectively (table 5). 74 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. concerning the risk factors associated with remature births, the current results reveal that the mothers in control vs. study groups omplained the following factors: gestational hypertension (18.8% vs < 0.001), gestational diabetes mellitus, the current study found that there are highly significant differences between the means of the risk factors among study and control group such as; gestational hypertension (0.19 vs. < 0.001), gestational diabetes mellitus (0.02 vs < 0.001) utis (0.98 vs 0.51), anemia ( 0.38 vs < 0.001), vaginal table 4: assessment of risk factors among mothers during pregnancy in both groups (study and control). study and control risk factors during pregnancy study. n.255 control. n. 255 yes f. (%) n0 f. (%) yes f. (%) n0 f. (%) gestational hypertension 48 (18.8) 207(81.2) 0 (0) 255 (100) gestational diabetes 5 (2) 250 (98) 0 (0) 255 (100) uti 250 (98) 5 (2) 131 (51.4) 124 (48.6) anemia 96 (37.6) 159 (62.4) 0 (0) 255 (100) vaginal bleeding 134 (52.5) 121 (47.5) 21 (8.2) 234 (91.8) premature rupture of membrane (prom) 37 (14.5) 218 (85.5) 0 (0) 255 (100) psychological problems 34 (13.3) 221 (86.7) 12 (4.7) 243 (95.3) infected with coronaviruses 116 (45.5) 139 (54.5) 20 (7.8) 235 (92.2) polyhydramnios 39(15.3) 216 (84.7) 4 (1.6) 251 (98.4) oligohydramnios 79 (31) 176(69) 4 (1.6) 251 (98.4) placenta previa 2 (0.8) 253(99.2) 0 (0) 255 (100) table 5:comparison between means of risk factors between case and control during pregnancy. during pregnancy case normal p-value ⸸ mean (%) mean (% gestational hypertension 0.19 (19) 0.00 (0) 0.001 (hs) gestational diabetes mellitus 0.02 (2) 0.00 (0) 0.0250 (s) uti 0.98 (98) 0.51 (51) 0.001 (hs) anemia 0.38 (38) 0.00 (0) 0.001 (hs) vaginal bleeding 0.53 (53) 0.08 (8) 0.001 (hs) premature rupture of membrane 0.15 (15) 0.00 (0) 0.001 (hs) psychological problems 0.13 (13) 0.05 (5) 0.001 (hs) infected with coronaviruses 0.45 (45) 0.08 (8) 0.001 (hs) polyhydramnios 0.15 (15) 0.02 (2) 0.001 (hs) oligohydramnios 0.31 (31) 0.02 (2) 0.001 (hs) placenta previa 0.01 (1) 0.00 (0) 0.157 (ns) ⸸ by mann-whitney u https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.07 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article and a significant association between premature births and the factors such as place of childbirth, singleton and type of delivery at p-values of 0.024, 0.031 and 0.044 respectively table 6). preterm gestational ages were intermediate to late preterm range [13]. the result confirmed by a brazilian researcher named maria reveals that 84.4% of preterm gestational ages were between mild and late preterm [14]. in india, far more data was collected, finding that 93.9% of preterm newborns were between mild and late preterm [15].half of the women in the study group gave birth at a public hospital, while more than half of the neonates in the control group were delivered to a private hospital. private hospitals appear to have prioritized childcare above state hospitals. the findings are inconsistent with data from brazil, which found that 79.1% of preterm newborns were delivered in government institutions [14]. in terms of neonatal gender, the study stated that the study found that the place of childbirth, singleton and types of delivery, were the main risk factors behind prematurity and revealed a highly significant association at p-value of 0.000, 0.006 respectively the current study discovered that twothirds of preterm babies were less than 2500gm, which is consistent with the findings of a study in india and discovered that the majority of premature births were less than 2500gm [12]. the majority of preterm newborns were delivered less than 2.500 grams [13]. the current study found that the majority of babies in both cases and control groups were singleton babies. this result is in agreement with casecontrol research, which found that most newborns were singleton babies [14].moreover, the result reveals that half of the participants were ntermediate to late preterm babies, with gestational ages ranging from 32 to 36 weeks. according to a study which studied the factors behind prematurity in basra city of iraq, most 75 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion table 6: assessment of risk factors during prenatal stage (during pregnancy). coefficients main risk factors unstandardized coefficients standardized coefficients t-value p-value b std. error beta (constant) 8.265 0.847 9.75 < 0.001 gestational age -1.419 0.107 -0.676 -13.2 < 0.001 economic status -1.006 0.244 -0.230 -4.12 < 0.001 type of family 0.803 0.218 0.202 3.68 < 0.001 age of mother -0.298 0.108 -0.140 -2.75 0.006 place childbirth 0.384 0.169 0.116 2.27 0.024 single and twin -0.758 0.348 -0.111 -2.17 0.031 type of delivery 0.368 0.182 0.102 2.02 0.044 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.07 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article the indian research, which stated that (58% and 39%) of mothers were poor [18]. moreover, it is not supported by a study which described that the majority of cases were of low socioeconomic status [13]. moreover, a study confirmed that (54% and 57%) of mothers live in rural areas [18]. more than half of the study group individuals resided in rural regions, whereas half of the control group participants split their time between urban and country locations. the majority (62% of mothers who had preterm infants) resided in rural areas. [13]. aside from their quality of life, the study found that one-third of the mothers in the study group were overweight, compared to 43.5% in the control group [19]. on the other hand, the present study is corroborated by a brazilian study that discovered that 20.5% of mothers were overweight and 64% of mothers were healthy [14]. according to china, 20.7% of the mothers were of normal weight [20]. a non-significant link was identified between the age of the mothers in the case and control groups, there was disagreement between our findings and investigations verified that teenagers above the age of 35 are at risk of preterm [2,6,7,5]. while the study discovered a strong relationship between case and control in terms of educational level, economic position, mother's bmi and manner of delivery, prematurity may be caused by a lack of knowledge [5,8], others added the economic status of the family [10], low maternal weight, or low bmi, multiple pregnancies[11], elective cesarean sections, induction of labor and socioeconomic and nutritional conditions [6].concerning the risk factors associated with premature births, the current findings show that mothers in both the control and study groups complained about the following: gestational hypertension, gestational diabetes millitus, utis, anemia, vaginal bleeding, prom, psychological problems, more than half of preterm newborns were male. the findings contradicted research that found 45.1%) were male and 54.9% were female [7]. a study confirmed that were 23.2 males and 21.3 females [16]. in terms of birth order, the study found that more than one-third of both groups had a birth order between 1 and 2. onequarter in case group versus two third in the control group of babies were in second and more birth orders [7], while a study done in bangladeshi showed that (24.3%) of birth orders were within fourth and more[16].fewer than half of the findings contradict the findings of a study which conducted in southern india, which discovered that the majority of mothers were between the ages of 20 and 34 years old [12]. moreover, another study found that 75% of caregivers were < 22 years [15]. regarding the participant’s level of education, the current study found that onethird of participants in the study group were illiterate, whereas one quarter of the mothers in the control group could read and write. the results corresponded with a survey conducted in bangladeshi, which stated that a large number of mothers graduated from basic and secondary school [16]. while disagreeing with iranian research which was conducted in yazd, (iran) stated that 12% of mothers were illiterate [17]. while, a survey conducted in 2018, reported that 61% of mothers have an elementary school education and 10% are illiterate [13].according to the current study, the majority of the participants in both the study and the control groups were housewives. this finding is consistent with research conducted in basra , iraq, which discovered that 89% of mothers were housewives [13].in terms of economic standing, the majority of participants in both groups (study and control) (78.4% and 89.8%) were in the middle. the study disagrees with the findings of 76 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.07 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article among 64.2% of full-term newborns and 73.5% of preterm infants [21,1,12,4]. two comparable studies in india discovered that mothers who had preterm babies complained of anemia during pregnancy [22,12]. a case-control study conducted in southern indian revealed that the mothers who gave birth prematurely complained of prom [21,12].according to the research, mothers had psychological issues during their pregnancies. in contrast, two comparative studies in indonesia and india found that pregnant stress causes preterm birth. [5,12].a recent investigation demonstrated that mothers infected with covid19 during pregnancy had babies born prematurely. descriptive statistical research indicated that covid-19-associated mortality increased to 10% of overall deaths, while preterm mortality increased. [23]. a recent investigation demonstrated that mothers infected with covid-19 during pregnancy had babies born prematurely. descriptive statistical research indicated that covid-19-associated mortality increased to 10% of overall deaths, while preterm mortality increased. [24]. the study found that polyhydramnios was a cause of preterm birth. this outcome is comparable to that of a study. [3,21,12]. polyhydramnios was one of the primary causes of preterm birth.risk factors during prenatal stage (during pregnancy).the study found that the place of childbirth, singleton, and types of delivery, were the main risk factors behind prematurity, and revealed a highly significant association with prematurity respectively, and a significant association between premature births and the factors such as place of childbirth, singleton, and type of delivery. the study reported a highly significant association with prematurity regarding hypertension [3,25,26]. gestational diabetes mellitus [27]. utis [19,25]. vaginal bleeding [13]. premature rupture of membrane covid-19 and polyhydramnios. the current study discovered highly significant differences in the means of risk factors among study and control groups, such as gestational hypertension, gestational diabetes mellitus, utis, anemia, vaginal bleeding, prom, psychological problems, infection with covid-19, polyhydramnios, oligohydramnios and placenta previa. the primary risk factors related to preterm births in the erbil-iraqi kurdistan region. the factors, such as pre-eclampsia [18]. premature pre-labor membrane rupture, a history of preterm deliveries, an iud, genitourinary infections, polyhydramnios or oligohydramnios, chronic conditions such as high blood pressure, diabetes mellitus, black race, smoking and alcohol usage and substance misuse during pregnancy infection, as well as a history of placental abruption[6]. premature rupture of membranes, prenatal bleeding and prenatal care. maternal care. anemia and iron deficiency [5,8]. anemia during pregnancy [10]. preeclampsia, chronic fetal distress, abruption placenta and placenta insufficiency .[11]vaginal bleeding, lifestyle behavior and marital status [3]. utis and fetal distress, hemorrhages such as intravascular [2]. a case-control study that included preeclampsia mothers in a case-control of southern india reported that preeclampsia induced prematurity [12]. the study grees with the results of a casecontrol study, which was carried out in brazil and referred to 6.7 % of cases and 15.4% of control [14]. 8.4% vs. 8.1% in southern india [12].urinary tract infection [19, 13]. according to a study carried out in liverpool, the united kingdom, and retrospective research in india, which recruited 154 cases and 334 as a control groups, 28.41% of the participants in case groups had anemia, and a case-control study conducted in southern india found 2.0% cases and 2.0% controls. anemia was seen 77 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.07 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article [6] victora jd, silveira mf, tonial ct, victora cg, barros fc, horta bl, et al. prevalence, mortality and risk factors associated with very low birth weight preterm infants: an analysis of 33 years. jornal de pediatria. 2020 jun 29; 96:327-32. [7] mohammad k, abu dalou a, kassab m, gamble j, creedy dk. prevalence and factors associated with the occurrence of preterm birth in i rbid governorate of j ordan: a retrospective study. international journal of nursing practice. 2015 oct;21(5):505-10. [8] hakem h, abdalla s, tanyous e. prevalence and risk factors of preterm births in the national ribat university teaching hospital, north sudan, january to april 2012. obstet gynaecol int j. 2015;2(1):27-9. [9] monica nf, pamela s, juan ql, li j. recent understanding of pathophysiology, risk factors and treatments of neonatal respiratory distress syndrome: a review. sci lett. 2017;5 (1):70-8. [10] ferri c, procianoy rs, silveira rc. prevalence and risk factors for iron-deficiency anemia in very-low-birth-weight preterm infants at 1 year of corrected age. journal of tropical pediatrics. 2014 feb 1;60(1):53-60. [11] mwansa k, ahmed y, vwalika b. prevalence and factors associated with spontaneous preterm birth at the university teaching hospital, lusaka zambia. medical journal of zambia. 2020 may 13;47(1):48-56. [12] rao cr, de ruiter le, bhat p, kamath v, kamath a, bhat v. a case-control study on risk factors for preterm deliveries in a secondary care hospital, southern india. international scholarly research notices. v.2014;2014. [13] al-assadi af, al-haroon ds, al-rubaye a, abdul-rahman ba. risk factors and neonatal outcome among preterm birth at basrah central hospitals. the medical journal of basrah university. 2018 dec 1;36(2):87-96. [14] forero r, nahidi s, de costa j, mohsin m, fitzgerald g, gibson n, et al. application of four-dimension criteria to assess rigour of qualitative research in emergency medicine. bmc health services research. 2018 dec;18 (1):1-1. [15] ahankari a, bapat s, myles p, fogarty a, tata l. factors associated with preterm delivery and low birth weight: a study from rural maharashtra, india. f1000research. 2017; 6:72 last updated: 08 may 2017. [25,27]. placenta previa [5,20]. the study concluded that preterm was associated with mothers who had prenatal hypertension, gestational diabetes melllitus, utis, anemia, prom, psychiatric disorders, covid-19, polyhydramnios and oligohydramnios. the authors would like to express their heartfelt gratitude to all the mothers who participated in the study. the study will approve by the ethical committee / college of nursing – hawler medical universityerbil. the authors (s) report no conflict of interests. [1] alijahan r, hazrati s, mirzarahimi m, pourfarzi f, hadi pa. prevalence and risk factors associated with preterm birth in ardabil, iran. iranian journal of reproductive medicine. 2014 jan;12(1):47. [2] hosny ae, fakhry mn, el-khayat w, kashef mt. risk factors associated with preterm labor, with special emphasis on preterm premature rupture of membranes and severe preterm labor. journal of the chinese medical association. 2020 mar 1;83(3):2807. [3] hanif a, ashraf t, pervaiz mk, guler n. prevalence and risk factors of preterm birth in pakistan. j pak med assoc. 2020 apr 1;70 (4):577-82. [4] van den broek nr, jean-baptiste r, neilson jp. factors associated with preterm, early preterm and late preterm birth in malawi. plos one. 2014 mar 3;9(3): e90128. [5] hidayat zz, ajiz ea, krisnadi sr. risk factors associated with preterm birth at hasan sadikin general hospital in 2015. open journal of obstetrics and gynecology. 2016;6(13):798. 78 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion acknowledgement ethical consideration conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.07 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article [26] xi c, luo m, wang t, wang y, wang s, guo l, lu c. association between maternal lifestyle factors and low birth weight in preterm and term births: a case-control study. reproductive health. 2020 dec;17(1):1-9. [27] aseidu ek, bandoh da, ameme dk, nortey p, akweongo p, sackey so, afari e, nyarko km, kenu e. obstetric determinants of preterm delivery in a regional hospital, accra, ghana 2016. bmc pregnancy and childbirth. 2019 dec;19(1):1-8. [16] shah r, mullany lc, darmstadt gl, mannan i, rahman sm, talukder rr, et al. incidence and risk factors of preterm birth in a rural bangladeshi cohort. bmc pediatrics. 2014 dec;14(1):1-1. [17] alijahan r, hazrati s, mirzarahimi m, pourfarzi f, hadi pa. prevalence and risk factors associated with preterm birth in ardabil, iran. iranian journal of reproductive medicine. 2014 jan;12(1):47. [18] mahajan a, magon s. study of risk factors for preterm births in a teaching hospital: a prospective study. international journal of medical and dental sciences. 2017 jan 1:1407-12. [19] soundarajan p, muthuramu p, veerapandi m, mariappan r. retrospective study factors related to preterm birth in government raja mirasudar hospital and obstetric and perinatal outcome. international journal of reproduction, contraception, obstetrics and gynecology. 2016 sep 1;5(9):3006-11. [20] chen s, zhu r, zhu h, yang h, gong f, wang l, et al. the prevalence and risk factors of preterm small-for-gestational-age infants: a population-based retrospective cohort study in rural chinese population. bmc pregnancy and childbirth. 2017 dec;17(1):1-8. [21] kuppusamy n, vidhyadevi a. prevalence of preterm admissions and the risk factors of preterm labor in rural medical college hospital. international journal of scientific study. 2016;4(9):123-6. [22] frey ha, klebanoff ma. the epidemiology, etiology, and costs of preterm birth. inseminars in fetal and neonatal medicine 2016 apr 1 (vol. 21, no. 2, pp. 68-73). wb saunders. [23] vasishtha g, mohanty sk, mishra us, dubey m, sahoo u. impact of covid-19 infection on life expectancy, premature mortality, and daly in maharashtra, india. bmc infectious diseases. 2021 dec;21(1):1-1. [24] zamaniyan m, ebadi a. aghajanpoor mir s, rahmani z, haghshenas m, azizi s (2020) preterm delivery in pregnant woman with critical covid-19 pneumonia and vertical transmission. prenat diagn.; 40(13): 1759– 1761. [25] wagura p, wasunna a, laving a, wamalwa d, ng’ang’a p. prevalence and factors associated with preterm birth at kenyatta national hospital. bmc pregnancy and childbirth. 2018 dec;18(1):1-8. 79 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.11 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article lifestyle factors and symptoms of gastroesophageal reflux disease: a cross-sectional study abstract background and objectives: gastroesophageal reflux disease (gerd) is a condition characterized by heartburn and acid regurgitation without signs of oesophagal mucosal injury on one hand, and erosive oesophagitis and barrett's oesophagus consequences like oesophagal cancer on the other. the aim of this study was to explore the involvement of different lifestyle-related factors in the aetiology of symptomatic gerd. methods: in this cross-sectional study, 79 patients (28 men and 51 women) aged between 20-68 years old were recruited randomly through a direct interview between january to october 2021, and they were prescribed proton pump inhibitors. prior to starting this study, the approvals had been granted by the ethics committee and oral consent was gained from the participants. a questionnaire was designed and consisted of demographic and clinical characteristics regarding gerd. statistical analysis was done using spss version 25 for describing frequencies and percentages, followed by chisquare and fisher’s exact tests as inferential statistical analysis for finding associations between variables. results: among the total of 79 patients with gastroesophageal reflux disease, the findings indicated that more than half of the study sample (58.2%) were overweight and obese (26.6% and 31.6% respectively), and the heavy smokers made the highest percentage among smokers (19%). there was a statistically significant association between gender and smoking and bmi among gerd patients (p-value = 0.001 and < 0.001 respectively). there was a very highly significant association between bmi and heartburn and nausea and vomiting (p-value = 0.001 for both), while there was a non-significant association between bmi and chest pain, cough, and sleep pattern disturbance (p-value = 0.324, 0.558, and 0.907 respectively). conclusion: a higher bmi and smoking are associated with a higher likelihood of gerd symptoms. keywords: lifestyle factors; gastro-esophagus reflux disease; population-based study. asmaa awni haydar; college of pharmacy, hawler medical university, kurdistan region, iraq. muzhda haydar saber; department of medical analysis, faculty of applied sciences, tishk international university, erbil, kurdistan region, iraq. goran noori saleh; department of nursing, faculty of nursing, tishk international university, erbil, kurdistan region, iraq. dara abdulla al-banna; department of nursing, faculty of nursing, tishk international university and hawler medical university, erbil, kurdistan region, iraq. (correspondence: dara.abdulla@tiu.edu.iq) 98 received: 24/05/2022 accepted: 27/09/2022 published: 30/11/2022 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:dara.abdulla@tiu.edu.iq https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.11 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article gastroesophageal reflux disease (gerd) or acid reflux occurs when the liquid content of the stomach regurgitates (backs up or refluxes) into the oesophagus. gerd is a long-term illness. it usually lasts a lifetime once it starts. heartburn, regurgitation, and nausea are symptoms of simple gerd [1]. a condition in which the refluxdamaged epithelium of the oesophagus is replaced by metaplastic columnar epithelium is known as barrett's oesophagus (be) and has been hypothesized as the end consequence of a stepwise disease process that transitions through gerd and oesophageal adenocarcinoma [2]. gastroesophageal reflux disease (gerd) is particularly frequent in asians, with prevalence rates ranging from 50 to 70% [3]. endoscopic evaluation of oesophagal mucosal changes in patients with reflux symptoms is essential for diagnosing patients with varying degrees of severity [4]. many studies have looked at the relationship between gerd and risk factors like age, gender [4-5,] bmi, and obesity, but there have been few large -scale studies focusing solely on gerd symptoms. because gerd is such a common disease that affects millions of individuals all over the world, it is critical to understand the underlying lifestyle variable that causes varied gerd symptoms [6]. this gender differential in the spectrum of gerd has previously been linked to sex steroid hormones, albeit little is understood about the mechanism behind it, according to several epidemiologic studies, the prevalence of gerd in women is strongly associated with reproductive status, implying a probable link with estrogen levels [7]. the inactivation of mast cells by the anti-inflammatory activity of estrogen may account for the gender difference in the gerd spectrum. other research has investigated the role of female steroid [2]. hormones in the gender gap in these disorders, while obesity is a major risk factor for gerd, and estrogen has been shown to influence fat metabolism. furthermore, smoking is associated with an increased risk of gerd in the elderly [8]. acidic foods, the amount and timing of meals as well as a lack of sleep can all contribute to gerd symptoms [9]. lifestyle factors such as smoking, being overweight or obese, and eating late at night have been linked to an increased risk of developing gastroesophageal reflux disease (gerd) [10]. people who eat spicy foods and sleep on their left side are more likely to get gerd. excessive painkiller usage, eating in between meals, drinking too much coffee, and taking unneeded drugs can all cause gerd [11]. also, gerd was found to be associated with meals before bedtime in past studies [12]. endoscopic observation can detect reflux esophagitis (re) and non-erosive reflux disease (nerd), two pathological stages of gastroesophageal reflux disease (gerd) (nerd, mainly diagnosed based on upper gastrointestinal symptoms). according to most studies, nerd patients make up more than half of all gerd patients [13]. in a study that used a newly developed and validated gerd questionnaire with an interview-based observational study to standardize the symptom-based diagnosis and evaluate treatment response in patients with gerd showed that a total of six symptoms, four positive and two negative predictors, were used to evaluate the frequency of gerd, the positive predictors included heartburn and regurgitation, as well as sleep disturbance, and the use of additional over-the-counter medication; while the negative predictors included pain or discomfort in the stomach and nausea [14]. when the normal symptoms of heartburn and regurgitation were combined with endoscopic evidence of esophagitis, gerd was identified. 99 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.11 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article process was not completed. a questionnaire was designed as a tool for data collection and consisted of two main parts. part one included some demographic characteristics like age, gender, body mass index based on weight and height, and current smoking status. part two included clinical characteristics regarding gerd such as heartburn, chest pain, cough, nausea, vomiting, and disrupted sleep patterns. statistical analysis was conducted using spss version 25 computer software “statistical package for social sciences”. the quantitative data were described by frequency and percentage. the inferential statistical analysis was assessed by using chi-square and fisher’s exact tests. the pvalue was considered significant at ≤ 0.05. the study enlisted the participation of 79 patients with gastroesophageal reflux disease. table 1 shows some demographic characteristics of the study sample. the majority of the study sample was between 30-39 and 40-49 years old (26.6% and 25.3% respectively). males made up 35.44% of the overall sample, while females made up 64.56% of the participants. regarding the body mass index, more than half of the study sample (58.2%) were overweight and obese (26.6% and 31.6% respectively). furthermore, half of the participants were light smokers (7.6%), moderate smokers (11.4%), heavy smokers (19%) and shisha smokers (10.1%). heavy smokers made the highest percentage among smokers (19%). table 2 shows the association between patients in each bmi category with age, gender, and smoking. a non-significant difference was found between age and bmi among gerd patients. there was a statistically significant association between gender and smoking with the bmi among gerd patients (p-value = 0.001 and < 0.001 respectively). patients who exhibited symptoms of reflux esophagitis and had been treated with proton pump inhibitors (omeprazole 20 mg twice daily) for 14 days were deemed to have gerd in the same external environment (e.g. similar time of sleep, daily activity, etc) so it has been suggested that the association with regular protein pump inhibitor (ppi) use was the result of indication bias, i.e., the relationship was due to the fact that regular ppi use was more common in patients with more severe gerd [15]. the aim of this study was to explore the involvement of different lifestyle-related factors in the aetiology of symptomatic gerd in those treated with proton pump inhibitors. this cross-sectional study was conducted between january to october 2021. the 79 patients (28 men and 51 women) aged between 20-68 years old were recruited randomly in the department of gastroesophageal reflux disease at rizgary teaching hospital in erbil city, kurdistan region of iraq between february and june 2021. the data were collected through a direct interview (face-to-face) method of approximately 45 minutes duration with each participant. they were prescribed proton pump inhibitors by their physicians. formal approval was obtained by the ethical committee of the college of pharmacy, hawler medical university under the code hmupe 461 on 24th january 2021 and carried out in compliance with the ethical standards. before the explaining purpose of this study to each participant, informed oral consent was obtained from each of them. the researchers guaranteed to keep the patient's information confidential and use the data for this study only. in addition to the above, the researcher told each participant that participation was voluntary, and he or she could leave at any time even if the 100 results methods copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.11 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article 101 table 1: demographic characteristics of the study sample demographic characteristics f. (%) age group (years) 20-29 30-39 40-49 50-59 ≥60 14(17.7) 21(26.6) 20(25.3) 15(19) 9 (11.4) gender male female 28(35.44) 51(64.56) bmi underweight normal overweight obesity 5 (6.4) 28(35.4) 21(26.6) 25(31.6) smoking non-smoker light smoker moderate smoker heavy smoker shisha 41(51.9) 6(7.6) 9(11.4) 15(19) 8 (10.1) table 2: association between body mass index and demographic characteristics demographic characteristics bmi category p-value underweight f.(%) normal f.(%) overweight f.(%) obesity f.(%) age group (years) 20-29 30-39 40-49 50-59 ≥60 1(1.32) 0(0) 2(2.63) 1(1.32) 1(1.32) 4(5.26) 6(7.89) 8(10.53) 6(7.89) 0(0) 3(3.95) 9(11.84) 5(6.58) 3(3.95) 1(1.32) 6(7.89) 6(7.89) 5(6.58) 4(5.26) 5(6.58) 0.848 gender female male 4(4.12) 1(1.03) 18(18.56) 10(10.31) 9(9.28) 12(12.37) 20(20.62) 5(4.15) 0.001 smoking non-smoker light moderate heavy shisha 1(1.03) 0(0) 0(0) 2(2.06) 2(2.06) 12(12.37) 3(3.09) 5(5.15) 4(4.12) 4(4.12) 9(9.28) 2(2.06) 1(1.03) 7(7.22) 2(2.06) 19(19.59) 1(1.03) 3(3.09) 2(2.06) 0(0) < 0.001 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3 demonstrates the association between patients in each bmi category with clinical characteristics regarding gerd. there was a very high statistically significant association between bmi and heartburn and nausea and vomiting (p-value = 0.001 for both), while there was a nonsignificant association between bmi and chest pain, cough, and sleep pattern disturbance (p-value = 0.324, 0.558, and 0.907 respectively). https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.11 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article 102 according to the current study, exogenous exposures in the form of lifestylerelated factors such as being overweight, and smoking have a crucial role in the aetiology of gerd. it found that there was a significant association between obesity and frequent gerd symptoms, but non-significant with smoking. a study done by yamamichi et al showed a significant association between bmi and obesity in gerd adult subjects. however, in contrast to previous studies [16-18] that showed a positive correlation between obesity or overweight and both erosive reflux disease, it only looked at the symptoms of gerd. several epidemiological studies have found a link between smoking and gerd or reflux symptoms [19-20]. cigarette smoking is thought to aggravate reflux disease by causing acid reflux and perhaps causing a long-term reduction in lower oesophagal sphincter pressure. the age of the participant has an effect and an increased risk of serious consequences in an elderly patient may require a more aggressive treatment approach [21]. although the examination and management of gerd in elderly individuals are largely the same as for all adults, there are some unique issues of cause, evaluation, and treatment that must be considered whe working with the elderly [22]. a study done by wang et al (2016) observed a positive relationship between gerd and increasing age [14]. this study showed a significant association between gender and gerd, and females' proportions grew with age, but males' proportions were lowest. increased body mass may or may not be a cause of cough. gerd symptoms can be avoided by maintaining a healthy weight, getting adequate sleep, and adhering to a healthy diet. an association between bmi and the frequency of chest pain was found to be insignificant. retrosternal burning, regurgitation, cough, sleep disturbances, and reflux esophagitis are all recognized as symptoms of gerd [23]. the latter is the most common manifestation of oesophagal injury as in a study of 3153 people with severe heartburn or regurgitation symptoms by nilsson et al. in a case-control study among gerd patients [24]. the findings of this study imply that an increased bmi is associated with a higher incidence of gerd symptoms. the effects of smoking on gastroesophageal reflux disease appear to be significant. the author reports no conflict of interests. the authors (s) report no funding support. table 3: association between body mass index and gastro-intestinal symptoms demographic characteristics bmi category p-value underweight f.(%) normal f.(%) overweight f.(%) obesity f.(%) heartburn chest pain cough nausea and vomiting disrupted sleep 4(4.12) 1(1.03) 0(0) 4(4.12) 0(0) 23(23.71) 5(5.15) 2(2.06) 15(15.46) 1(1.03) 16(16.49) 2(2.06) 3(3.09) 10(10.31) 1(1.03) 17(17.53) 5(5.15) 2(2.06) 17(17.53) 1(1.03) 0.001 0.324 0.558 0.001 0.907 discussion copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion conflict of interest funding https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.11 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article jan 1;132(1):87-95. available from: https:// www.sciencedirect.com/science/article/abs/ pii/s0016508506024747. [accessed 21st march 2021]. [9] emerenziani s, zhang x, blondeau k, silny j, tack j, janssens j, et al. gastric fullness, physical activity, and proximal extent of gastroesophageal reflux. official journal of the american college of gastroenterology| acg. 2005 jun 1;100(6):1251-6. available from: https://journals.lww.com/ajg/ abstract/2005/06000/ gatric_fullness,_physical_activity,_and_pro ximal.8.aspx. [accessed 21st march 2021]. [10] ness-jensen e, hveem k, el-serag h, lagergren j. lifestyle intervention in gastroesophageal reflux disease. clinical gastroenterology and hepatology. 2016 feb 1;14(2):175-82. available from: https:// www.sciencedirect.com/science/article/abs/ pii/s1542356515006357. [accessed 24th march 2021]. [11] khawaja mn, khan ma, khawaja zn. psychosocial determinants of gastroesophageal reflux disease. pakistan journal of medical and health sciences. 2009;3(2):117-120. available from: https:// www.pjmhsonline.com/2009/apr_june/pdf/ ii%20%20%20psychosocial% 20determinants%20of% 20gastroesophageal%20reflux% 20disease.pdf. [accessed 24th march 2021]. [12] cho yk, kim gh, kim jh, jung hy, lee js, kim n. diagnosis of gastroesophageal reflux disease: a systematic review. the korean journal of gastroenterology. 2010 may 1;55 (5):279-95. available from: https:// synapse.koreamed.org/articles/1006662. [accessed 24th march 2021]. [13] steevens j, botterweck aa, dirx mj, van den brandt pa, schouten lj. trends in incidence of oesophageal and stomach cancer subtypes in europe. european journal of gastroenterology & hepatology. 2010 jun 1;22(6):669-78. available from: https://journals.lww.com/eurojgh/ abstract/2010/06000/ trends_in_incidence_of_oesophageal_and_ stomach.4.aspx. [accessed 10th april 2021]. [14] wang hy, leena kb, plymoth a, hergens mp, yin l, shenoy kt, et al. prevalence of gastroesophageal reflux disease and its risk factors in a community-based population in southern india. bmc gastroenterology. 2016 dec;16(1):1-6. available from: 103 [1] antunes c, aleem a, curtis s. gastroesophageal reflux disease. national center for biotechnology information advances science and health. available from: https:// www.ncbi.nlm.nih.gov/books/nbk441938/. [accessed 19th june 2021]. [2] asanuma k, iijima k, shimosegawa t. gender difference in gastro-oesophagal reflux diseases. world journal of gastroenterology. 2016;22(5): 1800-10. available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc4724611/. [accessed 24th july 2021]. [3] goh k. changing epidemiology of gastroesophageal reflux disease in the asianpacific region: an overview. journal of gastroenterology and hepatology. 2004;19: s22-5. available from: https:// pubmed.ncbi.nlm.nih.gov/15324378/. [accessed 20th march 2022]. [4] moayyedi p, talley nj: gastro-oesophageal reflux disease. lancet. 2006;367(9528). 2086-2100. available from: https:// www.sciencedirect.com/science/article/ abs/pii/s0140673606689320. [accessed 1st may 2021]. [5] dent j, el-serag hb, wallander m, johansson s. epidemiology of gastro-oesophageal reflux disease: a systematic review. british medical journal-gut. 2005 may 1;54(5):710 -7. available from: https://gut.bmj.com/ content/54/5/710.short. [accessed 21st march 2021]. [6] lagergren j. influence of obesity on the risk of oesophagal disorders. nature reviews gastroenterology & hepatology. 2011 jun;8 (6):340-7. available from: https:// www.nature.com/articles/ nrgastro.2011.73. [accessed 21st march 2021]. [7] zagari rm, fuccio l, wallander ma, johansson s, fiocca r, casanova s, et al. gastrooesophageal reflux symptoms, oesophagitis and barrett’s oesophagus in the general population: the loiano–monghidoro study. british medical journal-gut. 2008 oct 1;57 (10):1354-9. available from: https:// gut.bmj.com/content/57/10/1354.short. [accessed 21st march 2021]. [8] zheng z, nordenstedt h, pedersen nl, lagergren j, ye w. lifestyle factors and risk for symptomatic gastroesophageal reflux in monozygotic twins. gastroenterology. 2007 references copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.11 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article [21] davidson s. davidson's principles and practice of medicine. elsevier health sciences; 2006. [22] chait mm. gastroesophageal reflux disease: important considerations for the older patients. world journal of gastrointestinal endoscopy. 2010 dec 16;2(12):388. available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc3010469/. [accessed 24th march 2021]. [23] cicala m, emerenziani s, caviglia r, guarino mp, vavassori p, ribolsi m, et al. intra‐ oesophageal distribution and perception of acid reflux in patients with non‐erosive gastro ‐oesophageal reflux disease. alimentary pharmacology & therapeutics. 2003 sep;18(6):60513. available from: https:// onlinelibrary.wiley.com/doi/full/10.1046/ j.1365-2036.2003.01702.x. [accessed 24th march 2021]. [24] van soest em, dieleman jp, siersema pd, sturkenboom mc, kuipers ej. increasing incidence of barrett’s oesophagus in the general population. british medical journal-gut. 2005 aug 1;54(8):1062-6. available from: https:// gut.bmj.com/content/54/8/1062.short. [accessed 24th march 2021]. https://bmcgastroenterol.biomedcentral. com/articles/10.1186/s12876-016-0452-1. [accessed 10th april 2021]. [15] mermelstein j., mermelstein a. c., and chait m. m. proton pump inhibitors for the treatment of patients with erosive esophagitis and gastroesophageal reflux disease: current evidence and safety of dexlansoprazole. clinical and experimental gastroenterology. 2016; 9: 163–172. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc4948703/. [accessed 18th april 2021]. [16] yamamichi n, mochizuki s, asada-hirayama i, mikami-matsuda r, shimamoto t, konnoshimizu m, et al. lifestyle factors affecting gastroesophageal reflux disease symptoms: a cross-sectional study of healthy 19864 adults using fssg scores. bmc medicine. 2012 dec;10(1):1-1. available from: https:// link.springer.com/article/10.1186/17417015-10-45. [accessed 10th april 2021]. [17] hampel h, abraham ns, el-serag hb. metaanalysis: obesity and the risk for gastroesophageal reflux disease and its complications. annals of internal medicine. 2005 aug 2;143(3):199-211. available from: https://www.acpjournals.org/doi/ full/10.7326/0003-4819-143-3-20050802000006. [accessed 2nd may 2021]. [18] corley da, kubo a. body mass index and gastroesophageal reflux disease: a systematic review and meta-analysis. official journal of the american college of gastroenterology| acg. 2006 nov 1;101(11):2619-28. available from: https://journals.lww.com/ ajg/abstract/2006/11000/ body_mass_index_and_gastroesophageal_ reflux.28.aspx. [accessed 2nd may 2021]. [19] fujiwara y, kubo m, kohata y, machida h, okazaki h, yamagami h, et al. cigarette smoking and its association with overlapping gastroesophageal reflux disease, functional dyspepsia, or irritable bowel syndrome. internal medicine.2011;50(21):24437.availablefrom:https://www.jstage.jst.go.j particleintenalmedcine/50/21/50_21_2443/ _article/-char/ja/[accessed 2nd may 2021] [20] matsuki n, fujita t, watanabe n, sugahara a, watanabe a, ishida t, et al. lifestyle factors associated with gastroesophageal reflux disease in the japanese population. journal of gastroenterology. 2013 mar;48(3):340-9. available from: https://link.springer.com/ article/10.1007/s00535-012-0649-1 [accessed 2nd may 2021]. 104 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.03 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article knowledge, attitudes, and barriers of blood donation among students of soran technical college: a cross-sectional study abstract background: safe and effective blood transfusion is a vital component in improving health and preventing the spread of blood-borne diseases worldwide. the current study aimed to assess knowledge, attitudes, and barriers toward blood donation among soran technical college students. methods: a cross-sectional study was conducted from 25th february 2022 to 7th may 2022. a non-probability convenience sampling method included 200 students; it was divided into medical and non-medical students. a self-administered questionnaire with closed-ended questions was used to collect information concerning socio-demographic characteristics, knowledge, attitude, and practice regarding blood donation. results: more than half of the study samples (59.5%) were within the age group of less than 20 years. the majority (68%) were female. and nearly half of the students came from an urban area. the majority of respondents (90.5%) had a fair level of knowledge, while 7% had good knowledge of blood donation. however, 59% of the students had a positive attitude toward blood donation. the most common motivators that encouraged blood donors were 72.5% getting subsidies and vacations, and 71% getting free laboratory examinations. common barriers for blood donors were worried about sanitation and getting infectious diseases, and the side effects (58.7%) and (54.5%), respectively. conclusion: despite most of the students having a favorable attitude toward blood donation but unexpectedly having a fair level of knowledge, the major barrier perceived by students was fear of acquiring an infectious disease. keywords: knowledge; blood donation; barriers; university students. sarud manaf ahmed; department of nursing, college of health and medical techniques/ shekhan, duhok polytechnic university, duhok, iraq. arazoo issa tahir; department of public health, college of health and medical techniques/ shekhan, duhok polytechnic university, duhok, iraq. (correspondence: arazoo.tahir@dpu.edu.krd). magroom esmail seniar; department of nursing, soran technical college, erbil polytechnic university, erbil, iraq. 22 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 05/10/2022 accepted: 10/01/2023 published: 30/5/2023 mailto:arazoo.tahir@dpu.edu.krd?subject=arazoo.tahir@dpu.edu.krd%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.03 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article human blood is a vital component of life, and there are currently no substitutes for blood components. the donation of blood or blood products into the recipient's bloodstream is known as a blood transfusion. replacing blood cells or blood products lost by bleeding with accident injuries, surgical conditions, malignancies, pregnancy issues, or other medical disorders is a life-saving strategy in both normal and emergencies (1). an essential part of enhancing healthcare delivery and halting the global spread of blood-borne infections is safe and effective blood transfusion. even though blood transfusions save millions of lives each year, there is considerable interest in the quality and safety of this procedure, particularly in hospitals in developing nations (2). according to the world health organization, 3-5% of people should donate blood annually (3). when blood is divided into its parts, one unit (450 ml) that is donated has the potential to save at least three lives. global efforts are ongoing to maintain an adequate number of blood donors to assure a sufficient, safe, and timely blood supply that is adequate to fulfill clinical demand. (4,5). due to the increase in chronic illnesses, surgeries, traumas, cancers, and automobile accidents, fresh blood is urgently needed, particularly during the first 24 hours of therapy (6). although it is believed that 60% of people in developing nations have sufficient knowledge about blood donation, the blood donation rate in low-income countries is far lower than that of middleand high-income countries. due to misconceptions, inadequate information, and a negative attitude toward donation, the blood donation percentage was less than desirable. additionally, it was discovered that sex, age, and educational status were predictors of voluntarily giving blood (7). young people represent a significant portion of the population and represent the future and present sources of a safe blood supply (1). university students, who may make up a larger share of the young population and are healthy, active, dynamic, resourceful, and receptive, need to be inspired, motivated and urged to donate blood willingly. students studying health sciences can become future blood donors as well as community role models and motivators if the right techniques are created and put into practice to enhance knowledge and attitude. therefore, the study aimed to assess knowledge, attitudes, and barriers toward blood donation among soran technical college students. a descriptive cross-sectional study was conducted from 25th february 2022 to 7th may 2022. a non-probability convenience sampling procedure was used to select 200 students, medical and nonmedical students from soran technical college. previously informed consent was obtained for the conduction of the study. the researcher used relevant english-language literature reviews to create the questionnaire, which was then translated into kurdish and completed by the students in 15-20 minutes. a self-administered questionnaire consists of socio-demographic data (age, gender, residency, department, etc.). knowledge of the student was measured with 19 questions that were rated by three options (poor, fair, and good) which gave two scores for the correct question, a score of 1 for the correct answer, and a score of 0 for incorrect responses. the sum of the score for all 19 items was calculated as the total knowledge score on blood donation, which ranged from 0 to 19. scoring was categorized as poor knowledge 0-5, fair knowledge 612, and good knowledge13-19.student’s attitude toward 23 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.03 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article blood donation was measured by 12 questions with two responses of (agree=1 score, disagree=0 score), the total scores were categorized as negative attitude (06) and positive attitude (7-12). and finally, statements related to reasons and barriers of blood donation with 2 responses yes (agree) and no (disagree). part one reasons for blood donation (5 statements) and the second is the barrier to blood donation (6 statements). the study has been approved by soran technical college and the scientific committee of akre technical institute. the data was entered into statistical package for science services (spss version 25), descriptive statistical analyses were used to report frequencies with percentages for categorical variables. while for figures excel and spss have been used. the result shows that the majority (59.5%) of study samples were within the age group of less than 20 years and the highest percentage (68%) of them were female while (32%) of them were male. the highest percentage (48.5%) of the study sample was from urban and 28% from rural. it is clear from this table that most (64%) of the study participants were in the second stage and less than half percentage (41%) of them had o+ blood group and rhpositive while (2.5%) of them had ablood group and rh-negative as shown in table 1. 24 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results table 1. distribution of study sample according to socio-demographic characteristics (n=200) variable no. (%) age group <20 years 20-24 years >24 years )59.5(119 )38(76 )2.5(5 gender male female )32(64 )68(136 residency urban suburban rural )48.5(97 )23.5(47 )28(56 stage first second )36(72 )64(128 blood group& rh a+ b+ o+ a b o )34(68 )13(26 )41(82 )2.5(5 )3.5(7 )6(12 total 022 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.03 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article the figure 1. shown highest percentage (90.5%) of study samples had a fair level of knowledge about blood donation and only (7%), (2.5%) of them had good and poor levels of knowledge respectively. the majority (59.5%) of study samples had a positive attitude toward blood donation while (40.5%) of them had a negative attitude as shown in table 2. receiving a subsidy and having free tests were the main reasons for donating blood, accounting for 72.5% and 71%, respectively. while (43%) cited receiving souvenirs as a motivation for giving blood. additionally, (65%), (63%) of the study's participants said that giving blood is beneficial to one's health and useful for using blood in therapeutic settings, respectively figure 2. most of the students (58.5%) reported that worries about sanitation and getting infectious diseases were the main barrier to blood donation. while only (21.5%) of them mentioned opposition from family as a barrier to blood donation. in addition, (54.5%), and (42%) of study students declared that blood donation would affect health and that no time for blood donation was a barrier to blood donation respectively table 3. 25 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. figure 1. distribution of study sample regarding the level of knowledge about blood donation. table 0. distribution of study sample regarding attitude toward blood donation attitudes n (%) positive )59.5(119 negative )40.5(81 figure 2. distribution of study samples regarding the reason for blood donation. barriers n (%) no time for blood donation )42(84 opposition from family )21.5(43 fear of needle pain )40.5(81 worry about sanitation and getting an infectious disease )58.5(117 blood donation would affect health )54.5(109 i do not be fit to donate blood )29(58 table 3. distribution of study sample regarding barriers to blood donation. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.03 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 26 similar factors in fear of infectious disease and not being fit to donate blood (19) and in qatar (20). inadequate knowledge was prevalent among a vast majority of university students in soran while the majority of study samples had a positive attitude toward blood donation. the primary motivation for donating blood was to receive benefits like subsidies, vacation days, and free laboratory tests. additionally, the greatest barrier to refusing blood donation was the fear of acquiring an infectious disease and its adverse outcomes. the findings suggest that providing workshops and lectures about blood donation for students to increase their level of knowledge, attitude, and practice about blood donation. the author reports no conflict of interest. [1] world health organization. towards 100% voluntary blood donation: a global framework for action. world health organization; 2010. [2] who and international federation of red cross and red crescent societies. world health. vol. 123. geneva, switzerland: who; 2010. towards 100% voluntary blood donation. a global framework for action. [3] alsalmi ma, almalki hm, alghamdi aa, aljasir ba. knowledge, attitude, and practice of blood donation among health professions students in saudi arabia; a crosssectional study. journal of family medicine and primary care. 2019 jul;8(7):2322. [4] mugion, r.g.; pasca, m.g.; di di pietro, l.; renzi, m.f. promoting the propensity for blood donation through the understanding of its determinants. bmc health services research.2021, 21, 127. copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. maintaining a sufficient and secure blood supply is an essential matter that worries health planners, particularly, because of the rise in demand. therefore, recognizing knowledge, attitudes, and barriers associated with blood donation customs are crucial (8). the study results illustrated that students had poor (7%) knowledge regarding blood donation. this finding was lower than studies in thailand and ethiopia (80%), (79.4%) respectively (9, 10). also, our students had lower knowledge than medical students in kollam, kerala (35%) (11). on the other hand, it is nearly in line with studies done among health science students of manipur (9%) (12). this variance may be the result of students' limited access to blood donation education programs and differences in socio-demographic characteristics, this wide gap should be minimized. in this study, about (59.5%) of the study participants had a positive attitude toward blood donation. this finding is in agreement with studies conducted in iraq (68.7%) (13), (67.9) among university students in pakistan (14), and in ethiopia (57.8%) of the study participants had positive attitudes (15). also, it is higher than that reported among students in pakistan (42%) (16), and ambo university students in ethiopia (47.4%) (17). this distinction may come as a result of the studying populations' instructional characteristics and sociocultural contrasts (18). in the present study, the main barrier was the fear of being infected with an infectious disease and the consequences of blood donation. comparable to a study conducted in nepal, the main reason was fear of weakness and not being asked to donate blood (8). on the other hand, other factors were more common in other nations (11). in addition, a study done in pakistan showed discussion conclusion conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.03 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 27 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [5] lownik e, riley e, konstenius t, riley w, mccullough j. knowledge, attitudes and practices surveys of blood donation in developing countries. the international journal of transfusion medicine. 2012 jul;103(1):64-74. [6] roberts dj, field s, delaney m, bates i. problems and approaches for blood transfusion in the developing countries. hematology/ oncology clinics. 2016 apr 1;30(2):477-95. [7] alfouzan n. knowledge, attitudes, and motivations towards blood donation among king abdulaziz medical city population. international journal of family medicine. 2014;2014. [8] amatya m. study on knowledge, attitude, and practice of blood donation among students of different colleges of kathmandu, nepal. international journal of pharmaceutical and biological archives. 2013;4(3):424-8. [9] wiwanitkit v. knowledge about blood donation among a sample of thai university students. the international journal of transfusion medicine. 2002;83:97-9. [10] gebresilase hw, fite ro, abeya sg. knowledge, attitude, and practice of students towards blood donation in arsi university and adama science and technology university: a comparative cross-sectional study. bmc hematology. 2017;17:20. [11] aslami an, jobby a, simon s, nazarudeen n, raj p, ramees m, et al. assessment of knowledge, attitude, and practice (kap) of blood donation among mbbs students of a medical college in kollam, kerala. journal of evolution of medical and dental sciences. 2015 apr 30;4(35):6086-95. [12] syiemlieh aj, akoijam bs, kumar s. assessment of knowledge, perception & practice of voluntary blood donation among health professional students in rims, imphal, manipur. journal of dental and medical science. 2016;15(10):26–30. [13] al-asadi jn, al-yassen aq. knowledge, attitude, and practice of blood donation among university students in basrah, iraq: a comparison between medical and non-medical students. asian journal of medical sciences. 2018 oct 29;9(6):62-7. [14] rasool ag, saud n, kamal a, amjad n, shahid n, nizam m. socio-demographic factors affecting knowledge, attitude and practice towards blood donation among university students in lahore, pakistan. pakistan journal of medical and health sciences. 2021;15 (3):638-41. [15] nigatu a and demissie db. knowledge, attitude, and practice on voluntary blood donation and associated factors among ambo university regular students, ambo town, ethiopia. journal of community medicine and health education. 2014;4:315.doi:10.4172/21610711.1000 315. [16] shamebo t, gedebo c, damtew m, woldegeorgis t, girma e, terefe d. assessment of knowledge, attitude, and practice of voluntary blood donation among undergraduate students in awada campus, hawassa university, southern ethiopia. journal of blood disorders and transfusion. 2020;11(1):431. [17] javaeed a, kousar r, farooq a, hina s, ghauri sk, tabbasum t. knowledge, attitude, and practice of blood donation among undergraduate medical students in azad kashmir. cureus. 2020 apr 19;12 (4). [18] ibrahim aa, koç m, abdallah am. knowledge level, motivators, and barriers of blood donation among students at qatar university. healthcare. 2021 jul 22 (vol. 9, no. 8, p. 926). mdpi. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article caregiver’s knowledge regarding homecare management of spastic cerebral palsy children under 12 years old in rapareen province abstract introduction cerebral palsy (cp) is an umbrella term that “describes a collection of movement background and objectives: spasticity, sometimes called hypertonia, makes movement difficult or even impossible. spastic children with cerebral palsy face many health problems that need significant attention at home. this study aimed to assess caregivers’ knowledge about home care management of spastic cp children in the rapareen region. methods: a quantitative, descriptive cross-sectional study was carried out in the rapareen region of sulaimani city. the period started from october 1st, 2020, to october 1st, 2021. purposive (non-probability) sampling techniques of 115 caregivers, who attend rehabilitation centers in ranya, chwarqwrne, and qaladeze in rapareen province, were respectively recruited to the study. the investigators prepared a questionnaire format after reviewing related literature. direct interview (face to face) and a home visit was conducted to collect the data. descriptive statistics spss version 25 was used, and statistics of frequencies, percentages, and inferential statistical analysis of chi-square test and regression were used. results: the vast majority (98.3%) of the primary caregivers were mothers of spastic cp children. almost all (94.8) of the caregivers were married. the majority (88.7%) of caregivers were housewives. less than half (48.7%) of the sample were between 31 to 40 years. more than three quarter (67%) of the sample were male children and more than half (65.2%) were school-age children with spastic cerebral palsy. there was a statistically highly significant association between formal years of education and residency area of caregiver with the caregiver’s knowledge at a p-value of 0.020 and 0.003 respectively. factors significantly associated with caregivers’ knowledge of homecare of spastic cp children include the level of education of caregiver, age of caregiver, and height of spastic cerebral palsy children. conclusion: the findings of the present study showed that level of education, age of caregiver, and residency areas are associated with caregiver’s knowledge regarding homecare of spastic cerebral palsy children. mothers are required educational programs to boost knowledge regarding homecare management of spastic cp children. keywords: spastic cp children; caregiver; internship and residency; homecare services. farida salim faqi-rashid; department of pediatrics, college of nursing, sulaimania university, sulaimania, kurdistan region, iraq. (correspondence: faridasaleem20@hotmail.com) shukir saleem hasan; department of nursing, college of nursing, hawler medical university and tishk international university, erbil, kurdistan region, iraq. 61 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 29/11/2021 accepted: 22/02/2022 published: 30/11/2022 mailto:faridasaleem20@hotmail.com, https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article and posture problems that cause activity restrictions and are related to nonprogressive disruptions in the developing fetus or infant’s brain” [1-2,8,11,17]. motor disorders may be accompanied by cognition, communication, perception, and epilepsy disorders [1-2]. cerebral palsy is one of the chronic diseases that has become a significant health concern worldwide [3]. however, the physical characteristics of cp include neuromotor disorders and the presence of pain [4]. cp manifests itself relatively early in childhood, despite being classified as a nonprogressive condition [4]. the brain damage induced by cp has no cure, and it is neither continuous nor progressive [6]. clinical signs and symptoms vary depending on which part of the central nervous system (cns) is damaged and range from average intelligence and wellfunctioning moderate monoplegia to severe spastic quadriplegia and mental retardation [5]. it affects about 2 out of every 1000 live births, making it the most prevalent motor disability in children [7]. injury to the developing brain has a variety of causes and consequences [5]. agenesis, schizencephaly, hemimegaloencephaly, pachygyria, polymicrogyria, lissencephaly, and other migration and embryogenetic abnormalities are caused by regional anatomical deformities with motor deficiencies [9]. congenital, genetic, inflammatory, anoxic, traumatic, toxic, and metabolic variables all have the potential to develop cp [8]. one of the predictors of a better prognosis is the early detection of neurological impairment and its progression to a clinical manifestation of cp [9]. the affected limbs [hemiparesis, diplegia, and quadriplegia]; the motor impairment of the global motor functions (gmfcs i to v); and the anatomical distribution, unilateral (monoprotic, hemiparetic) and bilateral (diparetic, triparetic, quadriparetic) can all be used to classify patients [10]. the difficulties in managing cp range from one sufferer to the next. the issues may be severe soon after birth in some people, while they are not apparent until early infancy in others [6]. incontinence, constipation, tooth decay, skin sores, and chest infection are all symptoms of intellectual impairment, epilepsy, failure to thrive, vision and hearing problems, impaired touch and pain sensation, hip dislocation, and spine curvature (scoliosis) there are the signs and symptoms cp [11]. medical treatment for seizures, spasticity, reflux, constipation and depression should be thoroughly researched, especially in terms of side effects and any combinations [5]. following a diagnosis, a detailed management regimen should be implemented. different components of the condition are managed by parents, doctors, speech therapists, occupational therapists, and other medical practitioners or specialists [6]. nursing management of children with cp is an option and depends on ambulatory status. thus, the family of a child with cp becomes crucial and will be very much necessary to guide the child’s development in a favorable environment and to care for and maintain their health status [10]. the primary medical care at home should include proactive care coordination, including monitoring, interpreting, and arranging with specialists and specialty teams, as well as communicating with therapeutic, educational, family support, and other community resources [12]. according to an official census in rapareen province general health directorate of rapareen, 160 spastic cp cases have been registered and are receiving medical care and physiotherapy care in rehabilitation centers (ghdr, 2020). when assessing therapy choices for children with cp, their caregivers prioritize motor development. physiotherapy interventions are administered over the lifespan to improve motor capacities, 62 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article participate in the study. caregivers who did not suffer from chronic diseases (diabetes, hypertension, asthma, etc.), took care of spastic cp children under 12 years old, spoke fluently kurdish language, and did not complain of mental and psychological problems were included. caregivers of children with other types of cp were excluded from the study. the researchers constructed a questionnaire consisting of two parts: part one assessed the socio-demographical characteristics of caregivers and cp children, such as the age of the caregiver, marital status, occupation, level of education, type of family, economic status, and type of delivery, and part two the second consisted of 20 questions related to caregiver’s knowledge regarding spastic cp. a three-point scale was used (0 for bad knowledge, 1 for fair knowledge, and 2 for good knowledge) and overall knowledge was categorized into three groups: bad knowledge (0-6), fair knowledge (7-13), and good knowledge (14-20). data were gathered through face-to-face interviews during the home visits and the investigator filled out the questionnaire tool. nineteen experts in related fields validated the questionnaire, and the pilot study of 10 caregivers indicated that the tool was eligible for data collection, the person correlation (r) was 0.87. before starting data collection, the researcher explained the research process and the aim to participants and asked each of the agreement participants to fill in a consent form. prior to the data collection, formal permission was obtained from the university of sulaimani/ college of nursing and rapareen health general administration in ranya city/ sulaimani/kurdistan/ iraq. the researchers explained the purpose of the study. all participants have the right to withdraw at any time. the researchers have promised to keep the data information for confidentiality and increase function, and avoid subsequent impairments while considering the preferences and values of the patient and family. children with cp and their caregivers want to know everything they can about their child's health, including their prognosis and rehabilitation needs. on the other hand, caregivers frequently believe that health professionals undervalue their demand for information [28-29]. caregivers’ understanding of how to manage homecare for children with impairments is sometimes overlooked. because of the potential for scorn and taunting from others, it is rarely carried outside the home. the greatest option to provide daily care and management for children with persistent disabilities is through home care [3]. this study aimed to determine the level of caregiver’s knowledge regarding homecare management of spastic cp children in the rapareen province. a quantitative, descriptive cross-sectional study was conducted. the study was carried out in the rapareen province in sulaimania city. a non-probability convenient sample of 115 caregivers was selected from three different rehabilitation centers with a total of 160 cases: kewarash primary health center in ranya city (90 spastic cp cases), qaladze center (60 spastic cp cases), chwarqurna rehabilitation center (10 spastic cp cases). data were collected from january 25th to april 25th, 2021, to identify caregivers’ knowledge of homecare management of spastic cp children in the rapareen region. according to rapareen general health directorate’s annual census, 160 spastic cp children are registered in the three centers. yamane formula has been used to estimate the sample size (n=n/(1+n(e)2), n=160/1+160 (0.05)2 and n=115. the study has recruited 115 spastic cp children with their caregivers willing to 63 methods copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article anonymity. the data were analyzed using spss software for statistical analysis version 25, to calculate descriptive statistical analysis (frequency and percentage). inferential statistical analysis (chi-square and regression) was used to determine the association between variables, the p-value ≤ 0.05 is considered statistically significant. the result shows that the majority (98.3%) of the main primary caregivers were mothers. most caregivers were primary school graduates (33%). less than half (48.7%) of caregivers were aged 31 to 40 years old and were of middle socioeconomic status. the majority of caregivers were housewives (88.7%), more than one-third (38.3%) lived in urban and suburban areas, and less than three-quarters (72.2%) were in a traditional nuclear family table 1. the higher percentage (65.2%) of spastic cp children were school-age children. sixty-seven percent were males, 63.5% were between one to six months of age at the time of diagnosis, 53% did not have birth asphyxia, and 80% were on a normal diet. about 60.9% were born by normal delivery, and 91.3% were delivered in public hospitals. most of the sample (80%) did not have a child previously affected with cp, and less than half (40%) of the children were the middle child in the family. about 75.7% have one or more complications associated with cp, and less than half (44.3%) were in the level v of independence table 2. a highly significant association between formal years of education and residency area of caregiver with the caregiver’s knowledge at a p-value of 0.020 and 0.003, respectively was observed. level of education, age of caregiver, and height of the spastic cp children were significantly associated with caregiver’s knowledge at p-values of 0.002. 0.050 and 0.012, respectively table 3. 64 results table 1: distribution of sample according to caregivers’ socio-demographic characteristics items f. (%) the main primary caregiver mother 113 (98.3) grandmother 1 (0.9) aunt 1 (0.9) level of education illiterate 33 (28.7) primary school 38 (33) secondary school 28 (24.3) institute diploma 10 (8.7) university and above 6 (5.2) age of caregiver/years 20-30 25 (21.7) 31-40 56 (48.7) 41-50 31 (27) 51 and above. 3 (2.6) marital status married 109 (94.8) unmarried 6 (5.2) occupation housewife 102 (88.7) governmental employee 8 (7) nongovernment employee 5 (4.3) place of residence rural 27 (23.5) urban 44 (38.3) suburban 44 (38.3) socioeconomic status high 11 (9.6) middle 56 (48.7) low 48 (41.7) types of family traditional nuclear family 83 (72.2) nuclear family 13 (11.3) blended family 2 (1.7) extended family 13 (11.3) single parent family 4 (3.5) total 115 (100) f. frequency ** % percentages copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article 65 table 2: distribution of sample according to spastic cp child socio-demographic characteristics. items f.* (%)** developmental stage toddler 7 (6.1) preschool-age 33 (28.7) school-age 75 (65.2) gender male 77 (67) female 38 (33) age at diagnosis/months 1 to 6 73 (63.5) 7 to 12 29 (25.2) 13 to 18 4 (3.5) 19 to 24 1 (0.9) 25 or more 8 (7) birth asphyxia yes 54 (47) no 61 (53) type of feeding breastfeeding bottle feeding 9 (7.8) mixed 14 (12.2) normal diet 92 (80) mode of delivery normal delivery 70 (60.9) cesarean section 45 (39.1) place of delivery home 10 (8.7) hospital 105 (91.3) another affected child with cp yes 23 (20) no 92 (80) child’s order in the family firstborn 38 (33) middle born 46 (40) young child 31 (27) complications associated pregnancy yes 87 (75.7) no 28 (24.3) level of independence level i 14 (12.2) level ii 6 (5.2) level iii 19 (16.5) level iv 25 (21.7) level v 51 (44.3) total 115 (100) *f. frequency ** % percentages copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article 66 table 3: association between caregiver's knowledge and socio-demographic characteristics. knowledge socio-demographical characteristics fair k.*** good k. x2 (sig.) f. (%) f.(%) primary caregiver mother 81 (71.5) 32 (28.5) 2.895(0.2350) father 0 (0.0) 0 (0.0) grandmother 0(0.0) 1 (100.0) aunt 1(100.0) 0 (0.0) level of education illiterate 18 (54.5) 15 (45.5) 11.652(0.020) read and wright 0 (0.0) 0 (0.0) primary school 25 (65.8) 13 (34.2) secondary school 25 (89.3) 3 (10.7) diploma institute 9 (90.0) 1 (10.0) university and above 5 (83.3) 1 (16.7) age/ years old 20-30 21 (84.0) 4 (16.0) 5.645(0.227) 31-40 41 (73.2) 15 (26.8) 41-50 17 (56.7) 13 (43.3) 51 and above. 3 (66.7) 1 (33.3) occupation housewife 70 (68.6) 32 (31.4) 3.395(0.183) public employee 7 (87.5) 1 (12.5) private employee 5 (100.0) 0 (0.0) marital status unmarried 5 (83.3) 1 (16.7) 448(0.503) married 77 (70.6) 32 (29.4) residency areas rural 13 (48.1) 14 (51.9) 11.968(0.003) urban 38 (86.4) 6 (13.6) suburban 31 (70.5) 13 (29.5) socio-economic status low 7 (63.6) 4 (36.4) 4.378(0.112) middle 45 (80.4) 11 (19.6) low 30 (62.5) 18 (37.5) type of family traditional nuclear family 62 (74.7) 21 (25.3) nuclear family 7 (53.8) 6(46.2) 3.841(0.428) blended family 2 (100.0) 0 (0.0) extended family 8 (61.5) 5 (38.5) single parent family 3 (75.0) 1 (25) ***k. knowledge copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article the parents were mothers aged 21 to 82 years old [12]. most (88.7%) of the caregivers were housewives. the result is in agreement with a study done in king saud medical city, riyadh, saudi arabia which states that almost 90% of the sample were unemployed and took care of their children [13]. regarding the residential areas of the participants, the current study found that more than one-third (38.3%) of the caregivers live in urban and suburban areas. this finding is in contrast with other studies that reported that more than half of caregivers were living in urban areas [3], and more than two-thirds of the caregivers were living in rural areas [16]. these results indicate that the residential areas of the caregivers sometimes create problems for the cp child because the parents are facing a lack of service facilities for their child’s treatment such as hospitals, clinics, pharmacies, and private and public sector physiotherapy departments. therefore, in this case, the cp child and his/her family might face great health difficulties. regarding socioeconomic status, less than half (48.7%) of the caregivers were of middle socioeconomic status. one study found that a moderate level of income was most frequently reported (79.3%) [13] and another study in egypt found that most cp children and their families were lowincome. a study in china reported a monthly family income of less than us $500 [15]. most of the caregivers (72.2%) are living in a traditional nuclear family, similar to another study which found that the family size of their study sample mainly consisted of three to five people [21]. assessment of socio-demographic characteristics of spastic cp childrenthe results show that about two-thirds (65.2%) of spastic cp children were school-age. this result is supported by other studies reporting sp children aged 2-10 years [22], and aged 2-6 years [20]. the result is in that level of education, age of caregiver, and height of the spastic cp were factors associated with the caregiver’s knowledge and shows a highly significant p-value of 0.002. 0.050 and 0.012 respectively table 4. the demographic characteristics of caregivers of children with cp. the results of the present study reflected that the majority (98.3%) of primary caregivers of spastic cp children were mothers. this result agreed with previous studies which mentioned that the caregivers of cp children were mothers and states that they are more effective in initiating and reciprocating the child’s needs [13-17]. regarding the caregiver’s marital status, the majority (94.8%) of caregivers in the present study were married. the current results showed that most of the caregivers were primary school graduates and illiterates. a similar study was conducted by hasan in erbil city of the iraqi kurdistan region which reported that 43% of the sample were illiterate, [3]. other studies report caregivers were literate and a high percentage of them had reached high school education (33.3% and 37.0%, respectively) [13]. around half of the sample were aged 31 to 40 years old with a mean age of mothers of 32.5 years old [3]. in another study, the majority of 67 table 4: factors associated with caregiver’s knowledge regarding homecare of spastic cp. factors score df sig.* exp [b] formal years of education 9.313 1 0.002 0.680 age of caregiver 3.715 1 0.050 1.986 height of scp child 6.312 1 0.012 0.209 p-value < 0.05 significant * significant discussion copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article conducted in baghdad’s children’s welfare teaching hospital found that, out of 100 cp participants, 70 were normal vaginal delivery, in which one only had assisted delivery (forceps), and 29 were cesarean section (13% of them were elective procedures and 16% were emergency ones) [24]. almost all the cp children were delivered in the public hospitals in the present study, and only a few (8.7%) were delivered at home. this is in contrast to a study conducted in nigeria where the majority of the cp children were delivered at home (310, 37.17%), and only 24 children (2.88%) were delivered at the university of port harcourt teaching hospital [25]. another study reported that most patients were born at a hospital or in a private clinic, and very few were born at home [11]. this could mean that the place of the cp childbirth varied across settings and could be interpreted in a way that the place of delivery is less associated with the cause of cp in children. in the present study, most of the caregiver families (80%) haven’t had any child previously affected by cp. the recurrence of cp in the same family is uncommon [26] indicating that the cp condition in children is not hereditary. less than half (40%) of the cp children were the middle child in the family, 33% of them were firstborn, and 27% were the last-born child in the family. studies report that 48% of children with cp were the first children in the family [19], and about one-fourth of them were the first born [16]. this could be interpreted in the way that cp condition in children can happen in any childbirth ordinal. three-quartier of respondents have one or more complications related to spastic cp studies have reported that the majority of the sample report epilepsy as the onset symptom (78.0%), and mental retardation was the least mentioned (6.0%) [19]. in the current study, the complications associated with spastic cp child disagreement with a study in erbil city stating that more than half (53%) of cp children were in the toddler developmental stage [3]. the cp children of the present study are mainly between the toddler ages to school ages. results of the current study show that two-thirds of spastic cp children were males. this result is in agreement with other studies reporting a higher sample proportion of boys [20], [22], [16], [19]. regarding the diagnostic age of spastic cp children, the study reveals that less than two-thirds were between one to six months of age at the time of diagnosis. another study reported that most of the children were less than one year at the time of their diagnosis [19]. cp condition is usually detected at the early ages of six months to one year. in the present study, more than half (53%) of the cp children did not have birth asphyxia, which is supported by a study done in osun state, nigeria which showed that the h asphyxia was 57.2% [23]. this is an indication of the fact that it is not always the case for children to experience birth asphyxia at the time of delivery. birth asphyxia was in 42 (36%) of cases [11], the contrast pattern occurred in the study by birth asphyxia (17.3%) of the child with cp condition [12], [29], only 6% or 7% of asphyxia at birth [12]. concerning the type of feeding, the study found that the majority (80%) of the cp children were on a normal diet. this result is in agreement with a study reporting that the majority of cp children were on oral feeding while only 18% of them were on tube feeding [16]. the current study also reveals that most spastic cp children were born by normal delivery. one study reported more than half of sp children were born by cesarean section delivery, three-quarter by vaginal deliveries, and less than one-fifth or few by caesarian sections [11]. a study 68 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article level of education of caregivers and total family caregivers’ knowledge regarding hemiplegic cp (x² = 127.8, p= 0 .000) [21]. the age of the caregiver was significantly associated with the caregiver’s knowledge (p=0.050). one study showed a significant association between the age of the mother and knowledge about homecare (p = 0.024) and revealed that caregivers aged 24 to 30 were less knowledgeable about homecare [3]. the height of the spastic cp was significantly associated with the caregiver’s knowledge (p= 0.012). a study in brazil found a statistically significant height difference, according to the reference curves specific for cp and those commonly used in pediatrics, with a kappa index obtained by comparing the caregiver’s awareness [30]. there was no significant association between any of the selected socio-demographic caregiver variables and the level of knowledge of the caregivers. [27]. another study reported significant differences were found, in caregivers’ knowledge of height (p = 0.001) [31]. the results of the present study indicated a highly significant association between formal years of education and residency area of caregiver with the caregiver’s knowledge regarding home care management of spastic cp children. the level of education of the caregiver, age of the caregiver, and height of the spastic cp were factors significantly associated with the caregiver’s knowledge regarding home care management of spastic cp children. the authors (s) report no conflict of interest. the authors (s) report no funding support . reported include mental retardation, convulsion, epilepsy, strabismus, blindness, deafness, and heart problems. less than half (44.3%) of the cp children participating in the current study were in level v (five) of independence. a similar pattern of 17 caregivers of cp children in iran found that of the participating children, 29.4% were in level iii of growth motor function classification system expanded and revised, (gmfcs e&r), 29.4% were in level v, 17.6% were in level iv, 17.6% in level i, and 6% were in the level ii [22]. this is the indication that children with cp can perform independently in almost all the five levels except spastic cp who will be staying in iv and v levels. association between caregiver's knowledge and sociodemographic characteristics. a highly significant association between formal years of education and residency area of caregiver with the caregiver’s knowledge at p-value of 0.020 and 0.003 respectively. also, independent factors that had a positive impact on observed knowledge scores were the caregiver's urban residence and higher family income. meanwhile, caregivers’ higher education had a negative impact, which means that the improvement of observed knowledge was higher among those caregivers with lower levels of education [16]. however, there is a significant association between the educational status of family caregivers with total knowledge scores (r = .521, p = .000) [21]. the other socio demographic variables of the other caregivers had no significance on their knowledge score [16].factors associated with caregiver’s knowledge regarding homecare of spastic cp the level of education of the caregivers of spastic cp is significantly associated with caregivers’ knowledge (p=0.002). in contrast, one study reported a significant difference between the 69 conclusion conflict of interest copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. funding https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article [12] cooley wc. providing a primary care medical home for children and youth with cerebral palsy. pediatrics. 2014 oct 1;114 [4]:1106–13. [13] alruwaished a, ali b, alhowaimil l, alhowaimil a, alhowaimil n, alessa a. knowledge and attitude of caregivers of cerebral palsy children in riyadh city. international journal of medicine in developing countries. 2020;12–7. [14] marrón em, redolar-ripol d, boixadós m, nieto r, guillamón n, hernández e, et al. burden on caregivers of children with cerebral palsy: predictors and related factors. universitas psychologica. 2013 sep;12 (3):767-77. [15] hu x, dolansky ma, hu x, zhang f, qu m. factors associated with the caregiver burden among family caregivers of patients with heart failure in southwest china: factors associated with caregiver burden. nursing & health sciences. 2016 mar;18[1]:105–12. [16] abd allah es, el awady s, hameed hs. improving the care provided to hemiplegics cerebral palsy children by their family caregivers: an intervention study. journal of american science. 2012;8(2). [17] hirsh at, gallegos jc, gertz kj, engel jm, jensen mp. symptom burden in individuals with cerebral palsy. journal of rehabilitation research and development. 2010;47(9):863. [18] dambi jm, mandizvidza c, chiwaridzo m, nhunzvi c, tadyanemhandu c. does an educational workshop have an impact on caregivers’ levels of knowledge about cerebral palsy? a comparative, descriptive crosssectional survey of zimbabwean caregivers. malawi medical journal. 2016;28(4):167-73. [19] hegazy ae, mekhamier ha. effect of self learning package on mothers of children with cerebral palsy. international journal of novel research in healthcare and nursing vol. 4, issue 2, pp: 210-226, month: mayaugust 2017, available at: www.noveltyjournals.com. [20] hadeya mh, amal ha. parental oral health knowledge, attitude, practice, and caries status of sudanese cerebral palsy children. pediatric health resource. 2017;2(11). [21] ahmed s, badr ed, shenuda m, mohamed a. home care is offered by family caregivers to preschool children, suffering from hemiplegic cerebral palsy. journal of biology, agricult,ure, and healthcare. 2015;5(4):65-72. [1] capucho py, carnier sa, de souza p, de castro dc, finocchio ap, de oliveira dm, et al. cerebral palsy-lower limbs: rehabilitation. acta fisiátrica. 2012 jun 9;19 (2):114-22. [2] craig f, savino r, trabacca a. a systematic review of comorbidity between cerebral palsy, autism spectrum disorders, and attention deficit hyperactivity disorder. european journal of paediatric neurology. 2019 jan 1;23(1):31-42. [3] hasan ss. home care management among mothers having children with cerebral palsy in erbil city. zanco journal of medical sciences (zanco j med sci). 2014;18(2):702 -9. [4] adams ms, khan nz, begum sa, wirz sl, hesketh t, pring tr. feeding difficulties in children with cerebral palsy: low‐cost caregiver training in dhaka, bangladesh. child: care, health, and development. 2012 nov;38(6):878-88. [5] darcey m. anaesthetic management of patients with cerebral palsy. aagbi anaesthesia tutorial of the week. 2010;196 [6] alshehri a, bach c. challenges of cerebral palsy management. in american society for engineering education (asee) conference 2014 apr. [7] hakkarainen e. cognitive and motor processing in mild spastic cerebral palsy: an event-related potential study. tampere university press. 2017. [8] mohammed fms, ali sm, mustafa maa. quality of life of cerebral palsy patients and their caregivers: a cross-sectional study in a rehabilitation center khartoumsudan (2014 – 2015). journal of neurosciences in rural practice. 2016 jul;07 (03):355–61. [9] pereira, h.v., paralisia cerebral. rev residencia pediátrica, 2018. 8(1), pp.49-55. [10] morilla cm, caldas cact, scarpellini acav, santos pl dos. family resources and promotion of the development of children with cerebral palsy. journal human growth and development. 2017 sep 6;27(2:166. [11] ashour dbm, sewasi dm. risk factors & complications of cerebral palsy in misurata hospital -libya. scholars journal of applied medical sciences (sjams) 2013 1(6):814-818. 70 references copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.07 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article [22] ghazisaeedi m, safari a, sheikhtaheri a, dalvand h. the effect of an android-based application on the knowledge of the caregivers of children with cerebral palsy. medical journal of the islamic republic of iran. 2016;30:456. [23] omole jo, adegoke sa, omole ko, adeyemi oa. pattern of cerebral palsy seen in children attending the outpatient paediatric physiotherapy clinics in osun state tertiary hospitals in nigeria. south african journal of child health. 2018;12 (2):52-7. [24] al-naddawi mn, saadi nw, abid ar. risk factors & clinical patterns of cerebral palsy in children welfare teaching hospital in baghdad. iraqi postgraduate medical journal. 2011;10(3). [25] frank-briggs ai, alikor ea. sociocultural issues and causes of cerebral palsy in port harcourt, nigeria. nigerian journal of pediatrics. 2011;38(3):115-9. [26] richer lp, dower na, leonard n, chan ak, robertson cm. familial recurrence of cerebral palsy with multiple risk factors. case reports in pediatrics. 2011 jan 1;2011. [27] olagunju tj, fatudimu mb, hamzat tk. clinical-demographic variables and compliance with home programme among nigerian informal caregivers of children with cerebral palsy. medical journal of zambia. 2017;44(3):157-65. [28] bailes af, giannotti m, bellows dm, shusterman m, lyman j, horn sd. caregiver knowledge and preferences for gross motor function information in cerebral palsy. developmental medicine & child neurology. 2018 dec;60(12):1264-70. [29] nitu ks, dahiya h. audio visual aids: an essential tool for teaching. amarjeet kaur sandhu. 2017 jan;9(1):64. [30] araújo la, silva lr. anthropometric assessment of patients with cerebral palsy: which curves are more appropriate? jornal de pediatria. 2013 may 1;89(3):307-14. [31] garcía-iñiguez ja, vásquez-garibay em, garcía-contreras a, romero-velarde e, troyo-sanroman r. assessment of anthropometric indicators in children with cerebral palsy according to the type of motor dysfunction and reference standard. nutrición hospitalaria. 2017;34(2):315-22. 71 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article assessment of psychological aspects among refugees in kurdistan region-iraq refugee camps abstract background and objectives: syria's civil war has received the highest refugee crisis of the twenty-first century. as a result of their exposure to conflict, violence, and postdisplacement stresses, syrian refugees living in refugee camps in kurdistan are at a greater risk of developing common mental illnesses. this study investigates the prevalence and predictors of depression, anxiety, and stress symptoms among syrian refugees residing in the kurdistan region of iraq. methods: a quantitative descriptive study was conducted in refugee camps in erbil, sulaymaniyah, and duhok in the kurdistan region of iraq from 1st september 20021 to 1st june 2022. convenient sampling was used to collect 400 participants, and the depression, anxiety, and stress scale-21 (dass-21) questionnaire was used to measure the level of depression, anxiety, and stress. results: the average age of participants was 37 ± 12.14 years; 71.8% were married, 53.3% had a smoking history, 92.2% were from syria, and the average refugee duration was 9 ± 1.32 years. during the refugee process, 79.3% of refugees had a low socioeconomic position, 34.0% had anxiety, 23.1% had stress, 47.5% were depressed. there is a statistical association between gender and stress levels based on a p-value of 0.004 and between smoking history and stress with a p-value of 0.006. conclusion: according to the findings, most refugees suffer from extreme depression, moderate anxiety, and severe stress. further studies are required by competent authorities to overcome mental health disorders among refugees. keywords: depression; anxiety; stress; refugees. ahmad naif ali; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: ahmed.ali@hmu.edu.krd). abdulqader hussein hamad; department of nursing, college of nursing, hawler medical university, erbil, iraq. 23 received: 22/07/2022 accepted: 06/11/2022 published: 30/05/2024 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:ahmed.ali@hmu.edu.krd?subject=ahmed.ali@hmu.edu.krd%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article when iraq recovered from years of conflict, thousands of vulnerable people stayed dislocated and required assistance. as of 31 august 2021, 248,721 syrian refugees (61% urban, 39% camp) and 37,798 refugees of other nationalities lived in iraq, with 98% of syrian refugees residing in the kurdistan region. the united nations high commissioner for refugees (unhcr) conducted a participatory assessment in six offices/ten governorates (erbil, dohuk, sulaymaniyah, kirkuk, ninewa, baghdad, basra, anbar, diyala, kerbala, salahaldeen) in july and august 2021 to ensure meaningful participation through structured discussion [1]. the migration process had a significant detrimental impact on refugees' mental health, and the majority of syrian refugees in camps in the kurdistan area of iraq reported feeling distressed and anxious [2]. there is a significant prevalence of anxiety and depression, as well as elevated stress levels, among refugees who have been through the refugee resettlement process in the past [3]. syria's civil war resulted in one of the biggest refugee crises in contemporary history. turkey has the highest number of registered syrian refugees, who are more likely to suffer from prevalent mental illnesses due to their dealings with war, brutality, and the stressors that come with being moved [4]. even in wealthy countries like germany, immigration and refugee policies seem to have a detrimental effect on mental health, and roughly half of the refugees experienced trauma, although participants' selfreported rates of melancholy, anxiety and stress symptoms were high. refugees in sweden's refugee camps report high levels of psychological discomfort and low quality of life. however, the service system appears to be able to assist them in overcoming this misery [6]. syrian refugees in kurdistan camps said that social interactions and environmental conditions are satisfactory but that home displacement has a detrimental effect on individual satisfaction [7]. the nature of the present study is descriptive and cross-sectional, conducted between 1st september 2021 to 1st june 2022. a questionnaire was adopted in english and arabic and a face-to-face interview was used. the questionnaires were divided into two parts. part one included questions around sociodemographic characteristics such as age, sex, marital status, number of children, country of birth, migration status, level of education, employment status, insurance, types of education, duration of refugee, ownership before and after refugee, level of income before and after refugee, past psychiatry history, history of alcohol use, and history of smoking. part two included questions using lovibond's depression, anxiety, and stress scale-21 (dass 21). lovibond's 1995 dass-21 is a reliable quantitative screening instrument for depression, anxiety, and stress. there are seven items for depression, anxiety, and stress. they can be categorized as mild, moderate, severe, and extremely severe. the dass-21 score was multiplied by two to determine the final result. cronbach‘s coefficient was estimated to test the internal consistency of the measurement. the result for cronbach’s alpha is 0.927 for depression, 0.916 for anxiety, 0.922 for stress, and 0.921 for all of them together. the inclusion criteria were all refugees over 18 years old. the participants were refugees from the kurdistan region of iraq refugee camps in erbil, sulaymaniyah, and duhok cities. according to the cochran formula, the population sizes of erbil, sulaymaniyah, dohuk, and the entire country are 24 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article table 1 shows the descriptive statistics for all demographic questions such as age, gender, marital status, number of children, education, past psychiatry history, past medical history, history of alcohol use, and history of smoking. the percentage of males (61.5%) is higher than the percentage of female participants (38.5%), while most of them are married (71.8%). most of the participants are aged between 21 and 30 years (30%), followed by 31-40 years (26.5%), 41-50 years (21.8%), more than 50 years (17%), and less than 21 years (4.8%) with the average being 37 years. the highest percentage of number of children in a family is between 1 and 3 children (32%), followed by 4-6 children (30.5%), and more than six children (7.5%). thirty percent do not have any child, and the average number of children per family is 3. most participants (27.3%) do not have any educational background, 24.8% can read and write, 17.3% completed primary school, 15.3% completed secondary school, 15% had a diploma/bachelor, and 5% were postgraduates. according to past psychiatry history, 88.8% did not have any past psychiatry history, 4.5% had depression, 4.3% had stress, and 2.5% had anxiety. on the other hand, 69.5% did not have any past medical history, while 15.8% had hypertension. the majority of the participants (87.8%) do not have a history of alcohol ,while 53.3% reported a history of smoking. (15459, 9580, 26384, and 51423), respectively, with a sample size of 382 based on a 95% confidence interval, a 5% margin of error, and 50% of the population percentage. in place of the 382 examples discovered by the cochran formula, 400 cases were gathered in order to have a more reliable sample size. following that, the sample sizes (400) were divided into three cities, erbil, sulaymaniyah, and duhok, according to stratified sampling, as follows: erbil (120), sulamaniah (75), and duhok (205). then, convenience sampling was utilized to gather the data from sulaymaniyah, duhok, and sulaymaniyah. ethical approval from hawler medical university/ college of nursing ethical committee was obtained. face-to-face interviews were used to collect the data. the study's purpose was explained to the respondents who voluntarily participated. chi-square is used to determine if the distributions of categorical variables differ, and the chisquared test for independence shows whether two categorical variables are independent[11]. the respondents were also assurred that their responses would be considered confidential and utilized only for research, the data were entered into spss for analysis, and frequency, percentage, mean, standard deviation, and chisquare test were used to analyze the data. 25 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 26 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: descriptive statistics for demographic questions (a) variables n (%) age less than 21 19 (4.8%) 21 30 120 (30%) 31 40 106 (26.5%) 41 50 87 (21.8%) 51 and more 68 (17%) (mean ± sd) (37 ± 12.14) sex male 246 (61.5%) female 154 (38.5%) marital status single 106 (26.5%) married 287 (71.8%) divorced 7 (1.8%) number of children no child 120 (30%) 1 3 children 128 (32%) 4 6 children 122 (30.5%) more than 6 children 30 (7.5%) (mean ± sd) (3 ± 2.45) level of education illiterate 109 (27.3%) read and write 99 (24.8%) primary school 69 (17.3%) secondary school 61 (15.3%) diploma or bachelor 60 (15%) postgraduate 2 (0.5%) occupation unskilled manual occupation 149 (37.3%) semi-skilled manual occupations 37 (9.3%) manual and non-manual occupations 8 (2%) associate professional occupations 45 (11.3%) skilled professional 8 (2%) housewife 103 (25.8%) student 50 (12.5%) employment employed 28 (7%) unemployed 372 (93%) history of smoking presence 213 (53.3%) absence 187 (46.8%) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 27 (11.3%), semi-skilled manual occupations (9.3%), and both manual and nonmanual occupations and skilled professional (2%) respectively. the highest percentage of duration of a refugee is between 9 and 12 years (75.8%), with the average refugee’s duration being nine years. the majority of the participants had a medium level of income before refugee (80%), while most of them have low income during refugee (79.3%). the percentage of refugees living in urban areas is higher than those living in rural areas (47.3%). table 2 shows the descriptive statistics for all demographic questions such as migration of status, employment, insurance, occupation, duration of refugee, level of income before refugee, level of income during refugee, and place of living before refugee. the percentage of participants who migrated from syria (92.2%) is higher than those who migrated to turkey (7.8%). most of them are unemployed (93%), and do not have insurance (99.5%). according to occupation results, most of the participants are in unskilled manual occupations (37.3%), followed by a housewife (25.8%), students )12.5 ,(% associate professional occupations copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2 :descriptive statistics for demographic questions (b) variables n (%) migration of status turkey 31 (7.8%) syria 369 (92.2%) employment employed 28 (7%) unemployed 372 (93%) insurance not insured 398 (99.5%) insured 2 (0.5%) duration of refugee 1 4 4 (1%) 5 8 93 (23.3%) 9 12 303 (75.8%) (mean ± sd) (9 ± 1.32) level of income before refugee low 14 (3.5%) medium 320 (80%) high 66 (16.5%) level of income during refugee low 317 (79.3%) medium 81 (20.3%) high 2 (0.5%) place of living before a refugee urban 211 (52.8%) rural 189 (47.3%) past psychiatry history anxiety 10 (2.5%) stress 17 (4.3%) none 355 (88.8%) past medical history no medical history 278 (69.5%) hypertension 63 (15.8%) asthma 1 (0.3%) diabetes 31 (7.8%) arrhythmia 6 (1.5%) peptic ulcer 11 (2.8%) migraine 5 (1.3%) heart failure 5 (1.3%) history of alcohol use presence 49 (12.3%) absence 351 (87.8%) history of smoking presence 213 (53.3%) absence 187 (46.8%) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article reported moderate anxiety, 27% reported moderate depression, and 26% reported moderate stress. most of the participants reported severe stress (23%), followed by severe depression (20.8%) and severe anxiety (17.8%). less than half (47.5%) of the participants had extremely severe depression, followed by extremely severe anxiety (35.8%) and extremely severe stress (18.8%). from extremely severe stress (65.3 %) is higher than the percentage of females (34.7%). there is no statistically significant association between gender (male and female) and depression (p=0.896) and anxiety (p=0.341). 28 table 3 shows the descriptive statistics for depression, anxiety, and stress. overall, 26.8% had depression, 23.7% had stress, and 17.9% had anxiety. most participants (32.3%) reported normal stress, 7.8% reported normal anxiety, and 2% reported normal depression. the percentage of mild anxiety (4.8%) is higher than mild depression (2.8%), while no participant reported mild stress. thirty-four percent table 4 demonstrates that there is a statistically significant association between gender (male and female) with stress (p=0.004). the percentage of males experiencing severe stress (70.7%) is higher than the percentage of females (29.3 %), and the percentage of males suffering copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3 :descriptive statistics for depression, anxiety, and stress levels depression anxiety stress n (%) n (%) n (%) normal 8 (2%) 31 (7.8%) 129 (32.3%) mild 11 (2.8%) 19 (4.8%) 0 (0%) moderate 108 (27%) 136 (34%) 104 (26%) severe 83 (20.8%) 71 (17.8%) 92 (23%) extremely severe 190 (47.5%) 143 (35.8%) 75 (18.8%) mean 26.80 17.93 23.66 sd 9.70 8.55 9.38 table 4 :association between gender and (depression, anxiety, and stress) using the chisquare test levels sex total chi-square p-value male female depression normal n (%) 5 (62.5%) 3 (37.5%) 8 (100%) 1.091 0.896 mild n (%) 7 (63.6%) 4 (36.4%) 11 (100%) moderate n (%) 67 (62%) 41 (38%) 108 (100%) severe n (%) 47 (56.6%) 36 (43.4%) 83 (100%) extremely severe n (%) 120 (63.2%) 70 (36.8%) 190 (100%) anxiety normal n (%) 17 (54.8%) 14 (45.2%) 31 (100%) 4.515 0.341 mild n (%) 10 (52.6%) 9 (47.4%) 19 (100%) moderate n (%) 82 (60.3%) 54 (39.7%) 136 (100%) severe n (%) 40 (56.3%) 31 (43.7%) 71 (100%) extremely severe n (%) 97 (67.8%) 46 (32.2%) 143 (100%) stress normal n (%) 63 (48.8%) 66 (51.2%) 129 (100%) 13.488 0.004 moderate n (%) 69 (66.3%) 35 (33.7%) 104 (100%) severe n (%) 65 (70.7%) 27 (29.3%) 92 (100%) extremely severe n (%) 49 (65.3%) 26 (34.7%) 75 (100%) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article smoking had less extremely severe stress (50.7%) compared to those without history of smoking (49.3%. there is no statistically significant association between the history of smoking (smoker and non-smoker) with depression (p=0.781) and anxiety (p=0.501). most respondents expressed significant stress, despair, and anxiety. a study among a similar age group of syrian refugees demonstrates the need for psychological services due to the high level of low quality of life as a result of psychological disorders in kurdistan refugee camps [7]. research from sweden reveals a high level of stress disorder and depression between the ages of 18-64 years old [12]. our findings indicate that there is a statistically significant difference between smoking history and table 5 shows a statistically significant association between smoking history (smoker and non-smoker) and stress (p=0.006). the percentage of participants with a history of smoking had severe stress (56.5%) compared with those who do not have a past history of smoking (43.5%). participants with a history of in the present study, we focused to assess the level of psychological aspects such as depression, anxiety, and stress among refugees in the kurdistan region. men experience severe stress more than females, whereas males suffer very severe stress more than females. in contrast, a study in istanbul shows a significant association between depression and gender [4]. in our study, most respondents expressed exteremly severe anxiety (47.5%), anxiety (35.8%), and normal stress (32.3%), 29 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion table 5 :association between the history of smoking and (depression, anxiety, and stress) using the chi-square test levels history of smoking total chisquare pvalue presence absence depression normal n (%) 4 (50%) 4 (50%) 8 (100%) 1.755 0.781 mild n (%) 6 (54.5%) 5 (45.5%) 11 (100%) moderate n (%) 62 (57.4%) 46 (42.6%) 108 (100%) severe n (%) 46 (55.4%) 37 (44.6%) 83 (100%) extremely severe n (%) 95 (50%) 95 (50%) 190 (100%) anxiety normal n (%) 18 (58.1%) 13 (41.9%) 31 (100%) 3.352 0.501 mild n (%) 9 (47.4%) 10 (52.6%) 19 (100%) moderate n (%) 70 (51.5%) 66 (48.5%) 136 (100%) severe n (%) 33 (46.5%) 38 (53.5%) 71 (100%) extremely severe n (%) 83 (58%) 60 (42%) 143 (100%) stress normal n (%) 55 (42.6%) 74 (57.4%) 129 (100%) 12.586 0.006 moderate n (%) 68 (65.4%) 36 (34.6%) 104 (100%) severe n (%) 52 (56.5%) 40 (43.5%) 92 (100%) extremely severe n (%) 38 (50.7%) 37 (49.3%) 75 (100%) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article [1] unhcr iraq: 2021 participatory assessment of refugees and asylum-seekers (june – august 2021) iraq | reliefweb [internet]. 2021 [cited 2022 jun 24]. available from. [2] mahmood hn, ibrahim h, goessmann k, ismail aa, neuner f. post-traumatic stress disorder and depression among syrian refugees residing in the kurdistan region of iraq. confl health. 2019;13:51. available from. [3] nissen a, cauley p, saboonchi f, j andersen a, solberg ø. mental health in adult refugees from syria resettled in norway between 2015 and 2017: a nationwide, questionnaire-based, cross-sectional prevalence study. eur j psychotraumatology. 2021;12 (1):1994218. available from. [4] acarturk c, mcgrath m, roberts b, ilkkursun z, cuijpers p, sijbrandij m, et al. prevalence and predictors of common mental disorders among syrian refugees in istanbul, turkey: a cross-sectional study. soc psychiatry psychiatr epidemiol. 2021 mar;56(3):475–84. available from. [5] tejada jj, punzalan jr. on the misuse of slovin’s formula. the philippine statistician. 2012;61(1):129-36. [6] leiler a, bjärtå a, ekdahl j, wasteson e. mental health and quality of life among asylum seekers and refugees living in refugee housing facilities in sweden. soc psychiatry psychiatr epidemiol. 2019 may;54(5):543– 51. available from. [7] aziz ia, hutchinson cv, maltby j. quality of life of syrian refugees living in camps in the kurdistan region of iraq. peerj. 2014;2:e670. available from. [8] böge k, hahn e, strasser j, schweininger s, bajbouj m, karnouk c. psychotherapy in the kurdistan region of iraq (kri): preferences and expectations of the kurdish host community, internally displacedand syrian refugee community. int j soc psychiatry. 2022 mar;68(2):346–53. available from. [9] fuhr dc, acarturk c, mcgrath m, ilkkursun z, sondorp e, sijbrandij m, et al. treatment gap and mental health service use among syrian refugees in sultanbeyli, istanbul: a crosssectional survey. epidemiol psychiatr sci. 2019 nov 15;29:e70. available from. [10] eslam parast n, taştekin ouyaba a. the impact of the demographic and migration process factors of refugee women on quality of life and the mediating role of mental health. stress (p=0.006). the percentage of history smokers have more severe stress (56.5%) in table 5 mention than those who do not have a smoking history, whereas the percentage of history smokers has less extremely severe stress than those who do not have a smoking history ((49.3%)). some of the respondents used tobacco as a means of reducing their stress [13]. while kurdish migrants used tobacco as a stress reliever, pre-migration trauma appeared to be related to lifelong tobacco use in finland and russia [14]. additionally, syrian refugees in lebanon are inactive and smokers. humanitarian organizations are developing regional healthcare systems as the crisis persists to give refugee populations better mental health services [15]. this study shows that the majority of the refugee population screened positive for depression, anxiety, and stress. there were statistically significant association between stress and gender. also, different levels of stress correlated with smoking habits. we recommend further study on refugees based on mental health promotion by more competent authorities. i would like to thank the higher education committee/ college of nursing for guiding us in the research process. the authors have disclosed no potential conflicts of interest or sources of financial assistance. 30 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. references conclusion acknowledgements conflict of interest https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.03 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article perspect psychiatr care [internet]. 2022 [cited 2022 jun 25];58(2):785–94. available from. [11] aroian k, uddin n, blbas h. longitudinal study of stress, social support, and depression in married arab immigrant women. health care for women international. 2017 feb 1;38(2):100-17. [12] tinghög p, malm a, arwidson c, sigvardsdotter e, lundin a, saboonchi f. prevalence of mental ill health, traumas and postmigration stress among refugees from syria resettled in sweden after 2011: a population-based survey. bmj open. 2017 dec 29;7(12):e018899. available from. [13] mehra r, mohanty vr, y b a, mehra k, kapoor s. afghan frontier: understanding tobacco practices among migrant population in india. asian pac j cancer prev apjcp. 2020 jul 1;21(7):1931–7. avialable from. [14] salama es, castaneda ae, lilja e, suvisaari j, rask s, laatikainen t, et al. pre-migration traumatic experiences, post-migration perceived discrimination and substance use among russian and kurdish migrants-a population-based study. addict abingdon engl. 2020 jun;115(6):1160–71. available from. [15] sethi s, jonsson r, skaff r, tyler f. community-based noncommunicable disease care for syrian refugees in lebanon. glob health sci pract. 2017 sep 27;5(3):495–506. available from. 31 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.05 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article nurses’ experiences during the covid-19 pandemic in duhok city abstract introduction the covid-19 outbreak was reported for the first time in wuhan, china, in december 2019[1]. it quickly became an international health crisis impacting physical, psychological, social, and economical status of people around the world [2, 3]. the virus is transmitted from person to person through respiratory droplets, unsanitary and highly crowded places, and enclosed environments[1]. the rapid background and objectives: covid-19 is one of the health issues that has had a major impact on health services all around the world. it was declared a pandemic on march 11, 2021. the nurses were on the frontline of the fight against the covid-19, which had physical, psychological, social, and economic effects on health and health outcomes. it is crucial that nurses’ experiences during the pandemic are identified. this study aimed to explore nurses’ experiences, knowledge, and practices regarding the pandemic. methods: a cross-sectional study was conducted among nurses in the duhok city in the kurdistan region of iraq. the online survey was distributed to nurses using a structured questionnaire. the number of nurses who participated in the study was 110. the data collection was conducted from 10th may to 10th august 2021. data analysis was conducted using spss statistical software (version 23.0). descriptive statistical analysis was conducted using frequency, percentage, mean, and standard deviation. results: the study revealed that the mean age of nurses was 30 years with a standard deviation of 7 years. the highest percentage of the nurses (44.5) were a bachelor’s degree holders. the nurses had concerns regarding their employment status, workload, and threatened to leave their job. having sufficient personal protective devices and work protocols to help decrease the risk of infection and stress and anxiety were important issues. nurses need more training and support systems from leaders and employers to go forward and work safely and comfortably. conclusions: the study highlighted essential points regarding the nurses’ experiences during the pandemic such as the impact of workload, shortage in staffing, threatened termination of employment, and having to do non-nursing activities or tasks. it was clear that the nurse managers have a significant role in providing efficient support to nurses. creating a safe work environment and essential guidelines is crucial for promoting a better quality of care during the pandemic. keywords: covid-19; nursing care; pandemic ronak hassan barwari; department of nursing, college of nursing, duhok university, duhok, iraq. (correspondence: ronak.muhammad@uod.ac) sarah jawad kadhim; department of nursing, college of nursing, duhok university, duhok, iraq. khalid ibrahim mohammed; department of nursing, college of nursing, duhok university, duhok, iraq. 43 erbil journal of nursing & midwifery received: 08/12/2021 accepted: 13/02/2022 published: 30/05/2022 mailto:ronak.muhammad@uod.ac https://doi.org/10.15218/ejnm.2022.05 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article spread of covid-19 resulted in a major risk to public health and economic systems globally. it changed the daily life of people significantly [4], becoming a public health emergency with a high rate of deaths, hospitalizations, and socio-economic disruption. the lack of hospital capacity, insufficient numbers of personal protective equipment, and insufficient ventilators were significant issues among the affected countries [5]. the pandemic impacted all health care providers, but especially nurses [6]. nurses are a crucial part of the health care system in responding to health crises, pandemics, and epidemics. the nurses were in the frontline to fight the covid-19 pandemic [7]. nurses provide direct patient care and play a key role to reduce the risk of exposure to infectious disease[8]. however, they are vulnerable to being infected because of their direct contact with the infected patients and their family members [9]. nurses’ knowledge of disease influences their attitudes and practices as any incorrect attitudes or practices increase the risk of disease transmission [6]. as a result of the pandemic, the health care workers get exhausted, impacted financially, and psychologically, often suffering from uncertainty, fear, anxiety, and dread, which have been reported globally [10]. furthermore, the health care system increases the demand for manpower and resources for prevention and treatment requirements [1]. nurses are the main members of a health care system who must control, treat, and prevent the spread of infectious diseases. moreover, they are responsible for providing care, and a variety of procedures in responding to patient needs that enhance the health of individuals as a result of the covid-19 virus [1]. despite the professional obligation of nurses toward their patients and the community during the pandemic, their concerns regarding their work and the risk of being infected or transmitting the disease to family members and friends increased significantly [8]. therefore, this study was conducted to identify nurses’ experience of the pandemic and to understand and identify the implications of the pandemic on their knowledge, access to personal protective equipment, nursing care and employment status. the purpose of this study was to explore nurses’ experiences during the pandemic and identify its impact on themselves and patient outcomes. the cross-sectional study design was conducted among nurses at teaching hospitals in duhok city. a total of 300 nurses were invited to participate in this study. the survey was distributed through an online link. the inclusion criteria encompassed all male and female nurses with different degrees in a nursing specialty, have one year and more of experience, and worked in different units of hospitals. the nurses who had less than one year of experience and worked at out-patient clinics were excluded from the study. the study was undertaken between may and august 2021 at the teaching hospitals in duhok city in the kurdistan region of iraq. after obtaining approval from the scientific committee of the college of nursing of university of duhok, the survey link was sent through emails and viber groups to the nurses. the informed consent was obtained from the nurses. nurses who agreed to participate in the study were asked to click on the survey link and respond to the survey. a total of 110 nurses participated in the study. the sample size was estimated based on slovin's formula which is a random sampling technique formula to measure sampling size. the formula is: n = n / (1+ne2). n = no. of samples n = total population 44 erbil journal of nursing & midwifery methods https://doi.org/10.15218/ejnm.2022.05 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article years with an sd of 6. results of table 1 show the mean score of weekly working hours that was 38 hours before the pandemic decreasing to 30 hours during the pandemic. e = error margin / margin of error (0.05) in our study, the total number of nurses at three public hospitals is 556. 556 / (1 + 556 * 0.5²) = 233 nurses. the response rate in this study was estimated at 233/556*100= 20%. the questionnaire was adapted and modified for the study purpose[3]. the modified survey consisted of two parts: part i was related to the participants’ demographics and part ii involved the survey items. part ii contained three subscales: the nurses’ professional experiences subscale included seven items, the nurses’ knowledge of covid-19 pandemic contained six items, and the nurses’ clinical practice subscale included six items. the response to all items was done by either yes or no. data analysis was conducted using spss version 23. descriptive statistics were applied to analyse the demographics, nurses’ experience, knowledge, and practices such as the frequency, percentage, mean, and standard deviation. the mean age of nurses was 30 years with ± 7 sd. the percentage of female nurses was 41.8%, while the percentage of male nurses was 58.2%. regarding the level of education of the participants, less than 10% of nurses had post-graduate degrees, almost half of the nurses had bachelors’ degrees (44.5%). the percentage of nurses who have graduated from the nursing institute was 42.7%, and only five nurses were graduated from nursing high school. results of the present study show that more than half of the nurses were married 51.8%, and 47.3% were single. regarding the unit of work 42.7 % of the nurses work in the intensive care unit, the number of participants who worked in the medical wards was 30%, and only three nurses were working in the emergency room. the calculated mean of experience years was 7 45 erbil journal of nursing & midwifery results table 1: nurses demographics demographics f (%) agemean ±sd = 30±7 110 (100) gender male 64 (58.2) female 46 (41.8) level of education postgraduate 9 (8.20) bachelor degree 49 (44.5) nursing institute 47 (42.7) school of nursing 5 (4.5) marital status married 57 (51.8) single 52 (47.3) divorced 1 (0.9) area of work (unit) critical care units (icu, ccu, hdu) 47 (42.7) surgical units 21 (19.1) medical units 33 (30) maternal and pediatric units 6 (5.5) emergency room 3 (2.7) total 110 (100) mean ±sd years of experience 7±6 weekly working hours before covid pandemic 38±28 weekly working hours during covid pandemic 30±25 https://doi.org/10.15218/ejnm.2022.05 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article 42.7%, and 53.6 % of the nurses experienced an increase in their employment hours during the pandemic. a high percentage of the nurses (59.1%) threatened to terminate their job and 47.3% were thinking about leaving their job. in addition, 70.9% of the nurses stated that they did non-nursing duties. covid-19 on health care workers including nurses. furthermore, 84.5% of the nurses knew that they were working in a high-risk environment. more than half of the participants (60.9%) stated that they got support from their employers. 46 table 2 shows that majority of nurses responded with yes for the experience items. the highest percent of the nurses (77.3%) declared the issue with the workload, understaffing, and lack of resources. the percentage of nurses who never had experience with chronic infectious diseases was table 3 shows nurses’ knowledge regarding covid-19. most of the nurses (91.8%) were knowledgeable regarding protecting themselves and their patients from the infection. the study results demonstrate that 90.9% of the nurses understand the risk of erbil journal of nursing & midwifery table 2: nurses’ experiences after the covid-19 pandemic nurses’ experiences yes no f (%) f (%) 1. experience with infectious illnesses (e.g., hepatitis virus) 63 (57.3) 47 (42.7) 2. increased hours of employment per week because of the pandemic 59 (53.6) 51 (46.4) 3. threatened termination of employment because of the pandemic 65 (59.1) 45 (40.9) 4. did you face workload, understaffing and lack of resources 85 (77.3) 25 (22.7) 5. reductions in nursing role (fewer tasks to do). 60 (54.5) 50 (45.5) 6. additional tasks within nursing role doing non-nursing duties. 78 (70.9) 32 (29.1) 7. did you think about leaving your job because of the pandemic? 52 (47.3) 58 (52.7) table 3: nurses’ knowledge regarding covid-19 pandemic nurses’ knowledge yes no f (%) f (%) 1. at present, i have sufficient knowledge of covid-19 77 (70) 33 (30) 2. understand the risks of covid-19 on patients and healthcare workers 100 (90.9) 10 (9.1) 3. i understand how to protect myself during the pandemic 101 (91.8) 9 (8.2) 4. i understand how to protect my patients during the pandemic 101 (91.8) 9 (8.2) 5. i feel that my work put my health at risk during the pandemic. 93 (84.5) 17 (15.5) 6. i feel well supported in my clinical role by my employer. 67 (60.9) 43 (39.1) https://doi.org/10.15218/ejnm.2022.05 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article personal protective equipment. moreover, the percentage of nurses who never got trained to work for covid-19 patients was 50.9%. the results show that 77.3 of nurses followed infection protection measures. fear of getting infected. also, nurses were concerned about doing additional tasks that were not related to their profession. this had a negative impact on their work and made them think about leaving their job. being threatened to lose or actual loss of employment during the pandemic was identified [3].it was clear that the nurses experienced a more stressful working environment because of increase in workload, lack of resources, nursing shortages, nonursing tasks, and burnout. the virus adversely affected health care providers’ job commitment and made them more anxious [14]. also, the anxiety and stress of the pandemic resulted in work dropout [14, 15]. it impacted nurses’ work and their thoughts to quit their job because of the pandemic. while, in another study, nurses did not intend to leave their job because of the pandemic[16]. protecting nurses who are in high-risk areas requires local, national, and international strategies to provide sufficient protective devices [11, 13]. moreover, having information and sufficient understanding related to the pandemic risk and using protective measures 47 erbil journal of nursing & midwifery table 4 reveals that 88.2% of the nurses knew the importance of wearing personal protective equipment during work. also, 70% of the nurses understood the importance of social distancing and wearing the covid-19 pandemic affected the kurdistan region of iraq with a large number of suspected and confirmed cases and the transmission of the virus to the health care providers [11]. providing health care services during the pandemic had significant impact on nurses [12]. they were aware of the danger of working in an environment that endangers their lives, family members, friends, and colleagues. based on our results, nurses’ working hours increased during the pandemic. it might be related to the shortages in nurses at duhok hospitals and the admission of a high numbers of covid-19 patients to the hospitals for treatment. in addition, there was an increase in nurses’ time off work because of the home quarantine when they were infected or had direct contact with infected people [13]. in comparison, a study that was conducted in australia showed that the working hours of nurses decreased during the pandemic[3]. this shortage was connected to the threatened termination of employment, and it was identified by the nurses in this study. it might be theresult of the stress of the pandemic and table 4: nurses’ practice regarding covid-19 pandemic nurses’ practices yes no f (%) f (%) 1. have you been trained to work for covid-19 patients? 54 (49.1 56 (50.9) 2. have you followed social distancing? 77 (70) 33 (30) 3. have you been wearing a mask and gloves during the hospital practice? 97 (88.2) 13 (11.8) 4. do you regularly follow infection protection measures? 85 (77.3) 25 (22.7) 5. i have sufficient personal protective equipment in my workplace 69 (62.7) 41 (37.3) 6. do you have guidelines about the use of personal protective equipment? 65 (59.1) 45 (40.9) discussion https://doi.org/10.15218/ejnm.2022.05 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article is required to protect them and mitigate psychological distress [16, 17]. nurses sacrificed their lives during the pandemic to care for patients [5]. however, in our study, some nurses were not satisfied with their employer’s support despite their hard work in high-risk environment. to alleviate the challenges related to working in highrisk settings, nurses need adequate support from hospital leaders and managers to continue their work and reduce that burden [18]. support systems and healthy work environments enhance the quality of care and commitment to work during critical times[19]. to ensure that the nurses are protected and able to provide nursing care, nurses must receive mental health support [3]. an unsafe environment during the pandemic increases turnover and retention issues [20]. the support system is important to be considered by the nursing leaders through the pandemic outbreak, especially for younger or less experienced nurses [12, 21, 22]. to help those nurses who provided direct care for suspected or confirmed cases of covid-19, it is suggested to give them formal leave days [21]. having guidelines regarding the safety measures is helpful for the nurses to feel more comfortable and supported in their work. the nurse leaders should ensure that the nurses’ work is based on a guidelines and consistent with protocols to provide health care efficiently. nurses require governments, policymakers, and nursing groups to engage in supporting nurses during the pandemic [8]. because increased risk of nurses being infected, it is important to develop specific protocols to reduce the risk of infection and interactions with covid -19 patients [9].concerning nurses’ health, the use of strict measures such as the practice of good personal hygiene, social distancing, using personal protective equipment appropriately involved wearing suits, masks, gloves, eye, and foot protective barriers, and following infection control measures were factors considered by the nurses through their practices. the shortage of protective equipment and resources impacts negatively on the quality of care [18]. moreover, nurses’ education and training through the pandemic regarding protective measures are helpful to decrease infection transmission [9]. as it shows, the lack of nurses’ experience about the pandemic increases the risk of infection [14].helping nurses to follow reliable sources for the care of a covid-19 patients, for example, assessment of their condition, and possibilities to deliver them special nursing care are important. furthermore, nurses need to participate in educational programs, and attend lessons that can greatly contribute to the development of their information and skills [7]. working together as a team in protecting each other during the pandemic and appreciating their colleagues and sharing their experiences is valuable [8]. the study concluded that the nurses gained valuable experience during the pandemic. they followed the infection control and social distancing measures to protect themselves from infection. to assist nurses and help them bear the difficulties they face while working, it is crucial to consider their protection through providing sufficient protective equipment. nurses need leadership support to go forward and overcome the complexity of putting their health at risk during the pandemic. the majority of nurses were happy with their leaders’ support. the authors would like to thank the nurses who participated in the study. also, special thanks to everyone who helped and supported us to conduct this study. 48 erbil journal of nursing & midwifery conclusion acknowledgment https://doi.org/10.15218/ejnm.2022.05 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article [9] huang l, lin g, tang l, yu l, zhou z. special attention to nurses’ protection during the covid-19 epidemic. springer; 2020. [10] chew c, eysenbach g. pandemics in the age of twitter: content analysis of tweets during the 2009 h1n1 outbreak. plos one. 2010;5 (11):e14118. [11] al‐abrrow h, al‐maatoq m, alharbi rk, alnoor a, abdullah ho, abbas s, et al. understanding employees’ responses to the covid ‐19 pandemic: the attractiveness of healthcare jobs. global business and organizational excellence. 2021;40(2):19-33. [12] roberts n, mcaloney-kocaman k, lippiett k, ray e, welch l, kelly c. levels of resilience, anxiety and depression in nurses working in respiratory clinical areas during the covid pandemic. respiratory medicine. 2021;176:106219. [13] mascha ej, schober p, schefold jc, stueber f, luedi mm. staffing with disease-based epidemiologic indices may reduce shortage of intensive care unit staff during the covid19 pandemic. anesthesia and analgesia. 2020;131(1):24. [14] godderis l, boone a, bakusic j. covid-19: a new work-related disease threatening healthcare workers. oxford university press uk; 2020. p. 315-316. [15] franck e, haegdorens f, goossens e, van gils y, portzky m, somville f, et al. the role of coping behavior in healthcare workers' distress and somatization during the covid19 pandemic. frontiers in psychology. 2021;12. [16] rose s, hartnett j, pillai s. healthcare worker’s emotions, perceived stressors and coping mechanisms during the covid-19 pandemic. plos one. 2021;16(7):e0254252. [17] cai z, cui q, liu z, li j, gong x, liu j, et al. nurses endured high risks of psychological problems under the epidemic of covid-19 in a longitudinal study in wuhan china. journal of psychiatric research. 2020;131:132-137. [18] karimi z, fereidouni z, behnammoghadam m, alimohammadi n, mousavizadeh a, salehi t, et al. the lived experience of nurses caring for patients with covid-19 in iran: a phenomenological study. risk management and healthcare policy. 2020;13:1271. [19] khalid i, khalid tj, qabajah mr, barnard ag, qushmaq ia. healthcare workers emotions, perceived stressors and coping strategies during a mers-cov outbreak. clinical medicine & research. 2016;14(1):7-14. the authors received no financial support for the research. the authors declare that they have no conflict of interest. [1] shu-ching c, yeur-hur l, shiow-luan t. nursing perspectives on the impacts of covid-19. journal of nursing research. 2020;28(3):e85. [2] ammar a, chtourou h, boukhris o, trabelsi k, masmoudi l, brach m, et al. covid19 home confinement negatively impacts social participation and life satisfaction: a worldwide multicenter study. international journal of environmental research and public health. 2020;17(17):6237. [3] halcomb e, mcinnes s, williams a, ashley c, james s, fernandez r, et al. the experiences of primary healthcare nurses during the covid‐19 pandemic in australia. journal of nursing scholarship. 2020;52(5):553 -563. [4] sheffler jl, joiner te, sachs-ericsson nj. the interpersonal and psychological impacts of covid-19 on risk for late-life suicide. the gerontologist. 2021;61(1):23-29. [5] gunawan j, aungsuroch y, marzilli c, fisher ml, sukarna a. a phenomenological study of the lived experience of nurses in the battle of covid-19. nursing outlook. 2021. [6] zhang y, wang c, pan w, zheng j, gao j, huang x, et al. stress, burnout, and coping strategies of frontline nurses during the covid-19 epidemic in wuhan and shanghai, china. frontiers in psychiatry. 2020;11:1154. [7] sheng q, zhang x, wang x, cai c. the influence of experiences of involvement in the covid‐19 rescue task on the professional identity among chinese nurses: a qualitative study. journal of nursing management. 2020;28(7):1662-1669. [8] fernandez r, lord h, halcomb e, moxham l, middleton r, alananzeh i, et al. implications for covid-19: a systematic review of nurses’ experiences of working in acute care hospital settings during a respiratory pandemic. international journal of nursing studies. 2020;111:103637. 49 erbil journal of nursing & midwifery funding conflict of interest references https://doi.org/10.15218/ejnm.2022.05 erbil j. nurs. midwifery, vol. 5, no. (1), may 2022 original article [20] wood e, king r, senek m, robertson s, taylor b, tod a, et al. uk advanced practice nurses’ experiences of the covid-19 pandemic: a mixed-methods crosssectional study. bmj open. 2021;11 (3):e044139. [21] huang l, chen c, chen s, wang h. roles of nurses and national nurses associations in combating covid‐19: taiwan experience. international nursing review. 2020;67 (3):318-322. [22] abdulah dm, mohammedsadiq ha, liamputtong p. experiences of nurses amidst giving care to covid‐19 patients in clinical settings in iraqi kurdistan: a qualitative descriptive study. journal of clinical nursing. 2021. 50 erbil journal of nursing & midwifery https://doi.org/10.15218/ejnm.2024.02 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article quality of nursing care for neonates with respiratory distress syndrome at neonatal intensive care unit in teaching hospitals in erbil city abstract background and objective: quality of nursing care has an important role in providing the highest care to neonates in the neonatal intensive care unit. improvement in the quality of nursing care is a main goal of the nurses. the study aimed to assess the quality of nursing care for neonates with respiratory distress syndrome. methods: a descriptive cross-sectional study was conducted on 50 nurses at neonatal intensive care units in teaching hospitals (rapareen teaching hospital for children and maternity teaching hospital) in erbil city. a convenience sampling technique was used to collect the data. two tools were used to collect the data which was developed by the researcher: the first tool was a self-administered questionnaire which contained two parts (sociodemographic characteristics, and questions related to neonatal respiratory distress syndrome), and the second tool was an observational checklist that was used to assess the quality of nursing care for nrds. the statistical package for social science was used to analyze the data (version 23) presenting descriptive and inferential statistics, including the chi-square test, fisher exact test, frequency, and percentage. results: more than half (54%) of the nurses were within the age group of 25-34 years. 62% of the nurses graduated from the college of nursing, 58% of the nurses were female, and the majority (88%) of the nurses were married. the highest percentage (64%) of the nurses had a good level of knowledge, while the highest percentage (74%) of the nurses had a fair level of quality nursing care. a highly significant association was found between the quality of nursing care with educational level and the duration of the training course. also, there was a weak positive correlation between the level of nurses’ knowledge and the quality of nursing. conclusion: based on the study findings of the present study, it was concluded that the highest percentage of the nurses had a good level of knowledge, and the high percentage of the nurses had a fair level of quality nursing care. keywords: quality of nursing care; neonates; nicu; nrds. jihad rasool mamo; department of nursing, college of nursing, hawler medical university, kurdistan region, iraq. (correspondence: jihadsenaway@gmail.com ) norhan zaki shaker; department of nursing, college of nursing, hawler medical university and tishk international university, kurdistan region, iraq. 10 received: 31/08/2022 accepted: 29/10/2022 published: 30/05/2024 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:jihadsenaway@gmail.com?subject=jihadsenaway@gmail.com%20%20%20%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article neonatal respiratory distress syndrome (nrds) is a potentially fatal condition caused by underdeveloped lungs and small alveoli in preterm infants that results from a surfactant deficiency and a decreased alveolar surface area available for gas exchange [1]. respiratory distress syndrome affects neonates born before 34 weeks of gestational age, and the most common causes of mortality rate among neonates in the first hours after birth are rds, prematurity and low birth weight [2]. respiratory distress syndrome can injure a preterm infant's lungs, which increases their chance of developing bronchopulmonary dysplasia [14].in the neonatal intensive care unit, nurses play an important role in the care of neonates with rds. also with technical skills, the care of the neonate with rds requires a high degree of interpersonal skills, and nursing services are the basis of the healthcare system [10].within a few minutes after delivery, the symptoms of respiratory distress syndrome appear like the blush of the skin (cyanosis), grunting, nasal flaring, deep respiration, use of the chest muscles, dyspnea, and apnea. at that time, the preterm neonates need emergency treatment in neonatal resuscitation healthcare [3].neonatal respiratory distress syndrome affects about 50% of newborns which born between 26 and 28 weeks of pregnancy, although fewer than 30% of preterm newborns are born between 3031 weeks of pregnancy [3]. respiratory distress syndrome is the main cause of admission of neonates to the neonatal intensive care unit (nicu), the incidence rate of nrds is approximately 7.8% among neonates. also, respiratory distress syndrome was the main leading cause of mortality among 50% of premature neonates[4]. in iraq, about 42% of infants die within the 28th day of life [5]. the incidence of nrds decreases as the gestational age increases [6].nurses have a critical role in decreasing the mortality rate among neonates with rds, through physical examination, assessing the respiratory rate, observing for grunting, suctioning, using cpap, using ventilator machines, and assessing the severity of rds. respiratory distress syndrome is more common in newborns born before 34 weeks of gestation. a family history of respiratory distress syndrome, neonates born by cesarean section, neonates with diabetic mothers, cold stress, hypoxia, and premature birth are the main attributed causes of nrds [7]. there were studies carried out in nondeveloped countries, such as egypt, turkey, and saudi arabia, that discovered that nurses had weak knowledge and practice, and were responsible for providing care for premature neonates with rds [8,9].the study aims to assess the quality of nursing care in nicus at rapareen teaching hospital for children (rthc) and maternity teaching hospital (mth), furthermore, until the quality of nursing care given to neonates with rds is evaluated, nurses do not know how well they are doing. good nurses’ knowledge and practice reduce their mortality and improve their outcomes [3].previous studies regarding care for neonates with rds had ignored important practices and procedures like suctioning, oxygen therapy, control of infection, and using cpap machines. neonatal respiratory distress syndrome is a significant factor in newborn mortality around the world [13]. invasive respiratory support methods like nasal continuous positive airway pressure (cpap) or non-invasive intermittent positive airway pressure (ncpap) are used to treat nrds. other methods including mechanical ventilation, oxygen therapy, and surfactant therapy are used to treat nrds. 11 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article based on the likert scale as the follows the correct answer was rated (2), and the incorrect answer was rated (1). the level of nurses’ knowledge was scored by calculating the total score of 24 items related to nurses’ knowledge as follows: low scores (24-32) represent a poor level, an average score (33–40) represent a fair level of knowledge, and high scores (41-48) represent a good level of the nurses’ knowledge. the second tool was an observational checklist; it was developed based on the usual nursing care that nurses should offer in the nicu. this part consists of 63 items, which were divided into 14 domains as follows: assessment ( 6 items), oxygen therapy administration (6 items), suctioning (7 items), pulse oximetry (5 items), intravenous administration (6 items), cannulation (10 items), infection control (7 items), chest physiotherapy (1 item), incubator care (5 items), maintaining thermoregulation (2 items), psychological support (1 item), nasogastric tube insertion (8 items), ng tube feeding (6 items), and documentation (1 item). regarding rating and scoring the quality of nursing care based on the likert scale. it was scored as the follows the completely done was given the score (3), the incompletely done was given the score (2), and the not done was given the score (1). the calculation of overall items regarding the quality of nursing care was categorized into three levels: low scores (63-104) represent a poor level of quality of nursing care, an average score (105–146) represents a fair level of quality of nursing care, and scores (147-189) represents a good level of quality of nursing care. the total score of each domain related to nurses’ knowledge was calculated by the mean of the score and classified into three levels as follows: a low mean score (1-1.33) represents a poor level, an average mean score (1.34-1.66) represents a fair level, and high mean score (1.67-2) a descriptive cross-sectional study was conducted on 50 nurses, 20 nurses from the nicu in rthc, 11 nurses from the pediatric intensive care unit (picu) in rthc, and 19 nurses from the nicu in mth in erbil city/ kurdistan region, from 1st november 2021 to 1st november 2022. a non -probability/convenience sampling technique was used to collect the data. the scientific and ethics committee of the college of nursing at hawler medical university gave its approval to the study (code 113) on 7/10/2021 before starting the research. the formal consent form was obtained from the general directorate of health in erbil, rapareen teaching hospital for children and maternity teaching hospital to conduct the study. the result of cronbach's alpha was 0.92 for the first group of nurses, and 0.87 for the second group of nurses which was statistically adequate. these results reflected the reliability of the tools. a relevant questionnaire and observational checklist were developed and designed based on a relevant literature review. two tools were used for data collection: the first tool was a selfadministered questionnaire, which consisted of two parts. the first part was composed of socio-demographic and professional data of the nurses, including age, gender, place of work, educational level, attending training courses, and marital status. the second part consisted of 24 questions related to nurses’ knowledge regarding nrds. it was divided into eight domains as follows: definition (1 question), cause (1 question), risk factors (3 questions), signs and symptoms (3 questions), complications (2 questions), surfactant(3), prevention(2 questions), and nurses’ knowledge regarding nursing care(9 questions). regarding rating and scoring of the scales, the nurses’ knowledge was scored 12 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article represents a good level. the total score of each domain related to the quality of nursing care was calculated by the mean of the score and classified into three levels as follows: a low mean score (1-1.66) represents a poor level, an average mean score (1.672.33) represents a fair level, and a mean score (2.34-3) represents a good level. nurses who agreed to participate in the study and who worked in nicus for at least six months were required inclusion criteria. volunteer nurses who worked in the nicu were among the study's exclusion criteria and were also nurses with less than six months of experience. the data were analyzed using ibm's statistical package for social sciences (spss) version 23. initially, to summarize numerical data, the mean was computed, and proportions were computed for categorical variables. to find out the association between the level of nurses’ knowledge, and practice with sociodemographic characteristics, the chisquare test was used. in cases, where 20% or more of the cells had less than five, fisher exact tests were used, and spearman’s rank correlation coefficient was used to find out the direction and correlation between the level of nurses’ knowledge and the quality of nursing care. table 1 shows that more than half (54%) of the nurses were within the age group of 25 -34 years the mean and standard deviation for the age range were 37.4 ± 8.3. the highest percentage (62%) of the nurses graduated from the college of nursing, while more than half (58%) of the nurses were female, and the majority (88%) of the nurses were married. also, table 1 shows that a high percentage (58%) of the nurses had the experience of 1-10 years in nursing, less than half (44%) of the nurses participated in training courses regarding care for neonates, and more than half (59.1%) of the nurses participated in the training courses for more than 1 week. 13 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result table 1: socio-demographic characteristics of the nurses items (n*= 50) variables no.** (%)*** places of work nicurthc nicu-mth picu-rthc 20 19 11 (40) (38) (22) age group ( years) 25-34 yrs. 27 (54) 35-44 yrs. 11 (22) 45-54 yrs. 10 (20) ≥55 2 (4) educational level nursing school graduate preparatory nursing school nursing institute graduate nursing college graduate 0 6 13 31 (0) (12) (26) (62) gender male female 21 29 (42) (58) marital status single married 6 44 (12) (88) are you satisfied with your income yes no 26 24 (52) (48) years of experience in nursing 1-10 yrs. 11-20 yrs. 21-30 yrs. ≥31 yrs. 29 12 5 4 (58) (24) (10) (8) years of experience in nicu 1-5 yrs. 6-10 yrs. 11-15 yrs. ≥16 yrs. 22 19 5 4 (44) (38) (10) (8) training course yes no 22 28 (44) (56) if yes: duration of course < 1week >1week 9 13 (40) (59) total 50 (100) • = number of the study samples • **= frequency • *** = percentage https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 14 mean score (1.82), while less than threequarters (70%)of the nurses had a good level of knowledge regarding the complications of nrds, and there was a high total mean (1.83).less than half (42%) of the nurses had a fair level of knowledge regarding surfactants; there was an average total mean (1.55). also, less than (48%) of the nurses had a fair level of knowledge regarding the prevention of nrds, there was an average total mean (1.64). regarding nursing care knowledge in the study a high percentage (64%) of the nurses had a fair level of knowledge, there was an average total mean (1.53). was a low total mean score (1.52). as regards infection control, half (50%) of the nurses had a fair level of quality nursing care, and there was an average total mean of scores (1.92)., more than half (54%) of the nurses had a fair level of quality of nursing care regarding intravenous administration, and there was an average total mean of scores in this domain (2.12).regarding cannulation, around half (52%) of the nurses had a fair level of quality nursing care, there was an average total mean of scores (2.23). also, concerning ng feeding, a high percentage (42%) of the nurses had a fair table 2 shows the nurses’ knowledge regarding nrds. it shows that a high percentage (94%) of the nurses had a good level of knowledge regarding the definition of nrds, and there was a high total mean (1.94). also regarding the causes, more than one-third (68%) of the nurses had a good level of knowledge. and there was a high total mean (1.86). less than threequarters (64%) of the nurses had a good level of knowledge regarding the risk factors of nrds, there was a high mean (1.83). the majority (92%) of the nurses had a good level of knowledge regarding signs and symptoms of nrds ; there was a high table 3 demonstrates that most (70%) of the nurses had a poor level of quality of nursing care regarding the assessment of the neonates with rds; there was a low total mean score (1.43). less than half (44%) of the nurses had a fair level of quality of nursing care regarding oxygen therapy administration, there was an average total mean of scores (2.13). concerning suctioning, less than half (40%) of the nurses had a fair level of quality of nursing care, there was an average total mean (1.92). also, nearly three-quarters (74%) of the nurses had a poor level of quality of nursing care regarding the use of pulse oximetry, there copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: domains of nurses’ knowledge regarding nrds domains of nurses’ poor fair good total m. evaluation no. (%) no. (%) no. (%) define 3 (6) 0 (0) 47 (94) 1.94 good causes 16 (32) 0 (0) 34 (68) 1.86 good risk factor 6 (12) 12 (24) 32 (64) 1.83 good sign and symptoms 0 (0) 4 (8) 46 (92) 1.82 good complications 2 (4) 13 (26) 35 (70) 1.83 good surfactant 15 (30) 21 (42) 14 (28) 1.55 fair prevention 9 (18) 29 (48) 12 (28) 1.64 fair nursing care 3 (6) 32 (64) 15 (30) 1.53 fair total nurses’ knowledge 0 (0) 18 (36) 32 (64) 1.75 good cut-off point: (1-1.33)= poor, (1.34-1.66)= fair, (1.67-2)=good https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article of scores (2.03). as regards psychological support, a high percentage (56%) of the nurses had a poor level of quality of nursing care; there was a low total mean of scores (1.56), regarding documentation, a high percentage (46%) of the nurses had a fair level of quality of nursing care; there was an average total mean (1.68). regarding nrds, and more than one-third (36%) of the nurses had a fair level of knowledge regarding nrds. 15 level, and there was an average total mean (2.01). physiotherapy, a high percentage (90%) of the nurses had a poor level of quality of nursing care, there was a low total mean (1.12).concerning incubator care more than one-third (68%) of the nurses had a poor level of quality nursing, and there was a low total mean figure 1 shows the levels of overall nurses’ knowledge regarding neonates with rds. the highest percentage (64%) of the nurses had a good level of knowledge copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3 :domains of quality of nursing care regarding nrds domains of quality of nursing care poor fair good total m.s evaluation no. (%) no. (%) no. (%) assessment 35 (70) 15 (30) 0 (0) 1.43 poor o2 therapy 12 (24) 22 (44) 16 (32) 2.13 fair suctioning 16 (32) 20 (40) 14 (28) 1.92 fair pulse oximetry 37 (74) 11 (22) 2 (4) 1.52 poor iv administration 2 (4) 28 (54) 20 (40) 2.12 fair cannulation 4 (8) 26 (52) 20 (40) 2.23 fair infection control 16 (32) 25 (50) 9 (18) 1.92 fair incubator care 34 (68) 14 (28) 2 (4) 2.03 fair maintain thermoregulation 14 (28) 21 (42) 15 (30) 2.06 fair ng feeding 9 (18) 21 (42) 20 (40) 2.01 fair documentation 23 (46) 20 (40) 7 (14) 1.68 fair psychological support 28 (56) 15 (30) 7 (14) 1.56 poor chest physiotherapy 45 (90) 4 (8) 1 (2) 1.12 poor total 12 (24) 35 (70) 3 (6) 1.82 fair cut-off point: (1-1.66)= poor, (1.67-2.33)= fair, (2.343)=good figure 1: overall nurses’ knowledge regarding nrds https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article nurses had a poor level of quality of nursing care, and a minority (6%) of the nurses had a good level of quality of nursing care. figure 2 shows overall the levels of quality of nursing care for nrds. less than threequarters (70%) of the nurses had a fair level of quality of nursing care, 24% of the 16 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. figure 2: overall levels of quality of nursing care for nrds. figure 3: correlation between the levels of nurses’ knowledge and the quality of nursing care for nrds https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article age group of the nurses, almost all (100%) of the nurses who had a good level of quality nursing care were in the age group 2534 years (p=0.005). also, there was a highly statistically significant association between the quality of nursing care and educational level (p=0.001). and there was a statistically significant association between the quality of nursing care and the duration of training courses (p=0.050). table 4 shows that there was a statistically non-significant association between the level of quality of nursing care and places of work, gender, marital status, educational level, experience in nursing, experience in the nicu and participation in training courses (p=0.110)(p=0.880)( p=1.000) ( p=0.526)( p=0.091)( p=0.794)( p=0.468). also, table 4 shows that there was a statistically highly significant association between the quality of nursing care and the 17 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: association between the quality of nursing care and demographic characteristics variables poor fair good total p-value sig. no. (%) no. (%) no. (%) no. (%) places of work nicu in rthc 5 (25) 15 (75) 0 (0) 20 (100) 0.110* n.s nicu in mth 5 (26) 13 (68.4) 1 (05.3) 19 (100) picu in rthc 0 (0) 9 (81.8) 2 (18.2) 11 (100) gender male female 5 (23.8) 5 (17.2) 15 (71.4) 22 (75.9) 1 (4.1) 2 (6.9) 21 (100) 29 (100) 0.880* n.s age group 25-34 yrs. 1 (3.7) 23 (83.2) 3 (11.1) 27 (100) 0.005* h.s 35-44 yrs. 3 (27.3) 8 (72.7) 0 (0) 11 (100) 45-54 yrs. 6 (60) 4 (40) 0 (0) 10 (100) ≥55 yrs. 0 (0) 2 (100) 0 (0) 2 (100) marital status single married 1 (16.7) 9 (20.5) 5 (83.3) 32 (72.7) 0 (0) 3 (06.8) 6 (100) 44 (100) 1.000* n.s educational levels preparatory nursing school nursing institute graduate nursing college graduate socioeconomic status satisfy with income unsatisfied with income experience in nursing 1-10 yrs. 11-20 yrs. 2130 yrs. ≥31 yrs. experience in nicu 1-5 yrs. 6-10 yrs. 11-15 yrs. ≥ 15 yrs. participation in the training course yes no duration of course <1 week >1 week 5 (83.3) 5 (38.5) 0 (0) 4 (15.4) 6 (25.0) 2 (06.9) 4 (33.3) 2 (40) 2 (50) 4 (18.2) 3 (15.8) 1 (20) 2 (50) 3 (13.6) 7 (25) 3 (33.3) 0 (0) 1 (16.7) 8 (68.5) 28 (90.3) 21 (80.8) 16 (66.7) 24 (82.8) 8 (66.7) 3 (60) 2 (50) 16 (72.7) 15 (78.9) 4 (80) 2 (50) 17 (77.3) 20 (71.4) 5 (55.6) 12 (92.3) 0 (0) 0 (0) 3 (9.7) 1 (3.8) 2 (8.3) 3 (10.3) 0 (0) 0 (0) 0 (0) 2 (9.1) 1 (05.3) 0 (0) 0 (0) 2 (9.1) 1 (3.6) 1 (11.1) 1 (7.7) 6 (100) 13 (100) 31 (100) 26 (100) 24 (100) 29 (100) 12 (100) 5 (100) 4 (100) 22 (100) 19 (100) 5 (100) 4 (100) 22 (100) 28 (100) 9 (100) 13 (100) 0.000* 0.526* 0.091* 0.794* 0.468* 0.050* vhs n.s n.s n.s n.s s total 10 (20) 37 (74) 3 (6) 50 (100) n.s= non-significant, s= significant h.s= highly significant vhs= very highly significant *=by fishers exact test https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article participate in the training courses, which may be due to a lack of training courses regarding care for neonates. this result was similar to a study done at zagazig university children's hospital in egypt by mohamed et al, who revealed that more than half of the study participants did not participate in the training courses [20]. also, the result of the current study shows that among nurses who participated in training courses more than half of the study nurses participated in the training courses for more than one week, while less than half of them participated for less than one week. the findings of the present study disagree with a cross-sectional study done in iraq by alridh et al, who found that a high percentage of the nurses participated in training courses several times [19].the result of the present study shows that the nurses had a good level of knowledge regarding the definition of nrds. the result of the present study agrees with a crosssectional study done in sudan by ahmad, which found that more than threequarters of the nurses had a good level of knowledge regarding the definition of nrds [14]. the result of the present study disagrees with a cross-sectional study done in port said city in egypt by loutfy et al, which found that the majority of the nurses didn’t know the definition of nrd [28]. regarding causes of nrds, the result of the present study revealed that most of the nurses had a good level of knowledge. however, the result of the present study was inconsistent with the result of the study done by elsayed et al, conducted in saudi arabia, who found that less than half of the nurses had unsatisfied knowledge regarding causes of nrds [29].the result of the study shows that less than twothirds of the nurses had a good level of knowledge regarding the risk factors of nrds. the result disagreed with the result of the study done at khartoum state in the nurses in the nicu are frontline healthcare workers who provide care and prevention for neonates with rds. the ability of the nurses to react to respiratory problems depend on their knowledge and practice. to find out the best understanding, this is the first study conducted in erbil city to demonstrate nurses’ knowledge and quality of nursing care for nrds. we conducted this study to fill a gap in the quality of nursing care and literature related to knowledge and quality of nursing care for nrds. the findings of the present study show that more than half of the nurses were in the age group 25-34 years. the result of the present study was similar to a study done by ali et al, conducted in jordan, which found that most of the nurses were within the age group of 23-33 years old [17].regarding the distribution of the study sample according to their hospitals and departments, the highest percentage of the nurses were from the nicu in rthc, more than one-third of them were from the nicu in mth, and a minority of them were from the picu in rthc. the highest percentage of nurses graduated from the college of nursing. the findings of the current study were supported by a study conducted in egypt by al-ziady et al. who found that a high percentage of nurses graduated from the college of nursing [18]. a high percentage of the nurses were female, this result was supported by a cross-sectional study done in iraq by alridh et al who found that the majority of the study samples were female [19].a high percentage of the nurses had experience in nursing for 1-10 years, the findings of the present study agreed with a study done in alnasiriyah in iraq by aziz and mansi; they found that the majority of the nurses had experience 1-10 years [21]. more than half of the nurses did not 18 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article limited number of nurses. the result was similar to a study done in the kurdistan region/iraq b jamshir km, who mentioned that the nurses had a poor level of quality nursing care for the assessment of neonates [28].as regards oxygen therapy administration, less than half of the nurses had a fair level of quality nursing care.the result of the study agrees with a study done by alfadil and elnageeb, who found that the majority (76%) of the nurses had provided oxygen therapy as needed [22]. concerning suctioning, less than half of the nurses had a fair level of quality nursing care. the result of the current study was supported by the study done in egypt by elsayed, who found that more than half of the nurses had incompetent practice regarding suctioning[9]. also, nearly threequarters of the nurses had a poor level of quality of nursing care regarding the use of pulse oximetry, the result of the study was inconsistent with a study done by masood [23].as regards infection control, half of the nurses had a fair level of quality nursing care. this result was supported by the results of the study done in egypt by mohamad et al in 2019 who found that more than half of the nurses had satisfied practice regarding infection control [24]. the nurses had a fair level of quality nursing care regarding the intravenous administration of medication, and the result of the present study was supported by the result of the study carried out by aziz and mansi, conducted in al-nasriayah in iraq, who found that the majority of the nurses know the way to administer the medication as prescribed [21]. regarding cannulation, more than half of the nurses had a fair level of practice, and only less than onequarter of the nurses wash their hands after cannulation, which may be due to the unavailability of the washbasin in the nicu. also, concerning ng feeding, 42% of the nurses had a fair level; this result sudan by alfadil ma and elnageeb mm, who found that less than two-thirds of the nurses had a poor level of knowledge regarding the risk factors of nrds[22]. regarding the sign and symptoms, the result of the present study shows that the majority of the nurses had a good level of knowledge. the result disagreed with the result of the study done by elsayed et al, who found that more than half of the nurses had unsatisfied knowledge regarding nrds [9].the findings of the present study show that less than half of the nurses had a fair level of knowledge regarding prevention and surfactant. this result was supported by the results of the study conducted in saudi arabia by elsayed et al who found that most of the nurses had unsatisfactory knowledge regarding the prevention of nrds and surfactant [9].regarding the knowledge of the nurses about nursing care for neonates with rds, the result of the study revealed that more than two-thirds of the nurses had a fair level of knowledge. this result agrees with the result of the cross-sectional study done by alfadil ma, conducted in sudan, who found that more than one-third of the nurses had a fair level of knowledge regarding nursing care [22].overall levels of nurses’ knowledge regarding nrds; a high percentage of the nurses had a good level of knowledge, which may be due to the high number of nurses who graduated from the college of nursing and participation in training courses regarding neonates. the result of the study was similar to a study done in iraq by alridh et al, who found that a high percentage of the nurses had a good level of knowledge regarding nrds [19].the findings of the present study demonstrate that more than twothirds of the nurses had a poor level of quality of nursing care regarding the assessment domain for nrds, which may be due to a large number of patients, and a 19 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article association between the level of quality of nursing care and place of work, gender, marital status, experience in nursing, socioeconomic status, experience in the nicu, and participation in the training course. the result of the current study revealed that there was a statistically significant association between the quality of nursing care and age group (p=<0.05). these findings disagreed with a study done by abdullatif al, who found that there was a non-significant association between the quality of nursing care and a group of nurses [8]. also, there was a very highly significant association between the quality of nursing care and the educational level of the study nurses (p=0.00). these results agree with the results of the study by aziz and mansi (2017), who found that there was a significant association between nurses’ practice and the educational level of the nurses [21]. there was a statistically significant association between the quality of nursing care and the duration of training courses. the results was supported by the results of aziz and mansi, who found that there was a non-significant association between nurse practice and the number of training courses [21].concerning the correlation between the total level of knowledge and the total level of quality of nursing care of the study participants about the care of neonates with respiratory distress syndrome; the result of the present study shows that there was a significant positive correlation between nurses’ knowledge and the quality of nursing care (rho=0.361). this result agrees with the result of a study done in egypt by hegazy (2019), who found that there was a positive correlation between nurses’ knowledge and nurses’ practice [27]. disagrees with a study done by osti et al [25]. as regards chest physiotherapy high percentage of the nurses had a poor level of quality nursing care; this result was similar to the result of the study done by elsayed[9]. concerning incubator care more than one-third of the nurses had a poor level of quality nursing care; the result of the current study was inconsistent with a study done by mohamed et al [24]. as regards psychological support, a high percentage of the nurses had a poor level of quality nursing care. concerning documentation, a high percentage of the nurses had a fair level of quality nursing care. these findings disagree with a study done by elnageb [22].figure 2 shows the overall levels of quality of nursing care for nrds. less than three-quarters of the nurses had a fair level of quality of nursing care, a minority of the nurses had a good level of quality of nursing care and 24%of the nurses had a poor level of quality of nursing care. the result of the present study agrees with a study conducted by elsayed et al, who found more than two-thirds (69.2%) of the nurses had an incompetent level of practice for nrds [9].also, the result of the present study shows that there was a statistically significant association between nurses’ knowledge and (participation in the training course, and the duration of training courses). it was evident that a majority of the nurses who participated in the training course had a good level of knowledge. these findings disagree with a study done by alridh et al, who found that there was a nonsignificant association between the level of nurses’ knowledge and participation in training courses and the duration of training courses [19]a. regarding the association between quality of nursing care and socio-demographic characteristics, the result of the present study shows that there was a statistically non-significant 20 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article [6] lovrenski j. lung ultrasonography of pulmonary complications in preterm infants with respiratory distress syndrome. upsala journal of medical sciences. 2012 mar 1;117 (1):10-7. available from: https:// www.sciencedirect.com/science/article/pii/ s0378603x15000066. [7] reuter s. moser c baack m. respiratory distress in the newborn. journal of pediatr review. 2014;35(10):417-29. [8] abdullatif al. quality of nursing care provided for preterm infants suffering from respiratory distress syndrome. port said scientific journal of nursing. 2014 dec 1; 1(2):281-95. [9] elsayed la, el-nagger ns, aly sm. nursing care is provided for neonates with respiratory distress syndrome in the neonatal intensive care units at makkah al-mukarramah in saudi arabia. life science journal. 2013 jan 1;10(1):3403-12. available from: 1097-8135 [10] alfouwais nm, seada ls, alahmadi ry, alassiri aa, alenazi aa, aljuaeed ms. assessment of knowledge, attitude and practice of saudi parents towards neonatal jaundice (nnj): a cross-sectional study. the egyptian journal of hospital medicine. 2018 jan 1;70(9):168694. available from: http:// platform.almanhal.com/mnhl/preview/? id=2-113871 [11] zaki am. quality of nursing care provided for neonates with tracheoesophageal fistula. journal of education and practice. 2014;5 (3):186-99. [12] abdallah ar. assessment of nurses' knowledge regarding care of preterm babies [doctoral dissertation].university of shendi: ahlam mohammed hagibrahem; 2019. available from: http:// repository.ush.edu.sd:8080/jspui/ handle/123456789/1060 [13] kamath bd, marcotte mp, defranco ea. neonatal morbidity after documented fetal lung maturity in late preterm and early term infants. american journal of obstetrics and gynaecology. 2011 jun 1;204(6):518-e1. available from: https:// www.sciencedirect.com/science/article/pii/ s0002937811003760 [14] ahmed saad e. assessment of nurses' knowledge regarding care of child with respiratory distress syndrome in ahmed gasim pediatric hospital, bahri, sudan 2018. acta scientific paediatrics [internet]. 2019 oct 21 [cited 2022 jun 21];2(11):46–9. availablefrom: https://actascientific.com/aspe/ in the present study's findings, it was concluded that the highest percentage of the nurses had a good level of knowledge, and a high percentage of the studied nurses had a fair level of quality nursing care. there was a statistically significant association between nurses’ knowledge with participation in the training course and the duration of the training course. there was a highly significant association between the quality of nursing care with educational level and the duration of the training course. there was a positive correlation between the level of nurses’ knowledge and the quality of nursing care. there are no conflicts of interest. [1] hamvas a, cole fs, nogee lm. genetic disorders of surfactant proteins. neonatology. 2007; 91(4):311-7. available from: https:// www.karger.com/article/fulltext/101347 [accessed 4th june 2022. [2] yadav s, lee b, kamity r. neonatal respiratory distress syndrome. in: statpearls. treasure island (fl): statpearls publishing; 2022 [cited 2022 aug 16]. available from http://www.ncbi.nlm.nih.gov/books/ nbk560779/ [3] kliegman rm, behrman re, jenson hb, stanton bm. nelson textbook of paediatrics ebook. 21th ed. canada: elsevier health sciences; 2020. [4] el he, hany s, mahmoud mk, ali am. lung ultrasonography in the evaluation of neonatal respiratory distress syndrome. the egyptian journal of radiology and nuclear medicine. 2015 jun 1;46(2):469-74. available from: https://www.sciencedirect.com/ science/article/pii/s0378603x15000066 [5] central statistics of iraq, kurdistan region statistic office, the iraqi ministry of health, unicef. multiple indicator cluster survey [internet]. 2018. available from: https:// www.who.int/news-room/fact-sheets/ detail/preterm-birth. 21 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.02 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article [24] mohamed bm, el dakhakhny am, bassam se, el sayed lm. assessment of nursing care provided to premature neonates at neonatal intensive care unit at zagazig university children hospital. zagazig nursing journal. 2019 jul 1;7(2):1-4. [25] osti c, khadka m, wosti d, gurung g, zhao q. knowledge and practice towards care and maintenance of peripheral intravenous cannula among nurses in chitwan medical college teaching hospital, nepal. nursing open journal. 2019 jul;6(3):1006-12. available from: https://onlinelibrary.wiley.com/ doi/abs/10.1002/nop2.288. [accessed 12th february 2022]. [26] abdelsadek a, khair mda, naga oa. lung ultrasound as an early diagnostic tool in neonatal respiratory distress syndrome (rds). egyptian journal of chest diseases and tuberculosis [internet]. 2016 jan [cited 2021 dec 18];65(1):377–82. available from: http://linkinghub.elsevier.com/retrieve/pii/ s0422763815300492. [27] mohamed elsayed hegazy w, el sayed abusaad f. nurses, knowledge and practices about care of neonates on mechanical ventilators with respiratory distress. international journal of novel research in healthcare and nursing. 2019;6(1) . [28] jamsheer km, shaker nz. quality of immediate nursing care provided to newborns at maternity teaching hospital in erbil city. erbil journal of nursing and midwifery. 2018 may 30;1(1):33-41. pdf/aspe-02-0168.pdf. [15] mahmood hj, sulaiman sj. assessment of factors causing mortality rate of neonate in al-batool teaching hospital in mosul city. kufa journal for nursing sciences. 2013;3(2). [16] pallant j. spss survival manual: a step-bystep guide to data analysis using spss. 7th edition. london: open university press; 2020. [17] ali ra, obeisat sm, tarawneh lh. improving nursing knowledge and care for neonates with respiratory distress in jordan. international nursing review. 2019 sep; 66 (3):338-45. [18] el-ziady sm, ouda we, hassan re. effect of implementing an educational program about family centered developmental care on neonatal nurses'knowledge and practices at neonatal intensive care units. mansoura nursing journal. 2017 jul 1;4 (2):171-90. available from: https:// mnj.journals.ekb.eg/article_149642.html [19] alridh ms, arrar aa, al-abedi ga. nurses of knowledge toward respiratory distress syndrome to have children maysan hospital for child and childbirth. indian journal of forensic medicine & toxicology. 2019 oct;13 (4):1062-7. available from: http:// www.indianjournals.com/ijor.aspx? target=ijor:ijfmt&volume=13&issue=4&article= 191 [20] mohamed bm, el dakhakhny am, bassam se, el sayed lm. assessment of nursing care provided to premature neonates at neonatal intensive care unit at zagazig university children hospital. zagazig nursing journal. 2019 jul 1;7(2):1-4. [21] aziz ar, mansi qh. assessment of quality of nursing care provided to neonates with respiratory distress syndrome at intensive care unit in al-nasiriyah city hospitals. kufa journal for nursing sciences. 2017;7(2):1-2. [22] alfadil ma, elnageeb mm. assessment of nurses’ knowledge and practice regarding care of neonate with respiratory distress syndrome in soba university hospital (doctoral dissertation, maaza alsharif alfadil. available from: http:// repository.ush.edu.sd:8080/xmlui/ handle/123456789/892 [23] masood es. quality of nursing care providing in neonatal intensive care units in minia university hospital. journal of health, medicine and nursing. 2018;57:11 22 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.14 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article nurses’ knowledge and practice of body mechanic techniques at emergency teaching hospitals in erbil city/kurdistan region – iraq abstract background and objectives: body mechanics is a term that indicates a coordinated effort between the neurological and musculoskeletal systems to maintain balance, posture, and body alignment in daily activities, which is essential for efficient bodily functioning. the study aimed to assess nurses’ knowledge and practice regarding mechanical body movement at emergency hospitals in erbil city. methods: the study was carried out at the west, east emergencies and emergency management center (emc) in erbil city -kurdistan region, iraq. a non-probability convenient sample of 300 nurses at all emergencies in erbil city was selected. a special questionnaire was prepared by an extensive literature review and opinion experts. the questionnaires consist of two parts, the nurses’ knowledge questionnaire, which consists of 25 items, and the observation checklist to evaluate practice, which consists of 35 items. the reliability of the questionnaire was determined the performance of the pilot study. data analysis was performed by using spss "vesion26" (frequency, percentage, and chi-square test). results: the highest percentage of overall knowledge scores was poor (71.7%) and the highest percentage of overall practice scores were fair, (86%). the result showed significant associations and high significant associations between gender, level of education (diploma in nursing), and knowledge. also, the result showed a very high significant association between extra jobs and practice. conclusions: the study concluded that the total means score of knowledge was better than practice about body mechanics techniques. those results revealed nurses' need for an education program to improve their knowledge and practice. keywords: knowledge; practice; body mechanics; nurses. kameran wzw rasool; department of nursing, college of nursing, duhok university, kurdistan region, duhok, iraq. (correspondence: kameranw.rasool@gmail.com) ronak nematalah hussain; department of nursing, college of nursing, hawler medical university, kurdistan region, erbil, iraq. 148 received: 18/10/2022 accepted: 01/07/2023 published: 30/11/2024 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:kameranw.rasool@gmail.com mailto:kameranw.rasool@gmail.com?subject=kameranw.rasool@gmail.com mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.14 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article body mechanics is a word that describes how to use the body in daily life, it includes the ways to maintain the body when sitting, standing, bending, and lifting heavy objects. by using body mechanics, the body protects from musculoskeletal injuries like low back pain; in contrast, un execution body mechanics principle the body at risk of injuries. [1]nurses are more prone to work-related physical injuries which result in symptoms like back pain and other msps (musculoskeletal problems). therefore, nursing officers required to incorporate knowledge and skills into the practice of body mechanics. many nursing activities require muscle exertion to reduce the risk of musculoskeletal injury to the nursing officers while transferring patients; the nursing officers must know about the proper body mechanics [2]. the use of good body mechanics can lessen the chance of musculoskeletal system injury while simultaneously facilitating body movement, allowing for physical mobility without causing muscular strain or excessive use of muscle energy [3] poor body mechanics are often the cause of back problems. when we do not move correctly and safely, the spine is subjected to abnormal stresses that over time can lead to degeneration of spinal structures like discs and joints, injury, and unnecessary wear and tear. that is why it is important to learn the principles of proper body mechanics [4].there are several practical reasons to use proper body mechanics when performing physical tasks. not only to reduce the risk of injury but also to use the correct techniques can keep from becoming overly fatigued when doing physical labor. employing the appropriate body mechanics requires less energy to complete a task, makes it easier to lift or move a large or heavy object, and puts less strain on the back, legs, and arms [5]. the study design was carried out in the (west emergency hospital, east, emergency hospital and emc-emergency management center) emergency hospitals in erbil city. the administration departments of emergency hospitals were provided with all necessary information to obtain on nurses during data collected from december 26th, 2021, to march 26th, 2022. samples of the study were non– probability purposive samples of 300 nurses who were worked in emergency hospitals that mentioned above. data was collected through self-structure tools based on an extensive review of literature which includes nurses’ sociodemographic data, and medical data of nurses’ knowledge and practices; by using an observation checklist for it. according to practice scores, nurses were always practicing took two, sometimes practice took one, and never practice took zero. statistical analysis was done by using spss 26, using frequency, percentage, and chisquare, with p-value =<0.05 considered statistically significant. table1 shows the sociodemographic characteristics of emergency nurses. the result revealed that 74.7% nurses were 40 years or less and 56.7% of them were males. the majority of them 77% have diplomas in nursing. whereas the highest percentage, 84% of them had less than fifteen years of experience, and about 47% of the nurses were from the west emergency hospital. 71% of nurses did not participate in body mechanics movement training sessions. and also 46.7 % of nurses had not done any extra jobs after hospital work. 80.7% of emergency nurses worked from four to six days per week. 149 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods result https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.14 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article only 28.3% of them had good knowledge about body mechanics the figure1 illustrates that 71.7 % of emergency nurses had poor knowledge, while . 150 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1 : sociodemographic characteristics of nurses emergency sociodemographic characteristics of emergency nurses f. (%) age group ( years) 26-30 12 (4) 31-35 110 (36.7) 36-40 102 (34) 41-45 48 (16) 46-50 13 (4.3) > 50 15 (5) gender of nurse male 170 (56.7) female 130 (43.3) level of education secondary nursing school 30 (10) technical diploma in nursing 231 (77) b.sc. in nursing 39 (13) years of experience 1-5 15 (5) 6-10 90 (30) 11-15 147 (49) 16-20 35 (11.7) 21-25 11 (3.7) >25 2 (0.6) setting of nurses east emergency 93 (31) west emergency 141 (47) emergency management center 66 (22) participation in body mechanic training session yes 87 (29) no 213 (71) secondary or extra job nothing 140 (46.7) private hospital 39 (13) self-clinic 41 (13.7) pharmacy 23 (7.7) others 57 ( 19) working days per week in hospitals 1-3 58 (19.3) 4-6 242 (80.7) figure 1 nurses’ level knowledge regarding body mechanic https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.14 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article figure2 depicts the distribution frequency of nurses according to the practice of body mechanics , the highest percentage regarding nurses’ knowledge, table 2 shows that the mean score is 15.113 for nurses' knowledge out of a total of 25 questions with a standard of emergency nurses, 86% had fair practice and 14% of emergency nurses had poor practices of body mechanics. deviation of 2.427. while the average practice score across all 70 scores was 27.7700, with a standard deviation of 5.685. 151 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. figure 2 nurses practice body mechanic the total mean of nurses’ knowledge and their practices overall knowledge overall practice mean 15.1133 27.7700 std. deviation 2.42765 5.68549 minimum 9 14 maximum 22 48 table 2 :the overall mean of nurses’ knowledge and their practice https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.14 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article 152 level of schooling, while there was a nonsignificant association between nurses’ knowledge with other characteristics such as age, job, experience, and working days per week, at p-value (0.35, 0.54, 0.39, 0.92, 0.36, 0.64 respectively). table 3 revealed a significant association between emergency nurses' knowledge and their gender (p-value of 0.022), and a highly significant p-value of 0.008 association between emergency nurses' knowledge of body mechanics and their copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table3: association between overall nurses’ knowledge and their sociodemographic characteristics socio-demographic characteristics overall knowledge poor good pvalue f (%) f (%) age group (years) 26-30 9 (75) 3 (25) 0.358 31-35 77 (70) 33 (30) 36-40 74 (72.5) 28 (27.5) 41-45 35 (72.9) 13 (27.1) 46-50 12 (92.3) 1 (7.7) > 50 8 (53.3) 7 (46.7) gender of nurse male 113 (66.5) 57 (33.5) 0.022 female 102 (78.5) 28 (21.50 level of education secondary nursing school 24 (80) 6 (20) 0.008 diploma in nursing 171 (74) 60 (26) b.sc. in nursing 20 (51.3) 19 (48.7) experience in job 1-5 8 (53.3) 7 (46.7) 0.541 6-10 64 (71.1) 26 (28.90) 11-15 108 (73.5) 39 (26.5) 16-20 27 (77.1) 8 (22.9) 21-25 8 (63.6) 5 (36.4) setting of nurse east emergency 71 (76.3) 22 (23.7) 0.396 west emergency 100 (70.9) 41 29.1 emergency management center 44 (66.7) 22 33.3 participation in body mechanic training session yes 62 (71.3) 25 (28.7) 0.921 no 153 (71.8) 60 (28.2) secondary or extra job nothing 105 (75) 35 (25) 0.366 private hospital 24 (61.5) 15 (38.5) self-clinic 32 (78) 9 (22) pharmacy 16 (69.6) 7 (30.4) others 38 (66.7) 19 (33.30 working days per week in hospital 1-3 days 43 (74.1) 15 (25.9) 0.642 4-6 days 172 (71.1) 70 (28.9) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.14 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article practice (p-value > 0.05), except for the variable extra job, which was significantly associated with practice (p-value 0.001). 153 table 4 showed that none of the sociodemographic characteristics of nurses were significantly associated with their copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: association between overall nurses’ practices and their sociodemographic characteristics. socio-demographic characteristics overall practice p-value poor fair f % f (%) age group ( years) 26-30 3 (25) 9 (75) 0.769 31-35 14 (12.7) 96 (87.3) 36-40 12 (11.8) 90 (88.3) 41-45 8 (16.7) 40 (83.3) 46-50 4 (30.8) 9 (69.2) > 50 1 (6.7) 14 (93.3) gender of nurse male 25 (14.7) 145 (85.3) 0.420 female 17 (13.1) 113 (86.9) level of education secondary nursing school 4 (13.3) 26 (86.7) 0.878 diploma in nursing 34 (14.7) 197 (85.3) b.sc. in nursing 4 (10.3) 35 (89.7) experience in job 1-5 3 (20) 12 (80) 0.603 6-10 13 (14.4) 77 (85.6) 11-15 16 (10.9) 131 (89.2) 16-20 8 (22.9) 27 (77.1) 21-25 2 (9.1) 11 (90.9) setting of nurses east emergency 10 (10.8) 83 (89.3) 0.238 west emergency 22 (15.6) 119 (84.4) emergency management center 10 (15.2) 56 (84.8) participation in body mechanic training session yes 10 (11.5) 77 (88.5) 0.596 no 32 (15) 181 (85) secondary or extra job nothing 22 (15.7) 118 (84.3) 0.001 private hospital 3 (7.7) 36 (92.3) self-clinic 4 (9.8) 37 (90.2) pharmacy 4 (17.4) 19 (82.6) others 9 (15.8) 48 (84.2) working days per week in hospitals 1-3 7 (12.1) 51 (87.9) 0.695 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.14 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article body mechanics is an important practice that should be practiced in simple or complex treatment procedures. to avoid musculoskeletal disorders such as back pain. in conclusion, this study tried to determine the extent of knowledge and practice of body mechanics among nurses, which revealed that their knowledge and practice were not good; therefore, nurses need education and training programs to improve their knowledge and practice. the authors report no financial assistance or conflicts of interest. [1] akhtar a, afzal m, kousar r, waqas a, gilani sa. assess knowledge and practices of body mechanic technique among nurses at punjab institute of cardiology lahore. saudi journal of medical and pharmaceutical sciences. 2017;3:545-55. [2] saini sk, pandey v, kumar a, elhence a. musculoskeletal problems and expressed practices of body mechanics among nursing officers at all india institute of medical sciences jodhpur, rajasthan, india. journal of integrative nursing. 2021 sep 29;3(3):12834. [3] rawat a, negi a, rana m, gusain m, negi n, tomar n, et al., knowledge assessment on use of body mechanics and safety measures among ward attendants in selected hospital of dehradun, uttarakhand. age (in years). 2017 dec 6;21(30):31-40. [4] jayakrishnan k. knowledge and practice among staff nurses regarding body mechanics. international journal of advances in nursing management. 2016 sep 28;4(3):259 -63. [5] howyida s, heba a, abeer y. impact of application of body mechanic principles on improving low back pain among female workers at benha university. journal of american science. 2011;7(11):457-67. the present study revealed that the majority of nurses had fair knowledge and 28.3% of nurses had good knowledge about body mechanics techniques. this result is supported by studies conducted by [1], in saudi arabia., [7, 9, 10,] in india, [11] in malaysia. and also, this result is not congruent with studies done by [4, 12, 13, 14], in india, who revealed that most nurses had good knowledge. the result of this study shows that the majority of nurses had fair practice and the lowest percentage of emergency nurses had poor practices of body mechanics. a similar result was found in a study done by [6] in india. this found that 60% of nurses had average practice and 40% of them had poor practice regarding body mechanics. there was a significant association and a high significant association between nurses’ knowledge and their select sociodemographic variables like gender and level of education (p-value 0.022, 0.008 respectively). there was no significant association between variables like age, experience in the job, setting, training session, or extra job at the level of p>0.05. this was congruent with the results of the studies done by [4,6] in india and [8], in egypt. there was no significant association between nurses’ practice and variables of sociodemographic except for the variable extra job. the p-value was 0.001 an indicators of a very high significant association between extra jobs and nurses’ practice regarding body mechanics. it was supported by [6,9,16] in india. [15], in south korea. [ 8], in egypt. 154 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion conclusion conflict of interes references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.14 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article [14] dash k, das m. a study to assess the effectiveness of self-instructional module regarding knowledge of correct body mechanics in prevention of low back pain among staff nurses working at tertiary care hospital, bhubaneswar, odisha. international journal of nursing education, 2019 apr;11 (2):32. [15] kang sw. the use of body mechanics principle, clinical-practice fatigue, and practice satisfaction of nursing students. nursing plus open. 2017 jan 1; 3:6-10 [6] kochitty a, devi s. a study to assess the effectiveness of a self instructional module on the knowledge & practice regarding proper body mechanics among the critical care nurses in selected hospitals of pune. kournal of advanced scientific research. 2015 nov 1;6(4). [7] priyanka, kaur ravneet, sakshi,sheetal, suar shubheert,chozzin tanzin . assess knowledge and use of body mechanics practices and its association with musculoskeletal problems among hospital attendants in selected wards of pgimer, chandigarh. international journal health science research. (2021). 11(9): 209-215. [8] hemed a, taha nm, abd-elwahab h, mohamed eh. effect of educational program on nurses' performance regarding body mechanics. zagazig nursing journal. 2017 jul 1;13(2):21-37. [9] swamy p, varghese r, kokani a. assess knowledge and practice of internship students regarding assisted body mechanics to reduce musculoskeletal disorders and to develop safety guideline on manual handling technique. journal integrated health sciences 2017;5 :11-7 [10] dewasi pk, khan p. a descriptive study to assess the knowledge regarding proper body mechanic techniques among staff nurses at selected hospitals of jodhpur with a view to develop self-instructional module. international journal of progressive research in science and engineering. 2020 jun 15;1(3):111-3. [11] ahmad n, chen ts, musa m. the association between knowledge and practice of body mechanic technique among nurses in emergency department from hospital in north borneo. international journal medical and exercise science ,(2021)., 7 (3); 10341040., www. ijmaes. org, www. jmmodernpublishers. ijmaes. org. [12] vidya vp, d’souza vf, vinyamol to, machado v, francis j, gireesh gr,et al., the knowledge and practice of body mechanics among staff nurses: descriptive correlational study . aijrhass. 2014;8(2):124-6. [13] gopi contractor, knowledge and practice of body mechanics techniques among the nurses, international journal of science and research. (2019), www.ijsr.ne 10.21275/ art2020126 155 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.09 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article knowledge and attitudes about precautionary measures of covid-19 among undergraduate students: a comparative study abstract introduction the pandemic of novel coronavirus disease 2019 (covid-19) was declared a public health emergency concern by the world health organization (who) in december 2019 [1]. covid-19 is an infectious respiratory illness caused by a new coronavirus that first appeared in china at the end of december 2019 and quickly spread worldwide [2].the incubation period of covid-19 is 2–14 days, and it causes respiratory infection (like the flu), with major clinical symptoms including dry cough, fever, pain or pressure in the chest, fatigue, and in more severe cases, myalgia, arthralgia, confusion, difficulty breathing and bluish lips or face. covid-19 background and objective: the pandemic caused by novel coronavirus disease 2019 (covid-19) is an infectious respiratory illness caused by a new coronavirus that first appeared in china at the end of december 2019 and quickly spread worldwide. the aims of this study are to assess undergraduate students’ knowledge and attitudes of the precautionary measures toward covid-19. methods: a descriptive comparative study design was used from 2nd january to 1st march 2022. a purposive sampling technique was used to collect the data. all students (240 students) in second grade from the nursing department and the english department at gasha technical institute, kurdistan region/iraq, were recruited and completed a self-reported questionnaire. result: around 70% of nursing students and 69% of students in the english department were males, and most students in both fields were aged between 18 and 22 years old. a total of 83.3 % of students in nursing and 77.5% of students in the english department were single. however, the rate of married students (21.7%) was higher in the english department. more than half of the nursing students (63.3%) showed good knowledge, 31.7% showed medium knowledge, and 5.0% showed poor knowledge. nursing students’ good attitude was 15.8%. in contrast, 30.0% of students in the english department had good knowledge, 50.8% had medium knowledge, and 19.2% had poor knowledge. good attitude of students in the english department was 5%. conclusion: overall, a higher level of knowledge was observed in nursing students than students in the english department. also, positive attitude toward covid-19 was higher among nursing students. keywords: covid-19; knowledge; attitude; precautionary measures; students. halmat authman rasheed; department of nursing, college of nursing, hawler medical university and tishk international university, erbil, iraq. (correspondence: halmat.rasheed@hmu.edu.krd) 79 received: 23/03/2022 accepted: 30/07/2022 published: 30/11/2022 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:halmat.rasheed@hmu.edu.krd%20, mailto:halmat.rasheed@hmu.edu.krd%20, mailto:halmat.rasheed@hmu.edu.krd%20, mailto:halmat.rasheed@hmu.edu.krd%20, https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.09 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article is a highly contagious virus with a high death rate, and it was designated as a class b infectious illness in china in january 2020 [3].according to the available research data, the covid-19 virus is transmitted between humans by close contact and droplets, not through airborne transmission. those in close contact with a covid-19 patient or who care for covid-19 patients are the most vulnerable to infection [4].following the pandemic nature of the diseases, countries implement various preventative measures, such as restricting people's movement, requiring them to stay at home, and closing schools and other social services [5]. the most effective preventative strategies/measures include closing schools, staying at home, maintaining social distance, avoiding touching your face, practicing respiratory hygiene when coughing or sneezing, wearing a medical mask, and appropriate hand-washing in public areas such as banks, markets, and mosques [6].as the risk of covid-19 spreads rapidly, individuals should take precautions to protect themselves and others from infection. though medical students are not actively involved in the managing infected patients with covid-19, they can serve as an information provider for the community about the importance of personal hygiene, the main clinical symptoms of covid-19, and how to limit its spread by following precautionary measures [7]. the crowded class of students in school, institution, and college eases the transmission of covid-19 [8]. to decrease the number of infected students with covid-19, undergraduate students must have a basic knowledge and understanding of the new coronavirus, which is essential to limit the spread of the virus and should be able to clear common misconceptions regarding covid-19 [9]. with this background, the study is aimed to assess the undergraduate students’ knowledge and attitudes toward precautionary measures about covid-19 in erbil city, kurdistan region of iraq. this descriptive comparative study design aimed to assess undergraduate (medical and non-medical students) students’ knowledge and attitudes toward the precautionary measures to prevent covid-19 infection. the study was conducted at the gasha technical institute in erbil, kurdistan region of iraq, from 2nd january to 1st march, 2022. the sample included a total of 240 students. students from the nursing department in the 2nd grade (120 medical students) and students from the english department (120 non-medical students) were recruited to participate in the study. the scientific and ethical committee approved this study at hawler medical university/ college of nursing, no (5) 16, december 2021. before data collection, permission was obtained from the director of administration of the gasha technical institute. at the beginning of the study, the details and the objectives were explained to the study participants. then, written informed consent was obtained. participants were assured that their information will be kept confidential using codes instead of personal information .after reviewing the related literature, a selfreported structured questionnaire was adopted from other published articles with a few modifications [10,11]. the questionnaire was designed in english language and then translated to the kurdish language with the assistance of a native kurdish professional. the self-reported questionnaire consisted of three sections: sociodemographics, knowledge, and attitudes toward covid-19. the first part determined undergraduate students’ sociodemographic characteristics, including sex, age, marital status, degree or certificate, and area of residence. the second part 80 methods copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.09 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article 77.5% of students in the english department, were single. the rate of married students (21.7%) was higher in the english department. most study participants in both departments lived in urban areas, less than 7% of nursing students lived in rural areas, and 5% of english students lived in suburban areas. the rate of students infected with covid-19 was higher among nursing students than english students. as demonstrated in table 2, more than half (63.3%) of nursing students showed good knowledge, 31.7% showed medium knowledge, and only 5.0% showed poor knowledge. 93.3% of nursing students had a positive attitude about covid-19. in contrast, 68.3% of students in the english department had positive. negative attitude toward covid-19 was higher among english students (31.7%) than nursing students (6.7%). measured students’ knowledge regarding covid-19 comprising 18 questions. the third part was measured students’ attitudes regarding covid-19 comprising 18 questions. the scientific committee at the college of nursing extensively reviewed the questionnaire for its validity and relevancy. a small pilot study was done to check for simplicity and difficulty. the samples of the pilot study were excluded from the actual study sample.students were given the following options to answer the questions: correct, incorrect, never, rarely, often. a question scoring system was used to measure the knowledge level of undergraduate students as follows: one point for a correct answer and zero point for the incorrect answer for each question. students’ knowledge was classified as poor (<50%), fair = (50-75%) and good (>75%). students’ attitude was classified as negative (<50%) and positive (³50%). statistical package of social science spss (version 23.0) were used to analyze the collected data. the socio-demographic features of the study participants were analyzed using descriptive statistics. person’s chi-square (x2) test was used to investigate the association between study participants’ sociodemographic variables and their knowledge level and attitude toward precautionary measures against covid-19. a p -value of less than and equal to 0.05 was considered significant. table 1 illustrates the socio-demographic characteristics of study participants. around 70% of nursing students and 69% of students in the english department were males. most of students in both departments were between 18 and 23 years old, and only 8.3% and 25% were between 24 and 30 years old in the nursing and english departments, respectively. the highest percentages, 83.3 % of students in nursing and 81 results table 1: nursing and english students’ distribution according to their sociodemographic characteristics characteristics nursing students n (%) english students n (%) sex male 35 (29.2) 37 (30.8) female 85 (70.8) 83 (69.2) age group 18-24 110 (91.7) 90 (75) 25-31 10 (8.3) 30 (25) marital status single 100 (83.3) 93 (77.5) married divorced 20 (16.7) 26 (21.7) 1 (0.8) degree or certificate diploma 120 (100) 120 (100) area of residence urban 79 (65.8) 94 (78.3) rural 8 (6.7) 20 (16.7) sub-urban 33 (27.5) 6 (5.0) did you infected with covid-19 yes no 51(42.5) 69 (57.5) 46 (38.3) 74 (61.7) copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.09 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article table 3 shows the relationship between participants’ socio-demographic characteristics, knowledge level and attitude. no significant differences were observed among nursing students’ knowledge with sex, marital status, and area of residence. there was a highly significant association between knowledge and age (p= 0.001). also, no significant differences were observed among nursing students’ attitudes with sex, age, marital status, and area of residence. regarding students in the english department, there were no significant differences between knowledge level with age, marital status, and area of residence. significant associations were noticed between knowledge and sex (p= 0.02), and attitude with age (p= 0.044).overall, a higher knowledge level was observed in nursing students than students in the english department with a mean score (14.59 ± 2.43 and 12.66 ± 2.88, respectively). 82 table 2: percent distribution of students’ knowledge and attitude. knowledge and attitude category students in nursing department (n=120) f.(%) students in english department (n=120) f.(%) knowledge poor 6 (5.0) 23 (19.2) fair 38 (31.7) 61 (50.8) good 76 (63.3) 36 (30) attitude positive 112 (93.3) 82 (68.3) negative 8 (6.7) 38 (31.7) table 3: participants’ socio-demographic-characteristics relationship with knowledge levels and attitude. variable students in nursing field students in english field knowledge p-value attitude p-value knowledge p-value attitude p-value sex 0.211 0.501 0.02 0.756 marital status 0.777 0.479 0.613 0.1 age 0.001 0.216 0.617 0.044 area of residence 0.593 0.495 0.170 0.761 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.09 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article 83 residencies. this is in agreement with the study done by akalu et al., 2020, the reason being explained as inadequate information about human health is not available online due to poor internet connection and weak mobile network systems in rural areas [20]. more than 90% of nursing students and 60% of students in the english field had a positive attitude toward covid-19. this is similar to a study conducted in egypt [21], which stated that more than 80% of the study participants had a positive attitude toward covid-19. the result of this study showed that 13.3% of students in nursing and 29.2% in the english department did not wear a surgical face mask. also, 73.3% of nursing students and 69.2% of participants in the english field did not always practice physical distancing of two meters. maheshwari et al., 2019, reported that more than 9% of the participants did not wear a surgical mask to protect themselves against covid-19 [2]. in general, nursing students in our research had higher good knowledge level and positive attitudes than participants in the english department towards using precautionary measures against covid19. this basic information is vital to decrease the spread of the disease. less than half of participants in nursing and around two-thirds of participants in the english department believed that vaccines could not be effective in preventing infection transmission. we recommend seminars and workshops about covid-19 vaccination for undergraduate students in all fields of study, especially for nonmedical students. also, the government needs to clarify the benefits of covid-19 vaccines for the community, in order to increase the societies’ positive attitudes about vaccines. discussion to the best of our knowledge, this is the first comparative study among undergraduate medical and non-medical students, assessing the knowledge and attitudes of precautionary measures toward covid-19. a good knowledge level has been shown by nursing students. this is consistent with the finding of other studies done recently [12,13]. nursing students were more knowledgeable than non-medical students. this result is consistent with research conducted in jordon [14], which found that students in colleges of medical science had higher knowledge levels on covid-19 than students in other fields of study. the knowledge level of students between 24 to 30 years old was higher than others between 18 to 23 years old. this finding is consistent with the study by olaimat et al., 2020, which explained that knowledge increases as age increases. female nursing students have a greater level of knowledge than male students. male english students had higher knowledge levels than female english students. our findings are consistent with research conducted in china and italy [15, 16]. however, studies done in ethiopia, malaysia, and saudi arabia found the reverse of this study’s findings [17,18,19]. nursing students who were married had higher knowledge than single students. however, divorced non-medical students had higher knowledge levels than single and married students in the same field of study. a study conducted by abate and mekonnen in 2020, showed that divorced individuals were less likely than single participants to have inadequate knowledge levels [4]. in our study, nursing students in urban residency were more knowledgeable than rural residency. in contrast, non-medical students of suburban residency had a higher knowledge level of covid-19 than rural and urban conclusion copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.09 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article [9] batra k, urankar y, batra r, gomes af kaurani p. 2021, may. knowledge, protective behaviors and risk perception of covid-19 among dental students in india: a crosssectional analysis. multidisciplinary digital publishing institute. in healthcare. 2021;9 (5): p.574. [10] almofada sk, alherbisch rj, almuhraj na, et al. knowledge, attitudes, and practices toward covid-19 in a saudi arabian population: a cross-sectional study. cureus. 2020;12(6). [11] saadatjoo s, miri m, hassanipour s, ameri h, arab-zozani m. knowledge, attitudes, and practices of the general population about coronavirus disease 2019 (covid-19): a systematic review and meta-analysis with policy recommendations. public health. 2021; 194: pp.185-195. [12] taghrir mh, borazjani r, shiraly r. covid-19 and iranian medical students; a survey on their related-knowledge, preventive behaviors and risk perception. archives of iranian medicine. 2020; 23: 249–254.[pubmed]. [13] nemati m, ebrahimi b, nemati f. assessment of iranian nurses’ knowledge and anxiety toward covid-19 during the current outbreak in iran. archives of clinical infectious diseases. 2020; 15: e102848. [14] olaimat an, aolymat i, shahbaz hm, holley ra. knowledge and information sources about covid-19 among university students in jordan: a cross-sectional study. frontiers in public health. 2020; 8: p.254. [15] zhong bl, luo w, li hm, zhang qq, liu xg, li wt, li y. knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online cross-sectional survey. international journal of biological sciences. 2020; 16: 1745–1752. [crossref] [pubmed]. [16] gallè f, sabella ea, da molin g, de giglio o, caggiano g, di onofrio v, ferracuti s, montagna mt, liguori g, orsi gb, napoli c. understanding knowledge and behaviors related to covid–19 epidemic in italian undergraduate students: the epico study. international journal of environmental research and public health. 2020; 17(10): p.3481. [17] [17]kebede y, yitayih y, birhanu z, mekonen s, ambelu a, tu wj. knowledge, perceptions and preventive practices towards covid-19 early in the outbreak among jimma 84 conflict of interest the author reports no conflict of interests. the authors (s) report no funding support. [1] tadesse db, gebrewahd gt, demoz gt. knowledge, attitude, practice and psychological response toward covid-19 among nurses during the covid-19 outbreak in northern ethiopia. new microbes and new infections. 2020; 38: p.100787. [2] maheshwari s, gupta pk, sinha r, rawat p. knowledge, attitude, and practice towards coronavirus disease 2019 (covid-19) among medical students: a cross-sectional study. journal of acute disease. 2020; 9(3): p.100. [3] alimohamadi y, sepandi m, taghdir m, hosamirudsari h. determine the most common clinical symptoms in covid-19 patients: a systematic review and metaanalysis. journal of preventive medicine and hygiene. 2020; 61(3): p.e304. [4] abate h, mekonnen ck. knowledge, attitude, and precautionary measures towards covid-19 among medical visitors at the university of gondar comprehensive specialized hospital northwest ethiopia. infection and drug resistance. 2020; 13: p.4355. [5] saadeh d, sacre h, hallit s, farah r, salameh p. knowledge, attitudes, and practices toward the coronavirus disease 2019 (covid‐19) among nurses in lebanon. perspectives in psychiatric care. 2021; 57(3): pp.1212-1221. [6] sajed an, amgain k. corona virus disease (covid-19) outbreak and the strategy for prevention. europasian journal of medical sciences. 2020; 2(1): pp.1-3. [7] khasawneh ai, humeidan aa, alsulaiman jw, bloukh s, ramadan m, al-shatanawi tn, et al. medical students and covid-19: knowledge, attitudes, and precautionary measures. a descriptive study from jordan. frontiers in public health. 2020; 8: p.253. [8] stein-zamir c, abramson n, shoob h, libal e, bitan m, cardash t, et al. a large covid19 outbreak in a high school 10 days after schools’ reopening, israel. eurosurveillance. fundin references copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2022.09 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2022 original article university medical center visitors, south west ethiopia. plos one. 2020;15(5): e0233744. doi:10.1371/ journal. pone.023374419. [18] bhagavathula as, aldhaleei wa, rahmani j, mahabadi ma, bandari dk. novel coronavirus (covid-19) knowledge and perceptions: a survey on healthcare workers. medrxiv. 2020; 29. [19] azlan aa, hamzah mr, sern tj, ayub sh, mohamad e, tu w-j. public knowledge, attitudes and practices towards covid-19: a cross-sectional study in malaysia. plos one. 2020;15(5): e0233668. doi:10.1371/ journal.pone.023366831. [20] akalu y, ayelign b, molla md. knowledge, attitude and practice towards covid-19 among chronic disease patients at addis zemen hospital, northwest ethiopia. infection and drug resistance. 2020; 13:1949. doi:10.2147/idr.s25873615 [21] abdelhafiz as, mohammed z, ibrahim me, ziady hh, alorabi m, ayyad m, sultan ea, knowledge, perceptions, and attitude of egyptians towards the novel coronavirus disease (covid-19). journal of community health. 2020; 45(5): pp.881-890 85 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.07 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article premenstrual syndrome: presence, knowledge, and attitude among female university students abstract background and objectives: premenstrual syndrome (pms) is fairly high and may interfere with personal and social activities. the current study aims to identify the frequency of experiencing pms symptoms among students, assess their knowledge and attitude towards pms and identify their perception of whether pms has an impact on the academic lives of female university students. methods: a quantitative cross-sectional study was applied to the current study. an online survey using google form was conducted among female university students at the college of nursing/hawler medical university. a total of 222 students participated in the current study. a questionnaire was designed to assess pms symptoms using the criteria of the american college of obstetricians and gynecologists, students’ knowledge and attitude towards pms, the impact of pms on daily living activity and academic performance, and self-management options. results: the mean age (+standard deviation) of the students was 20.77 (+1.876) years and the mean for calculated bmi of students was 22.42kg/m2. the majority of students (70.3%) had regular menstrual cycle with 86% of them having moderate amount of menstrual blood flow. more than half (53.6%) of students responded that they experience pms, and 34.7% responded that they do not experience pms. more than half (52.3%) of students obtained good knowledge score and positive attitude towards pms. around three quarters (70.3%) of the students responded that pms disturbs normal routine. getting plenty of sleep (75.2%), taking hot drinks (72.1%), and applying hot pack (59.5) were among the commonest ways of pms self-management by students. the data demonstrated no statistically significant association between students’ knowledge score and their stage of study, family history of pms, regularity of menstruation, experiencing pms, and knowing about pms. conclusion: a considerable number of students obtained good knowledge score about pms, however, their actual knowledge of pms experience might be different from what they perceive as pms. the majority of students hold a positive stance regarding pms issue. the study revealed that more than half of students reported lack of motivation and concentration due to pms. keywords: premenstrual syndrome; knowledge; attitude; nursing students; iraq. kazhan ibrahim mahmood; department of nursing, college of nursing, hawler medical university, erbil, iraq (correspondence:kazhan.ibrahim@gmail.com) 54 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 28/01/2023 accepted: 15/03/2023 published: 30/5/2023 mailto::%20kazhan.ibrahim@gmail.com https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.07 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article premenstrual disorders comprise a range of premenstrual symptoms from mild premenstrual syndrome (pms) to premenstrual dysphoric disorder (pmdd) [1]. pms is characterized by a wide range of physical, emotional, and behavioral changes, occurring prior to the menstruation phase of menstrual cycle and settling after the commencement of the menstrual period. although the underlying mechanism of pms is unclear, diet, stress, hormonal values, and lifestyle have been implicated. for pms, known risk factors include thyroid dysfunction, hypoglycemia, hormonal imbalance, genetic factors, fluid retention, stress and psychological factors [2]. symptoms generally related to pms include physical and psychological symptoms such as abdominal bloating, breast swelling and tenderness, weight gain, nausea, headache, restlessness, irritability and anger [2].to diagnose pms, the criteria of american college of obstetricians and gynecologists (acog) for pms is usually used [3]. based on a systematic review, it was found that the occurrence of premenstrual related symptoms is fairly high (98%) in iran [4], and in nearly 5% of women the symptoms are severe enough to interfere with personal, social relationships or work, and in many cases requiring pharmacological treatment [5]. an individual's social relationships, productivity, school performance, and emotional well-being can all be affected by pms [6]. in addition, in more severe form of pms, female students’ academic performance can be negatively influenced by pmdd symptoms [7]. the students quality of life can also be affected by pms [8]. several studies have shown that pms had a negative impact on students’ academic life, their concentration along with their social activities [11, 21, 31]. acikgoz and colleagues reported that there was a statistically significant relationship between pms and the risk of depression [9]. in iraq generally and in its kurdistan region particularly, few studies have been found investigating either menstrual disorder or pms in different context [10, 11]. for instance, a study conducted in iraq investigated menstrual disorders but not pms [10] and another study conducted in erbil city investigated pms among school students but not university students [11]. to the best of the researcher’s knowledge, no study has been previously conducted that assesses the existence of pms among female university students with their knowledge and attitude, thus, this study aims to identify the frequency of female students experiencing pms symptoms. the objectives of the current study are to identify the frequency of experiencing pms symptoms among students, assess their knowledge and attitude towards pms and identify their perception of whether pms has an impact on daily living activities and academic life. it also identifies an association between students’ knowledge and some selected variables. a quantitative cross-sectional study was applied to the current study. female students studying at the college of nursing/ hawler medical university (hmu) were invited to take part in a self-administered online survey. female students who were studying nursing or midwifery invited to participate included in the study. first stage, married, and postgraduate students were excluded from the study. the reason behind excluding these students was that, for instance, first stage students might not be able to answer questions related to the impact of pms on their academic life or married students might have different experience than unmarried students. the total number of female students including both nursing and midwifery students 55 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.07 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article statements (eighteen statements) were true or false. the overall students’ knowledge score was categorized into three groups: poor knowledge (score between 0-6), fair knowledge (score between 7-12), and good knowledge (score between 13-18) [11]. the fourth section was about students’ attitude about pms and the related questions were asked based mainly on a five-point ordinal scale (strongly disagree=1, disagree=2, neither agree nor disagree=3, agree=4, and strongly agree=5). the last section was about the impact of pms on daily living activities and college life as well as students pms selfmanagement. to diagnose pms, the criteria of acog is usually used and it includes that at least one of the affective and somatic symptoms is essential to be present in the five days before menses for at least three previous menstrual cycles in a row, diminish within four days after the onset of menstruation without relapse until after 13th day of the menstrual cycle, and must exist in the absence of any pharmacologic therapy, ingestion of hormone, or alcohol or drug use. those who suffer from pms must display identifiable impairments in social, academic, or work performance [3]. survey participants were provided with an information letter including full details of the study objectives, data protection, and confidentiality. participants’ consent was indicated by participants reading the information letter on the introductory page of the survey and clicking through to the next page of the questionnaire survey. all information and participants’ anonymity were kept confidential. ethical approval was obtained from the ethics and scientific committees of the college of nursing-hmu (approval number 12 on 19th june 2022).the data were analyzed through the application of the statistical package of social science (spss) (version 25). (except first stage students) was about 520 students. the calculated sample size was 222 students considering 95% confidence level and 5% margin of error using epi infotm software for windows (version 7.2). the survey link was open until the desired number of students responded to fill in the virtual questionnaire (i.e., from 7/11/2022 until 11/1/2023). thus, 222 students participated in the current study. the students were recruited through the author sharing the survey link with student representatives and students. an online survey using google form was conducted among female university students at college of nursing/hmu. the survey questionnaire was self-administered and developed based on reviewing the literature and on experts’ view. a number of experts in the field reviewed the questionnaire in order to check its content and it was amended based on their comments and suggestions. in addition, the survey link was pilot tested by sending it to a number of students to test the clarity of the content and the practicality of completing and submitting the questionnaire. it was concluded that respondents had no comments on the terminology used in the questionnaire and that the questionnaire could be completed in an appropriate time frame. the questionnaire was composed of several sections. the first section included socio-demographic questions such as age, weight, height, and residence area. in addition, it also included questions about the menstrual cycle such as regularity of menstruation, amount of blood flow, and presence of pms among students. the second section was about pms symptoms, which is composed of different pms symptoms ranging from no experience to severe experience. the third section was about students’ knowledge of pms. to explore their knowledge, students had to identify whether the 56 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.07 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article descriptive statistics including frequency and percentages were used for categorical variables and mean and standard deviation for quantitative variables. chi squared test and fisher’s exact test were applied to identify the association between some selected variables with students’ knowledge score. the students’ characteristics are shown in table 1. the mean age (+standard deviation) of the students was 20.77 (+1.876) years, their mean height was 160.84 cm and mean weight was 58.04 kg. the mean for the calculated bmi of students was 22.42kg/m2. most of the students, about 44%, were fourth stage students followed by second stage (32.9%), and third stage (23.4%). more than half (63.1%) of the students lived inside the city and 66.7% of them were not lived in the dormitory. regarding information on students’ menstrual cycle, the majority of students (70.3%) had regular menstrual cycle with 86% of them having moderate amount of menstrual blood flow. dysmenorrhea was present among 62.6% of the students and more than half (53.6%) of them responded that they experience pms, and 34.7% responded that they do not experience pms. approximately, 12% of students responded that they do not know whether they are experiencing pms or not. the pms symptoms reported by students are shown in table 2. most of the students did not experience symptoms like swollen extremities (68%), fluid retention (66.2%), constipation (63.1%), weight gain (56.8%), palpitations (56.3%), dizziness or fainting (55%), insomnia (50.9%), and diarrhea (50.5%). other physical and psychological symptoms such as breast tenderness, abdominal bloating, acne, restlessness, anxiety, irritability, mood swings were experienced either to a mild or moderate extent. only, backpain was reported to be experienced severely by the students compared to other symptoms. 57 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results table 1: characteristics of the study participants (n = 222). characteristics f. (%) stage second 73 (32.9) third 52 (23.4) fourth 97 (43.7) address inside city 140 (63.1) outside city 82 (36.9) living in dormitory no 148 (66.7) yes 74 (33.3) regularity of menstruation regular 156 (70.3) irregular 66 (29.7) amount of menstrual flow scanty 11 (5) moderate 191 (86) heavy 20 (9) dysmenorrhea absent 83 (37.4) present 139 (62.6) family history of pms i don’t know 108 (48.6) no 65 (29.3) yes 49 (22.1) experience pms i don’t know 26 (11.7) no 77 (34.7) yes 119 (53.6) quantitative data mean (+ sd) age (year) 20.77 (1.876) height (cm) 160.84 (5.737) weight (kg) 58.04 (13.244) computed body mass index 22.4262 (4.942) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.07 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 58 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: prevalence of pms symptoms pms symptoms no experience mild moderate severe no. (%) no. (%) no. (%) no. (%) anxiety 36 (16.2) 87 (39.2) 73 (32.9) 26 (11.7) irritability 42 (18.9) 85 (38.3) 64 (28.8) 31 (14) mood swings 31 (14) 60 (27) 75 (33.8) 56 (25.2) nervous tension 47 (21.2) 80 (36) 59 (26.6) 36 (16.2) feeling depressed 51 (23.0) 78 (35.1) 50 (22.5) 43 (19.4) crying 84 (37.8) 65 (29.3) 48 (21.6) 25 (11.3) forgetfulness 98 (44.1) 79 (35.6) 36 (16.2) 9 (4.1) confusion 102 (45.9) 71 (32) 35 (15.8) 14 (6.3) insomnia 113 (50.9) 66 (29.7) 29 (13.1) 14 (6.3) fluid retention 147 (66.2) 47 (21.2) 24 (10.8) 4 (1.8) weight gain 126 (56.7) 58 (26.1) 29 (13.1) 9 (4.1) swollen extremities 151 (68) 45 (20.3) 22 (9.9) 4 (1.8) breast tenderness 82 (36.9) 73 (32.9) 40 (18) 27 (12.2) abdominal bloating 68 (30.6) 56 (25.2) 74 (33.3) 24 (10.9) oily skin 68 (30.6) 77 (34.7) 55 (24.8) 22 (9.9) acne 29 (13.1) 74 (33.3) 91 (41) 28 (12.6) constipation 140 (63.1) 46 (20.7) 30 (13.5) 6 (2.7) diarrhea 112 (50.5) 58 (26.1) 41 (18.5) 11 (5) backache 29 (13.1) 56 (25.2) 59 (26.6) 78 (35.1) restlessness 43 (19.4) 84 (37.8) 65 (29.3) 30 (13.5) hot flashes 99 (44.6) 79 (35.6) 33 (14.9) 11 (5) bursts of energy 90 (40.5) 77 (34.7) 43 (19.4) 12 (5.4) feeling of wellbeing 105 (47.3) 91 (41) 20 (9) 6 (2.7) appetite increase 99 (44.6) 62 (27.9) 49 (22.1) 12 (5.4) headache 92 (41.4) 59 (26.6) 50 (22.5) 21 (9.5) fatigue 34 (15.3) 65 (29.3) 80 (36) 43 (19.4) dizziness or fainting 122 (55) 52 (23.4) 34 (15.3) 14 (6.3) palpitations 125 (56.3) 58 (26.1) 28 (12.6) 11 (5) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.07 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 59 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. regarding the onset of the symptoms, only 43.2% of students stated that their symptoms started a week before the period and 50.5% of the students stated that their symptoms started during the period (as illustrated in fig. 1). as shown in table 3, getting plenty of sleep (75.2%), taking hot drinks (72.1%), and applying hot pack (59.5) were among the commonest ways of pms self-management by students. the majority of students did not take traditional remedies (80.6%), exercise regularly (73%), eat a healthy, balanced diet (58.1%), and take painkillers (55.4%). table 4 shows how pms affects students’ college life and daily routine. around three quarters (70.3%) of the students responded that pms disturbs normal routine. although most of the students responded that they did not miss college (63.1%) and did not obtain low score (55%) due to pms, most of them responded that they lacked motivation (67.1%) and concentration (62.2%). the data illustrates that most of the students answered almost all of the knowledge questions correctly as more than half (52.3%) of students obtained good knowledge score, about 46% of students obtained fair knowledge score, and only 1.8% of students obtained poor knowledge score (as shown in table 5). figure 1: onset of pms symptoms table3:students pmsself-management pms selfmanagement no yes no. (%) no. (%) exercise regularly 162 (73) 60 (27) eat a healthy, balanced diet 129 (58.1) 93 (41.9) get plenty of sleep 55 (24.8) 167 (75.2) taking hot drinks 62 (27.9) 160 (72.1) applying hot pack 90 (40.5) 132 (59.5) take painkillers 123 (55.4) 99 (44.6) traditional remedies 179 (80.6) 43 (19.4) do nothing 154 (69.4) 68 (30.6) other 148 (66.7) 74 (33.3) table 4: impact of pms on college life and normal routine impact of pms no yes no. (%) no. (%) pms disturbs normal routine 66 (29.7) 156 (70.3) missed college due to pms 140 (63.1) 82 (36.9) missed social events due to pms 103 (46.4) 119 (53.6) obtained low score due to pms 122 (55) 100 (45) lack of motivation 73 (32.9) 149 (67.1) lack of concentration 84 (37.8) 138 (62.2) table 5: students’ knowledge score about pms knowledge score f. (%) poor 4 (1.8) fair 102 (45.9) good 116 (52.3) total 222 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.07 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 60 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. figure 2 depicts the attitude of students towards pms. more than a quarter of the students strongly agreed that pms leave should be an option at university. also, 31.1% of students strongly agreed that the data demonstrates no statistically significant association between students’ knowledge score and their stage of the study, family history of pms, regularity of pms is a significant issue that needs to be discussed. less than half (41%) of the students agreed that they feel comfortable talking to their family about pms. menstruation, experiencing pms, and knowledge about pms as their p values were greater than 0.05 significant level (see table 6). figure 2: students’ attitude about pms table 6: association between students’ knowledge and some selected variables variables knowledge level (group) pvalue poor no. (%) fair no. (%) good no. (%) total stage of study second 2 (2.7) 31 (42.5) 40 (54.8) 73 (100) 0.348 third 0 (0) 29 (55.8) 23 (44.2) 52 (100) fourth 2 (2.1) 42 (43.3) 53 (54.6) 97 (100) total 4 (1.8) 102 (45.9) 116 (52.3) 222 (100) don’t know 1 (0.9) 54 (50) 53 (49.1) 108 (100) family history of pms no 1 (1.5) 33 (50.8) 31 (47.7) 65 (100) 0.130 yes 2 (4.1) 15 (30.6) 32 (65.3) 49 (100) total 4 (1.8) 102 (45.9) 116 (52.3) 222 (100) regularity of menstruation regular 1 (0.6) 74 (47.5) 81 (51.9) 156 (100) 0.153 irregular 3 (4.6) 28 (42.4) 35 (53) 66 (100) total 4 (1.8) 102 (45.9) 116 (52.3) 222 (100) don’t know 1 (3.8) 11 (42.4) 14 (53.8) 26 (100) experiencing pms no 1 (1.3) 36 (46.8) 40 (51.9) 77 (100) 0.953 yes 2 (1.7) 55 (46.2) 62 (52.1) 119 (100) total 4 (1.8) 102 (45.9) 116 (52.3) 222 (100) don’t know 0 (0) 6 (37.5) 10 (62.5) 16 (100) do you know about pms? no 1 (2.2) 26 (57.8) 18 (40) 45 (100) 0.372 yes 3 (1.9) 70 (43.5) 88 (54.6) 161 (100) total 4 (1.8) 102 (45.9) 116 (52.3) 222 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.07 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 61 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. the current study reveals the presence of pms among female college students, their knowledge and attitude towards pms, and the impact of pms on academic and college life. the present study highlighted that the majority of students obtained good knowledge score about pms. likewise, another study reported that the majority (80%) of students were knowledgeable about pms [12]. in contrast with the current findings, a study [13] reported that only 3.6% of participants had good knowledge about pms. this might be due to the fact that the study participants were not students in the medical field as students studying different medical fields might be more knowledgeable about pms. regarding students’ attitude towards pms, the majority of students in the present study strongly agreed that pms is a significant issue that needs to be discussed. similar finding was reported by another study [12], in which it was reported that 90% of students hold the same stance. in addition, another study [14] reported that 77.5% of students hold the similar viewpoint. furthermore, the majority of the students in the current study agreed/strongly agreed that pms leave should be an option at the university. this is in accordance with another study [12] in which 81.5% of students believed that pms leave should be an option. another study [14] also reported that 61.6% of students believed the same. pms symptoms occur during the luteal phase of the menstrual cycle and they will be diminished with the start of menstruation [15]. in the current study, a remarkable number of students (54%) perceived that they experienced pms. however, when students were asked to identify the onset of pms symptoms, most of them mentioned that they had the symptoms during the menstrual period. this suggests that there might be some discrepancies between the student’s actual knowledge of pms and what they perceive to be pms. this is indeed have been shown in a study [14] where they found that 79.5% of students stated that they experience pms, however, when they were evaluated based on the criteria for the pms diagnosis, they revealed that only 23.9% of students actually experience pms. they concluded that there is a great inconsistency between having actual pms and self-perceived pms. studies have shown different prevalence of pms, for instance, it was reported that 81.6% of college students experienced no or mild pms in india [16]. in pakistan [17], it was reported that the prevalence of pms was 26.5% among nursing students. a study [18] in turkey identified pms symptoms in 36.4% of students. in a systematic review and meta-analysis study conducted on 25 studies [19], it was found that the pooled prevalence of pms was 43% indicating high pms prevalence in india. in other systematic review and meta-analysis studies, the prevalence of pms was around 48% and 71% [4, 20]. in saudi arabia, the pms prevalence was reported to be about 65% [21]. other studies reported 31.1% and 84.5% pms prevalence among students [22, 23]. the current findings revealed that backpain, breast tenderness, abdominal bloating, acne, restlessness, anxiety, and irritability were the most common symptoms reported to be experienced by the students. similarly, in a study conducted in jordan on 594 medical students, it was found that the majority of students experienced breast tenderness, bloating, nervousness, anxiety and mood swings to a moderate level [24]. likewise, other studies found that breast tenderness, abdominal bloating and headache were the most common symptoms reported by students [25, 26]. other studies reported other symptoms, discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.07 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 62 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. for instance, a study [16] reported that fatigue or lack of energy was the most common reported symptoms. another study also reported that muscle pain and lack of energy were the most prevalent symptoms followed by abdominal pain, headache, and irritability [27]. in addition, mood changes, depressed mood, and fatigue were also reported by participants in other studies [6, 28].regarding students’ pms self-management, around 60% and 27% of students in the current study apply hot back and exercise regularly to relieve their pms symptoms, respectively. this is in agreement with another study which reported that 56.2% and 26.9% of students use hot pack and do exercise to alleviate their discomfort [12]. the current findings also highlighted that 55.4% of students did not take any medications such as painkillers to alleviate their symptoms. similarly, another study conducted among pakistani women reported a higher figure (81.3%) of females who did not take any medications [27]. in addition, the present study found that only 19.4% of students used traditional remedy to relieve their pms symptoms. however, higher figure was reported in a study conducted in lebanon [25], in which around 49% of medical students applied some kind of remedies to alleviate their pms symptoms. however, a study found that 49.4% of students do nothing, this figure is a bit higher compared to the current study findings where 30.6% of students did nothing. the female students’ academic performance and university related duties might be undesirably affected by pms [24]. regarding the impact of pms on daily life activities and college life, the current findings revealed that 82.2% of students reported the lack of motivation. similarly, around 77% of students’ school work productivity was impaired due to pms [16]. in addition, another study also reported that almost 73% of students’ daily activities were affected due to the pain. furthermore, another study concluded that pms has a significant negative impact on students’ performance academically and their emotional well-being [29]. it was also concluded that a substantial number of students felt that pms impaired their daily living and social activities [30]. it was reported that 53.8% of students stated that pms impaired their college work and concentration [12]. other studies have documented that the severity of symptoms of pms hinders daily routine activities and has a substantial consequence on the academic participation of female university students. in addition, 49.2% of them reported that pms impaired their social activities compared to 53.6% of students who reported that they missed social events due to pms in the current study [21, 31]. although the current study highlighted substantial findings regarding pms among female university students, it is not without limitations. as the current study included only nursing and midwifery students, the outcomes of the study might not be generalizable to other students studying other medical and nonmedical specialties. henceforth, conducting other studies exploring the issue among other students studying medical and non-medical specialties is deemed necessary. a considerable number of students obtained good knowledge score about pms, however, their actual knowledge about pms experience might differ from what they perceive as pms. the majority of students hold a positive stance regarding the pms issue. the study revealed that the majority of students reported the lack of motivation and concentration due to pms. further studies exploring the pms among other students studying medical conclusion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.07 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 63 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. and non-medical specialties are considered essential. the author reports no conflict of interest. the author received no funding support for the current study. [1] bakhshani nm, mousavi mn, khodabandeh g. prevalence and severity of premenstrual symptoms among iranian female university students. journal of the pakistan medical association. 2009; 59(4): p. 205-8. [2] sahin s, ozdemir k, unsal a. evaluation of premenstrual syndrome and quality of life in university students. journal of the pakistan medical association. 2014; 64(8): p. 915-22. [3] hofmeister s, bodden s. premenstrual syndrome and premenstrual dysphoric disorder. american family physician. 2016; 94(3): p. 236-40. [4] direkvand-moghadam a, sayehmiri k, delpisheh a, kaikhavandi s. epidemiology of premenstrual syndrome (pms)-a systematic review and meta-analysis study. journal of clinical and diagnostic research: jcdr. 2014; 8(2): p. 106. [5] cheng s-h, shih c-c, yang y-k, chen k-t, chang y-h, yang y-c. factors associated with premenstrual syndrome — a survey of new female university students. the kaohsiung journal of medical sciences. 2013; 29(2): p. 100-5.https://doi.org/10.1016/ j.kjms.2012.08.017. [6] farrokh-eslamlou h, oshnouei s, heshmatian b, akbari e. premenstrual syndrome and quality of life in iranian medical students. sexual & reproductive healthcare. 2015; 6(1): p. 23-7. https://doi.org/10.1016/ j.srhc.2014.06.009. [7] shehadeh jh, hamdan-mansour am. prevalence and association of premenstrual syndrome and premenstrual dysphoric disorder with academic performance among female university students. perspectives in psychiatric care. 2018; 54(2): p. 176-84. https:// doi.org/10.1111/ppc.12219. [8] victor ff, souza ai, barreiros cdt, barros jlnd, silva facd, ferreira alcg. quality of life among university students with premenstrual syndrome. revista brasileira de ginecologia e obstetrícia. 2019; 41: p. 312-7. https://doi.org/10.1055/s-00391688709. [9] acikgoz a, dayi a, binbay t. prevalence of premenstrual syndrome and its relationship to depressive symptoms in first-year university students. saudi medical journal. 2017; 38(11): p. 1125-31. https:// doi.org/10.15537/smj.2017.11.20526. [10] al-qazaz hk, al-dabbagh ro. menstrual disorder: cross-sectional study on prevalence and self-care practice among adolescents in iraq. annals of tropical medicine and health. 2020; 23: p. 125-32. http:// doi.org/10.36295/asro.2020.23416. [11] ahmed s, saeed a. knowledge and selfcare practices of adolescent students with pre-menstrual syndrome in erbil city. erbil journal of nursing and midwifery. 2019; 2 (1): p. 9-18. https://doi.org/10.15218/ ejnm.2019.02. [12] teotia s, kumari s, taneja n, kaur kn, awasthi aa, janardhanan r. a study on premenstrual syndrome among female students of a private university of delhi ncr. journal of womens health and development. 2020; 3(4): p. 413-22. [13] dadi givshad r, nourani saadoldin s, esmaily h. the relationship of perceived severity of premenstrual syndrome with knowledge, attitude and recorded severity of syndrom by a daily calendar among university students in iran. journal of midwifery and reproductive health. 2016; 4(1): p. 522-9. https://doi.org/10.22038/ jmrh.2016.6124. [14] mohib a, zafar a, najam a, tanveer h, rehman r. premenstrual syndrome: existence, knowledge, and attitude among female university students in karachi. cureus. 2018; 10(3). https://doi.org/10.7759/ cureus.2290. [15] kwan i, onwude jl. premenstrual syndrome. bmj clinical evidence. 2015; 2015. [16] raval cm, panchal bn, tiwari ds, vala au, bhatt rb. prevalence of premenstrual syndrome and premenstrual dysphoric disorder among college students of bhavnagar, gujarat. indian journal of psychiatry. 2016; 58(2): p. 164-70. https:// doi.org/10.4103/0019-5545.183796. [17] ul haq n, gill s, nasim a, tahir m, yasmin r, batool f. prevalence and impact of premenstrual syndrome among the female references conflict of interest funding https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.07 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 64 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. nursing students of quetta. asian journal of nursing education and research. 2019; 9(2): p. 239-42. https://doi.org/10.5958/23492996.2019.00050.8. [18] guvenc g, kilic a, akyuz a, ustunsoz a. premenstrual syndrome and attitudes toward menstruation in a sample of nursing students. journal of psychosomatic obstetrics & gynecology. 2012; 33(3): p. 106-11. https:// doi.org/10.3109/0167482x.2012.685906. [19] dutta a, sharma a. prevalence of premenstrual syndrome and premenstrual dysphoric disorder in india: a systematic review and meta-analysis. health promotion perspectives. 2021; 11(2): p. 161-70. https:// doi.org/10.34172/hpp.2021.20. [20] ranjbaran m, omani samani r, almasihashiani a, matourypour p, moini a. prevalence of premenstrual syndrome in iran: a systematic review and meta-analysis. international journal of reproductive biomedicine. 2017; 15(11): p. 679-86. [21] al-shahrani am, miskeen e, shroff f, elnour s, algahtani r, youssry i, et al. premenstrual syndrome and its impact on the quality of life of female medical students at bisha university, saudi arabia. journal of multidisciplinary healthcare. 2021; 14: p. 2373. [22] akbari r, sudharani m, kallupurackal sjx, ramya v, mr ng, suryakantha a. prevalence of premenstrual syndrome among medical students. national journal of community medicine. 2017; 8(06): p. 292-4. [23] i̇şik h, ergöl ş, aynioğlu ö, şahbaz a, kuzu a, uzun m. premenstrual syndrome and life quality in turkish health science students. turkish journal of medical sciences. 2016; 46 (3): p. 695-701. https://doi.org/10.3906/sag1504-140. [24] alshdaifat e, absy n, sindiani a, alosta n, hijazi h, amarin z, et al. premenstrual syndrome and its association with perceived stress: the experience of medical students in jordan. international journal of women's health. 2022; 14: p. 777-85. https:// doi.org/10.2147/ijwh.s361964. [25] attieh e, maalouf s, richa s, kesrouani a. premenstrual syndrome among lebanese medical students and residents. depression. 2013; 19: p. 826. https://doi.org/10.1016/ j.ijgo.2012.11.006. [26] goker a, artunc-ulkumen b, aktenk f, ikiz n. premenstrual syndrome in turkish medical students and their quality of life. journal of obstetrics and gynaecology. 2015; 35(3): p. 275-8. https:// doi.org/10.3109/01443615.2014.948820. [27] pal sa, dennerstein l, lehert p. premenstrual symptoms in pakistani women and their effect on activities of daily life. jpmajournal of the pakistan medical association. 2011; 61(8): p. 763. [28] shamnani g, gupta v, jiwane r, singh s, tiwari s, bhartiy ss. prevalence of premenstrual syndrome and premenstrual dysphoric disorder among medical students and its impact on their academic and social performance. national journal of physiology, pharmacy and pharmacology. 2018; 8 (8): p. 1205-. https://doi.org/10.5455/ njppp.2018.8.0415728042018. [29] durairaj a, ramamurthi r. prevalence, pattern and predictors of premenstrual syndrome (pms) and premenstrual dysphoric disorder (pmdd) among college girls. the new indian journal of obgyn. 2019; 5(2): p. 93-8. https:// doi.org/10.21276/obgyn.2019.5.2.6 [30] yokota j, shinozaki a, kamo t, horiguchi f, uchida k. a questionnaire study on the prevalence of premenstrual syndrome, premenstrual dysphoric disorder, and related coping mechanisms among female medical students. tokyo women's medical university journal. 2017; 1: p. 1-7. https:// doi.org/10.24488/twmuj.2017001. [31] tolossa fw, bekele ml. prevalence, impacts and medical managements of premenstrual syndrome among female students: cross-sectional study in college of health sciences, mekelle university, mekelle, northern ethiopia. bmc women's health. 2014; 14(1): p. 1-9. https:// doi.org/10.1186/1472-6874-14-52 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.15 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article knowledge and attitude regarding the family planning among spouses in sub-urban primary health care centres in erbil province abstract background and objectives: family planning refers to couples who make educated choices about having children, such as timing their pregnancies and limiting the number of children that they will have via contraceptive techniques. objective of the study: to assess couples' knowledge and attitudes about family planning and its association with their socio-demographic characteristics. methods: a quantitative, cross-sectional study using a self-administered questionnaire which consisted of socio-demographic characteristics, couple’s knowledge (17 question) and couple’s attitude (18 questions) among 288 couples in primary health care centers sub-urban erbil province from september 2021 to december 2022, met the exclusion criteria for pregnant who refused participation and inclusion criteria in reproductive age 1549, married women with their partner and who use contraceptives. the data were analyzed with the statistical package for the social science version 26. results: most of the spouses were in the age group 25–34 years old. the sources of information about family planning methods for husbands were 56.3% from social media, and the wives 54.9% from family. most of the husbands are 51.4%. their overall knowledge regarding family planning methods was fair. there was an association between the husbands’ occupation and knowledge of family planning methods (p-value=0.044). the highest proportions of the study sample (66%) of the husband and (63.2%) of wives preferred oral contraceptive pills as the best method for family planning. conclusion: the overall knowledge of the husbands was fair(acceptable), while the wives had good knowledge. there was a correlation between the husband's knowledge and the wife's attitude towards family planning methods based on sociodemographic characteristics, but there was no correlation between the husbands' knowledge and the wives' knowledge. keywords: knowledge; attitude; practices; family planning methods; contraceptive types. suzan mustafa muhammed; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq (correspondence: suzan.muhamad@hmu.edu.krd) tiran jamil piro; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq 156 received: 27/11/2022 accepted: 22/01/2023 published: 30/11/2024 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.15 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article a couple describes family planning and spacing as a deliberate attempt to limit or minimize the number of children they want using contraceptive methods. the way of life is accepted by individuals and couples, based on knowledge, attitude, and responsible decision-making, to promote the wellbeing and health of their families and contribute to promoting society. birth control is recognized as an important response to improving women’s health and human rights [1].people may use family planning to achieve their desired number of children and calculate the spacing between their pregnancies and births. it is accomplished by the use of contraceptive techniques as well as the treatment of infertility problems. a family planning program assists couples and individuals in realizing their basic right to select for themselves when they want to have children and how many children they want to have[2].birth control is a decision by a person or a couple to know how many babies they want to have, when to decide to have children and how long to continue between conceptions. the action should be freely taken without force after a person has had full knowledge of the benefits of family-size planning, the procedures to use, the relative benefits of each approach, and the expected complications of the mentioned methods [3].contraceptives are tools or medications that inhibit ovulation or avoid sperm delivery to the womb to prevent conception. it is claimed that a woman’s ability to space and track pregnancy directly impacts her health and her children’s health. contraceptive use also has a vital role in alleviating problems like accidental pregnancy and abortion. to increase maternal health, abortion is also used, and the criteria for family planning are reduced[4].while the adolescent fertility rate in iraq is still among the highest in the area, contraception is only approximately 36% of the total population of iraq. this implies that many couples and people who need family planning services will not get them, violating their reproductive rights. the ministry of health developed the national family planning strategy (2021-2025) with the support of the united nations population fund (unfpa) and funding from sweden, and in consultation with a wide range of stakeholders, including women and young people, to ensure that their rights and needs are adequately addressed [5]. importance of the study: no major studies have been conducted to elaborate on the standard of family planning methods in the kurdistan region, but it seems that males play an important role in family planning-related decisionmaking, and they are the ones who usually fix the number of kids in the family. in the few previous studies, only one partner participated (female). the aim of the study is to assess couples' knowledge and attitudes about family planning and its association with their socio-demographic characteristics. a descriptive (cross-sectional) study was conducted to identify knowledge, and attitude of family planning among spouses in sub-urban primary health care centers in erbil province.the study was carried out in three primary health care centers in suburban areas in erbil province, kurdistan region, (razhan, kasnazan and daratw) primary health care centers (phc). the distribution of the area was according to municipalities. razhan health care center belongs to the bnaslawa municipality, kasnazan primary health care center belongs to kasnazan municipality and the daratw health care center belongs to the daratw municipality.this study was carried out from 1st september 2021 to 1st 157 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.15 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article method was used for the statistical calculation to determine the overall knowledge and attitude. knowledge of spouses regarding family planning consists of 17 questions and the knowledge is classified as follow: good, fair, and poor. attitudes of spouses regarding family planning. it consists of 18 questions, and the attitude is classified as follows: positive, neutral, and negative. according to the statistical findings, the overall level of the husband’s knowledge was 51.4% and the wife’s 39.6% and the husband’s attitude was 39.2% and the wife’s 37.5%. data from the study were analyzed using the statistical package for social science (spss, version 26), included a descriptive statistical analysis of frequency, the percentage of the questionnaire items and a chi-square test for the association between demographic characteristics and other sections of the questionnaire. table 1 shows that the highest percentage of the husband-and-wife participants were in the age group 25–34 years, which is 33.3% for husbands and 41.3% for wives. the highest percentage of the sample members in the level of education holding a secondary school were 27.8% for husbands and 31.3% for the wife. as for the occupation, the findings reveal that most husbands had skilled manual workers, about 25.7%, while 30.6% of wives were unemployed. december 2022. this period includes preparing the questionnaire tools and writing the methodology with data collection, data analysis, result and conclusion. prior to the initiation of the present study, the approval was obtained from the ethical and scientific committee of college of nursing / hawler medical university and minister of health/ director of health/ planning department of kurdistan region, iraq. the ethical form was approved with code number (116) dated on 7th oct 2021. both anonymity and the confidentiality of the participants were preserved. the names of the participants, their addresses, and any other information that could be used to personally identify them were not used in this study. the objectives of the study were explained to the people who took part in the research, and their agreement was gained. epi info 7 was used to calculate the sample size. this method was used to calculate the sample size by entering the total number of spouses which was about 1145, with a confidence level of %95 and an error margin of %5. the calculation resulted in 288 samples. the researcher took 288 spouses in razhan, kasnazan, and daratw health care centers in erbil city. a thorough examination of the pertinent literature was used by the researcher as the basis for the construction and selection of a questionnaire as well as an interview technique. the interview lasts for approximately 7 to 10 minutes. a structure for conducting interviews in the form of a questionnaire was designed in order to ensure accurate data collection. this format is comprised of five components and includes the information presented below. demographic characteristics: such as; spouses age, religion, ethnicity, husband and wife occupation, husband and wife education, income, house ownership and car ownership. family planning history. the absolute category rating (acr) 158 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.15 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article the finding in figures 1 illustrated that the highest percentage of both husbands and wives were in the age category under 20 years old regarding the family planning history related to age at marriage, which is about 43%, and 55% of the wives were under 20 years old for the same age category related to age at marriage. 159 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: distribution study sample according to the socio-demographic characteristics of spouses variables husband wife frequency(%) frequency(%) age group 15-24 71(24.7) 100(34.7) 25-34 96(33.3) 119(41.3) 35-44 89(30.9) 57(19.8) 45-54 32(11.1) 12(4.2) education level illiterate 33(11.5) 33(11.5) read & write, and prima76(26.4) 35(12.2) intermediate 63(21.9) 83(28.8) secondary 80(27.8) 90(31.3) college and above 36(12.5) 47(16.3) occupation unemployed 47(16.3) 88(30.6) unskilled manual worker 57(19.8) 57(19.8) skilled manual workers 74(25.7) 56(19.4) non-manual workers 65(22.6) 51(17.7) high level occupations 45(15.6) 36(12.5) number of the sample study= 288 figure 1: husband and wives age at marriage https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.15 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article 160 availability for wives were health care centers, pharmacies, and government hospitals, with 53.5%, 55.2%, and 52.4%, as shown in the same figure 3. the result in figure 2 regarding the sources of contraceptive availability for husbands were pharmacies, which is about 55.9%. while the sources of contraceptive copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. figure 2: sources of availability of contraception for husband figure 3: sources of availability of contraception for wife https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.15 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article of wives expressed a good level of knowledge regarding family planning. family planning, while 31.9% of them expressed a neutral level and 28.8% expressed negative level. association between other variables of socio-demographic characteristics and age group of husbands (p-value 0.493), husband's religion (p-value 0.893), husband's education level (p-value 0.608) and husband's age at marriage (p-value 0742). 161 table 2 demonstrated that 51.4% of husbands expressed a fair level of knowledge regarding family planning. while 39.6% table 3 indicated that 37.5% of wives expressed a positive attitude regarding family planning, while 39.2% of husbands expressed a positive attitude regarding table 4 shows a significant association between the husband's occupation and the husband's knowledge regarding family planning, where the significance value was (p-value 0.044). this value was less than the alpha value (p-value ≤ 0.05). while, there was non-significant copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: overall husband’s and wife’s knowledge’s regarding family planning husbands wives levels frequency (%) frequency (%) good 111(38.5) 114 (39.6) fair 148 (51.4) 80 (27.8) poor 29 (10.1) 94 (32.6) total 288 (100) 288 (100) table 3: overall husband’s and wife's attitudes of spouses regarding family planning husbands wives levels frequency (%) frequency (%) positive 113 (39.2) 108 (37.5) neutral 92 (31.9) 82 (28.5) negative 83 (28.8) 98 (34.0) total 288 (100) 288 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.15 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article 162 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: association between socio-demographic characteristics and husband's knowledge regarding family planning in the study sample variables overall knowledge p-value yes no age group of husband 15-24 46 25 0.493 ns 25-34 66 30 35-44 61 28 45-54 14 18 husband's religion muslim 150 81 0.893 ns christian 37 20 husband's education level illiterate 21 12 0.608 ns read & write, and primary 52 24 intermediate 38 25 secondary 56 24 college and above 20 16 husband’s occupation unemployed 29 18 0.044 s unskilled manual worker 29 28 skilled manual workers 48 26 non-manual workers 49 16 high level occupations 32 13 husband's age at marriage under 20 years 78 47 0.742 ns 20-25 32 10 26-31 59 35 32-37 6 5 38 and above 12 4 number of the sample study= 288 spouses https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.15 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article and the wife's knowledge of spouses regarding family planning, where all values were greater than the alpha value (p-value 0.05). table 5 revealed that there was a nonsignificant association between all variables of the socio-demographic characteristics, 163 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 5: association between socio-demographic characteristics and wife's knowledge regarding family planning in the study sample variables overall knowledge p-value yes no age group of wife 15-24 69 31 0.845 ns 25-34 84 35 35-44 35 22 45-54 6 6 wife's religion muslim 154 74 0.254 ns christian 40 20 wife's education level illiterate 21 12 0.466 ns read & write, and primary 23 12 intermediate 51 32 secondary 65 25 college and above 34 13 wife’s occupation unemployed 56 32 0.897 ns unskilled manual worker 39 18 skilled manual workers 39 17 non-manual workers 37 14 high level occupations 23 13 wife's age at marriage under 20 years 110 49 0.414 ns 20-25 53 32 26-31 26 9 32-37 3 3 38 and above 2 1 number of the sample study= 288 spouses https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.15 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article where all values were more than the alpha value (p-value 0.05). the result accepted the null hypothesis, which is that the variables are independent, and rejected the alternative hypothesis. table 6 demonstrated that there was a non-significant association between all variables of the socio-demographic characteristics, and the husband's attitudes of spouses regarding family planning, 164 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 6: association between socio-demographic characteristics and husband's attitudes regarding family planning in the study sample number of the sample study= 288 spouses variables overall attitude p-value agree neutral disagree age group of husband 15-24 34 22 15 0.575 ns 25-34 29 35 32 35-44 30 26 33 45-54 20 9 3 husband's religion muslim 86 75 70 0.303 ns christian 27 17 13 husband's education level illiterate 15 12 6 0.298 ns read & write, and primary 35 17 24 intermediate 25 17 21 secondary 21 35 24 college and above 17 11 8 husband’s occupation unemployed 19 16 12 0.846 ns unskilled manual worker 24 20 13 skilled manual workers 34 21 19 non-manual workers 21 20 24 high level occupations 15 15 15 husband's age at marriage under 20 years 51 40 34 0.722 ns 20-25 17 14 11 26-31 35 28 31 32-37 4 5 2 38 and above 6 5 5 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.15 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article socio-demographic characteristics and age group of the wife (p-value 0.062), wife's religion (p-value 0.898), wife's education level (p-value 0.661), and wife's occupation (p-value 0.367), where these significance values were more than the alpha value (pvalue 0.05). table 7 shows that there was a significant association between the wife's age at marriage and the wife's attitudes toward spouses regarding family planning, where the significance value was (p-value 0.016). while there was a non-significant association between other variables of 165 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 7: association between socio-demographic characteristics and wife's attitudes regarding family planning in the study sample variables overall attitude p-value agree neutral disagree age group of wife 15-24 34 36 30 0.062 ns 25-34 48 26 45 35-44 24 17 16 45-54 2 3 7 wife's religion muslim 86 66 76 0.898 ns christian 22 16 22 wife's education level illiterate 13 10 10 0.661 ns read & write, and primary 16 10 9 intermediate 28 24 31 secondary 34 22 34 college and above 17 16 14 wife’s occupation unemployed 33 30 25 0.367 ns unskilled manual worker 27 11 19 skilled manual workers 19 18 19 non-manual workers 13 16 22 high level occupations 16 7 13 wife's age at marriage under 20 years 60 47 52 0.016 s 20-25 35 22 28 26-31 10 11 14 32-37 3 0 3 38 and above 0 2 1 number of the sample study= 288 spouses https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.15 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article table (2) demonstrated that more than half of the husbands overall knowledge regarding family planning was expressed at a fair level, which is friendly to a study that was conducted in egypt among 284 married husbands in 2017 and showed the highest percentage of husbands were fair in knowledge regarding fp [12].while in (table 2) the wives expressed a good level of knowledge of spouses regarding family planning. similar to the present study, a cross-sectional study was done in pakistan in 2016 among 503 married women which showed the majority 99% of wives have good knowledge regarding fp [13].in the current study, both the husbands and the wives expressed a positive overall attitude regarding family planning, as shown in (table 3). similar to the present study, a cross-study was conducted among 560 married couples in saudi arabia in 2017 which showed the highest rate of spouses having a good attitude toward family planning methods [14]. the present study shows a significant association between the husband's occupation and section two of the questionnaire related to the husband's knowledge regarding family planning, where the significance value was (pvalue 0.044) as shown in (table 6). in contrast to the current study, in 2021 in india, a cross-sectional study carried out among 200 married husbands. the result showed that there is a non-significant association between the husband’s knowledge of fp methods and socio-demographic characteristics; the values were more than (pvalue 0.05) [15]. the current study shows there is a non-significant association between all variables of the sociodemographic characteristics and the wife's knowledge regarding family planning, where all values are greater than the alpha value (p-value 0.05) as shown in (table 6). similar to the recent study, a nonexperimental survey that was conducted in the finding of the current study is similar to a quantitative, cross-sectional study that has been done in karachi, pakistan in 2014 on 200 couples for the age group 2534 [6]. and another cross-sectional study design with a quantitative approach has been conducted in ghana in 2019 on 206 married couples, which is equal to the current results of the study [7]. a recent study shows that most of the participants in the level of education hold a secondary school, 27.8% for husbands and 31.3% for the wife shows in (table 1). agreeing with a cross-sectional study conducted in egypt in 2017 on 284 showed the highest level of education for both wives and husbands: 39.1% had a secondary level [8]. the result of the present study illustrated that most husbands and wives were in the category of under 20 years regarding the family planning history related to age at marriage as shown in (figure 1), for both husbands and wives. a descriptive cross-sectional design was utilized in egypt in 2020 among 176 married couples which showed that most of the husbands and wives in the study were >25 years old which is in contrast to the current study [9].regarding the sources of spouse's information toward the fp methods, the current study showed the information source about the wives' family planning was friends, family and relatives as seen in (figure 3), similar to a cross-sectional study performed on 547 women in mumbai, india in 2016 showing the highest percentage of married women got information from the social circle (10).according to the same result of the current study, the sources of information about the family planning of husbands were the media (tv, radio, newspaper, and journal), and friends. similar to a study done in egypt in 2020 on 176 married couples shows that the husbands got the information from television [11]. 166 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.15 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article women and showed a highly significant association between the sociodemographic values and wife’s attitudes toward family planning [20]. also, an opposite quantitative study done in india in 2019 among 92 participants (married women) showed an alpha value of more than (p-value 0.05) [21]. apart from sociodemographic data, the results suggest that more than half of the couples obtained their contraceptives through pharmacies as a source of availability. the spouses used contraceptive methods for 1-5 years, and they visited primary health care centers and clinics every six months. according to the statistical data, the assessment of the husband's knowledge of contraceptive techniques was fair when compared to the wife's knowledge of the same variable, which passed in the assessment. the findings are based on statistical analysis of the husband's awareness of contraceptive methods. both partners' attitudes were positive, and a wife's overall practices regarding fp approaches were positive. regarding the association between the sociodemographic characteristics and the knowledge of the spouses, the study indicated that there was a significant association between the husband’s sociodemographic variables (occupation), and knowledge regarding the fp methods is in contrast to the wife’s knowledge regarding the fp methods; there was no significant association. furthermore, there was no association between the husband's attitude and knowledge of fp methods, while there was an association between the wife's attitude and sociodemographic characteristics (years of marriage), and finally, there was no significant association between the sociodemographic characteristics and the wife's practices regarding fp methods. india among 200 married women in 2021 showed that there is a non-significant association between socio-demographic characteristics and knowledge of husbands regarding the family planning methods the value; was more than (p-value 0.05) [16]. the current study shows there is a nonsignificant association between all variables of the socio-demographic characteristics, and the husband's attitudes regarding family planning, as demonstrated in (table 7). a similar study has been done in gangwadi, india among 320 married men in 2014 which showed that statistically there was a non-significant association between the attitude of the husbands and the variable of the socio-geographic characteristics [17].along with the present study, a cross-sectional study done among 150 married men in 2015 in nigeria showed that there was a non-statistically significant association among the husband’s attitude with socio-demographic characteristics [18].there is a significant association between the wife's age at marriage and section three items of the questionnaire related to the wife's attitudes regarding family planning, where the significance value was (p-value 0.016) as shown in (table 8). similar to the current study regarding the significant association of wife practices regarding the fp methods with socio-demographic variables, a crosssectional study was done in al-amara city, iraq in 2020 among 270 married women showed there were a highly significant association between the attitudes of wives and socio-demographic characteristics) [19].while, there was a non-significant association between other variables of socio -demographic characteristics, age group of the wife, religion, education level, and wife's as demonstrated in (table 8). in contrast to the current research, a crosssectional study has been conducted in alamara, iraq in 2020 among 270 married 167 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.15 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article references [11] shaukat f, naeem z, ahmed z. family planning: knowledge, attitudes and practice among married couples. international journal of health sciences. 2011;5(2 suppl 1):45. [12] hamed zf, el-gazzar af, moftah fm. knowledge, attitude and practice of family planning methods among husbands in a village of assiut governorate. the egyptian journal of hospital medicine. 2018;73 (4):6489-93. [13] hameed s, haq nu, haque n, nasim a, riaz s, tahir m, et al. knowledge, attitude and practices (kap) regarding family planning services among married women of quetta pakistan. family planning services. international journal of research and reports in gynaecology 2019;2:1-12. [14] subba m, devi b, devi r. knowledge, practice and barriers in utilization of family planning methods among married couples of urban and rural areas of sikkim. international journal of advance research in community health nursing 2022;1(4):19-28. [15] subba m, devi b, devi r. knowledge, practice and barriers in utilization of family planning methods among married couples of urban and rural areas of sikkim. international journal of advance research in community. 2022;4(1):19-28. [16] subba m, devi b, devi r. knowledge, practice and barriers in utilization of family planning methods among married couples of urban and rural areas of sikkim. journal of advance research in community health nursing. 2022;1(4):19-28. [17] chaudhary bk, wantamutte a, sah jk. knowledge, attitude and practices regarding family planning methods among married men in urban field practice area of ramnagar urban health center. belagavi-a crosssectional study. us national library of medicine enlisted journal 2015;8:212-9. [18] owopetu c, chukwuma s, nwozichi c. knowledge and attitude of men about vasectomy as a method of family planning among married men working in babcock university, ogun state, nigeria. international journal of nursing midwifery. 2015;7(3):30-5. [19] hussein al abedi ga, arar aa, alridh msa. assessment of knowledge, attitude and practices for women’s toward family planning in primary health care centers at alamara city/iraq. international journal of psychosocial rehabilitation. 2020;24(09). [1] manandhar n, amatya i, gautam a, kumar g, ahlawat h, adhikari n, et al. knowledge, attitude and practice regarding family planning among the reproductive age women of khopasi, kavrepalanchowk. journal of chitwan medical college. 2020;10(3):53-6. [2] bekele d, surur f, nigatu b, teklu a, getinet t, kassa m, et al. knowledge and attitude towards family planning among women of reproductive age in emerging regions of ethiopia. journal of multidisciplinary healthcare. 2020;13:1463. [3] semachew kasa a, tarekegn m, embiale n. knowledge, attitude and practice towards family planning among reproductive age women in a resource limited settings of northwest ethiopia. bmc research notes. 2018;11(1):1-6. [4] asadisarvestani k, khoo sl, malek nm, yasin sm, ahmadi a. determinants of contraceptive usage among married women in shiraz, iran. journal of midwifery reproductive health. 2017;5(4):1041-52. [5] ebrahim sm, nihad. knowledge, attitude and practice of family planning among women in basrah city south of iraq. the medical journal of basrah university. 2011;29(1):706. [6] sultan s, ali m, bardai s, kanpuralla m, womens health ic. knowledge, attitude, and practice of family planning methods among married men and women. 2018;7(3):2. [7] fellah af. knowledge, attitudes and practice of family planning among married partners in ledzokuku krowor municipality in the greater accra region of ghana. science and technology. 2021. [8] hamed zf, el-gazzar af, moftah f. knowledge, attitude and practice of family planning methods among husbands in a village of assiut governorate. the egyptian journal of hospital medicine. 2018;73 (4):6489-93. [9] ali s, hassan s, el-nemer a. assessment of family planning knowledge and practice among married couples. mansoura nursing journal. 2020;7(2):214-26. [10] shukla m, fonseca m, deshmukh p. a study on contraceptive knowledge, attitudes and practices among women in the reproductive age group. international journal of reproduction, contraception, obstetrics and gynecology. 2017;6(8):3560-3. 168 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.15 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article 169 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [20] hussein al abedi ga, arar aa, alridh msa. assessment of knowledge, attitude and practices for women’s toward family planning in primary health care centers at alamara city/iraq. international journal of psychosocial rehabilitation. 2020;24(09). [21] wani rt, rashid i, nabi ss, dar h. knowledge, attitude, and practice of family planning services among healthcare workers in kashmir–a cross-sectional study. journal of family medicine primary care. 2019; 8(4):1319. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.16 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article attitudes of pregnant women towards husband’s attendance in delivery room in erbil city abstract background and objectives: pregnancy is a beautiful and challenging time in a woman's life. a pregnant woman needs more care and support from her husband and family during this time because of physical and hormonal changes in her body. husbands' attendance and support of women during labor can positively affect pregnant women and child’s health. the purpose of this study is to assess women’s attitudes towards the presence of their husbands during labor in erbil city. method: a descriptive cross-sectional study was conducted on pregnant women who visited primary health care and maternity teaching hospital in erbil city. epi info 7 was used to determine the sample size which three hundred participants were the sample of the calculation. statistical package for social science (spss) version 26 was used to analyze and organize the data thorough using frequency, percentage, and chi-square test. result: the study revealed that 62% of the participants were in the age group 20-30 years old. most of the women obtained an elementary school certificate, with a percentage 23.3%. most of the participants were urban residents, which was 81.3%. regarding the income of the participants, the result indicated that most of them were in conditions sufficient for daily living, which was about 57.3%. women expressed a good level of attitude towards husbands' attendance in the delivery room 80.3%. conclusion: this survey illustrated that most pregnant women agreed to the husband's attendance in the delivery room. pregnant women needed their husbands during labor which is important in their life. keywords: pregnant women; husband's attendance; delivery room. mhadasa farooq saadi; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq (correspondence: noorfarooq1994@gmail.com) tiran jamil piro; department of midwifery, college of nursing, hawler medical university, erbil, kurdistan region, iraq. 146 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 25/07/2022 accepted: 12/09/2022 published: 30/5/2023 mailto::%20noorfarooq1994@gmail.com?subject=:%20noorfarooq1994@gmail.com https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.16 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article pregnancy is a huge life transition that necessitates considerable psychological adaptations, which are frequently linked with worry and stress. a pregnant woman's lack of psychological and emotional adjustment through pregnancy is a risk factor. depressed mood during pregnancy, for example, has been established as a predictor of postpartum depression moods [1]. childbirth is one of the most worrying events that a pregnant woman undergo in her life [2]. father’s presence in the delivery room has been characterized as a process of behavioral and social effort which is for fathers to perform more responsible roles in maternity, and care to guarantee the wellbeing of women and children [3].in patriarchal societies, male partner involvement becomes extremely necessary if substantial changes in maternal health outcomes are to be made. men's involvement in maternal health care need to focus on raising their awareness of acute obstetric conditions and including them in birth preparedness and complication readiness (bpcr). men's presence would enable them to encourage their wives to seek emergency obstetric care early in the pregnancy, and the couple will be better prepared for birth and complications[4].according to the world health organization (who) in 2017, more than 295 000 women lost their lives during childbirth and after giving birth[5]. the majority of this mortality 94% occurred in lowresource regions and most of them could have been prevented. through the prenatal care concept, the world health organization created a birth readiness plan. the plan aims to reduce obstetric delays by encouraging the use of competent birth attendants, which reduces the risk of problems during labor. male participation refers to the partner's assistance and cares for the pregnant lady to have a positive pregnancy result. men's engagement is critical to the success of maternal health initiatives[6].men play a crucial influence in their female partners' pregnancy and birthing safety. furthermore, men's exclusion from maternal and child health (mch) services fostered the concept that pregnancy and delivery are primarily female experiences, and that maternity facilities are only for women. according to studies, men are affected crucial partners in improving maternal health and lowering maternal and infant mortality throughout pregnancy and delivery[7].the presence of a man during pregnancy and childbirth affects the pregnancy's and delivery outcome. it lowers the risk of preterm birth, low birth weight, fetal growth restraint, and child mortality by reducing harmful maternal health habits. male participation decreases maternal stress (by providing social, organizational, and financial support), increases prenatal care uptake, contributes to the reduction of risk behaviors, and ensures men's involvement in their potential parental positions from an early age, according to epidemiological and physiological proof[8].husbands are seen by wives as the most crucial source of support throughout pregnancy and labor, and in certain situations, their help is valued higher than that provided by midwives. support from husbands during labor is conducive to a more positive experience of childbirth, a shorter duration of labor, and a positive attitude toward growing into motherhood. expectant men can take on one of three roles to help their wives during labor: coach, teammate, or observer [9]. male engagement during pregnancy and labor can result in a healthier marital connection and better birth outcomes for the mother and child. emotional support during labor and deliveries are all examples of a husband's positive involvement [10].this study was designed due to the fact that this topic has not been raised 147 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.16 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article centers in erbil city according to geographical designations (east, west, north, and south). the inclusion criteria are composed of the participants during the pregnancy period and who were in the birth room. the study was accepted by the nursing ethical committee of hawler medical university college of nursing in 7th october 2021number 108, and official authorization was acquired from the ministry of health's director of health in erbil. data were collected via a checklist and a questionnaire. the questionnaire consists of 2 parts. part one includes socio-demographic characteristics and professional background of the pregnant woman and her husband. this part, also, includes information like (age of pregnant woman, age of husband, level of education of the pregnant woman and her husband, woman's occupation, husband's occupation, residence, income, religion, and the number of the husband's wives). the second part items focused on women’s attitudes towards their husbands’ attendance to the delivery room, this part includes 28 items. the descriptive statistics of the participants according to their hospitals were as follows: the majority of the participants were in the teaching maternity hospital. their percentage scored 41.7%, malafandy 14%, nizdar bamarni 13.0%, azady 14.6%, and mohamad bajalan 16.7%. : for analyzing the collected data, statistical package for social science (spss) version 26 was used. the mean and standard divisions were checked to determine the acceptance rate of participants. in addition, the chi a square test was used to test the association between women's attitudes and socio-demographic characteristics such as age, level of education, occupation, and economic status. the respondents' rights and confidentiality were protected throughout the study. they were ensured that their personal information before in kurdistan. and in kurdistan, men do not stay with their wives during the childbirth process. men’s participation in maternal and child health (mch) care services is inferior, due to our culture, religion, and community policy. the limitation laid down by the researcher was covid-19 outbreak period, due to the aforementioned reason; the author faced many difficulties in visiting the places to collect the needed data. the consequences of the covid-19 pandemic, which continues to endanger people every day, caused people to avoid each other [25]. the objectives of the present study were: 1) explore women’s attitudes towards the presence of their husbands during their labor. 2) to find out the socio-demographic characteristics and obstetrical history such as; age, level of education, economical status, and occupation of pregnant women. 3) to find out the associations between sociodemographic data such as; age, level of education, occupation, and women’s attitudes. a quantitative descriptive cross-sectional study was applied on pregnant women who visited primary health care centers and maternity teaching hospital in erbil city. data were collected by using a nonprobability (purposive sample) technique. epi info 7 was utilized to extract the sample size from the population which included 1380 of women. the sample size was calculated via implementing the aforementioned method and yielding a 95% confidence level and a 5% margin of error. the three hundred participants were the output of the calculation. the study was conducted at maternity teaching hospital, malafandy primary health care centers, nazdar bamarny primary health care centers, azadi primary health care centers, and mohamad bajalan primary health care 148 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.16 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article were kept secretly and explained the goals of the study to them. table 1 socio-demographic characteristics (age of women, age of husband, religion, residence, income, and the number of the husband's wives) of the study samples reveal that most of the participants aged between 20-30 years old. the percentage was 62% for the women’s age and 58.3% for the ages of their husbands. also, the study sample reveals that 100% of the participants were of the muslim religion. most of the participants were urban residents, which was 81.3%. regarding the income of the participants, the result indicated that most of them were in conditions sufficient for daily living, which was about 57.3%. most husbands have only one wife with a percentage 98.3%. also, a small part of them was in bigamy conditions, which was about 1.7%. 149 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results table 1 : socio-demographic characteristics (age of women, age of husband, religion, residence, income, and the number of the husband's wives) of the study sample variables f (%) age of women under 20 years 35 (11.7) 20-30 186 (62) 31-40 68 (22.6) 41-50 11 (3.7) total 300 (100) age of husband under 20 years 2 (0.7) 20-30 175 (58.3) 31-40 95 (31.7) 41-50 25 (8.3) 51 and above 3 (1) total 300 (100) religion muslim 300 (100) residence rural 56 (18.7) urban 244 (81.3) total 300 (100) income sufficient for daily living 172 (57.3) insufficient 87 (29) exceed need 41 (13.7) total 300 (100) the number of the husband's wives one wife 295 (98.3) bigamy 5 (1.7) total 300 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.16 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 150 with a percentage of 23.3%. and most of the husbands were at the intermediate level which was about 24.7%, and at the secondary school level, which was about 24.0%. were unemployed, with a percentage 81.3%. while the majority of husbands were self-employed, this was about 73.7%. copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2 socio-demographic characteristics related to the woman's educational level, and their husband's educational level in the study sample. the table also illustrated that most of the women were obtained the primary school certificates, table 3 socio-demographic characteristics related to the woman's occupation, and their husband's occupation in the study sample, show that the majority of women table 2: socio-demographic characteristics related to the woman educational level, and the husband educational level in the study sample variables f (%) woman educational level illiterate 22 (7.3) read and write 2 (0.7) primary school 70 (23.3) intermediate 48 (16) secondary school 57 (19) institute graduate 41 (13.7) college graduate 59 (19.7) post graduate 1 (0.3) total 300 (100) husband educational level illiterate 20 (6.7) read and write 1 (0.3) primary school 55 (18.3) intermediate 74 (24.7) secondary school 72 (24) institute graduate 23 (7.7) college graduate 49 (16.3) post graduate 6 (2) total 300 (100) table 3: socio-demographic characteristics related to the woman occupation, and the husband occupation in the study sample variables f (%) women occupation employer 33 (11) unemployed 244 (81.3) self-employer 23 (7.7) total 300 (100) husband occupation employer 73 (24.3) unemployed 6 (2) self-employer 221 (73.7) total 300 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.16 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 151 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4 descriptive statistics of items in table 4 related to women’s attitudes towards their husband attendance to the delivery room. illustrated the acceptance rate of participants for all items of part three in the questionnaire related to women’s attitudes about husband attendance in the delivery room, which was 28 items. the item which stated (the husband should escort the wife to the hospital for delivery) got the highest score which is the value 2.96 depending on the women's responses. other items got a high score, as the value 2.91 for the item regarding (the presence of the husband is calming for his pregnant woman). and, the value was 2.86 for these items (it helps women feel their husband's love for them and their family.), and (if your husband is present in the delivery room you can ask for anything that you want or you need because your husband has good communication). while the item that got the lowest score was (husband culture affects the women, staff, and delivery procedure) with a value 2.13. table 4: descriptive statistics of items related to women’s attitudes about husband attendance in the delivery room items disagree neutral agree mean f (%) f (%) f (%) q1. it is pleasurable if your husband be with you in the most important moments in life such as childbirth. 39 (13) 1 (0.3) 260 (86.7) 2.74 q2. your husband can improve your emotional (psychological) and physical activity during childbirth. 26 (8.7) 5 (1.7) 269 (89.7) 2.81 q3. the husband increases the women's self-confidence during labor. 23 (7.7) 5 (1.7) 272 (90.7) 2.83 q4. the woman can explain her pain of delivery with her husband. 90 (30) 3 (1) 207 (69) 2.39 q5. husband attendance helps the pregnant woman bear labor pain. 24 (8.8) 3 (1) 273 (91) 2.83 q6. prepares your husband to accept his paternal (parental) responsibility. 40 (13.3) 1 (0.3) 259 (86.3) 2.73 q7. the presence of a husband in the delivery room has a positive effect on women’s feelings. 35 (11.7) 7 (2.3) 258 (86) 2.74 q8. it strengthens the couple’s relationship. 20 (6.7) 6 (2) 274 (91.3) 2.85 q9. husband attendance decreases the mother's anxiety in the delivery room. 30 (10) 10 (3.3) 260 (86.7) 2.77 q10. it can transfer the husband's anxiety to the mother. 99 (33) 9 (3) 192 (64) 2.31 q11. it has a positive effect on the father-child relationship. 53 (17.7) 6 (2) 241 (80.3) 2.63 q12. it helps women to feel their husband's love for them and their family. 21 (7) 0 (0) 279 (93) 2.86 q13. it helps the woman to feel that she was not alone during a difficult time. 23 (7.7) 2 (0.7) 275 (91.7) 2.84 q14. the presence of the husband is calming for his pregnant woman. 13 (4.3) 0 (0) 287 (95.7) 2.91 table 4: cont. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.16 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 152 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. items disagree neutral agree mean f (%) f (%) f (%) q15. it is unpleasant for the woman that her husband is with her during childbirth. 267 (89) 0 (0) 3 (11) 2.39 q16. it is not helpful to the woman when the partner is present. 272 (90.7) 0 (0) 28 (9.3) 2.39 q17. husband attendance in the delivery room is against kurdish culture. 220 (73.3) 2 (0.7) 78 (26) 2.21 q18. better to replace another person in place of your husband for companionship in the delivery room. 239 (79.7) 2 (0.7) 59 (19.7) 2.25 q19. the women listening to their husbands effectively during labor. 27 (9) 9 (3) 264 (88) 2.79 q20. societies can affect allowing husbands to participate in childbirth and be present during labor. 167 (55.7) 3 (1) 130 (43.3) 2.06 q21. if your husband is present in the delivery room you can ask for anything that you want or you need (because your husband has good communication). 20 (6.7) 1 (0.3) 279 (93) 2.86 q22. husband may make the woman uncomfortable during labor if he has bad behavior. 215 (71.7) 2 (0.7) 83 (27.7) 2.20 q23. husband culture affects the women, staff, and delivery procedure. 208 (69.3) 3 (1) 89 (29.7) 2.13 q24. the presence of the husband during childbirth can also be problematic for the mother because she may feel more inhibited and have a hard time letting go. 230 (76.7) 0 (0) 70 (23.3) 2.24 q25. the presence of the husband in the delivery room can be traumatic to some of them; such birth trauma can lead to a subsequent loss of sexual desire as it may cause a mental block for the husband. 203 (67.7) 9 (3) 88 (29.3) 2.18 q26. preparing a husband for childbirth (pregnancy course), allows men to get an idea of what the birth will be like, how they can best support their partner, and what do to in case of unforeseen events. 44 (14.7) 2 (0.7) 254 (84.7) 2.70 q27. the husband should escort the wife to hospital for delivery. 6 (2) 0 (0) 294 (98) 2.96 q28. the husband should escort the wife to a delivery room. 42 (14) 0 (0) 258 (86) 2.72 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.16 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article the result demonstrated that there were a significant association in women’s attitudes and their age groups (pvalue=0.014),residence (p-value =0.027) income (p-value =0.001), and education levels (p-value =0.001). these values were less than the alpha value (α ≤ 0.05). the results accepted the alternative hypothesis, which means that the variable is not independent, and rejected the null hypothesis. also, the result reveals that there were no significant association in women’s attitudes and the women's occupations (pvalue =0.728), where the significance values were more than the alpha value (a ≥ 0.05). the result accepted the null hypothesis, which is that the variable was independent, and rejected the alternative hypothesis. table 5 shows the levels of women’s attitudes towards their husband’s attendance in the delivery room. the result of the women’s attitudes was as follows: 88.33% of them had a positive attitude, and 11.67% had a negative attitude. table 6 shows the association between women’s attitudes and sociodemographic characteristics of the women’s age, woman's educational level, women’s occupation, residence, and income. 153 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 5: overall women’s attitudes about husband attendance in the delivery room overall attitude f (%) posetive 265 (88.33) negative 35 (11.67) total 300 (100) table 6: statistical differences in women's attitudes regarding the age of women, woman's educational level, women occupation, residence, and income variables overall practices p-value never done sometimes done done total age of women under 20 years 6 21 8 35 0.014 hs 20-30 73 74 39 186 31-40 24 27 17 68 41-50 5 3 3 11 total 108 125 67 300 woman educational level illiterate 9 7 6 22 0.001 hs read and write 1 1 0 2 primary school 28 25 17 70 intermediate 17 24 7 48 secondary school 20 24 13 57 institute graduate 11 21 9 41 college graduate 21 23 15 59 post graduate 1 0 0 1 total 108 125 67 300 women occupation employer 10 14 9 33 0.728 ns unemployed 86 105 53 244 self-employer 12 6 5 23 total 108 125 67 300 residence rural 13 30 13 56 0.027 s urban 95 95 54 244 total 108 125 67 300 income sufficient for daily living 73 61 38 172 ˂0.001 hs insufficient 20 48 19 87 exceed need 15 16 10 41 total 108 125 67 300 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.16 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article et al., (2018) [15] that the majority of respondents were muslim. these findings differ from earlier research by adeniran et al., (2015) [19], which found that half of the participants were muslim. additionally, these findings are in contrast to another survey conducted in india, where most of the women were hindu that was done by diamond-smithet al., (2016) [17].moreover, the study shows that most of the study participants were urban residents. these results are consistent with the study conducted in ethiopia by teklesilasie and deressa, (2018)[21] who report that most of the participants were from urban areas. regarding monthly income, the present study reveals that the majority of the participants were in a status of sufficient for daily living. this finding does not incompatible with the study done by tadesse et al., (2018) [4] who, in the ethiopian village of wolaita sodo, performed research among 608 spouses of expectant and nursing mothers. they found that 381 of the households had an income of more than 1000 ethiopian birr (45 usd) per month; this income was insufficient for daily life. also, the present study shows that most women’s husbands had only one wife. this result was similar to the study done by alharbi et al., (2018)[19] in riyadh, information was gathered from 250 spouses, all of who were chosen randomly from the waiting areas of the delivery rooms. most of them were saudis and had just one wife. while these results are similar to the study done by amogne et al., (2018) [23] in southeast ethiopia which was the first wives of their husbands. study findings showed that attitudes toward husband attendance in the delivery room were positive in most participants. the result of the study was similar to the study done by rafat et al., (2016) [14] in rasht, most of the participants had a positive attitude towards husband attendance the findings of the current study show that the highest percentage of the study sample was in the age group 20-30 years old. these results are almost similar to previous studies that showed that the majority of the participants were between the ages of 24-29, such as a study done by sokoya et al., (2014)[7]. the present study also, shows that the highest percentage of the husband's age of the study sample was in the age group between 20-30 years old. these results are in contrast to previous studies, such as a study conducted in al zahra hospital in rasht under the title couples' attitudes toward husband's attendance in the delivery room among 259 pregnant women and their spouses rafat et al.,(2016)[11]. the distribution of the sample regarding the women's level of education reveals the majority of the induced groups were primary school graduates this finding was similar to the result of the previous study which had been conducted in kenya by kalisa and malande, (2016)[12] . the present study shows that most of the husbands were at the intermediate level and the secondary school level. the result is inconsistent with the privacy study done by kakaire et al., (2011)[13] , that their spouses had only a primary level of education respectively. the study's findings revealed that the majority of the study sample—housewives—were mostly self-employed. the results of this study are in contrast to those studies which were conducted in ethiopia by kahsay et al., (2013) in which 376 husbands whose wives gave birth participated in a crosssectional survey. the biggest proportions of women and their husbands were farmers. the result of the study shows that all participants were muslim. these results are similar the results of the study which was conducted in bangladesh by rahman 154 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.16 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 155 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. to a subsequent loss of sexual desire as it may cause a mental block for the husband. the result of the study was supported by oboro et al.,( 2011)[22] in a qualitative cross-sectional study conducted on 197 women in nigeria, it was found that some pregnant women refused to have their spouse present during labor because of concerns about losing their sexual appeal. besides the study results showed a significant difference in women’s attitudes with age and educational levels. the finding of the study was consistent with the previous study done by el-magrabi and mohamed, (2012)[23] in egypt. the study used a quota sample of 200 pregnant women who visited the outpatient prenatal clinic at the end of the third trimester. the attitude scores were significantly related to age, job, and education. nejad, (2005) [20] showed that attitude scores were significantly related to age, job, and education. that was the result of the previous study in agreement with the results of the present study. the present study shows significant differences in women’s attitudes and education levels. the results accepted the alternative hypothesis, which means that the variable is not independent, and rejected the null hypothesis. this result was similar to the study done by rafat et al., (2016) [11] in rasht. that reports a significant relationship between the mother's education level and attitude toward the husband’s attendance in the delivery room. finally, the findings of the present study show that there were no significant differences in women’s attitudes and the women's occupations. the finding of the study is inconsistent with the study done by agushybana, (2016) [24] in indonesia. this study found that women's occupations significantly determine complications during pregnancy and childbirth at a significant level. women with occupations are more likely to be in the delivery room. in a study conducted in iran by nejad, (2005)[20] on attitudes of couples about the presence of the spouse in the delivery room during childbirth among 150 couples showed that most women had positive outlooks toward the husband’s presence in the delivery room. which is in agreement with the result of the present study. these results have been supported by sokoya et al., (2014)[7], who conducted a study on 200 women and found that the majority of participants felt that wives needed their husbands' assistance throughout pregnancy, labor, and delivery. the item 27 which states the husband should escort the wife to the hospital for delivery) got the highest score depending on the women's responses. these results are in contrast to previous studies, such as a study conducted by kalisa and malande, (2016) [12] in kenya, among 350 pregnant women. another items got a high score, item 14, which focuses on the presence of the husband is calming for his pregnant woman), the finding of the study was consistent with the previous study done by sokoya et al., (2014) [7] at ogun, among 200 women who were visiting the prenatal and baby welfare clinics of four hospitals were randomly given questionnaires with closedended items as part of a descriptive survey design. that said their husband's support made pregnancy calming and less stressful for them. and similar to the previous study demonstrating the importance of the husband's participation in labor since his presence in the delivery room can help the mother emotionally. indeed, the highest attitude score was for the item “it is calming for the mother.”., which was by alharbi et al., (2018)[19]. the present study also, showed that some of the women agree that the presence of the husband in the delivery room can be traumatic for some of them; such birth trauma can lead https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.16 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 156 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. childbirth complications in mulago hospital, uganda. bmc pregnancy childbirth. 2014 jan 31;14(1):54. [9] ip wy. relationships between partner’s support during labour and maternal outcomes. journal of clinical nursing. 2000 mar;9(2):265-72. [10] story wt, burgard sa, lori jr, taleb f, ali na, hoque de. husbands’ involvement in delivery care utilization in rural bangladesh: a qualitative study. bmc pregnancy childbirth. 2012 dec;12(1):28. [11] rafat f, rezasoltani p, ghanbari a, moridi m. couples’ attitudes toward husband’s attendance in delivery room. hayat journal. 2016 jul; 15(22):138–47. [12] kalisa r, malande oo. birth preparedness, complication readiness and male partner involvement for obstetric emergencies in rural rwanda. the pan african medical journal. 2016;25(91). [13] kakaire o, kaye dk, osinde mo. male involvement in birth preparedness and complication readiness for emergency obstetric referrals in rural uganda. reprod health journal. 2011 may 7;8(1):12. [14] kahsay w, gidey g, gebrehiwot h. assessment of husbands’ participation on birth preparedness and complication readiness in enderta woreda, tigray region, ethiopia, 2012. journal womens health care. 2013 dec; 31(3). [15] rahman ae, perkins j, islam s, siddique ab, moinuddin m, anwar mr, et al. knowledge and involvement of husbands in maternal and newborn health in rural bangladesh. bmc pregnancy childbirth journal. 2018 dec;18(1):247. [16] adeniran as, aboyeji ap, fawole aa, balogun or, adesina kt, adeniran pi. male partner’s role during pregnancy, labour and delivery: expectations of pregnant women in nigeria. international journal of health sciences. 2015 jul;9(3):305. [17] diamond-smith n, sudhinaraset m, melo j, murthy n. the relationship between women’s experiences of mistreatment at facilities during childbirth, types of support received and person providing the support in lucknow, india. midwifery journal. 2016; 40 (1):114–23. [18] teklesilasie w, deressa w. husbands’ involvement in antenatal care and its association with women’s utilization of skilled birth attendants in sidama zone, ethiopia: a prospective cohort study. bmc pregnancy independent to make antenatal care compared to those who do not have occupations. the result of the present study indicates that most women expressed a positive attitude towards husbands' attendance in the delivery room. and a very highly significant association was observed between socio-demographical characteristics (age, level of education, and income) with women’sattitudes. [1] maharlouei n. the importance of social support during pregnancy. womens health bull jornal .2016; 3(1). [2] kiche po. a survey of the necessity for the presence of male partners in the delivery room among east african women: a case study of a district hospital in east africa. east african women journal. 2015. [3] kululanga li, sundby j, malata a, chirwa e. male involvement in maternity health care in malawi. african journal of reproductive health. 2012;16(1):145–57. [4] tadesse m, boltena at, asamoah bo. husbands’ participation in birth preparedness and complication readiness and associated factors in wolaita sodo town, southern ethiopia. african journal of primary health care and family medicine. 2018;10(1):1–8. [5] unfpa, world health organization, unicef, world bank group, the united nations population division. trends in maternal mortality: 2019-09-19; 104. [6] cheptum j, omoni g, mirie w. role of men in birth preparedness: a qualitative study of women attending antenatal clinics in migori county, kenya. journal of midwifery and reproductive health. 2019;7(1):1506-13. [7] sokoya m, farotimi a, ojewole f. women’s perception of husbands’ support during pregnancy, labour and delivery. iosr journal of nursing and health science. 2014;3 (3):45-50. [8] kaye dk, kakaire o, nakimuli a, osinde mo, mbalinda sn, kakande n. male involvement during pregnancy and childbirth: men’s perceptions, practices and experiences during the care for women who developed conclusion references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.16 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 157 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. childbirth journal. 2018; 18(1):315. [19] alharbi aa, alodhayani aa, aldegether ms, batais ma, almigbal th, alyousefi na. attitudes and barriers toward the presence of husbands with their wives in the delivery room during childbirth in riyadh, saudi arabia. journal of family medicine and primary care. 2018 ;7(6):1467. [20] amogne f, kassahun c, nigussie a, ganfurie g. international journal of nursing and midwifery prevalence of male attendance and associated factors at their partners’ antenatal visits among antenatal care attendees in bale zone, south east ethiopia. international journal of nursing and midwifery. 2018; 10(9):109–20. [21] nejad vm. couples’ attitudes to the husband’s presence in the delivery room during childbirth. east mediterr health journal. 2005;11(4):7. [22] oboro vo, oyeniran ao, akinola se, isawumi ai. attitudes of nigerian women toward the presence of their husband or partner as a support person during labor. international journal of gynecology & obstetrics. 2011;112(1):56-8. [23] el-magrabi nm, mohamed na. woman’s attitude towards the presence of the husband’s in the labor room during childbirth. life science journal.2012; 9(4):3615-3620 [24] agushybana f. influence of husband support on complication during pregnancy and childbirth in indonesia. journal of health research. 2016;30(4):249-55. [25] yılmaz v, ameen ss. the role of local government in combating the crisis of covid-19 pandemic in erbil–iraq. route educational & social science journal. 2021; 8(6): 78-92. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.06 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article nurses’ knowledge regarding preeclampsia and eclampsia in maternity teaching hospital in erbil city abstract background and objectives: preeclampsia is a severe blood pressure condition that progresses during pregnancy. pregnant women with preeclampsia often have high blood pressure (hypertension) and high levels of protein in their urine (proteinuria). preeclampsia typically progresses after the 20th week of pregnancy. we would have assessed knowledge of them regarding preeclampsia and eclampsia, and found a difference between mean of sociodemographic characteristics and the level of nurse knowledge. methods: a quantitative, descriptive cross-sectional study was conducted at maternity teaching hospital and the study was conducted from (1 the september 2021) to (december 2022). the study sample size were 150 nurses who worked in this hospital. data was collected through interviews (face-to-face) using a questionnaire designed by the investigator. the data was analysed by spss software for statistical analysis version 25. results: the majority (45.3%) of the participants were age between 3039 years old, and majority (81%) of the study participants were married. the majority (46%) of study participants have a nursing diploma. most of the nurses (32%) have six to ten years of experience as the nurse at the hospital. in this study, must of the participants (78.7%) in this study have fair knowledge of the hospital. there was a statistically significant difference between the mean level of education and the of overall knowledge. conclusion: the study concluded that the nurses had fair knowledge regarding preeclampsia and eclampsia. based on the results of the present study, it has been recommended that ongoing health educational programs, seminars and training courses to improve the knowledge of nurses in order to provide good health care for cases of preeclampsia and eclampsia and become more knowledgeable about this condition. keywords: nurse; knowledge; preeclampsia; eclampsia silan muhammad abdulrahman; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: silan.muhammed9@gmail.com) awaz aziz saied; department of nursing, college of nursing, hawler medical university, erbil, iraq. 57 received: 02/09/2022 accepted: 30/10/2022 published: 30/05/2024 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:silan.muhammed9@gmail.com?subject=silan.muhammed9@gmail.com https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.06 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article during a healthy pregnancy, there are numerous physiological changes in how various organs work. lowgrade proteinuria and alterations in renal function are common occurrences during pregnancy. however, one of the key signs for the clinical diagnosis of preeclampsia is new-onset proteinuria [1].pre-eclampsia is one of the most prevalent and significant problems (potentially affecting up to 10% of pregnancies), and is often characterized as blood pressure greater than 140 mmhg / 90 mmhg and proteinuria greater than 300 mg / 24h at or after 20 weeks of pregnancy. the second most common cause of maternal death worldwide is severe pe. a major factor in both maternal and foetal morbidity and mortality is severe preeclampsia [2].oedema, protein in the urine, and hypertension are the first signs of preeclampsia. headache, blurred vision, and bloating appear as the symptoms worsen, seizures or convulsions in a pregnant woman, a woman in labour, or within 42 days after delivery who does not have a history of epilepsy are the primary symptoms of eclampsia. other signs of eclampsia include muscle discomfort and pain, agitation, loss of consciousness, and stroke. both the mother and the foetus may also pass away as a result of eclampsia and eclampsia risk factors include having a family history of the condition or having previously experienced both pre-eclampsia and eclampsia, being pregnant at a young age, being over 35, multi-foetal gestation, being a prim gravida, and having a poor pregnancy outcome in the past, such as intrauterine growth restriction, placenta abruption, and foetal death [3].eclampsia is generally understood to be the new start of seizures and/or an unexplained coma during pregnancy or postpartum in a woman with signs or symptoms of preeclampsia. it is regarded as a consequence of severe preeclampsia. eclampsia often happens at or after the 20th week of pregnancy or in the postpartum period, affecting roughly 1 in every 200 women with preeclampsia. eighty percent of eclampsia seizures happen during labour or in the first 48 hours after delivery. rare cases have been documented as early as 20 weeks of pregnancy and as late as 23 days after delivery [4]. of all pregnancies, 5 to 8 percent are complicated by preeclampsia. this amounts to 8.5 million instances annually around the world. one of the three main causes of maternal death is still this condition. as a result of poorly controlled hypertension (sbp > 160 mmhg), cerebral haemorrhage is the primary cause of the majority of these maternal deaths. other preeclampsia problems include placenta abruption, haemorrhage, retinal detachment, cortical blindness, pulmonary oedema, liver failure or rupture, convulsions, and disseminated intravascular coagulation [5].the reduction in uterine and placental blood flow that causes oligohydramnios, intrauterine growth retardation, placental abruption, foetal discomfort, and eventually foetal death is the most significant threat to the foetus during preeclampsia [6].inadequate knowledge of health professionals in direct link with complications of pregnancy, and inability to keep up through medical knowledge, have possibly severe effects on the quality of care and increase maternal and perinatal death [7].clinical data or biochemical markers cannot be used to predict which women will get preeclampsia. the incidence of eclampsia and the case fatality rate connected to it, however, have been reduced by 90% in high-income nations. using a combination of early detection during antenatal care and improved access to hospital care for women who experience severe preeclampsia/eclampsia [8].pre-eclampsia 58 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.06 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article study samples and 48 of them either could not to participate due to giving care to patients or not were available during the data collection period. informed consent was obtained from the study sample after explaining the purpose of the study and providing reassurance regarding the confidentiality of the data. the investigators prepared a questionnaire format after reviewing related literature and the questionnaire format consisted of two parts. the first part was on the sociodemographic the questionnaire format consisted of two parts. the first part focused on the socio-demographic characteristics of the study sample such as age, marital status (single, married, divorced, widowed), level of education (preparatory nursing school, diploma institute, bachelor degree, master degree), word unit, and years of experience. the second part consisted of 20 items of questions designed to assess the knowledge of nurses about preeclampsia/eclampsia and each one of the 20 items has three categories. the questionnaire was scored on a likert scale for the scoring system. the answers from each one of the questionnaire items were recoded into numerical values by applying the following scores: incorrect=1, i do not know=2, correct=3. direct face-to-face interview through a questionnaire was conducted by the researcher in the maternity teaching hospital and separately with each of the participating candidates for at least 20-30 minutes and the investigator filled out the questionnaire. twelve experts in related fields validated the questionnaire, and the pilot study of 15 nurses indicated that the tool was eligible for data collection. before starting data collection, the researcher explained the research process, the purpose of the study and the aim to participants and asked each of the participants to fill out a consent form. prior to the data collection, ethical approval was risk factors have been reported to include low socioeconomic status, a poor diet (lack of vitamins c and e), poor antenatal care, a history of pregnancy-related hypertension, extreme poverty, poor reproductive care seeking behaviour, restricted access to quality maternal services, and low levels of medical professionals' knowledge [9]. preeclampsia and eclampsia in pregnant women with severe symptoms can be prevented by early detection, quick action, accurate therapy, and prompt delivery. the absence of core knowledge leads to poor decision -making and management of emergency maternal health conditions. additionally, inadequate knowledge can be attributed to delays in treatment and referrals, appropriate knowledge is essential to correctly recognize women with preeclampsia with and without severe features. this foundational knowledge helps confirm timely evidence-based decision making and care based on global guidelines [10].according to the researcher’s experience, lack of knowledge leads to poor decision-making and poor management of emergency maternal health conditions. furthermore, insufficient knowledge can be attributed to delays in treatment and referrals and because preeclampsia and eclampsia are common diseases in the world, and all nurses should have good knowledge related to preeclampsia and eclampsia. these were the main reasons for the researcher to assesses nurses’ knowledge regarding preeclampsia/ eclampsia in the maternity teaching hospital in erbil city and found an association between sociodemographic characteristics and level of nurse knowledge a cross-sectional study was conducted (1 the september 2021) to (december 2022). from the total 198 nurses who were working in the hospital 150 were recruited as 59 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.06 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article obtained from the research ethics committee at the collage of nursing/ hawler medical university (no.118 dated october 7,2021) and formal permission was obtained from general directorate of health in erbil city kurdistan /iraq. also, formal permission was obtained from the maternity teaching hospital administrator. the data was analysed using spss software for statistical analysis version 25, to calculate descriptive statistical analysis (frequency and percentage). inferential statistical analysis (one way anova) was used to determine the association between variables. p-value ≤ 0.05 is considered statistically significant. table 1: shows the descriptive data for the socio-demographic question, including the nurse's age, marital status, level of education, word unit, and years of experience. the majority of participants (45.3%) are between the ages of 30 and 39, followed by those who are older than 39 (33.3%) and those who are between the ages of 20 and 29 (21.3%). since their average age is 36. the majority (81.3%) of nurses were married and (18.7%) of them were single. the majority of study participants (46%) have a nursing diploma, followed by bachelor's degrees (29.3%) and nursing preparatory nursing schools (24.7%), in that order. since some of the nurses work in both the postpartum and operation units (3.3 %)., the majority of them (19.3 %) were in highrisk area. most of the nurses have six to ten years (32%) of experience as a nurse at the hospital followed by 1-5 years (20.7%) and 11-15 years (19.3%), more than 20 years (18.7%) and 16-20 years (9.3%), respectively since the average of experience is 13 years. table 2: the nurses check the highest proportion of eleven items. (1-preeclampsia is increased blood pressure 140/90mmhg before 20 weeks of gestational age, 2-eclampsia is a severe complication of preeclampsia with convulsion, 3-preeclampsia and eclampsia occurred in both in the second and third trimester, 4-blurred vision, severe headache ,nausea, vomiting and epigastric pain are symptoms of preeclampsia, 5-lack of exercise during pregnancy is a risk factor for preeclampsia, 9-cardiovascular disease is one of the complications of preeclampsia, 12-immediate intervention in cases of convulsion is to check blood pressure,13 calcium sulphate 60 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result table 1: socio-demographic data of the study sample characteristics subgroups n=150 f. (%) age group (years old) 20 29 32 (21.3) 30 39 68 (45.3) 40 and more 50 (33.4) marital status of nurse single 28 (18.7) married 122 (81.3) level of education preparatory nursing school 37 (24.7) diploma in nursing 69 (46) bachelor degree 44 (29.3) ward unit high risk 29 (19.3) neonatal unit 21 (14) postpartum unit 5 (3.3) emergency 24 (16) word unit 28 (18.7) operation unit 5 (3.3) post operation 19 (12.7) delivery room 19 (12.7) years of experience 1-5 31 ( 20.7) 6-10 48 (32) 11-15 29 (19.3) 16-20 14 (9.3) 21+ 28 (18.7) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.06 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article 61 dose of magnesium sulphate that is given in case of preeclampsia is 10gintravenous and 10g intramuscular) these are actually incorrect questions. additionally, the nurses check the maximum percentage of four items (6-the exact cause of preeclampsia is unknown, 8 preeclampsia is affected on gallbladder, 19-respiratory depression and convulsion are signs of magnesium sulphate toxicity, 20during urine analysis if protein presence in the urine less than 300mg/24hrs is considered proteinuria during pregnancy). table 3: most of the participants in this study have fair knowledge of the hospital (78.7%) followed by good knowledge (18.7%) and poor knowledge (2.7%) respectively. table 4: shows there is no statistically significant difference between the mean of age groups and the measure of overall knowledge because p-values (0.295) is higher than the significant level of α=0.05. it means, there is no difference between the mean of age groups including 20-29, 30-39, and more than 39 years with measurement of both overall knowledge. table 5: shows there is a statistically significant difference between the mean level of education and the measure of overall knowledge because its p-value (0.029) is less than the significant level of α=0.05. it means, there is a difference between the mean level of education including preparatory, diploma, and bachelor degree of nurses with measurement of overall knowledge. is recommended for the control of convulsions during preeclampsia, 14-after convulsion the nurse should be given oxygen 8 litres per minute by mask or nasal mask, 16 another management of eclampsia is inserted a urinary catheter to monitor urine output and proteinuria, 17hydralazine and diazepam are 2 drugs used for the control of blood pressure during pregnancy) as correct answers (c); the proportion of correct answers from nurses is ([6/11] *100 = 54.55%) since six of them ( 2-eclampsia is a severe complication of preeclampsia with convulsion, 3-preeclampsia and eclampsia occurred in both in the second and third trimester, 4-blurred vision, severe headache ,nausea, vomiting and epigastric pain are symptoms of preeclampsia, 9cardiovascular disease is one of the complication of preeclampsia , 14-after convulsion the nurse should be given oxygen 4-6 litres per minute by mask or nasal mask, 16 another management of eclampsia is inserted a urinary catheter to monitor urine output and proteinuria) in actually are correct questions. also, the nurses check the highest proportion of five items (7vitamin d and folic acid that are required in the diet to prevent preeclampsia, 10-tetanus toxoid vaccine is reduce risk of the onset of preeclampsia, 11ultrasound is the screening test you can use for the detection of preeclampsia, 15the recommended intravenous fluid for managed eclampsia is normal saline, 18the dose of magnesium sulphate that is given in cases of preeclampsia is 10gintravenous and 10g intramuscular) .as incorrect answers (i), the proportion of incorrect answers from nurses is ([4/5] *100 = 80%) since four of them (7 vitamin d and folic acid that are required in the diet to prevent preeclampsia, 10tetanus toxoid vaccine is the risk reduce of the onset of preeclampsia, 11ultrasound is the screening test you can use for the detection of preeclampsia, 18the copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.06 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article 62 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: assessment of nurse’s knowledge regarding preeclampsia/eclampsia knowledge incorrect i do not know correct n (%) n (%) n (%) 1 preeclampsia is increased blood pressure 140/90mmhg before 20 weeks of gestational age (i) 39 (26) 9 (6) 102 (68) 2 eclampsia is a severe complication of preeclampsia with convulsion (c) 13 (8.7) 12 (8) 125 (83.3) 3 preeclampsia and eclampsia occurred in both in the second and third trimester (c) 26 (17.3) 31 (20.7) 93 (62) 4 blurred vision, severe headache, nausea, vomiting and epigastric pain are symptoms of preeclampsia (c) 10 (6.7) 9 (6) 131 (87.3) 5 lack of exercise during pregnancy is a risk factor for preeclampsia (i) 53 (35.3) 40 (26.7) 57 (38) 6 the exact cause of preeclampsia is unknown (c) 25 (16.7) 65 (43.3) 60 (40) 7 vitamin d and folic acid that required in the diet to prevent preeclampsia (i) 57 (38) 45 (30) 48 (32) 8 preeclampsia is affected on gallbladder (c) 55 (36.7) 56 (37.3) 39 (26) 9 cardiovascular disease is one of the complications of preeclampsia (c) 26 (17.3) 40 (26.7) 84 (56) 10 tetanus toxoid vaccine is reduced risk of the onset of preeclampsia (i) 86 (57.3) 41 (27.3) 23 (15.3) 11 ultrasound is the screening test you can use for detection of preeclampsia (i) 128 (85.3) 7 (4.7) 15 (10) 12 immediate intervention for case of convulsion is to check blood pressure (i) 55 (36.7) 14 (9.3) 81 (54) 13 calcium sulphate is recommended for the control of convulsion during preeclampsia (i) 53 (35.3) 30 (20) 67 (44.7) 14 after convulsion the nurse should be given oxygen 4-6 litres per minute by mask or nasal mask (c) 22 (14.7) 30 (20) 98 (65.3) 15 the recommended intravenous fluid for managed eclampsia is normal saline (c) 96 (64) 21 (14) 33 (22) 16 another management of eclampsia is inserted a urinary catheter to monitor urine output and proteinuria (c) 11 (7.3) 24 (16) 115 (76.7) 17 hydralazine and diazepam are 2 drugs used for the control of blood pressure during pregnancy (i) 43 (28.7) 40 (26.7) 67 (44.7) 18 the dose of magnesium sulphate that given in case of preeclampsia is 10gintravenous and 10g intramuscular (i) 67 (44.7) 51 (34) 32 (21.3) 19 respiratory depression and convulsion are sign of magnesium sulphate toxicity (i) 48 (32.0) 68 (45.3) 34 (22.7) 20 during urine analysis if protein presence in urine less than 300mg/24hrs is considered proteinuria during pregnancy (i) 22 (14.7) 87 (58) 41 (27.3) notice: i: incorrect and c: correct https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.06 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article of α=0.05. it means, there is no difference between the mean of experience groups including 1-10, 11-20, and more than 20 years with measurement of overall knowledge. table 6: shows there is no statistically significant difference between the mean of experience in years and the measure of overall knowledge because p-values (0.817) is higher than the significant level 63 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: descriptive statistics for overall response from nurse’s knowledge variables poor fair good n % n % n % overall knowledge level 4 2.7% 118 78.7% 28 18.7% table 4: difference between mean of age group and measure of (overall knowledge) table 5: difference between mean of level of education and measure of (overall knowledge) variables n mean sd f-value p-value overall knowledge 1-5 31 42.968 5.199 0.202 0.937 6-10 48 42.542 4.222 11-15 29 42.724 3.945 16-20 14 42.000 4.624 21+ 28 43.179 4.714 total 150 42.733 4.472 variables n mean sd f-value p-value overall knowledge 20 29 32 43.438 4.370 1.232 0.295 30 39 68 42.118 4.530 11-15 29 42.724 3.945 40 and more 50 43.120 4.434 total 150 42.733 4.472 table 6: difference between mean of experience in years and measure of (overall knowledge) variables n mean sd f-value p-value overall knowledge 1-5 31 42.968 5.199 0.202 0.937 6-10 48 42.542 4.222 11-15 29 42.724 3.945 16-20 14 42.000 4.624 21+ 28 43.179 4.714 total 150 42.733 4.472 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.06 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article provinces, southern mozambique and conducted with community health workers, the highest percentage of participants their ages were between (40-49,31%) [13]. other studies disagree with the present study which was done in mosul city, reveals that the majority of the study's participants were between the ages of 21 and 30[16]. another study disagrees with the present result which reveals that the majority of the study's participants were between the ages of 21 and 30. (50%) [14] other study disagrees with the present result which reported nearby half of the studied nurses (45%) were their age ranging less than 30 years [ 18].regarding marital status, more than four/five of the study samples were married (81.3%), this result supported by a qualitative study conducted in nigeria in 2011–2012 that nearly all participants were married [15]. another study agrees with the present study which reported that 62.5% of the study nurses were married [19]. this result disagrees the study conducted from 2013 to 2014 from southern mozambique by boene h et al. reported that most of the participants were single (47%) [13].in the present study, the highest percentage of participants (46%) held diplomas degree. this result supported by other studies that reported that the majority of respondents (46.7%) held diplomas degree [16] a previous study done by bahy ma et al. reported that the majority of the nurses (86.7%) held nursing diplomas which is agrees with present study. [17] this result disagrees with a study conducted by ekbalabd el rheem and nahed reported that the majority of nurses (68.3%) held technical institute [18]. another study disagreed with the present study which reported that 43.8% of the study sample had a bachelor degree in nursing or secondary school nursing [19]. another study contrasts with the present study which was conducted in preeclampsia refers to the new beginning of hypertension, and proteinuria and major end-organ dysfunction with or without proteinuria afterward 20 weeks of gestation or postpartum in a previously normotensive patient, 4.6 percent (95% ci 2.78.2) of pregnancies globally were complicated by preeclampsia. the occurrence in the united states is approximately 5 percentages, differences in occurrence among countries reflect, at least in part, changes in the maternal age, spreading and proportion of nulliparous pregnant women in the population (11).the current study has tried to determine the knowledge of nurses regarding preeclampsia/eclampsia. nurses are the most important medical workers who provide health education to patients and the general population and thereby help in the prevention of disease and aid in health promotion, thus staff nurses can play a very crucial role in hospitals. a recent study has shown that the majority of nurses have fair knowledge about preeclampsia/eclampsia. the socio-demographic characteristics of nurses regarding preeclampsia/eclampsia the subjects in this study included nurses (n = 150). the highest percentage of nurses belonged to the age group of 30-39 years (45.3%) with a mean age of (36 ± 9.29).this result supported by other studies reported that the majority of respondents were aged between (30-39 years) (44.5%) [12]. a previous study conducted in india among staff nurses and auxiliary nurse midwives to assess their knowledge and management of preeclampsia, had a similar mean age to the present study (36.5 ±4.8) [14]. another study agrees with present study and reports that most participants were in the age group from of (31 40) years [3]. the result is disagreement with a study done in maputo and gaza 64 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.06 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article level of education and the measure of overall knowledge because its p-value (0.029) as shown in (table 5). this result is in disagreement with [13] which reported that there is no significant association between the knowledge of the participant and with level of education. and there is no statistically significant difference between the mean of experience in years and the measure of overall knowledge because p-values (0.817) are higher than the significant level of α=0.05 as shown in (table 6).this result supported by another study which reported that there is no significant association between years of experience and with knowledge of participants about pregnancy induced hypertension [21].another study supported the present result which reported that there is no significant association between years of practice and with knowledge of participants [13]. this result is in disagreement with a previous study which reported that there is a significant association between the overall knowledge of participant and with years of experience [12].(table 4) shows there is no statistically significant difference between the mean of age groups and the measure of overall knowledge because p-values (0.295) is higher than the significant level of α=0.05.this result is supported by a previous study which conducted in iraq at mosul teaching hospitals which revealed that there are no significant relationships between study group outcomes (pre-test and post-test) and with all demographic characteristic [16].a previous study reported that there is a significant association between age and the knowledge of participants; this result is in contrast with the present result[13]. bangladesh and stated that more than half of the study participants had a bachelor in nursing and less than one third had a diploma[20] in the present, study the majority of nurses working in high –risk department (19.3 percent). most of the nurses had six to ten years (32%) of experience as nurses at the hospital, this is result supported by [12] which reported that most of the study participant had 5 to 10 years of experience 35%. this result is in disagreement with a previous study which conducted by hendiya ie which reported that more than half of the study participants had experienced less than five years [19].another study in contrast with the present study which reported that the majority of study participants had (1-5) years of experience [16].assessment of nurse’s knowledge regarding preeclampsia/ eclampsia this research revealed that the majority of the nurses had fair knowledge (78.7%) followed by good knowledge (18.7%) and poor knowledge (2.7%) regarding pre-eclampsia/eclampsia. this result is supported by other study which reported that more than half of them 58.80% had fair knowledge before intervention [19]. a descriptive cross-sectional study conducted in lagos, southwest nigeria among health care providers which reported that study participants had average knowledge about pre-eclampsia. this result is in contrast to the present result [12].another study disagreed with the present result which reported that 53.3 % of nurses had poor knowledge the before implementation of the educational program. then, after implementation, 70 % of them had excellent knowledge [16]. comparison between overall knowledge and demographic characteristics of nurses regarding the comparison between overall knowledge and level of education, it has been found that there is a statistically significant difference between the mean 65 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.06 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article available from: doi:www.noveltyjournals.com [accessed: 5th july 2022. [5] g. lambert, j. f. brichant, g. hartstein, v. bonhomme and p. y. dewandre. preeclampsia: an update. acta anaesthesiol belg. 2014;65(4):137-49. available from:_preclamsia-with-cover-page-v2.pdf (d1wqtxts1xzle7.cloudfront.net) : [accessed: 6th july 2022. [6] rahmati r, mohebbi dehnavi z, kamali z, mohebbi dehnavi a. the effect of mobilebased and lecture-based training methods on midwives' knowledge regarding management of pre-eclampsia/eclampsia. journal of midwifery and reproductive health. 2018 oct 1;6(4):1430-6. available from: doi: the effect of mobile-based and lecture-based training methods on midwives' knowledge regarding management of pre-eclampsia/ eclampsia (nlai.ir) [accessed: 6th july 2022] [7] soggiu-duta cl, crauciuc dv, crauciuc e, dmour a, iov t, bulgaru-iliescu d, et al. the impact of an intensive educational program regarding preeclampsia on health professional knowledge. revista de chimie bucharestoriginal edition. 2019 jun 1;6. available from: doi: https:// doi.org/10.37358/rc.19.6.7315 . [accessed: 6th july 2022] [8] kim ym, ansari n, kols a, tappis h, currie s, zainullah p et al. prevention and management of severe pre-eclampsia/eclampsia in afghanistan. bmc pregnancy and childbirth. 2013 dec;13(1):1-0. available from kim: prevention and management of severe preeclampsia/ec... google scholar [accessed: 25august 2022] [9] anorlu ri, iwuala nc, odum cu. risk factors for pre‐eclampsia in lagos, nigeria. australian and new zealand journal of obstetrics and gynaecology. 2005 aug;45(4):278-82. available from anorlu: risk factors for pre‐ eclampsia in lagos, nigeria google scholar [accessed: 25august 2022] [10] angelina ja, kibusi sm, mwampagatwa i, ernest a. knowledge on prevention and management of preeclampsia and eclampsia among nurses in primary health settings: baseline findings from an interventional study in dodoma region, tanzania. the east african health research journal. 2020;4 (1):33. available from: doi: 10.24248/eahrj. v4i1.619. [accessed: 7th july 2022] in conclusion, the majority of nurses in the current study had fair knowledge regarding preeclampsia and eclampsia. a significant difference was found between the measure of overall knowledge of nurses and the mean level of education. based on the results of the present study. it has been recommended that ongoing health educational programs, seminars and training courses to improve the knowledge of nurses in order to provide good health care for cases of preeclampsia and eclampsia and become more knowledgeable about this condition. none of the writers have any conflicts of interest or sources of financial support. [1] müller-deile j, schiffer m. preeclampsia from a renal point of view: insides into disease models, biomarkers and therapy. world journal of nephrology. 2014 nov 11;3 (4):169. available from: doi: 10.5527/wjn. v3. i4.169. [accessed: 25th june 2022. [2] al-matouti ay, ibrahim rh. nurses knowledge regarding preeclampsia care at mosul teaching hospitals. annals of the romanian society for cell biology. 2021 oct 3;25(6):20596-607.available from: doi: nurses knowledge regarding preeclampsia care at mosul teaching hospitals | annals of the romanian society for cell biology (annalsofrscb.ro) [accessed: 5th july 2022. [3] jaffar rj. knowledge and skills on managing eclampsia among nurse-midwives working at mnazi mmoja hospital, unguja zanzibar (doctoral dissertation, muhimbili university of health and allied sciences.). available from: knowledge and skills on managing eclampsia among... google scholar [accessed: 7august 2022. [4] shaheen ap, hendiya r. i. e, eshra p.d. m. k, kassem p. i. k. a. effect of educational program on the knowledge of nurses caring for women with eclampsia and preeclampsia. international journal of novel research in healthcare and nursing. may august 2020; 7(2) :(577-587). 66 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.06 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article [17] elmohamed hi, salam ns, nasr eh. effect of educational program for nurses about pregnancy induced hypertension on their knowledge in port said hospitals. the medical journal cairo university. 2013;81(2):17988. available from: “effect of educational program for nurses about... google scholar [accessed: 3 august 2022] [18] emam ee, saber nm. effect of nursing program on improving nurses’ knowledge and skills regarding care of eclamptic women. american journal of nursing research. 2018 oct 8;6(6):430-6.available from: doi:10.12691/ajnr-6-6-10 [accessed: 6 august 2022] [19] hendiya ie, eshra mk, kassem ka, shaheen ae. effect of educational program on the knowledge of nurses caring for women with eclampsia and preeclampsia. international journal of novel research in healthcare and nursing. 2020;7:577-87.available from: effect of educational program on the knowledge of... google scholar [accessed: 7august 2022] [20] khatun r, mohammad f, chowdhury aa. nurse’s knowledge regarding management of eclampsia at selected private hospital in bangladesh. international research journal of natural and applied sciences.2017 december ;4(12): 6981.available from :nurse's knowledge regarding management of eclampsia... google scholar [accessed: 7august 2022] [21] tadele w, debebe f, tadele a, tilahun l. assessment of knowledge and practice of nurses working in gynecology emergency room towards pregnancy induced hypertension in selected government public hospitals found in addis ababa, ethiopia. research square. may 4th, 2020.available from: https://www.researchsquare.com/article/rs25189/v1 [11] august p, sibai bm. preeclampsia: clinical features and diagnosis. post tw, uptodate. waltham, ma: uptodate. 2017 dec. available from: doi: https://www.medilib.ir/ uptodate/show/6814 [accessed: 24th july 2022] [12] olaoye t, oyerinde oo, elebuji oj, ologun o. knowledge, perception and management of pre-eclampsia among health care providers in a maternity hospital. international journal of maternal and child health and aids. 2019;8(2):80. available from: https:// doi.org/10.21106%2fijma.275 [accessed: 26th july 2022] [13] vidler m, augusto o, sidat m, macete e, menéndez c. community health worker knowledge and management of preeclampsia in southern mozambique. reproductive health. 2016 sep;13(2):149-62. available from: [pmc free article] [pubmed] [google scholar] [accessed: 26th july 2022] [14] ramadurg u, vidler m, charanthimath u, katageri g, bellad m, mallapur a et al. community health worker knowledge and management of pre-eclampsia in rural karnataka state, india. reproductive health. 2016 sep;13(2):141-8. available from:community health worker knowledge and management of pre-eclampsia in rural karnataka state, india | reproductive health | full text (biomedcentral.com) [accessed: 31h july 2022] [15] akeju do, vidler m, oladapo ot, sawchuck d, qureshi r, von dadelszen p et al. community perceptions of pre-eclampsia and eclampsia in ogun state, nigeria: a qualitative study. reproductive health. 2016 jun;13 (1):17-26. available from: community perceptions of pre-eclampsia and eclampsia in ogun state, nigeria: a qualitative study | reproductive health | full text (biomedcentral.com) [accessed: 31h july 2022] [16] ayed ay, ibrahim rh. effect of educational program of eclampsia management on knowledge of maternity nurses at mosul teaching hospitals. in1st international ninevah conference on medical sciences (incms 2021) 2021 oct 12 (pp. 175-180). atlantis press. available from: https:// dx.doi.org/10.2991/ahsr.k.211012.029 [accessed: 3 august 2022] 67 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.09 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article mother’s practices concerning care of low-birth-weight neonates in rapareen teaching hospital for children in erbil city abstract background and objectives: low birth weight is a major contributor to an indirect cause of neonatal mortality. the study's goal was to evaluate mothers' practice regarding lowbirth-weight neonate's care. methods: this is a quantitative descriptive cross-sectional study. the research was conducted at erbil's rapareen teaching hospital for children. non-probability (purposive) sample of 245 mothers who visited the nicu at rthc. the questionnaire format was used to collect data during a direct face to face interview. the data collecting period was from january 1st to august 1st, 2022, with interviews lasting roughly 20-30 minutes. neonates with low birth weights who were admitted to the hospital were included. formal and ethical authorization was obtained prior to data collection. validity is determined by a panel of 15 experts in the field. person correlation was used to determine and quantify internal consistency reliability, which was 0.81. the pilot trial included 15 mothers. the connection between variables was determined using inferential statistical analysis (chisquare). a p-value is regarded statistically significant if it ≤ 0.05. results: the study results reveal, housewives outnumbered mothers aged between 27 to 33years old. completed secondary school. we had a middle-class income and lived in the city. normal vaginal delivery was used to birth the babies. in public hospitals, neonates aged 1 to 5 days were born, with females being the majority. most women examine the umbilical cord for symptoms of infection. moreover, half of those interviewed did not apply ointment to their skin. furthermore, the study found a statistically significant association between socio-demographic characteristics such as the mother's age at marriage, mode of delivery, antenatal care, house ownership, the mother's occupation, socioeconomic status, and the mothers' practices, with p-values of 0.002, 0.004, 0.012, 0.033, 0.007, and 0.034, respectively. conclusion: the outcome of the study revealed that most of mothers had good practices for age, low income, infection, and house ownership, which are the primary causes of low birth weight newborns in erbil. improving mothers' practices will lead to improved maternal care for lbw and reduction in lbw in erbil. keywords: mothers; intensive care units; low birth weight; umbilical cord; occupations. barzan issa omar; general directorate of health, gulan health center, erbil, kurdistan region, iraq. (correspondence: barzanissa466@gmail.com) shukir saleem hasan; department of nursing, college of nursing, hawler medical university and tishk international university, erbil, kurdistan region, iraq. 92 received: 03/09/2022 accepted: 26/11/2022 published: 30/05/2024 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:barzanissa466@gmail.com. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.09 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article low birth weight is the delivery of a live infant weighing less than 2500g, according to the world health organization (who).there are two levels of low birth weight: very low and extremely low [1]. around the world, 18 million lbw infants are born each year. ethiopia had a 28.3% prevalence of lbw infants in sub-saharan africa, while zimbabwe had 199 per 1,000 live births. about 5 to 6 million children in nigeria are impacted by lbw each year[2]. every year, it causes between 60% and 80% of all neonatal deaths [3]. low birth weight babies are more susceptible to morbidity, stunted growth, impaired cognitive development, and continued underweight and stunted weight throughout infancy. girls are more likely to develop into women with short stature and an underdeveloped pelvis, which increases the risk of obstetric complications during childhood [4]. health conditions like infections, high blood pressure, malaria, and syphilis can all cause lbw [3]. birth weight (bw) has a direct impact on a child's development and survival and places a financial and social burden on individuals, families, health care systems, and governments [5]. pulmonary tuberculosis and iugr share a number of maternal characteristics, risk behaviors, and social determinants in common, such as maternal malnutrition, low body mass index, poverty, black race, close child spacing, low maternal education, subpar antenatal care, substance abuse, and emotional and physical stress are causes to have lbw neonates. chorioamnionitis, vaginitis, bacteriuria, and systemic or remote site infections like sepsis and periodontal disease are additional factors that contribute to lbw neonates [6] . respiratory failure, hypoxia, and intra-ventricular hemorrhage cause the immediate squeal of lbw [7]. the cardiovascular, nervous, and metabolic systems are all involved in the complex process of producing heat [9]. infants who are underweight are more at risk for complications like cerebral palsy, mental retardation, respiratory diseases, sudden infant death syndrome, and physical and neurological disabilities[9]. increased breastfeeding and weight gain may result from parental caregiving for lbw [10]. increased breastfeeding and weight gain may result from parental caregiving for lbw[11]. nowadays all mothers who give birth at hospital received instruction on good hygiene and how to keep the baby warm [13]. breast milk is sufficiently rich in vitamins, minerals, protein, carbohydrates, and lipids to support adequate growth and development of lbw neonates, and it has the advantages of bioavailability and economic viability [14]. kangaroo mother care, a special approach to caring for lb infants, entails keeping the infant close to the mother while solely breastfeeding [15]. a quantitative; cross-sectional descriptive study was used for conducting this study. the study was carried out at rapareen teaching hospital for children (rthc) in erbil city. it has been established in 2005. the inpatient department includes the emergency, surgery unit, medical unit, and neonatal intensive care unit (nicu). this study was conducted in rapareen teaching hospital for children in /erbil and the time interval was between 1st of jan to 1st of aug. 2022.non-probability purposive of 245 mothers who attended nicu at rthc were selected. data was gathered through direct interview by using the questionnaire format which was prepared by the investigator after rich interview of related. according to nonofficial census of rthc there were, 630 cases associated with the lbw and admitted to nicu in 9 months (11). non-probability of 245 causes, after the calculation of the sample size 93 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.09 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article consistency reliability was determined and measured through applying person correlation(r), and this was 0.81, and indicated that the scales were adequately reliable the practice. pilot study was conducted on 15 mothers. the data was analyzed through using spss software for statistical analysis version 25, for calculating descriptive statistical analysis (frequency and percentage). inferential statistical analysis (chi -square) and (fisher’s exact test) used to determine the association between variables. the p-value considered statistically significant if it's ≤ 0.05. the study shows that the highest percentage 35.1% of the mothers aged between 27-33 years old, most 75.5% were housewives. one quarter (24.5% )of the mothers graduated from secondary school. the majority 97.6% were muslim. regarding the mother's socioeconomic status, the current study shows that the highest percentages 91.8% of them were in middle economic live level. finally, regarding the mother's residential areas 60% were living in urban. concerning mothers' obstetrical history table 1, shows, that more than onethird 40.4 % of the mothers had a normal vaginal delivery. the highest percentages 44.1% were married at the age of 20-26 years. regarding biographical characteristics of lbw table 2 regarding mothers’ antenatal care 57.1% of mothers apply ointment to their lbw umbilical. one-third 35.9% of neonates aged were between 1-5 days, and a half 51.8% were close relatives. meanwhile, females represented the highest percentage 58.8%. regarding the place of delivery, the study found that more than half 63.3% of the babies were born in public hospitals and only one quarter 27.8% of the babies were breastfeeding. by substitution the numbers into the yamane formula as follow: n=sample size n= population size e=level of precision or sample errors = 0.05 were recruited to the study. all mothers with their lbw neonates lbw neonates who admitted to hospital. lbw aged between first day to one month and admitted to the hospital with their mother. mothers those are free of medical and psychological problems. mothers who agreed to participate in the study. before data collection, formal permission was obtained from hawler medical university collage of nursing and rthch for conducting the study. ethical approval was obtained from the scientific and ethical committee number 106 in 7 / 10/ 2021 , and finally the verbal permission was taken from the mothers before starting interview. the tool was not consisting of personal information such as personal phone number, address, personal information, and the researcher promised to keep the data for confidentiality and anonymity. the tool of data collection consisted of two parts: part one: this part consists of three sections: section one consisted of items that related to the sociodemographical characteristics of the mothers. second section was to assess the mothers' obstetrical history. section three was to assess the biographic information of lbw. second part was to assessment the mother's practice regarding lbw baby: this part consisted of 14 related questions. three likert scales include: good 3, fair 2, and poor 3. the scores were rating between 1-10 for poor practices, 11-20fair practices, and 21-28 good practices. data was gathered through the direct interview (face to face) by using the questionnaire format which was prepared by the investigator. validity of the study instrument was determined initially through the panel of 15 experts of different specialties. internal 94 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.09 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 95 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: assessment of socio-demographic characteristics of the mothers (n= 245) variables f. (%) age/years old less than 20 20-26 27-33 34-40 more than 40 30(12.2) 75(30.6) 86(35.1) 42(17.2) 12 (4.9) occupation housewife public employee private employee student self-employee 185 (75.5) 44(18) 12(4.9) 2 (0.8) 2 (0.8) level of education illiterate can read and write primary school secondary school diploma institute high degree 58 (23.7) 21(8.6) 36(14.7) 60(24.5) 34(13.9) 36 (14.7) the religions muslim christian yazidi 239(97.6) 3(1.2) 3(1.2) socio-economic status low middle high 2(0.8) 225(91.8) 18 (7.3) residential areas urban rural sub-urban 147(60) 64(26.1) 34 (13.9) table 2: mothers' obstetrical history (n=245) mothers' obstetrical history f. (%) mode of delivery nvd cs nvd with episiotomy 100(40.4) 62(25.3) 83(34.3) age at married/years less than 20 20-26 27-33 34-40 more than 40 105(42.9) 108(44.1) 21(8.6) 11(4.5) 0(0) antenatal care private facilities primary health centers both sector 215(87.8) 4(1.6) 26(10.6) total 245(100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.09 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 96 ointment to their lbw umbilical. the majority 82.9% of mothers pay attention to umbilical for signs of infection. more than half of mothers 54.7% did not apply ointment on skin to protect dermatitis. majority of mothers 89.4% change babies’ body's position to keep them from pressure area. moreover, the study reveals a highly significant and some significance association between sociodemographical characteristics such as the age of the mother at /marriage, mode of the delivery, antenatal care, house ownership, occupation of the mother and socio-economic status (12). with p – value: 0.002, 0.004, 0.012, 0.033, 0.007 and 0.034 respectively (table 5). table 4 shows the highest percentage 62% of mothers keep temperature between3536.5 °c. meanwhile 49% of them give relaxing massage to their neonates. almost three quarters 72.2% of mothers feel comfort while breastfeed to lbw. using a cup or a spoon till the baby can suck effectively is refused by more than half of mothers 59.2%. 81.2% of mothers feed their neonates 6-8 times in 24hrs some of mothers 42.4% pick their lbw when crying while breastfeeding. three quarter 75.1% of mothers did not put their lbw in quiet and healthy environment during feeding. wiping the breast nipple when feeding to prevent infection was done by 60.8%. almost 94.7% of mothers did not give their lbw 15 -20ml/kg/day. most mothers 79.6% clean cord daily. 57.1% of mothers apply copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: assessment of biographical characteristics of lbw (n= 245) biographical characteristics of lbw f. (%) age of neonate/days 1-5 6-10 11-15 16-20 more than 20 88(35.9) 85(34.7) 36(14.7) 20(8.2) 16(6.5) parents’ degree of relatives close relative distance relative 127(51.8) 118(48.2) gender of neonate female male 144(58.8) 101(41.2) place of the delivery home public hospital private hospital 8(3.3) 155(63.3) 82(33.5) gestational age fullterm post-term preterm 244(99.6) 1(0.4) 1(0) type of feeding breastfeed bottle-feeding both ng tube nothing per oral 68(27.8) 58(23.7) 52(21.2) 63(25.7) 4(1.6) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.09 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 97 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: mothers’ practice regarding caring for lbw neonates (n= 245) practices of mothers of lbw did you…… good fair poor f (%) f (%) f (%) keep the ambient body temperature in the incubator at around 35-36.5 °c 152(62) 87(35.5) 6(2.4) give the baby a warm, relaxing massage. 120(49) 16(6.5) 109(44.5) breastfeed your neonate and notice it comforting for you and the neonate. 177(72.2) 28(11.4) 40(16.3) feed neonate using a cup or a spoon until the baby can suck effectively 84(34.3) 16(6.5) 145(59.2) feed your neonate 6-8 times within 24 hours. 199(81.2) 41(16.7) 5(2) feed your baby and pick him\her up when crying? 59(24.1) 104(42.4) 82(33.5) place your baby in a quiet and healthy environment, particularly during feeding. 57(23.3) 4(1.6) 184(75.1) wipe the breast nipple before each feeding to prevent infection. 149(60.8) 15(6.1) 81(33.1) give 15-20ml/kg/day to your neonate weight < 1kg? 12(4.9) 1(0.4) 232 (94.7) the clean cord of your neonate daily? 195(79.6) 27(11) 23 (9.4) appling any ointment on your neonates' umbilical? 140(57.1) 18(7.3) 87(35.5) observe your baby's umbilical for signs of inflammation or any discharge. 203(82.9) 32(13.1) 10(4.1) apply any topical skin ointment to reduce dermatitis and the risk of sepsis. 99(40.4) 12(4.9) 134(54.7) change the baby's body position by doing a range of motion your baby to prevent pressure area breakdown. 219(89.4) 12(4.9) 14(5.7) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.09 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 98 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 5: association between mothers’ practices and socio-demographical characteristics regarding caring mothers’ practices socio-demographical characteristics good fair poor p-value f (%) f (%) f (%) age/ years less than 20 20-26 27-33 34-40 58(55.2) 59(54.6) 11(52.4) 5(45.5) 47(44.8) 49(45.4) 8(38.1) 5(45.5) 0(0) 0(0) 2(9.5) 1(9.1) 0.002 hs level of education illiterates can read and write primary school secondary school diploma institute high degree 34(58.6) 13(61.9) 16(44.4) 30(50) 17(50) 23(63.9) 24(41.4) 8(38.1) 19(52.8) 29(48.3) 17(50) 12(33.3) 0(0) 0(0) 1(2.8) 1(1.7) 0(0) 1(2.8) 0.706 ns mode of the delivery nvd cs episiotomy 21(14.7) 29(33.3) 2(13.3) 107(74.8) 44(50.6) 11(73.3) 15(10.5) 14(16.1) 2(13.3) 0.004 hs the religion muslim christian yazidi 229(95.8) 3(100) 3(100) 9(3.8) 0(0) 0(0) 1(0.4) 0(0) 0(0) 0.992 ns antenatal care private facilities primary health centers both sector 51(23.7) 0(0) 1(3.8) 141(65.6) 2(50) 19(73.1) 23(10.7) 2(50) 6(23.1) 0.012 s table 5: association between overall mothers’ practices and socio-demographical characteristics regarding caring for lbw mothers’ practices socio-demographical characteristics good fair poor p-value f (%) f (%) f (%) house ownership owned partially owned rent 174(96.1) 20(90.9) 41(97.6) 7(3.9) 1(4.5) 1(2.4) 0(0) 1(4.5) 0(0) 0.033 s occupation of the mother housewife public employee private employee student self-employee 72(38.9) 29(65.9) 6(50) 1(50) 0(0) 22(11.9) 0(0) 0(0) 1(50) 0(0) 91(49.2) 15(34.1) 6(50) 0(0) 2(100) 0.007 hs socio-economic status low middle high 1(50) 91(40.4) 7(38.9) 1(50) 132(58.7) 11(61.1) 0(0) 2(0.9) 0(0) 0.034 s https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.09 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article antenatal care the highest percentage of them 87.8% attend privet facilities, at the same time in a study that has been done by abdullah cs [20] there was accepted the same similarity between age at early stage, attending facilities. one-third 35.9% of neonates aged between 1-5 days, and a half 51.8% were close relatives. meanwhile, females represented the highest percentage 58.8%. regarding the place of delivery, the study found that more than half 63.3% of the babies were born in public hospitals and only one quarter 27.8%of the babies were breastfeeding the study result dose not constant with another study that majority of mothers breast feed to their neonates [23].the highest percentage 62%of mothers keep temperature between35-36.5 °c, the study result is constant with another study which confirm that the mothers kept their baby and tried keep their body temperature normally [19]. meanwhile 49% of them give relaxing massage to their neonates. almost three quarter 72.2% of mothers feel comfort while breastfeed to lbw there is acceptance between this finding and another study done by [20]who were did the similar steps that have been done in our study as having relaxing massage. using a cup or a spoon till the baby can suck effectively refused by more than half of mothers 59.2%.81.2% of mothers feed their neonates 6-8 times in 24hrs,the findings are similar with the findings confirmed the similarity [25].some of mothers 42.4% pick their lbw when crying while breastfeeding. three quarter 75.1% of mothers did not put their lbw in quiet and healthy environment during feeding. wiping the breast nipple since feeding to prevent infection implemented by 60.8%. almost all 94.7% of mothers did not give their lbw 15-20ml/kg/day the results of those findings are similar to the findings that confirmed that lbw babies were give less the results of highest percentage of maternal age 35.1% were between 27-33 years old which is consistent with the findings of ,talie asmare (2019) who found that the most age of their participants were between 25 to 32 years old [4], which is similar to the results of study [13] who showed that majority of attendances were in between 23-31 years old, and most 75.5% were housewives also this finding is accepted by another study (14) who confirmed that mostly attendances were house wives. one quarter 24.5% of the mothers graduated from secondary school. at the same time these findings are accepted by another investigation proposed by [15] showed that most of participants have not got high degrees and study secondary schools. the majority of mothers 97.6% were muslims there is acceptance between our findings and another survey [14].the current study shows that the highest percentages 91.8% of mothers live living middle economic status, in another study unlike our study that have been conducted by borders aeb [16] most of participants live in high economic status. regarding the mother's residential areas the majority 60% were living in urban, unlike our study the majority of participants in a study done by abdullah who confirmed that participants were live in rural area [14]. concerning mothers' obstetrical history current study shows, that around one-third 28.2% of the mothers had a normal vaginal delivery. unlike our study the majority of mothers delivered their baby through cs [15].the highest percentages 44.1% were married at the age of 20-26 years, these findings are accepted by a study by schuler and the colleagues[17]almost most of the attendances were get married when their ages were between 20-27 ages. regarding mothers’ 99 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussions https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.09 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article i would like to recognize, appreciate, and acknowledge all mothers who have low birth weight baby in neonatal intensive care unit for their grateful cooperation, support and help. the study approved by ethical committee/hawler medical university-erbil the author reports no conflict of interests. [1] muchemi om, echoka e, makokha a. factors associated with low birth weight among neonates born at olkalou district hospital, central region, kenya. pan african medical journal. 2015;20(1). [2] dahlui m, azahar n, oche om, aziz na. risk factors for low birth weight in nigeria: evidence from the 2013 nigeria demographic and health survey. global health action. 2016 dec 1;9(1):28822. [3] tshotetsi l, dzikiti l, hajison p, feresu s. maternal factors contributing to low-birthweight deliveries in tshwane district, south africa. plos one. 2019 mar 1;14(3): e0213058. [4] eshete a, alemu a, zerfu ta. magnitude and risk of dying among low-birth-weight neonates in rural ethiopia: a community-based cross-sectional study. international journal of pediatrics. 2019 may 16;2019. [5] schuler c, ntow ge, agbozo f. mothers' experiences with neonatal care for low-birthweight infants at home; a qualitative study in the hohoe municipality, ghana. journal of pediatric nursing. 2019 mar 1;45: e44-52. [6] cutland cl, lackritz em, mallett-moore t, bardají a, chandrasekaran r, lahariya c, nisar mi, tapia md, pathirana j, kochhar s, muñoz fm. low birth weight: case definition & guidelines for data collection, analysis, and presentation of maternal immunization safety data. vaccine. 2017 dec 12;35(48part a):6492. [7] kader m, perera nk. socio-economic and nutritional determinants of low birth weight in india. north american journal of medical sciences. 2014 jul;6(7):302. than 15 ml/day [5].majority of mothers 79.6% clean cord daily. 57.1% of mothers apply ointment to their lbw umbilical, special attention to cleaning of umbilical cord also accepted by another finding in an investigation [21] .the greater part 82.9% of mothers pay attention to umbilical for signs of infection. more than half of mothers 54.7% did not apply ointment to skin to protect dermatitis. majority of mothers89.4% change baby's body's position to keep them from pressure area, these findings were also supported by a conducted study [22].moreover, the study reveals a significant association between socio-demographical characteristics such as the age of the mother at /marriage, mode of the delivery, antenatal care results of those findings are similar to the findings that confirmed in [23]. house ownership, occupation of the mother and socio-economic status, so these findings are accepted by another study [24]who confirmed that there were significance association between mode of delivery and house ownership. the outcome of the study revealed that most of the mothers had good practice regarding care of lbw neonates in erbil city. at the same time mothers have not got good practice regarding kangaroo mother care. meanwhile there were significant association between sociodemographical characteristics such as (the age of the mother at /marriage, mode of the delivery, antenatal care, house ownership, occupation of the mother and socioeconomic status). meantime there were not any significant association between level of education and religion of participants. 100 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. references conclusion conflict of interest aknowledgment ethical consideration https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.09 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article india. general of biological and scientific opinion. 2013; 1:300-. [19] abdullah cs, hassan ss. mothers’ awareness regarding home care management of a preterm baby at the rapareen pediatric teaching hospital in erbil city. erbil journal of nursing and midwifery. 2019 nov 30;2 (2):163-79. [20] talie a, taddele m, alemayehu m. magnitude of low birth weight and associated factors among newborns delivered in dangla primary hospital, amhara regional state, northwest ethiopia, 2017. journal of alsadi e. international journal of pediatrics. 2017;5 (3):4601-11. [21] borders ae, grobman wa, amsden lb, holl jl. chronic stress and low birth weight neonates in a low-income population of women. obstetrics & gynecology. 2007 feb 1;109(2 part 1):331-8. [22] khan a, nasrullah fd, jaleel r. frequency and risk factors of low birth weight in term pregnancy. pakistan journal of medical sciences. 2016 jan;32(1):138. [23] küçükoğlu s, çelebioğlu a. effect of naturalfeeding education on successful exclusive breast-feeding and breast-feeding selfefficacy of low-birth-weight infants. iranian journal of pediatrics. 2014 feb;24(1):49. [24] sacks e, moss wj, winch pj, thuma p, van dijk jh, mullany lc. skin, thermal and umbilical cord care practices for neonates in southern, rural zambia: a qualitative study. bmc pregnancy and childbirth. 2015 dec;15 (1):1-1. [25] aradhya as, kaur i, gupta r, kaur s, shrimanth ys, masih pd, kumar p. implementing a three-hourly feeding schedule in stable preterm infants to decrease maternal fatigue. bmj open quality. 2021 jul 1;10 (suppl 1): e001439. [26] stewart d, benitz w, watterberg kl, cummings jj, eichenwald ec, poindexter bb, aucott sw, goldsmith jp, puopolo km, wang ks. umbilical cord care in the newborn infant. pediatrics. 2016 sep 1;138(3). [27] sacks e, moss wj, winch pj, thuma p, van dijk jh, mullany lc. skin, thermal andumbilical cord care practices for neonates in southern, rural zambia: a qualitative study. bmc pregnancy and childbirth. 2015 dec;15(1):11. [8] hockenberry mj, wilson d. wong's essentials of pediatric nursing9: wong's essentials of pediatric nursing. elsevier health sciences; 2013. [9] loureiro cv, fonteles mm, mascarenhas mb, chaves ef, firmino py. medication follow-up in newborns with extremely low birth-weight. pharmacy practice (granada). 2019 dec;17(4). [10] moradi g, khazaei z, esmailnasab n, roshani d, zokaii m, ghaderi e, nouri b. the relationship between maternal diseases during pregnancy and low birth weight: a nested case-control study in rural areas of kurdistan province (west of iran). international journal of pediatrics. 2017;5(8):550114. [11] lv b, gao xr, sun j, li tt, liu zy, zhu lh, latour jm. family-centered care improves clinical outcomes of very-low-birth-weight infants: a quasi-experimental study. frontiers in pediatrics. 2019 apr 12; 7:138. [12] nabiwemba el, atuyambe l, criel b, kolsteren p, orach cg. recognition and home care of low-birth-weight neonates: a qualitative study of knowledge, beliefs and practices of mothers in iganga-mayuge health and demographic surveillance site, uganda. bmc public health. 2014 dec;14(1):1-1. [13] cinar n, kose d, alvur m, dogu o. mothers’ attitudes toward feeding twin babies in the first six months of life: a sample from sakarya, turkey. iranian journal of pediatrics. 2016 oct;26(5). [14] rahman m, chowdhury ma, hoque m, jahan n, shaha lc. kangaroo mother care for low-birth-weight babies: a randomized controlled trial in a tertiary care hospital of bangladesh. journal of pediatric neonat care. 2017 oct;7(2):00285. [15] official census, rapareen teaching hospital for pediatric in erbil 2021. [16] schuler c, ntow ge, agbozo f. mothers' experiences with neonatal care for low-birth -weight infants at home; a qualitative study in the hohoe municipality, ghana. journal of pediatric nursing. 2019 mar 1;45: e44-52. [17] khan a, nasrullah fd, jaleel r. frequency and risk factors of low birth weight in term pregnancy. pakistan journal of medical sciences. 2016 jan;32(1):138. [18] krishna k, moniqa a, wahid a. umblical cord blood nutrients among low birth weight and normal birth weight babies in primary health care set up in lucknow 101 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.09 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article [28] tadesse berehe t, modibia lm. assessment of quality of antenatal care services and its determinant factors in public health facilities of hossana town, hadiya zone, southern ethiopia: a longitudinal study. advances in public health. 2020 aug 17;2020. [29] khan a, nasrullah fd, jaleel r. frequency and risk factors of low birth weight in term pregnancy. pakistan journal of medical sciences. 2016 jan;32(1):138. 102 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.08 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article neonatal outcomes of spinal versus general anesthesia among women undergoing elective cesarean section in erbil city abstract background and aims: general anesthesia and spinal anesthesia are the primary anesthetic techniques for cesarean deliveries. both the mother and the fetus are affected by each of these anesthestics. due to its safety profile and advantages for both mother and fetus, the choice of anesthetic procedures for cesarean birth may occasionally depend on the mother’s or doctor’s request. this study compared how general anesthesia and spinal anesthesia affected newborn outcomes during cesarean delivery. methods: a quantitative comparative study on 200 kurdish women who were undergoing a cesarean section with a spinal anesthesia and general anesthesia preference for mothers or physician was included in a purposive sample carried out in the operating theatre at maternity teaching hospital from 2021 to 2023. the assessment of newborn outcomes related to weight, apgar score, well and alive status or immediate admission to intensive care unit was done using a questionnaire method. the data interpretation, the statistical program for social science spss (version 26), frequency and percentages, mean and standard division was used. for determining the acceptance rate of participants, chisquare test and independent sample t-test with p-value were employed. results: the study shows that the most (54%, 44%) of the participants in both groups general and spinal anesthesia were in the age group 20–29 years old, and 35%, 44% were in the group 30-39 years old respectively. 25% of the general anesthesia group held a primary school degree and 30% of the spinal anesthesia group held an institute or university degree. 65% and 45% of the participants in both were in multi-gravity respectively. 87% and 53% responded that the decision to choose types of anesthesia was made by the physician's request for both groups. a statistically significant difference between both groups general and spinal anesthesia regarding newborn apgar score in the first and five min pvalue 0.007 and p-value 0.017 respectively. conclusion: there was a statistically significant difference between both groups regarding newborns alive and well and immediately admitted to the intensive care unit p-value 0.001. keywords: spinal anesthesia; cesarean section; general anesthesia; neonate outcome; apgar score. sahar ismail abdulla; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. (correspondence: sahar.abdullah@hmu.edu.krd) awaz aziz saeed; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. abubakir majeed saleh; college of medicine, hawler medical university, erbil, kurdistan region, iraq. 67 received: 13/03/2023 accepted: 14/05/2023 published: 30/05/2025 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:(correspondence:%20dara.albanna@hmu.edu.krd) mailto:sahar.abdullah@hmu.edu.krd?subject=sahar.abdullah@hmu.edu.krd mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.08 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article today, having children is still regarded as one of the divine favors for human reproduction. cesarean section (cs) has been utilized to assist moms with high-risk pregnancies in recent years because one of the purposes of the birth control policy is to ensure safe and healthy birthing. [1]. a surgical procedure known as a cesarean section can save both the mother's and the baby's lives. it is crucial to understand the potential public health risks brought on by the overuse of cesarean sections. [2].the overall cesarean section rate in iraq in 2012 was 24.4%, which was comparable to the rates in the kurdistan region (25.4%) and central/southern iraq (24.3%). iraq's cesarean rate is significantly higher than the 10% who-recommended rate. from 2008 to 2012, iraq's cesarean section rates grew sharply, with the kurdistan region mostly to blame for the rise. [3]in both developed and developing nations, general anesthesia is still frequently used when mothers request this practice. because the mother refused to employ spinal methods, general anesthetic was used in 20% of cesarean deliveries in england and wales [4]. general anesthesia was used for elective cesarean deliveries in 5% of reported instances in the united states. about 15% of elective cesarean deliveries in great britain, 4% in belgium, 30% in spain, 34% in italy, 10% in germany, and 44% in the czech republic involved general anesthesia. [5, 6]due to a lack of understanding and common misconceptions about spinal anesthesia, women typically favored general anesthesia. when the mother's or the fetus's life is in immediate danger, this situation becomes even more essential. for many years, general anesthesia was the most often used kind of anesthetic during caesarean sections. utilizing anesthetics that pass the placental barrier has many benefits, including quicker induction, improved cardiovascular stability with a decreased incidence of hypotension, and good control over ventilation, but it can also result in newborn depression. [7, 8, 9] spinal anesthesia (sa) has recently seen an increase in caesarean section rates, and is currently the preferred anesthetic method for preventing difficulties for both the mother and the fetus. [10,11]. spinal anesthesia-related hypotension brought on by sympathetic blockade may have an impact on neonatal short-term outcomes by impairing uteroplacental perfusion, despite numerous studies showing that general anesthesia and spinal anesthesia have nearly identical indexes of neonatal wellbeing [12]. a growing number of anesthesiologists prefer spinal anesthesia when performing elective procedures. additionally, headache, nausea, and vomiting may occur as a result of cerebrospinal fluid (csf) leaking during lumbar puncture [9, 13, 14, and 15]. in several investigations, clinical outcomes such as maternal mortality, postoperative discomfort, and hemorrhage were compared between anesthetic techniques used during caesarean sections. for the majority of caesarean sections (css), spinal and epidural anesthesia are preferred over general anesthesia (ga) due to a number of variables, including increased maternal and fetal safety with spinal anesthetic [14, 16]. the danger of unsuccessful endotracheal intubation and aspiration of gastric contents in pregnant women who receive general anesthesia is the main justification for advising regional blocks, even if there is evidence that general anesthesia is linked to an increased requirement for newborn resuscitation [17]. this study aimed to compare fetal outcomes among women undergoing scheduled cesarean section under general and spinal anesthesia. since the choice of anesthesia for cesarean delivery is very important for both maternal and fetal outcomes. 68 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.08 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article informed consent, those refused to participate in this study and women with mental disorders. questionnaires were applied to gather data that included three parts: first part: sociodemographic characteristics of pregnant women including age, educational level, occupation, residence, and their body mass index (bmi). second part: obstetrical history: this includes the number of gravida, para, miscarriages, gestational age of the fetus by ultrasound report, previous type of anesthesia, number of cesarean section and indication of cesarean section. third part: neonatal outcomes such as: weight, apgar score, well and alive baby and early administration to neonatal care unit and dead baby. questionnaires were filled by the researcher in 30-45 minutes. the newborn assessment was made by a pediatrician who was present in the operating room. information about the newborns existence of meconium, sex of the newborn, his/her weight, first and fifth minute apgar scores, information about hospitalization in the pediatric clinic and indications for hospitalization was all recorded in the mothers chart. the validity of tools was assessed by a panel of experts from health specialties (maternity and community nursing). a pilot study was done on 20 pregnant women who were not part of the samples for simplicity, objectivity, applicability, and possibility of the tools. it also was carried out to know any difficult situations dealing with providing the tools and to know the period required for the collection of data. consistency of questionnaires; the p-value significance of the mann-whitney u-test was 0.131, which means that there were no statistical differences between the two groups with the same questionnaire. ethical approval was achieved from the ethics committee of the college of nursing/ hawler medical university as the code number is 144 on 7/10/2021. a quantitative comparative study design was carried out to assess the neonatal outcome among women undergoing elective cesarean section under general and spinal anesthesia. the current study was conducted on 200 non-probability purposive pregnant mothers who underwent cesarean section due to elective indications. the data were collected during the period from january/ 25th / 2022 to july / 28th /2022. the patients were divided into general anesthesia (n = 100) and spinal anesthesia (n = 100) groups in the operation room, postoperative and emergency ward at maternity teaching hospital in erbil city, kurdistan region, iraq. it is the only governmental maternity teaching hospital established in 1984 in erbil city; it contains 200 beds. the maternity hospital has eight main departments including (the consultation department, emergency department, delivery room, operative room, postpartum department, postoperative department, intensive care unit (ncu) neonatal intensive care unit, and high-risk department) which give maternal health care service, especially emergency and special care to all populations of erbil governorate. the study commenced during the period from 1st november 2020 to 1st november 2023. after taking oral permission from the participant and inclusion criteria included: primigravida and multigravida pregnant women and their gestational age between 37-42 weeks. female age 18 and over who were scheduled for elective cesarean section, kurdish nationality, could communicate properly and accepted to participate in the research. patients presenting the following were not included in the study: those who had converted to general anesthesia from spinal anesthesia, patients undergoing emergency caesarean section for any reason, those who refused to give 69 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.08 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article permission was obtained from the director of health/erbil. official permission (written and oral consent) was also obtained from participants. the data were interpreted by using spss software for statistical analysis version 26, for calculating descriptive statistical analysis frequency, percentage, mean, and standard deviation. inferential statistical analysis such as chi-square and independent sample t-tests was used to find the association between variables. the p-value is considered statistically significant if it's ≤ 0.05 which rejects the null hypothesis. table 1 shows that the most (54%) of the participants in general anesthesia were in the age group 20–29 years, while 44% in spinal anesthesia were between 30-39 years. regarding education level, the result indicates that the highest percentage 25% of the general anesthesia group held a primary school degree in comparison with 30% of the spinal anesthesia who held an institute or university degree. the majority of participants 93% and 77% in both groups were housewives respectively. the same table indicates that the highest percentage 54% of women in general anesthesia live in rural areas while 52% of women in spinal anesthesia live in urban areas. regarding body mass index, the result mentioned that the highest percentage 40% and 38%of women in both groups were in the group of bmi that represent overweight respectively. 70 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results table 1: socio demographic characteristics of the study sample no. = 200 variables general=100 spinal=100 f (%) f (%) age (year) <20 7 (7) 4 (4) 20-29 54 (54) 41 (41) 30-39 35 (35) 44 (44) ≤40 4 (4) 11 (11) mean (sd) = 27.880 (5.8175) mean (sd) =30.090 (6.7136) education level illiterate 19 (19) 13 (13) can read and write 7 (7) 8 (8) primary school 25(25) 27 (27) intermediate school 17 (17) 13 (13) high school 10 (10) 9 (9) institution and university 22 (22) 30 (30) occupation house wife 93 (93) 77 (77) governmentalemployment 6 (6) 18 (18) student 1(1) 5 (5) residency urban 46 (46) 52 (52) rural 54 (54) 48 (48) bmi under weight 8 (8) 18(18) normal 39 (39) 28 (28) over weight 40 (40) 38 (38) obese 13 (13) 16 (16) p-value= 0.310 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.08 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article 71 and 51% of the women in both groups had previously miscarriage zero respectively. in addition, over half 68% and 63% of study sample in both general and spinal anesthesia were between 38-39 weeks of gestational age of pregnancy respectively. table 4 indicated that the highest percentage 57% and 43% of participants in both general and spinal anesthesia believe that a previous cesarean section is the main reason for choosing the types of anesthesia by physician. table 5 regarding apgar scores in the first minute, the majority 69% and 85% of newborns had apgar scores equal or to higher than 7 in both groups of anesthesia. while, in 5 min, the result shows that most 92% and 99% of newborns have their apgar scores equal to or higher than 7 in general and spinal anesthesia respectively, a statistically significant difference between both groups general and with spinal anesthesia regarding new born apgar score in the first and five min p0.007 and p-0.017 respectively . table 2 reveals that the highest percentages 65% and 45% of the participants in both general and spinal anesthesia were in multi-gravity respectively, also the percentage 60% and47% of both general and spinal group had1-2 para respectively. regarding miscarriage, the result indicates that the highest percentage 63% table 3 revealed the results of the study sample in both groups who had general anesthesia and spinal anesthesia. the highest percentage 87%& 53% responded that the decision to choose types of anesthesia was made by physician's request for both general and spinal anesthesia. in addition, the highest percentage 56% and 55% of study sample of participant in both groups had previous 1-2 cesarean sections. regarding the previous spinal anesthesia, the finding showed that the majority 92% and 78% of study sample in both groups did not have the previous type of anesthesia. otherwise, more than half 65% of the women in general anesthesia have previous general anesthesia, while over half 56% of study sample in spinal anesthesia have previous general anesthesia. copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: obstetric history regarding the spinal and general anesthesia no.= 200 variables general anesthesia spinal anesthesia f (%) f (%) gravida primigravida 15(15) 22 (22) multi gravity 65 (65) 45 (45) grand multi gravity 20 (20) 33 (33) para none 21 (21) 22 (22) 1-2 60 (60) 47 (47) 3-4 16 (16) 23 (23) 5 and above 3 (3) 8 (8) previous miscarriage none 63 (63) 51 (51) 1-3 36 (36) 47 (47) 4 and above 1 (1) 2 (2) ga (gestational age) 37 weeks 27(27) 26 (26) 38-39 68(68) 63 (63) 40-42 5 (5) 11 (11) total 100 100 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.08 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article 72 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: distribution of participants according to choose of anesthesia and previous anesthesia no. = 200 variables general anesthesia spinal anesthesia f (%) f (%) the decision to choose types of anesthesia made by mother’s request 13 (13) 47 (47) physician request 87 (87) 53 (53) number of cs (cesarean section) none 26 (26) 38 (38) 1-2 56 (56) 55 (55) 3-4 17 (17) 7 (7) 5 and above 1 (1) 0 (0) prevoius spinal anesthesia no 92 (92) 78 (78) yes 8 (8) 22 (22) prevoius general anesthesia no 35 (35) 56 (56) yes 65 (65) 44 (44) total 100 100 table 4: distribution of obstetric history regarding indications of current cesarean section no=200 variables general anesthesia spinal anesthesia f (%) f (%) i̇ndication of cesarean section cpd 16 (16) 13 (13) oligohydramnious 1 (1) 5 (5) polyhydramnious 2 (2) 0 (0) breach presentation 7 (7) 6 (6) previouse cs 57 (57) 43 (43) post date 3 (3) 2 (2) hypertention 4 (4) 15 (15) diabetese 3 (3) 4 (4) meconium 7 )7( 5 (5) tubal ligation 0 (0) 5 (5) smoker 0 (0) 2 (2) total 100 100 table 5: distribution of newborn apgar scores among study sample variables general anesthesia spinal anesthesia t-value p-value f (%) f (%) apgar 1min <7 score 31 (31) 15 (15) 2.725 0.007 ≤7 score )69 (69 85 (85) mean (sd) 1.6900 (0.46482) 1.8500 (0.35887) apgar 5min <7 score )8 (8 1 (1) 2.725 0.017 ≤7 score )92 (92 99 (99) mean (sd) 1.9200 (0.27266) 1.9900 (0.10000) total 100 100 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.08 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article care unit under general anesthesia compared to only 12% under spinal anesthesia. there was a statistically significant difference between both groups regarding newborns alive and well and immediately admitted to the intensive care unit p0.001. the same table shows that only 3% in general anesthesia and 1% of spinal anesthesia had fetal death. current study, the majority of moms under general anesthesia were between the ages of 20 and 29, while those under spinal anesthesia were between the ages of 30 and 39. additionally, the current outcome is remarkably similar to that of the study conducted in india by vishnuvardhan reddy and srikanth chirra. [19] they performed a prospective, randomized, singleblind trial on 60 pregnant patients with spinal anesthesia class ii who were scheduled for caesarean sections with general anesthesia or spinal anesthesia. the participants in a different trial, which involved 64 parturients having elective cesarean sections under spinal anesthesia, were all over table 6 illustrates that there was the highest percentage 90% and 98%.of newborn in both general and spinal anesthesia with their body weight between 2500-2399mg, there was no a statistically difference between both groups regarding newborn weight p-0.566. the majority 68% and 88% of newborns in both groups were alive and well respectively. there were32% of newborn admission to the neonatal intensive although there is a global trend towards spinal anesthesia, there is still no unquestionably acknowledged and perfect cesarean procedure, and despite growing knowledge and competence, cesarean delivery still involves higher risks for maternal and neonatal death and morbidity than vaginal delivery. in a uk study by kolas et al., the spinal anesthetic rate increased from 69.4% in 1992 to 94.9% in 2002. [18]. it is suggested that spinal anesthesia is preferable to general anesthesia in terms of fetal welfare because this is the largest study to examine the effect of anesthetic type for cesarean section on neonatal health. according to the findings of the 73 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion table 6: distribution of newborn outcomes among study sample no. =200 variables general anesthesia spinal anesthesia t-value p-value f (%) f (%) wieght <2500 (mg) )6 (6 1 (1) 0.575 0.566 2500-3999 (mg) 90 (90) 98 (98) ≤4000 (mg) 4 (4) 1 (1) mean (sd) 1.9800 (0.31718) 2.0000 (0.14213) alive and well no 32 (32) 12 (12) 3.500 0.001 yes 68 (68) 88 (88) mean (sd) 0.6800 (0.46883) 0.8800 (0.32660) immediate admit to ncu no 68 (68) 88 (88) 3.345 0.001 yes 32 (32) 12 (12) mean (sd) 0.3100 (0.46482) 0.1200 (0.32660) early fetal death no 97 (97) 99 (99) 0579 0.563 yes 3 (3) 1 (1) mean (sd) 0.0200 (0.14071) 0.0100 (0.10000) total 100 100 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.08 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article (emergency and elective categories). in the emergency category, the mean apgar score was statistically higher under spinal anesthesia than under general anesthesia (p-value < 0.001 and 0.026, respectively), but there was no discernible difference in the elective category. the present study illustrates there were statistically significant difference between both types of anesthesia regarding neonatal intensive care admission. spinal anesthesia is associated with better neonatal outcomes than general anesthesia, according to research by mitra et al [23], which was conducted in west bengal, india during elective caesarean deliveries. according to the present research, newborns exposed to general anesthesia were considerably more likely than those exposed to spinal anesthesia to have apgar scores of <7 in the first and fifth minutes and to be admitted to the intensive care unit. in addition to avoiding the hazards associated with a general anesthetic, such as the chance of unsuccessful intubation and its repercussions, spinal anesthesia is the preferred method for caesarean deliveries. the better fetal and maternal outcomes of spinal anesthesia also make it appear to be a preferable choice. however, cesarean deliveries continue to be performed under both spinal and general anesthesia. the operating department staff as well as the anesthesiology and postoperative care teams at the maternity teaching hospital were a huge help to the author all through the duration of the research. the authors have no conflict of interest. the age of 18 and under the age of 40. this study was conducted in an indian medical college. the current study's findings showed the majority of the participants in both groups were housewives respectively. on the one hand, our research showed that newborns exposed to general anesthesia were more likely than those exposed to spinal anesthesia to have apgar scores of 7 at the first and fifth minutes and to be admitted to the intensive care unit. the apgar scores of 7 at the first minute were higher in emergency cesarean section cases when the same newborns were evaluated according to whether they were delivered as an emergency or electively. however, newborn morbidity was not categorized in accordance with the cesarean section indication. therefore, our findings imply that the emergency nature of the procedure and the rationale for the cesarean section surgery may have an impact on the majority of unfavorable newborn outcomes associated with general anesthesia. alhusban et al [20] investigated both elective and emergency cesarean section procedures and found that there was no significant difference in the elective category12 and that the apgar scores were higher in emergency category cases that had spinal anesthesia as opposed to those who received general anesthesia. in contrast spinal anesthesia had a better impact on apgar scores in elective cesarean section than general anesthesia, according to mancuso et al. and sayg et al. [21]. this result is consistent with research by taşgöz et al. [22]. there were substantially more newborns in the general anesthetic group than the spinal group who had an apgar score of less than seven during the first and fifth minutes of life. the current study, which involved 3599 cesarean sections and was conducted in amman, jordan, is in contradiction with another retrospective comparative study by naser al-husban et al [20]. 74 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion acknowledgement conflict of interest https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.08 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article [9] vishnuvardhan reddy, srikanth chirra. general versus spinal anesthesia on quality of life in women undergoing caesarean delivery: a prospective comparative study. international archives of integrated medicine, 2021; 8(7): 35-41. https://iajmjournal.com. [10] reynolds f. general anesthesia is unacceptable for elective cesarean section. international journal of obstetric anesthesia,2010;19(2):212-7.:https:// doi.org/10.1016/j.ijoa.2009.10.002 [11] bucklin ba, hawkins jl, anderson jr, ullrich fa. obstetric anesthesia workforce survey: twenty-year update. american society of anesthesiologists, 2005; 103 (3):645-53. available at: www.awhonn.org/awhonn/? pg8736230-7000-4730-4760. [12] saygi al.ozdamar o,gun i, emirkad h, mungen e.akpak ykcomparison of maternal and fetal outcomes among patients undergoing cesarean section under general and spinal anesthesia: a randomized clinical trial. sao paulo medical journal, 2015; 133(3):227 -34. doi: 10.1590/1516-3180.2014.8901012. [13] van de velde m, schepers r, berends n, vandermeersch e, de buck f. ten years of experience with accidental dural puncture and post-dural puncture headache in a tertiary obstetric anesthesia department. international journal of obstetric anesthesia, 2015; 17 (4):329-35. doi: 10.1590/15163180.2014.890101. [14] bloom, steven l. spong, catherine y. weiner, steven j. landon, mark b. rouse, dwight j. varner, michael w, et al. complications of anesthesia for cesarean delivery. journal of obstetrics & gynecology, 2005; 106(2):p281-287.doi: 10.1097/01.aog.0000171105.39219.55. [15] laudenbach v, mercier fj, rozé jc. anaesthesia mode for caesarean section and mortality in very preterm infants: an epidemiologic study in the epipage cohort. international journal of obstetric anesthesia, 2009; 18(2):142-9.https://doi.org/10.1016/ j.ijoa.2008.11.005. [16] bollag l, lim g, sultan p, habib a s, landau r, zakowski m, et al. society for obstetric anesthesia and perinatology: consensus statement and recommendations for enhanced recovery after cesarean. journal for anesthesia and analgesia, 2021. 132 (5):1362-1377,doi:10.1213/ ane.0000000000005257 [1] sheidaei, s., jafarnejad, f., mohammadzadeh, f., tajiheravi,a. the effect of peer education on pregnant women‘s choosing mode of delivery. journal of midwifery and reproductive health: jmrh. 2019; 7(1): 1880 1887.https://doi.org/10.22038/ jmrh.2019.38654.1429. [2] begum, t., ellis, c., sarker, m., rostoker, j.f., rahman, a., anwar, i., reichenbach, l. a qualitative study to explore the attitudes of women and obstetricians towards caesarean delivery in rural bangladesh. bmc pregnancy childbirth. 2018; 18, 368. https:// doi.org/10.1186/s12884-018-1993-9. [3] shabila, n. rates and trends in cesarean sections between 2008 and 2012 in iraq. bmc pregnancy and childbirth.2017; 17(22). https://doi.org/10.1186/s12884-016-1211-6. [4] mcglennan a, mustafa a. general anaesthesia for caesarean section. journal of continues education in anesthesia, critical care and pain. 2009; 9 (5):148-151. 10.1093/ bjaceaccp/mkp025. [5] stourac p, blaha j, klozova r, noskova p, seidlova d, brozova l et al. anesthesia for cesarean delivery in the czech republic: a 2011 national survey. society for obstetric anesthesia and perinatology.2015; 120 (6):1303-1308.doi:10.1213/ ane.0000000000000572. [6] ghaffari s, dehghanpisheh l, tavakkoli f, mahmoudi h. the effect of spinal versus general anesthesia on quality of life in women undergoing cesarean delivery on maternal request. cureus.2018;10 (12):e3715. doi:10.7759/cureus.3715 [7] mancuso a, de vivo a, giacobbe a, priola v, maggio savasta l, guzzo m, et al. general versus spinal anesthesia for elective caesarean sections: effects on neonatal short-term outcome: a prospective randomized study. journal of maternal –fetal and neonatal medicine.2010; 23 (10).1114-1118. https:// doi.org/10.3109/14767050903572158. [8] van de velde m, schepers r, berends n, vandermeersch e, de buck f. ten years of experience with accidental dural puncture and post-dural puncture headache in a tertiary obstetric anaesthesia department. international journal of obstetric anesthesia, 2008;17(4):329-335.https://doi.org/10.1016/ jioa.2007.04.009. 75 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.08 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article [17] charles s algert, jennifer r bowen, warwick b giles, greg e knoblanche, samantha j lain and christine l roberts. regional block versus general anaesthesia for caesarean section and neonatal outcomes: a populationbased study. bmc medicine 2009; 7(20). doi: 10.1186/1741-7015-7-20. [18] kolas t, saugstad od, daltveit ak, nilsen st, qian p. planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes. american journal of obstetrics and gynecology, 2006; 195 (6):1538-43.https://doi.org/10.1016/ j.ajog.2006.05.005. [19] al-husban n, elmuhtaseb ms, al-husban h, nabhan m, abuhalaweh h, alkhatib ym, et al. anesthesia for cesarean section: retrospective comparative study. international journal of womens health, 2021;13:141-52. http://doi.org/10.2147/ijwh.s292434. [20] mancuso a, vivo a, giacobbe a, priola v, savasta lm, guzzo m, et al. general versus spinal anesthesia for elective caesarean sections: effects on neonatal short-term outcome. a prospective randomized study. journal of maternal-fetal and neonatal medicine, 2010; 23(10):1114-8. https:// doi.org/10.3109/14767050903572158. [21] saygı ai̇, özdamar ö, gün i̇, emirkadı h, müngen e, akpak yk. comparison of maternal and fetal outcomes among patients undergoing cesarean section under general and spinal anesthesia: a randomized clinical trial. sao paulo medical journal, 2015; 133(3):22734. doi: 10.1590/1516-3180.2014.8901012 [22] fatma nurgül taşgöz and nermin kılıçarslan. effect of anesthesia type on outcome measures in cesarean section in the presence of fetal macrosomia. revista associassion medical brasileir, 2022; 68 (10):14101415.https://doi.org/10.1590/18069282.20220382 [23] mitra jk, roy j, bhattacharyya p, yunus m, lyngdoh nm. changing trends in the management of hypotension following spinal anesthesia in cesarean section. journal of postgraduate medicine, 2013; 59(2):121-6. doi: 10.4103/0022-3859.113840 76 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.01 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article nurses, knowledge and attitude regarding cervical cancer screening in erbil city abstract background and objectives: cervical cancer occurs in the cells of the cervix and the lower part of the uterus that connects to the vagina. cervical cancer is a condition that can be prevented with the proper screening and prevention techniques. healthcare practitioners with sufficient expertise, especially nurses, play a crucial role in enlightening the community about the need and availability of screening tests, so it is important to explore the knowledge and attitude of nurses about cervical cancer and screening. this study aimed to assess the level of knowledge and attitude of nurses towards cervical cancer screening and its associated factors in erbil city methods: a quantitative, descriptive cross-sectional study was conducted in teaching hospitals in erbil city, kurdistan region, iraq, from september 1st, 2021, to september1st, 2022. also, nonprobability (convince) sampling techniques were used for a sample, which included 284 nurses. data was collected through face-to-face interviews using a questionnaire designed by the investigator. descriptive statistics spss version 25 was used, and statistics of frequencies, percentages, and inferential statistical analysis of chi-square test and fisher exact test were used. results: less than one-third (25.7%) of the study sample aged between (29–33) years, the majority (94.7%) were married, and less than half (49.30%) of them graduated with a technical diploma. more than one-third (38.7%) had 1–5 years of nursing experience. more than half (53.3%) of the participants achieved a good overall knowledge score and had a positive attitude (95.5%) toward cervical screening. the primary source for obtaining information regarding cervical cancer and screening was healthcare workers (37.6%), followed by medical textbooks (14.8%). there was a highly significant association between age and the overall knowledge of nurses regarding cervical screening (pvalue = 0.007). conclusion: kurdistan nurses have a good knowledge and a positive attitude regarding cervical cancer screening. a highly significant association was found between the level of knowledge and the age of the participants. examining their practice and their role in encouraging women of the kurdish society to performing cervical cancer screening is recommended. however nurses, need continuous knowledge and training through seminars and lectures regarding cervical cancer screening. keywords: nurses; knowledge; attitude; cervical cancer; cervical screening. iman fadhil omar; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: imanfazil66@gmail.com). awaz aziz saied; department of nursing, college of nursing, hawler medical university, erbil, iraq. 01 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 07/12/2022 accepted: 07/09/2022 published: 30/5/2023 mailto::imanfazil66@gmail.com https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.01 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article cervical cancer is the fourth most common cancer in women, ranking after breast cancer (2.1 million cases), colorectal cancer (0.8 million), and lung cancer (0.7 million) [1]. cervical cancer is characterized by symptoms including abnormal vaginal bleeding and foul-smelling vaginal discharge. however in many situations, women with cervical cancer have no symptoms [2]. human papillomavirus (hpv), a sexually transmitted infectious disease, is the most common cause of cervical cancer. several common risk factors recognized to be associated with cervical cancer worldwide. sexually transmitted infections (primarily hpv and herpes simplex virus), reproductive sexual factors (multiple sexual partners, early age at first sexual activity, early age at first delivery, parity, and hormonal birth control pills),behavioral factors (cigarettes and obesity), and host factors (genetic sensitivity) are all known to be associated with cervical cancer [3]. over the past several decades, the incidence of cervical cancer has decreased in developed countries [4]. this is mainly attributed to increased awareness and more effective screening and prevention strategies employed in these countries [5, 6]. in 2018, there were 570,000 new cases and 311,000 deaths from cervical cancer worldwide [1]. africa has the world’s highest cervical cancer incidence and fatality rates, roughly ten times higher than western countries. organized screening programs can effectively control cervical cancer [7]. according to the world health organization (who), the crude incidence rate of cervical cancer in iraq is 2.1 per 100,000 women of all ages[8]. .kurdistan is a self-governing province in northern iraq. it has a population of 8.35 million people and occupies an area of around 40.000 square kilometers, with 36 million people living in iraq [9].in iraq, studies conducted in various cities have indicated an increased frequency of several types of cancer. however, very few studies have been conducted to assess cancer incidence in the country, particularly in the kurdistan region. ramadhan et al. (2011) showed an increased risk of all cancers, including cervical cancer .in recent years, in the first study on cancer incidence in the kurdistan region, the risk of cancer has increased in the kurdistan region of iraq as a result of several environmental and epidemiological factors. for example, the incidence of cancer in halabja city, kurdistan, is ten times greater than the usual rate owing to the long-term repercussions of the chemical bombing in 1988 [10]. early diagnosis and treatment of cervical precancerous lesions are critical for lowering cervical cancer morbidity, and death [11] can be prevented by early detection and treatment. cervical cancer screening programs like the pap smear test visual inspection with acetic acid application (via) and hpv screening test have been proven to be the most effective way to prevent cervical cancer. until 2004, there were no cervical cancer screening programs in the kurdistan region. the ministry of health in the kurdistan region created screening after first study on cervical intraepithelial neoplasia (cin) the results revealed dysplasia in 4.4% of the population .the program was launched in erbil in 2006, duhok in 2008, and sulemania in 2009 [12]. while there is no mandatory requirement to check for cervical cancer the recommendation of doctors and nurses appears to be the most powerful motivator [13].nowadays nurses play a various of roles including patient advocate, caregiver, and research investigator. nurses can offer correct information to the public to increase knowledge, awareness, and attitudes, thereby motivating females in the community to follow recommended cervical cancer screening procedures [14].nurses may educate 02 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.01 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article of the study sample such as age, level education, working experience, residency, marital status and family history of cervical cancer. the second part consisted of 11 questions about nurses’ knowledge of cervical screening. responses were evaluated as follows: correct = 1 and incorrect = 0. nurses’ responses to questions regarding cervical cancer screening knowledge were divided into three categories and scored as follows: poor knowledge (0 to 3), good knowledge (4 to 7), and high knowledge (8 to 11).the final part consisted of seven items evaluating the attitudes of nurses regarding cervical cancer screening. responses were ranked as follows: disagree = 1, neutral = 2, and agree =3. attitudes were divided into two categories and scored as follows: positive (14 to 21) and negative (7 to 13).eighteen experts in related fields validated the questionnaire, and the pilot study of 25 nurses indicated that the tool was eligible for data collection. the cronbach’s alpha (reliability of the questionnaire) was 0.75. before data collection, the researcher explained the research process and study aims to participants and asked each of the participants who agreed to participate to complete a consent form. formal permission was obtained from the hawler medical university/college of nursing and general directorate of health in erbil kurdistan /iraq. all participants have the right to withdraw from the study at any time. the researchers have promised to keep the data information for confidentiality and anonymity. the data were analyzed using spss software for statistical analysis version 25, to calculate descriptive statistical analysis (frequency and percentage). inferential statistical analysis (chi-square and fisher exact test) was used to determine the association between variables, the (p-value ≤ 0.05) is considered statistically significant. women more about the risk factors of carcinoma of the cervix. a pessimistic outlook, lack of awareness, and understanding of cervical cancer screening techniques among healthcare practitioners [15], particularly nurses, might seriously challenge cervical cancer control. [15].nurses are role models for other women if they routinely get cervical cancer screening checks, they may encourage their colleagues to do the same [16]. the aim of this study is to assess the knowledge and attitude of the nurses regarding cervical cancer screening in erbil city. a quantitative, descriptive cross-sectional study was conducted. the study was carried out in erbil city, kurdistan region iraq from september 1st, 2021, to september 1st, 2022, with convenience (convince) samples consisting of 284 nurses who worked in maternity teaching hospital, rzgary teaching hospital, raparin paediatric teaching hospital, hawler teaching hospital, surgical teaching hospital cardiac centre, and east emergency teaching hospital and have agreed to participate in the research. the study included the female nurses who were willing to participate in the study, regardless of their degrees of education (primary and high school of nursing, diploma, bachelor, master, ph.d.). volunteer nurses were excluded from the study. the yamane formula has been used to estimate the sample size n= sample size, e2= margin of error, confidence level =95% and margin of error =0.05. [n= n/(1+n(e)2], n=985/1+985 (0.05)2 and n=284 nurses. direct face-toface interviews ranging from 25–30 minutes using a questionnaire developed by the researcher were conducted in different hospitals. the questionnaire consisted of three parts. the first part included the socio-demographic characteristics 03 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.01 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article according to the results, less than onethird of the participants (25.7 %) were between 29 and 33 years old. regarding their educational background, approximately half of the study sample (49.3%) holds a technical diploma/degree. the study samples also reveal that more than one-third (38.7%) of the participants had one to five years of working experience. about 65.1% of participants are married, and most of them (94.7%) live in the cities. more than a quarter of the participants (30.6%) work in maternity teaching hospitals. ninety-three percent of nurses did not have a history of cervical cancer in their family. only 6.7% reported a family history of cervical cancer among their mother, sister, grandmother, and aunt (31.6%, 21.1%, 31.6%, and 15.8%, respectively) (table 1).table 2 illustrates the knowledge levels of participants regarding cervical cancer screening. most of the participants (83.8%) correctly responded to the statement, “if cervical changes are detected early, they can be easily cured,” and 81.0% of the participants believed that cervical biopsy could detect cancer of the cervix. more than threefourths (76.8%) knew a pap smear test might reveal precancerous and cancerous abnormalities. table 3 demonstrates the attitude of nurses regarding cervical screening eighty-two percent of nurses agreed with the statement “screening helps in controlling of carcinoma,” and (72.6%)agreed with the statement “speculum examination and pap smear are doctors and nurses’ procedures.” less than half (48.2%) of participants believed carcinoma of the cervix could not be transmitted. 04 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results table 1 :distribution of the sociodemographic characteristics of the study sample (n=284) marital status single 90 (31.7) married 185 (65.1) divorced/widowed and separate 9 (3.2) residence urban 269 (94.7) rural 15 (5.3) name of hospital working in maternity teaching hospital 87 (30.6) raparin pediatric teaching hospital 35 (12.3) hawler teaching hospital 70 (24.6) rizgary teaching hospital 38 (13.4) surgical specialty teaching hospital cardiac center 36 (12.7) east emergency teaching hospital 18 (6.3) variables subgroups f. (%) age (groups) 19-23 32 (11.3) 24-28 66 (23.2) 29-33 73 (25.7) 34-38 43 (15.1) ≥39 70 (24.6) level of preparatory nursing 54 (19.0) technical diploma 140 (49.3) bachelor 81 (28.5) postgraduate 9 (3.2) working 1-5 110 (38.7) 6-10 63 (22.2) 11-15 47 (16.5) ≥16 64 (22.5) as a nurse do u have any family history of cervical cancer? yes 19 (6.7) no 26 (93.3) if yes who? mother 6 (31.6) sister 4 (21.1) aunt 6 (31.6) grandmother 3 (15.8) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.01 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 05 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: nurse’s knowledge towards cervical cancer screening. variables correct f. (%) uncertain f. (%) incorrect f. (%) -during the visit for the screening, a few cells will be collected from your cervix in the form of a sample. 212 (74.6) 63 (22.2) 9 (3.2%) -a pap test can detect both cancerous and precancerous lesions 218 (76.8) 40 (14.1) 26 (9.2) -if cervical changes are detected early they can be easily cured. 238 (83.8) 34 (12.0) 12 (4.2) -pap smear test is the only method it can be used for detecting cervical cancer 112 (39.4) 79 (27.8) 93 (32.7) -married women should be screened at least once in whole life 193 (68.0) 57 (20.1) 34 (12.0) -pap smear test it must be done by using vaginal ultrasound 86 (30.3) 100 (35.2) 98 (34.5) -healthy women need to have regular cervical screening once every three years from age 25-65 when cervical screening is normal 138 (48.6) 96 (33.8) 50 (17.6) cervical screening it’s not necessary until the end of life. 61 (21.5) 70 (24.6) 153 (53.9) -the best time for doing a pap smear test is during menstrual flow 59 (20.8) 10 (35.6) 124 (43.7) -cervical biopsy can detect cancer of cervix 230 (81.0) 42 (14.8 ) 12 (4.2) table 3: attitude of the nurses towards cervical cancer screening. attitude disagree neutral agree f. (%) f. (%) f. (%) like any woman, i am susceptible to developing cervical cancer. 37 (13.0) 73 (25.7) 174 (61.3) carcinoma of the cervix cannot be transmitted from one person to another. 51 (18.0) 38 (13.4) 195 (68.7) screening helps in controlling of carcinoma 24 (8.5) 27 (9.5) 233 (82.0) *cultural belief prevent me from having cervical screening 113 (39.8) 42 (14.8) 129 (45.4) *pap smear is unnecessary if there are no signs and symptoms. 118 (41.5) 51 (18.0) 115 (40.5) speculum examination and pap smear are doctors and nurses procedures. 32 (11.3) 40 (14.1) 212 (74.6) *cervical cancer is a sexual transmitted disease 87 (30.6) 35 (12.3) 162 (57.0) *disagree is the correct response. for all the other statements, ‘agree’ is the correct response. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.01 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 06 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. a high statistically significant association was found between nurses’ age and overall knowledge regarding cervical screening (pvalue=0.007). no significant association was found between the level of education and overall knowledge of the study variables poor knowledge f. (%) good knowledg e f. (%) high knowledge f. (%) total f. (%) p* age 19-23 5(1.8) 20(7.0) 7(2.5) 32(11.3) 24-28 2(0.7) 45(15.8) 19(6.7) 66(23.2) 0.00 7 29-33 7(2.5) 32(11.2) 34(12.0) 73(25.7) hs 34-38 6(2.1) 17(6.0) 20(7.0) 43(15.1) ≥39 2(0.7) 38(13.4) 30(10.6) 70(24.7) education preparatory nursing school 5(1.8) 30(10.6) 19(6.7) 54(19.1) technical diploma 15(5.3) 73(25.7) 52(18.3) 140(49.3) 0.128 bachelor 2(0.7) 42(14.7) 37(13.0) 81(28.4) ns postgraduate 0(0) 7(2.5) 2(0.7) 9(3.2) working experience 1 – 5 10(3.5) 67(23.6) 33(11.6) 110(38.7) 6-10 6(2.1) 32(11.3) 25(8.8) 63(22.2) 0.27 5 11-15 3(1.1) 22(7.7) 22(7.7) 47(16.5) ns ≥16 3(1.1) 31(10.9) 30(10.6) 64(22.6) samples regarding cervical screening, the value of (p -value= 0.128). according to the present study’s findings, there was no significant association between the working experience group and overall knowledge of cervical screening (p-value= 0.275) (table 4). table 4: the association between some demographic characteristics (age, level of education and working experiences) of the nurses with overall knowledge towards cervical cancer screening (n=284) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.01 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article figure 3 reveals that the overall attitude of the participants was positive (90.5%), and only (9.5%) had a negative attitude regarding cervical screening. cervical cancer is the most common malignancy among women worldwide with about half a million cases per year, with four out of five women coming from developing and underdeveloped nations. [10]. the key to addressing cervical cancer is effective screening. in kurdistan, there is no mandatory requirement to check for cervical cancer [17]. in recent years, there appears to have been an increase in noncommunicable diseases, as in prior decades. in developed countries, cervical cancer prevention has been successful thanks to simple and inexpensive screening tests that aid in the identification of pre-invasive cervical changes that develop and progress slowly over the years prior to the development of invasive cervix cancer, and treatment of these precursor lesions has greatly reduced the incidence of invasive cervix cancer in worldwide. other procedures, such as colposcopy and cervical biopsies, necessitate training and money [18]. this study aimed to learn more about nurses’ knowledge and attitudes towards cervical screening. thus, staff nurses can play figure 1 demonstrates the overall knowledge of nurses regarding cervical screening and indicates that 53.5% had overall good knowledge, 38.7% had a high level of knowledge, and 7.7% had poor knowledge. figure 2 indicates the main sources of obtaining information regarding cervical screening by participants. healthcare workers (37.6%) was the most common source for gaining knowledge regarding cervical cancer screening, followed by medical textbooks (14.8%), google (14.3%), social media (14.1%), television/ radio (10.1%), friends and spouses (6.1%) and newspaper (3.0%), 07 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion figure 1: distribution of the study participants by the level of knowledge regarding cervical screening n=284 figure 2: illustrates nurse’s source of information regarding cervical screening figure 3: illustrates overall attitude of nurses regarding cervical cancer screening. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.01 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article cervical cancer. they were first-degree relatives, consisting of the mother, sister, grandmother, and aunt. similarly, a study conducted in saudi arabia found that 3.8% were first-degree relatives [23]. our study demonstrates that most of study sample had between 1 -5 years of working experience. a similar study by getahun in addis ababa, ethiopia, found that the majority had 1-9 years of working experience. this result disagrees with a study conducted in tanzania, where more than half of the nurses had more than 20 years of working experience [24]. assessment of knowledge of nurses regarding cervical screening adequate knowledge about cervical cancer and its screening is crucial for nurses as it determines their screening practice for cervical cancer. the present study has shown more than half (53.3%) of respondents had good knowledge of cervical screening. a similar investigation was reported by sait [25]. in our study, more than one-third (48.6%) of participants knew that screening should begin at 25 years or 3 years after starting sexual activity whichever is earlier. this is comparable with a research conducted in tertiary institutions in rural india among nurses, which was a cross-sectional study [16]. the current study illustrates, that most nurses responded that “married women should be screened at least once in their whole life”. this is comparable with the study conducted by devi et al. in south india [26]. our study demonstrates three-fourths of participants knew that if cervical changes are detected early they can be easily cured. a similar study investigation was reported by desaraju and cody [20]. in the current study, more than three-quarters of the participants knew that biopsy can detect cancer of the cervix. similar investigations were reported by singh et al and shekhar et al [17, 19]. in the present study, more than one-third of the participants (37.6%) acrucial role in cervical cancer screening if they are adequately trained, and their services are utilized in the right direction. the present study has shown that most respondents had good knowledge of cervical screening [19].the sociodemographic characteristics of nurses regarding cervical screening the subjects in this study included female nurses (n = 284), with the highest percentage of nurses between the ages 29 to 33 years old. more than two-thirds of the study sample were married. this result is supported by other studies reporting that the participants were aged between 26 and 30 years and were married (61.7%) [17], ages of samples were between 26 and 40 years, and a majority (90%) of them were married [16]. in a cross-sectional study by ayub in pakistan among nursing staff, their ages were between 25-34, and more than two-thirds of nurses (72%) were married [18]. another result agrees with the present study, which was done in an institution in rural india by shekhar among nursing staff their age was between (20-29) and most of them (86.6%) were married [19]. the result disagrees with a study done among doctors and nurses indicating the highest percentage of participants their ages were between (21 – 30) years old (32.9%) [20].another that two-thirds of participants (67.9%) were married and their ages were between 41-50 years is also in disagreement with the present study [21]. the current study shows that, the highest percentage of study samples (49.5%) held a technical diploma/degree. like a study done in addis ababa-ethiopia by getahun et al., less than one-third of health workers (25.9%) held a diploma in nursing [22]. in contrast, a study reported more than two-thirds of study sample 68.9% held bachelor's degrees [19]. in the current study, only 6.7 % of participants had a family history of 08 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.01 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article improve the women’s health outcome and reduce the cost of care [17].assessment of the attitude of the participants regarding cervical screeningthe current study demonstrates that four-fifths (82.0%) of the participants agreed that “screening helps in controlling carcinoma.” this result agrees with a cross-sectional study done in riyadh, saudi arabia [23]. in our study, about three-fourth (74.6%) of participants agreed “to the speculum examination and pap smear are doctor and nurses procedure”. this result disagreement with a study done by devi et al. which mentioned the speculum examination and pap smear are only doctors’ procedures[17].another cross-sectional study conducted among healthcare workers by henna et al. in a tertiary hospital in riyadh, saudi arabia indicated two-thirds of participants were nurses (66.1%). a majority of the nurses (76.2%) mentioned that the speculum examination and pap smear can only be done by doctors [26]. the study revealed more than two-thirds (68.7%) of participants responded that “carcinoma cannot be transmitted from one person to another” which agreed with another similar study [23]. association between overall knowledge and some demographic characteristics the score range among participants was wide and we found a highly significant inverse association between age and overall knowledge (p-value = 0.007) among nurses. findings are similar to the studies conducted by rahman and kar in pakistan among nursing staff which showed there was a highly significant relationship between overall knowledge regarding cervical screening among the respondents (pvalue=0.007)[33]. in the present study, there was no a significant association between the level of education and the overall knowledge of nurses. a finding which is in agreement with the result of the studies [32, 23]. in contrast to a study done received information about cervical screening from healthcare workers. it is matched with studies conducted in different countries [27, 21, 28]. in contrary, research conducted in tanzania by urasa and darj among 137 nursing staff the study showed the study samples got information through nursing school and social media as a main source for gaining their knowledge regarding cervical cancer screening (53.3%, 47.4% respectively) [24]. the current study showed that most participants (76.8%) knew that a pap smear test can detect both cancerous and precancerous lesions. this result agrees with studies done by authors singh et al and ayub et al [17, 18]. married nurses were more aware than unmarried women, because they are more likely to approach a health facility for obstetric, gynaecological, or other reasons, where they would be offered opportunistic screening during these visits. additionally,, partners in long-term relationships demonstrate real care for one other's health and may play a crucial role in screening and other health maintenance. these finding matches a study has done by siahpush et al [29].regarding the knowledge of samples toward cervical cancer screening, more than half of them had a good level of knowledge (53.35%), more than one-third of nurses (38.7%) had a high knowledge and only 7.7% had a poor level of knowledge. this could be because nurses were interested in receiving cervical screening information, but do not have opportunities to improve their knowledge. it also could be due to the level of education as 49.30% had a nursing diploma, the present study demonstrated that nurses are key providers of women’s education during admission and pre-discharge. this leads to increased awareness toward the disease prevention and cervical screening programs to 09 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.01 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article conclusion references in egypt by abdulraof et al, there was a significant association between level of education and overall knowledge [11]. regarding nurses working experiences the current study showed that there was no a relationship between overall knowledge and working experience, matched with a study done in ethiopia, india and tanzania [22,23,24]. in contrast, another study done in egypt demonstrated there was a significant association between work experience and overall knowledge [11]. in developing countries like iraq, healthcare personnel, particularly nurses, are at the heart of the health system. most of the nurses in the current study illustrated a good understanding of cervical cancer screening and a positive attitude toward it. age was a significant factor associated with their knowledge. however, regular training in the form of a seminar or lecture for all healthcare providers or as part of the orientation program for newly hired nursing staff is suggested. this will provide a chance to raise women’s awareness of screening tests and their comfort and confidence in them. nurses routinely subjected to screening exams may act as other women's role models. none of the writers have any conflicts of interest or sources of financial support. 10 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conflict of interest [1] arbyn m, weiderpass e, bruni l,de sanjosé s ,saraiya m, ferlay j et al. estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. the lancet global health. 2020 feb 1; 8 (2):e191-203. [2] momenimovahed z, salehiniya h. incidence, mortality and risk factors of cervical cancer in the world. biomedical research and therapy. 2017 dec 8;4(12):1795-811. [3] misra m, tiwari v, tripathi p. awareness, attitude and practices regarding cervical cancer screening and vaccination among north indian women population. journal of biosciences and medicines. 2020 mar 5; 8 (03):73. [4] adegoke o, kulasingam s, virnig b. cervical cancer trends in the united states: a 35-year population-based analysis. journal of women's health. 2012 oct 1; 21(10):1031-7. [5] torre la, bray f, siegel rl, ferlay j, lortet‐ tieulent j, jemal a. global cancer statistics, 2012. ca: a cancer journal for clinicians. 2015 mar; 65(2):87-108. [6] torre la, islami f, siegel rl, ward em, jemal a. global cancer in women: burden and trends. cancer epidemiology and prevention biomarkers. 2017 apr 1; 26(4):444-57. [7] arbyn m, rebolj m ,dekok im, fender m, becker n , o’reilly m et al. the challenges of organising cervical screening programmes in the 15 old member states of the european union. european journal of cancer. 2009 oct 1; 45(15):2671-8. [8] majid, e., shaikh, m.a., qazi, o.a., khan, s., majeed, i. and bano, k., 2022. awareness, screening, practices and attitudes of cervical cancer among doctors and nursing staff working at a tertiary care center. journal of the pakistan medical association. [9] othman rt, abdul-jabbar r, saeed a, sadiq s, kittani hm, mohammed sa, rashid rm, hussein nr. cancer incidence rates in the kurdistan region/iraq from. asian pacific journal of cancer prevention. 2011; 12:12614. [10] rasul vh, cheraghi ma, moqadam zb. influencing factors on cervical cancer screening from the kurdish women’s perspective: a qualitative study. journal of medicine and life. 2015; 8(spec iss 2):47. [11] abdelraof am, anwar mm, el bahrawe rs. assessment of the knowledge toward cancercervix among nurse staff in health care https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.01 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 11 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. facilities in beni-suef city egypt. egyptian journal of medical research. 2020 jan 1; 1 (1):7-15. [12] rasul vh, cheraghi ma, moqadam zb. influencing factors on cervical cancer screening from the kurdish women’s perspective: a qualitative study. journal of medicine and life. 2015; 8(spec iss 2):47. [13] arulogun os, maxwell oo. perception and utilization of cervical cancer screening services among female nurses in university college hospital ibadan nigeria. pan african medical journal. 2012; 11(1). [14] ifemelumma cc, anikwe cc, okorochukwu bc, onu fa, obuna ja, ejikeme bn et al. cervical cancer screening: assessment of perception and utilization of services among health workers in low resource setting. international journal of reproductive medicine. 2019 feb 3;2019. [15] bint-e-iftikhar r, ahmed s, begum b. pap smear: a screening test for cervical cancer. journal of rawalpindi medical college. 2019 feb 18;23(s-1):53-5. [16] kosambiya rj, gohil a, kamdar zn, patel p, modi a. knowledge attitude and practices about cervical cancer and screening among nurses of a tertiary care centre in western india. national journal community medicine 2018;9(6):391-5. [17] singh e, seth s, rani v, srivastava dk. awareness of cervical cancer screening among nursing staff in a tertiary institution of rural india. journal of gynecologic oncology. 2012 jul 1;23(3):141-6. [18] ayub n, maqsud m, tahseen h, sharif m, waris n, rai af. knowledge and awareness of cervical cancer and screening practices among nurses at lahore general hospital pakistan. journal of pharmaceutical research international.2020 may(18)7-12 [19] shekhar s, sharma c, thakur s, raina n. cervical cancer screening: knowledge attitude and practices among nursing staff in a tertiary level teaching institution of rural india. asian pacific journal of cancer prevention. 2013;14(6):3641-5. [20] desaraju a, kodey pd. knowledge attitude and practices of cervical cancer screening in health care providers in a teaching hospital. journal of dr. ntr university of health sciences. 2021 jan 1;10(1):33. [21] mahajan sm, jadhay vs, magare ar, adchitre sa, salve sb. awareness and screening practices of cervical cancer among nursing . staff working in tertiary care hospital. international journal community med public health.2017 sep;4(10):3590-5 [22] getahun f,addissie a, negash s, gebremichael g. assessment of cervical cancer services and cervical cancer related knowledge of health service providers in public health facilities in addis ababa ethiopia. bmc research notes. 2019 dec;12(1):1-5. [23] heena h, durrani s, alfayyad i, riaz m,tabasim r , parvez g et al. knowledge attitudes and practices towards cervical cancer and screening amongst female healthcare professionals: a cross-sectional study. journal of oncology. 2019 oct 17;2019. [24] urasa m, darj e. knowledge of cervical cancer and screening practices of nurses at a regional hospital in tanzania. african health sciences. 2011;11(1). [25] sait kh. knowledge attitudes and practices regarding cervical cancer screening among physicians in the western region of saudi arabia. saudi medical journal. 2011 nov 1;32(11):1155-60. [26] devi ss, babu va, kumari da. nursing staff awareness of cervical cancer and pap smear screening in a remote medical college hospital in south india. international journal research health science. 2014 oct 31; 2:108590. [27] goyal a vaishnav g shrivastava a verma r modi a. knowledge attitude & practices about cervical cancer and screening among nursing staff in a teaching hospital. international journal medical science public health. 2013 apr 1;2(2):249-53. [28] awodele o, adeyomoye aa, awodele df, kwashi v, awodele io, dolapo dc.a study on cervical cancer screening amongst nurses in lagos universityteaching hospital lagos nigeria. journal of cancer education. 2011 sep;26(3):497-504. [29] siahpush m, singh gk. sociodemographic predictors of pap test receipt, currency and knowledge among australian women. preventive medicine. 2002 oct 1; 35(4):362-8. [30] sankaranarayanan r, rajkumar r, arrossi s, theresa r, esmy po, mahé c, muwonge r, parkin dm, cherian j. determinants of participation of women in a cervical cancer visual screening trial in rural south india. cancer detection and prevention. 2003 jan 1; 27 (6):457-65. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.01 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 12 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [31] philips z, johnson s, avis m,whynes dk. human papillomavirus and the value of screening: young women’s knowledge of cervical cancer. health education research. 2003 jun 1;18(3):318-28. [32] nganwai p, truadpon p,inpa c,sangpetngam b,mekjarasnapa m,apirakarnm et al. knowledge,attitudes and practices vis-a-vis cervical cancer among registered nurses at the faculty of medicine khon kaen university thailand. asian pacific journal cancer prevention. 2008 jan 1;9(1):15-8. [33] rahman h, kar s. knowledge, attitudes and practice toward cervical cancer screening among sikkimese nursing staff in india. indian journal of medical and paediatric oncology. 2015 apr;36(02):105-10. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.08 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article motivations of wearing face mask: a cross-sectional study abstract background and objectives: coronavirus disease 2019 (covid-19) is a respiratory illness caused by the sars-cov-2 coronavirus, which initially appeared in china in december 2019 and has since spread to most countries in the global. initial preventive recommendations called for the use of masks for protection against infection. to reduce covid-19 transmission in the community. the purpose of this study was to assess motivation factors for wearing surgical face masks and investigate reasons for not wearing face coverings, and gain insights from our study population about messaging strategies. methods: a cross-sectional descriptive study of 297 administrative staff of hawler medical university was conducted from february to october 2022. the data was gathered through direct interviews using a questionnaire that had been modified, include sociodemographic information and fifteen questions about the reason participants want to use face covering. the data were analyzed by statistical package for social science (spss version 25). chi-square and fisher's exact tests were used to determine the study's result. the p-value was considered significant at ≤ 0.05. results: the result revealed the highest percentage of the administrative staff was 34-46 years old (54.3%). most of the participants in this study were female (55.6 %). half of the participants demonstrated a high level of motivation (51.9 %). the highest level of motivation was related to "i want to protect people who are vulnerable (85.7%) and "i feel a responsibility to wear a facemask (81.9%) and wearing a facemask could prevent me from giving covid-19 to the family (80.9%). conclusion: the studied sample had a high motivational level for wearing a face mask; the desire to protect people who are vulnerable and the feeling of responsibility to wear a face mask and oneself are often the driving motivation for using face coverings. it is necessary to implement massive education campaigns at the level of hawler medical university for administrative staff to increase motivation toward using a facemask to stop the separation of viruses covid-19. keywords: motivation; facemasks; covid-19. burhan izzaddin sabir; department of nursing, college of nursing, hawler medical university, kurdistan regioniraq. (correspondence: burhan.sabir@hmu.edu.krd ). dara abdulla al-banna; department of nursing, faculty of nursing, tishk international university and hawler medical university, erbil, kurdistan region, iraq . 65 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 05/01/2023 accepted: 02/04/2023 published: 30/5/2023 mailto:burhan.sabir@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.08 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article coronavirus disease 2019 (covid-19) is a respiratory illness caused by the sars-cov2 coronavirus, which first appeared in china in december 2019 and has since spread to most countries around the world, resulted in a coronavirus pandemic in 20192020. the virus is primarily transmitted through respiratory droplets, released when an infected person coughs or sneezes or through touching contaminated surfaces or objects and then touching their mouth, nose, or eyes [1]. in wuhan, hubei province, china, the coronavirus (2019-ncov) was discovered for the first time [2]. the full clinical picture is still unknown, but the most commonly described symptoms are fever, cough, myalgia or tiredness, pneumonia, and complex dyspnea. sars-cov-2 nucleic acid is detected using real-time fluorescence (rt-pcr) [3]. covid-19 is the third emerging coronavirus to pose a global public health threat, following the severe acute respiratory syndrome coronavirus (sars-cov) in 2002 [4]. due to the similarity in covid-19 and previous coronaviruses, initial preventive recommendations called for the use of masks for protection against infection. social distancing and hand hygiene were initially implemented to reduce covid-19 transmission in the community [5]. on march 11, 2020, the world health organization (who) proclaimed the sarscov-2 coronavirus disease 2019 (covid19) outbreak to be a pandemic [6]. face masks quickly rose to the top of the pandemic's most recognizable symbols. the general agreement is that using a mask lowers the risk of contracting and transmitting the virus, protecting both the person wearing it and those nearby [7]. but how well masks function is largely dependent on human behavior. studies on the effectiveness of mask use make the assumption that people wear masks and do so correctly [8]. while older persons have a significantly higher mortality risk from disease complications than younger people, covid-19 offers varied intrinsic motives for mask wear for different age groups. therefore, it is possible that there would be a generational conflict in the reasons people follow the pandemic limitations, such as wearing masks. we, therefore, postulate that specific methods for conveying public health advice on mask use to the older and younger age groups are required [9]. the lack of evidence regarding the virus's mode of transmission at the beginning of the pandemic caused conflicting public health recommendations from health organizations and political leaders. for instance, the who initially held off on endorsing mask use, partly because of the dearth of data and partially out of concern for the depletion of supplies for frontline workers. the who even stated in march 2020 that wearing a mask when "not ill or caring for someone who is ill" would constitute "wasting a mask " [10]. understanding how to encourage people of various ages to wear masks in public is crucial, especially when doing so is up to them. people may choose to wear masks for either to protect themselves from contracting the illness (risk preferences) or to prevent spreading it to others. this study aims to investigate the driving forces of face coverings. this cross-sectional study was onducted between february to october 2022 among administrative staff at hawler medical university (colleges of medicine 67, dentistry 49, pharmacy 73, nursing 59, and health sciences 45) both genders (male and female) during the corona virus pandemic in erbil city, kurdistan region of iraq. the sample of the study was estimated according to the total number of 66 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.08 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article table 1 shows that the highest proportion of the study sample was between ages 34 to 46 years, followed by 31.4% in ages 21 to 33 years and female groups of gender (55.6%). the highest percentage of the current study samples graduated from universities (40.6%). the table shows the number of married in the study sample exceeds two third (67.9%). close to half (49.8%) of the study sample got covid-19, and 51.9% of the sample wore masks. administrative staff. among 1300 staff, 297 of them were selected as the study sample. the estimated sample size of the study was determined by using a sample size calculation formula known as power analysis with a 95% confidence interval (ci) and a 5% margin of error for the required sample size [11]. the tool and method of data collection include a questionnaire consisting of two parts. the first part includes the sociodemographic characteristics of respondents, including age, gender, educational level, marital status, and religion. the second part consisted of the statements to identify why participants want to use face covering (motivation). the data were collected through direct face-to-face interview techniques with the participants. after describing the contents of all parts of the questionnaire, the responses to the participants about motivational levels of wearing face mask items included two answers 0 = not motivated (no) and 1= motivated (yes). the calculation of the overall motivational levels of wearing face masks (15 items) was categorized into three groups highly motivated (1-5), moderately motivated (6-10), and low motivated (11-15). this study was submitted to the ethical committee at the college of nursing, hawler medical university, in order to get an approval letter for conducting it. then, getting the informal oral approval from each participant after clarification of the purpose of the study. the data were entered into the computer by using a statistical package for social science (spss version 25). the quantitative data were described by frequency and percentage. the inferential statistical analysis was assessed by using chi-square and fisher's exact tests. the p-value was considered significant at ≤ 0.05. 67 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium results table 1: socio demographic characteristics of the study sample sociodemographic characteristics (n=293) n. (%) age group (years) 21-33 92 (31.4) 34-46 159 (54.3) 47-59 42 (14.3) gender male 130 (44.4) female 163 (55.6) level of education basic 32 (10.9) secondary 51 (17.4) institute 65 (22.2) university 119 (40.6) higher education 26 (8.9) marital status single 94 (32.1) married 199 (67.9) religion muslim 272 (92.8) christian 18 (6.1) others 3 (1) had covid-19 definitely no 68 (23.2) not sure 79 (27) definitely yes 146 (49.8) face covering use (mask) never 29 (9.9) some of the time 152 (51.9) most of the time 112 (38.2) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.08 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article other responses included "i feel a responsibility to wear a face mask" at 81.9%, "wearing a face mask could prevent me from giving covid-19 to the family" at 80.9%, "will allow the school to open" at 74.4%, and "allow me to see family and friends" at 72%. of the sample is highly motivated for wearing masks. 68 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2 shows that 77.8% of the sample was widely motivated by using face masks to protect themselves and others from covid-19. 85.7% wanted to protect vulnerable people to wear facemasks. participants were motivated by a desire to exert control and typically agreed that covering one's face will protect the community from risk , with a 74.1% response rate. table 3 is concerning the motivation of the overall sample; the table shows that 51.9% table 2: motivations for face mask used by the study sample motivations for face mask use (n=293) correct incorrect n. (%) n. (%) i don't want to give covid-19 to anyone 228 (77.8) 65 (22.2) i want to protect people who are vulnerable 251 (85.7) 42 (14.3) wearing a face covering will prevent my community (e.g., members from my neighborhood, work, university, and church) from being at risk. 217 (74.1) 76 (25.9) i feel a responsibility to wear a face covering 240 (81.9) 53 (18.1) wearing a face covering could prevent me from giving covid-19 to my family 237 (80.9) 56 (19.1) wearing a face covering helps keep our hospitals from getting too full 210 (71.7) 83 (28.3) i want to follow the experts' advice. 194 (66.2) 99 (33.8) wearing a face covering could prevent me from getting covid-19. 191 (65.2) 102 (34.8) wearing a face covering is something i can control in an uncontrollable situation. 193 (65.9) 100 (34.1) wearing a face mask will allow the government to ease restrictions. 201 (68.6) 92 (31.4) wearing a face mask will allow schools to open. 211 (72) 82 (28) wearing a facemask allows me to see my friends and family. 218 (74.4) 75 (25.6) i would be embarrassed if people saw me not wearing a face covering. 102 (34.8) 191 (65.2) i am afraid of getting in trouble if i don't wear a face mask 146 (49.8) 147 (50.2) i feel pressure from friends and family 107 (36.5) 186 (63.5) table 3: overall motivational levels of wearing face masks motivational levels n. (%) high 152 (51.9) moderate 103 (35.1) low 38 (13) total 293 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.08 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 69 between the motivation level of wearing a face mask and the use of face masks, and significance with genders having high motivation (p-values of 0.001 and 0.009, respectively). copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4 illustrates the association between sociodemographic characteristics and the level of motivation for wearing a face mask. the result shows a very highly statistically significant association table 4: association between sociodemographic characteristics with motivation the level wearing a face mask sociodemographic characteristics motivational levels (n=293) p-value high moderate low n. (%) n. (%) n. (%) age group (years) 21-33 45 (48.9) 28 (30.4) 19 (20.7) 0.126 ns 34-46 85 (53.5) 59 (37.1) 15 (9.4) 47-59 22 (52.4) 16 (38.1) 4 (9.5) gender male 67 (51.5) 38 (29.2) 25 (19.2) 0.009 ns female 85 (52.1) 65 (39.9) 13 (8) level of education basic 14 (43.8) 14 (43.8) 4 (12.5) 0.286 ns secondary 28 (54.9) 14 (27.5) 9 (17.6) institute 34 (52.3) 22 (33.8) 9 (13.8) university 58 (48.7) 49 (41.2) 12 (10.1) higher education 18 (69.2) 4 (15.4) 4 (15.4) marital status single 44 (46.8) 34 (36.2) 16 (17) 0.290 ns married 108 (54.3) 69 (34.7) 22 (11.1) religion muslim 138 (50.7) 96 (35.3) 38 (14) 0.217 ns christian 11 (61.1) 7 (38.9) 0 (0) others 3 (100) 0 (0) 0 (0) had covid-19 definitely no 37 (54.4) 25 (36.8) 6 (8.8) 0.835 ns not sure 40 (50.6) 27 (34.2) 12 (15.2) definitely yes 75 (51.4) 51 (34.9) 20 (13.7) face covering use (mask) never 6 (20.7) 5 (17.2) 18 (62.1) < 0.001 vhs some of the time 73 (48) 65 (42.8) 14 (9.2) most of the time 73 (65.2) 33 (29.5) 6 (5.4) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.08 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 70 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. knowing when and why people are covering their faces is crucial because the covid -19 pandemic is still affecting all communities in the world. there are opportunities to increase compliance even among people who frequently cover their faces, especially in social settings. the result of the present study shows that more than half of the study sample occurred in middle age between 34-46 years old and were female. this finding agrees with study conducted by vereen et al., 2021 among 448 participants on motivation, barriers, and communication for promoting face covering during the covid-19 pandemic, in which more than half of the participants are females [12]. another study conducted by shelus et al. in 2020 about perceptions of wearing face masks among 34 focus groups showed 82% of them were female. [13]. regarding educational level, the present study shows that a considerable proportioof both genders had university degrees. this finding is consistent with previous research, which found that the majority of the study sample, 46% had a bachelor's degree [12]. in terms of the marital status of the study sample, the findings revealed that the highest percentage of the study sample was married. this finding is similar internet-based cross-sectional study conducted in 2022 by xu y. et al. on factors associated with protective mask-wearing behavior to avoid covid-19 infection in china, which included 10,304 survey respondents. over half of the study participants (n = 5302, 51.46%) were married. [26]. about half of the participants reported having had covid-19. this result contrasts with the result of a study done by vereen et al. in 2021, which reported among 448 participants, few (just 6%) reported having had covid-19 [12]. regarding motivational factors for facemask use, many participants were motivated by statements about discussion wearing face coverings because they don't want to give covid-19 to anyone majority of the study sample wearing the facemask to protect vulnerable people, wearing a face covering will prevent the community and some participants were motivated by statements that face coverings could prevent themselves from getting covid-19. this finding is similar to a previous study that reported that the most (77%) frequently endorsed motivations were, "i don't want to give covid-19 to anyone, and 76% wear a face covering to protect old people [12]. the current study's findings are consisten with a previous study on data on illness complications and mortality, which found that older people are more likely to fall into the covid-19 risk group. furthermore, the median cutoff for both the younger and older subgroups falls within the age range with a covid-19 death rate of 1% or higher [10]. the prominence of risk as the primary motivator for mask use can be due to significant agerelated changes. while reducing the risk of infection may serve as the primary reason for older individuals, who are more likely to develop significant symptoms. the results are consistent with earlier research suggesting that people may be more altruistic when faced with uncertainty [14] and with newer research showing links between the intention to cover one's face and the desire to protect one's community [15]. messages encouraging the safety of loved ones are therefore encouraged. most of the study participants like to follow the expert's advice regarding the importance of wearing facemasks. this result is supported by a previous study about the perception of face covering that reported the majority of participants expressed a desire to follow the rules of face covering based on health experts' recommendations and data supporting their efficacy [16]. about one-third of the participants in https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.08 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 71 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. this study responded that "wearing a face covering is something i can control in an uncontrollable situation" (65.9%). the face coverings were frequently worn out of a sense of duty or because it was thought to be morally correct. the choice to cover one's face must not be influenced by the actions of those around one; some people choose to cover their faces in an effort to "keep the peace" by adhering to social norms [16]. on the other hand, the least endorsed statement is that half of the participants feel pressure, get into trouble, feel embarrassed if one is observed without a facial covering. according to the supporting research, messages evoking emotions reduced the intention to cover one's face more than messages evoking reasoning. [17]. while the use of fear in health communication campaigns is supported by some literature [18]. according to our findings, it may not be appropriate to promote covid-19 prevention behaviors by using messages that incite fear or call for harsh punishment. social norms are a welldocumented prerequisite for both the intention to perform and subsequent participation in a behavior [19,20]. the present study shows association between gender and motivational level to wearing facemasks. this result disagrees with the study conducted by howard in 2021 regarding gender, face mask perceptions, and face mask wearing among 698 participants showed that gender did haven't relationship with face mask wearing [21]. both men and women are known to engage in comparable amounts of passive health behaviors, such as vaccination and presentism, but men are less likely to wear face masks than women. according to numerous authors of popular press in terms of risky active health behaviors, men are known to use drugs, drink alcohol, and smoke more than women [22]. while there is a non-significant relationship between educational level and motivational level, this finding contradicts a previous crosssectional study regarding knowledge, attitude, and practice of wearing a facemask in the population presenting to tertiary hospitals in a developing country, where a statistically significant relationship was noted between education levels and the practice of wearing a facemask (p = 0.01) [23]. many previous studies have clearly proven this concept [24,25]. according to the findings, there is a non-statistically significant relationship between marital status and motivation to wear face masks. this finding concurs with the findings of the study about factors associated with protective mask-wearing behavior to avoid covid-19, whereas the marital status of family members did not show a significant relationship with the wearing of the facemask [26]. understanding the motivations behind using ace masks by administrative staff members is essential for influencing health behavior and informing health communication. the participant in the study was very motivated to don a facemask. in our study sample, the desire to protect the weak and the feeling of responsibility to wear a face mask and provide protection for both oneself and others.at the level of hawler medical university, massive education campaigns must be launched to spread the word about the advantages of wearing a facemask to prevent the transmission of viruses. covid-19. the author reports no conflict of interest. conclusions conflict of interest https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.08 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 72 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. difference of susceptibility by age. scien tific reports. 2020 oct 6;10(1):16642. [11] ho, h. s. w. (2012). use of face masks in a primary care outpatient setting in hong kong: knowledge, attitudes and practices. public health, 126(12), 1001-1006. [12] vereen rn, lazard aj, frank sc, pulido m, richter ap, higgins ic, shelus vs, vandegrift sm, hall mg, ribisl km. motivations, barriers, and communication recommendations for promoting face coverings during the covid-19 pandemic: survey findings from a diverse sample. plos one. 2021 may 7;16(5):e0251169. [13] shelus vs, frank sc, lazard aj, higgins ic, pulido m, richter ap, vandegrift sm, vereen rn, ribisl km, hall mg. motivations and barriers for the use of face coverings during the covid-19 pandemic: messaging insights from focus groups. international journal of environmental research and public health. 2020 dec;17(24):9298. [14] kappes a, nussberger am, faber ns, kahane g, savulescu j, crockett mj. uncertainty about the impact of social decisions increases prosocial behaviour. nature human behaviour. 2018 aug;2(8):573-80.. [15] capraro v, barcelo h. the effect of messaging and gender on intentions to wear a face covering to slow down covid-19 transmission. arxiv preprint arxiv:2005.05467. 2020 may 11. [16] fisher ka, barile jp, guerin rj, esschert kl, jeffers a, tian lh, garcia-williams a, gurbaxani b, thompson ww, prue ce. factors associated with cloth face covering use among adults during the covid-19 pandemic—united states, april and may 2020.. [17] capraro v, barcelo h. telling people to "rely on their reasoning" increases intentions to wear a face covering to slow down covid‐19 transmission. applied cognitive psychology. 2021 may;35(3):693-9. [18] simpson, j.k., 2017. appeal to fear in health care: appropriate or inappropriate?. chiropractic & manual therapies, 25 (1), pp.1-10. [19] mceachan r, taylor n, harrison r, lawton r, gardner p, conner m. meta-analysis of the reasoned action approach (raa) to understanding health behaviors. annals of behavioral medicine. 2016 aug 1;50(4):592 -612. [1] sohrabi c, alsafi z, o'neill n, khan m, kerwan a, al-jabir a, iosifidis c, agha r. world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19). international journal of surgery. 2020 apr 1;76:71-6. [2] feng s, shen c, xia n, song w, fan m, cowling bj. rational use of face masks in the covid-19 pandemic. the lancet respiratory medicine. 2020 may 1;8(5):434-6. [3] who statement regarding cluster of pneumonia cases in wuhan, china. access date: [april 27 2020]. available at: https:// www.who.int/china/news/detail/09-012020. [4] mersha a, shibiru s, girma m, ayele g, bante a, kassa m, abebe s, shewangizaw m. perceived barriers to the practice of preventive measures for covid-19 pandemic among health professionals in public health facilities of the gamo zone, southern ethiopia: a phenomenological study. bmc public health. 2021 dec;21:1-0. [5] munster vj, koopmans m, van doremalen n, van riel d, de wit e. a novel coronavirus emerging in china—key questions for impact assessment. new england journal of medicine. 2020 feb 20;382(8):692-4. [6] al naam ya, elsafi sh, alkharraz zs, alfahad oa, al-jubran km, al zahrani em. community practice of using face masks for the prevention of covid-19 in saudi arabia. plos one. 2021 feb 19;16(2):e0247313. [7] mahase e. covid-19: who declares pandemic because of "alarming levels" of spread, severity, and inaction. bmj. 2020 mar 12;368 (march):m1036. https://doi.org/10.1136/ bmj.m1036. [8] asri a, asri v, renerte b, föllmi-heusi f, leuppi jd, muser j, nüesch r, schuler d, fischbacher u. wearing a mask—for yourself or for others? behavioral correlates of mask wearing among covid-19 frontline workers. plos one. 2021 jul 19;16 (7):e0253621. [9] betsch c, wieler lh, habersaat k. monitoring behavioural insights related to covid-19. the lancet. 2020 apr 18;395(10232):1255-6. https://doi.org/10.1016/s0140-6736(20) 30729-7 . [10] omori r, matsuyama r, nakata y. the age distribution of mortality from novel coronavirus disease (covid-19) suggests no large references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.08 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 73 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [20] sheeran p, maki a, montanaro e, avishaiyitshak a, bryan a, klein wm, miles e, rothman aj. the impact of changing attitudes, norms, and self-efficacy on health-related intentions and behavior: a meta-analysis. health psychology. 2016 nov;35(11):1178. https://doi.org/10.1037/hea0000387. [21] howard mc. gender, face mask perceptions, and face mask wearing: are men being dangerous during the covid-19 pandemic?. personality and individual differences. 2021 february 15;170:110417. [22] haischer mh, beilfuss r, hart mr, opielinski l, wrucke d, zirgaitis g, uhrich td, hunter sk. who is wearing a mask? gender-, age-, and location-related differences during the covid-19 pandemic. plos one. 2020 oct 15;15(10):e0240785. [23] furnaz s, baig n, ali s, rizwan s, khawaja ua, usman ma, haque mt, rizwan a, ali f, karim m. knowledge, attitude and practice of wearing mask in the population presenting to tertiary hospitals in a developing country. plos one. 2022 mar 10;17 (3):e0265328. [24] hayat k, rosenthal m, xu s, arshed m, li p, zhai p, desalegn gk, fang y. view of pakistani residents toward coronavirus disease (covid-19) during a rapid outbreak: a rapid online survey. international journal of environmental research and public health. 2020 may;17(10):3347. [25] iqbal ma, younas mz. public knowledge, attitudes, and practices towards covid-19 in pakistan: a cross-sectional study. children and youth services review. 2021 jan 1;120:105784. [26] xu y, wu q, xu s, zhao y, zhang x. factors associated with protective mask-wearing behavior to avoid covid-19 infection in china: internet-based cross-sectional study. journal of medical internet research, public health and surveillance. 2022 may 26;8 (5):e32278. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.02 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article nursing staff practices regarding infection control measures at raparin teaching hospital for children in erbil city abstract introduction infection prevention and control (ipc) implies the policies, strategies, procedures, decisions, and activities applied to decrease or limit the spread of infections [1]. nosocomial infection (ni) also known as a healthcare-associated infection is one of the primary reasons of mortality and has great financial cost due to raised hospitalization and prognosis [2, 3]. since nis are serious problems, they should be prevented and controlled [4]. it has been demonstrated in the literature that these . background and objectives: nosocomial infection is one of the main reasons of mortality and has significant financial costs due to elevated hospitalization and prognosis; thus, they should be prevented and controlled. this study aimed to assess the practice of the nursing staff regarding infection control measures at raparin teaching hospital for children. methods: a descriptive study was conducted in raparin teaching hospital for children in erbil city, kurdistan region/iraq. a purposive sample involving 81 nurses working in emergency, icu, nicu, and surgical units at raparin teaching hospital for children who care for children was selected for the study. the researcher developed a checklist format developed by the researcher for data collection that included three parts: sociodemographic characteristics, vaccination history, and nurses’ practice regarding infection control measures. the data were processed and analyzed using statistical package for the social sciences (spss), version 26. results: most (77.8%) of the nurses were living in urban areas and they showed fair performance (81%). the results showed that 45.5% of icu nurses outperformed their counterparts in terms of performance. the results also revealed that the younger nurses were better in terms of performance. furthermore, the results revealed that 75.3% of the nurses have fair performance, 17.3% have good performance, and 7.4% have poor performance. conclusion: based on the overall performance of the nurses, most of the nurses have fair infection control practices, and the minority of them have poor practices. younger nurses showed better performance in comparison to others. keywords: infection control; children; nurses; practice. ramyar mutalib kalhury; department of nursing, college of nursing, hawler medical university, erbil, iraq . (correspondence: ramyar_kalhury@yahoo.co.uk). norhan zeki shaker; department of nursing, college of nursing, hawler medical university, erbil, iraq. 13 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 07/08/2022 accepted: 06/09/2022 published: 30/5/2023 mailto:(correspondence:%20ramyar_kalhury@yahoo.co.uk%20%20) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.02 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article infections substantially influence patient safety the many unfavorable results include raised hospital admissions days, increased healthcare expenditures, economic hardship for patients and their families, and sometimes even deaths [5, 6]. however, infections in any healthcare facility can be avoided if they are appropriately treated or when infection prevention and control measures are implemented [7]. as reported in a study, nurses play significant role in preventing and controlling infections. some effective ipc procedures that a nurse can employ to prevent the spread of infection include hand hygiene, sterilization, and putting on personal protective equipment, such as gloves, gowns, facemasks, and head caps [3]. since the caregivers and nurses are one of the major personnel who can lead to the spread of infections, solid knowledge of ipc theory and practice is essential for all healthcare providers and nurses to meet professional as well as governing regulations and protect themselves and their patients from preventable infections [4].the risk of healthcare-associated infection is two to about twenty times higher in developing countries than in developed countries, with five percent to ten percent of patients admitted to hospitals in developed countries emerging these diseases [8]. children in pediatric services and pediatric intensive care units, are more likely to contract nis [9-11]. extended stays in the hospital, invasive procedures, congenital abnormalities, and total parenteral nutrition are all variables that raise the risk of nis in children. nis prevention and related mortality rate minimization in pediatric patients require an understanding of the risk factors that cause healthcare-associated infections [9, 12, 13].understanding the nature of the interaction between organisms and the human host in hospital settings offers justification for control strategies to prevent transmission and minimize the occurrence of hospital-acquired infections [14]. hand cleanliness, including hand washing, antisepsis, disinfection, antiseptic wash, or antiseptic massage, is an important factor in preventing infection transmission [15].gonzalez and goldfarb conducted a pediatric study of 149 children who received a living donor liver transplant. they discovered that bloodstream infection had developed in 21% of the patients within the first 30 days [11]. kassim and colleagues conducted a cross-sectional study using an online survey sent to other medical staff in nineveh to assess the adherence of healthcare professionals and nurses to ipc measures in iraq. healthcare professionals and nurses in iraq have supposedly adhered to ipc measures [16]. however, the results showed that the percentage of healthcare providers and physicians following various ipc measures was ranged from 31% (wearing personal protective equipment) to 97% (washing and cleaning hands constantly). recently, daulay and co -workers conducted a study to examine the impact of infection control and prevention management on the compliance of nurses in adopting hand hygiene in rantauprapat hospital’s in-patient rooms [17]. the results revealed a relationship between infection control and prevention management and nurses’ compliance in adopting hand hygiene in rantauprapat hospital’s in-patient rooms. mainly speaking, infectious diseases remain a significant cause of illness and death in iraq, according to information from the centre of communicable disease control in the ministry of health (moh) [18]. there is no published study about the practice of infection control by nurses in children’s hospitals in erbil city; thus, it is an excellent opportunity to conduct a study concerning this topic. the main objectives of the study are to identify the association between the 14 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.02 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article does not perform all the practices, he or she obtains 29 scores. based on this, the calculation of the overall nurses’ practice regarding infection control measures was categorized into three groups: poor performance (29-38), fair performance (39-48), and good performance (49-58).the data were analyzed by using statistical package for the social sciences (spss), version 26, for calculating descriptive statistical analysis: frequency and percentage. inferential statistical analysis (chi-square and fisher’s exact tests) was used to determine the association between variables. the p-value is considered statistically significant if it is ≤ 0.05 which rejects the null hypothesis. table 1 demonstrates the distribution of the eighty-one participating nurses based on their socio-demographic characteristics and professional background. based on their age group, 58.0% of the nurses were aged between 28 and 35, and only six of the participants were between 52 59 years of age. more than half (55.6%) of the nurses were male, 81.5% were married, 77.8% resided in urban areas, and 55.6%) belonged to the medium class. a little less than half (48.1%) of the nurses were working in the emergency unit, 23.5% in nicu, 13.6% in icu, and 14.8% in the surgical unit. considering education level, slightly more than half (51.9%) of the nurses were institute graduates, and 32.1% were college graduates. more than half of the nurses (53.1%) had 1-10 years of experience and 27.2% had 11-20 years of experience. among the total number of participating nurses, only 3.7% of them had attended training regarding infection control. hand washing, personal protective equipment (ppe), environmental control, needles and other sharps, and bloodstream infection were the five domains of infection control practice that were observed in nurses. professional characteristics of the participating nurses and their practice towards infection control at raparin teaching hospital for children and to find out the association between nurses’ ic practice and some variables. this cross-sectional study was conducted in the emergency, nicu, icu, and surgical units in raparin teaching hospital for children in erbil city kurdistan region/iraq. the population of the study was nurses caring for children. a non-probability purposive sample was selected for this study, which involves all the nurses who agreed to participate, working at raparin teaching hospital for children in erbil city kurdistan region. the study was carried out from 1st september 2021 to 1st july 2022. a direct observation method checklist, which 11 experts validate, was designed for data collection. the checklist included three parts: i) socio-demographic data and professional background variables, ii) vaccination history, and iii) nurses’ practice throughout infection control measures. reliability was conducted by cronbach correlation (r = 0.8). informed consent for participation was obtained from all 81 participants working at raparin teaching hospital for children in erbil. observation checklist of nurses’ practice regarding infection control at emergency, nicu, icu, and surgical units involved five domains: hand washing (4 items), personal protective equipment (8 items), environmental control (3 items), needles, and other sharps (6 items) and bloodstream infection (8 items). each item in the observation was measured and scored on three rounds, and each round was scaled with done and not done; (1) is given for not done and (2) is given for done. if a nurse performs all the practices, he or she receives 58 scores, and if a nurse 15 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods results https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.02 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 16 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: distribution of nurses according to their socio-demographic characteristics and professional background (n=81). variables—socio-demographic f.(%) age group 28 35 47 (58) 36 43 15 (18.5) 44 51 13(16) 52 59 6(7.5) gender male 45(55.6) female 36(44.4) marital status married 66(81.5) single 14(17.3) divorced 1(1.2) address urban 63(77.8) suburban 14(17.3) rural 4(4.9) economic status lower class 14(17.3) medium class 45(55.5) high class 22(27.2) professional background place of work emergency 39(48.1) ncu 19(23.5) icu 11(13.6) surgical units 12(14.8) education level nursing school 13(16) institute 42(51.9) college 26(32.1) years of experience 110 43(53.1) 11-20 22(27.2) 21 -30 11(13.5) 3140 5(6.2) attending training about ic yes 3(3.7) no 78(96.3) duration of course 1-3 days 1(33.4) 46 days 1(33.3) 7-9 days 1(33.3) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.02 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 17 26% applied environmental control measures, 72% disposed of needles and other sharps following appropriate guidelines, and 81% performed bloodstream infection control measures. participants, fifteen nurses aged between 36 and 43, corresponding to 18.5 %, thirteen nurses aged between 44 and 51, corresponding to16.0 % of the total number of participants, and only six of the participants were between 52 59 years of their age. copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2 displays the nurses’ overall effectiveness practicing and implementing infection control measures. according to the findings, 44% of the nurses practiced hand washing, 27% used personal protective equipment, table 3 shows the association between several studied variables and nurses’ infection control practice. the results showed that forty-seven of the nurses were aged between 28 35, corresponding to 58.0 % of the total number of table 2: overall nurses’ practices distributed in five domains of infection control measures (81 nurses). table 3: associations between nurses’ infection control practices and the studied variables. no. items of infection control measures done not done f.(%) f.(%) 1 hand washing 36(44) 45(56) 2 personal protective equipment (ppe) 22(27) 59(73) 3 environmental control 21(26) 60(74) 4 needles and other sharps disposal 58(72) 23(28) 5 bloodstream infection 65(81) 16(19) variables levels of practices poor fair good p-value f.(%) f.(%) f.(%) age group 28 – 35 1(2.1) 35(74.5) 11 (23.4) 0.016 s 36 – 44 1(6.7) 12(80) 2(13.3) 44 – 51 4(30.8) 8(61.5) 1(7.7) 52 – 59 0(0) 6(100) 0(0) residence urban 6(9.5) 51(81) 6(9.5) 0.012 s suburban 0(0) 8(57.1) 6(42.9) rural 0(0) 2(50) 2(50) place of work emergency 2(5.1) 32(82.1) 5(12.8) 0.038 s ncu 1(5.3) 15(78.9) 3(15.8) icu 0(0) 6(54.5) 5(45.5) surgical unit 3(25) 8(66.7) 1(8.3) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.02 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 18 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion figure 1 shows the breakdown of nurses’ vaccination history. the results showed that 98.8% of the nurses had been vaccinated against bacilli calmette-guerin (bcg vaccine for tuberculosis disease), 64.2% had been vaccinated against hepatitis-b (hbs vaccine), and 75.3% had received one or two doses of the covid-19 vaccine. the overall performance of the 81 nurses at raparin teaching hospital for children who participated in the study regarding infection control practices is shown in figure 2. the results revealed that 7.4% of the nurses have poor performance, 75.3% have fair performance, and 17.3% have good performance. figure. 1: distribution of nurses according to their prevention measures of vaccination history (n=81). figure 2: distribution of nurses according to levels of infection control measures (n=81). regarding the socio-demographic characteristics of the nurses, less than 10% of the nurses who participated in our study aged 52 years or older, and about three-fifths are between the ages of 28 35. this agrees with the results of the studies by hussin and idaned [19] and al-kerity and naji [20], in which the percentage of nurses who were 50 years or older were 4% and 12.9%, respectively. another research done by zenbaba et al. found that 51.27% of participants were male and 48.73% were female, which agrees with the participants’ gender distribution in this study [21]. in the current study, fewer than 5% of participants were single, slightly more than 45% were married, and a small fraction were divorced nurses. this agrees with the results of the study by kassim et al., in which 24%, 75%, and 1% of participants were single, married, and divorced/widowed, respectively. most of the nurses living in urban areas showed fair performance (81%) [16]. accounting for economic status of the participated nurses, the results of the current study revealed that 17.3% of the nurses were from low economic level. this result agrees with the result obtained by salh and turki where 11.8% of the nurses had an insufficient monthly income [22].the professional background results showed that one-third of the nurses in current research had a college degree, which agrees with another study’s findings of 26% [23]. the percentage of participants who are graduates of an institute is likewise in agreement: slightly more than half of the participants in the current study and 56% of the participants in rounak's study are graduates of an institute. in terms of the number of years of experience the nurses had, more than half of the nurses who took part in the study https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.02 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article such materials [25].concerning the overall performance, less than a fifth of the nurses demonstrated good performance when it came to using the infection control measures. perhaps it is because they do not have sufficient knowledge of the infection control measures or they do not pay attention to practice these measures. however, just over three-quarters demonstrated fair performance. the findings of aljohani and sulaiman supported our findings which revealed that 58.5% of participants demonstrated an adequate overall level of practice pertaining to standard precautions of infection control [26], as well as those of fashafsheh et al., which found that 91.1% of the studied sample performed well when practicing infection control measures [8]. the study by shrestha and thapa indicated that more than half of the nurses had poor performance overall, whereas only 7.4% of the nurses who participated in the current study had poor performance overall regarding infection control procedures [27]. around quarter of the nurses who took part in the study employed environmental control techniques, and many of them followed bloodstream infection control guidelines. it can be concluded that the overall performance of the 81 nurses who participated in the study regarding infection control practices was fair. it was also found that younger nurses performed better than elder nurses. had 1 10 years of experience. only a few nurses had taken part in infection control training, and this result is in disagreement with the result rounak obtained in her study where 18% of the nurses had taken a course on infection prevention and control methods [23].according to the present study, more than a quarter of the nurses had received an anti-hbs vaccination which agrees with the result obtained by hussin and idaned who evaluated the rate of needle stick and sharp object injuries among the iraqi nursing staff at kindy teaching hospital and found 36% of the nurses had received the hepatitis b vaccination [19]. according to bonanni et al., widespread use of the hepatitis b vaccine has decreased hepatitis b virus infection in medical professionals in italy from 48% to 18% over 10 years [24]. this percentage is considerable because hepatitis b is one of the sources of the spread of infectious diseases. according to the overall performance findings, 44% of the nurses generally practiced hand washing hygiene. since hand washing is one of the main methods for preventing the spread of infectious diseases, this percentage should to be higher. a little bit more than 25% of the participants used full personal protective equipment as require. on the other hand, in the study by zenbaba et al., 70.10% of the participants donned the required personal protective equipment [21]. a little more than a quarter of the nurses used environmental control strategies. the findings also showed that slightly fewer than threequarters of nurses appropriately disposed of needles and other sharps and followed bloodstream infection prevention procedures, respectively. the results in the current study showed that 28% of the nurses do not dispose of needles and other sharps which disagrees with the results acquired by thazha et al. where only 5.1% of the nurses disagreed to dispose of 19 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.02 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article springer, cham. [12] aktar f, tekin r, güneş a, ülgen c, tan i, ertuğrul s, et al. determining the independent risk factors and mortality rate of nosocomial infections in pediatric patients. biomed research international. 2016 feb. [13] li k, li x, si w, cui y, xia h, sun x, et al. preoperative and operation-related risk factors for postoperative nosocomial infections in pediatric patients: a retrospective cohort study. plos one. 2019 dec 23; 14 (12):e0225607. [14] lawal, w. u. & nwolisa, e. prevention and control of infectious diseases. in: jc azubuike, nkanginieme; paediatric and child health in a tropical region. educational printing and publishing (publishers). surulere, lagos. 3rd edition. 2016. isbn: 97881906735-01. page 494-543. [15] gravel d, gardam m, taylor g, miller m, simor a, mcgeer a, et al. canadian nosocomial infection surveillance program. infection control practices related to clostridium difficile infection in acute care hospitals in canada. american journal of infection control. 2009 feb 1; 37(1):9-14. [16] kassim za, al-mulaabed sw, younis sw, abutiheen aa. infection prevention and control measures for covid-19 among medical staff in nineveh governorate, iraq. journal of contemporary medical sciences| vol. 2020 jul; 6(4):150-155. [17] daulay fc, sudiro s, amirah a. management analysis of infection prevention: nurses’ compliance in implementing hand hygiene in the inventories of rantauprapat hospital. journal of scientific research in medical and biological sciences. 2021 feb 28; 2(1):42-49. [18] alwan ad. health in iraq: the current situation, our vision for the future and areas of work. baghdad: ministry of health. 2004 dec 2. [19] hussin bk, idaned zk. incidence of needle stick and sharp items injuries among nurses at al-kindy teaching hospital. pakistan journal of medical & health sciences. 2022 jun 1; 16(04):961-963. [20] al-kerity sh, naji ab. evaluation of healthcare workers' practices concerning infection control measures at primary health care centers. scientific journal of medical research. 2017; 1(2):63-68. [21] zenbaba d, sahiledengle b, bogale d. practices of healthcare workers regarding [1] world health organization. infection prevention and control: guidance to action tools. world health organization. regional office for europe. 2021. available from: https://apps.who.int/iris/ handle/10665/341107. [accessed 23rd oct 2021]. [2] buowari oy. universal precautions: a review. nigerian health journal. 2012; 12 (3):68-74. [3] chisanga cp. knowledge, attitudes and practices of nurses in infection prevention and control within a tertiary hospital in zambia (master’s thesis, stellenbosch: stellenbosch university). 2017. [4] wynn mo. understanding the principles of infection prevention and control. nursing standard. 2021 apr 26; 36(5):61-66. [5] klevens rm, edwards jr, richards jr cl, horan tc, gaynes rp, pollock da, et al. estimating health care-associated infections and deaths in us hospitals, 2002. public health reports. 2007 mar; 122 (2):160-166. [6] kaye ks, anderson dj, sloane r, chen lf, choi y, link k, et al. the effect of surgical site infection on older operative patients. journal of the american geriatrics society. 2009 jan; 57(1):46-54. [7] cavalcante ss, mota e, silva lr, teixeira lf, cavalcante lb. risk factors for developing nosocomial infections among pediatric patients. the pediatric infectious disease journal. 2006 may 1; 25(5):438-445. [8] fashafsheh i, ayed a, eqtait f, harazneh l. knowledge and practice of nursing staff towards infection control measures in the palestinian hospitals. journal of education and practice. 2015;6(4):79-90. [9] moore dl. essentials of paediatric infection control. paediatrics and child health. 2001 oct 1; 6(8):571-579. [10] alemayehu t, tadesse e, ayalew s, nigussie b, yeshitila b, amsalu a, et al. high burden of nosocomial infections caused by multi-drug resistant pathogens in pediatric patients at hawassa university comprehensive specialized hospital. ethiopian medical journal. 2019:45-55. [11] gonzalez be, goldfarb j. nosocomial infections in pediatric solid organ transplantation. in healthcare-associated infections in children. 2019; (pp. 301-321). x 20 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.02 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article infection prevention in bale zone hospitals, southeast ethiopia. advances in public health. 2020 oct; 1-7. [22] salh n, turki s. assessment of causes of wounds infection (wi) after caesarean section at al-batol teaching hospital in iraq. kufa journal for nursing sciences. 2022 jun 14; 12(1). [23] rounak, n. a. (2005). assessment of infection control process at hemodialysis and peritoneal dialysis units in kurdistan region (master’s thesis, university of hawler, college of nursing). [24] bonanni p, pesavento g, bechini a, tiscione e, mannelli f, benucci c, et al. impact of universal vaccination programmes on the epidemiology of hepatitis b: 10 years of experience in italy. vaccine. 2003 jan 30; 21(7-8):685-691. [25] thazha sk, cruz jp, alquwez n, scaria b, rengan ss, almazan ju. infection prevention and control awareness, attitudes, and practices among healthcare professionals in south india. the journal of infection in developing countries. 2022 apr 30;16 (04):659-67. [26] aljohani hs, sulaiman aa. assessment of health care workers’ knowledge and practice toward infection standard precautions in primary health care setting, buraidah, saudi arabia. middle east journal of family medicine. 2021 aug 1; 7(10):81. [27] shrestha gn, thapa b. knowledge and practice on infection prevention among nurses of bir hospital, kathmandu. journal of nepal health research council. 2018 nov 2; 16(3):330-335. 21 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article impact of self-efficacy intervention program on caregivers adherence toward home-based care children with type i diabetes mellitus abstract background and aims: diabetes is a metabolic disorder associated with many complications; caregivers’ self-efficacy is essential for sustained home management. the study aimed to find out the effects of nursing intervention programs on caregivers’ selfefficacy regarding adhering to home-based management of child to type1 diabetes mellitus. methods: a quasi‐experimental study design on home-based nursing intervention was conducted and recruited 60 caregivers who took homecare for their diabetes type 1. the systematic sampling method was used to select the participants who were divided into two groups (30 in an intervention group and 30 in a control group) and who were registered at the gulan general hospital in akre / duhok city of iraqi kurdistan region. verbal consent was obtained. starting from 3rd of january to the end of 5th september 2022.the home-based lesions were adopted for 5 months, mann-whitney u test, and ttest ware used to identify the comparison between the variables. a p-value of ≤ 0.05, considered statistically significant. results: there is no significant association between the control and study groups at the pretest before conducting the intervention program, while after conducting a homebased program for the intervention group, the results show that there was a highly significant difference between the pre and post test, the result reflects and successful program to change the self-efficacy of the caregivers from intervention, and it means a provided compared with the control group ( non-intervention group), at a p-value of ≤ 0.05. conclusion: the results show that the caregivers who participated in the program (intervention group), were successfully adapted to the self-efficacy program. applying the program to a wider range of caregivers, to adhere to the caregivers and improve their self -efficacy toward home-based management of type 1 diabetes mellitus. keywords: impact; self-efficacy; caregiver; home-based care; type 1 diabetes mellitus. shevan younis othman; department of nursing, akre technical institute, duhok polytechnic university, duhok, kurdistan region of iraq. (correspondence: shevan.osman@dpu.edu.krd) shukir saleem hasan; department of nursing, college of nursing, hawler medical university and tishk international university, erbil, kurdistan region, iraq. nadir abdullah garjees; department of pediatric, college of medicine, university of duhok, duhok, kurdistan region of iraq. 158 received: 03/05/2023 accepted: 19/07/2023 published: 30/11/2023 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:shevan.osman@dpu.edu.krd?subject=shevan.osman@dpu.edu.krd mailto:shevan.osman@dpu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article diabetes mellitus is the general name for a group of chronic metabolic diseases characterized by high blood glucose levels that result from defects in insulin secretion and/or action. the two main forms of diabetes are insulin-dependent diabetes mellitus (iddm) or type 1 diabetes and noninsulin-dependent or type 2 diabetes. type 2 diabetes is more commonly diagnosed in adulthood and is characterized by the body’s inability to use insulin properly. although type 1 diabetes can be diagnosed in adulthood, it usually develops and is diagnosed in childhood and adolescence [1]. currently, type 1 diabetes affects 1 in every 400 to 600 children, and more than 13,000 children are newly diagnosed each year [2]. the total population of iraq is over 32 million, a diabetes prevalence of 9.1% in 2011 [3]. in updating prevalence in this 2019, rate lowered to 8.8% (ages 20 to 79) [5]. and will be expected to reach 10.4% by 2030; in 2017 the number of diabetic cases in iraq was 1,411.5. the estimated national prevalence of t1dm increased from 7.8 per 100,000 children (aged under 15) in 1995 to 14.2 in 2000, and 24.7 in 2014 [5]. the average annual incidence rate of t1dm was 7.4 per 100,000, which takes place in the intermediate group [2]. the increase in rates of diabetes across the globe brings with it an increase in diabetes complications. poor diabetes management, whether through lack of education, limited access to care, or undiagnosed conditions, means diabetes complications are a real problem in most countries [5].due to the behaviors, abilities, and knowledge gaps that cause non-adherence to treatment and a considerable rise in long-term consequences, managing the condition effectively in children and adolescents has proven difficult [8]. it can cause major coping issues in children. [9]. the difficulties in educating children with diabetes about nutrition are frequently tied to their ages and reflect the differing nutritional and developmental needs ; they are shown to be influenced by family functioning and interactions during mealtimes [10].the aim of the study is to find out the effects of home-based nursing intervention programs on the self-efficacy of caregivers regarding based home care of children with t1dm. a quasi-experimental (pre/post) research design was utilized to accomplish the aim of this study. a home-based intervention program was carried out. sixty (60) patients were selected based on the simple random sampling methods, from the list of all patients, listed in gulan general hospital in akre dohuk governorate, kurdistan region, iraq, until the list of 60 caregivers was completed. the caregivers were split into two groups: one group of 30 caregivers who participated in the nursing intervention program was designated as the intervention group, and the other group of 30 caregivers was designated as a control group. the study's entire time frame spanned eight months, starting on january 3 and ending on september 5, 2022. the researcher collects the data, maintaining the privacy and anonymity of the information. the data collecting form was used without stating the participants' names, sensitive cultural considerations were considered, and approval was acquired; from the duhok university ethics committee at the college of nursing to perform the study. a non-probabilistic (purposive) sample of 60 (caregivers) was recruited for the study. patients and their caregivers for outpatient treatment and regular follow-up at the gulan general hospital in akre, the investigator, after obtaining consent to conduct home visits for each study sample, all caregivers. 159 methods copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article caregiver occupation, the result reveals that, majority (80.0% and 73.2% respectively) of caregivers were out of work in both control and intervention groups respectively. moreover, it shows that marriage is 90.0% in control groups and 93.4% in intervention groups, respectively. regarding residential areas, most of them are distributed to sub-urban (40.0%) in control groups; however, in intervention groups, most of them are in urban (43.4%%). most caregivers have one child with dmt1in both control and intervention groups (76.6% vs. 73.4%). concerning the caregiver's socioeconomic status, most of them are middle-class in control and intervention groups (50.0% vs. 33.4%) respectively (table 1).regarding the biographical information of the diabetes child patients the study found that the highest percentage (63.4% vs. 70.0% respectively) of the t1dm patients ages were between 9 and 12 years old in both the control and intervention groups and most of them were female (66.6% vs. 53.4%) respectively. concerning school attendance, the patients in the control group had the highest percentage of not attending school (56.6%) while in the intervention groups, most of them were not regular attendees (53.4%) and the lowest of them in both groups were regular attendees (0.0% and 10.0%) respectively. regarding the family history of diabetic disease, most (53.4% and 46.6%) respectively of children in both the control and intervention groups have a positive family history, such as (an uncle, grandfather, or one of the parents). regarding bmi the highest percentage (53.4%), in both groups were within acceptable weight (table 2). the researcher wrote down their phone number. the caregivers who have patients with t1dm, aged less than 13 years, who are interested in participating in the study, the patient is registered at gulan general hospital in akre city were included. then the investigators were obtained oral consent to allow the study group to visit home. home based visit was obtained for all the participants (intervention and control group), the health promotion model (hpm) was adapted for applying the education program “notes that each person has unique personal characteristics and experiences that affect subsequent actions“ was used as a guide for designing effective home care intervention programs, adhering to interventions, and removing barriers to delivering interventions. the researcher prepared the tools depending on the diabetes rating skills (dbrs) available at: https://scholarscompass.vcu.edu/etd/185). data were analyzed using the statistical program for social sciences (spss) version 25. the researcher used frequency and percentage to describe the demographic variables and distribution of the sample in each group. to compare the nursing intervention programs between the control and intervention groups (pre-test and posttests 1 and 2), mann-whitney u, and ttests were used;, a p-value of ≤0.05 is considered significant difference. the present study shows that most (46.6% %) of the caregivers were mothers in the control group and 40.0% in the intervention groups a respectively. regarding the caregiver's age in both groups, most (43.4% vs. 33.4%) were between 40 and 45 years old in both groups. regarding the caregiver’s level of education in the caregivers in control and intervention groups in the highest percentage had primary school degrees (56.6% vs. 63.4%). concerning the 160 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 161 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: socio-demographical characteristics of the caregiver socio-demographical characteristics control intervention no.( %) no.( %) the main caregiver mother 14(46.6) 12(40) father 13(43.4) 16(53.4) brother 3(10) 2(6.6) age of the caregiver/year above 45 8(26.6) 9(30) 40 to 45 13(43.4) 10(33.4) 35 to 39 8(26.6) 10(33.4) less than 35 1(3.4) 1(3.4) level of education illiterate 2(6.6) 0 can read and write 7(23.4) 7(23.4) primary school 17(56.6) 19(63.4) secondary school 2(13.2) 1(3.4) higher education 2(13.2) 3(20) caregiver occupation public employed 4(26.6) 6(40) unemployed 4(26.6) 2(13.2) out of work 12(80) 11(73.2) housewife 9(60) 8(26.6) retired 1(3.4) 3(10) marital status married 27(90) 28(93.4) single 3(10) 2(6.6) residential area urban 10(33.4) 13 rural 8(26.6) 10(33.4) sub-urban 12(40) 7(23. 4) no. of children with diabetic mellitus type1 in the family one patient 23(76.6) 22(73.47) more than one patient 7(23.4) 8(26.6) socio-economic status high 4(13.4) 3(10) middle 15(50) 10(33.4) low 11(36.6) 17(52.6) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 162 5 times per week most caregivers do not apply it their child (66.6%) in both groups, (52.6% vs 66.6%) of participate do not use anything for his child to prevent blood sugar level from dropping when exercising in the control and intervention groups. about (70% vs 40%) of participants do not know what to do when their child’s blood sugar levels goes higher or lower than it should be, most (36.6% vs 70%) of caregivers in both groups have not judged when the changes in his child’s illness mean should visit the doctor and about (66.6% vs 76.6%) of participants in the control and intervention groups. most caregivers do not control their child’s diabetes so that it does not interfere with the things they want to do (table 3). concerning the assessment of self-efficacy for diabetes scale of caregivers of intervention and control group pre-test the, majority (76.6%) vs (53.4%) of control groups the caregivers not applicable for their child about eating meals every 4 to 5 hours every day, including breakfast every day while of intervention strongly the caregivers disagree regarding his child eat meals every 4 to 5 hours every day, including breakfast every day about (53.4% vs 86.6%) of participate don’t obligated to prepare the diet for his child when must prepare or share food with other people who do not have diabetes in both groups (46.6% vs 76.6%) caregivers in both groups do not choose the appropriate food for a child to eat when are hungry (for example, snacks), regarding exercise 15 to 30 minutes 4 to copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: assessment of biographical information of the diabetes child patients (n= 60) diabetes patients demographical characteristics control group intervention group no.( %) no.( %) age/year less than 4 years 3(10) 0 4 to 8 years 8(26.6) 9(30) 9 to 12 years 19(63.4) 21(70) gender of patient male 10(33.4) 14(46.6) female 20(66.6) 16(53.4) school attendance regular 0 3(10) irregular 13(43.4) 16(53.4) no attendance 17(56.6) 11(36.6) family history for diabetic disease father 3(20) 3(20) mother 2(13.2) 2(13.2) others 16(53.4) 14(46.6) no history of diabetes in the family 6(20) 9(30) parents 3(10) 2(6.6) bmi underweight 5(16.6) 2(6.6) acceptable weight 16(53.4) 16(53.4) overweight 9(30) 12(40) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 163 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3. assessment of self-efficacy for diabetes scale of caregivers of intervention and control group (pre and post-test) (n= 30). case-control items control intervention strongly agree agree disagree strongly disagree n/a strongly agree agree disagree strongly disagree n/a 1 eat meals every 4 to 5 hours every day, including breakfast every day? 0 0 1 (3.4) 11 (36.6) 23 (76.6) 0 0 7 (23.4) 16 (53.4) 4 (13.4) 2 follow diet when you must prepare or share food with other people who do not have diabetes? 0 0 3 (10) 7 (23.4) 16 (53.4) 0 0 26 (86.6) 4 (13.4) 0 3 choose the appropriate food for your child to eat when you are hungry (for example, snacks)? 0 0 1 (3.4) 6 (20) 14 (46.6) 0 0 23 (76.6) 5 (16.6) 2 (6.6) 4 exercise 15 to 30 minutes, 4 to 5 times per week? 0 0 4 (13.4) 6 (20) 20 (66.6) 0 0 20 (66.6) 8 (26.6) 2 (6.6) 5 do something to prevent your blood sugar level from dropping when you exercise? 0 0 4 (13.4) 2 (6.6) 17 (52.6) 0 0 20 (66.6) 9 (30) 1 (3.4) 6 know what to do when your child’s blood sugar level goes higher or lower than it should be? 0 0 0 3 (10) 21 (70) 0 0 0 (0) 12 (40) 7 (23.4) 7 judge when the changes in your child’s illness mean you should visit the doctor? 3 (10) 0 2 (6.6) 5 (16.6) 11 (36.6) 0 0 21 (70) 6 (20) 3 (10) 8 control your child diabetes so that it does not interfere with the things you want to do? 0 0 2 (6.6) 1 (3.4) 20 (66.6) 0 0 23 (76.6) 6 (20) 1 (3.4) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article between the self-efficacy for diabetes scale of caregivers before conducting the program ( pre-test) at p-value 0.953 (table 4). two months of applying the intervention programs between pre and post2. but in control groups there are no-significant differences between pre and post-test 1&2 in the assessment of self-efficacy for the diabetes scale of caregivers (table 5). concerning comparing domains between the intervention and control groups before conducting the program ( pre-test), the study found non-significant differences in terms of comparison between selfefficacy for the diabetes scale of the caregiver’s domain, preand post-tests 1 and 2 show that there was a highly significant difference between the intervention group at p value < 0.001 and 0.008. however, there is a non-significant difference after 164 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4. compare of domains between intervention and control group before conduct the program (pre-test) ( n= 60 ) self-efficacy n mean sd p-value (mann-whitney u) assessment of self-efficacy for diabetes scale of caregivers control 30 2.088 0.986 0.953 (ns) intervention 30 2.033 0.512 table 5. compare between self-efficacy for diabetes scale of caregiver’s domain pre and post -test 1 and 2 ( n= 30) interventional groups pre-test and post-test 1 pre-test and post-test 2 selfefficacy for diabetes scale of caregivers mean sd t-test d.f. p-value mean std. deviation t-test d.f . pvalue 2.033 0.512 -32.311 29 < 0.001 2.033 0.512 -0.249 29 0.008 3.533 0.325 2.046 0.937 selfefficacy for diabetes scale of caregivers control groups pre-test and post-test 1 pre-test and post-test2 mean sd t-test d.f. p-value mean std. deviation t-test d.f . pvalue 1.183 0.249 < 0.001 29 1.000 1.183 0.249 < 0.001 29 1.000 1.183 0.249 1.1833 0.249 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article groups. according to marital status, the current result shows that most caregivers were married in control groups and intervention groups respectively. correspondingly a study was conducted in baghdad, found that almost all caregivers were out of work [14]. regarding the residential area, the study reveals that most of the samples were distributed into sub-urban control groups and urban intervention groups. these results are the opposite of a study by [15], who found that most of parents were lived in urban. concerning the number of children affected by dmt1 in the family, the result shows that most of the caregivers have one affected child with dmt1 in both the control and intervention groups. this result is in disagreement with a study conducted by keklik et al., (2020), who reported that 51.8% of the families had more than two affected children with t1dm. concerning the caregiver's socioeconomic status, the results who that most families lived in the middle of socioeconomic status (ses). our results were in agreement with the results of a study conducted in baghdad – iraq and who found that most participants lived in middle ses in this study conducted in baghdad [15]. concerning the biographical information of the patient’s current study it indicates that the highest percentage of the age of patients were 9 to 12 years old in both the control and intervention groups and most of them are female. the results of the current study were in agreement with a study conducted in addis ababa, ethiopia in 2021 in which it was found that 54.9% of age patient were about 5 to 12 years old and found 56.6% female [15] .concerning school attendance in the control group, the highest percentage is not attendance while, in the intervention groups, most of them are not regular attendance and the lowest of them in both groups regular attendance. the opposite result was also the findings of the present study show that most of the caregivers in the control groups were patients’ mothers, but in the intervention groups, they were fathers. a study confirmed that the18 caregivers who represented the study of children with t1dm, there were 12 of the participants were mothers’ children [11]. this may be attributed to the males' desire to participate in the program more than females. as they have sufficient and appropriate time to participate compared to females, on the other hand, the, social, culture, customs, and traditions of our society, do not allow strangers to visit him in her home and communicate with females. concerning the caregivers’ age group, the study reveals that the majority of participants were between 40 and 45 years old in the control and intervention groups, respectively. when compared with the results of [2], they found that most of the mothers’ age was over 41years old in both the control and intervention group . while this result is in contrast with a study which found that the age of the caregivers was between 36 to 40 years old, they added with respect to their level of education, the present study found that the highest percentage of caregivers were primary school graduates. in contrast with the current result a study reveals that forty-two percent of caregivers had a secondary school education, 21.9% had some form of higher education [13 &14]. a crosssectional study conducted in addis ababa, ethiopia, entitled health-related quality-of -life and associated factors among children and adolescents with type 1 diabetes mellitus: a cross-sectional study, found that the most of caregivers were private employees. this result is in contrast with our result which reflects that majority of the caregivers were out of work in both 165 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article intervention program, the present study found that there is a highly significant difference between pre and post-tests1&2 in the intervention group compared to the control group regarding self-efficacy for the diabetes scale of caregivers). this result is supported by a study that was conducted an intervention program on children with tidm, found that there were highly significant differences between pre and post-tests (1 and 2) regarding the selfefficacy for diabetes scale of caregivers in the intervention group, and they found there were non-significant differences between pre and post-tests (1 and 2) in control groups [21] , the majority of caregivers of children with type 1 diabetes mellitus improved their self-efficacy about the disease, and disease management performed by these caregivers is satisfactory in general after being exposed to nursing intervention programs. however, there is a need to intervene in some ways, changing attitudes to cope more adequately with the disease as well as improving the effectiveness of diabetes education. the authors would like to express their heartfelt gratitude to all the caregivers who participated in the study. this study has been approved by the ethical committee at duhok university, college of nursing. the authors declare that they have no conflict of interest. documented by alabedi, 2020, whose study found that most participation in regular school attendance is about (9.4% vs. 15%) in both groups. researcher's opinion that the family fears the complications, especially hypoglycaemia. regarding family history for diabetic disease, most of the children in both control and intervention groups have a family history. these findings agree with qadir & zangana, 2020, who concluded that most of the participants have a family history entitled the effect of swimming program on glycaemic control in male adolescents with type 1 diabetes mellitus).with regard to bmi the highest percentage in both groups is acceptable weight. some of them are overweight; this result is the same with [19]. he found that in children with diabetes type, about 29% were obese or overweight. regarding the assessment of the self-efficacy of the intervention and control group pre-test. in this study, the researcher found that most of the caregivers' answers were not applicable in both groups. these results are in agreement with a study conducted in egypt [20], which conducted a health educational program for dm caregivers and found before the intervention programs, the patients had poor self-efficacy. the same result was found in a result of a study which showed that patients with diabetes had poor self efficacy [21]. concerning the comparison of overall domains between the intervention and control groups before conducting the program (pre-test) the study indicates that there are no significant differences between all domains in intervention and control groups before intervention programs. the present results agree with the study by gürkan et al., 2019, who stated that no there was no significant differences in the diabetes behavior rating scale and self-efficacy domain in the control and intervention groups. after the nursing 166 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion acknowledgement ethical consideration conflict of interest https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article p.https://doi.org/10.1016/ j.cobme.2021.100312 [10] smart ce, annan f, higgins la, jelleryd e, lopez m, acerini cl. ispad clinical practice consensus guidelines 2018: nutritional management in children and adolescents with diabetes. pediatr diabetes. 2018;19 (june):136–54. https://doi.org/10.1016/ j.diabres.2017.09.001. [11] tong h-j, qiu f, fan l. parents’ experience of caring for children with type 1 diabetes in mainland china: a qualitative study. world journal of clinecal cases. 2021;9(11):2478. doi: 10.12998/wjcc.v9.i11.2478 [12] grover s, bhadada s, kate n, sarkar s, bhansali a, avasthi a, et al. coping and caregiving experience of parents of children and adolescents with type-1 diabetes: the journal of pediatrics an exploratory study. perspect clin res. 2016;7(1):32. doi: 10.4103/2229-3485.173776 . [13] kobos e, imiela j. factors affecting the level of burden of caregivers of children with type 1 diabetes. applied nursing research. 2015;28(2):142–9. https://doi.org/10.1016/ j.apnr.2014.09.008. [14] bekele bt, demie tg, worku f. healthrelated quality-of-life and associated factors among children and adolescents with type 1 diabetes mellitus: a cross-sectional study. pediatr heal med ther. 2022;243–56. doi: https://doi.org/10.5812/compreped-134561 [15] shukur sj, hussein wa, kadhum nl. quality of life of parents of children with type i diabetes mellitus, baghdad 2017. al-kindy college medical journal. 2021;17(2):107–14. doi: https://doi.org/10.47723/ kcmj.v17i2.536 [16] keklik d, bayat m, başdaş ö. care burden and quality of life in mothers of children with type 1 diabetes mellitus. future journal of pharmaceutical sciences. 2020;40(3):431– 5.https:// doi.org/10.1080/17482631.2018.1487758. [17] alabedi rf. comparative study between multiple daily injections and conventional insulin regimens in iraqi children and adolescents with type 1 diabetes mellitus. ann trop med & public health; 2020;23:218–31. https://doi.org/10.36295/ asro.2020.2312018 [18] qadir kj, zangana ko. effect of swimming program on glycemic control in male adolescents with type 1 diabetes mellitus. journal of sports medical and phys fitness. 2020;60 [1] chiang jl, maahs dm, garvey kc, hood kk, laffel lm, weinzimer sa, et al. type 1 diabetes in children and adolescents: a position statement by the american diabetes association. diabetes care. 2018;41(9):2026– 44. doi: 10.2337/dci18-0023. [2] anderson bj, laffel lm, domenger c, danne t, phillip m, mazza c, et al. factors associated with diabetes-specific health-related quality of life in youth with type 1 diabetes: the global teens study. diabetes care. 2017;40(8):1002–9.https://doi.org/10.2337/ dc16-1990. [3] zalzala sh, al-lami fh, fahad s. epidemiological profile of type 1 diabetes among primary school children in baghdad, iraq. journal of contemporary medical sciences. 2020;6(1):1–5. https://dx.doi.org/10.22317/ jcms.02202003. [4] carracher am, marathe ph, close kl. international diabetes federation 2017. journal of diabetic. wiley online library; 2018. https://doi.org/10.1111/1753-0407.12644. [5] kadhim dm, al-kaseer ea, al-zubaidi ma. glycemic control in children and adolescents with type 1 diabetes mellitus in post conflict iraq: a primary report. journal of the faculty of medicine baghdad. 2016;58(3):273–5. doi: 10.039406.2022.31-103. [6] almahfoodh d, alabbood m, alali a, mansour a. epidemiology of type 1 diabetes mellitus in basrah, southern iraq: indian journal of forensic medicine & toxicology,a retrospective study. diabetes res clin pract. 2017;133:104–8. https://doi.org/10.1016/ j.diabres.2017.09.001. [7] association ad. diagnosis and classification of diabetes mellitus. diabetes care. 2014;37 (supplement_1):s81–90.https:// doi.org/10.2337/dc14-s081 . [8] faludi aa, izar mc de o, saraiva jfk, bianco ht, chacra apm, bertoluci mc, et al. diretriz brasileira baseada em evidências sobre prevenção de doenças cardiovasculares em pacientes com diabetes: posicionamento da sociedade brasileira de diabetes (sbd), da sociedade brasileira de cardiologia (sbc) e da sociedade brasileira de endocrinol. arq bras cardiol. 2017;109(6):1–31. https:// doi.org/10.1111/jocn.15040. [9] cameron fj, garvey k, hood kk, acerini cl, codner e. ispad clinical practice consensus guidelines 2018: diabetes in adolescence. vol. 19, pediatric diabetes. 2018. 250–261 167 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.17 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article (2):302–7. doi: 10.23736/s00224707.19.10053-9 [19] sandhu ν, witmans mb, lemay j-f, crawford s, jadavji n, pacaud d. prevalence of overweight and obesity in children and adolescents with type 1 diabetes mellitus. journal of pediatr endocrinol metab. 2008;21 (7):631–40. https://doi.org/10.1515/ jpem.2008.21.7.631. [20] sabaq ag, bassam sea, said km. effect of transition care educational program on transitional readiness, self-efficacy and quality of life among adolescents with type 1 diabetes mellitus. tanta scientific nursing journal. 2022;24(1):74–103. doi. 10.21608/ tsnj.2022.221543 [21] yosefi z, afshar m, mirbagher ajorpaz n, sadat z. the effect of training based on james brown model on self-efficacy in adolescents with type 1 diabetes mellitus. journal of holistic nursing and midwifery. 2021;31(2):76–84. doi.org/10.32598/ jhnm.31.2.2048 [22] gürkan kp, bahar z, böber e. effects of a home‐based nursing intervention programme among adolescents with type 1 diabetes. journal clinical nursing. 2019;28 (23–24):4513–24. https://doi.org/10.1111/ jocn.15040 168 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.04 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article students’ attitude towards moodle learning management system as a teaching strategy in nursing educations abstract moodle is a free e-learning software platform designed to help instructors facilitate online courses that promote student participation and group work in the creation of course materials. there are many aspects of the moodle e-learning platform (mep) that make it useful for educational and learning purposes. self-directed learning (sdl) is a difficult goal for many professors teaching at the undergraduate level, but mep can help make it easier if utilized correctly [1].the moodle e-learning platform is an effective e-learning tool because it permits the instructor to switch things up in the classroom in ways that pique the students' attention and encourage them to take an active role in the learning process [2].moodle is a free and open-source online learning management system (lms). moodle is an example of an e-learning platform that may be utilized in the classroom. moodle allows students a lot of freedom to explore on their own, which in turn encourages them to study, background and objectives: moodle stand for modular object-oriented dynamic learning environment. it was created in australia by martin dougiamas. moodle is freely available as open-source software, and is flexible and easy to modify. the aim of this study was to evaluate attitude of nursing students towards using moodle as a learning management system in the nursing programs. methods: a cross-sectional descriptive study was conducted at the college of nursing in erbil city-kurdistan region-iraq. the study included 100 nursing and midwifery students. a non-probability-convenience sampling technique was used to enroll 100 nursing students by submitting a questionnaire to assess their perspectives about new teaching methods such as moodle in their learning process. results: the vast majority of the study sample was female and third-year stage students. most of the students were living in the urban area and mostly is unmarried. most of the students believed that moodle improved their academic performance in the teaching process at the college of nursing. conclusion: there was believed that moodle as a teaching strategy in nursing education programs has a pivotal role in attracting nursing students to learn. keywords: moodle; teaching strategy; student; nursing education. dlzar sedeeq anwer; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: dlzar.anwer@hmu.edu.krd) 28 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 03/09/2022 accepted: 15/01/2023 published: 30/5/2023 introduction mailto:dlzar.anwer@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.04 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article engage with one another, and build knowledge through collaborative efforts. integrating learning with moodle helps students reach their goals [3].students' ability to communicate and engage with others is enhanced when moodle is used in the classroom. there is no disputing the importance of learning management systems (lmss) to nursing education's faculty development and capacity building. in the event of a corona pandemic shutdown, working from home has shown to be highly useful [4].since not enough research had been done on moodle's efficacy as a nursing teaching method, this study was undertaken. a nurse educator's use of moodle as a teaching approach in nursing education is essential in the context of a university-level nursing program since it encourages students to take charge of their own education.using moodle platform at the college of nursing in hawler medical university is widely available for the nursing students as a synchronous and asynchronous methods. the students were taught by professional instructors about how to use moodle because this learning management system (moodle) was new teaching method for nursing students. during pandemic in 2020, the students and faculty were able to use the moodle as a distance learning instead of the classroom learning. it was an effective teaching strategy in the college of nursing during covid-19.the purpose of this research was to examine nursing and midwifery students' perspectives on utilizing moodle as an lms in the curriculum. it also evaluates moodle's usefulness as a teaching method for students. the cross-sectional descriptive design was conducted in this study. the setting of the study: the study was conducted at the college of nursing in hawler medical university. students in the stages 3 and 4 were included in this study. time of the study: the study was conducted from june 21 to july 26, 2022.sample size and sampling method: a non-probability-convenience sample (n=100) of students was used in this study since it was easier to collect data and catch samples. data collection: each question included a "agree" or "disagree" answer and a "don't know" alternative. a unique number was assigned to each form submitted by each student. there were two parts to the questionnaire. a maximum of thirty questions were allowed in the questionnaire, with twenty-six about students' feelings toward moodle and four requesting basic demographic information. in the first section, students' demographic details were gathered, including their gender, marital status, state of residence, and academic year. part two included student attitudes on moodle's usefulness as a teaching tool in nursing education based on their experiences. data analysis: information was analyzed with spss version 22 (statistical package for the social sciences). descriptive statistics like frequency and percentage were used to examine the data at first. there were three possible replies to the participant's experiences items: 'don't know,' 'agree,' and 'disagree. ethical consideration: participants in the study were made aware of the research's goals before they agreed to take part willingly. additionally, the respondents were assured that their responses would remain anonymous and be utilized just for academic investigation. the responders filled out the questionnaires and handed them in to the researcher. 29 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.04 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article them improve their academic performance.61% of students thought that using moodle was an interesting method to study, and 66% of students said that they thought utilizing moodle in a nursing school was a good concept to help them learn. more than half of respondents 53% found the moodle setup procedure to be simple and straightforward, and nearly as many 48% appreciated being able to access course materials from anywhere, not just on campus, thanks to moodle.60% of respondents confirmed that they received timely instructor feedback through moodle, and 43% of respondents said that moodle improved the ease with which they could complete course activities. as can be seen in table 1, 89% of the participants were female. the vast majority of the respondents 74%, were city residents. the majority of the students 60%, were at the third-stage level . table 2 shows that nearly half of the respondents 49%, think moodle is helpful for their education in a nursing program because of the good effects it has had on their learning. almost two-thirds of the respondents 65%, said they were comfortable navigating moodle. a majority of the attendees 40%, thought they knew enough about moodle after the course to get started. it was reported by 32 respondents 32%, that using moodle facilitated more fruitful two-way interactions between students and teachers. in addition, most people who used moodle were positive about it. 60% of the students have found using moodle to be a positive experience. overall, 55% of respondents believed that they could use moodle without being shown how it works, and 47% of those polled said that moodle had helped 30 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results table 1: socio-demographical of students socio-demographical characters frequency no. (%) gender female male 89(89) 11(11) residence rural urban 26(26) 74(74) marital status single married 91(91) 95(95) students’ stage third fourth 60(60) 40(40) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.04 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 31 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: students’ perspective about moodle as a teaching strategy no. questions agree no. (%) disagree no. (%) do not known no. (%) 1 moodle enables me to learn more effectively 47 (47) 39(39) 14(14) 2 moodle helps my academic achievement 44 (44) 41 (41) 15(15) 3 moodle improves the effectiveness of my learning 42(42) 46(46) 12(12) 4 moodle facilitates university learning 52(52) 31(31) 17(17) 5 moodle empowers me to direct my own learning 42(42) 40(40) 18(18) 6 overall, moodle is beneficial to my learning 49(49) 31(31) 20(20) 7 i have access to moodle's material 51(51) 31(31) 18(18) 8 this moodle site is completely accessible to me 38(38) 36(36) 26(26) 9 i can use moodle without being informed how it works 55(55) 31(31) 14(14) 10 i can troubleshoot moodle issues 36(36) 51(51) 13(13) 11 if there are user instructions available, i can utilize moodle 43(43) 37(37) 20(20) 12 overall, i can utilize moodle 65(65) 29(29) 6(6) 13 moodle is simple for me to learn 57(57) 32(32) 11(11) 14 moodle materials are simple to obtain 57(57) 27(27) 16(16) 15 the moodle process is simple and straightforward 53(53) 32(32) 15(15) 16 in general, i think moodle is quite user-friendly 54 (54) 36(36) 10(10) 17 moodle makes education enjoyable 43(43) 40(40) 17(17) 18 it is an excellent idea to use moodle 66(66) 24(24) 10(10) 19 moodle is an attractive learning platform 61(61) 24(24) 15(15) 20 overall, i enjoy working with moodle 38(38) 46(46) 16(16) 21 i feel confident enough to begin using moodle with the training i received. 40(40) 38(38) 22(22) 22 with moodle, i was able to access all of my college coursework even when i was not physically in class 48(48) 37(37) 15(15) 23 moodle makes it easier for me to complete my course activities 43(43) 41(41) 16(16) 24 moodle facilitated my communication with the instructor 32(32) 53(53) 15(15) 25 moodle helped me to communicate and collaborate with my classmates 28(28) 61(61) 11(11) 26 moodle helped me to get prompt feedback from the instructor 60(60) 28(28) 12(12) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.04 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 32 and these results are consistent with those of an egyptian study showing that undergraduate nursing students have a favorable attitude toward moodle's capacity to boost their interest in the course [10].current study results showed that moodle was used as a feedback platform, which is consistent with the findings of deliwe (2020), who claimed that moodle was implemented for many reasons, one of which was as an interim student feedback system, a platform for student feedback [11].the present study indicated that 54% of the students thought that moodle is quite user-friendly, and this result is consistent with a study conducted in palestine it mentioned that their faculty members 73.5% believed that moodle offers flexibility [12].a study has been conducted in china, it showed that the students had very positive attitudes towards moodle. most of them acknowledged that moodle helped them to learn medical statistics to a large extent. the study matches with the present study which identify that moodle makes it easier for students 43% to complete their course activities [13]. most of the nursing and midwifery students believed that moodle as a teaching strategy in nursing education programs has an important role in improving students’ academic performance. in contrast, some of the students blamed their lack of communication with instructors when they used moodle in the nursing program. it is important for nursing college to improve this weakness, such as communication with the students. limitations of the study and recommendations. the current study's most obvious drawback and the impediment is its tiny sample size. more research with a bigger sample size is copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. performance, happiness, and participation in the classroom are all on the upswing thanks to moodle. moodle is being utilized more frequently as a platform for adaptive and collaborative learning, as well as for improving online examinations. rapid growth in moodle's use is being driven by its ability to improve academic integrity, ethics, and security, as well as to streamline its interface [6]. the majority of students in this analysis 44% reported that using moodle had a positive impact on their academic achievement. and 42% said that thanks to moodle, they're able to learn more efficiently. the majority of students 65% in this survey said they were able to use moodle as a technology, and these results corroborated the positive attitudes students showed toward the use of technology. this study was congruent with one conducted in south africa. 70% said they were introduced to moodle for the first time in college, and 68.3% said they had access to a computer. 67% said they were not proficient with moodle [7]. in addition to a study from taiwan showing that students in the moodle group reported better levels of perceived satisfaction with the pediatric nursing course [8], the current study concluded that utilizing moodle is an appealing way to learn about 61% of students. findings from this study are inconsistent with those from a descriptive study done in nigeria and indonesia, which found that the learning management system application (moodle) was useful for facilitating communication and collaboration among users throughout the entire learning process [9]. only 28% of students in the current study agreed that moodle had been useful for them in these regards. more than half of nursing students in this study found learning with moodle enjoyable, discussion conclusions https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.04 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 33 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. recommended. another constraint is the geographical region that only includes the college of nursing-hawler medical university. the author declared that there is no conflict of interest to this study. [1] amandu gm, muliira jk, fronda dc. using moodle e-learning platform to foster student self-directed learning: experiences with utilization of the software in undergraduate nursing courses in a middle eastern university. procedia social and behavioral sciences. 2013; 93, 677-683. [2] ishtaiwa f. faculty attitudes and use of moodle course management system as a supplement to face-to-face instruction: a jordanian case study. journal of educational and psychological sciences. 2011; 12(1):1144. [3] mostafa mf, salama h, elwasefy sa. introducing moodle as a new path for nursing education: students' perception, experience and barriers. american journal of nursing research. 2017; 5(6):243-249. doi:10.12691/ajnr-5-6-7. [4] deliwe ap. the use of learner management system (moodle) in promoting teaching and learning. universal journal of educational research. 2020; 8(12): 8383-8392. doi: 10.13189/ujer.2020.082644. [5] sharma m, arora s. moodle in nursing education: a review article", international journal of science and research (ijsr). 2020; 9 (5):477– 478. [6] gamage sh, ayres jr, behrend mb. a systematic review on trends in using moodle for teaching and learning. international journal science, technology, engineering and mathematics (stem) education. 2022; 9(1): 2-24. doi: 10.1186/s40594-021-00323-x. [7] buthelezi li, van wyk jm. the use of an online learning management system by postgraduate nursing students at a selected higher educational institution in kwazulu-natal, south africa. african journal of health professions education. 2020; 12(4): 211-213. [8] chen y, chen cj, lee m. effects of a moodle-based e-learning management system on e-collaborative learning, perceived satisfaction, and study achievement among nursing students: a cross-sectional study. research square. 2022; doi: 10.21203/rs.3.rs-1402422/v1. [9] taufiqurrochman r, muslimin i, rofiki i, abah ja. students’ perceptions on learning management systems of arabic learning through blended learning model. jurnal al bayan: jurnal jurusan pendidikan bahasa arab. 2020;12 (1):22-36. 10.24042/ albayan.v12i1.5276. [10] fadel ea, elbilgahy aa, ibrahim ia, elmashad ha. undergraduate nursing students' and lecturers' attitudes towards modular object-oriented dynamic learning environment: a quasi experimental study. american journal of nursing. 2019; 7(1):2430. [11] deliwe ap. the use of learner management system (moodle) in promoting teaching and learning. universal journal of educational research. 2020; 8(12): 83838392. doi: 10.13189/ujer.2020.082644 [12] salhab ra. faculty members' attitudes towards using moodle at palestine technical khadoorie (ptuk). world journal of education.2019;9(2):152-165. doi:10.5430/ wje.v9n2p151 . [13] luo, l., cheng, x., wang, s. blended learning with moodle in medical statistics: an assessment of knowledge, attitudes and practices relating to e-learning. biomedical central medical education.2017;17(170): 28. doi.org/10.1186/s12909-017-1009-x. conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.08 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article knowledge and practice of nurses and midwives regarding immediate care after birth at two tertiary centers in the kurdistan region abstract background and objectives: the first two hours following birth are considered the immediate postpartum period, which starts as soon as the placenta is delivered. during the first few days after giving birth, the mother and child should be seen as a unit, supported by their family and/or friends. the first two hours following the baby's birth correspond to the fourth stage of labor. irregularly, deadlines are separated into three categories: urgent (within 24 hours), early (7 days), and late (6 weeks). the purpose of this study is to ascertain the nurses' and midwives' practices and knowledge of immediate postpartum care and its associated factor between socio-demographical characteristics of nurses and midwives' knowledge and our practice regarding immediate care after birth. methods: a descriptive study was conducted in the kurdistan region. the study was conducted at two hospitals, maternity teaching hospital and soran maternity hospital. the hospitals had several departments, such as the neonatal intensive care unit, delivery unit, postpartum unit, and postoperative unit. a purposive non-probability sample of fifty nurses and midwives from the delivery and postpartum unit was used. version 23 of the statistical package for the social sciences was used to analyze the data. results: more than half (51.9%) of the study samples’ level of education was institute nursing, while msc holders made up the highest percentage (1.9%). most of the samples (71.2%) had trained less than 5 years. more than one-third (36.5%) of nurses-midwives have 15 years of experience. almost all of the samples (94.2%) had high knowledge about immediate care after birth, and the highest percentage (71.2%) of samples had a good practice in caring for babies after birth. conclusion: midwives have a high level of practice in drying and wrapping babies immediately after birth, it can be concluded that most of the midwfe-nurses who participated in the study have a high level of knowledge regarding immediate care after delivery. keywords: nurses; knowledge; attitude; newborn; labor; midwives. nergz bayiz abdulrahman; department of nursing, mergasor technical institute, erbil polytechnic university, erbil, iraq. (correspondence: nergz.abdulrahman@epu.edu.iq). sazan bahram ahmed; department of nursing, college of nursing, hawler medical university, erbil, iraq. nazeera tahseen kareem; department of nursing, maternity teaching hospital, ministry of health, erbil, iraq. suham mirhamad abdullah; department of nursing, hareer teaching hospital, ministry of health, erbil, iraq. 80 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 26/11/2023 accepted: 18/05/2024 published: 30/05/2024 mailto:nergz.abdulrahman@epu.edu.iq?subject=nergz.abdulrahman@epu.edu.iq https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.08 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article the first two hours following birth are considered the immediate postpartum period, which starts as soon as the placenta is delivered. during the first few days after giving birth, the mother and child should be seen as a unit, supported by their family and/or friends. the first two hours following the baby's birth are considered the fourth stage of labor [1]. the postpartum phase follows childbirth and is characterized by the anatomical and physiological restoration of body tissues, particularly the pelvic organs, to their pre-pregnancy state. within 24 hours, early up to 7 days, and late up to 6 weeks are the arbitrary categories into which deadlines are separated [2]. the process of the placenta, membranes, and fetus being expelled through the birth canal is called labor [3]. the birth process and the first few hours of life are critical times in a child's development. the newborn is viewed as a tiny, defenseless being that depends entirely on other people to survive. a typical newborn transitions from a dependent fetal state to an independent existence in less than a minute after birth [4]. health care providers need to be aware of and supportive of the baby's early adaptations and the transition to the extrauterine stage, as these are crucial to the infant's long-term health. by offering essential care for newborns (enc). according to the world health organization, 75 percent of neonatal deaths take place during the initial week of life. between 25% and 45% of these deaths happen within the first 24 hours [5]. the care was as given by medical professionals at birth is essential for avoiding complications and guaranteeing survival. for nurses and other health professionals to give mothers and newborns the critical medical care they need, they must possess the necessary knowledge and abilities, following delivery, care should be given [6]. the world health organization (who) states that such attention is an integral part of vaginal birth care. immediate care includes: dry the baby with a towel or warm cloth, ensuring the airway is clear, removing mucus and other substances from the mouth, nose, and throat with a suction pump, mesuring to maintain body temperature, clamping and cutting the umbilical cord with a suction pump and sterile instruments, a few drops of silver nitrate solution or antibiotics are often placed in the eye to prevent infection by any harmful organisms the baby may be exposed to during birth (e.g. mother, sexually transmitted disease). vitamin k is also used to prevent hemorrhagic disease in newborns. the child's general condition is recorded 1 minute and 5 minutes after birth using the apgar scale. breastfeed the child as soon as possible. breastfeeding/early breastfeeding should be encouraged within the first hour after birth [7]. in addition to maternal vaccinations, such as postpartum measles or rh prophylaxis if necessary, breastfeeding and newborn care are also important [8].to get baseline rates of knowledge and practices for nurses, it is helpful to know information about the assessment of nurses' and midwives' knowledge and practice for immediate care after birth. planning and evaluating nurses for any necessary training on providing emergency care following childbirth can be facilitated by this information. since a nurse or midwife is the first healthcare professional to have direct contact since a nurse or midwife is the first healthcare professional to have direct contact with a newborn during delivery, they are the first to know the quality of care they provide until it is evaluated. as a result, researchers believed that carrying out the current study was crucial to evaluating the nurse's performance in the delivery room in light of the care standards established by the world health organization. 81 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.08 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article collected by using a questionnaire by the investigator and through direct (face-toface) interviews and observational checklist methods with all nurses and midwives in the delivery and postpartum room, who kindly agreed to participate in the study. the cases that fulfill the inclusion criteria were selected. the interviews were conducted at the delivery and postpartum units of the maternity hospital. the data collection started from the period 1st of june to 1st of july in the delivery room and 1st of july to 1st of august 2023 in the postpartum unit, and each interview session took approximately 15-30 minutes. the investigator delete created the format for the questionnaire. the following sections are included in the questionnaire: first section: the socio demographic attributes of nurses and midwives, including years of experience, years of education, and age. second section: a nurse's understanding of postpartum care for mothers and newborns. it was put together using option (2), type (correct, incorrect). it covered (the psychological and local physiological changes, the general physiological changes, nurses' knowledge of postpartum care, and the instructions given to mothers regarding the care of their newborns and hospital discharge). third section: a nurse's approach to provide a newborn with an immediate care following delivery using three types of options (2 for always, 1 for occasionally, and 0 for never). it included providing immediate care for the newborn, including monitoring their body temperature and airway, taking their apgar score one and five minutes after delivery, tending to their umbilical cord, looking for any abnormalities , and identifying and stopping bleeding by giving them vitamin k. after constructing the questionnaire, it was sent to several experts in the fields of medicine, nursing, and biostatistics. the comments the aim of the study is to determine the nurses’ and midwives’ knowledge and practice regarding immediate care after birth in erbil governorate. the specific objectives are to determine the sociodemographic characteristics of nurses and midwives in the delivery room and postpartum area, to identify the knowledge and practice regarding critical care for mothers and babies for nurses and midwives in the delivery and postpartum unit in kurdistan region, and to find out the association between socio-demographical characteristics of nurses and midwives' knowledge and practice regarding critical care for both mother and baby in the kurdistan region. the research design was a descriptive study. maternity teaching hospital and soran hospital, two hospitals in the kurdistan region, served as the study's sites. midwives and nurses who worked in the delivery and postpartum areas were the target demographic. it was divided into several departments, such as the neonatal intensive care unit (nicu), delivery unit, postpartum unit, and postoperative unit. the study was conducted during the period from the 1st of march to the 1st of december 2023. a convenient sample size of 52 participants was included in the study in the delivery and postpartum unit and would be asked respectfully to participate in the study. 32 nurses and midwives were in the delivery room and postpartum in the maternity teaching hospital in erbil city and 20 nurses and midwives were in the delivery room and postpartum area in soran maternity hospital. the participants included in the study should have had working experience in delivery and postpartum units and they accepted to participate in the study, but the cases did not fulfill the inclusion criteria and refused to participate in the study were excluded. data was 82 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.08 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 83 lowest. the highest percentage marital status of the nurses in the study sample (67.3%) nurses and midwives who had married and the lowest percentage (1.9%) who had divorce also, according to their work place, the highest percentage (65.4%) of the study sample was in the delivery room and the lowest percentage (34.6%) in the postpartum unit. according to previous training courses, regarding immediate care after birth, nurses, and midwives had the highest percentage (71.2%) in less than 5 years and the lowest percentage (9.6%) in five or more. also, about the years of experience in nursing or midwifery, the highest percentage (36.5%), had more than 15 years of experience and the lowest percentage (5.8%) had 10-15 years of experience. copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. of experts were taken into consideration regarding clarity, relevancy, and adequacy to achieve the objectives. prior to data collection, formal permission was obtained from the ethical approval of the ethical committee at the college of nursing and official permission was obtained from the erbil directorate of health. a primary approval was obtained from the research ethics committee, at soran university/nursing. hawler medical university/college of nursing with number 10 in 11 april 2023 approved. oral informed consent was obtained from nurses and midwives before data collection, after the explanation of the purpose of the study, benefits, rights to privacy, and rights to withdraw at any time. the investigator was promised to keep the information for confidentiality and anonymity. data was collected, coded ,analyzed and then organized into tables using the statistical package for social science (spss 23), through frequency, percentage, p-values and the chi-square test to identify the association between the variables. 3.1socio-demographic characteristics of the study sample table 3-1 focuses on the socio demographic characteristics of the study sample; they had been estimated according to their age, level of education, work place, level of education, marital status, previous training and courses regarding immediate care after birth, years’ experience in nursing or midwifery, and place of the previous training courses. the highest percentage (28.9%) of the study sample aged between 30-39 years old, while the lowest percentage (17.3%) aged between 40-49 years old. according to the nurse and midwifery level of education, it shows that the institute nursing level was the highest percentage (51.9%) while master holders 1.9% were the results https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.08 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 84 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3-1: socio demographic characteristics of the study sample (n=52). variables age group f. (%) 20-29 13 (25.0) 30-39 15 (28.8) 40-49 9 (17.4) ≥ 50 15 (28.8) level of education marital status of nurse single 16 (30.8) married 35 (67.3) divorce 1 (1.9) work place delivery room 34 (65.4) postpartum 18 (34.6) prior instruction and training in relation to the immediate care after birth no 10 (19.2) less than 5 years 37 (71.2) 5 or more 5 (9.6) years of experience in nursing or midwifery less than 5 years 17 (32.7) 5-10 years 13 (25.0) 10-15 years 3 (5.8) more than 15 years 19 (36.5) place of the previous training courses none 11 (21.1) ministry of health 27 (51.9) university 7 (13.5) other 7 (13.5) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.08 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article breastfeeding. regarding the item’s knowledge for the mother and baby, the breastfeeding increases the immunity of newborn; it shows that the highest percentage (100.0%) were “each newborn baby needs suction with a bubble syringe, while the lowest percentage (42.4%). 85 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. 3.2nurse and midwifery level of knowledge regarding immediate care after birth table 3-2 indicates the total of nurse and midwifery knowledge, the highest percentage (94.2%) had high knowledge, while the lowest percentage (5.8%) had poor knowledge’ regarding the benefits of table 3-2: nurse and midwifery knowledge regarding immediate care after birth no . items correct (%) incorrect (%) 1. the care was given to a parturient woman and her newborn in the first two hours after the placenta fully exits the body after the baby is born is referred to as the immediate postpartum period. (78.8) (21.2) 2. relaxed uterus causes loss of blood rapidly. (82.7) (17.3) 3. involution is the process whereby the reproductive organs return to their no pregnant state. (92.3) (7.7) 4. the fundus of the uterus may be palpated through the abdominal wall hallway between the umbilicus and the symphysis pubis within a few minutes after birth. (86.5) (13.5) 5. uterus massage after delivery of placenta helps the uterus to contract. (88.5) (11.5) 6. oxytocin is given to the mother to prevent bleeding. (94.2) (5.8) 7. vaginal blood contains small clots and mucus after birth. (92.3) (7.7) 8. bladder empty after birth decreases the occurrence of bleeding. (94.2) (5.8) 9. promote rest in the early postpartum period. (96.2) (3.8) 10. breastfeeding initiates after 2 hours after birth. (84.6) (15.4) 11. all mother are encouraged to breastfeed after birth. (98.1) (1.9) 12. breastfeeding increases the immunity of newborn. (100) (0) 13. breastfeeding is the best way to maintain body temp. (92.3) (7.7) 14. skin-to-skin contact between mother and newborn occurs after 1hr after birth. (78.8) (21.2) 15. skin-to-skin contact is important for newborn breastfeeding. (92.3) (7.7) 16. skin-to-skin contact is important to prevent newborn eat lose. (88.5) (11.5) 17. holding th newborn head down helps to drain the fluid from the infant’s chest. (88.5) (11.5) 18. each newborn baby needs suction with bubble syringe. (42.3) (57.7) 19. identification band put immediately before cutting the cord. (57.7) (42.3) 20. the band should include only the mother’s name (59.6) (40.4) total level of nurse and midwifery knowledge regarding (icab) f. (%) good knowledge 49 (94.2) poor knowledge 3 (5.8) total 52 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.08 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article care after birth nurses and midwifery the highest percentage (71.2%) were high practice and the lowest percentage had been (5.8%) poor practice with all socio demographic data of the study sample. (p > 0.05). table 33: nurses and midwifery level of practice of the study sample for immediate care after birth. table 3-3 indicated to the total level of practice to immediate table 4 it shows that there was no statistical significant association between nurse and midwifery knowledge regarding (icab) 86 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3-3: nurses and midwifery level of practice of the study sample for immediate care after birth. total level of nurses and midwifery practice of (icab) f. (%) bad practice 12 (23.1) poor practice 3 (5.8) high practice total 37 52 (71.1) (100) table: 3-4 association between nurse and midwifery knowledge with socio-demographic data regarding (icab) items good knowledge poor knowledge p-value age group (years old) 20-29 11(84.6) 2 (15.4) 30-39 15 (100) 0 (0) 40-49 8 (88.9) 1 (11.1) 0.160 ns ≥ 50 0(0) 15 (100) workplace delivery room 33 (67.3) 1(33.3) postpartum room 16 (32.7) 2 (66.7) 0.272 ns level of education secondary nursing 21 (95.5) 1 (4.5) institute nursing 25 (92.6) 2(7.4) college nursing 2(100) 0(0) 0.100 ns master in nursing 1(100) 0(0) single 15 (93.8) 1(6.3) married 33 (94.3) 2(5.7) 0.1000ns divorce 1 (100) 0(0) years of experience less than 5 years 15 (88.2) 2 (11.8) 5-10 years 12 (92.3) 1(7.7) 0.461ns 10-15 years 3 (100) 0(0) more than 15 years 19(100) 0.(0) previous training and courses no 9 (90.0) 1(10) less than 5years 35 (94.6) 2 (5.4) 0.648 ns 5 or more 5 (100) 0 (0) fishers exact test https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.08 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article the workplace, p-value 0.001. level of education, previous course, and training nurse and midwifery of the study sample p-value 0.045 and 0.030 respectively. statical significant association between knowledge with practice nurses and midwifery regarding (icab). table 3-5 indicates that there was a highly statistically significant association between nurse and midwifery practice (icab) with age, but non-significant with 3-6 association between knowledge with practice nurses and midwifery regarding (icab) table 3-6 shows that there was no 87 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table: 3-5 association between nurse and midwifery practice with socio-demographic data regarding (icab) variables good practice poor practice bad practice pvalue age group 20-29 2 (16.7) 9 (75.0) 1(8.3) 30-39 9 (81.8) 1 (9.1) 1(9.1) 0.001s 40-49 4 (80) 0(0) 1(20) more than 50 10(90.9) 0 (0) 1(9.1) delivery room 18(66.7) 2 (7.4) 7 (25.9) postpartum 7 (58.3) 5 (41.7) 0 (0) 0.5.5ns level of education secondary nursing 12 (80) 3 (20) 0(0) institute nursing 12 (54.5) 9 (40.9) 1 (4.5) 0.605ns college of nursing 1(100) 0 (0) 0 (0) master in nursing 1(100) 0 (0) 0(0) previous training and courses no 4(40) 5(50) 1 (10) less than 5years 19 (73.1) 6 (23.1) 1(3.8) 0.306 ns 5 or more 2 (66.7) 1 (33.3) 0 (0) table: 3-6 association between knowledge with practice nurses and midwifery regarding (icab) bad practice poor practice good practice p-value poor knowledge 0(0) 2 (100) 0(0) good knowledge 10(27) 2 (5.4) 25 (67.6) 0.190 ns https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.08 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article percentage (9.6%) in five or more. the finding disagreed with a study in northeast ethiopia by hawa abdul in 2019 [11].the current study findings illustrate that the highest percentage (36.5%) have more than 15 years of experience; they will affect the process positively by supporting and educating mothers to have information regarding diseases affecting both of them. the finding was in contrast with the study in tigray, ethiopia, by berhe in 2016, in which 52.1% of respondents have 1-5 years of experience [12]. regarding nurses and midwives’ knowledge about immediate care after delivery: the study revealed a total of nurse and midwifery knowledge; the highest percentage (94.2%) had high knowledge, while the lowest percentage (5.8%) had poor knowledge regarding the benefits of breastfeeding. the study in masindi, uganda by richard in 2014 [13], found a generally low level of knowledge among health workers (nurses and midwives) regarding immediate newborn care, whereby fewer than 60% of health workers were considered to have adequate knowledge in prenatal care, regarding reastfeeding and hygienic care. regarding the item’s knowledge for the mother and baby, breastfeeding increases the immunity of newborns; it shows that all of them (100.0%) were “each newborn baby needs suction with a bubble syringe, while the lowest percentage (42.3%). a study in australia by ruth in 2003 found that 90% of midwives reported being confident and effective in meeting the needs of breastfeeding women in immediate care after delivery [14].according to the same study, 94.2 percent of midwife nurses have correct responses about oxytocin given to mothers to prevent bleeding, the same finding was seen in são paulo, brazil by masip in 2017, where 88% have 88 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion the present study was done in the maternity teaching hospital and soran maternity hospital-erbil city iraqi kurdistan to determine the knowledge and practice of nurses and midwives regarding immediate care after birth in the delivery and postpartum units. according to experts and highly professional midwives, it is quite important for midwife-nurses to have awareness regarding labor and delivery processes to decline the mortality rate and morbidity rate because during this time both mother and fetus face more health problems like a virus infections, bacterial infections, mothers' psychological and physiological changes. analysis of demographic characteristics revealed that the highest percentage of midwife-nurses (28.9%) of the study sample were aged between 30-39 years old, while the lowest percentage (17.3%) aged between 40-49 years old. the study had a similar finding by ali and ghafel in 2022 in karbala [9], and the study conducted in kirkuk revealed the highest percentage of midwives aged between (30-39 years) and constituted (40%) [10].according to the education level of nurses and midwives, more than half a percent (51.9%) of study samples had an institute nursing level, while msc holders made up the lowest percentage (1.9%). it is disagreed with a study done by darya in kirkuk that most of the participants had secondary nursing level [10]. regarding the other variable in sociodemographic characteristics, the participated midwife-nurse marital status of the study sample (67.3%) nurses and midwives who had married and the lowest percentage (1.9%) who had divorced. a similar finding was found in a study on northeast ethiopia by hawa abdu et-al in 2018) [11]. concerning previous training and courses about the immediate care after birth, nurses and midwives had the highest percentage (71.2%) in less than 5 and the lowest https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.08 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article the study have a high level of knowledge regarding immediate care after delivery. the association of midwife knowledge with some socio demographic characteristics will be non-significant statistically. also, midwives have a high level of practice in drying and wrapping babies immediately after birth, keeping the baby on the mother's abdomen or chest immediately after birth. and for others practicing in the labor room. highly significant association with the place of work from the delivery room and postpartum. also, the relation will be statistically significant with the level of education and previous training and courses. recommendation: the study recommends that it should be providing regular training courses, especially outside the country, on the importance of nursing care and enhancing their practices, experiences, and abilities in women's postpartum care. continuous educational programs are necessary to improve the nurses' and midwives' ability to provide care and deal with any problem occurring immediately after birth., it also suggests that frequent training courses on the value of nursing should be offered, especially outside of kurdistan and iraq. attention and level of nursing services offered soon after birth for both the mother and the baby. 89 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. correct responses to giving oxytocin to control uterine bleeding immediately after birth [15].overall knowledge and practice of respondents toward immediate newborn care. this study was 94.2% and 71.1% respectively, which is higher than what was found in the study done in bahir dar city by yemaneh in 2016 which is 56% and 59.7% respectively [16]. also, midwives have a high level of practice of drying and wrapping babies immediately after birth (97.2%) and keeping the baby on the mother's abdomen or chest immediately after birth. and for others practicing in the labor room. concerning the association between socio demographic data and level of knowledge of nurses and midwives in the delivery room and postpartum, there will be a nonsignificant association statistically between their age group and level of knowledge. the same finding for the level of education and years of experience the relation will be non-significant [17].regarding the association between the practice of nurses-midwives in the delivery room and socio demographic characteristics, the data shows a statistically non-significant association between midwives' age group and practice which is similar to the study in the university of york in 2003 [18]. this might be attributed to low nurses' information. on the other hand, the study shows a highly significant association between the place of work from the delivery room and postpartum. also, this relation was similar to a study done by heydari in iran, which showed there will be a statistically significant with the level of education and previous training and courses [19]. based on the findings of the present study, it can be concluded that most of the midwife-nurses who participated in conclusion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.08 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article [10] y mustafa d, al–mukhtar sh. evaluation of knowledge and practice of nursing staff regarding immediate care after birth in kirkuk city hospitals. mosul journal of nursing. 2015 aug 28;3(2):81-6. file:///c:/users/yoga/downloads/ documents/6fab59738196008a_2.pdf [11] abdu h, gebrselassie m, abdu m, mare ku, tadesse w, liben ml. knowledge and practice of immediate newborn care among midwives and nurses in public health facilities of afar regional state, northeast ethiopia. bmc pregnancy and childbirth. 2019 dec;19:1-0. doi: https:// doi.org/10.1186/s12884-019-2581-3. [12] berhe ak, tinsae f, gebreegziabher g. knowledge and practice of immediate newborn care among health care providers in eastern zone public health facilities, tigray, ethiopia, 2016. bmc pediatrics. 2017 dec;17:1-9. doi: 10.1186/s12887017-0915-8 [13] ayiasi rm, criel b, orach cg, nabiwemba e, kolsteren p. primary healthcare worker knowledge related to prenatal and immediate newborn care: a cross sectional study in masindi, uganda. bmc health services research journal. 2014 dec;14:11. https://doi.org/10.1186/1472-6963-1465 [14] cantrill rm, creedy dk, cooke m. an australian study of midwives’ breast-feeding knowledge. midwifery journal. 2003 dec 1;19(4):310-7. https://doi.org/10.1016/ s0266-6138(03)00046-9 [15] masip, j. m., toledano, l. a., martínez, s. f., & roig, m. d. g. massive postpartum hemorrhage:protocolandredcode. inernational obstetrics journal. intech open. 2017. https://www.intechopen.com/ chapters/56365 [16] yemaneh y, dagnachew e. knowledge and practice of immediate new born care (inc.) among health professionals in governmental health facilities of bahir dar city, north ethiopia. quality in primary care journal (2017) 25 (6): 360-367. file:///c:/users/yoga/downloads/ documents/incqualityprimarycare.pdf [17] fenwick j, gamble j, nathan e, bayes s, hauck y. pre‐and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of australian women. journal of clinical nursing. 2009 mar;18(5):667-77. https:// 90 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [1] el-khawaga ds, ahmed mh, elwelely mz. effect of implementation of a teaching program about immediate postpartum care on nurses’ knowledge and practice. tanta scientific nursing journal. 2019 may 1;16 (1):95-112. doi: 10.21608/tsnj.2019.71352. [2] maville j and huerta c. health professional in nursing. 3rd ed., brazil, delmar cengage learningcom.,2013;172-80. doi: 10.21608/ tsnj.2019.71352 [3] nuriy la, ahmed hm. nurse/midwives' practices during labor and delivery in maternity teaching hospital in erbil city. erbil journal of nursing and midwifery. 2018 may 30;1(1):23-32. doi: https:// doi.org/10.15218/ejnm.2018.04 [4] jamsheer km, shaker nz. quality of immediate nursing care provided to newborn at maternity teaching hospital in erbil city. erbil journal of nursing and midwifery. 2018 may 30;1(1):33-41. doi: https:// doi.org/10.15218/ejnm.2018.05 [5] y mustafa d, al–mukhtar sh. evaluation of knowledge and practice of nursing staff regarding immediate care after birth in kirkuk city hospitals. mosul journal of nursing. 2015 aug 28;3(2):81-6. file:///c:/users/ yoga/downloads/ documents/6fab59738196008a_2.pdf [6] negussie bb, hailu fb, megenta ad. knowledge and practice of essential newborn care and associated factors among nurses and midwives working at health centers in jimma zone, ethiopia, 2016. journal of nursing and care. 2018. 7:1. doi:10.4172/2167-1168.1000446 [7] devi yn, mahadalkar p, varghese r. to assess the knowledge and self-reported practices regarding immediate newborn care among the staff nurses from birthing units of selected hospitals of pune city. int j appl res. 2017;3(6):doi: 499-502. file:///c:/ users/yoga/downloads/documents/ nrp.pdf [8] macdonald s and cuerden j. mayes’ midwifery, 14th ed., new york, bailliere tindall com., 2011; 730-52. [9] ali sh, ghafel hh. evaluation of nursemidwive's practices about immediate postpartum care for mothers. pakistan journal of medical & health sciences. 2022 may 11;16(03):1069-. doi: https:// doi.org/10.53350/pjmhs221631069 references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.08 erbil j. nurs. midwifery, vol. 7, no. (1), may, 2024 original article 91 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. doi.org/10.1111/j.1365-2702.2008.02568.x [18] rice n. the labour supply of nurses in the uk: evidence from the british household panel survey. university of york, health economics resource centre; 2003 jul 22.https://www.york.ac.uk/media/ economics/documents/herc/wp/05_10.pdf [19] heydari a, mazlom sr, ranjbar h, scurlock‐ evans l. a study of iranian nurses’ and midwives’ knowledge, attitudes, and implementation of evidence‐based practice: the time for change has arrived. worldviews of evidence-based nursing journal. 2014 oct;11(5):325-31. https://doi.org/10.1111/ wvn.12052. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.16 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article effectiveness of a health education program on coronary artery bypass graft patients’ knowledge in surgical specialty hospital-cardiac center in erbil city abstract background and objective: coronary artery bypass graft is considered an important surgical procedure and due to the lack of sufficient knowledge in cabg patients, it is necessary and vital to carry out interventions to improve the knowledge of patients. therefore, the purpose of this study is to determine the effect of a health education program on patients' knowledge. methods: this study is a quasi-experimental conducted between 2021 and 2023. the population of the study sample consisted of patients who were admitted to the cardiac center hospital in erbil city. the samples were divided into two groups by random allocation, each group of 100 people. data collection was based on a researcher-made questionnaire including three socio-demographic, medical data of patients with cabg and knowledge related to cabg. the intervention consisted of 6 sessions, which included 2 sessions of general training for patients, and 4 sessions of training including physiological aspects, self-concept, reciprocal relations and the fulfillment of obligations. results: the mean age in the control group is 56.63±9.74 and in the intervention group is 54.32±11.123. after the intervention, the mean knowledge score in the general information, risk factor, complication, diagnosis, and management of coronary artery bypass grafting sections showed a significant increase among patients in the intervention group compared to the control group (p≤0.001). the results showed that the mean overall awareness score in the intervention group at the beginning of the study is lower than the average awareness score after the intervention, and this mean difference is significant (p≤0.001). the mean overall knowledge score in the intervention group has a significant difference compared to the control group (0.001). conclusion: considering the important effects of the educational program on increasing knowledge about various aspects of coronary artery bypass graft, educational programs should be given more attention. keywords: coronary artery bypass graft; education program; risk factor; co-morbidity; diagnosis; management. dlzar omer qadir; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. (correspondence: dlzar.qadir@hmu.edu.krd) yousif mohammed younis; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. 170 received: 01/03/2023 accepted: 04/06/2023 published: 30/11/2024 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:dlzar.qadir@hmu.edu.krd mailto:dlzar.qadir@hmu.edu.krd?subject=dlzar.qadir@hmu.edu.krd%20 mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.16 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article cardiovascular disease (cvd), sometimes known as heart disease [1]. coronary artery disease is the greatest cause of mortality in the world. according to the world health organization (who), ischemic heart disease caused roughly nine million deaths in 2016 [2]. the onset of coronary artery disease is often linked to a chronic inflammatory process, beginning with the creation of a fatty streak and progressing to the formation of a fibrous atheroma [3]. this situation results in a mismatch between myocardial oxygen supply and demand [4]. cardiovascular disease clinical manifestations might range from asymptomatic to classic. [5].coronary artery bypass grafting (cabg) is an important surgical procedure in which athermanous blockages in a patient's coronary arteries are bypassed with venous or arterial conduits. bypass blood flow restores the function and viability of the ischemic myocardium, and relieves the symptoms of angina. approximately 400,000 cabg procedures are performed annually, making it the most common major surgery [6]. although cabg improves overall long-term mortality in individuals who meet the criteria for cabg, there is an initial operative mortality risk after cabg. the rates reported in the freedom and syntax trials, 1.7 percent and 3.5 percent, respectively, are consistent with conventional mortalities [7, 8]. despite the advantages of cabg surgery, it also has some complications, the most important of which include the following [9]. sternal wound, svg failure, postoperative renal failure, stroke, and atrial fibrillation. diet, exercise and lifestyle modifications have been shown to play a potentially significant role in improving post-cabg outcomes in the few studies conducted [10] .post-cabg discharge education and counseling ease recovery issues, lower rehospitalization rates, and medical expenses enhance patient satisfaction and quality of life (qol), promote functional independence, and allow patients to do self-care tasks and take care of their own requirements [11, 12]. kalogianni et al., [13] discovered that preoperative education provided by nurses decreased postoperative problems of patients undergoing heart surgery, but it was ineffective in lowering readmissions or duration of stay.it seems that due to the high prevalence of cardiovascular diseases and the lack of sufficient knowledge and awareness in coronary artery bypass graft patients, it is necessary and vital to carry out interventions to improve the awareness of patients. therefore, the purpose of this study is to determine the effect of a health education program on the cabg patient’s knowledge in a cardiac center in erbil city. the study employed a quantitative quasiexperimental design with a pre-test and post-test approach to examine the impact of a training program on patients admitted to the coronary care unit of a cardiac center hospital in erbil city between 2021 and 2023. the samples were divided into two groups by random allocation. to enhance comparability between the intervention and control groups, several matching criteria were considered, including age, gender, socioeconomic status, and the severity of illness. through random allocation, 100 patients were assigned to the intervention group, where they received the training program, while another 100 patients were assigned to the control group, where they did not receive the intervention. by incorporating these matching criteria, the study aimed to minimize potential confounding variables and strengthen the internal validity of the findings. sample size according to the studies by p sharma et al., [14] and k zia et 171 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.16 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article distributed anonymously and coded. after completing the questionnaires, the samples were randomly assigned to two intervention and control groups by means of random allocation software. the samples were divided into two groups. 100 patients were exposed to the training program as the study group, and another 100 patients were not exposed to the training program as the control group. then, before implementing a real training program, the researcher used a questionnaire consisting of three parts, which include demographicsocial data, medical data of cabg patients and knowledge related to cabg. the intervention of the upcoming research consisted of 6 sessions, which included 2 sessions of general education of patients, 4 sessions on physiological dimensions, self-concept, mutual relations and role playing, and these 4 sessions were direct interventions by the researcher in the format. by actively addressing the main and underlying factors contributing to incompatible behaviors identified in the needs assessment form, the researcher played a crucial role in helping every patient within the intervention groups meet their individual needs. this was achieved through the researcher's physical presence at the hospital and department, ensuring personalized support and intervention for each participant. ethical approval was achieved from the ethics committee of the college of nursing/ hawler medical university as a code number is 145 in 7/10/2021. permission was obtained from the director of health/erbil. data analysis was reported with the assumption of normality using central indicators of mean (standard deviation) and frequency (percentage) for quantitative variables. (chi-square) test was used to check the statistically significant relationship between quantitative variables. a t-test and a paired-t test were used to evaluate the effect of training al., [15] was determined. the prevalence of cabg surgery in previous studies was 70%. accordingly, due to the same prevalence of the disease in both groups, a sample size of 81 patients was considered for each group. the calculated sample was 81 patients, which was considered to increase the strength and external validity of the study and the availability of samples for each group of 100 patients. the inclusion criteria of the study were: age above 30, ability to participate in the study, lack of prior training experience, individuals' personal interest in participating in the study, an adult patient who performs cabg, and patients with stable conditions. exclusion criteria of the study were: patients who refuse to complete the post-test, patients with mental retardation, and mental illnesses, patients with sensory problems such as blindness and deafness, patients with alzheimer's people who changed their opinion about participating in the study or missed two consecutive educational intervention sessions for any reason. after several literature reviews and previous studies, the investigator constructed the questionnaire and applied it before the application of the actual educational program. it consists of three parts, which are sociodemographic, medical data of patients with cabg and knowledge related to cabg. all patients with coronary artery bypass grafts in erbil cardiac center hospital who had the conditions to participate in the study were included in the study after completing the consent form. the researcher explained the demographic characteristics questionnaire and the quality of life questionnaire to the patients, and the questionnaires were face-to-face (interview) individually for about 20-30 minutes with each patient in two sessions of the educational program before and after the test was completed using a questionnaire format. the questionnaire was 172 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.16 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article in two groups. data were analyzed using spss v. 23 software. a significance level of p ≤ 0.05 was considered. table 1 shows that the mean age of the two groups of people under investigation participants showed that the mean age in the control group is 56.63±9.7455.14±6.47 years and in the intervention group is 54.32±11.12353.21±5.41 years. the age group of patients showed that (7%) patients in the intervention group and (12%) patients in the control group were in the age group of 30-39 years. (22%) patients in the intervention group and (24%) patients in the control group were in the age group of 40-49 years old. (33%) patients in the intervention group and (31%) patients in the control group were in the age group 50 -59. (27%) patients in the intervention group and (24%) in the control group were in the age group of 60-69 years, and the two groups did not differ in terms of age groups. the gender description of the patients in the two groups showed that (57%) patients in the intervention group and (59%) patients in the control group were male, and the two groups had no significant differences in terms of gender distribution. the level of education of patients in the two groups showed that (19%) patients in the intervention and control groups were illiterate. (15%) patients in the intervention group and (19%) patients in the control group had the lit level reading read and write. likewise, (15%) patients in the intervention group and (20%) patients in the control group had primary school graduates literacy. the literacy level of intermediate school graduate was seen in (22%) intervention group patients and (16%) control group patients, and the two groups had a significant difference in terms of education level (p ≤ 0.02). occupation status of the two groups of patients, it was found that (17%) patients in the intervention group and (18%) patients in the control groups were employed, and (24.69%) patients in the intervention and control group were unemployed. other patients had the jobs of housewife, self-employed, and retired, and the two groups had a significant difference in terms of their employment status (p ≤ 0.001). 88% of patients in the intervention and control group returned to work after a coronary artery bypass graft. (87%) patients in the intervention group were married and (83%) patients in the control group were married, (8%) in the intervention group and (6%) in the control group were single. patients' residential area, it was found that (83%) patients in the intervention group and (87%) patients in the control group lived in urban areas. only (18%) patients in the intervention group had a history of smoking and (17%) patients in the control group had a history of smoking. 173 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.16 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article 174 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: socio-demographic characteristics of the study sample (n= 200) socio-demographical characteristics class groups p-value* intervention group control group frequency (%) frequency (%) age 30-39 7 (22%) 12 (12%) c.c = 0.13 p=0.1(ns) 40-49 22 (22%) 24 (24%) 50-59 33 (33%) 31 (31%) 60-69 27 (27%) 24 (54%) 70-79 10 (10%) 7 (7%) 80-89 1 (1%) 2 (2%) mean 54.32 ± (11.123) 56.63 ± (9.74) gender male 57 (57%) 59 (59%) c.c = 0.02 0.886 (ns) female 43 (43%) 41 (41%) education illiterate 19 (19%) 19 (19%) c.c = 0.13 0.023 (s) read and write 15 (15%) 19 (19%) primary school graduate 15 (15%) 20 (20%) intermediate school graduate 22 (22%) 16 (16%) preparatory school graduate 11 (11%) 13 (13%) institute graduate 12 (12%) 7 (7%) college graduate 4 (4%) 4 (4%) post-graduate 2 (2%) 2 (2%) occupation before coronary artery bypass graft employed 17 (17%) 16 (16%) c.c = 0.05 0.004 (hs) unemployed 24 (24%) 24 (24%) housewife 17 (17%) 19 (19%) self-employed 27 (27%) 29 (29%) retired 15 (15%) 12 (12%) after coronary artery bypass graft returned to work 88 (88%) 88 (88%) 1(ns) out of work 12 (12%) 12 (12%) marital status single 8 (8%) 11 (11%) c.c = 0.06 0.5 (ns) married 87 (87%) 83 (83%) widowed 3 (3%) 3 (3%) divorced 2 (2%) 3 (3%) residential area urban 83 (83%) 87 (875) c.c = 0.05 0. 553 (ns) rural 17 (17%) 13 (13%) cigarette smoking yes 18 (18%) 17 (17%) c.c = 0.01 0.5 (ns) no 82 (82%) 83 (83%) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.16 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article in the investigation of ischemic heart diseases in two groups, it was found that (44%) patients in the intervention group had a history of the disease and a history of ischemic heart diseases was observed in (22%) patients in the control group (p≤0.002). (36%) patients in the intervention group and (16%) had a history of kidney disease (p≤0.001). (38%) patients in the intervention group and (33%) patients in the control group had a history of other diseases (p≤0.031). 175 table 2 shows that the clinical information of the patients was that (27%) patients in the intervention group and (30%) patients in the control group were overweight; the two groups did not have significant differences in terms of bmi status. the duration of the disease in the patients showed that (61%) patients in the intervention group and (71%) patients in the control group had a disease duration of less than 5 years. (22%) patients in the intervention group had disease duration between 5 and 9 years and the rest of the patients had disease duration of more than 10 years. (23%) patients in the control group had disease duration between 5 and 9 years and the rest of the patients had disease duration of more than 10 years, and the two groups had no significant difference in terms of disease duration. there was a significant difference in the previous hospital admission in the two groups (p ≤ 0.003). in the intervention group, (59%) patients had a history of one hospital admission, and (23%) patients had a history of two hospital admissions. (13%) patients had a history of admission three times, and (5%) patient had a history of being admitted to the hospital more than three times. in the control group (66%) patients had a history of admission to the hospital once and (23%) patients had a history of being admitted to the hospital twice. (8%) patients had a history of admission three times and (3%) patients had a history of admission to the hospital three times. the history of concomitant diseases in the two groups showed that (41%) patients in the intervention group had hypertension and (21%) patients in the control group had a history of hypertension (p≤0.005). the history of diabetes showed that (34%) patients in the intervention group had a history of diabetes and (18%) patients in the control group had a history of diabetes (p≤0.015). copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.16 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article sections general information, risk factor, complication, diagnosis and management of coronary artery bypass grafting among patients in the intervention group showed a significant increase compared to the baseline model (p≤0.001). the results showed that the mean overall awareness score in the intervention group at the beginning of the study is lower than the average awareness score after the intervention, and this mean difference is significant (p≤0.001). the mean overall knowledge score in the intervention group has a significant difference compared to the control group. there were no significant differences in the control group at different stages of the study (p > 0.050). table 3 indicated that at the beginning of the study and before the start of the intervention, there was no significant difference in the average knowledge score in the general information, risk factor, complication, diagnosis and management of coronary artery bypass grafting sections between the intervention and control group patients. after the intervention, the mean knowledge score in the general information, risk factor, complication, diagnosis and management of coronary artery bypass grafting sections showed a significant increase among patients in the intervention group compared to the control group (p≤0.001). the analysis of the results within the group showed that the 176 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: distribution of the study group’s medical data (n= 200) medical data class group p-value* intervention group (n=100) control group (n=100) f (%) f (%) bmi normal weight 73 (73) 70 (70) c.c = 0.05 p = 0.77 (ns) overweight 27(27) 30 (30) duration of the disease < 5 61 (61) 71 (71) c.c = 0.02 p = 0.65 (ns) 5 – 9 22 (22) 23 (23) > 10 17 (17) 6 (6) previous admission to the hospital one time 59 (59) 66 (66) c.c = 0.1 0.003 (hs) two times 23 (23) 23 (23) three times 13 (13) 8 (8) more than three times 5 (5) 3 (3) hypertension yes 40 (40) 21 (21) c.c = 0.2 0.005 (hs) no 60 (60) 79 (79) diabetes mellitus yes 34 (34) 18 (18) c.c = 0.17 0.015 (s) no 66 (66) 82 (82) ischemic heart disease yes 44 (44) 22 (22) c.c = 0.22 0.001 (hs) no 56 (56) 78 (78) kidney disease yes 36 (36) 16 (16) c.c = 0.24 0.001 (hs) no 61 (61) 84 (84) others yes 38 (38) 33 (33) c.c = 0.16 0.031 (s) no 62 (62) 77 (77) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.16 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article it was shown that the mean duration of chest pain and cad is less than 5 years, and according to the results of the present study, the duration of the disease is less than 5 years, so the results of these two studies are consistent. based on the findings of this study, high blood pressure, diabetes, ischemic heart disease, kidney diseases and other diseases were identified in the study subjects, and the patients of the intervention and control groups had significant differences in all co-morbidities. in the study conducted by ejheisheh et al., [18] co-morbidities were identified as blood pressure, diabetes, dyslipidemia, the mean age of the patients in the control group was 56.63±9.74 years and in the intervention group was 54.32±11.123 years. in the quasi-experimental study conducted by z noor et al., (2022) [16] in kuala lumpur, malaysia, it was shown that the mean age group in the control group was 58.14 ± 11.78 and in the intervention group was 57.4 ± 12.3, which is higher than the mean age of the present study in both the control and intervention groups. also, the two groups did not have a significant difference in mean age, which is consistent with this study. in a study conducted in saudi arabia by m hussain et al., [17] 177 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: comparison of the mean score of knowledge of coronary artery bypass grafting between the two groups (n= 200) variables group before the intervention after the intervention (t) value p-value* general information intervention 121.20 ± 54.39 161.21 ± 65.57 40.1 0.001 control 124.44 ± 26.14 126.22 ± 45.80 1.78 0.954 p 0.341 0.001 risk factor intervention 28.50 ± 43.25 38.60 ± 4.33 10.1 0.001 control 29.50 ± 34.65 30.41 ± 32.62 0.91 0.821 p 0.514 0.001 complication intervention 25.05 ± 5.02 32.77 ± 47.21 7.72 0.001 control 23.10 ± 57.69 21.22 ± 74.26 -1.88 0.914 p 0.784 0.001 diagnosis intervention 22.46 ± 7.24 29.80 ± 32.16 7.34 0.001 control 24.31 ± 0.21 23.42 ± 66.31 -0.89 0.651 p 0741 0.001 management of coronary artery bypass grafting intervention 15.32 ± 88.21 24.20 ± 32.14 8.88 0.001 control 15.30 ± 33.83 16.20 ± 55.19 0.9 0.149 p 0.145 0.001 knowledge intervention 53 .33 ±17.32 94 .17 ±74.12 40.84 0.001 control 54.32 ±47.36 55.14 ± 69.74 0.82 0.688 p 0.552 0.001 discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.16 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article of conducting educational programs in patients similar to our study. increasing awareness and information about the disease is very vital and important for the patient. in a study, the effect of training sessions to improve the knowledge of health care workers in early detection, diagnosis and management of rf and rhd in remote rural areas of western nepal has been conducted. the results showed that holding training sessions and carrying out the intervention improved the knowledge score about risk factors and disease diagnosis which is consistent with the results of our study on the effect of intervention in increasing the awareness of patients of diagnostic methods. by carrying out interventions and educational programs, awareness can be increased and earlier diagnosis of the disease will be better possible [22]. coronary artery bypass surgery is one of the most effective treatment methods for cardiovascular diseases. adherence to treatment and compliance with treatment orders after cabg is essential. the clinical trial study was conducted by torknejad et al., [23] was shown that the scores of focus on treatment, willingness to participate in treatment, ability to adapt, combining treatment with life adherence to treatment, commitment to treatment and doubt in the implementation of treatment in the intervention group, after the intervention and 3 months after the intervention, had a significant increase compared to the control group. and finally, the mean of knowledge, attitude, behavioral intention, subjective norms and enabling factors in the intervention group has increased significantly compared to the control group. following treatment regimens and following behaviors related to health is called the healthy adherer effect. its evaluation is very important in cardiovascular diseases. a cross-sectional study results, by lee et al., [24] showed that carrying out and hypercholesterolemia. and among the patients of that study, unlike the present study, there was no difference in blood pressure and diabetes. the clinical trial study was conducted by yuroong et al., [19] showed that educational interventions before surgery, during surgery and after surgery were useful and effective in improving and increasing the awareness of patients. the aforementioned study and the implementation of the educational program are in line with the results of our study, which has led to an increase in the general awareness of patients about the disease. in our study, after the intervention, there was a significant difference between the intervention and control groups regarding the awareness of risk factors, and the intervention improved awareness in the intervention group. in case of coronary artery disease, a low level of health literacy and a lack of awareness of disease risk factors may have adverse consequences for patients. in a multicenter cohort study conducted by brørs et al., [20] in norway and denmark, after 6 months of follow-up, changes in the risk factors of physical activity, smoking, and psychological factors (hads -t score, hads-a score, and hads-d score) have occurred, and these results are in line with the results of our study, indicating the positive effect of the educational intervention. as a chronic and debilitating disease, heart diseases can result in a high mortality rate, so they can have a significant impact on the lives of patients. in this regard, it is important and necessary to improve and promote the lives of patients and to be aware of the complications and problems of patients. habibzadeh et al., [21] have shown that nutrition, physical activity, health responsibility, stress management, interpersonal relations and spiritual growth improved significantly and showed the importance 178 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.16 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article we are thankful to all patients who participated in this study. the author declares no conflict of interest. [1] benjamin, e.j, virani, s.s, callaway, c.w, chamberlain, a.m, chang, a.r, cheng, a and et al. heart disease and stroke statistics2018 update: a report from the american heart association circulation. 2018; 137(12): p. e67-e492. [2] nowbar, a.n, mauro gitto, m, howard, j.p, francis, d.p and al-lamee, r. mortality from ischemic heart disease. circulation, cardiovasc qual outcomes. 2019; 12(6): p. e005375. [3] olvera lopez, e, b.d. ballard, and a. jan, cardiovascular disease, in statpearls. 2022, statpearls publishing, copyright © 2022, statpearls publishing llc.: treasure island (fl). [4] ferrari, r, camici, p.g, crea, f, danchin, n, fox, k, maggioni, a.p and et al. expert consensus document: a 'diamond' approach to personalized treatment of angina. nature reviwe cardiology. 2018; 15(2): p. 120-132. [5] kreatsoulas, c, shannon, h.s, giacomini, m, velianou, j.l and anand, s.s. reconstructing angina: cardiac symptoms are the same in women and men. jama internal medicine. 2013; 173(9): p. 829-31. [6] alexander, j.h and p.k. smith, coronaryartery bypass grafting. the new england journal of medicine. 2016; 375(10): p. e22. [7] farkouh, m.e, domanski, m, sleeper, l.a, siami, f.s, dangas, g, mack, m and et al. strategies for multivessel revascularization in patients with diabetes. the new england journal of medicine. 2012; 367(25): p. 237584. [8] serruys, p.w, morice, m.c, kappetein, a.p, colombo, a, holmes, d.r, mack, m.j and et al., percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. the new england journal of medicine. 2009; 360(10): p. 961-72. educational programs and interventions could improve patients' adherence to treatment regimens and lifestyle modification, and salt consumption, low-fat diet and/or weight loss diet, regular exercise, stress reduction in daily life, drinking in moderation, and smoking cessation of the studied patients were significantly improved in order to improve health. these results, in line with the results of our study, have already revealed the importance and role of interventions and educational programs. the results of this study showed that most of the patients were in the age group of over 50 years, most of the studied patients in both the intervention and control groups were male. and the samples of both groups were at a low level in terms of education, they were mostly married and urban dwellers. most of the patients had normal weight, their disease duration was less than 5 years, most of the samples had high blood pressure, diabetes, ischemic disease and kidney disease, and the number of smokers in both groups was low. the patients of the two groups had significant differences in demographic variables, disease course, educational background, type of employment before surgery, and previous hospitalization. improvement in the level of knowledge of patients in the intervention group in general information, risk factors, complications, diagnosis and management of the disease has been established after the intervention. this study proved that the health education program had a positive effect on the coronary artery bypass graft patient’s knowledge. 179 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion acknowledgements conflect of inetest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.16 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article [18] ejheisheh, m, correa-rodríguez, m, fernández-aparicio, a, batran, a, suleiman-martos, n, schmidt-riovalle. j.prior percutaneous coronary intervention is associated with low health-related quality of life after coronary artery bypass graft. nursing health sciences. 2020; 22(4): p. 1022-1029. [19] yuroong, a, asdornwised, u, wanpen pinyopasakul, w, wongkornrat, w and chansatitporn, n .the effectiveness of the transitional care program among people awaiting coronary artery bypass graft surgery: a randomized control trial. journal of nursing scholarship. 2021; 53(5): p. 585-594. [20] brørs, g, dalen, h, allore, h, deaton, c, fridlund, b, osborne, r.h and et al. health literacy and risk factors for coronary artery disease (from the concardpci study). the american journal of cardiology. 2022; 179: p. 22-30. [21] habibzadeh, h, shariati, a, mohammadi, f and babayi, s. the effect of educational intervention based on pender's health promotion model on quality of life and health promotion in patients with heart failure: an experimental study. bio medical central cardiovascular disorders. 2021; 21(1): p. 478. [22] bhatt, n, karki, a, shrestha, b, singh, a, rawal, l.b and sharma, s.k. effectiveness of an educational intervention in improving healthcare workers’ knowledge of early recognition, diagnosis and management of rheumatic fever and rheumatic heart disease in rural far-western nepal: a pre/postintervention study. bmj open. 2022; 12(4): p. e059942. [23] torknejad, a., s. babaei and m. mirmohammadsadeghi, effect of an educational intervention based on basnef model on treatment adherence after coronary artery bypass surgery: a randomized clinical trial. arya atherosclerosis. 2020; 16(3): p. 105114. [24] lee, y-m, kim, r.b, lee, h.j, kim, k, shin, mh, park. h-k and et al. relationships among medication adherence, lifestyle modification, and health-related quality of life in patients with acute myocardial infarction: a cross-sectional study. health and quality of life outcomes. 2018; 16 (1): p. 100. [9] hillis, l.d, smith, p.k, anderson, j.l, bittl, j.a, bridges, c.r, byrne, j.g, cigarroa, j.e and et al., 2011 accf/aha guideline for coronary artery bypass graft surgery: a report of the american college of cardiology foundation/american heart association task force on practice guidelines circulation. 2011; 124(23): p. e652-735. [10] coyan, g.n, k.m. reeder, and j.l. vacek, diet and exercise interventions following coronary artery bypass graft surgery: a review and call to action. the physician and sportsmedicine. 2014; 42(2): p. 119-129. [11] albert, n.m., s. paul, and m. murray, complexities of care for patients and families living with advanced cardiovascular diseases: overview. the journal of cardiovascular nursing. 2012; 27(2): p. 103-113. [12] fredericks, s. and t. yau, educational intervention reduces complications and rehospitalizations after heart surgery. western journal of nursing research. 2013; 35(10): p. 1251-1265. [13] kalogianni, a, almpani, p, vastardis, l, baltopoulos, g, charitos, c, brokalaki, h. can nurse-led preoperative education reduce anxiety and postoperative complications of patients undergoing cardiac surgery? european journal of cardiovascular nursing. 2016; 15(6): p. 447-458. [14] sharma, p, yadav, l, nepal, r , khanal, s.b, agrawal, s and kattel, v. coronary artery bypass grafting among patients undergoing cardiac surgery in a tertiary care hospital: a descriptive cross-sectional study. journal of nepal medicine assocation. 2022; 60 (246): p. 116-120. [15] zia, k, mangi, a.r, minhaj, s, tariq, k, rabbi, f, \musharafand,m and et al., an overview of first 100 cardiac surgery cases at a newly developed satellite center in sukkur, pakistan, cureus. 2020; 12(6): p. e8490. [16] noor hanita, z, l. a. khatijah, s. kamaruzzaman, c. karuthan and r. a. raja mokhtar. a pilot study on development and feasibility of the 'myeducation: cabg application' for patients undergoing coronary artery bypass graft (cabg) surgery. biomed central nursing. 2022; 21(1): p. 40. [17] hussain, m, khan, n, uddin, m and alnozha, m.m. duration analysis for coronary artery disease patients with chronic chest pain: an output from saudi arabia. journal of cardiovascular and thoracic research. 2015; 7(1): p. 6-12. 180 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article impact of an educational program on quality of life among patients undergoing hemodialysis in akre/ iraqi kurdistan region abstract background and objective: chronic kidney diseases is an international public health issue, and it has a rising extent, occurrence and significant treatment expenditures. the guidance is a crucial step in raising the standard of dialysis care and improving the results of quality of life for endstage renal disease patients. therefore, the study's objectives were to establish, implement, and evaluate the impact of the educational program on hemodialysis patients' quality of life at the study site. methods: a quasi-experimental research study was conducted at the urology center's hemodialysis units at golan general hospital in akre. data were collected from 30 adult dialysis patients who were undergoing dialysis regularly. results: according to the current study, patients' overall mean quality of life scores increased in many aspects of quality of life (physical, psychological and social) with a statistically significant difference shortly after the program's introduction. this increased level was marginally reduced after a month of program implementation. conclusion: the overall quality of life of the patients who underwent the intervention saw an improvement in score, all metrics relating to quality of life and health were significantly improved by the educational program. key words: end-stage renal disease; hemodialysis; educational program; quality of life. zikri mahmood mirza; department of nursing, akre technical institute/ akre university for applied sciences, duhok, kurdistan region, iraq. (correspondence: zekri.mirza@dpu.edu.krd) 214 received: 07/06/2024 accepted: 01/11/2024 published: 30/11/2024 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:zekri.mirza@dpu.edu.krd?subject=zekri.mirza@dpu.edu.krd%20 mailto:zekri.mirza@dpu.edu.krd?subject=zekri.mirza@dpu.edu.krd%20 mailto:zekri.mirza@dpu.edu.krd mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article renal function is thought to permanently deteriorate in end-stage renal disease (esrd). it is considered a fatal condition for which only hemodialysis (hd) or peritoneal dialysis can guarantee a life[1].end-stage renal disease requires lifetime treatment, which may include renal replacement therapy, education, and dietary and hydration restrictions. as a result, it significantly affects the affected patients' qol, morbidity, and death [2].information from the literature indicates that the health of esrd patients is extremely low when compared to the general population's state of health [3]. this is the rationale behind the increased focus given to health-related quality of life (hrqol).[4] some medical treatments for people with renal failure focus more on enhancing qol than they do on addressing the underlying pathology and consequences. consequently, it is recognized that hrqol evaluation is subjective [5].patients with renal failure must adjust their lifestyles in a number of ways because hd is a chronic condition in order to manage its complications and cope with their sickness [6].the care of patients with esrd is thought to focus primarily on improving qol [7].because of the worrisome increase in the prevalence of renal failure, expensive therapy, and general reduction in patients' qol, the adoption of efficient treatment is crucial [3].approaching patients' qol through an educational program is essential since qol is seen as a main goal in the therapy of renal failure [8].as it significantly increases a patient's alertness of their ailment, active patient participation in their method of therapy and managing is a crucial element to the enhancement of their qol generally[9]. this educational program aims to educate esrd patients with hd to improve their health condition and their overall qol. a quasi-experimental study design was carried out in akre golan general hospital in order to evaluate the impact of an instructive program on hrqol among hd patients undergoing treatment at hd facilities. the present study was executed in akre general hospital at akre district during the period from 2nd january to 20th june 2023. the study included 30 patients, who were on regular dialysis; they were ready to share willingly in the study, and agreed to grant consents. for the purpose of this study, a two-part instrument to evaluate patients' quality of life while receiving hemodialysis was created. the demographic data sheet is concerned with the determination of the demographic characteristics of patients (age, gender, place they grew up, level of education, and duration hours of dialysis).also, the construct questionnaire for q.o.l was created by the whoqolbref, or world health organization instrument of quality of life [10]. questionnaires with 24 items to evaluate the level of hemodialysis patients' quality of life.physical health, psychological health, social relationships, and environmental domains, these domains are commonly used in research and evaluation to understand various aspects of an individual's well-being.regarding the (whoqol-bref) part, data was gathered through direct interviews (face-to-face) which had been completed by all samples of the study for 20 30 minutes by using the (whoqol-bref) questionnaire. the patients qol was assessed by the score cutoff point to poor was (1-3), good (< 3 5). an official administrative satisfactory from the akre directorate of education was acquired before the data was collected by the planning department to conduct the present study. the data was 215 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article table 1 illustrates of the sociodemographic features of 30 patients undergoing hemodialysis that attends to golan general hospital (hemodialysis unit). concerning patients age about 43.3% of the patients belonged to the age group above 40 years, 53.3% of them were male, and 46.7% female. also, it shows that 26.6% had no formal education. with regard to the place where he grew up the highest percentage 56.7% was in urban areas. the greatest percentage with regard to the duration of dialysis 56.7%, remains 4 hours on the dialysis machine. collected during the time from 1st may to 5th july 2023 in akre teaching hospital. the educational intervention was implemented at akra golan general hospital in akra city, and focused on four main domains (physical, psychological, social and environmental). the educational was implemented through four meetings, where patients were divided into five groups, each group included six patients according to the number of dialysis machines available in the hospital. information was provided in each session related to the patient's quality of life on dialysis, and the evaluation phase focused on knowing the impact of the educational program by using a similar quality of life questionnaire that was used in the initial tests directly and after one month of implementing the program. the primary guideline for gathering data was ethical considerations. therefore, before beginning the interview, patient must sign the informed permission form that the researcher has produced. before collection of data, the researcher clarified the study's goals for the patient and its appeal for participation. statistical package for the social sciences software was used to evaluate the data after it was collected. “spss 19” software. to determine the statistical significance of specific variables, the outcomes were given as frequencies, percentages, chi-square tests, and paired t-tests. a result is significant when the p-value is less than or equal to 0.05. 216 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result table 1: sociodemographic characteristics of (30) patients. variables characteristics no. (%) age 20-30 years 8 (26.7) 31-40 years 9 (30) above 40 years 13 (43.3) gender male 16 (53.3) female 14 (46.7) level of education no formal education 8 (26.6) illiterate 5 (16.7) primary school 5 (16.7) middle school 6 (20) collage and above 6 (20) the place where he/ she grew up urban 17 (56.7) rural 13 (43.3) duration hours of dialysis 3 hours 13 (43.3) 4 hours 17 (56.7) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article 217 posttest2 mean=64.2) and the p-value was shown (pre. p= 0.14, immediately. p= 0.00, and posttest. 2 p=0.02), although the mean scores of patients’ q.o.l. decreased statistically significant after thirty days of executing the program in comparison to right away subsequently carrying out the program. table 3 illustrates q.o.l scores of all patients in dialysis patients before, right away, and one month after the program's implementing. most of the studied patients 43.3% gained good q.o.l as soon as the program was implemented compared to 3.3% prior to putting the protocol into action. this high quality of life declined to 20% after thirty days from executing the program. figure 1 shows the total mean scores of patient’s q.o.l in dialysis patients prior to, immediately after and one month the program's implementation there was a statistically significant rise in patients’ q.o.l both immediately and one month after starting the program in comparison to prior to the program's implementation (pretest mean=57.3, posttest 1 mean = 68.3 and table 2 demonstrations mean scores of patient’s q.o.l in dialysis patients prior to, right away and one month after the program's implementation: the mean patient q.o.l scores increased statistically significantly in all domains except environmental during right away and thirty days after program execution in comparison to before program execution, while the quality of life decreased marginally significantly in all domains thirty days after program execution in comparison to right away after implementing a program. copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. figure (1) shows total mean scores of patient’s q.o.l in dialysis patients pre, immediately, after one month the program's implementation. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article 218 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: mean scores of patient’s q.o.l in dialysis patients pre, right away, and one month after the program's implementation. (n=30). table 3: total patient’s q.o.l scores in dialysis patients pre, right away, and one month after the program's implementation (n=30). domain no. of items pretest mean ± sd right away post test mean ± sd posttest after 1 month mean ± sd significance test t1 t2 t3 physical 7 19.67±5.07 21.70±3.97 21.17±3.73 t= (-3.47) p = 0.002 t=(2.36) p= 0.025 t= (2.44) p=0.021 psychological 7 15.9±3.94 18.47±3.20 18.23±3.35 t= (-4.06) p= >0.001 t=(-3.48) p= 0.002 t= (2.25) p= 0.032 social 3 6.1±1.21 7.83±2.45 7.43±2.58 t= (-2.85) p= 0.008 t=(-7.95) p= 0.015 t= (2.35) p=0.026 environmental 8 21.90±5.50 21.97±5.58 22.03±5.70 t=(1.44) p=0.16 t= (-1.28) p= 0.21 t= (-1) p = 0.327 (t1) test = pre-test and immediately post-test paired samples t-test. (t2) test=paired samples t-test between pre-test and thirty days post-test. (t3) test = paired samples t-test between immediately and thirty days post-test. p = significance score pre test immediately post test after one month post test significance test x2 1 x2 2 x2 3 no (%) no (%) no (%) x2= 23.86 p = 0.000 x2=7.8 p = 0.02 x2=6.18 p = 0.046 poor <50 % 23 (76.7) 5 (16.7) 13 (43.3) fair 50 -75% 6 (20) 12 (40) 11 (36.7) good >75% 1 (3.3) 13 (43.3) 6 (20) (x2 1) = chi square (significance) between pre-test and immediately post-test. (x2 2) =chi square (significance) between pre-test and thirty days post-test. (x2 3) = chi square (significance) between immediately and thirty days post-test. p = significance https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article sociodemographic traits and quality of life except level of education in the pretest, right away and after the one-month posttest. table 4 illustrates the association between patients q.o.l scores in dialysis patients and sociodemographic traits: there was no significant different between 219 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: shows relationship between total patient’s q.o.l score in dialysis patients and sociodemographic characteristics(n=30) p; poor f; fair g; good x21= base line relationship between level patient’s q.o.l score in dialysis patients and sociodemographic characteristics. x22 = immediately posttest relationship between level patient’s q.o.l score in dialysis patients and sociodemographic characteristics. x2 3= after 1 month posttest relationship between level patient’s q.o.l score in dialysis patients and sociodemographic characteristics. variables pretest n=30 right away posttest n= 30 after 1 month posttest n= 30 significance test q.o.l q.o.l q.o.l p f g p f g p f g x2 1 x2 2 x2 3 age 20-30 years 6 1 1 1 3 4 6 1 1 x2= 7.59 p = 0. 11 x2= 2.76 p = 0. 599 x2= 5.74 p = 0.22 31-40 years 5 4 0 3 3 3 4 3 2 above 40 years 12 1 0 1 6 6 3 7 3 gender male 10 5 1 2 6 8 7 6 3 x2= 3.94 p = 0. 14 x2= 0.76 p = 0. 68 x2= 0.35 p = 0.98 female 13 1 0 3 6 5 6 5 3 level of education no formal education 6 1 1 0 0 8 1 1 6 x2= 3.67 p = 0.88 x2= 15.68 p = 0.04 x2= 21.74 p = 0.005 illiterate 4 1 0 1 2 2 3 2 0 primary school 4 1 0 1 3 1 2 3 0 middle school 5 1 0 2 3 1 3 3 0 collage and above 4 2 0 1 4 1 4 2 0 the place where he/she grew up urban 14 2 1 3 8 6 8 7 2 x2= 2.26 p = 0.32 x2= 1.1 p = 0.58 x2= 1.67 p = 0.43 rural 9 4 0 2 4 7 5 4 4 duration hours of dialysis 3 hours 11 1 1 3 3 7 5 6 2 x2= 3.23 p = 0.19 x2= 2.79 p = 0.25 x2= 0.93 p = 0.63 4 hours 12 5 0 2 9 6 8 5 4 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article total qol. the aggregate average results for the patient's quality of life increased in a statistically meaningful way directly and thirteen days from executing the program in comparison to before executing the program, whereas statistically significant deterioration was seen in the mean patient q.o.l scores one month following the execution of a program compared to the program's initial implementation. this outcome was in line with the results of mohammed et al.[16] which they found in their study that patient counseling might enhance patients' health-related quality of life (qol) by raising their level of awareness and dispelling any misconceptions they may have regarding their disease's course and how to manage it. the current study revealed that no statistically significant difference existed between total quality of life and their age, gender, the place where they grew up, and duration of hours of dialysis. this finding conflicted with bayoumi et al.[17] who narrated that age and being a man were poor predictors of life quality. this conclusion also contradicted seica et al.,[18] claims that female gender and older age were all linked to lower quality of life. the study also revealed that there was a statistically significant difference between their level of education and their overall quality of life. this could be ascribed to an improvement in the patients' quality of life due to effective knowledge transmission from the researcher to them. this result is in disagreement with alshraifeen et at.,[19] studies have indicated a beneficial association between education level and quality of life. also, sathvik, b. s. et al.,[20] studies have revealed a favorable correlation between gender, education level, and quality of life. from the researcher’s point of view, perhaps the reason for this difference is due to the patients not receiving educational programs in hospitals that would increase a major side effect of chronic kidney disease (ckd) progression is end-stage renal disease (esrd), which has a meaningful global impact on morbidity and death. patients with hd deal with a variety of issues that have an impact on many areas of their lives[11]evaluation of hrqol in patients with chronic diseases like ckd has become a cornerstone of patient care and medical management. therefore, assessing qol in hemodialysis patients will assist in evaluating the level of care given and the effectiveness of medical treatment[12].regarding the effect of the educational program offered to patients, according to the current study, the average rating of patients' quality of life significantly improved both right away and one month after using the program compared to previously. these results are very comparable to the research of bakarman et al.,[13] the educational program's effects on hd patients' improved qol were evaluated eight weeks later, according to their statement. after health education, the results revealed a considerable enhancement in each domain. also, this finding goes with ghadam et al.,[14] demonstrating that after completing a self-care education program, hd patients' qol improved in all dimensions of direct communication training groups (p 0.001). regarding total patients' q.o.l score, the patients’ level was good of q.o.l soon following implementation of the program, which partially reduced after one month. this issue is agreement with the finding of abraham et al.,[15],which was demonstrated a striking disparity. during their first and second visits, hd patients in the test group experienced significant improvements in qol, but the control group experienced little to no change. when in comparison to the control group, the patients in the test group had an advanced 220 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article (8) d. l. mapes et al., “health-related quality of life as a predictor of mortality and hospitalization: the dialysis outcomes and practice patterns study (dopps),” kidney int., vol. 64, no. 1, pp. 339–349, 2003. (9) f. yang et al., “health-related quality of life of asian patients with end-stage renal disease (esrd) in singapore,” qual. life res., vol. 24, pp. 2163–2171, 2015. (10) s. m. skevington, m. lotfy, and k. a. o’connell, “the world health organization’s whoqol-bref quality of life assessment: psychometric properties and results of the international field trial. a report from the whoqol group,” qual. life res., vol. 13, pp. 299–310, 2004. (11) m. k. jahromi, s. javadpour, l. taheri, and f. poorgholami, “effect of nurse-led telephone follow ups (tele-nursing) on depression, anxiety and stress in hemodialysis patients,” glob. j. health sci., vol. 8, no. 3, p. 168, 2016. (12) c. bale et al., “psychosocial factors in endstage kidney disease patients at a tertiary hospital in australia,” int. j. nephrol., vol. 2016, 2016. (13) m. a. bakarman, m. k. felimban, m. m. atta, and n. s. butt, “the effect of an educational program on quality of life in patients undergoing hemodialysis in western saudi arabia,” saudi med. j., vol. 40, no. 1, p. 66, 2019. (14) m. s. ghadam, f. poorgholami, z. b. jahromi, n. parandavar, n. kalani, and e. rahmanian, “effect of self-care education by face-to-face method on the quality of life in hemodialysis patients (relying on ferrans and powers questionnaire),” glob. j. health sci., vol. 8, no. 6, p. 121, 2016. (15) s. abraham, a. venu, a. ramachandran, p. m. chandran, and s. raman, “assessment of quality of life in patients on hemodialysis and the impact of counseling,” saudi j. kidney dis. transplant., vol. 23, no. 5, pp. 953– 957, 2012. (16) i. s. salam and m. a. abdelhady, “impact of teaching guidelines on quality of life for hemodialysis patients,” nature and science,vol. 8 , no. 9, p. 219, 2011. (17) m. bayoumi, a. al harbi, a. al suwaida, m. al ghonaim, j. al wakeel, and a. mishkiry, “predictors of quality of life in hemodialysis patients,” saudi j. kidney dis. transplant., vol. 24, no. 2, pp. 254– 259, 2013. the quality of life in renal failure at its last stage. the results of the present study indicate that enhancing educational initiatives and hemodialysis patients' counseling results in an improvement that is both clinically and statistically meaningful in their qol. also, these initiatives will raise social, emotional, physical, and overall hrqol scores. furthermore, the results demonstrate the importance of providing routine counseling during the daily lives of dialysis patients in order to improve their quality of life. (1) k. landreneau, k. lee, and m. d. landreneau, “quality of life in patients undergoing hemodialysis and renal transplantation-a meta-analytic review,” nephrol. nurs. j., vol. 37, no. 1, p. 37, 2010. (2) 2e. nemati and m. motalebi, “a better quality of life in hemodialysis patients with viral hepatitis: is it a reality?,” hepat. mon., vol. 13, no. 11, 2013. (3) z. wen et al., “health related quality of life in patients with chronic gastritis and peptic ulcer and factors with impact: a longitudinal study,” bmc gastroenterol., vol. 14, pp. 1– 10, 2014. (4) a. h. a. mazairac et al., “differences in quality of life of hemodialysis patients between dialysis centers,” qual. life res., vol. 21, pp. 299–307, 2012. (5) s. w. klarenbach, m. tonelli, b. chui, and b. j. manns, “economic evaluation of dialysis therapies,” nat. rev. nephrol., vol. 10, no. 11, pp. 644–652, 2014. (6) a. h. pakpour, i. m. zeidi, n. chatzisarantis, s. molsted, a. p. harrison, and r. c. plotnikoff, “effects of action planning and coping planning within the theory of planned behaviour: a physical activity study of patients undergoing haemodialysis,” psychol. sport exerc., vol. 12, no. 6, pp. 609–614, 2011. (7) y. lii, s. tsay, and t. wang, “group intervention to improve quality of life in haemodialysis patients,” j. clin. nurs., vol. 16, no. 11c, pp. 268–275, 2007. 221 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.20 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article (18) a. seica et al., “factors affecting the quality of life of haemodialysis patients from romania: a multicentric study,” nephrol. dial. transplant., vol. 24, no. 2, pp. 626–629, 2009. (19) a. alshraifeen, m. mccreaddie, and j. m. m. evans, “quality of life and well‐being of people receiving haemodialysis treatment in s cotland: a cross‐sectional survey,” int. j. nurs. pract., vol. 20, no. 5, pp. 518–523, 2014. (20) b. s. sathvik, g. parthasarathi, m. g. narahari, and k. c. gurudev, “an assessment of the quality of life in hemodialysis patients using the whoqol-bref questionnaire,” indian j. nephrol., vol. 18, no. 4, p. 141, 2008. 222 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2023 original article effect of tracheostomy care training on nurse’s performance at critical care units in erbil city abstract background and objectives: tracheostomy is one of the oldest known surgical procedures. tracheostomy patients are at high risk for airway obstruction, impaired ventilation, and infection as well as other lethal complications. skilled bedside nursing care can prevent these complications. therefore, this study aimed to evaluate the effect of progressive tracheostomy care practice on nurses and physiotherapists in the icu and rcu in erbil city-iraq. methods: a quasi-experimental study was conducted at four intensive care units (icu) and respiratory care unit (rcu) hospitals (hawler teaching hospital, east emergency hospital, west emergency hospital, and lalav rcu hospital) in erbil city/iraqi kurdistan region. nurses and physiotherapists from hospitals were selected as the control group, and study group respectively. nurses and physiotherapists were evaluated through the demographic data questionnaire and tracheostomy care (preparatory phase, performance phase, and follow-up phase) scale. results: a total of 90 nurses and physiotherapists (40 nurses and 5 physiotherapists from the interventional group and 38 nurses and 7 physiotherapists from the control group) participated. at the end of the study, there were significant improvements in tracheostomy care practice (p-value was 0.001). conclusion: nurses and physiotherapists had incompetent practice regarding tracheostomy care (tc) in the icu, and rcu and the nurses and physiotherapists who received progressive tracheostomy care procedure training had more knowledge and practice than those who did not attend this program. attempts should focus on improving tracheostomy care in icus and rcus and establish management guidelines. keywords: effect; nurses; practice; tracheostomy. yousif bakr omar; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: yousif.omar@hmu.edu.krd) abdullah faqiyazdin ahmed; kbms and college of medicine, hawler medical university, erbil, iraq. 125 received: 15/07/2022 accepted: 29/09/2022 published: 30/11/2023 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:yousif.omar@hmu.edu.krd)?subject=yousif.omar@hmu.edu.krd) mailto:yousif.omar@hmu.edu.krd)?subject=yousif.omar@hmu.edu.krd) mailto:yousif.omar@hmu.edu.krd?subject=yousif.omar@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2023 original article tracheostomy is one of the oldest and most famous surgical procedures. tracheostomy is a rescuing procedure done for emergency open-airway inpatients with upper respiratory tract obstruction. needs to be opened in the trachea or stoma, and then a tube is inflicted through the gate to the passage of air and remove respiratory or other secretions through the tracheostomy. according to some authors, tracheostomy is more permanent opining when described in this terms [1].airway obstruction is a life-threating and medical emergency that needs artificial airway support, such as the use of tracheostomy. a capable nurse is required to educate the patient or their relatives, to help in the supply of care, and to finance the obviousness of the airways [2]. a greater number on third of patients in rcus and icus will need tracheostomy tube for long-period ventilation. recently, there have been an estimated 6.5 million people in the united states living with tracheostomy despite of its increasing prevalence, care of the stoma is a’’ high-risk, low -incidence skill’’ that is in many cases educated as described interesting knowledge from one provider to another [3]. this term (tracheostomy) is increasingly carried out in icus and rcus by adults for upper airway protection or maintenance, airway obstruction, bronchial cleaning, lengthening mechanical ventilation, and promoting weaning. the tracheostomy causes physical changes in the person, such as body image, airway clearance, communication, breathing, smell, and swelling. these often cause social and psychological outcomes. these changes can also self-esteem, and the sense of self-efficacy and often reduce interpersonal and social relationship activity [4]. nurses are a frontline caregiver and first react in an airway emergency. as much, need to be provided to replay appropriately to prevent unnecessary mortality and morbidity, being sufficient knowledgeable of the respiratory system, anatomical tracheostomy, and underline physiology are necessary aspects of a nurse’s ability to sufficiently assess and care for patients both knowledge and practice essential main component in exactly identifying potential problems and acting immediately to prevent serious complications. complications associated with nurses who are absent the essential skills and training are mucus plugging, accidental decannulation, bleeding, tube displacing inappropriate or inadequate tracheostomy suctioning, or complications during tracheostomy change [5].an important surgery called a tracheostomy is used to help patients with respiratory distress secure their airways so that they can receive adequate care and avoid situations that could lead to death. the practice problem is that, as seen during yearly competency evaluations, staff nurses have shown poor knowledge, abilities, and confidence in the delivery of care to patients living with a tracheostomy. for instance, despite evidence that the practice is unsafe; nurses are continuing to caring for patients with tracheostomies by installing a standard saline bullet into the ostomy to break up mucus. additionally, the nurses are not adhering to the advised practice when making judgments about tracheostomy care on an individual basis. additionally, they are not keeping the necessary supplies in patient rooms to act quickly if a tracheostomy tube comes loose.the objective of this study is to evaluate the effect of progressive tracheostomy care on nurses and physiotherapists in icus and rcus in erbil city-iraq. 126 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2023 original article and the remaining 90 were recruited). participants were randomly assigned to control or intervention groups using a numbered list of names (the odd names recruited into the control group and the even names recruited into the intervention group) with proper matching of the two groups in factors such as age, sex, academic qualification, marital status, years of experience, and attending training course. after the exclusion of the 40 nurses for a variety of reasons, including (the limitation of their time and having second jobs), an interview was performed for 45 participants (40 nurses and 5 physiotherapists) in the intervention group and 45 participants (38 nurses and 7 physiotherapists) in the control group (figure 1). control and interventional groups of nurses and physiotherapists were recruited as per the quasi-experimental study design from the intensive care unit (icu) and respiratory care unit (rcu) of four hospitals (hawler teaching hospital, east emergency hospital, west emergency hospital and lalav rcu hospital) in erbil city/iraqi kurdistan region. inclusion criteria: include nurses and physiotherapists who provided tracheostomy care for patients admitted to rcu and icu, both genders, who had experience at least one year, and also who have graduated from [hawler medical institute (nursing institute which also includes physiotherapy department and/ or nursing college)]. after an interview with 130 nurses and physiotherapists (40 nurses and physiotherapists refused to enroll in the study 127 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods assessed for eligibility (n= 130) assessment for eligibility of nurses in intervention group (n= 47) not meeting inclusion criteria=1 enrolment assessment for eligibility of nurses in control group (n=83) not meeting inclusion criteria=38 intervention group (n=46) dropouts for variety reasons (n=1) allocation control group (n=45) no dropouts for variety reasons follow up figure 1. flow diagram of control and interventional group of tracheostomy care. assessment after three months (n=45) assessment after three months (n=45) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2023 original article in a 20-minutes direct interview with participants (face to face), the questionnaire and check lists were filled out; five minutes for sociodemographic data, and 15 minutes for observing participants during practices by the researcher in pre and posteducational programs two times per week. the program was developed from the fundamental of nursing, lippincott manual of nursing practice and tracheostomy care program [6,7,8]and validated by expert recommendations the study questionnaire consisted of socio demographic characteristics including (age, sex, academic qualification, marital status, years of experience, and attending training courses) and the practice (6 items included for suctioning the trachea during tracheostomy care and 27 activities to be done). the practice was prepared for three tracheostomy care aspects (preparatory phase, performance phase, and follow-up phase). each of the aspects of tracheostomy scores on a 2point scale (0: not achieved and 1 achieved). thus, scores on each subscale range from 0 to 33. good scores indicate good performance of the practice; the categories of pre and post-practice are interpreted as poor (below 16), fair (16-24), and good (25-33).at the beginning of the study, the two groups were interviewed and the data were taken (a questionnaire was filled out and checklist completed), then the tracheostomy care practice level of participants in both groups was evaluated (pretest), and then the intervention group underwent the tracheostomy care practice training ( 4 hours per week for two successive weeks). all the participants carried on their official duties at the icus and rcus of their hospitals. three months later, participants from both groups were interviewed again and evaluated for their levels of tracheostomy care practice (post-test). ethical consideration was the main principle in data collection. permission is taken from nurses before starting the interview by signing the informed consent prepared by the researcher. the researcher is fully aware of research ethics; therefore, nurses dignity, values, and protection from impacts that could happen during data collection. before data collection, the researcher explained the objectives of this study for nurses and the request for participation in this study. the answers and information raised from the study were kept confidential and used for this study only. in addition, the researcher provided opportunities for participants to ask questions or express concerns at any point. moreover, the local ethical approval was obtained from the ethical committee of hawler medical university at the college of nursing to conduct the study. the date was october 25, 2020, and the code number was 129. data were analyzed through the spss (version23) application for statistical data analysis based on the objective by using descriptive and inferential statistics. [frequency, percentage, mean, and standard deviation] and t-test. table1 shows that the number of participants (nurses and physiotherapist) was 45 per each of the control groups and the intervention. participants were grouped into 3 age categories, where the category of 20 -31 years scored the highest percentage among both groups of participants (44.4%). the gender distribution was 66.7% and 71.1% female in the control and intervention groups, respectively. the qualifications of participants were 57.8% diploma graduates from hawler medical technical institute (nursing and physiotherapist) in the control group and 53.3% in the intervention group. according to the marital status 57.8% and 60% were married in intervention and control groups, 128 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2023 original article 129 there were no significant differences between the socio demographic characteristics of the nurses and physiotherapists in intervention and control groups (p. value ≥ 0.05). follow-up phase) in the pre-test, while a very high significant difference result was observed in the post-tests after three months in the study group (pvalue=0.001). respectively; most of participants at both control and interventional groups had 1-4 years of work experience in critical care units (73.3%). the majority of the participants had not attended any previous training on tracheostomy care (91.1% of the control group and 95.6% of the interventional group). table 2 reveals that there is no statistically significant difference between the control and intervention groups regarding doing tracheostomy care (preparatory phase, performance with suctioning phase, and copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1 : socio-demographic characteristic of nurses items control group (n=45) intervention group (n=45) p. value f (%) f (%) 0.170 age group/years 20-31 29 (64.4) 30 (66.7) 32-43 12 (26.7) 13 (28.9) 44-55 4 (8.9) 2 (4.4) sex male 15 (33.3) 13 (28.9) 0.160 female 30 (66.7) 32 (71.1) qualification institute 26 (57.8) 24 (53.3) 0.160 college 19 (42.2) 21 (46.7) marital single 19 (42.2) 18 (40.0) 0.323 married 26 (57.8) 27 (60.0) work experience in critical department (rcus & icus)/years 1-4 33 (73.3) 33 (73.3) 0.209 5-8 8 (17.8) 8 (17.8) 9-12 4 (8.9) 4 (8.9) tracheostomy care training yes 4 (8.9) 2 (4.4) 0.160 no 41 (91.1) 43 (95.6) table 2 tracheotomy care practice mean score in pre and post tests tc control group mean intervention group mean t-test p-value c.n pre-tests 10.7333 10.8000 0.404 ns posttest (after 3 months) 10.4667 27.7111 0.000 vhs https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2023 original article a control group in both pre and post-test 95.6%, while in the intervention group the performance was poor level in the pre-test 97.8 % and good level at the post-test 91.1 %. result of the present study shows that the highest percentage of the study sample was married and this result was supported by nwakaego (2016) [16]. the intensive care facilities are lacking in erbil and the nurses and physiotherapists usually rotate among governmental hospitals departments according to moh rules. this affected on years of work of participants (majority of study sample were within 1-4 year work group, a finding of this study similar to the study by pritchett etal (2019) and khanum, et.al. (2021) [17,18]. in regard to the training program for nurses and physiotherapists in critical care units in erbil city, the results indicated that the majority of the study sample did not attend any training courses in chest physiotherapy, possibly because of a lack of interest in attending and a lack of encouragement and training programs by their institution; on the other hand, there may be limited time to attend such trainings because of long duties at icus and rcus , this result agreed with the results of the studies conducted by alnemare (2020) and qalawa 130 table3 shows the performance of tracheostomy care practices in pre and postprocedures (preparatory phase, performance with tracheostomy suctioning phase, and follow-up phase), where apoor level of performance was observed in in this study, the ages of the participants in the control group (20-31) (64.4%) and intervention group (20-31) (66.7%) were consistent with the results of thomas and dhudum (2021), and babiker and yousif (2016) [9, 10].the majority of the study samples were females; this finding is supported by padma et al. (2016) [11] study and mwakanyanga etal (2018) with abdulrahman, and hamed (2015) study. [12,13], possibly because of a cultural belief in the kurdistan region that females can better manage nursing duties and hence more encouraged to attend such carriers. for decades, the only teaching institution for nursing and physiotherapist in hawler (erbil) was hawler medical institute which used to provide diploma certificates, and it is just recently that more institutions and nursing and physiotherapist colleges established, that is why the majority of participants were diploma graduates, which means fewer years of study and training, this result agreed with the result conducted by ochoki etal. (2021) mungan, etal. (2019) [14, 15]. the copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3 : overall tracheostomy care practices level in pre and post test. tc practice level control group intervention group pre test post test pre test post test f (%) f (%) f (%) f (%) poor 43 (95.6) 43 (95.6) 44 (97.8) 0 (0) fair 2 (4.4) 2 (4.4) 1 (2.2) 4 (8.9) good 0 (0) 0 (0.0) 0 (0) 41 (91.1) discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2023 original article we are thankful to the nurses and physiotherapists for giving their time to interview with us and providing reliable practice. ethical consideration was the main principle in data collection. permission is obtained from nurses and physiotherapists before starting the interview by signing the informed consent prepared by the researcher. the researcher is fully aware of research ethics; therefore, nurses and physiotherapists dignity, values, and protection from impacts that could happen during data collection. before data collection, the researcher explained the objectives of this study for nurses, and physiotherapists, and the request for participation in this study. the answers and information raised from the study were kept confidential and used for this study only. in addition, the researcher provided opportunities for participants to ask questions or express concerns at any point. finally, the results of the study were given to all the participants of the study. moreover, the local ethical approval was obtained from the ethical committee of hawler medical university, at college of nursing to conduct the study. the authors declare that they have no competing interests. etal (2017) [19,20].the present study showed that three months after cpt training, the performance of participants in the intervention group improved statistically very significantly (pvalue < 0.000) as compared to control group. the performance difference between the two groups was not significant at baseline evaluation (pretest pvalue = 0.632); the mehta etal (2019) [21] and other studies [22,23,24,25,26,27,28] did not show the difference in performance between intervention and control group in pre-test but showed a significant difference in the tracheostomy care program at the post-test. furthermore, the findings of the present study found that the majority of both the intervention and control groups had poor level scores regarding the performance of chest physiotherapy in the pre-test. after three months of training, the score changed just in intervention group from poor to good performance in the post test. this result was in concordance with the study done by frota, et.al. (2013) [29] and other studies [30,31]. studied nurses and physiotherapists had incompetent practice regarding tracheostomy care in intensive care units and respiratory care units in erbil hospitals, while those who underwent training for three months improved in their practice of three phases (preparatory phase, performance phase, and follow-up phase) of tracheostomy care. attempts should focus on improving tracheostomy care among nurses and physiotherapists at icus and rcus and establish protocols to be developed according to guidelines. 131 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion acknowledgements ethics approval and informed consent to participate conflict of interest https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2023 original article (2021); vol. 25, issue 3, pages. 7193 – 7203. available from:https://www.annalsofrscb.ro/ index.php/journal/article/view/2249 [accessed: 14th jan 2022]. [10] babiker ma, and yousif ym., assessment of nurses knowledge and practice regarding tracheostomy care in almak nimer university hospital. shendi university faculty of postgraduate studies and scientific research. (2016). available from:http:// repository.ush.sd:8080/xmlui/ handle/123456789/418 [accessed: 21th jun 2022]. [11] padma k, arundathi s, latha a, dr. indira s, and sreelakshmi t. a study to assess the knowledge regarding tracheostomy care among staff nurses and nursing students in narayana medical college and hospital, nellore. international journal of advanced scientific research. (2016); 1 (3): 05-08. available from: http:// www.allscientificjournal.com/ archives/2016/vol1/issue3/1-3-14 [accessed: 18th jun 2022]. [12] mwakanyanga et, masika gm, and tarimo ea. intensive care nurses’ knowledge and practice on endotracheal suctioning of the intubated patient: a quantitative crosssectional observational study. plos one journal. (2018); 13(8): e0201743. available from: https://doi.org/10.1371/ journal.pone.0201743 [accessed: 29th nov. 2021]. [13] abdulrahman,and hamed ee. effect of an educational training program in tracheostomy care on nurses’ knowledge and skills at sennar teaching hospital. university of khartoum. (2015). available from: http:// khartoumspace.uofk.edu/items/4b12024b98d7-40a7-9c44-2521c0520f42 [accessed: 2th dec. 2021]. [14] ochoki no, kyalo ma, and githinji me. health system factors associated with adherence to tracheostomy care guidelines among critical care nurses at a national referral hospital in kenya. international journal of nursing science. (2021); 11(2): 36 -40 11(2): 36-40 available from: http:// article.sapub.org/10.5923.j.nursing.20211102.0 2.html [accessed: 30th nov. 2021]. [15] mungan i, kazancı d , bektaş ş, sarı s, çavuş m, and turan s. the evaluation of nurses’ knowledge related to tracheostomy [1] rajesh o, and meher r. historical review of tracheostomy. the internet journal of otorhinolaryngology.(2013); 4 (2). available from:http://ispub.com/ ijorl/4/2/7498 [accessed: 31th dec 2021]. [2] gaterega t, mwiseneza j, and chironda g. nurses knowledge and practices regarding tracheostomy care at a selected referral hospital in rwanda – a descriptive crosssectional study. international journal of africa nursing sciences. (2021); 15(2):100350. available from: https://doi.org/10.1016/ j.ijans.2021.100350 [accessed: 18th jun 2022]. [3] mcdonough k, crimlisk j, nicholas p, cabral h , quinnek, and jalisi s. standardizing nurse training strategies to improve knowledge and self-efficacy with tracheostomy and laryngectomy care. applied nursing research. (2016); 32: 212-216. available from: https://www.sciencedirect.com/science/ article/pii/s0897189716301215 [accessed: 22th jun 2022].. [4] queirós smm, pinto iem, de brito mac, and de brito santos csv., (2021). nursing interventions for the promotion of tracheostomy selfcare: a scoping review. journal of clinical nursing . (2021); 30(21-22):30553071.00:1–17. available from: https:// onlinelibrary.wiley.com/doi/abs/10.1111/ jocn.15823[accessed: 15th jan 2022]. [5] onuoha j. developing an educational program for tracheostomy care. walden university. (2019). available from: https://scholarworks.waldenu.edu/ dissertations/6934/ [accessed: 22th jun 2022]. [6] perry a, potter p, and ostendorf w. clinical nursing skills & techniques. 8th ed. canada. elsevier mosby publishing; (2014). [7] potter p, perry a, stockert p, and hall a, fundamentals of nursing. nineth editions. united states of america. 9th ed. elsevier publishing; (2017). [8] nettina sm., lippincott manual of nursing practice. 11th ed. china. wolters kluwer publishing; (2019). [9] thomas lb, and dhudum b., a study to assess the knowledge and practices for endotracheal care among staff nurses working in selected hospitals of pune. annals of the romanian society for cell biology journal. 132 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2023 original article pmc6684148/ [accessed: 16th jun. 2022]. [22] qadir mb. a study to assess the impact of structured teaching programme on knowledge regarding tracheostomy care among staff nurses working in selected hospital of kashmir. international journal of nursing research (ijnr). (2018); 4 (1): 29-35. available from: innovationalpublishers.com/ journal/ijnr [accessed: 16th jun. 2022]. [23] yelverton jc, nguyen jh, wan w, kenerson mc, and schuman ta. effectiveness of a standardized education process for tracheostomy care. the american laryngological, rhinological and otological society, inc. (2015);125(2): 342-347. available from: https://onlinelibrary.wiley.com/doi/ abs/10.1002/lary.24821[accessed: 18th jun. 2022]. [24] agarwal a, marks n, wessel v, willis d, bai s, tang x, ward wl, schellhase de, and carroll jl. improving knowledge, technical skills, and confidence among pediatric health care providers in the management of chronic tracheostomy using a simulation model. pediatric pulmonology. (2016) 51 (7): 659-766. available from: https:// onlinelibrary.wiley.com/doi/abs/10.1002/ ppul.23355[accessed: 16th jun. 2022].. [25] sodhi k, shrivastava a, and singla m. implications of dedicated tracheostomy care nurse program on outcomes. japanese society of anesthesiologists. (2014); 28(3):37480. available from: https:// pubmed.ncbi.nlm.nih.gov/24097169/ [accessed: 16th jun. 2022]. [26] bayram sb, and caliskan n. effect of a gamebased virtual reality phone application on tracheostomy care education for nursing students: a randomised controlled trial. nurse education today. (2019); 79: 25-31. available from: https:// www.sciencedirect.com/science/article/abs/ pii/s0260691718305240?via%3dihub [accessed: 24th jun. 2022]. [27] prickett k, deshpande a, paschal h, simon d,and hebbarkb. simulation-based education to improve emergency management skills in caregivers of tracheostomy patients. international journal of pediatric otorhinolaryngology. (2019); 120: 157-161. available from: https://www.sciencedirect.com/ science/article/abs/pii/ s016558761930031x?via%3dihub. [accessed: 24th jun. 2022]. care in tertiary intensive care units. international medicine. (2019); 1(6): 313-318. available from: mno=54258 [accessed: 16th jun. 2022]. [16] nwakaego o. knowledge and practice of tracheostomy care: a case of federal medical centre, umuahia south east of nigeria. texila international journal of nursing. (2016); 2 (2). available from: https:// www.texilajournal.com/nursing/article/599knowledge-and-practice [accessed: 18th jun. 2022]. [17] pritchett cv, rietz mf, ray a , brenner mj, and brown d. inpatient nursing and parental comfort in managing pediatric tracheostomy care and emergencies . jama otolaryngol head neck surg. (2016); 142 (2):132 -137. available from: http:// archotol.jamanetwork.com/. [accessed: 5th jul. 2022]. [18] khanum t, zia s, khan t, kamal s, khoso mn, alvi j, and ali a. assessment of knowledge regarding tracheostomy care and management of early complications among healthcare professionals. brazilian journal of otorhinolaryngology. (2021); 88 (2):251-256 available from: https:// pubmed.ncbi.nlm.nih.gov/34419386/. [accessed: 5th jul. 2022]. [19] alnemare ak. nurses training and onϐ dence in management of tracheostomy patients in a community hospital in saudi arabia. journal of research in medical and dental science. (2020); 8 (5): 110-118. available from: https://www.jrmds.in/articles/nursestraining-and-confidence-in-management-oftracheostomy-patients-in-a-communityhospital-in-saudi-arabia-authors.pdf [accessed: 17th jun. 2022]. [20] qalawa sa, diab ae, gazzar se, and elgawab hm. quality of nursing care on patient with tracheostomy. port said scientific journal of nursing. (2017); 4 (1):202-215. available from: https:// pssjn.journals.ekb.egartcle_33096_95fe012f 99bf64e02fee24b1493773b9.pdf [accessed: 18th oct. 2021]. [21] mehta k, schwartz m, falcone te, and kavanagh kr. tracheostomy care education for the nonsurgical first responder: a need based assessment and quality improvement initiative. american academy of otolarengologyhead and neck surgery, oto open. (2019); 3(2):1-6. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ 133 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.14 erbil j. nurs. midwifery, vol. 5, no. (2), nov 2023 original article [28] kaur k. a pre-experimental study to assess the effectiveness of structured teaching programme on knowledge and practice regarding tracheostomy care among staff nurses at selected hospitals of punjab. international journal of science and research (ijsr). (2019); 8 (3): 593 – 598. available from: https://www.ijsr.net/ get_abstract.php?paper_id=art20196062 [accessed: 17th dec. 2021]. [29] frota op, rolan loureiro md, and ferreira am., (2013). knowledge about endotracheal suctioning on the part of intensive care nursing professionals: a descriptive study. online brazilian journal of nursing. (2013); 12 (3): 546-554. available from: https:// www.redalyc.org/ pdf/3614/361433917013.pdf [accessed: 18th dec. 2021]. [30] singh r , and raghavendran m.a study to assess the effectiveness of video assisted teaching module on knowledge regarding tracheostomy care among b.sc. nursing students in selected colleges in kanpur. iosr journal of nursing and health science. (2020); 9 (6): 40-44. available from: https:// www.iosrjournals.org/iosr-jnhs/papers/vol9 -issue6/series-1/f0906014044.pdf [accessed: 17th july 2022]. [31] varshney s, sharma sk, and jelly p. tracheostomy suctioning: exploration of knowledge and practices of nurses working in selected tertiary care hospitals in uttarakhand state. nursing and midwifery research journal. (2017); 13 (2). available from: https://journals.sagepub.com/doi/ abs/10.1177/0974150x20170203 [accessed: 16th jun 2022]. 134 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.15 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article health related quality of life among patients with prostate cancer in erbil, iraq abstract background and objectives: prostate cancer is one of the most common types of cancer that affects men, especially older men. the quality of life of men with prostate cancer is affected by several things, such as how long it has been since they were diagnosed and their body mass index. the study aims to identify health-related quality of life domains of participants and compare health-related quality of life among prostatic cancer patients with their body mass index and time passed from cancer diagnosis. methods: a quantitative descriptive cross-sectional study was conducted from february 2024 to february 2025 on 100 male patients with prostate cancer. sociodemographic data forms and the european organization for research and treatment of cancer quality of life questionnaires (core 30) and the prostate cancer module (25 items) were used to collect data from the participants. descriptive and inferential statistics were used to analyse data by using the statistical package for the social science spss (version 25). results: half of the participants were aged 70 or older, and more than half were illiterate and retired. health-related quality of life function scores differed significantly with body mass index at p-value in role (0.017), emotional (0.010), social (0.016), and sexual functioning (0.006), with normal body mass index patients showing better outcomes. in addition, significant differences were reported between the time elapsed since cancer diagnosis and symptoms such as urinary issues (p-value 0.043), bowel problems (0.009), hormonal symptoms (0.004), and sexual activity (0.019). conclusion: the study concluded that both body mass index and time since diagnosis significantly affect health-related quality of life in prostate cancer patients. keyword: health-related quality of life; prostate cancer; body mass index; time since diagnosis; european organization for research and treatment of cancer quality of life hiwa ahmed omar; department of nursing, college of nursing, hawler medical university, erbil, kurdistan regioniraq (correspondence: hiwa.aomar@hmu.edu.krd) berivan star hamad ameen; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region-iraq bakhtyar othman omer; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region-iraq yousif bakr omar; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region-iraq 144 received: 27/07/2025 accepted: 11/09/2025 published: 30/11/2025 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:hiwa.aomar@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.15 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article prostate cancer (pca) is the second most frequent cancer in males and the fourth most common type of cancer overall [1]. in 2018, there were 1.3 million new cases diagnosed with prostate cancer in males around the world [2]. a recent analysis of data suggests that pca is the most frequent type of cancer among men in the us, with the number of new cases growing by 21% per year [3]. prostate cancer is becoming more common and is the most common cancer in men in europe. it has great and big effects on healthcare systems in the world. about 450,000 european males are diagnosed with prostate cancer each year. it has surpassed colorectal cancer and is now the second most prevalent cause of cancer death in men. the number of deaths due to prostate cancer was 107,000 men in europe in 2018, so it is not a slow-moving illness, but it is increasing more frequently. prostate cancer ranks as one of the cancers, which affect patients’ quality of life [4]. age and the length of time the disease lasts are just two out of many other factors that affect the quality of life in patients with this disease. knowing and awareness about these factors has a huge impact on the quality of life of patients to know how to deal with the disease and the disease affects the quality of life of patients after affecting them with prostate cancer, because one of the worst things that can happen to a patient's health is the impairing of quality of life [5]. most prostate tumors are confined when they are found (clinical stage t1a to t2c, with no signs of lymph node invasion or distant metastases) [2]. the five-year relative survival rate for localized prostate cancer is around 100%, which is far higher than the general population. the survival rates for all stages are 98% and 96% at 10 and 15 years, respectively [6]. as a result, the health-related quality of life (hrqol) of patients with prostate cancer (pca) often declines over time, particularly three years after diagnosis [7]. having a high quality of life (qol) does not mean living longer [8]. to find out how well cancer treatments work, it is necessary to examine both the cancer survival rate and the health-related quality of life (hrqol) of people with pca. prostate cancer is a condition that mostly affects the quality of life of the patient, making it difficult for them to do everyday things. patients and their families have many emotional and social challenges because of a chronic sickness [9]. this study aimed to identify health related-quality of life domains in patients with prostate cancer and compare it with body mass index and time passed from prostate cancer diagnosis. a descriptive cross-sectional study design was carried out from february 2024 to may 2025 among 100 patients who were diagnosed with prostate cancer at rizgary and nanakaley teaching hospitals in erbil city. the sample size was determined by z2 p q/ d2, z = confidence interval 95% (1.96), p= prevalence= (0.07), q = (1-p) = (0.93), d = sampling error (0.05) [10]. non-probability, purposive sampling techniques were used to collect the relevant study data. the inclusion criteria include adult male patients more than 18 years old who had pca and were diagnosed with pca more than three months. the exclusion criteria included patients who had psychiatric or mental problems and patients with communication problems. the researcher obtained an approval letter from the ethics committee at hawler medical university/ college of nursing (code no.2475, date 1/1/2024). the official approval was taken from the general directorate of health, rizgary and nanakaly teaching hospitals in erbil city. ء 145 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.15 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article in symptom domains, the higher score means worse condition [5]. regarding data analyses statistical package for social science (spss) version 25, was used for calculating descriptive statistical data analysis (such as frequency, percentage, mean and standard deviation), and for comparison of health-related quality of life (hrqol) with body mass index and time since cancer diagnosis, inferential statistical data analysis (anova test) was used. table 1 shows the distribution of sociodemographic characteristics of 100 patients diagnosed with prostate cancer pca, half of them 50% were aged 70 years and older, while 33% were between 60–69 years, and the lowest 17% were below 60 years. all participants were married. regarding education, 52% were illiterate, 21% had elementary education, 18% had institute-level education, and only 9% had a college degree respectively. in terms of occupation, 51% were retired, 37% unemployed, and only 12% were employed. less than half, 38%, of the participants reported needing help with daily living activities, while 62% were independent. regarding the time since diagnosis, 46% had been diagnosed for 1–3 years, 28% for less than one year, and 26% for more than 3 years. additionally, 42% of the patients reported being smokers, and 37% had a history of sexual problems prior to diagnosis. regarding bmi, 45% of the patients had normal weight, 35% of them were overweight, and 20% were obese. informed consent was obtained from patients after explaining the aim of the study before starting the interview. data collected by questionnaire includes three parts: the first part is "socio-demographic characteristics," like age, marital status, level of education, occupation, need for help with daily tasks, time since cancer diagnosis, underlying disease, smoking habit, history of sexual problems before cancer diagnosis, and body mass index (bmi). the second part is about quality of life and uses a questionnaire made by the european organization for research and treatment of cancer. the quality of life questionnairecore 30 version 3 (eortc qlqc30 v. 3), has 30 questions in total, divided into five functional scales: physical, role, cognitive, emotional, and social function. there were also nine symptom scales and one global health-status/quality of life scale. the symptom scales measured fatigue, nausea, pain, shortness of breath, insomnia, loss of appetite, constipation, diarrhea, and financial problems. there were four possible answers for each question: "not at all" (1), "a little" (2), "quite a little" (3), and "very much" (4). the worldwide health-status/ quality of life scale featured answers that ranged from very poor (1) to excellent (7) [5]. the third part: the prostate cancer module of the quality of life questionnaire (eortc qlq pr25), has 25 questions, which are divided into six symptom scales and function: urine symptoms, bowel symptoms, incontinence, hormone symptoms, sexual activity, and sexual function. there were four answers for each item: not at all (1), a little (2), quite a little (3), and very much (4). [11]. the questionnaires gave us a formula to use to figure out the function score, which was then changed to a number between 0 and 100. the scores for each domain were given separately. in the functional domains, a higher scores meant a better condition but 146 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.15 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article table 2 shows health-related quality of life (hrqol) scores, between body mass index (bmi) categories (normal, overweight and obese). patients with normal bmi had higher scores in physical functioning (29.78 ± 24.40), role functioning (31.11 ± 26.73), and emotional functioning (31.39 ± 20.79), indicating better quality of life compared to overweight and obese patients. bmi significantly affected p-values for emotional functioning (0.010), role functioning (0.017), social functioning (0.016), and sexual functioning (0.006), with obese individuals reporting lower scores in these domains. however, global health status, fatigue, and pain did not differ significantly by bmi categories pvalue (> 0.05). table 3 revealed that the comparing health -related quality of life (hrqol) score with the time passed since cancer diagnosis, as a general patients diagnosed from 1–3 years ago had higher scores in role functioning (28.53 ± 24.53) and emotional functioning (28.67 ± 20.56) compared to those recently diagnosed or with longterm diagnoses (>3 years). time since diagnosis significantly affected at p-values for urinary symptoms (0.043), bowel symptoms (0.009), hormonal symptoms ( 0.004), and sexual activity (0.019). other domains such as fatigue, pain, and global health status in these findings showed no statistically significant differences across the diagnosis duration groups. 147 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table1: socio-demographic characteristics of prostate cancer patients (n = 100) socio-demographic characteristics category frequency (n) percent (%) age group >60 17 )17( 60–69 33 )33( ≥70 50 )50( marital status married 100 )100( educational level illiterate 52 )52( elementary 21 )21( institute 18 )18( college 9 )9( occupation employed 12 )12( unemployed 37 )37( retired 51 )51( needs help with daily living activities yes 38 )38( no 62 )62( time passed since cancer diagnosis >1 year 28 )28( 1–3 years 46 )46( >3 years 26 )26( smoking habit yes 42 )42( no 58 )58( history of sexual problems before diagnosis yes 37 )37( no 63 )63( body mass index normal 45 )45( overweight 35 )35( obese 20 )20( https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.15 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article 148 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2:health related quality of life and symptoms scales by body mass index body mass index normal (n=45) (mean ± sd) overweight (n=35) (mean ± sd) obese (n=20) (mean ± sd) p-value anova qlq-c30 functioning scale global hrqol 81.66±41.42 82.85±37.75 97.50±40.16 0.33 physical functioning 29.78 ±24.40 20.43 ±20.05 18.25 ±22.38 0.083 role functioning 31.11 ±26.73 18.21 ±19.02 15.63 ±24.63 01010 cognitive functioning 25.28 ±20.38 20.36 ±17.96 15.00 ±18.85 0.132 emotional functioning 31.39 ±20.79 27.14 ±18.93 15.00 ±18.29 01010 social functioning 33.89 ±23.18 29.64 ±23.50 15.63 ±23.25 01010 qlq-c30 symptom scale fatigue 26.11 ±25.41 20.95 ±21.43 22.92 ±21.94 0.614 nausea and vomiting 9.72 ±23.06 4.64 ±10.97 1.88 ±6.12 0.180 pain 23.89 ±23.21 22.14 ±27.47 20.63 ±24.43 0.880 dyspnea 9.44 ±18.68 9.29 ±14.96 8.75 ±16.77 0.989 insomnia 27.22 ±25.46 20.71 ±23.86 20.00 ±23.79 0.393 appetite loss 16.11 ±23.33 13.57 ±24.51 8.75 ±18.63 0.491 constipation 11.67 ±21.72 14.29 ±24.47 6.25 ±13.75 0.412 diarrhea 10.00 ±20.23 6.43 ±15.27 3.75 ±12.23 0.366 financial difficulties 33.89 ±24.52 32.86 ±24.08 20.00 ±25.13 0.094 qlq-pr25 scale urinary symptoms 18.77 ±19.09 24.76 ±21.15 21.53 ±19.97 0.416 bowel symptoms 6.30 ±13.31 11.43 ±18.86 5.42 ±19.17 0.300 hormonal symptoms 6.81 ±14.83 10.36 ±17.87 9.38 ±18.31 0.622 sexual activity 18.33 ±14.86 19.46 ±19.81 10.63 ±20.08 0.181 sexual functioning 30.78 ±24.45 26.86 ±27.74 8.75 ±21.70 01000 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.15 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article prostate cancer were married, old and had low educational levels [11,12]. regarding occupation, the present study findings agree with the findings of a study done by hacettepe university faculty of medicine on 173 patients, in which more than half of the prostate cancer patients were retired [13]. furthermore, regarding the smoking habits and sexual history, the majority of the patients were nonsmokers, and approximately one-third of the patients had sexual dysfunction before diagnosis. it agrees with the result of a study done in iran on 210 patients, which showed that most of them were nonsmokers and more than 35% received treatment for sexual 149 the present study findings demonstrate that the highest percentages of prostate cancer patients were aged 70 years and older and married. a high percentage were illiterate and the majority were retired. the current findings are supported by a cross-sectional study conducted in egypt from ain salam university hospital on 101 patients diagnosed with prostate cancer, which showed that over 60% of prostate cancer patients were aged above 65, with the majority of them being retired and illiterate. similarly, another study supports the findings of the present study, which conducted in jordan, found that most of the patients diagnosed with copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: health related quality of life and symptoms scales by time passed from cancer diagnosis time passed from diagnosis <1 year 1–3 year < 3 year (n=28) (n=40) (n=20) (mean ± sd) (mean ± sd) (mean ± sd) p-value anova qlq-c30 functioning scale global hrqol 92.41±43.07 84.78±38.72 78.36±43.81 0.45 physical functioning 23.75 ±24.21 25.33 ±20.85 22.69 ±25.66 0.891 role functioning 19.20 ±22.17 28.53 ±24.53 19.23 ±26.51 0.170 cognitive functioning 21.43 ±22.01 22.83 ±18.50 19.23 ±18.79 0.757 emotional functioning 24.33 ±21.34 28.67 ±20.5 25.48 ±19.60 0.644 social functioning 30.80 ±26.24 26.90 ±23.27 29.81 ±23.74 0.773 qlq-c30 symptom scale fatigue 15.77 ±16.09 28.26 ±26.20 24.04 ±22.89 0.081 nausea and vomiting 7.14 ±16.11 8.15 ±21.44 2.40 ±6.14 0.383 pain 14.73 ±17.70 27.99 ±28.16 21.63 ±23.33 0.080 dyspnea 4.46 ±11.89 11.96 ±19.54 9.62 ±15.93 0.181 insomnia 15.18 ±18.43 29.35 ±25.44 22.12 ±26.76 0.051 appetite loss 11.61 ±20.95 17.93 ±25.64 8.65 ±18.63 0.216 constipation 16.07 ±26.54 10.87 ±20.17 7.69 ±16.98 0.348 diarrhea 7.14 ±17.82 7.61 ±16.56 7.69 ±18.40 0.992 financial difficulties 33.04 ±27.26 29.35 ±22.55 30.77 ±26.75 0.828 qlq-pr25 scale urinary symptoms 16.37 ±17.51 26.81 ±20.45 17.31 ±19.94 01043 bowel symptoms 3.27 ±14.58 13.41 ±17.87 3.21 ±13.96 01000 hormonal symptoms 2.23 ±13.09 14.27 ±17.31 5.29 ±15.68 01004 sexual activity 11.83 ±17.71 22.55 ±16.16 13.46 ±19.10 01010 sexual functioning 23.75 ±29.21 26.30 ±25.33 24.04 ±25.50 0.901 discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.15 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article finland showed that men with prostate cancer significantly improved in sexual functioning and urinary control 12 to 24 months after disease [20]. in addition, another study in canada confirmed that longterm survivors (≥3 years post-diagnosis) promote better quality of life outcomes [21]. health-related quality of life in the pca was affected by the patients’ body mass index; this findings highlights the importance of paying attention to functioning scales such as role, emotional and social function and sexual function in the quality of life of prostate cancer 25 items (qlq-pr 25) scale: regarding time passed after prostate cancer diagnosis, it is important to pay attention to patients’ symptom scales and quality of life of prostate cancer such urinary, bowel, hormonal and sexual activity. [1] bray f, ferlay j, soerjomataram i, siegel rl, torre la, jemal a, et al. global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries,correction in: ca a cancer journal for clinicians. 2020;70:313 doi:10.3322/caac.21492. [2] rawla p. epidemiology of prostate cancer. world journal of oncology. 2019;10(2):63– 89. doi:10.14740/wjon1191. [3] siegel rl, miller kd, jemal a. cancer statistics, 2020. ca: a cancer journal for clinicians.2020;70(1):7–30. doi:10.3322/ caac.21590 [4] wirth m, van der poel h, anderson j, graefen m, stief c, wiegel t, et al. the european prostate cancer centres of excellence: a novel proposal from the european association of urology prostate cancer centre consensus meeting. european urology.2019;76 (2):179–186.doi:10.1016/ j.eururo.2019.01.025 [5] fayers p, aaronson n, bjordal k, groenvold m, curran d, bottomley a, et al. the eortc qlq-c30 scoring manual (3rd edition). brussels: european organisation for research and treatment of cancer; 2001. problems before the diagnosis [14]. moreover, a retrospective cohort study, which was conducted at two oncology hospitals in saudi arabia, revealed that most patients with prostate cancer were married, aged above 65, and living with chronic comorbidities [15]. about health-related quality of life (hrqol) and symptoms compared with body mass index (bmi) categories, there are significant relationships between body mass index (bmi) and several health-related quality of life (hrqol) domains, including emotional functioning, role functioning, social functioning, and sexual functioning. patients with a normal bmi reported better quality of life across these domains compared to overweight and obese participants. the results of the present study are consistent with the findings of a study that was conducted, which showed that elevated bmi had a negative effect on sexual and emotional functions in men with this type of cancer [16]. moreover, the current study findings come along with a cross-sectional study conducted in the netherlands on 314 patients, which body mass index had significant association with better scores on physical, role, social, and emotional functioning scales measured by eortc qlq-c30 and pr25 modules [17,18]. regarding time passed after diagnosis, table 3 shows that health-related quality of life domains such as urinary symptoms, bowel function, hormonal symptoms, and sexual activity significantly affected the quality of the patient’s life. patients diagnosed less than one year reported more severe symptoms than those patients who had passed the disease for 1 to 3 years or more. these findings are compatible with the result of a study conducted in south korea, which found that symptom burdens were highly affected during the first year after diagnosis and gradually tended to decrease [19]. additionally, a cohort study done in 150 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.15 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article prevention.2022;23(5):1575–1582. doi:10.31557/apjcp.2022.23.5.157515. [15] al-harbi ma, al-saadi as, al-eid aa. healthrelated quality of life and its sociodemographic determinants in prostate cancer patients in saudi arabia. middle east journal of cancer. 2022;13(1):83–92. doi:10.30476/ mejc.2021.91268.1476. [16] tzenios n, tazanios me, chahine m. the impact of body mass index on prostate cancer: an updated systematic review and meta -analysis. medicine (baltimore).2022;101 (47):e30191.doi:10.1097/ md.0000000000030191 [17] korfage ij, essink-bot ml, borsboom gj, madalinska jb, kirkels wj, de koning hj, et al. health-related quality of life in prostate cancer patients: normal weight vs. overweight. european urology. 2021;79(3):411– 419. doi:10.1016/j.eururo.2020.10.008 [18] press ar, lee mc, nguyen pl. obesity and health-related quality of life outcomes in prostate cancer patients. journal of clinical oncology.2023;41(5):688–695. doi:10.1200/ jco.22.01471 [19] park s, lee y, kim j. time since diagnosis and quality of life in prostate cancer survivors: a nationwide cross-sectional survey. health and quality of life outcomes. 2022;20(1):127. doi:10.1186/s12955-02202009-3 [20] torvinen s, färkkilä n, sintonen h, saarto t, roine rp, taari k, et al. health-related quality of life and symptoms among prostate cancer patients over time. acta oncologica. 2020;59(1):17–24. doi:10.1080/0284186x.2019.1663143 [21] chambers sk, hyde mk, occhipinti s, zajdlewicz l, lowe a, dunn j, et al. long-term quality of life outcomes among prostate cancer survivors in community settings. bmc cancer. 2023;23(1):91. doi:10.1186/s12885023-10557-w [6] american cancer society. cancer facts & figures 2019. atlanta: american cancer society; 2019. available from: https:// www.cancer.org/content/dam/cancer-org/ research/cancer-facts-and-statistics/annualcancer-facts-and-figures/2019/cancer-factsand-figures-2019.pdf. [7] holm m, doveson s, lindqvist o, wennmanlarsen a, fransson p. quality of life in men with metastatic prostate cancer in their final years before death – a retrospective analysis of prospective data. bmc palliative care. 2018;17(1):126. doi:10.1186/s12904-0180385-0 [8] bourke l, boorjian sa, briganti a, klotz l, mucci l, resnick mj, et al. survivorship and improving quality of life in men with prostate cancer. european urology. 2015;68 (3):374–383.doi:10.1016/ j.eururo.2015.04.007 [9] kikkawa k, iba a, kohjimoto y, noda y, sonomura t, hara i. impact of age on quality of life in patients with localized prostate cancer treated with high-dose rate brachytherapy combined with external beam radiotherapy. international journal of urology. 2018;25 (4):366–371. doi:10.1111/iju.13505 [10] amin im, khidhir ba, niranji ss, hussein nr. cancer incidence in the kurdistan region of iraq: results of a seven-year cancer registration in erbil and duhok governorates. journal formedical internet research public health and surveillance. 2021;7(12):e25045. doi:10.2196/25045 [11] ahmed me, el-nakeeb aa, saleh rs. sociodemographic and clinical profile of prostate cancer patients in egypt: a cross-sectional study. journal of geriatric oncology. 2023;14(2):245–251. doi:10.1016/ j.jgo.2022.08.006 [12] al-tarawneh hs, qudah mf, alshraideh ha. prostate cancer awareness and screening behavior among elderly males in jordan. eastern mediterranean health journal. 2022;28(3):195–201.doi:10.26719/ emhj.22.022 [13] kaya b, goktas s, cikrikcioglu ma. the impact of socioeconomic status on prostate cancer presentation: a hospital-based study. turkish journal of urology.2021;47(4):255– 260. doi:10.5152/tud.2021.21142 [14] rezaei n, hosseini m, ghaffari r. sexual dysfunction and smoking status in iranian men with prostate cancer: a correlational study. asian pacific journal of cancer 151 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.04 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article covid-19 among smokers and non-smokers in erbil city, kurdistan region, iraq abstract background and objectives: coronavirus disease (covid-19), a severe respiratory syndrome caused by a novel strain of coronavirus (sars-cov-2), became a global public health concern and was declared a pandemic by who. the associations between smoking and covid-19 infection and the outcomes were ambiguous. this study aimed to determine the associations of self-reported confirmed cases of covid-19 among smokers and to compare it with the rate among non-smokers in erbil city. methods: this cross-sectional house survey was conducted between september 2021 and june 2022 through a multi-stage cluster sampling method on a sample of 2601 respondents in erbil city through direct interviews using a specially designed questionnaire to collect data. results: the mean age was 38.75 + 13.79 years (range 18 to 76 years). more than half (58.9%) of the sample were males. the proportion of current daily smokers was 44.3%, and 33.2% were those who had never smoked before. 17.5% of the sample were infected by the covid-19 virus during the pandemic. there was a statistically significant association between the occurrence of covid-19 and the age, gender, marital status, education level, occupation, smoking status, and socioeconomic level of participants. conclusion: the occurrence of covid-19 among smokers was significantly higher than among non-smokers. a statistically significant association was found between selfreported confirmed cases of covid-19 and the age, gender, marital status, education level, occupation, smoking status, and socioeconomic level of participants. keywords: smoking; household; survey; covid-19; non-smokers kareem jamal hamad; department of nursing, soran technical college, erbil polytechnic university, kurdistan region, iraq (correspondence: kareem.hamad@epu.edu.iq) namir ghanim al-tawil; department of community medicine, college of medicine, hawler medical university, erbil, kurdistan region, iraq. 30 received: 28/04/2024 accepted: 18/12/2024 published: 30/05/2025 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:kareem.hamad@epu.edu.iq?subject=kareem.hamad@epu.edu.iq mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.04 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article since being reported in china in late december 2019, coronavirus disease (covid19), which is a severe acute respiratory syndrome caused by a novel strain of coronavirus (sars-cov-2) became a global public health concern and then on march 11, 2020, who declared covid-19 a pandemic [1]. although at first associations between smoking and covid-19 infection and the outcomes were ambiguous, to date the reported data about tobacco smoking and covid-19 disease adverse prognosis remain controversial [2]. smoking is the greatest risk factor for developing chronic obstructive pulmonary disease (copd) leading to pulmonary inflammation. smoking in addition to copd is related to allcause mortality due to cancer (mainly lung cancer) [3], other respiratory infections, and cardiovascular disease [4, 5]. up to researchers' knowledge, it was necessary to evaluate the smoking status and the risk of coronavirus infection. as a result, this cross -sectional house survey was carried out to determine the association between selfreported confirmed cases of covid-19 among smokers and to compare it with the rate among non-smokers. a descriptive cross‐sectional household survey was carried out among a sample of residents in erbil city to determine the associations of self-reported confirmed cases of covid-19 among smokers and to compare it with the rate among non-smokers. the study was conducted in erbil city, the capital of the kurdistan region-iraq, between september 1, 2021, and june 30, 2022.a sample of 2601 residents of both genders, aged 18 years or over, who gave their consent to participate in the study, comprised the sample selected using a multi-stage cluster sampling method, and 25% of quarters in each municipality were chosen randomly based on the administrative map of the city, and then through the systematic random sampling method, households in each quarter were selected (table 1). data was collected through direct interviews with the participants using a specially designed questionnaire comprising sociodemographic and economic features, besides smoking-related questions. smoking status was determined using the who criteria for smoking as a current daily smoker, an occasional smoker, an exsmoker, and a never-smoker [6]. the socioeconomic level of participants was calculated based on the socioeconomic index for health research in iraq [7].data were analyzed using the spss software (version 25). means were calculated to summarize numerical variables and proportions for the categorical variables. the chi-square test was used to compare the proportions. a p-value of ≤ 0.05 was considered statistically significant. ethical approval for this study was granted by the ethics committee of the college of medicine, hawler medical university (2020/11/4, number 7). informed consent was provided by all participants; verbal consent was taken from all the samples and they had been informed about the purpose of the study. 31 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.04 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article a total of 795 (30.6%) were semi-skilled manual workers, and 1182 (45.4%) perceived that their economic situation was from middle socioeconomic levels (table 2). the mean age + sd was 38.75 + 13.790 years. about one-quarter (25.1%) of the sample were 50 or older. more than half (58.9%) were males and married (57.1%). concerning education level, 30% were illiterate or had a primary education level. 32 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result table 1: distribution of the required sample according to the erbil quarters municipality municipality population 250/100,000 no. of quarters 25% of quarters no. of sample/ quarter required sample m 1 45576 147.048556 11 3 49 147 m 2 96276 310.629405 22 6 52 311 m 3 110964 358.019457 26 7 51 358 m 4 338100 1090.86170 34 9 121 1091 m 5 97884 315.817532 23 6 53 316 m 6 117040 377.623349 25 6 63 378 total 805840 2,599.9999 141 37 2601 table 2: distribution of the study population by socio-demographic characteristics variables no. (%) age groups less than 20 176 (6.8) 20 29 647 (24.9) 30 39 597 (23) 40 49 525 (20.2) 50 and more 656 (25.1) gender female 1069 (41.1) male 1532 (58.9) marital status single 984 (37.8) married 1485 (57.1) divorced 21 (0.8) widowed 111 (4.3) education illiterate/ primary 781 (30) intermediate 306 (11.8) high school or vocational 469 (18) graduates* 1045 (40.2) occupation unskilled manual 534 (20.5) semi-skilled manual 795 (30.6) skilled manual 693 (26.6) others** 579 (22.3) socioeconomic level low 1134 (43.6) middle 1182 (45.4) high 285 (11) total 2601 (100) * including institute, college, and higher education ** including associate professionals, skilled or highly professionals, and senior managers https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.04 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article as presented in table 3, more than 44% of the participants were current daily smokers, 14.5% were occasional smokers, 8% were ex-smokers and about one-third (33.2%) never smoked. a total of 460 (30.1%) of the sample started cigarette smoking at the age of 15-19 years, while the lowest rate, 87 (5.7%) indicated less during the covid-19 pandemic, 17.5% of the study population was infected by the virus. the majority of those infected by the virus (87%) stopped smoking during the than 15 years. less than half (46.6%) of the participants have ever tried waterpipe smoking; 835 (68.9%) started waterpipe smoking at an age of fewer than 30 years. regarding the frequency of waterpipe smoking, the highest rate (37.2%) smoked waterpipe every day. disease period, but mostly (almost all of them) (99.2%) returned to smoking after recovery (table 4). 33 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: distribution of the study population by smoking-related characteristics variables no. (%) smoking status (n=2601) current daily smoker 1153 (44.3) occasional smoker 376 (14.5) ex-smoker 207 (8) never smoker 865 (33.2) age of starting cigarette smoking (n=1529) less than 15 87 (5.7) 15 – 19 460 (30.1) 20 – 24 440 (28.7) 25 – 29 290 (19) 30 and more 252 (16.5) ever tried waterpipe smoking? (n=2601) no 1390 (53.4) yes 1211 (46.6) age of starting waterpipe smoking (n=1211) less than 15 21 (1.7) 15 – 19 241 (19.9) 20 – 24 333 (27.5) 25 – 29 240 (19.8) 30 and more 376 (31.1) frequency of waterpipe smoking (n=1211) everyday 450 (37.2) once weekly 193 (15.9) once every 2-4 days 381 (31.5) sometimes 187 (15.4) table 4:distribution of the study population by covid-19-related characteristics variables no. (%) during the covid-19 pandemic been infected by the virus? (n=2601) no 2147 (82.5) 454 (17.5) if yes, did you stop smoking during the disease period? (n=454) no 59 (13) 395 (87) returned to smoking after symptoms disappeared? (n=395) no yes 3 (0.8) 392 (99.2) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.04 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article 34 than among non-smokers (0.7%). the infection with covid-19 was slightly higher among the age group 40-49 years compared to the other age groups, divorced, skilled manual /non-manual workers, and participants who were from high socioeconomic levels. table 5 shows that the occurrence of covid-19 was significantly (p= 0.001) higher among males (24.5%) than among females (7.3%) and among those from the intermediate education level (26.5%) than the other groups. the confirmed cases of covid-19 among smokers were (29.2%) which was significantly (p= 0.001) higher copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 5:infection with covid-19 by socio-demographic characteristics of the sample variables infected by covid-19 total p-value yes no no. (%) no. (%) age groups less than 20 19 (10.8) 157 (89.2) 176 0.012 20 29 126 (19.5) 521 (80.5) 647 30 39 105 (17.6) 492 (82.4) 597 40 49 106 (20.2) 419 (79.8) 525 50 and more 98 (14.9) 558 (85.1) 656 gender female 78 (7.3) 991 (92.7) 1069 0.001 male 376 (24.5) 1156 (75.5) 1532 marital status single 182 (18.5) 802 (81.5) 984 0.001 married 264 (17.8) 1221 (82.2) 1485 divorced 4 (19) 17 (81) 21 widowed 4 (3.6) 107 (96.4) 111 education illiterate/ primary 113 (14.5) 668 (85.5) 781 0.001 intermediate 81 (26.5) 225 (73.5) 306 high school or vocational 93 (19.8) 376 (80.2) 469 graduates* 167 (16) 878 (84) 1045 occupation unskilled manual 69 (12.9) 465 (87.1) 534 0.002 semi-skilled manual 138 (17.4) 657 (82.6) 795 skilled manual /non-manual 148 (21.4) 545 (78.6) 693 others** 99 (17.1) 480 (82.9) 579 smoking no 7 (0.7) 1065 (99.3) 1072 0.001 yes 447 (29.2) 1082 (70.8) 1529 socioeconomic level low 167 (14.7) 967 (85.3) 1134 0.006 middle 231 (19.5) 951 (80.5) 1182 high 56 (19.6) 229 (80.4) 285 total 454 (17.5) 2147 (82.5) 2601 * including institute, college, and higher education ** including associate professionals, skilled or highly skilled professionals, and senior managers. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.04 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article icu admission, which was 88% lower in heavy smokers compared to non-smokers [15]. in contrast, a study reported that current smoking was independently associated with self-reported confirmed covid-19 infection [2]. additionally, several studies revealed a substantial association between smoking history and several negative outcomes, such as severe covid-19 and mortality [16-18]. the occurrence of covid-19 among smokers was significantly higher than among non-smokers. a statistically significant association was found between self-reported confirmed cases of covid-19 and age, gender, marital status, education level, occupation, smoking status, and socioeconomic level. the authors report no conflict of interest. this study is authors-based funded. (1) shastri md, shukla sd, chong wc, kc r, dua k, patel rp, et al. smoking and covid-19: what we know so far. respiratory medicine. 2021 jan;176:106237. doi: 10.1016/ j.rmed.2020.106237. epub 2020 nov 19. pmid: 33246296; pmcid: pmc7674982. (2) jackson se, brown j, shahab l, steptoe a, fancourt d. covid-19, smoking and inequalities: a study of 53 002 adults in the uk. tobacco control. 2021 dec;30(e2):e111-e121. doi: 10.1136/tobaccocontrol-2020-055933. epub 2020 aug 21. pmid: 32826387. (3) biondini d, semenzato u, bonato m, tinè m, bazzan e, damin m, et al. lymphopenia is linked to an increased incidence of cancer in smokers without copd. european respiratory journal. 2019;54(suppl 63):pa2586. doi: 10.1183/13993003.congress-2019.pa2586 (4) aikphaibul p, theerawit t, sophonphan j, wacharachaisurapol n, jitrungruengnij n, puthanakit t. risk factors of severe 35 the study found that below half of the participants were from the middle socioeconomic level. this result is consistent with a study on a group of men in mosul, iraq [8]. in this study, (44.3%) were current daily smokers. numerous studies demonstrate a substantial variance in the reported prevalence of current smoking, (40.08%) in saudi arabia [9], and (26.4%) in libya [10]. the discrepancies in the reported prevalence of smoking may be explained by the various study sites, sample frames, demographics of the enrolled populations, and cultural and religious considerations. self-reported cases of covid-19 during the pandemic were about (17.5%). the majority of those infected by the virus (87%) stopped smoking during the disease period but most (99.2%) returned to smoking after recovery. the infection by the covid-19 virus was significantly higher among the age group 40-49 years (20.2%), males (24.5%), divorced (19.0%), and those with an intermediate education level (26.5%). in this study, infection by the covid-19 virus was significantly more (21.4%) among participants who worked in skilled manual or non-manual occupations; furthermore, covid-19 among smokers (29.2%) was significantly higher than among nonsmokers (0.7%). the reported role and association of smoking with covid-19 are highly controversial. several studies agreed that covid-19 was more prevalent among smokers than non-smokers [2, 11, 12], while the opposite result was reported by other studies [13, 14]. a prospective cohort study conducted early in the pandemic about the risk of severe covid-19 disease among 8.3 million participants in the uk observed that smokers had a noticeably lower probability of developing covid-19 disease and being admitted to the icu and reported the incidence of copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion conclusion conflict of interest funding references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.04 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article (13) lippi g, henry bm. active smoking is not associated with severity of coronavirus disease 2019 (covid-19). european journal of internal medicine. 2020 may;75:107-108. doi: 10.1016/j.ejim.2020.03.014. (14) hopkinson ns, rossi n, el-sayed moustafa j, laverty aa, quint jk, freidin m, et al. current smoking and covid-19 risk: results from a population symptom app in over 2.4 million people. thorax. 2021 jul;76(7):714722. doi: 10.1136/thoraxjnl-2020-216422. (15) hippisley-cox j, young d, coupland c, channon km, tan ps, harrison da, et al. risk of severe covid-19 disease with ace inhibitors and angiotensin receptor blockers: cohort study including 8.3 million people. heart. 2020 oct;106(19):1503-1511. doi: 10.1136/ heartjnl-2020-317393. (16) williamson ej, walker aj, bhaskaran k, bacon s, bates c, morton ce, et al. factors associated with covid-19-related death using opensafely. nature. 2020 aug;584 (7821):430-436. doi: 10.1038/s41586-0202521-4. (17) ponsford mj, gkatzionis a, walker vm, grant aj, wootton re, moore lsp, et al. cardiometabolic traits, sepsis, and severe covid-19: a mendelian randomization investigation. circulation. 2020 nov 3;142 (18):1791-1793. doi: 10.1161/ circulationaha.120.050753. (18) jiménez-ruiz ca, lópez-padilla d, alonsoarroyo a, aleixandre-benavent r, solanoreina s, de granda-orive ji. covid-19 y tabaquismo: revisión sistemática y metaanálisis de la evidencia [covid-19 and smoking: a systematic review and meta-analysis of the evidence]. archivos de bronconeumologia. 2021 jan;57:21-34. spanish. doi: 10.1016/j.arbres.2020.06.024. hospitalized respiratory syncytial virus infection in tertiary care center in thailand. influenza and other respiratory viruses. 2021 jan;15(1):64-71. doi: 10.1111/irv.12793. (5) yoon jg, noh jy, choi ws, lee j, lee js, wie sh, , et al. a comparison of epidemiology and clinical outcomes between influenza a h1n1pdm09 and h3n2 based on multicenter surveillance from 2014 to 2018 in south korea. influenza and other respiratory viruses. 2021 jan;15(1):99-109. doi: 10.1111/ irv.12795. (6) nasser ama, zhang x. knowledge and factors related to smoking among university students at hodeidah university, yemen. tobacco induced diseases. 2019;17:42. doi: 10.18332/tid/109227. (7) omer w, al-hadithi t. developing a socioeconomic index for health research in iraq. eastern mediterranean health journal. 2017;23(10):670-677.doi: 10.26719/2017.23.10.670. (8) ahmed rr, al-tawil ng. role of obligatory banning of smoking in 2014 2016 on the smoking habits of a group of men in mosul, iraq. zanco journal of medical sciences. 2021 aug. 9;25(2):577-85. available from: https://zjms.hmu.edu.krd/index.php/zjms/ article/view/842 (9) albangy fh, mohamed ae, hammad sm. prevalence of smoking among male secondary school students in arar city, saudi arabia. pan african medical journal. 2019 apr 8;32:156. doi: 10.11604/ pamj.2019.32.156.18558. (10) el shareif hj. prevalence, pattern, and attitudes of smoking among libyan diabetic males: a clinic-based study. ibnosina journal of medicine and biomedical sciences. 2019;11(4):171-175. available from: https:// doi.org/10.4103/ijmbs.ijmbs_37_19 (11) zhang h, ma s, han t, qu g, cheng c, uy jp, et al. association of smoking history with severe and critical outcomes in covid-19 patients: a systemic review and metaanalysis. european journal of integrative medicine. 2021 apr;43:101313. doi: 10.1016/j.eujim.2021.101313. (12) tattan-birch h, perski o, jackson s, shahab l, west r, brown j. covid-19, smoking, vaping and quitting: a representative population survey in england. addiction. 2021 may;116(5):1186-1195. doi: 10.1111/ add.15251. 36 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.01 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article effect of percutaneous coronary intervention on quality of life among coronary artery disease patients in erbil city abstract background and objective: quality of life is acknowledged as a vital outcome of healthcare measures, mostly in persons with heart disease. the main purpose of percutaneous coronary intervention is improving patients' quality of life. this study aimed to evaluate the effect of percutaneous coronary intervention on the quality of life of coronary artery disease patients at surgical specialty hospital-cardiac center in erbil city. methods: a pre-post study design was conducted to evaluate the quality of life of 100 patients with coronary artery disease before undergoing percutaneous coronary intervention, and three months after the performed percutaneous coronary intervention, it was conducted from january 2022 until december 2022. the quality of life data was assessed through the short form-36 health status survey. it consists of 36 questions that measure eight health concepts divided into two dimensions: the physical and mental aspects. the highest score indicates better quality of life. data were analyzed using the statistical package for the social sciences (version 26). results: most of the study participants were males with mean and standard deviation of age 47.9±6.8. the highest percentage were married, able to read and write, selfemployed, and hasn’t previous percutaneous coronary intervention. the results showed that patients who underwent percutaneous coronary intervention significantly improved their quality of life after performing percutaneous coronary intervention in the following subdomains of physical component summary (physical functioning, role-physical, general health) and (social functioning), p-value <0.05. while in subdomains of mental component summary (bodily pain, vitality, role-emotional and mental health) there were no statistically significant differences p-value >0.05. conclusion: the study concluded that overall quality of life significantly improved after performing percutaneous coronary intervention for coronary artery disease patients, mostly in the physical aspect compared with the mental aspect. keywords: percutaneous coronary intervention; quality of life; coronary artery disease. chnar salahaddin qadir; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. (correspondence: : chnar.qadir@hmu.edu.krd) yousif mohammed younis; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq 01 received: 20/01/2023 accepted: 29/03/2023 published: 30/05/2025 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:chnar.qadir@hmu.edu.krd?subject=chnar.qadir@hmu.edu.krd mailto:chnar.qadir@hmu.edu.krd?subject=chnar.qadir@hmu.edu.krd mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.01 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article cardiovascular diseases (cvds) are the main causes of death worldwide. a predictable 17.9 million persons died from cvds in 2019, representing 32% of overall deaths globally >75% of coronary artery disease deaths happen in low and -middleincome countries [1]. according to the latest who data published in 2020, coronary artery disease (cad) deaths in iraq reached 36,594 (24.98%) of total deaths in 2021. the age-adjusted death rate is 227.26 per 100,000 of the population which ranking iraq 23rd in the world [2]. the cardiac and metabolic indicators carry a predisposition to a chronic disease, such as heart disease, it can comprise a single factor or can be associated with metabolic syndrome. early coronary intervention is crucial to prevent cardiovascular complications [3]. percutaneous coronary intervention (pci) is nowadays the well-known gold standard treatment; it should be conducted along with other therapeutic methods for secondary prevention. pci offers numerous advantages together, which include fewer mortality rates, faster medical improvement, decreased disability, lower risk of new cardiac events, slower the development of cad, and better quality of life [4]. in iraq, although precise statistics are not available, nonetheless, with the prevalence increasing, the number of patients with coronary artery disease, and a great number of patients are daily undergoing pci, in accordance with statistical facts from the surgical specialty hospitalcardiac center in erbil city. the number of pci was 2526 in 2020 [2]. patients with cvd experience numerous physical symptoms, including fatigue, dyspnea, or chest pain, which affect their physical, emotional, and social well-being with significant impairment in quality of life (qol) [5]. during the past decades, pci has been one of the fastest-growing therapeutic coronary interventions for patients with narrowed/ blocked coronary arteries and improves the quality of life [6]. quality of life is recognized as a significant outcome measure of health care, particularly in patients with long-lasting diseases such as coronary artery disease [7]. poor quality of life has been identified as an independent risk factor for mortality and major cardiac events in patients with cardiovascular disease [8].for patients with cad who underwent pci, quality of life is an important outcome indicator, along with death and recurrence rates [9]. all things considered, this study aimed was to evaluate the impact of percutaneous coronary intervention on quality of life through the used of the sf-36 health survey in erbil city in the kurdistan region of iraq. a pre-post design study was conducted at surgical specialty hospital-cardiac center after taking ethical approval from the ethical committee (code no. 140) and date sep 2021, at college of nursing/hawler medical university, erbil, kurdistan region of iraq from jan 2022 to dec 2022, on 100 coronary artery diseases (cad) patients before undergoing percutaneous coronary intervention, after 3 months who performed percutaneous coronary intervention were carefully chosen with the purposive sampling method according to the inclusion criteria of the study. the participants of this study were adult patients diagnosed with coronary artery disease, which needed percutaneous coronary intervention, which was confirmed by coronary angiography, and were conscious, while; the exclusion criteria were patients who had communication problems and coronary artery bypass graft. the questionnaire consisted of demographic data and clinical 02 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.01 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article (0.96-1.0), and high (>1.0) [13,14]. regarding the echo study, left ventricular ejection fraction (lvef) is classified by the american college of cardiology (acc) as hyper dynamic = lvef (greater than 70%); normal lvef 50% to 70% (midpoint 60%); mild dysfunction lvef 40% to 49% (midpoint 45%); moderate dysfunction lvef 30% to 39% (midpoint 35%); severe dysfunction = lvef less than 30% [15]. the standardized quality of life (qol) assessment tool was a validated and reliable short form-36 (sf-36) survey and is a common multidimensional tool containing eight domains, called physical functioning (pf), role-physical (rp); bodily pain (bp); general health (gh); role-emotional (re); vitality (vt); social functioning (sf); and mental health (mh). the scores are gathered into two aspects: the physical component summary (pcs) and the mental component summary (mcs). the overall scores range from zero to 100 with higher scores representing better qol. there is a different likert scale used in the quality of life (sf-36) health survey. in regard to the transformation score, scores are converted to a 0-100 scale. the lowest score indicates functional limitation, severe social and role disability, and distress. high scores indicate the absence of limitations and disability [16,17]. patients were informed and verbally consented to the participation of the study, also explaining the purpose of this study before starting the interview, and were told that their participation would be voluntary. patients who evaluate the effect of pci on qol by changing the outcome variables of the study, in the post-test, cad patients were taken again after three months of pci. statistical data were analyzed using (spss version 26). mean and standard deviation (sd) were accessible for measurable variables; frequencies and percentages were given for categorical data. a paired t-test data such as (age, gender, level of education, marital status, occupation, cigarette smoking, family history, previous history of pci, duration of diagnosis of heart disease) and cardiac and metabolic indicators such as blood pressure, which was classified by the world health organization (who) as normal < 120/<80 mmhg; prehypertension: >120-139/85-89 mmhg; stage 1 hypertension 140-159/90-99 mmhg; stage 2 hypertension: >160/>100 mmhg[10]. regarding biomedical lipid values classified based on the american diabetes association (ada) as total cholesterol / (mg/dl) (high ≥200, low <200), triglycerides (mg/dl) (high ≥150, low <150), lowdensity lipoprotein (ldl) (mg/dl) (high ≥100, low<100), high-density lipoprotein (hdl) (mg/dl) high ≥ 45, low <45) [11]. glycated hemoglobin (hba1c) is a medical term that refers to the typical levels of blood sugar in a person with type 2 diabetes mellitus, which is classified by the american diabetes association (ada), good glycemic control hba1c (≤7%) and poor glycemic control hba1c (>7%) [12]. body mass index (bmi): it was calculated as the weight (kg) divided by height squared (m2). in addition, body mass index was categorized according to the world health organization (who) as underweight (< 18.5), (18.5-24.9) normal, and overweight (25-29.9). obesity class i (30.0– 34.9) class ii (35.0–39.9) extreme obesity class iii (40.0) [13,14]. mean waist circumference (wc) ranges between populations from 83-98 cm in men and from (78-91) cm in women. mean hip circumference (hc) ranged from 94-105cm in men and from (97-108) cm in women, respectively, and the world health organization classifies the risk of being affected by weight-related health conditions according to the waisthip ratio (whr). for women: low (≤ 0.80), medium (0.81-0.85), and high (>0.86). while for men, low (≤ 0.95), medium 03 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.01 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article was used to compare subdomain and overall quality of life. the kolmogorov-smirnov test is used to evaluate the assumption of normality. p values less than 0.05 were considered significant. table 1 shows the demographic and medical data of the study sample; the age of participants ranged from 33-60 years, and the mean age was 47.90 years (sd = 6.8); nearly half the percentage 47% was within the age group 47-53 years, and 66% of the sample was male. in regard to the level of education, less than half the percentage 42% were able to read and write, and a higher proportion 88% were married. regarding occupation 38% of the selfemployed, in relation to cigarette smoking 10% were current smoker, 70% of patients had smoked less than 1 pack/day for less than 10 years. more than half a percentage 55% of patients does not have a family history of heart disease. the finding of the study shows 89% of patients had not undergone pci previously; also, 49% of patients had been diagnosed with coronary artery disease (cad) between one and three years. 04 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result table 1: demographic and clinical data of the study participants variables n=(100) f (%) age group (year) 33-39 13(13) 40-46 25(25) 47-53 47(47) 54-60 15(15) m±sd 47.90±6.8 gender male female 66(66) 34(34) level of education able to read and write primary school secondary school institute graduation 42(42) 27(27) 19(19) 12(12) marital status married single widowed divorced 88(88) 3(3) 6(6) 3(3) occupation governmental employed self-employed unemployment housewife 26(26) 38(38) 12(12) 24(24) cigarette smoking non-smoker 57(57) current smoker 10(10) ex-smoker 33(33) number of cigarettes per day less than 1 pack/day more than 1 pack/day 7(70) 3(30) duration of cigarettes smoking less than 10 years more than 10 years 7(70) 3(30) family history no 55(55) yes 45(45) previous of pci no 89(89) yes 11(11) duration diagnosis of heart diseases less than 1years 35(35) 1-3 years 49(49) more than 3 years 16(16) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.01 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article 05 it was (43%) of patients’ hdl more than 45 mg/dl. relating to glycemic control, it was shown before pci (65%) of patients had poor glycemic control (hba1c ≥7%) compared to postpci nearly half of the patients had their hba1c change to good glycemic control (hba1c <7%). furthermore, concerning body mass index (bmi), 52% of patients were overweight. while in post-education, 23% was within normal body weight. concerning waist to hip ratio (whr) male, and female patients 26%, 19% respectively, had median whr, while in post-pci, it changed to 24%,17% consequently. in regard, to left ventricular ejection fraction (lvef) 40% of patients have moderate lvef, however, in post-coronary intervention, a higher percentage 41% of patients had mild lvef [in table 2]. table 2 shows cardiac and metabolic indicators of cad patients concerning hypertension in the pre-test, more than half the percentage 69% of the patients were stage 1 hypertension, while compared to postpci, it was reduced to 30%. regarding total cholesterol, at baseline, most of the patients 67% had their total cholesterol was more than (200 mg/dl). while in postpercutaneous coronary intervention more than half the pre-test (59%) of patients of a total cholesterol less than (200 mg/dl). regarding triglycerides in the pre-pci 58% of patients, triglycerides were more than 150 mg/dl, while in post-pci, it was 53%. in relative terms, low-density lipoprotein (ldl) at baseline (64%) of the patient’s ldl was more than 100 mg/dl after coronary intervention dropped to (58%). moreover, the highest percentage 67% of patients hdl was less than 45mg /dl, whereas inpost copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: cardiac and metabolic indicators of cad patients of before and after pci cardiac and metabolic indicators pre pci f(%) post pci f(%) hypertension bp normal (120/<80 mmhg) 3(3) 7(7) pre-hypertension (>120-139/85-89 mmhg) 10(10) 41(41) hypertension stage 1(140-159/90-99 mmhg) 69(69) 30(30) hypertension stage 2 (>160/>100 mmhg) 18(18) 12(12) total-cholesterol (tc) low (<200) mg/dl 33(33) 59(59) high (≥200) mg/dl 67(67) 41(41) triglycerides (tg) low (<150) mg/dl 42(42) 47(47) high (≥150) mg/dl 58(58) 53(53) low-density lipoprotein (ldl) low (<100) mg/dl 36(36) 42(42) high (≥100) mg/dl 64(64) 58(58) high-density lipoprotein (hdl) low (<45) mg/dl 67(67) 57(57) high (≥45) mg/dl 33(33) 43(43) glycated hemoglobin (hba1c) good control <7 % 35(35) 47(47) poor control ≥ 7 % 65(65) 53(53) body mass index (bmi) normal (18.5-24.9) 17(17) 23(23) overweight (25-29.9) 52(52) 40(40) obese (≥30) 31(31) 37(37) waist-hip ratio of males (whr) low (<0.95) 17(17) 12(24) medium (0.95-1.0) 26(26) 24(24) high >1.0 23(23) 30(30) waist hip ratio of females (whr) low ≤ 0.80 6(6) 3(3) medium 0.81-0.85 19(19) 17(17) high >0.86 9(9) 14(14) left ventricular ejection fraction (lvef) normal (50% to 70%) 24(24) 29(29) mild (40% to 49%) 36(36) 41(29) moderate (30% to 39%) 40(40) 30(30) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.01 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article (39.90±15.70 to 40.60 ±14.31, p-value =0.753), in role-emotional (39.56±14.05 to 41.33±31.11, p-value =0.630), in mental health (39.67±17.21 to 40.52±11.91, pvalue =0.815). finally, the total mean score in the aspect of physical component summary (pcs) significantly raised from (39.57±12.62 to 45.49±11.63, p-value <0.001) compared to no significant in mental component summary (mcs) (38.69±11.17 to 40.99±9.37, p-value =0.103), in term of overall mean score quality of a life a highly significant improvement after performing percutaneous coronary intervention (39.13±9.61 to 43.24±8.07, p= 0.001). cohort study from 2 large academic medical centers in massachusetts that included patients who experienced a myocardial infarction, most of the patients were 45% years of ages between 44-50 years [18,19]. also, findings agree with a study done by huber et al., who determined the psychometric properties of the german heartqol, which was done among (n=489) patients with heart diseases from five centers in austria and switzerland to validate 06 table 3 illustrates the average mean score of quality of life of coronary artery disease patients before and after undergoing percutaneous coronary intervention. according to this table, the mean score subdomains quality of life, in physical functioning were increased significantly (39.70±11.99 to 44.90±10.47, p-value =0.003), in role-physical (40.00±12.76 to 48.75±14.57, p-value =0.048), in general health (40.0±17.38 to 44.21±12.63, pvalue =0.03), and social functioning (35.63±13.58 to 41.50±18.37, p-value =0.024). while no statistically significant difference in bodily pain (38.58±13.98 to 44.10±16.23, p-value =0.128), vitality the present study findings demonstrate that the highest percentages were ages ranging between 47-53 years old, a high proportion of them were male, married, able to read and write, and the majority of patients self-employed. it also shows most of coronary artery disease patients were non-smokers, with no family history and coronary artery disease duration between 1 and 3 years. the current study finding was supported by a retrospective copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: comparison mean score of quality of life (sf-36) before and after pci sf-36 domains mean + sd mean difference t-test p-value pre pci post pci physical functioning 39.70±11.99 44.90±10.47 -5.20 -3.10 0.003 role-physical 40.00±12.76 48.75±14.57 -8.75 -2.00 0.048 bodily pain 38.58±13.98 44.10±16.23 -5.52 -1.53 0.128 general health 40.00±17.38 44.21±12.63 -4.21 -2.17 0.033 pcs 39.57±12.62 45.49±11.63 -5.92 -0.32 <0.001 vitality 39.90±15.70 40.60±14.31 -0.70 -0.32 0.753 social functioning 35.63±13.58 41.50±18.37 -5.87 -2.29 0.024 role-emotional 39.56±14.05 41.33±13.11 -1.66 -0.48 0.630 mental health 39.67±17.21 40.52±11.91 -0.96 -0.24 0.815 mcs 38.69±11.17 40.99±9.37 -2.30 -1.65 0.103 overall quality of life 39.13±9.61 43.24±8.07 -4.11 -3.58 0.001 pcs-physical component summary; mcs-mental component summary discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.01 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article and hypertriglyceridemia. [7]. relative to ldl, most of the patients had high ldl, and low hdl. the results are supported by the study done in baghdad city which most participants have dyslipidemia [22]. concerning bmi, more than half a percentage was overweight. also, it is agreed by a study that that revealed that most cad patients were more likely to have a higher bmi [23]. in regard to glycemic control, it was shown before pci most of the patients had poor glycemic control, the present study agrees with the study by dzhun et al, which reported that a higher proportion of patients had hba1c >7 %) [24]. in addition to cigarette smoking, being overweight, hypercholesterolemia, hypertension, diabetes, and bmi significantly impact the quality of life [21,25]. the present study was supported by a study done by pasdar et a l, which found that the majority of study participants had a higher waist-hip ratio (whr) than normal [26]. concerning left ventricular ejection fraction (lvef), the current study was a supported study that shows the lvef pre-pci was 52% between (40-50%) [15]. the overall quality of life better improved in physical aspects, it was similar to previous studies [17,27] shown that the effect of qol was observed in most subdomains and was significant with regard to physical functioning, general health, social functioning and role-physical. moreover, the current findings agree with prior studies conducted on a convenience sample of 119 palestinian patients in 2020, using the short form-36 health survey applied 1 year after the coronary artery surgery [16]. also, it came with study [28] that evaluated the quality of life (qol) after percutaneous coronary intervention (pci) using a short form health survey (sf36) questionnaire at a tertiary care hospital in pakistan. a total of 433 adult patients who underwent pci, showed that the highest mean score was reported for pf, re, the german version of the heartqol, who revealed that most of the patients were married (71.1%) and did not complete school (62.6%) and about half of them were self-employed (52.1%) [7]. moreover, the study results come along with a descriptive, cross-sectional study on 210 patients with coronary artery disease in south korea [20] to investigate the factors influencing hrqol in patients with coronary artery disease who had received pci. most of the patients were married. furthermore, the results of the present study agree with a cross-sectional study conducted on 106 patients referred to a cardiac clinic who attended the follow-up visit 3 months after coronary angioplasty during 2015-2016 in rasht, iran. most of the patients were married (71.7%) nonsmokers (67%) no family history of heart disease; the majority of them had coronary artery disease duration between 1-3 years [21]. concerning cardiac and metabolic indicators, the study findings found more than half a percentage of patients were stage 1 hypertensive. the current result findings are similar with study done by gasecka et al., who evaluated hrqol in patients after the first ami treated in a reference cardiology centre in poland and assessed which clinical variables affect hrqol through short form (sf) 36 after ami in patients undergoing pci, who found that most of the 61% of patients had hypertension [15]. also, the findings are compatible with a previous study on health-related quality of life (hrql) among 305 patients with angina (n = 101), myocardial infarction (n = 123), or ischemic heart failure (n = 81) in austria and switzerland using german versions of the heartqol, and the short form -36 health survey (sf-36) done by huber et al., who show that more than one-half of the patients had hypertension. regarding lipid profile tests, the highest percentage of patients had hypercholesterolemia 07 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.01 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article [3] huang rc, prescott sl, godfrey km, davis ea. assessment of cardiometabolic risk in children in population studies: underpinning developmental origins of health and disease mother-offspring cohort studies. journal of nutritional science. 2015;4:e12. published 2015 apr 10. doi:10.1017/jns.2014.69. [4] smith sc, jr benjamin ej, bonow ro, braun lt, creager ma, franklin ba, et al. aha/ accf secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the american heart association and american college of cardiology foundation [published correction appears in circulation. 2015 14;131 (15):e408]. circulation.2011;124(22):24582473. doi:10.1161/cir.0b013e318235eb4d. [5] moryś, j. m., bellwon, j., höfer, s., rynkiewicz, a., & gruchała, m. quality of life in patients with coronary heart disease after myocardial infarction and with ischemic heart failure. archives of medical science. 2016;12(2), 326–333. https:// doi.org/10.5114/aoms.2014.47881 [6] windecker s, kolh p, alfonso f, collet jp, cremer j, falk v et al. esc/eacts guidelines on myocardial revascularization: the task force on myocardial revascularization of the european society of cardiology (esc) and the european association for cardiothoracic surgery (eacts)developed with the special contribution of the european association of percutaneous cardiovascular interventions (eapci). european heart journal. 2014;35 (37):2541-2619. doi:10.1093/ eurheartj/ehu278. [7] huber a, oldridge n, benzer w, saner h, höfer s. validation of the german heartqol: a short health-related quality of life questionnaire for cardiac patients. quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation. 2020;29(4), 1093–1105. https:// doi.org/10.1007/s11136-019-02384-6 [8] conradie a, atherton j, chowdhury e, duong m, schwarz n, worthley s, eccleston d. “health-related quality of life (hrqol) and the effect on outcome in patients presenting with coronary artery disease and treated with percutaneous coronary intervention (pci): differences noted by sex and age.” journal of clinical medicine. 2022;11,17 5231. 5 sep. 2022, doi:10.3390/ jcm11175231 and rf were significantly higher in overall score, mostly in pcs than in the mcs score. an increasing trend, with respect to patients’ perception of qol compared to one year ago. furthermore, the current study was a come along with follow-up a study done in japan on a total of 118 patients treated with percutaneous coronary intervention (pci) who revealed an improvement in the aspect of physical functioning in relation to quality of life was seen at 6 months after discharge [29]. to sum up, the quality of life of cad patients who underwent pci improved better in general specifically in the domains of general health, physical functioning, social functioning, and role physical. also, the findings revealed that cardiometabolic risk indicators improved after percutaneous coronary intervention. the authors would like to thank the personnel of the surgical specialty hospitalcardiac center in erbil city for their cooperation. the author reports no conflict of interests. the authors (s) report no funding support. [1] world health organization. cardiovascular diseases (cvds). key facts cardiovascular diseases (2021). available from (who.int) https://www.who.int. [accessed: 2nd december 2022]. [2] world health organization. iraq coronary artery diseases icd-10 codes; (2022). 120125. available from https:// www.worldlifeexpectancy.com/iraqcoronary-heart-disease [accessed: 10th may 2022]. 08 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion acknowledgement conflict of interest references funding https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.01 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article doi.org/10.7759/cureus.17982 [18] moreno pr, stone gw, gonzalez-lengua ca, puskas jd. the hybrid coronary approach for optimal revascularization: jacc review topic of the week. j am coll cardiol. 2020;76(3):321-333. doi:10.1016/ j.jacc.2020.04.078 available from https:// pubmed.ncbi.nlm.nih.gov/32674795/ [accessed: 1st december 2022]. [19] defilippis em, singh a, divakaran s, gupta a, collins bl, biery d, et al. cocaine and marijuana use among young adults with myocardial infarction. journal of the american college of cardiology. 2018;71(22), 2540–2551. https://doi.org/10.1016/j.jacc.2018.02.047. [20] kim y. health-related quality of life in patients with coronary artery disease undergoing percutaneous coronary intervention: a cross-sectional study. journal of nursing research. 2021;30(1):e186. published 2021 oct 29. doi:10.1097/jnr.0000000000000465 [21] darvishpour a, javadi-pashaki n, salari a, sadeghi t, taleshan-nejad m. factors associated with quality of life in patients undergoing coronary angioplasty. international journal of health sciences, (qassim). 2017;11 (4):35-41. https:// pubmed.ncbi.nlm.nih.gov/29085266/. [22] mansour ka, al-sarraf , mf, najm ma. health status among patients with percutaneous coronary intervention at cardiac centers in baghdad city. indian journal of public health research & development, january; 10,01, doi number: 10.5958/09765506.2019.00162.1. [23] yeng sh, gallagher r, elliott d. factors influencing health-related quality of life after primary percutaneous coronary intervention for st-elevation myocardial infarction. applied nursing research. 2016;30:237-244 https://doi.org/10.1016/j.apnr.2015.09.002. [24] dzhun y, mankovsky g, rudenko n, mankovsky b, marushko y. the effect of increased adherence to glycemic control on coronary artery disease and quality of life in patients with concomitant impaired glucose metabolism. georgian medical news,. 2021;(318):86 -9.https:// pubmed.ncbi.nlm.nih.gov/34628385 [25] yazdani-bakhsh r, javanbakht m, sadeghi m, mashaiekhi a, ghaderi h, rabiei k. comparison of health-related quality of life after percutaneous coronary intervention and coronary artery bypass surgery. arya atherosclerosis journal. 2016;12(3):124–31. [9] van nguyen h, khuong l q, nguyen at, nguyen alt, nguyen ct, nguyen h tt, et al. changes in, and predictors of, quality of life among patients with unstable angina after percutaneous coronary intervention. journal of evaluation in clinical practice. 2021;27 (2):325-332. doi:10.1111/jep.13416 [10] nugroho p, andrew h, kohar k, noor ca, sutranto al. comparison between the world health organization (who) and international society of hypertension (ish) guidelines for hypertension. annals of medicine. 2022;54 (1):837-845. https:// doi.org/10.1080/07853890.2022.2044510 [11] bhargava s, de la puente-secades s, schurgers l, jankowski j. lipids and lipoproteins in cardiovascular diseases: a classification. trends in endocrinology & metabolism. 2022;33(6):409-423. doi:10.1016/ j.tem.2022.02.001. [12] american diabetes association (ada). standards of medical care in diabetes-. diabetes care, 2012; 35 suppl 1: p. s11-s63. [13] world health organization ( 2011) . use of glycated haemoglobin ( hba1c) in diagnosis of diabetes mellitus: abbreviated report of a who consultation. world health organization. https://apps.who.int/iris/ handle/10665/70523 [14] lockie rg, ruvalcaba tr, stierli m, dulla jm, dawes jj, orr rm. waist circumference and waist-to-hip ratio in law enforcement agency recruits: relationship to performance in physical fitness tests. journal of strength and conditioning research. 2020;34 (6): pp.1666-1675. doi:10.1519/ jsc.0000000000002825 [15] gasecka a, rzepa b, skwarek a, cwiek a, pluta k, szarpak l, et al. health-related quality of life increases after first-time acute myocardial infarction: a population-based study. zdravstveno varstvo. 2021;61(1):2431.doi:10.2478/sjph-2022-0005 [16] ejheisheh ma, correa-rodríguez m, fernández-aparicio á, batran a, suleiman-martos n, schmidt-riovalle j. prior percutaneous coronary intervention is associated with low health-related quality of life after coronary artery bypass graft. nursing & health sciences. 2020;22(4):1022-1029. doi:10.1111/ nhs.12761 [17] chatzinikolaou a, tzikas s, lavdaniti m. assessment of quality of life in patients with cardiovascular disease using the sf-36, macnew, and eq-5d-5l questionnaires. cureus. 2021;13(9),e17982.https:// 09 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.01 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article https://www.ncbi.nlm.nih.gov. pmc5055370/ [26] pasdar y, moradi s, moludi j, saiedi s, moradinazar m, hamzeh b, et al. waist-to-height ratio is a better discriminator of cardiovascular disease than other anthropometric indicators in kurdish adults. scientific reports. 2020;10(1):16228. published 2020 oct 1. doi:10.1038/s41598-020-73224-8. [27] hassan am, el nahas ng. efficacy of cardiac rehabilitation after percutaneous coronary intervention. international journal of pharmtech research (ijprif). 2016;9(4),pp 134-141. 135 issn: 0974-4304. [28] kumar r, ammar a, shah ja, saghir t, kumar a, shaikh ah et al. quality of life after primary pci in pakistani population – does it really change? pakistan heart journal. 2021;54(3).sep.3 https:// pakheartjournal.com/index.php/pk/article/ view/2164. [29] shibayama k. factors related to the improvement of quality of life at 6 months after discharge for myocardial infarction patients treated with percutaneous coronary intervention. journal of rural medicine. 2012;7 (1):33-37. doi:10.2185/jrm.7.33 10 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.10 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article nurses’ knowledge, attitude, and practice regarding pain management for cancer patients in erbil city abstract background and objectives: pain is one of the main common manifestations of patients with cancer disease and its treatment that seek individuals to find medical treatment in clinics and hospitals. the study assessed nurses’ knowledge, attitude, and practice toward cancer pain management in nanakali hospital for blood diseases and cancer and the chemotherapy department in rizgary teaching hospitals. methods: a crosssectional study was carried out in nanakali hospital for blood diseases and cancer and the chemotherapy department in rizgary teaching hospitals from may 2020 to the end of november 2022 on a purposive sample which includes 64 nurses through applying self-administered questionnaires by using the knowledge and attitudes survey regarding pain (kasrp) tool for assessment of knowledge and attitudes of nurses, and observational checklists for assessment of nurses’ practice toward pain. the data were analyzed using spss software for statistical analysis (version 26) for calculating descriptive statistical analysis (frequency, percentage, mean, and standard deviation). results: study shows that less than half of nurses 42.2% were between 21-33 years of age, 59.4% were males, 78.1% had a diploma in nursing, 75% were formal employees, and 50% of them participated in training courses previously. in this study, the highest percentages of participants had fair knowledge and negative attitudes toward management of pain for cancer patients. they did not provide sufficient practice about nonpharmacological management of pain for cancer disease. conclusion: nurses who work in oncology wards had fair knowledge, negative attitudes and inadequate practice toward pain management for cancer patients. therefore, it is important to do training courses for enhancing nurses’ knowledge, attitude, and practices regarding the management of pain. keywords: nurse; knowledge; attitude; practice; pain management; cancer pain management. bakhtyar othman omer; department of nursing, college of nursing, hawler medical university, kurdistan region, erbil, iraq. (correspondence: bakhtyar.omer@hmu.edu.krd). ronak nemat allah hussain; department of nursing, college of nursing, hawler medical university, kurdistan region, erbil, iraq. 86 received: 07/12/2022 accepted: 02/03/2023 published: 30/05/2025 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:bakhtyar.omer@hmu.edu.krd?subject=bakhtyar.omer@hmu.edu.krd%20 mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.10 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article cancer has increased more and more from the past to now. it takes disturbances in the function of an organ that is damaged and affected. cancer is a chronic disease; it involves over 100 various conditions and is characterized by abnormal growth of cells, distributed abnormal and unregulated growth of cells [1]. a recent estimation has shown that more than 25,000 cases of current cancer, as well as 14,000 cancer deaths, were presented in the year 2018 in iraq [2]. regarding the kurdistan region of iraq, the total number of which suffered from cancer, was dramatically increased in erbil and duhok, for example, 73 cancer cases per 100,000 populations in erbil city in 2013, and this number has increased more than doubled to 174 cancer cases per 100,000 populations in 2019. regarding duhok city, the total number of cancer cases in 2013 was 486 (36 cases per 100.000 population), while this number increased to 1365 (85 cancer cases per 100,000 population) in 2019 [3].according to two studies [4,5], which declared that pain is mentioned as one of the main issues that occur with cancer disease. it is the main common symptom that lead individuals to seek medical treatment in clinics and hospitals. pain has been defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage" [6,7]. pain may be caused by cancer disease, the spreading tumor "metastases" and damage to the nerve, or sometimes this pain may be due to treatments of cancer such as chemotherapy and radiotherapy. it has also remained without treatment and control in many different cases of cancer [8, 9]. according to many studies [10, 11,12,13,14 15, 16] in both developed and developing countries and all over the world, there is a continuously reported lack of knowledge and poor attitudes of nurses, and also found insufficient knowledge of nurses such as problems due to physiology and assessment of pain, pharmacology of analgesic medications, and risks related to the use of opioid medications and opioid tolerance and addiction inaccurately. pain management practice was defined as a group of activities that have been done by nurses practically and effectively to alleviate and reduce cancer pain. therefore, this study aimed to assess the knowledge, attitudes, and practices of nurses toward the pain management for cancer patients in erbil city. a cross-sectional design was carried out to assess the knowledge, attitudes, and practices of nurses regarding pain management for cancer patients in nanakali hospital for blood diseases and cancer and rzgari teaching hospital in erbil city/ kurdistan region/ iraq. the study commenced from may 2020 to the end of november 2022 among a purposive sample of all participants (64 nurses) available in hospitals during the period of gathering data included in the study. all nurses signed the informed consent and inclusion criteria included nurses who provide care for cancer patients in nanakali hospital for blood diseases and cancer and rzgari teaching hospital, both genders (male and female). self-administered questionnaires were applied to gather data that included three parts: the first part is related to sociodemographic characteristics of nurses, including age, gender, and educational level, years of working in the oncology department, place of work, and participation in a training course about pain management for cancer patients. second part: included the modified pain management questionnaires “(knowledge 87 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.10 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article groups: poor practice (0-6), fair practice (7 -13), and good practice (14-20). the validity of tools was assessed by a panel of experts from health specialties (adult health nursing, oncologist medicine). a pilot study (test-retest) was done among 11 nurses who were not part of the samples. a pilot study was carried out to know any difficult situations dealing with providing the tools and know the period required for the collection of data. consistency of questionnaires was done by using the mann-whitney u value test (test-retest) the time interval between the test and the retest was two weeks. ethical approval was obtained from the ethics committee of the college of nursing/ hawler medical university, as a code number 142 on 1/11/2021. permission was obtained from the director of health/erbil. verbal consent was received from participants. the data were interpreted by using spss software for statistical analysis version 26, for calculating descriptive statistical analysis (frequency, percentage, mean, and standard deviation). table 1 illustrates a total of 64 nurses with a mean age of 37.2 ± 9.72 years were included, with less than half of participants 42.2 % in between the 21-33year of age group. regarding gender, 59.4% were males and 40.6% were females, and majority of the participants 78.1% had a diploma in nursing. the highest percentage 84.4% of nurses worked in the nanakali hospital for blood diseases and cancer, 37.5% of them had more than 10 years of experience in management of cancer pain, 75% of participants are formal employed in the nanakali hospital for blood diseases and cancer and rizgary teaching hospital and 50% of nurses participated previously in training courses toward management of cancer pain. and attitude survey regarding pain tool constructed by the american pain society, the world health organization, and the agency for health care policy and research pain management guidelines)”[17], the questionnaire consisted of 34 questions that were to 25 questions (14 questions are true and false and 11 questions are multiple-choice) for assessment of nurses’ knowledge, and 9 questions (7 questions are true and false and two questions are multiple-choice) for assessment of nurses’ attitude. questionnaires were filled out by participants in 20-25 minutes, and the responses to the nurses’ knowledge about pain management for patients with cancer items included: (0 = incorrect and 1= correct). the overall calculation of nurses' knowledge regarding the management of cancer pain (25 items) was classified into three groups: poor knowledge (0-8.2), fair knowledge (8.316.6), and good knowledge (16.7-25). the responses to the nurses' attitudes about the management of pain for cancer patient items included: (0 = negative and 1= positive). the overall calculation of nurses' attitudes about the management of cancer pain (9 items) was categorized into two groups: negative attitudes (0-4) and positive attitudes (5-9). the questionnaire was in the english language and it was translated into the kurdish language and then the kurdish version was translated again to english into determine the consistency of the tool. third part: included assessment of nurses' practice on pain management: it was done by using observational checklists based on an extensive review of the literature [18]. the responses to the nurses' practice about the management of pain for patients with cancer items included: (0 = not achieved and 1= achieved). the overall calculation of nurses' practice about pain management for patients with cancer (20 items) was classified into three 88 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.10 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article table 2 shows the knowledge of nurses toward cancer pain management, as the percentages of nurses who administered correct answers for each of the 25 questions in the knowledge survey regarding pain. the correct responses with the highest percentage for questions were after an initial dose of opioid analgesic is given, subsequent doses should be adjusted by the individual patient’s response (85.9%), patient’s spiritual beliefs may lead them to think pain and suffering are necessary (true) (79.7%), intravenous route is the recommended route of administration of opioid analgesics for patients with brief, severe pain of sudden onset, such as trauma or postoperative pain (75%), tramadol is registered as a golden standard for cancer pain management (true) (75%), opioid addiction is a chronic neurological disease (true) (67.2%), and the time to peak effect for morphine given intravenous is 15 min (64.1%). however, the lowest percentage of correct responses for questions were patients may sleep despite severe pain (true) (14.1%), aspirin and nsaid are not effective analgesics for boney metastasis (false) (17.1%), if the source of the patient’s pain is unknown, opioids should not be used during the pain evaluation period, as this could mask the ability to correctly diagnose the cause of pain. (false) (15.6%), the oral route is the recommended route of administration of opioid analgesics for patients with persistent cancer-related pain (9.4%), morphine is an opioid analgesic medication which is considered the drug of choice for the treatment of prolonged moderate to severe pain for cancer patients (7.8%), and abrupt 89 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: sociodemographic characteristics of nurses sociodemographic characteristic (n= 64) f. (%) age group (years) 21-33 27 (42.2) 34-46 22 (34.4) 47-59 15 (23.4) gender male 38 (59.4) female 26 (40.6) qualification diploma 50 (78.1) bachelor 13 (20.3) master 1 (1.6) name of hospitals nanakaly hospital 54 (84.4) rizgary teaching hospital 10 (15.6) year of experience 1-5 22 (34.4) 6-10 18 (28.1) > 10 24 (37.5) type of employment formal 48 (75) contract 16 (25) training course about pain management yes 32 (50) no 32 (50) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.10 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article 90 ing: sweating, yawning, diarrhea and agitation (18.8%). of an opioid, physical dependence is manifested by the follow copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2. nurses’ knowledge towards cancer pain management knowledge of nurses towards cancer pain management (n= 64) incorrect correct f. (%) f.(%) vital signs are always reliable indicators of the intensity of a patient’s pain (false) 38 (59.4) 26 (40.6) because their nervous system is underdeveloped, children under two years of age have decreased pain sensitivity and limited memory of painful experiences. (false) 32 (50) 32 (50) patients may sleep in spite of severe pain (true) 55 (85.9) 9 (14.1) aspirin and nsaid are not effective analgesic for boney metastasis (false) 53 (82.8) 11 (17.2) combining analgesic works better than a single analgesic (true) 38 (59.4) 26 (40.6) the usual duration of analgesia of 1-2 mg morphine iv is 4-5 hours (false) 44 (68.8) 20 (31.3) promethazine and hydroxyzine as potentiates of opioids (false) 33 (51.6) 31 (48.4) patient’s spiritual beliefs may lead them to think pain and suffering are necessary (true) 13 (20.3) 51 (79.7) after an initial dose of opioid analgesic is given, subsequent doses should be adjusted in accordance with the individual patient’s response. (true) 9 (14.1) 55 (85.9) tramadol is regarded as a golden standard for cancer pain management (true) 16 (25) 48 (75) if the source of the patient’s pain is unknown, opioids should not be used during the pain evaluation period, as this could mask the ability to correctly diagnose the cause of pain. (false) 54 (84.4) 10 (15.6) anticonvulsant drugs such as gabapentin (neurontin) produce optimal pain relief after a single dose. (false) 45 (70.3) 19 (29.7) benzodiazepines are not effective pain relievers (true) 31 (48.4) 33 (51.6) opioid addiction is a chronic neurological disease. (true) 21 (32.8) 43 (67.2) oral route is the he recommended route of administration of opioid analgesics for patients with persistent cancer-related pain. 58 (90.6) 6 (9.4) intravenous route is the recommended route of administration of opioid analgesics for patients with brief, severe pain of sudden onset, such as trauma or postoperative pain. 16 (25) 48 (75) morphine is opioid analgesic medication which is considered the drug of choice for the treatment of prolonged moderate to severe pain for cancer patients. 59 (92.2) 5 (7.8) a 30 mg dose of oral morphine is approximately equivalent to 10 mg of morphine is given intravenously. 43 (67.2) 21 (32.8) analgesics for post-operative pain should initially be given around the clock on a fixed schedule. 47 (73.4) 17 (26.6) chance of respiratory depression for cancer patients on opioid analgesics is less than 1%. . 51 (79.7) 13 (20.3) the most likely reason a patient with pain would request increased doses of pain medication is that the patient is experiencing increased pain. 41 (64.1) 23 (35.9) ibuprofen (motrin) hydromorphone (dilaudid) gabapentin (neurontin) are useful for treatment of cancer pain. 49 (76.6) 15 (23.4) the time to peak effect for morphine given intravenous is 15 min. 23 (35.9) 41 (64.1) the time to peak effect for morphine given orally is 1-2 hour. 51 (79.7) 13 (20.3) abrupt discontinuation of an opioid, physical dependence is manifested by the following: sweating, yawning, diarrhea and agitation 52 (81.3) 12 (18.8) mean of percentage of correct answers 60.75 39.252 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.10 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article overall fair knowledge toward cancer pain management and majority with poor knowledge level. who have been receiving stable doses of opioids for months (true) (75%) and elderly patients cannot tolerate opioids for pain relief (false) (53.1). 91 table 3 shows the overall nurses' knowledge regarding cancer pain management, the majority of nurses 84.4% had table 4 shows nurses' attitude toward the management of cancer pain, as the percentages of nurses who administered correct answers for each of 9 questions in the attitude survey regarding pain. from 9 items, most of the items has negative attitudes which were: patients who can be distracted from pain usually do not have severe pain (false) (89.1%), patients should be encouraged to endure as much pain as possible before using an opioid (false) (84.4%), and giving patients sterile water by injection (placebo) is a useful test to determine if the pain is real (false) (76.6%), children less than 11 years old cannot reliably report pain so clinicians should rely solely on the parent’s assessment of the child’s pain intensity (false) (71.9%), 5-15% patients likely are patients who develop pain already have an alcohol and/or drug abuse problem (67.2%), the patient is the most accurate judge of the intensity of the patient’s pain (64.1%), and opioids should not be used in patients with a history of substance abuse (false) (51.6%). nurses only had positive attitudes with those questions: respiratory depression rarely occurs in patients copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: nurses’ overall knowledge regarding cancer pain management overall knowledge of nurses towards cancer pain management (n= 64) f. (%) poor fair 10(15.6) 54(84.4) total 64(100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.10 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article regarding the management of pain for the cancer patient, and only 25% of the sample study had positive attitudes. table 5 represents overall nurses’ attitude regarding pain management for cancer patients, the highest percentage (75%) of participants had overall negative attitudes 92 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: nurses’ attitude regarding cancer pain management nurses’ attitude towards cancer pain management (n= 64) negative positive f. (%) f. (%) patients who can be distracted from pain usually do not have severe pain. (false) 57 (89.1) 7 (10.9) respiratory depression rarely occurs in patients who have been receiving stable doses of opioids over a period of months (true) 16 (25) 48 (75) opioids should not be used in patients with a history of substance abuse. (false) 33 (51.6) 31 (48.4) elderly patients cannot tolerate opioids for pain relief (false) 30 (46.9) 34 (53.1) patients should be encouraged to endure as much pain as possible before using an opioid. (false) 54 (84.4) 10 (15.6) children less than 11 years old cannot reliably report pain so clinicians should rely solely on the parent’s assessment of the child’s pain intensity. (false) 46 (71.9) 18 (28.1) giving patients sterile water by injection (placebo) is a useful test to determine if the pain is real. (false) 49 (76.6) 15 (23.4) the most accurate judge of the intensity of the patient’s pain is. (patient) 41 (64.1) 23 (35.9) how likely is it that patients who develop pain already have an alcohol and/ or drug abuse problem? (5-15%) 43 (67.2) 21 (32.8) table 5 :overall nurses’ attitude regarding pain management for cancer patients: overall attitude of nurses towards cancer pain management (n= 64) f. (%) negative 48 (75) positive 16 (25) total 64 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.10 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article percentage of participants did not achieve practice for non-pharmacological pain management for cancer patients, except in change positioning (90.6%) which provided. table 6 shows nurses' practice toward pharmacological and non-pharmacological pain management. the highest percentage of the study sample had achieved the practice of all items related to pharmacological pain management while the highest 93 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 6 :nurses’ practice regarding cancer pain management practice of nurses’ regarding cancer pain management: (n= 64) not achieved achieved f. (%) f. (%) assess general condition 35 (54.7) 29 (45.3) check medications order 0 (0) 64 (100) procedure/ handwashing 4 (6.3) 60 (93.8) procedure / identify the patient 1 (1.6) 63 (98.4) procedure/ administering pain medication as ordered 0 (0) 64 (100) non-pharmacological pain management positioning 6 (9.4) 58 (90.6) distraction of patients 62 (96.9) 2 (3.1) relaxation technique 54 (84.4) 10 (15.6) heat and cold compress application 43 (67.2) 21 (32.8) massage therapy 44 (68.8) 20 (31.3) emotional support 37 (57.8) 27 (42.2) biofeedback 61 (95.3) 3 (4.7) hypnosis 64 (100) 0 (0) imaginary 64 (100) 0 (0) deep breathing 52 (81.3) 12(18.8) meditation 64 (100) 0 (0) post care/ assess of patient response after 1/2 hours 36 (56.3) 28 (43.8) post care/ observed patients nonverbal care 2 (3.1) 62 (96.9) post care/ monitored for analgesic side effect 1 (1.6) 63 (98.4) document of patient response 64 (100) 0 (0) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.10 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article however, only 4.7% of them had overall poor practice towards cancer pain management. which reported that jordanian nurses had inadequate knowledge and poor attitudes towards the management of cancer pain [23].the finding of the present study showed the highest percentages of participants had overall fair knowledge and negative attitudes toward the management of cancer pain. this result may be related to less specialization or high qualification of nurses toward the management of cancer pain in our hospitals. another reason behind this is that the majority of nurses who are working in these hospitals have a diploma degree in nursing, while only a few nurses have a bachelor degree in nursing science, they may be more understanding and follow up the internationally updated articles on the management of cancer pain. the result of the present study is in disagreement with the study carried out in the united arab emirates, as revealed participants had inadequate knowledge and negative attitudes regarding the management of cancer pain [24]. another crosssectional study is in disagreement with the present study which was conducted in china by using the knowledge and attitudes survey regarding pain (kasrp), which stated that oncology nurses had good knowledge and positive attitudes toward the management of cancer pain [25]. table 7 shows overall nurses’ practice toward cancer pain management, as the majority of nurses (93.4%) had overall fair practice toward cancer pain management. pain is the worst indicator of cancer disease and its treatment [19]. cancer patients are required to reduce or manage their pain either pharmacologically or nonpharmacologically to support those bao et al states that pain management is essential in cancer patients’ care and also important for enhancing cancer patients’ outcome [20]. in addition, adjuvant therapy should be applied for cancer pain management such as analgesics and complementary or alternative therapy [21]. for that reason, nurses must assess and improve their knowledge, attitudes, and practices regarding pain management. the result of the present study shows most of the nurses who work in the oncology department had fair knowledge and negative attitudes regarding the pain management for cancer patients. this may be due to most of the nurses who work in oncology wards graduating from the institute, the older nurses, and the health system policy and regulations of the hospitals. the result of the present is supported by the result of the study which found inadequate knowledge and negative attitudes during the management of cancer pain [22]. moreover, the present result is very close to the finding of the research carried out in jordan by applying exploratory descriptive design, 94 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion table 7 : nurses’ overall practice towards cancer pain management: overall practice of nurses toward cancer pain management (n= 64) f. (%) poor 3 (4.7) fair 61 (95.3) total 64 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.10 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article conclusion the study concluded that the highest percentage of nurses had fair knowledge and negative attitudes toward pain management in cancer patients. the majority of nurses did not provide sufficient practices toward non-pharmacological pain management for cancer patients. we want to thank the nurses who shared in our study and the head nurse of the chemotherapy department in rzgari and nanakaly teaching hospitals for their help and cooperation during the period of doing this research. the authors have no conflict of interest. [1] williams ls, hopper pd. understanding medical surgical nursing. 5th ed. usa: fa davis; 2015. [2] bray f, ferlay j, soerjomataram i, siegel rl, torre la, and jemal a. global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca: a cancer journal for clinicians. 2018; 68: 394–424. [3] amen km, abdullah o, amin a, hasan b, mohamed z, sulaiman l, et al. cancer incidence in the kurdistan region of iraq: results of a seven-year cancer registration in erbil and duhok governorates. asian pacific journal of cancer prevention. 2022; 23 (2): 601-15. [4] nettina sm, msn a-b, nettina sm. lippincott manual of nursing practice. 10th ed. usa, new york: lippincott williams and wilkins; 2013. [5] shahriary s, shiryazdi sm, shiryazdi sa, arjomandi a, haghighi f, vakili fm, et al. oncology nurses knowledge and attitudes regarding cancer pain management. asian pacific journal of cancer prevention: apjcp. 2014;16(17):7501-6. [6] lewis sl, bucher l, heitkemper mm, harding mm, kwong j, roberts d. medical-surgical nursing: assessment and management of 16. it may be due to most of the nurses having diploma qualifications, who do not have a role in the hospital policy and having workload that does not allow nurses to participate in training courses. in addition, the sample size is small. the current study's findings showed the majority of nurses were not achieved in the practical items regarding non-pharmacological pain management such as; distraction of patients, relaxation, heat and cold compress, massage therapy, emotional support, biofeedback, hypnosis, imagery, deep breathing and meditation, which is in agreement with musleh et al [18] applying the same checklists conducted in egypt, revealing that the highest percentage of nurses did not perform care and management of cancer pain adequately. nurses also had an insufficient level of practice in the nonpharmacological management of pain. it may be due to most of the participants having a diploma in nursing; they are less qualified in the management of pain practices. matthews and malcolm [26] reported that alternative and complementary therapy is the most effective technique for managing and alleviating pain in cancer patients. another study was conducted in ethiopia showing that nurses generally had poor practice regarding pain management for cancer patients (27). the present result is in disagreement with the result of a study which found nurses were good at practicing pharmacologically and nonpharmacologically for cancer pain management (28). 95 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. acknowledgement conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.10 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article clinical problems. 10th ed. usa, st. louis: elsevier health sciences; 20 [7] ababa a, kassa h, murugan r, zewdu f, hailu m, woldeyohannes d. assessment of knowledge, attitude and practice and associated factors towards palliative care among nurses working in selected hospitals, addis ababa, ethiopia. bmc palliative care. 2014; 13(1): 1-11. [8] den beuken-van v, everdingen mhj, hochstenbach lmj, joosten eaj, tjanheijnen vcg, janssen dja. update on prevalence of pain in patients with cancer: systematic review and meta-analysis. journal of pain symptom management.2016; 51 (6):1070-90. [9] bennett mi, kaasa s, barke a, korwisi b, rief w, treede rd. the iasp classification of chronic pain for icd-11: chronic cancerrelated pain. the journal of the international association for the study of pain. 2019; 160 (1):38–44. [10] hamieh nm, akel r, anouti b, traboulsi c, makkii,hamiehl, tfayli a. cancer-related pain: prevalence severity and management in a tertiary care center in the middle east. asian pacific journal of cancer prevention: apjcp. 2018; 19(3):769-75. [11] anderson ko, richman sp, hurley j, palos g, valero v, mendoza tr, et al. cancer pain management among underserved minority outpatients: perceived needs and barriers to optimal control. cancer. 2002; 94 (8): 2295304. [12] makhlouf sm, pini s, ahmed s, bennett mi. managing pain in people with cancer-a systematic review of the attitudes and knowledge of professionals, patients, caregivers and public. journal of cancer education. 2020; 35(2): 214-40. [13] rurup ml, rhodius ca, borgsteede sd, boddaert msa, astrid gm, keijser hr, et al. the use of opioids at the end of life: the knowledge level of dutch physicians as a potential barrier to effective pain management. bmc palliative care. 2010; 9(1): 23. [14] jarrett a, church t, shackelford j, lofton a, and fancher gk. nurses 'knowledge and attitudes about pain in hospitalized patients. clinical nurse specialist. 2013; 27(2). [15] yava a, hatice ç, nuran t. knowledge and attitudes of nurses about pain management in turkey. international journal of caring science. 2013; 6 (3): 494-505. 96 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [16] jho hj, kim y, kong ka, kim dh, choi jy, nam ej, et al. knowledge, practices, and perceived barriers regarding cancer pain management among physicians and nurses in korea: a nationwide multicenter survey. plos one. 2014; 9(8). [17] samarkandi oa. knowledge and attitudes of nurses toward pain management. saudi journal of anesthesia. 2018;12(2):220-6. [18] musleh ba, erfan sa, mohammed ma, and elaziz ma. impact of educational program about cancer pain management on nurses’ knowledge, attitudes, and practice at intensive care unit. assiut scientific nursing journal. 2015; 3 (6): 40-49. [19] algahtani m, jones lk. quantitative study of oncology nurses’ knowledge and attitudes towards pain management in saudi arabian hospitals. european journal of oncology nurses. 2015; 19: 44-49. [20] bao y, kong x, yang l, liu r, shi z, li w, et al. complementary and alternative medicine for cancer pain: an overview of systematic reviews. evidence-based complementary and alternative medicine. 2014. [21] cassileth b, trevisan c, and gubili j. complementary therapies for cancer pain. current pain and headache reports. 2007; 11 (4): 265-9. [22] al-sayaghi km, fadlalmola ha, aljohani wa, alenezi am, aljohani dt, aljohani ta, et al. nurses’ knowledge and attitudes regarding pain assessment and management in saudi arabia. in healthcare. 2022; 10 (3); 528. [23] mcmillan sc, tittle m, hagan s, and laughlin j, tabler re. knowledge and attitudes of nurses in veterans’ hospitals about pain management in patients with cancer. oncology nursing forum. 2000; 27(9);1415-23. [24] al-atiyyat n, salim na, tuffaha mg, abu nigim ha, saleh mm, alkhodary m, brant jm. a survey of the knowledge and attitudes of oncology nurses toward pain in united arab emirates oncology settings. pain management nursing. 2019; 20 (3):276 -83. [25] li d, gao l, ren ly, zeng x, cui ep, zhang lj, et al. knowledge and attitudes regarding cancer pain management among oncology nurses in china. journal of international medical research. 2021; 49(1). [26] matthew e, and malcolm c. nurses’ knowledge and attitudes in pain management practice. british journal of nursing. 2007; 16(3): 147-9. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.10 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article [27] kassa rn, kassa gm. nurses’ attitude, practice and barrier s toward cancer pain management, addis ababa, ethiopia. journal of cancer science therapy. 2014; 6 (12): 483-7. [28] toba h, samara a, zyoud s. nurses’ knowledge, perceived barriers, and practices regarding cancer pain management: a crosssectional study from palestine. bmc medical education. (2019); 19(1): 1-7. 97 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.19 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article risk factors associated with congenital anomalies among children admitting surgical unit in rapareen pediatric teaching hospital in erbil city abstract backgrounds and objectives: congenital anomalies, which can affect how the body operates, are anatomical, functional, or metabolic abnormalities that develop during intrauterine life. the study aimed to identify risk factors associated with congenital anomalies among children who are admitting to the surgical unit at rapareen pediatric teaching hospital in erbil city. methods: descriptive, case-control design was used to conduct this study. this study was conducted in rapreen pediatric teaching hospital in erbil from 1st of july to 1st of october 2022. nonprobability purposive sample of 100 mothers with congenital anomalies children and admitted to the surgical unit and 100 mothers with other health condition children (control group) at rapareen pediatric teaching hospital were asked respectfully to participate in the study. descriptive and frequency, regression analytics was used for exploring the factors associated with congenital anomalies, chi-square was used to find out the association between dependent and independent variables, and t-tests were used to identify the differences between case and control groups. results: the results show that that anemia in pregnancy, previous history of congenital anomalies, family history of congenital anomalies, pesticide use, living near of mobile station, passive smoke, stress during pregnancy, didn't use folic acid, and drink of coffee during pregnancy had a very high statistical difference between case and control p-value <0.001, while radiation exposure had a difference between case and control p-value of 0.045. that age of mothers and weight were factors which highly statistical associated with congenital anomalies among children p-value 0.001 and <0.001 respectively, moreover age of father and history of previous abortion were factors behind the congenital anomalies p-value 0.033 and 0.017 respectively. conclusions: the study concluded that age of mothers and father, weight, and history of previous abortion were factors behind the congenital anomalies. primary prevention is most important to reduce the incidence of congenital anomalies and the morbidity associated with it. keywords: congenital; risk factor; rapareen; erbil. chawarwan saleem abdullah; department of nursing, college of nursing, hawler medical university, kurdistan region iraq. (correspondence: chawarwan.abdullah@hmu.edu.krd) shukir saleem hasan; department of nursing, college of nursing, hawler medical university and faculty of nursing, tishk international university, kurdistan regioniraq. 182 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 13/02/2023 accepted: 30/04/2023 published: 30/05/2024 mailto:chawarwan.abdullah@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.19 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article congenital anomalies also known as congenital malformations have been defined as a " structural or functional anomalies that occur during intrauterine life and can be identified prenatally, at birth, or sometimes may only be detected later in infancy". congenital anomalies increase the risk of long term disability, an estimated 240 000 newborns die worldwide within 28 days of birth every year, and congenital anomalies also are the main causes of further 170 000 deaths of children between the ages of 1 month and 5 years [1]. nearly 95% of the babies who died from congenital malformation were lived in middleand low-income countries [2].the prevalence rates of conginatal anomalies are different from country to other country, the prevalence of congenital anomalies in japan is low which 1.07% and as high as in taiwan which is 4.3%, in us was 2-3%, in england has been reported is 2%, and in lebanon has been estimated as 1.64% [3]. in turkey, depend to the turkish statistical institute congenital malformations and chromosomal anomalies were responsible for 1.23% of all causes of death in 2018[4]. in iran the prevalence rate among children was estimated to be 2.3%, the total prevalence rates, in terms of gender, were more in boys (3%) than girls (2%) [5]. in 2007 high rate of congenital anomalies was reported from bagdad city in iraq which is estimated in 12.36 per 1000, in al-anabr was 8.5 per 1000 birth, however, a study from erbil, iraq on live births between 1990 and 1999 revealed an unexpected high rate of 23.9 congenital anomalies per 1000 live births [6]. other study revealed that in erbil city\ iraq for about 35,803 recorded births, 130 mothers delivered newborns with congenital anomalies in maternity teaching hospital from the time period of april 2015 to the march of 2016 [7].babies are born babies are born with congenital anomalies because of many causes and risk factors. for about 50% of congenital anomalies, causes are undefined yet, but the studies showed that 30-40% may due to genetic, 5 to 10% related to environment, chromosomal abnormality constitutes 6%, and multifactorial 2030% [3]. reported that every year in 8 million births, 6% of total births are born with serious congenital anomalies of genetic or partially genetic origin. additionally more than 100 \1000 are born with serious birth defects of post conception origin related to maternal exposure to environmental agents [8]. the study was conducted in mardan (pakistan) suggested that consanguineous marriages and lack of folic acid are the topmost risk factors that had the role to increasing rate of congenital anomalies [9]. ameen and her colleagues in erbil\iraq (2018) showed that mothers with history of previous congenital anomalies, parental consanguinity, and mothers with medical disorder during pregnancy were risk factors for delivered babies with congenital anomalies [7]. a number of congenital anomalies can be prevented through many ways like vaccination, adequate intake of folic acid or iodine through fortification of staple foods or supplementation, and adequate care before and during a pregnancy are examples of prevention methods [1]. knowing information about the risk factors of congenital anomalies is beneficial to obtain baseline rates of risk factors, documenting changes over time, and identifying clues to the etiology of conditions. this information is also helpful to plan and assess antenatal screening for congenital anomalies, especially for highrisk populations. the study aimed to identify factors associated with children with congenital anomalies who are admitted to the surgical unit at rapareen 183 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.19 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article after constructing the questionnaire, it will send to the number of experts in the fields of medicine, nursing, and biostatistics. the comments of experts were taken into consideration regarding clarity, relevancy, and adequacy to achieve the objectives. the reliability of the questionnaire was tested by the pilot test of 10 children with congenital anomalies, and who admitted to surgical unit at raparin teaching hospital for children.before data collection, formal permission was obtained from hawler medical university\ college of nursing and rapareen pediatric teaching hospital for conducting the study (12)19-june-2022. a primary approval was obtained from the research ethics committee, hawler medical university/nursing. oral informed consent was obtained from mothers before data collection, after the explanation of the purpose of the study, benefits, rights to privacy, and rights to withdraw at any time. the investigator promised to keep the information for confidential and anonymity. a pilot study was conducted on 10 % of the total sample of congenital anomaly babies to test the content validity and feasibility of designed tools and estimate the time required for filling the tool modifications will do accordingly. the data was analyzed by the statistical package for the social sciences version 23 (spss). frequency and linear regression analytics for exploring the factors associated with congenital anomalies, chi-square to find out the association between dependent and independent variables, and t-test test to identify the differences between case and control the current results show that less than half of participants in case and control group were between the ages of 21-25 (46% and 48% respectively). concerning the occupation of mothers 71% in case and 78% in pediatric teaching hospital in erbil city. quantitative design, descriptiveretrospective, case and control study were used to conduct this study. the study was carried out at rapareen pediatric teaching hospital (rpth) in erbil city. this study was conducted in rapreen pediatric teaching hospital in erbil and the time interval was from 1st of july to 1st of october 2022. nonprobability purposive sample of 100 mothers, who born children with congenital anomalies and were admitted to the surgical unit at rpth, and 100 mothers had children with other health conditions at rpth were asked respectfully to participate in the study. mothers who are willing to participate in the study, child diagnosed by the related consultant surgeon and admitted to surgical department, and child admitted to the surgery department and complained of congenital anomalies were included in the study. while, the congenital anomalies children are admitted to others sectors (private hospitals), orphan children (mother's die), and mothers with psychological problems were excluded from the study. data was collected by using a questionnaire format and was distributed by the investigator and thought direct (face to face) interview method with mothers have children with congenital anomalies , who kindly accept to participate in the study. the cases that fulfill the inclusion criteria were selected. the interviews were conducted at surgical unit of rapareen pediatric teaching hospital. to avoid extra crowded, the researcher attended the hospital during evening shift from 2 pm to 6 pm every other day, and each interview session took approximately (1530) minutes. the questionnaire format was prepared by the investigator. the questionnaire includes the following parts. 184 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.19 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article control were housewives, while more than half of participants in case and control groups were illiterate(54% and 63% respectively). more than half (53%) of mothers in case group lived in urban area while, the majority (72%) of mothers in control group lived in urban area. as for the economic status of participants, results showed that the result of current study in table 2 shows that 58% of children in case and 67% of children in control were ages between 1days -1 years old, while more than half (56%) of children in case and 43% of children in control group were male. concerning the gestational age 40% in case and the highest parentage in case and control groups had satisfied with economic status for daily needs (66% and 80% respectively). the result showed that 40% of fathers in case group were between the ages of 26 -35 but, 37% of fathers in control group were between the ages of 21-25 years old table 1. 47% in control were preterm. the weight of children accounted as 62% in case group and 68% in control were between (1-10kg). the majority of mothers in case and control groups hadn't history of abortion (85% and 80% respectively). 185 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: assessment of sociodemographic characteristics of mothers in case and control group. (n0. 100: case and control) socio-demographics case group control group no. % no. (%) mother age (years) ≤ 20 13 (13) 11 (11) 21-25 46 (46) 48 (48) 26-35 27 (27) 36 (36) ≥ 36 14 (14) 5 (5) occupation housewife 71 (71) 78 (78) governmental employee 14 (14) 8 (8) private employee 11 (11) 8 (8) student 4 (4) 6 (6) level of education illiterate 54 (54) 63 (63) able to read and write 16 (16) 11 (11) primary school 8 (8) 1 (1) secondary school 8 (8) 1 (1) institute graduate 8 (8) 13 (13) college graduated 6 (6) 11 (11) post graduated 0 (0) 0 (0) residency areas rural 33 (33) 16 (16) urban 53 (53) 72 (72) suburban 14 (14) 12 (12) economic sufficient for daily need 66 (66) 80 (80) insufficient 24 (24) 16 (16) exceeds needs 10 (10) 2 (2) father age (years) ≤ 20 5 (5) 5 (5) 21-25 31 (31) 37 (37) 26-35 40 (40) 27 (27) ≥ 36 24 (24) 31 (31) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.19 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 186 table 3 show comparison between case and control regarding risk factors associated with congenital anomalies, concerning consanguinity, medical disease, andoligohydramina , there was a highly statistical difference shown between case and control with p. value (<0.001, <0.001, and 0.001 respectively), while there was no statistical difference happen between case and control regarding polyhydramine with p.value= 0.150. the result of study indicated that anemia in pregnancy, previous history of congenital anomalies, family history of congenital anomalies, pesticide use, living near of mobile station, passive smoking, stress during pregnancy, didn't using folic acid, and drink of coffee during pregnancy had a very high statistical difference between case and control p. value <0.001, while radiation exposure had a difference between case and control p. value=0.045. at the same time there was no statistical difference happen between case and control regarding using of unprescribed medication ,chemical substance use, living near electrical tower,active smoker during pregnancy, infection during pregnancy, and having corona virus which ( p. value = 0.098, 1.00, 0.857, 1.000, 0.723, and 0.055) respectively. copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international concerning the types of congenital anomalies (fig.1) the result of chart shows that 41% of case groups had genitourinary anomalies, 33% had digestive anomalies, 10% hand musculoskeletal anomalies, 7% of case had respiratory anomalies, 6% had circulatory anomalies, and 8% had other anomalies. table 2: assessment of demographic characteristics of children. children characteristics case group control group no. (%) no. (%) child age 1days1years 58 (58) 67 (67) 1years3years 26 (26) 20 (20) 3years6years 14 (14) 8 (8) ≥ 7 years 2 (2) 5 (5) gender male 56 (56) 43 (43) female 44 (44) 57 (57) gestational age preterm 40 (40) 47 (47) term 45 (45) 45 (45) post term 15 (15) 8 (8) weight (kg) 1-10 62 (62) 68 (68) 11-20 20 (20) 19 (19) 21-30 16 (16) 9 (9) ≥ 31 2 (2) 4 (4) abortion none 85 (85) 80 (80) 1-3 4-6 14 1 (14) (1) 12 8 (12) (8) ≥ 7 0 (0) 0 (0) figure 1: types of congenital anomalies https://creativecommons.org/licenses/by-nc-sa/4.0/ https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.19 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 187 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: compare between case and control regarding risk factors associated congenital anomalies. (n. 100 case and control). risk factors associated with congenital anomalies group n mean sd f p-value t 95% confidence interval the difference lower upper consanguinity case 100 0.68 0.4688 35.45 0.001 -2.87 -0.2864 -0.05357 control 100 0.850 0.3588 -2.87 -0.2864 -0.05352 medical disease case 100 0.780 0.4163 44.05 0.001 -3.06 -0.2464 -0.05357 control 100 0.930 0.2564 -3.06 -0.2465 -0.05345 oligohydraminas case 100 0.900 0.3015 11.70 0.001 -1.66 -0.1310 0.01102 control 100 0.960 0.1969 -1.66 -0.1310 0.01109 polyhydraminous case 100 0.950 0.2190 2.089 0.150 -0.719 -0.0748 0.03485 control 100 0.970 0.1714 -0.719 -0.0748 0.03487 anaemia case 100 0.800 0.4020 21.43 0.001 -2.22 -0.2074 -0.01252 control 100 0.910 0.2876 -2.22 -0.2075 -0.01246 previous congenital anomalies case 100 0.830 0.3775 27.02 0.001 -2.46 -0.1980 -0.02192 control 100 0.940 0.2386 -2.46 -0.1981 -0.02182 family history case 100 0.780 0.4163 66.08 0.001 -3.61 -0.2627 -0.07723 control 100 0.950 0.2190 -3.61 -0.2629 -0.07705 unprescribed medication use case 100 0.980 0.1407 2.768 0.098 0.826 -0.0277 0.06773 control 100 0.960 0.1969 0.826 -0.0277 0.06776 radiation case 100 0.990 0.1000 4.082 0.045 -1.00 -0.0297 0.00972 control 100 1.00 0.0010 -1.00 -0.0298 0.00984 chemical substance use case 100 0.960 0.1969 0.001 1.00 0.001 -0.0549 0.05493 control 100 0.960 0.1969 0.001 -0.0549 0.05493 pesticide use case 100 0.770 0.4229 73.80 0.001 -3.77 -0.2739 -0.08607 control 100 0.950 0.2190 -3.77 -0.2741 -0.08588 mobile station case 100 0.830 0.3775 73.50 0.001 -3.72 -0.2294 -0.07055 control 100 0.980 0.1407 -3.72 -0.2297 -0.07027 electrical tower case 100 0.900 0.3015 0.032 0.857 -1.70 -0.3882 0.02821 control 100 1.08 1.011 -1.70 -0.3891 0.02911 active smoker case 100 0.940 0.2386 0.001 1.00 0.001 -0.0665 0.06657 control 100 0.940 0.2386 0.001 -0.0665 0.06657 passive smoker case 100 0.710 0.4560 20.56 0.001 -2.21 -0.2456 -0.01438 control 100 0.840 0.3684 -2.21 -0.2456 -0.01435 stress case 100 0.820 0.3861 19.29 0.001 -2.11 -0.1932 -0.00679 control 100 0.920 0.2726 -2.11 -0.1932 -0.00672 didn’t use folic acid case 100 0.920 0.2726 41.30 0.001 -2.93 -0.1337 -0.02623 control 100 1.00 0.0001 -2.93 -0.1341 -0.02590 coffee drink case 100 0.890 0.3144 15.22 0.001 -1.88 -0.1431 0.00317 control 100 0.960 0.1969 -1.88 -0.1432 0.00326 infection case 100 0.810 0.3942 0.126 0.723 0.178 -0.1010 0.12104 control 100 0.800 0.4020 0.178 -0.1010 0.12104 corona virus case 100 0.870 1.106 3.718 0.055 -0.174 -0.2469 0.20693 control 100 0.890 0.3144 -0.2479 0.20795 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.19 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 188 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. the same time age of father and history of previous abortion were factors behind the congenital anomalies p.value (0.033 and 0.017 respectively). years in the control group [10, 11]. concerning the occupation of mothers nearly three quarter of case and two-thirds in control were housewives, this result matches with a case-control study reported in ethiopia (2021) which mentioned that number of participants in case and control were housewife [10], and also same with the case-control study done in erbil city which indicated that the most of mothers in both groups were housewives [7]. regarding the level of education of participants, more than half in case and control groups were illiterate, this finding disagreed with the study which was carried out in saudi arabia which stated that discussion table 4 shows that age of mothers and weight were factors which highly statistical associated with congenital anomalies p.value (0.001 and <0.001 respectively), at the majority of children are born with congenital anomalies and they are impacted physically, mentally or socially, or it may be have a chance to boosting the risk of morbidity related to many health problems. based on the analysis presented in the results, less than half, respectively, of participants in the case and control groups were aged between (21-25) years, this result is similar to a case-control study carried out in ethiopia, which revealed that less than half of samples in the case and control groups were between 21 and 25 years old, and disagrees with the study done in iran, which reported that the mean mothers age was 29.48 years in the case group and 27.9 table 4: factors associated with congenital anomalies selected factors unstandardized coefficients standardized coefficients t pvalue 95% confidence interval for b b std. error beta lower bound upper bound (constant) -0.390 0.156 -2.495 0.015 -0.701 -0.079 age mother 0.137 0.041 0.152 3.360 0.001 0.056 0.219 occupation -0.004 0.049 -0.004 -0.078 0.938 -0.101 0.094 level education 0.025 0.026 0.050 0.943 0.349 -0.028 0.078 residency -0.008 0.055 -0.006 -0.138 0.891 -0.117 0.101 economic -0.040 0.060 -0.034 -0.676 0.501 -0.159 0.078 father age 0.102 0.047 0.109 2.165 0.033 0.008 0.196 abortion -1.125 0.462 -0.140 -2.436 0.017 -2.045 -0.206 gender -0.056 0.073 -0.035 -0.760 0.449 -0.202 0.090 gestational age 0.018 0.051 0.016 0.357 0.722 -0.083 0.119 weight 0.974 0.230 1.006 4.234 0.001 0.516 1.432 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.19 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 189 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. more than half in case and control were schooling up to high school [12]. more than half in case group lived in urban area while, the majority of mothers in control group lived in urban area. the study done in ethiopia which stated that less than half of mothers in case group lived in urban area, at the same time, the majority of mothers in control group lived in urban area [13].the area of living is effect on mother's knowledge and awareness regarding congenital anomalies and safe pregnancy, newborn care and antenatal care during pregnancy. the majority in case and control groups had satisfied with economic status for daily needs. the study carried out in riyadh, saudi arabia mentioned that less than half of participant in case and control hand satisfied family monthly income [12]. the study done ethiopia in 2018 reported that totally 47.8% of samples in both groups had middle economic status [13]. the result showed that less than half of fathers in case group was between the ages of (26-35) meanwhile, onethird of fathers in control group were between the ages of (21-25). this result nearly agreed with the study which is done in ethiopia which revealed that 40% in case was their ages ranged between 26-34 but, 29.7% samples in control group aged was <=25 [10].more than half of children in case and 43% of children in control group were male. this finding is agreed with the study which carried out in egypt which reported that more than half of children in case and less than half of children in control were male, but, disagreed with the study done in nepal which mentioned that more than half of children in case and less than half of children control was girl [2,14]. concerning the gestational age 40% in case and 47% in control were preterm. this outcome unsupported with the case-control study which carried out in egypt which announced that the majority of children in both group were full term [2]. the weight of children accounted as more than half in case and control group were between (1-10kg). the study carried out in brazil which stated that most of the children in case and control were normal weight [15]. the majority of mothers in case and control groups hadn't history of abortion. this result supported with the casecontrol study which was carried out in erbil city in iraq which announced that majority of mothers in case and control hadn’t history of abortion [7]. as in my experience during my duty i detected mothers with multiple abortions are risk of having infants with congenital anomalies in comparison with others mothers. regarding the assessment the types of congenital anomalies in current study, the results show in fig.1 that the most of congenital anomalies are shown in genitourinary system, this finding is matches with prospective study which is done in punjab (india) which indicated that major defects were present in 68.11%. cns and urogenital systems were most commonly involved [16], and disagreed with the study of done in erbil city in iraq which mentioned that the most common area for anomalies was the central nervous system (37.7%) followed by the musculoskeletal (23.1%) and gastrointestinal systems (20.8%) [7]. table 3 explains the compare between case and control regarding risk factors associated with congenital anomalies. concerning consanguinity, medical disease, oligohydramina, anaemia in pregnancy, previous history of congenital anomalies, family history of congenital anomalies, pesticide use, living near of mobile station, passive smoking, stress during pregnancy, not using folic acid, and drink of coffee during pregnancy, there was a highly statistical difference shown between case and control. iraq in which mentioned that there were https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.19 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 190 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. high statistical differences shown between case and control regarding consanguinity, medical disease, and oligohydramina [7]. the prospective analytic cross sectional study carried out in neonatal intensive care unit in egypt announced that consanguinity and family history of congenital anomalies were a high statistical difference shown between case and control but, mentioned that there were no statistical differences shown between case and control regarding having medical diseases and drug use during pregnancy [17]. other study done in india indicated that there were no statistical difference shown between case and control regarding having medical diseases and history of anemia during pregnancy [18]. the study which was done in india mentioned that there was a statistical difference happen between case and control regarding consanguinity, previous child with congenital anomalies, and no intake of iron/folic acid. still, there were no statistical difference happen between case and control regarding medical disease and anemia during pregnancy [19]. the result of the current study shows that radiation exposure had a difference between case and control, this finding is unequal with the study done in hamadan which mentioned that there was no statistical difference happens between case and control regarding radiography during pregnancy, stressful pregnancy, medical disease, oligohydramina, exposure to chemicals and family medical history of congenital anomalies [20]. another study in china mentioned that there were a highly statistical difference shown between case and control regarding family history of congenital anomalies, stressful life events, taking folic acid, and smoking, while there was no statistical difference shown between case and control regarding medical disease during pregnancy [21]. the study which carried out the study in ethiopia mentioned that there was a high statistical difference occurred between case and control regarding passive smoking, folic acid use during pregnancy, and exposure to pesticides. still, announced that there was no statistical difference between case and control regarding drinking coffee during pregnancy [10]. other studies in india mentioned that there were statistical differences occurred between case and control regarding living near mobile station and passive smoking [8]. table 4 showed that weight was factor which highly statistically associated with occurrence of congenital anomalies and a history of previous abortion was a factor behind the congenital anomalies. the casecontrol study done in erbil city showed that the weight of children was a factor which highly statistically associated with the occurrence of congenital anomalies, and the history of previous abortion was the factor behind the congenital anomalies [7]. the result of the current study indicated that the age of mothers factors which highly statistical associated with occurrence of congenital anomalies. this result is agreed with the study done in nepal which reported that the age of mothers was a factors that highly statistical associated with congenital anomalies, but mentioned that the weight of children wasn't a factors that statistical associated with congenital anomalies [14]. another study in india showed that the weight of the mother and history of abortion were a factors that statistical significant with congenital anomalies [8]. the research carried out in egypt found that the age of mother and the history of previous abortion didn't factors that causes for congenital anomalies [17]. the result of study indicated that father age is a factor that statistically significant with congenital anomalies. this outcome is supported by the study done in mexico https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.19 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 191 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. which mentioned that father age and birth weight are factors that highly statistically significant with congenital anomalies [22] also, equal to the study which was done in iran which stated that father age is a factor that statistical significant with congenital anomalies [11]. early marriage and early and late pregnancy are increase the risk of having children with congenital anomalies because of the anatomical and functional maturation of reproductive organs. the finding reported that consanguinity, medical disease, oligohydramina, anaemia in pregnancy, previous history of congenital anomalies, family history of congenital anomalies, pesticide use, living near of mobile station, passive smoking, stress during pregnancy, not using folic acid, radiation exposure and drink of coffee during pregnancy, there was a highly statistical difference shown between case and control. the results were indicated that that age of mothers and weight were factors which highly statistically associated with congenital anomalies, and at the same time age of father and history of previous abortion were factors behind the congenital anomalies [1] world health organization.birth defects. who headquarters in geneva.2022. available from: https://www.who.int/news-room/ fact-sheets/detail/birth-defects [2] abdoul sm, sherif aa, wahdan im, ashour ks. pattern and risk factors of congenital anomalies in a pediatric university hospital, alexandria, egypt. journal of the egyptian public health association. 2019.94(3). https://doi.org/10.1186/s42506-018-0004-3 [3] francine r, pascale s, aline h. congenital anomalies: prevalence and risk factors. universal journal of public health. 2014. 2(2): 58 -63.https://www.researchgate.net/ publication/259526843_congenital_anomalies_pre valence_and_risk_factors [4] turkbay d, canpolat fe, derme t, altug n, yilmaz y. the birth prevalence of selected major congenital anomalies: six-year’s experience in a tertiary care maternity hospital. turk pediatri ars 2020; 55(4): 393–400. https://www.ncbi.nlm.nih.gov/pmc/ articles/pmc7750351/pdf/tpa-55-393.pdf [5] vatankhah s, jalilvand m, sarkhosh s, azarmi m, mohseni m. prevalence of congenital anomalies in iran: a review article. iran j public health. 2017; 46 (6).733-743.https://www.ncbi.nlm.nih.gov/ pmc/articles/pmc5558066/pdf/ijph-46733.pdf [6] al-hadithi, al-diwan jk, saleh am, shabila np. birth defects in iraq and the plausibility of environmental exposure: a review. conflict and health. 2012; 6(3). available from: https://www.researchgate.net/ publication/230574961_birth_defects_in_iraq_an d_the_plausibility_of_environmental_expo sure_a_review/ link/00463521db66f13dec00000 [7] ameen sk, alalaf sk, shabila np.pattern of congenital anomalies at birth and their correlations with maternal characteristics in the maternity teaching hospital, erbil city, iraq. bmc pregnancy and childbirth. 2018. 18:501. https://doi.org/10.1186/ s12884-018-2141-2 . [8] singh a, sinha s. risk factors of congenital malformations in north india: a case control study. journal of postgraduate medicine, education and research. 2016 res;50 (1):22-27. https://www.jpmer.com/doi/ jpmer/pdf/10.5005/jp-journals-100281186#:~:text=significant%20association% 20of%20cmf%20was,also%20important% 20predictors%20of%20cmf. [9] qadir m, amir s, bano s. prevalence and associated risk factors of congenital anomalies at a tertiary care hospital. pakistan journal of medical and health sciences.2017.11(3).https:// pjmhsonline.com/2017/july_sep/ pdf/942.pdf . [10] abebe s, gebru g, amenu d, mekonnen z, dube l. risk factors associated with congenital anomalies among newborns in southwestern ethiopia: a case-control study. plos one. 2021. 16(1): e0245915. https://doi.org/10.1371/ journal.pone.0245915 conclusion reference https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.19 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 192 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [11] shahmirzady ps, esteghamat a, sadough a, sarvi f. the risk factors associated with congenital anomalies in newborns. journal of comprehensive pediatrics. 2020. 11 (3) :e90136. https://brieflands.com/articles/ jcp-90136.pdf . [12] kurdi am, majeed saidan ma, al rakaf ms, alhashem am, botto ld, baaqeel hs et al. congenital anomalies and associated risk factors in a saudi population: a cohort study from pregnancy to age 2 years. bmj open. 2019;9:e026351. 10.1136/ bmjopen-2018026351. [13] taye m, afework m, fantaye w, diro e, worku e. factors associated with congenital anomalies in addis ababa and the amhara region, ethiopia: a case-control study. bmc pediatrics.2018. 18:142. https://dnb.info/116201301x/34 . [14] paudel p, sunny ak, gurung r, gurung a. burden and consequence of birth defects in nepal-evidence from prospective cohort study. bmc pediatrics.2021. 21:81. https:// bmcpediatr.biomedcentral.com/ articles/10.1186/s12887-021-02525-2 . [15] costa cmds., gama sgnd. and leal, mdc. congenital malformations in rio de janeiro, brazil: prevalence and associated factors. cadernos de saude publica. 2006. 22 (11), pp.2423-2431. https://www.scielo.br/j/ csp/a/q9sr5yqbzbfphccq4wzbwsk/? lang=en. [16] marwah sh, sharma s, kaur h, gupta m, goraya s. surveillance of congenital malformations and their possible risk factors in a teaching hospital in punjab. international journal of reproduction, contraception, obstetrics and gynecology. 2014. 3(1):162-167. https://www.ijrcog.org/index.php/ijrcog/ article/view/808 . [17] shalaby am and el-gazzar af. "the frequency, types and risk factors of congenital anomalies in a tertiary neonatal intensive care unit (a hospital based study)". annals of neonatology journal. 2021.3(1): 24-0. https://anj.journals.ekb.eg/ artcle_132479_ab8cebb5ac9d56a33e21d3d 72439392a.pdf . [18] verma r, khanna p, malik m. associated of maternal risk factors to congenital anomalies among infants: a community based study in rural area of haryana, india. journal of the association of physicians of india. 2019. 67. issn 0004-5772. https:// www.japi.org/q2f4e484/association-of maternal-risk-factors-to-congenitalanomalies-among-infants-a-communitybased-study-in-rural-areas-of-haryanaindia [19] sinha a, tripathi s, nigam n, kumar m, singh. profile of neonates born with congenital birth defects in a tertiary care hospital of north india: an observational study. clinical epidemiology and global health. 2022. 14.100999. https://cegh.net/ article/s2213-3984(22)00040-9/pdf. [20] sedighi i, nouri sh, sabzehei mk, sangestani m, mohammadi y, amiri j et al. determining the risk factors of congenital anomalies of newborns in hamadan province. journal of comprehensive pediatrics. 2020. 11(2):e90907. https:// brieflands.com/articles/jcp-90907.html [21] guo l, zhao d, zhang r. a matched casecontrol study on the association between colds, depressive symptoms during pregnancy and congenital heart disease in northwestern china. scientific reports. 2019 ,9:589. https://www.nature.com/ articles/s41598-018-36968-y [22] robledo-aceves m, bobadilla-morales l, mellín-sánchez el, corona-rivera a, pérezmolin j, velasco jj et al. prevalence and risk factors for gastroschisis in a public hospital from west méxico. congenital anomalies. 2015. 55, 73–80. https:// onlinelibrary.wiley.com/doi/full/10.1111/ cga.12087 . https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.12 erbil j. nurs. midwifery, vol. 7, no. (2), nov, 2024 original article assessing the performance of statistical tools for postoperative nursing care quality of patients with laparoscopic cholecystectomy in teaching hospitals at erbil city abstract background and objectives: laparoscopic cholecystectomy is a minimally invasive surgery for or conducting gallbladder removal, providing faster recovery times and fewer complications compared to conventional open surgery. this study aims to evaluate and compare the standard of post-operative nursing care provided to patients who undergo laparoscopic cholecystectomy procedures in surgical units at teaching hospitals and understand statistical tools' performance in evaluating care quality. methods: a cross-sectional descriptive study design, involving fifty nurses via nonprobability (purposive) sampling technique, who had been working in the surgical unit. the data were collected through the use of the observational checklist, which consisted of two parts; the first part includes information about the socio-demographic characteristics of respondents, and the second part is about the assessment of postoperative nurses' care items consisting of five main domains. the data were collected from october -2023 to february -2024 after approval of the proposal by the ethical committee, using statistical tools to analyze the data. result: the finding of the study showed that most study items responding to the questionnaire showed significant differences and that there is insufficient provision of highquality postoperative nurse interventions for patients undergoing laparoscopic cholecystectomy at surgical wards at erbil city teaching hospitals. conclusion: this study concludes that several demographic factors, such as age, marital status, and level of education, among nursing staff significantly correlate with the quality of nursing care provided in surgical wards. despite their educational background, many nurses lacked adequate professional skills and training in postoperative nursing interventions for care. keywords: assessment; postoperative nursing care; laparoscopic cholecystectomy; statistical tools. yahya zakarya shakir; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. (correspondence: yahya.shakir@hmu.edu.krd). burhan izzaddin sabir; department of nursing, college of nursing, hawler medical university, kurdistan region, erbil, iraq. paree khan abdulla omer; department of statistics and informatics, college of administration and economics, salahaddin university, erbil, kurdistan region, iraq. ali taher mohammedameen; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq 127 received: 31/03/2024 accepted: 26/05/2024 published: 30/11/2024 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:yahya.shakir@hmu.edu.krd) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.12 erbil j. nurs. midwifery, vol. 7, no. (2), nov, 2024 original article the liver, gallbladder, and pancreas work together to secrete enzymes and other substances that aid in the digestion of food in the stomach and small intestine. if these organs are not functioning correctly, it can lead to digestive problems, which can result in poor nutrition. collaborative care for patients with biliary system problems should include enhanced nutrition to support healthy cellular function (abdelgilil et al., 2020). laparoscopic cholecystectomy (lc) is a minimally invasive surgery for performing gallbladder removal, providing faster recovery times and fewer complications compared to conventional open surgery (aziret et al., 2019; farhangmehr & menzies, 2020). however, despite its benefits, postoperative nursing care plays a critical role in ensuring optimal patient outcomes and quality of care delivery. postoperative nurses need to understand the importance of the procedure, potential risk factors, and know the signs of complications. precise nursing assessment, as well as intervention is essential to support patients in quickly and safely regaining optimal function. nursing attention is concentrated on restoring the patient's physiological equilibrium to prevent or identify postsurgery complications promptly. moreover, timely nursing implementation is necessary for checking vital signs, alleviating pain levels, managing nausea and vomiting, promoting wound healing, and minimizing drainage. nurses should intervene promptly to ensure adequate ventilation, alleviate pain, preserve skin integrity, provide optimal nutrition, and implement measures to minimize patient discomfort during recovery. furthermore, nurses should educate patients on essential information for postoperative recovery and after discharge (edwards et al., 2019; el-shatby & elmonem, 2020; salime & shakweer, 2021). assessing the performance of statistical tools within this context aids in gauging the effectiveness of postoperative nursing interventions. patients expect the use of effective and safe interventions and avoidance of unnecessary or inappropriate therapies. post-operatively, the proficiency and application of healthcare professionals are crucial factors in managing patients' care. lack of information persists regarding the pre and postoperative nursing care quality for patients undergoing lc in erbil city. despite some available data indicating substandard levels of care in various cities across iraq, such as kirkuk (hussein & khudair, 2019), al-najaf (kareem et al., 2022), and al-nasiriya (ibrahim & muhamad, 2021), sulaymaniyah city stands out for its commendable proficiency in both knowledge acquisition and practical application. (hassan & saeed, 2023) in teaching hospitals across erbil city, the efficacy of postoperative nursing care for patients undergoing lc is paramount, necessitating a comprehensive evaluation of the statistical tools employed to assess care quality. aim of the study: the current study aims to evaluate and compare the standard of post-operative nursing care provided to patients who undergo laparoscopic cholecystectomy procedures in surgical units at teaching hospitals and understand statistical tools' performance in evaluating care quality. a cross-sectional descriptive study was conducted about the post-operative quality of nurse care at a teaching hospital. a non-randomly purposeful sample of fifty nurses was selected, who has been working in surgical wards, from teaching hospitals (hawler teaching hospital, rizgary teaching hospital, and rojhalat emergency hospital) including both genders. the duration of the study, which 128 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.12 erbil j. nurs. midwifery, vol. 7, no. (2), nov, 2024 original article administrative personnel, as well as head nurses/supervisors of surgical departments. participation in the study entails no inherent risks. information is anonymized to protect the confidentiality of participants, thereby fostering maximal cooperation from study samples. data were coded and analyzed utilizing microsoft office excel 2016, in addition to the software statistical package for the social sciences (spss version 27). here used the useful test called the chi-square test, and is a nonparametric test that is specifically used for two tasks: (a) testing the hypothesis that two or more groups, populations. (b) calculating the probability that the observed data distribution fits the expected distribution (i.e., evaluating goodness of fit). it is meant to evaluate categorical data, such as patients who are male or female, smokers or not (rana & singhal, 2015), (elsayed, 2022). the expected count deducted from the observed count is to determine the difference between them. then, the square of the difference is computed, to eliminate the negative values because the squares of (2 and 2) are naturally both four. the hypothesis of null and alternative for this test will be (rana & singhal, 2015): h0: no association between two categorical variables. h1: an association between two categorical variables. the binomial distribution used in statistics and probability theory, which generally offers only two possible outcomes for any experiment: such as gender (male or female) and (success or failure). similarly, there are only two possible outcomes while taking a test: pass or fail , yes or no (phillips, 2006). was conducted during the period of 15, sep. 2023 to april. 2024. the data were collected from oct. 2023 to feb. 2024 after approving the proposal. the data were collected through the use of a standard postoperative observation checklist, by the researchers after a strong review of the relevant literature (abdelhafiez et al., 2021; brenner & kautz, 2015) which consisted of two parts; the first part includes information about the socio-demographic characteristics of respondents such as (age, gender, marital state, level of education, years of experience, number of years of experience in surgical unit, training course on post-operative nursing care for patients undergoing laparoscopic cholecystectomy). the second part is about the assessment of postoperative nurses' care items consisting of five main domains. first: nurses' practices concerning monitoring and managing potential complications included 8 items. second: nurses' practices concerning improving respiratory status included 6 items. third: nurses' practices concerning relieving pain included 4 items. fourth: nurses' practices concerning maintaining skin integrity and drainage included 11 items. fifth: nurses' practices concerning maintaining nutritional status included 6 items. the checklist was administered through direct observation utilizing the standardized post-operative observational checklist. all nursing personnel actively serving in surgical units at the designated teaching hospitals were encompassed in the study, encompassing both male and female cohorts. exclusion criteria were applied to individuals declining participation in interviews or facing impediments to study involvement. the ethical aspect of data collection is paramount, with prior approval secured from the ethics committee at the nursing college, university of hawler medical. verbal consent and authorization were sought from 129 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.12 erbil j. nurs. midwifery, vol. 7, no. (2), nov, 2024 original article table 1 shows that there is a significance among the level of the studied (y1) gender variable because (α = 0.05) is greater than (p-value = 0.033) (α > p-value). while it reports a highly significant, with (y2) age groups, (y3) marital state, (y4) educational level, (y5) years of experience in hospitals, (y6) years of experience in surgical units, and (y7) training course on post-operative nursing care for patients undergoing lc. the male study participants were 17 (34%); while the female participants were 33 (66%). the majority of the study participants is 29 (58%) between 34 – 45 years old, in addition to that, the mean of the total sample age is (3.88 years) with a standard deviation (1.365 years). regarding the level of education, half of the study samples 25 (50%) had diplomas degree. regarding the number of years of experience in hospitals, the majority of the sample (36%) having 14 – 18 years of experience. while for number of years of experience in surgical units was 15 (30%) having 6 – 10 years. concerning the subject of the training course on post-operative nursing care for patients undergoing lc, the samples who answered "yes" were reported only 6 (12%), while who answered ''no" accounted for 44 (88%). 130 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result table 1. socio-demographical characteristics with comparison between all variables and their significances. variables groups f. (%) cumu. percent p-value y1 = gender male 17 (34) 34 binomial 0.033 s female 33 (66) 100 y2 = age groups 22 – 27 2 (4) 4 χ2 = 25.880 < 0.001 hs 28 – 33 4 (8) 12 34 – 39 15 (30) 42 40 – 45 14 (28) 70 46 – 51 9 (18) 88 52 – 57 4 (8) 96 ≥ 58 2 (4) 100 mean ± sd 3.88 ± 1.365 y3 = marital state single 9 (18) 18 χ2 = 20.480 < 0.001 hs married 41 (82) 100 divorced 0 (0) 0 y4 = level of education nursing school 19 (38) 38 χ2 = 11.320 0.003 hs diploma 25 (50) 88 bachelor's 6 (12) 100 y5 = number of years of experience in hospitals 4 – 8 5 (10) 10 χ2 = 22.720 < 0.001 hs 9 – 13 10 (20) 30 14 – 18 18 (36) 66 19 – 23 12 (24) 90 24 – 28 0 (0) 90 29 – 33 3 (6) 96 ≥ 34 2 (4) 100 y6 = number of years of experience in surgical units 1 – 5 11 (22) 22 χ2 = 22.960 < 0.001 hs 6 – 10 15 (30) 52 11 – 15 14 (28) 80 16 – 20 8 (16) 96 21 – 25 1 (2) 98 26 – 30 0 (0) 98 31 – 35 1 (2) 100 y7 = training course on post-operative nursing care for patients undergoing lc yes 6 (12) 12 binomial < 0.001 hs no 44 (88) 100 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.12 erbil j. nurs. midwifery, vol. 7, no. (2), nov, 2024 original article 131 between these items and the quality of post-operative nursing intervention provided by the nurses for patients with cholecystectomy, and (x13, x15, x20, x35) reported significant differences. this means there is a significant relationship between these items and the quality of the nursing intervention. only five items (x4, x6, x9, x12, x14), reported a nonsignificant, it means there is a weak assessment of postoperative nurse intervention. table 2 displays the majority of the examined elements across the five categories, including monitoring and managing potential complications, enhancing respiratory function, alleviating pain, preserving skin integrity, managing drainage, and optimizing nutritional status (x1, x2, x3, x5, x7, x8, x10, x11, x16, x17, x18, x19, x21, x22, x23, x24, x25, x26, x27, x28, x29, x30, x31, x32, x33, x34) reported highly significant, it means there is a strong relationship copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2. assessment of postoperative nurses’ practices on different items. postoperative nurses' interventions items responses f. (%) ms p-value 1. nurses’ practices concerning monitoring and managing potential complications x1 = monitoring vital sings (t, pr, rr, bp) achieved 14 (28) 1.72 binomial 0.003 hs non achieved 36 (72) x2 = ensuring the dress is clean, dry, and intact achieved 42 (84) 1.16 binomial < 0.001 hs non achieved 8 (16) x3 = observing the surgical dressing and any drains achieved 48 (96) 1.04 binomial < 0.001 hs non achieved 2 (4) x4 = moving patient slightly on bed after 4-6 hrs. post operatively achieved 27 (54) 1.46 binomial 0.672 ns non achieved 23 (46) x5 = helping the patient to go out of bed achieved 11 (22) 1.78 binomial < 0.001 hs non achieved 39 (78) x6 = instructing the patient and family to record any change in the color of the waste (stool) achieved 21 (42) 1.58 binomial 0.322 ns non achieved 29 (58) x7 = assessing the patient for increased tenderness rigidity of the abdomen achieved 11 (22) 1.78 binomial < 0.001 hs non achieved 39 (78) x8 = record the abdominal distention achieved 4 (8) 1.92 binomial < 0.001 hs non achieved 46 (92) 2. nurses’ practice concerning improving respiratory status x9 = assessing the rate, depth and sound of breathing achieved 21 (42) 1.58 binomial 0.322 ns non achieved 29 (58) x10 = recording the rate, depth and sound achieved 5 (10) 1.90 binomial < 0.001 hs non achieved 45 (90) x11 = raising the head of the patient’s bed achieved 39 (78) 1.22 binomial < 0.001 hs non achieved 11 (22) x12 = putting the patient in the low fowler’s position achieved 29 (58) 1.42 binomial 0.322 ns non achieved 21 (42) x13 = encouraging the patient to turn, take deep breaths and cough gradually achieved 16 (32) 1.68 binomial 0.015 s non achieved 34 (68) x14 = helping patients to walk early by supporting the surgical incision site when coughing and walking achieved 23 (46) 1.54 binomial 0.672 ns non achieved 27 (54) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.12 erbil j. nurs. midwifery, vol. 7, no. (2), nov, 2024 original article 132 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2. assessment of postoperative nurses’ practices on different items. postoperative nurses' interventions items responses f. (%) ms p-value 3. nurses’ practices concerning relieving pain x15 = assessing and recording characteristic (location, type and severity) achieved 33 (66) 1.34 binomial 0.033 s non achieved 17 (34) x16 = helping the patient in a pillow or binder over the surgical incision during turn, coughing achieved 15 (30) 1.70 binomial 0.007 hs non achieved 35 (70) x17 = performing massage to the patient’s back achieved 4 (8) 1.92 binomial < 0.001 hs non achieved 46 (92) x18 = administering analgesics as prescribed achieved 48 (96) 1.04 binomial < 0.001 hs non achieved 2 (4) 4. nurses’ practices concerning maintaining skin integrity and drainage x19 = recording skin status and eye sclera achieved 5 (10) 1.90 binomial < 0.001 hs non achieved 45 (90) x20 = recording characteristic (color and amount) of wound drainage achieved 16 (32) 1.68 binomial 0.025 s non achieved 34 (68) x21 = checking the potency of drainage tube achieved 49 (98) 1.02 binomial < 0.001 hs non achieved 1 (2) x22 = caring of the drainage bag achieved 49 (98) 1.02 binomial < 0.001 hs non achieved 1 (2) x23 = assess drain insertion site for signs of leakage, redness or signs of ooze achieved 48 (96) 1.04 binomial < 0.001 hs non achieved 2 (4) x24 = dressing on the drainage tube achieved 48 (96) 1.04 binomial < 0.001 hs non achieved 2 (4) x25 = assessing if drain is secured with suture or tape and document achieved 42 (84) 1.16 binomial < 0.001 hs non achieved 8 (16) x26 = changing of the outer dressings and protection of the skin from irritation achieved 37 (74) 1.26 binomial 0.001 hs non achieved 13 (26) x27 = ensuring drain is located below the insertion site and free from kinds or knots achieved 35 (70) 1.30 binomial 0.007 hs non achieved 15 (30) x28 = recording fluids output and any change in color of urine achieved 9 (18) 1.82 binomial < 0.001 hs non achieved 41 (82) x29 = encouraging patient mobilized with a drain achieved 43 (86) 1.14 binomial < 0.001 hs non achieved 7 (14) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.12 erbil j. nurs. midwifery, vol. 7, no. (2), nov, 2024 original article of participants were female and there is a highly significant relationship between providing nursing care and gender. this result is in line with a study on the “effect of a self-learning package on nurses' knowledge and practices regarding patient care undergoing laparoscopic cholecystectomy” in egypt in 60 samples of nurses, showed that the majority of nurses were female (salime & shakweer, 2021). our study shows that the majority of the participants were married. this result agrees by a study done on “assessment of nursing practices provided for patients post laparoscopic cholecystectomy” in egypt in 65 samples of nurses, their findings showed that the majority of nurses were married (el-shatby & el-monem, 2020). our results show that half of them graduated from the nursing institute. this result is supported by (abdelgilil et al., 2020). their result concurred with the study carried out in sulay over the past 50 years, lc has been the preferred method of treating cholelithiasis. the low cost, quick recovery, minimally invasive procedure, and high success rate were attained with lc to avoid postoperative complications and enhance quality of life, nurses play a critical role in the patients’ management following lc by assessing, comprehending, and providing the best and appropriate nursing care. (gao et al., 2021) the majority of nurses are in the age group (34-39) years, there is a significant relationship between the age of the participant and the quality of nursing care. this study disagrees with the finding of (el -shatby & el-monem, 2020) on the “assessment of nursing practices provided for patients post laparoscopic cholecystectomy” in egypt in 65 samples of nurses, their findings showed that their age group is twenty years to less than thirty years old. nurses in surgical wards need to be young. our study shows that the majority 133 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2. assessment of postoperative nurses’ practices on different items. postoperative nurses' interventions items responses f. (%) ms p-value 5. nurses’ practices concerning improving nutritional status x30 = administration iv therapy as prescribed achieved 50 (100) 1.00 binomial < 0.001 hs non achieved 0 (0) x31 = monitoring the state of swallowing and bowel sounds achieved 12 (24) 1.76 binomial < 0.001 hs non achieved 38 (76) x32 = encouraging soft diet after bowel sounds return achieved 37 (74) 1.26 binomial < 0.001 hs non achieved 13 (26) x33 = recording fluid intake achieved 14 (28) 1.72 binomial 0.003 hs non achieved 36 (72) x34 = assessing the symptoms of the digestive system as nausea and vomiting achieved 39 (78) 1.22 binomial < 0.001 hs non achieved 11 (22) x35 = assessing the color and consistency of stool achieved 17 (34) 1.66 binomial 0.033 s non achieved 33 (66) discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.12 erbil j. nurs. midwifery, vol. 7, no. (2), nov, 2024 original article training programs offered both domestically and internationally., by continuing their education for those working in surgical wards, and by using guidelines for postoperative interventions. these measures will enhance the quality and strength of the nurses' patient care and raise their knowledge about how to prevent complications from lc. thus, if the nurse is impacted by an attitude barrier or lacks sufficient knowledge, effective intervention will not be possible. this study concludes that the study identified a significant correlation between the various demographic factors (such as age, age group, marital state, level of education, etc.) of nursing staff and the quality of nursing care provided. nurses in the age group of 34-39 years constituted the majority, suggesting a potential influence of experience and maturity on care delivery. this finding contradicts previous studies emphasizing the necessity of a younger nursing workforce in surgical wards. inadequate professional backgrounds and lack of competent skillful practice were expressed by most of the nurses who worked at surgical wards related to their postoperative nursing interventions in lc care regardless of their educational level and nonsatisfactory training background. most postoperative nurses' assessments were directly correlated with their intervention domains. additionally, some sociodemographic characteristics affected the assessments of postoperative nurses' intervention. the study's assessment of postoperative nursing interventions revealed both strengths and areas for improvement. while significant progress was noted in various domains, including monitoring vital signs, ensuring clean dressings, and administering analgesics, certain aspects, such postoperative nurse intervention in patients with laparoscopic cholecystectomy at teaching hospitals”, which showed most of the nurses had 1-5 years of experience in the surgical unit and half of them did not participate in training courses established by the teaching hospitals. on the other hand, more than two-thirds of them participated in the training courses for <6 months (hassan & saeed, 2023). regarding the practical items of quality of postoperative nurse’s intervention most of the studies items for the five parts reported 30 significant differences except 5 items reported non-significance. the result shows that most of the nursing interventions not achieved are related to insufficient structural and continuous education programs by the policy of those hospitals and the ministry of health for improve nursing intervention, and insufficient nursing resources like an advanced nursing electronic library. this finding concurs with the study carried out in baghdad teaching hospitals regarding the assessment of the post -operative nursing intervention for patients undergoing lc, showed that most of the studied items reported significant differences, except for items such as “changing the patient's position, raising the head of the patient's bed, install drainage bag, turn the patient position frequently, reads and check patient’s chart immediate after operation carefully to see how the operation takes place to avoid complications in the surgical unit” (kadhim, 2014). this issue stems from inadequate structural and ongoing educational programs within hospital policies and ministry of health initiatives aimed at enhancing nursing interventions, as well as a lack of resources such as advanced nursing electronic libraries. provides postoperative patients in surgical wards with high-quality nursing interventions, nurses should be reinforced by 134 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.12 erbil j. nurs. midwifery, vol. 7, no. (2), nov, 2024 original article 553-566. doi. https://doi.org/https:// doi.org/10.1213/ane.0000000000004018 [6] el-shatby, a. m., & el-monem, h. a. a. assessment of nursing practices provided for patients post laparoscopic cholecystectomy. international journal of novel research in health care and nursing.2020. (1),9(2), 4857. doi. https://www.iosrjournals.org/iosrjnhs/papers/vol9-issue2/series-4/ i0902044857.pdf . [7] elsayed, k. a. chi-square independence test: to study the effect of chronic diseases and recovery from covid-19. egyptian journal of business studies. 2022. 46(4), 335306. doi. [8] farhangmehr, n., & menzies, d. laparoscopic cholecystectomy: from elective to urgent surgery. laparoscopic surgery, 5. (2020). doi. https://doi.org/http:// dx.doi.org/10.21037/ls-20-4 [9] gao, y., huang, j., zheng, y., & han, j. effect of comfort nursing on postoperative quality of life, negative emotions and nursing satisfaction in patients undergoing laparoscopic surgery. american journal of translational research, 2021.13(12), 13825-13834. doi. [10] hassan, h. d., & saeed, k. a. assessment of postoperative nurse’s intervention in patients with laparoscopic cholecystectomy at teaching hospitals in sulaimaniyah, iraq. journal of zankoy sulaimani. 2023part a, 25(1), 11. doi. https://doi.org/https:// doi.org/10.17656/jzs.10894 [11] hussein, t. h. s., & khudair, k. m. assessment nurse's knowledge toward nursing management for patients post cholecystectomy in kirkuk city hospitals. indian journal of public health research & development. 2019. 10(10). doi. https://doi.org/http:// dx.doi.org/10.5958/09765506.2019.03296.0 [12] ibrahim, b. k., & muhamad, s. j. assessment of nurses knowledge toward pre and post nursing interventions laparoscopic cholecystectomy at al-imam al-hussein teaching hospital in al-nasiriya city. kufa journal for nursing sciences. 2021. 11(2), 105-113. doi. [13] kadhim, h. assessment of postoperative nurses' interventions for the patients with laparoscopic cholecystectomy at baghdad teaching hospitals. iraqi national journal of nursing specialties. 2014. 27(1), 11-22. doi. [14] kareem, m. m. a., shraida, a. a., & razzaq, m. s. assessment of nurses' knowledge regarding management of patient's with as recording changes in waste color and assessing breathing depth, showed nonsignificant results, suggesting areas for enhancement. recommendations: to enhance postoperative nursing care quality for lc patients in erbil city's teaching hospitals, several recommendations are proposed. these include ongoing training courses, developing manual guidelines, providing comprehensive handbooks, promoting professional development activities, and conducting further research to develop and assess the implementation of an educational program’s efficacy. [1] abdelgilil, s. a., talaat, t., & mahmoud, b. h. nurses performance regarding care of patients undergoing laparoscopic cholecystectomy. international journal of novel research in health care and nursin. 2020. (1), 1202-1216. doi. [2] abdelhafiez, h. m., hegazy, s. m., nada, m. a., & abdelatif, d. a. developing nurses` performance guidelines for patients undergoing cholecystectomy based on needs assessment. egyptian journal of nursing and health science. 2021. 2(1), 53-69. doi. https://doi.org/10.21608/ ejnhs.2021.160263 . [3] aziret, m., karaman, k., ercan, m., vargöl, e., toka, b., arslan, y., et al.. early laparoscopic cholecystectomy is associated with less risk of complications after the removal of common bile duct stones by endoscopic retrograde cholangiopancreatography. the turkish journal of gastroenterology, 2019. 30(4), 336-344. doi. https://doi.org/https:// doi.org/10.5152/tjg.2018.18272 [4] brenner, p., & kautz, d. d. postoperative care of patients undergoing same-day laparoscopic cholecystectomy. 2015 aorn journal, 102(1), 16-29; quiz 30-12.doi. https://doi.org/10.1016/j.aorn.2015.04.021 [5] edwards, d. a., hedrick, t. l., jayaram, j., argoff, c., gulur, p., holubar, s. d., et al,. american society for enhanced recovery and perioperative quality initiative joint consensus statement on perioperative management of patients on preoperative opioid therapy. anesth analg. 2019. 129(2), 135 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.12 erbil j. nurs. midwifery, vol. 7, no. (2), nov, 2024 original article 136 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. cholelithiasis disease. international journal of current science research and review. 2022. 5(6), 1942-1947. doi. https://doi.org/ http://dx.doi.org/10.47191/ijcsrr/v5-i6-17 [15] phillips, c. the binomial distribution. mathematics learning centre, 2006. sydney. doi. [16] rana, r., & singhal, r. chi-square test and its application in hypothesis testing. journal of primary care specialties. 2015. 1(1), 6971. doi. [17] salime, r. a. a. e., & shakweer, t. t. effect of self-learning package on nurses knowledge and practices regarding patient care undergoing laparoscopic cholecystectomy. egyptian journal of health care. 2021. 12(1), 156-170 .doi. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article effect of body mass index, caffeine consumption and physical activity on in vitro fertilization outcome in erbil city/iraq” abstract background and objective: several factors influence the success of in vitro fertilization. in recent years, there has been a lot of focus on how lifestyle factors like body weight, physical activity levels, cigarette smoking, alcohol, and caffeine consumption affect in vitro fertilization (ivf) outcome (biochemical pregnancy). the term "biochemical pregnancy" is defined as a pregnancy that can only be determined by the presence of serum levels of the hormone human chorionic gonadotrophin (hcg). this study aimed to assess the effect of women's lifestyle factors, such as body mass index, caffeine consumption, and physical activity, on the outcome of in vitro fertilization (biochemical pregnancy). methods: a descriptive cross-sectional study design was conducted from september 2021 to september 2022.a convenience sampling technique was used among 110 women in total who consented to take part in this study, but because 10 of them cancelled (ivf) treatment before embryo transfer or oocyte retrieval, were excluded from analysis, only 100 infertile women undergoing (ivf) were included in the analysis in the maternity teaching hospital's (in vitro fertilization center) and some private hospitals in erbil, kurdistan region, iraq. the women in the study ranged in age from 20 to 45, were undergoing ivf. result: (44%) of infertile women had a successful biochemical pregnancy (positive beta hcg test). the majority (74%) of the study sample consumed caffeinated beverages. results showed a significant difference between caffeine consumption and ivf outcome (biochemical pregnancy) (p=0.01), but there was no statistically significant difference between body mass index (bmi), and physical activity (vigorous, moderate) with ivf outcome (biochemical pregnancy). only walking showed a significant difference with ivf outcome (biochemical pregnancy) (p=0.017). conclusion: increased caffeine consumption is a significant factor that can affect ivf outcome. keyword: physical activity; bmi; caffeine consumption; in vitro fertilization; biochemical pregnancy. muzhda masood fateh; surgical specialty hospital cardiac center, ministry of health, kurdistan region, erbil, iraq. (correspondence: mzhdamasud29@gmail.com) awaz azizz said; department of nursing, college of nursing, hawler medical university, kurdistan region, iraq. 137 received: 26/10/2022 accepted:22/01/2023 published: 30/11/2024 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:mzhdamasud29@gmail.com?subject=mzhdamasud29@gmail.com mailto:mzhdamasud29@gmail.com mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article in vitro fertilization success is influenced by several factors. in recent years, there has been a lot of focus on how lifestyle factors like body weight, physical activity levels, cigarette smoking, alcohol, and caffeine consumption affect ivf outcomes [1]. obesity has become much more prevalent in recent decades, particularly in europe and north america. it has a wide range of health implications, including the function of reproduction. obesity is linked to an increased risk of dysovulation and anovulation [2]. physical activity has been demonstrated to improve reproductive outcomes during pregnancy; the majority of the researchers concluded that moderate physical activity improves female fertility [3]. being overweight and obese are the results of a persistent imbalance between energy intake and energy expenditure. although energy consumption has increased calorically, there has been a concomitant decline in the amount of physical activity, which has contributed to the obesity pandemic [4]. infertility and a higher likelihood of miscarriage also occur in overweight and obese women who do not exercise. changes in the release of gonadotropin-releasing hormone, luteinizing hormone (lh), and ovarian and adrenal hormones are thought to be the mechanism, leading to anovulation, slowed follicular development, stunted fetal growth, and unsuccessful implantation [5]. caffeinated beverages, diet sodas, and sugary sodas are among the most popular drinks drunk by reproductive-age women. caffeine is a central nervous system stimulant. caffeine consumption is linked to reduced estrogen levels during the luteal phase [6]. wilcox et al. were the first to report that "women who drank more than one cup of coffee per day were less likely to become pregnant than women who drank less” [7]. assessing the outcomes of in vitro fertilization by biochemical pregnancy can only be identified by the presence of the hormone human chorionic gonadotrophin (hcg) in the serum after a frozen egg transfer, clinics advise waiting two weeks before performing a pregnancy test (hcg), as doing so frequently yields incorrect results [17]. human chorionic gonadotropin, often known as hcg, is frequently referred to as the pregnancy hormone because it is produced by cells in the placenta, which feeds the egg after it has been fertilized and connected to the uterine wall. about 11 days after conception, a blood test can be used to identify levels; about 12–14 days later, a urine test can be used to identify levels [18].both infertile couples and professionals now view how to enhance assisted reproductive outcomes as a key issue. many patients want to collaborate with their doctors and want to learn specific practices to have a healthy lifestyle and increase their chances of having a successful ivf. this study aimed to assess the potential effect of women's lifestyle factors, such as body mass index, caffeine consumption, and physical activity, on the outcome of in vitro fertilization (biochemical pregnancy). this cross-sectional descriptive study was conducted on a convenience sample of 110 women in total who consented to take part in this study, but 10 of them cancelled (ivf) treatment before embryo transfer or oocyte retrieval and were excluded from analysis. only 100 infertile women undergoing ivf were included in the analysis during the period between 1st september 2021 and 1st september 2022 at the ivf unit of a maternity teaching hospital and some private hospitals in erbil, kurdistan region, iraq. due to the small number of patients in public hospitals and the lack of support for the 138 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article questionnaire short form (ipaq-sf) ask questions about three specific forms of activities (walking, moderate-intensity activities, and vigorous-intensity activities) [9]. they were designed to be used by people aged between (18–65 year) [10]. each type of activity was measured by the frequency of vigorous, walking, and moderate activity per week and recorded time per day [11]. these physical activity data was converted to metabolic equivalent tasks (met). the (met) is ratio at which a person expends energy while engaging in a certain activity, according to that person's mass, the quantity of oxygen consumed while sitting at rest, and is equal to 3.5 ml o2 per kg body weight x min [12]. the metabolic equivalent of task (met) values was used, as well as equations for calculating met minutes. for each type of activity, a total met score was calculated. for instance, all types of walking were added, and a walking average met value was calculated. moderate-intensity and vigorous-intensity activities were both subject to the same technique. for the analysis of ipaq data, the following values are being used: walking equals 3.3 mets, moderate physical activity (pa) equals 4.0 mets, and vigorous pa equals 8.0 mets. researcher summed all of the activities' frequency in minutes per week, and the score was used to categorize the amount of physical activity as low, moderate, or high. and other domains of activity, including the number of hours spent sitting ≤ 3 hours per week of moderate-intensity exercise or ≤ 5 hours per week of low-intensity exercise, were considered to be inactive [13].the type of beverages consumed and the average amount consumed were recorded. the frequency with which tea, coffee, soda, or energy drink is consumed was recorded in cups per day, each cup=250 ml. the daily caffeine intake (mg) was calculated based on the number of cups of caffeine study in most private hospitals. women included were aged 20–45 years were having in vitro fertilization (ivf). the researcher obtained ethical approval from the scientific committee and ethical committee of college of nursing / hawler medical university (code no.110, date: 7/10/2021). permission was also obtained from the general directorate of health/erbil as well as the administration of maternity teaching hospital in erbil city. informed consent was obtained from all the participants who were included in the study. direct interviewing was used to gather the information, which was then documented in a questionnaire that included sociodemographic characteristics of couples such as age, occupation, religion, level of education, and economic status. data of study participants obtained from the baseline questionnaire. a detailed history was collected for each woman about past medical, surgical, family, and gynecological history, obstetrical data, and data about the menstrual cycle. it also included questions on lifestyle and health habits, which contain data about caffeine consumption, body mass index, and performing physical activity. to assess body mass index, the researcher was extracting body weight and height from clinical records; when missing, data was calculated from the self-reported height and weight. in this study, the researcher measured obesity using an index called bmi, which is calculated and defined as women's weight in kilograms divided by the square of their height in meters (kg/ m2). the women were grouped according to the world health organization classification of bmi (<18.50 underweight, 18.50 –24.99 normal , 25.00–29.99 overweight, and obese ≥30.00 kg/m2 )[8]. to assess and collect information on physical activity, the investigator used simple language for communication, and questions about the international physical activity 139 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article beverage consumed [14]. the researcher calculated each person's total caffeine intake by assuming that one cup of instant ( coffee had 65 mg of caffeine, 40 mg of caffeine in soft drinks, and 50 mg of caffeine in tea) [15].total caffeine consumption was grouped into four categories: 0–800 mg/week, 801–1400 mg/week, and > 1400 mg/week [16].to assess ivf outcome, researchers obtained (biochemical pregnancy). according to hospital policy, a positive β-hcg pregnancy test 12-14 days after embryo transfer was used to detect pregnancy, and successful biochemical pregnancy was defined as a serum β-hcg level over 10 miu/ml the pilot study was conducted from 1st january to 15th january 2022on 10% of the women surveyed (10 women) to assess the clarity of the questions and to identify any additional issues or challenges that would aid in making the necessary changes that would necessitate reconstructing the questionnaire. the data was analyzed using statistical package for social science (spss) version 26, to calculate descriptive statistical analysis (frequency and percentage). inferential statistical analysis (independent sample t-test) was used to determine the difference between variables. a chi-square test used to find out the association between two variables; and the p-value ≤ 0.05 is considered statistically significant [31]. table1shows the descriptive statistics for all demographic questions such as the age of the husband and wife, type of hospital, level of education, nationality, religion, residence, duration of the marriage, economic status, and occupation. the percentage of patients from the public hospital (61%) is higher than the percentage of patients from private clinics or hospitals (39%). the mean age (+ sd) of husbands was (37 ± 7.07) years, ranging from 20 to 45 years. table 1 shows that the highest 31% of the study sample (husband) were aged 41 years and over, and only 6% were 26 years. the mean age (+ sd) of wives was (33 ± 5.91) years, most of the study sample (wives) 30% were aged between 36 and 40 years, and only 7% were 41 years and over. the highest duration of marriage in this study is higher than 9 years (34%) followed by 7-9 years (22%), 4-6 years (29%), and 13 years (15%) since the average of their duration of marriage is 9 years. the majority of the study sample (75%) is unemployed individuals, followed by employed (25%). the most prevalent type of infertility in the study sample was primary infertility (58%). 140 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result table1: distribution of the sociodemographic characteristics of the study sample (n=100) variable category f. (%) hospital public 61 (61) private 39 (39) age group husband(years) ≤25 6 (6.0) 26-30 12 (12) 31-35 25 (25) 36-40 26 (26) ≥41 31 (31) age group wife (years) ≤25 14 (14) 26-30 24 (24) 31-35 25 (25) 36-40 30 (30) ≥41 7 (7) marriage duration (years) 1-3 15 (15) 4-6 29 (29) 7-9 22 (22) more than 9 34 (34) (mean ± sd) (9 ± 5.68) occupation employed 25 (25) non employed 75 (75) type of infertility primary 58 (58) secondary 42 (42) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article 141 (31%), soda (21%), and energy drinks (8%), respectively. most of the caffeine group is between 0 and 800 mg/week (44%), followed by greater than 1400 mg/week (19%), and 801–1400mg/week (11%) respectively, since 26% of them do not drink at all. followed by overweight (30%), and normal (27%). table 2 shows the descriptive statistics for lifestyle and health habit characteristics such as drinking caffeine in tea, coffee, soda, energy, and the total caffeine group. caffeine is consumed by the majority of patients (74%), as opposed to those who did not consume it (26%), because the majority of them drink tea (68%), coffee figure 1 depending on bmi results, most of the patients in this survey are obese (43%) copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. variable category f (%) did you drink any caffeine beverages? yes 74 (74) no 26 (26) tea yes 68 (68) no 32 (32) coffee yes 31 (31) no 69 (69) soft drinks energy drinks yes 21 (21) no 79 (79) total caffein consumption mg/weak yes 8 (8) no 92 (92) 0–800 44 (44) 801–1400 11 (11) > 1400 19 (19) table 2 :descriptive statistics for caffeine consumption figure 1 percentage about body mass index classification https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article survey have low activity (66%) followed by moderate (25%). results(56%) is higher than the percentage of successful results of ivf (44%). 142 figure 2 shows the classification of physical activities, depending on the physical activity results, most of the patients in this figure 3 shows the percentage about the biochemical pregnancy rate, depending on the result , the percentage of failed copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. figure 2 level of physical activity figure3 percentage of biochemical pregnancy rate (successful and failed) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article energy mg (6.364) is lower than the mean of those patients who have failed ivf (35). next, the mean of successful ivf patients who drink caffeine in general (382.965) is lower than the mean of those patients who have failed ivf (1022.795). there is no statistically significant difference in the mean of the biochemical pregnancy with each of the drinks separately, including coffee (mg) and soda (mg) because their pvalues (0.234, 0.201) respectively, are higher than the significant level of α=0.05. the chi-square test because the p-value (0.489) is greater than the significance level of α = 0.05. table 3 shows there is a statistically significant difference between the mean of biochemical pregnancy with each of the drinking tea/ mg, energy drink/mg, and total caffeine separately because their (p= 0.004, 0.044, and 0.001) respectively are less than the significant level of α=0.05.for example, the mean of successful ivf patients who drink tea/mg (274.709) is lower than the mean of those patients who have failed ivf (827.273).for example, the mean of successful ivf patients who drink table 4 shows that there is no statistically significant difference between a biochemical pregnancy and bmi classification using 143 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3 :difference between biochemical pregnancy (success and failure) with caffeine consumption biochemical pregnancy n mean sd t-value p-value how much tea mg/weak success 44 274.709 314.085 -2.99 0.004 failure 56 827.273 1178.374 how much coffee mg /weak success 44 82.727 163.398 -1.198 0.234 failure 56 132.031 231.373 how much soda mg/weak success 44 27.045 69.536 -1.286 0.201 failure 56 48.750 93.363 how much energy drink mg/weak success 44 6.364 42.212 -2.043 0.044 failure 56 35.000 93.439 total caffeine mg /weak success 44 382.965 423.134 -3.435 0.001 failure 56 1022.795 1295.720 table 4: association between the classification of bmi and biochemical pregnancy (success and failure) biochemical pregnancy total chi-square p-value success failure classification of bmi normal f 13 14 27 1.432 0.489 % 48.1 51.9 100.0 over f 15 15 30 % 50.0 50.0 100.0 obese f 16 27 43 % 37.2 62.8 100.0 total f 44 56 100 % 44.0 56.0 100.0 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article there is no statistically significant difference between the means of biochemical pregnancy (success and failure) with each of the vigorous, moderate, walking, and total physical activities because their (pvalues=0.557, 0.334, and 0.508) are higher than the significant level of α=0.05. higher than what it has been reported in our study [19]. while the mean age for infertile husbands in erbil (2016) was 35.28 years [20]. the highest percentage of the age group for women looking for infertility treatment in the current study was ranged between (36 and 40) with a mean of 33 years. this is comparable to the reported mean ages of women in erbil (2018) and (2016) which were 33.36 ± 4.5, 31.25 ± 7.0 years [17,20]. while in the uk, which mean age was 31± 6 years [21]. in italy (2018), the women's mean age was 36.6 [19]. in our study, the mean ± sd for marriage duration was 9 ±5.68, while in iraq (2015) was 7.4 ± 4.5 years [23].the majority of the table 5 shows there is a statistically significant difference between the mean of biochemical pregnancy (success and failure) and walking as a physical activity because its p-value (0.017) is less than the significant level of α=0.05. for example, the mean of successful ivf patients who walk in physical activities (434.615) is higher than the mean of those patients who have failed ivf (262.232). socio-demographic characteristic of the sample the present study aimed to assess the effect of women's lifestyle factors, such as body mass index, caffeine consumption, and physical activity, on the outcome of in vitro fertilization. the subjects in this study included (n =100) infertile women; the majority of the sample was in a public hospital. according to our finding, the highest percentage of the age group for the study sample (husbands) was (≥41) with a mean of 37 years. the mean age of husband in milan, italy in (2018) who studied 339 couples. the mean age husband who seeking infertility treatment was 39.4 years. this result 144 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 5: difference between biochemical pregnancy (success and failure) with physical activities physical activity biochemical n mean sd t-value p-value vigorous success 4 3560.000 2678.507 0.605 0.557 failure 9 2808.889 1783.231 moderate success 26 434.615 709.897 0.976 0.334 failure 28 295.000 254.944 walking success 44 487.875 549.038 2.426 0.017 failure 56 262.232 317.348 total physical activity success 44 1068.330 1558.646 0.664 0.508 failure 56 861.161 1540.145 *there is a sample missing because not all sample engaged (vigorous and moderate) activities like (swimming, or running ..) you can skip that question if you do not engage. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article only (20%) of participants reported drinking caffeinated beverages [26]. a study carried out on 339 infertile couples in an italian fertility clinic showed that caffeine consumption was not associated with a negative effect on ivf outcome [19]. the finding in the present study shows that most of the study sample (44%) indicated they consumed 0 800 mg/week. which is nearly consistent with a study conducted by choi et al., which shows that most of the study sample consumed 0 -800 mg/week [16]. body mass index: regarding bmi, our findings show that the highest percentage (43%) of the sample were obese and the lower percentage was normal weight. however, this disagrees with the result of a study by cesta et al., for 485 women receiving fertility treatment, in which the highest percentage (69.9%) of the sample was of normal weight and the lowest percentage was obese [27]. there were no statistically significant differences between the bmi and ivf outcome. however, our study is not the first that has failed to demonstrate any association between female obesity and ivf outcome [28]. similar findings have been validated in other recent studies, which found no link between rising female body weight and poor ivf outcome and live birth rate, showing that bmi should not be used as a cause to refuse ivf therapy [29]. these results are not consistent with a result of previous studies conducted by kudesia et al., indicate that female obesity negatively affects the success of ivf [30].physical activity: based on the analysis, the majority (66%) of the sample has low physical activity, and the lowest percentage (9%) of the study sample has high physical activity. it is worth mentioning that the results of the present study do not agree with the findings of a study by youness in egypt (2018) showing that the highest percentage (52%) of infertile women was highly active while only sample was unemployed (housewives) (75%). this finding is nearly consistent with other studies done in erbil (2018) for 1158 infertile couples, showing that the highest percentage (73.9 %) of wives were unemployed [20].in this study, the highest percentage of the sample (58%) was primary infertility. this finding is nearly consistent with other studies done in iraq (2020), and in erbil (2016), primary infertility (64%,63%) higher than secondary infertility [20,22]. in duhok (2002), a primary infertility rate was (77.2%) and a secondary infertility rate was (22.8%) [23]. regarding ivf outcome, (44%) of infertile women had a successful biochemical pregnancy (positive hcg test). these results are similar to a study carried out on 107 infertile women done by sõritsa et al., which mentioned that (43.6%) of the women who underwent an hcg test had a positive result [24].caffeine consumption: the majority (74%) of the study sample reported drinking caffeinated beverages such as tea, coffee, soft drinks, and energy drinks and tea was the most common source of caffeine consumption. no association was found between coffee or soda drinking and biochemical pregnancy; while there is a statistically significant difference between tea or energy drinks and biochemical pregnancy, only caffeine consumption by women was significantly associated with the biochemical pregnancy of ivf (p = 0.001). while a study conducted by al-saleh et al., for 619 women showed that the majority of the study sample (97%) was drinking caffeinated beverages, and coffee was the most common source of caffeine consumption, and there is a significant association between coffee drinking and ivf outcome [25]. these results are not coordinated with a previous study conducted in egypt for 200 women, which reported that the majority (72%) of the study sample was not drinking any caffeinated beverage and that 145 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article reproduction outcomes . womens health. 2010 jul 1;6(4):517–24. [5] mangum mm. the effects of exercise on success rates of in vitro fertilization. med heal sci commons. 2013aug;10:437. [6] hey e. coffee and pregnancy. british medical journal. 2007 feb 24;334(7590):377. [7] machtinger r, gaskins aj, mansur a, adir m, racowsky c, baccarelli aa, et al. association between preconception maternal beverage intake and in vitro fertilization outcomes. fertility and sterility. 2017 dec;108(6):1026– 33. [8] banker m, sorathiya d, shah s. effect of body mass index on the outcome of in-vitro fertilization/intracytoplasmic sperm injection in women. journal of human reproductive sciences. 2017;10(1):37–43. [9] sepidarkish m, omani-samani r, mansournia ma, yekaninejad ms, mardi-mamaghani a, vesali s, et al. the casual effect of lifestyle factors on outcomes of assisted reproductive techniques: a protocol study on iranian infertile couples. reproductive health. 2018 dec 17;15(1):210. [10] craig cl, marshall al, sj ̈ ostro ̈ m m, bauman ae, booth ml, ainsworth be, et al. international physical activity questionnaire: 12-country reliability and validity: medicine and science in sports and exercise. 2003 aug;35(8):1381–95. [11] scoring_protocol.pdf [internet]. 2005 [cited 2022 mar 9]. available from: https:// docs.google.com/viewer? a=v&pid=sites&srcid=zgvmyxvsdgrvbwfp bnx0agvpcgfxfgd4oje0ndgxmdk3ndu1y wrlztm [12] jetté m, sidney k, blümchen g. metabolic equivalents (mets) in exercise testing, exercise prescription, and evaluation of functional capacity. clinical cardiology. 1990 aug;13 (8):555–65. [13] ramezanzadeh f, kazemi a, yavari p, nasresfahani mh, nejat s, rahimi-foroshani a, et al. impact of body mass index versus physical activity and calorie intake on assisted reproduction outcomes. european journal of obstetrics &gynecology and reproductive biology. 2012 jul 1;163(1):52–6. [14] salih joelsson l, elenis e, wanggren k, berglund a, iliadou an, cesta ce, et al. investigating the effect of lifestyle risk factors upon number of aspirated and mature oocytes in in vitro fertilization cycles: interaction with antral follicle count. plos one. 2019 aug (29%) of infertile women was low activity [26]. the main finding of our study is that there is no statistically significant difference between women's physical activity (vigorous, moderate activity) and ivf outcomes. only there is a statistically significant difference between walking and biochemical pregnancy because (p=0.017). few women in our sample engaged in vigorous activity before ivf. this is in line with previous findings, where no associations of physical activities in women before and during ivf treatment with ivf outcomes such as positive hcg, clinical pregnancy and live birth were detected [24]. it has been concluded that caffeine consumption and physical activity (walking) are significant factors that can affect ivf outcome. [1] petanovska kostova e. the interaction of female age and active male smoking has negative influence on success rates of the in vitro fertilization treatments. balkan journal of medical genetics. 2020 jun;23 (1):57–62. [2] qu p, mi y, zhao d, wang m, dang s, shi w, et al. effect of the interaction between prepregnancy body mass index and fresh/ frozen embryo transfer on perinatal outcomes of assisted reproductive technologyconceived singletons: a retrospective cohort study. frontiers in endocrinology [internet]. 2020 [cited 2021 jul 15];0. available from: https://www.frontiersin.org/ articles/10.3389/fendo.2020.560103/full [3] rao m, zeng z, tang l. maternal physical activity before ivf/icsi cycles improves clinical pregnancy rate and live birth rate: a systematic review and meta-analysis. reproductive biology and endocrinology. 2018 feb 7;16:11. [4] ferreira rc, halpern g, de cássia savio figueira r, de almeida ferreira braga dp, iaconelli a, borges e. physical activity, obesity and eating habits can influence assisted 146 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.13 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article a longitudinal study exploring the associations with controlled ovarian stimulation and pregnancy outcomes. journal of assisted reproduction and genetics. 2020 aug 1;37 (8):1869–81. [25] al-saleh i, el-doush i, grisellhi b, coskun s. the effect of caffeine consumption on the success rate of pregnancy as well various performance parameters of in-vitro fertilization treatment. international medical science monitor. 2010 nov;16(12):cr598-605. [26] youness em. lifestyle factors between fertile and infertile women at assiut women’s health hospital. egyptian nursing journal. 2018;15(1):9. [27] cesta ce, johansson alv, hreinsson j, rodriguez-wallberg ka, olofsson ji, holte j, et al. a prospective investigation of perceived stress, infertility-related stress, and cortisol levels in women undergoing in vitro fertilization: influence on embryo quality and clinical pregnancy rate. acta obstetricia et gynecologica scandinavica. 2018 mar;97(3):258–68. [28] styne-gross a, elkind-hirsch k, scott jr rt. obesity does not impact implantation rates or pregnancy outcome in women attempting conception through oocyte donation. fertility and sterility. 2005 jun 1;83(6):1629–34. [29] friedler s, cohen o, liberty g, saar-ryss b, meltzer s, lazer t. should high bmi be a reason for ivf treatment denial? gynecological endocrinology. 2017 nov 2;33(11):853– 6. [30] kudesia r, wu h, hunter cohn k, tan l, lee ja, copperman ab, et al. the effect of female body mass index on in vitro fertilization cycle outcomes: a multi-center analysis. journal of assisted reproduction and genetics.2018 nov 1;35(11):2013–2 [31] blbas ht, aziz kf, nejad, sh, & barzinjy aa. phenomenon of depression and anxiety related to precautions for prevention among population during the outbreak of covid-19 in kurdistan region of iraq: based on questionnaire survey. journal of public health. 2020 jun 10:1-5. doi:10.1007/s10389-02001325-9 16;14(8):e0221015. [15] wilcox a, weinberg c, baird d. caffeinated beverages and decreased fertility. the lancet. 1988 dec;332(8626–8627):1453–6. [16] choi jh, ryan lm, cramer dw, hornstein md, missmer sa. effects of caffeine consumption by women and men on the outcome of in vitro fertilization. journal of caffeine research. 2011 mar;1(1):29–34. [17] hussein mj, alalaf sk, al-tawil ng. effect of maternal age on the ovarian reserve markers, and pregnancy outcome in a sample of kurdish women in erbil city. zanco journal of medical sciences. 2018 apr 1;22(1):8 _ 16 -8 _ 16. [18] what is hcg? [internet]. american pregnancy association. 2021 [cited 2022 dec 9]. available from: https:// americanpregnancy.org/getting-pregnant/ hcg-levels/ [19] ricci e, noli s, cipriani s, la vecchia i, chiaffarino f, ferrari s, et al. maternal and paternal caffeine intake and art outcomes in couples referring to an italian fertility clinic: a prospective cohort. nutrients. 2018 aug 17;10(8):1116. [20] ahmed as, othman sm. patterns of infertility among couples attending ivf center in maternity teaching hospital in erbil. zanco journal of medical science (zanco j med sci). 2016;20(3):1467_1475-1467_1475. [21] wilkes s, chinn dj, murdoch a, rubin g. epidemiology and management of infertility: a population-based study in uk primary care. family practice. 2009 aug 1;26(4):269– 74. [22] matin hh, sehhati sf, zoodfekr l. comparing menarche age, menstrual regularity, dysmenorrhea and analgesic consumption among athletic and non-athletic female students at universities of tabriz-iran. international journal of women’s health and reproduction sciences.2014 jan 1;2(5):307– 10. [23] hasan na, abdulhameed wa, rahim ai. correlation among obesity, oocyte characteristics, embryo characteristics and maternal plasma folate level in a sample of iraqi women undergoing intracytoplasmic sperm injection (icsi). iraqi journal of embryos infertility researches. 2020 dec 13;10:1–19. [24] sõritsa d, mäestu e, nuut m, mäestu j, migueles jh, läänelaid s, et al. maternal physical activity and sedentary behaviour before and during in vitro fertilization treatment: 147 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article knowledge, practices, and attitudes of nurses regarding nonpharmacological pain management in the midwifery ward abstract background and objectives: pregnant women are frequently worried about labor pain, and it is usually the most important problem for them and their relatives. nonpharmacological pain relief methods provide several benefits, such as no harmful effects on the fetus or baby, no interruption of labor, and even being pleasurable for the mother and fetus. the aim of this study was to assess the nurse’s knowledge practice and attitude toward non-pharmacological pain management methods in the delivery room in erbil governorate. method: the descriptive cross-sectional design was utilized to determine nurses' knowledge, practices and attitudes about labor pain and non-pharmacological pain management, as well as to monitor nurses' practices in the delivery rooms during labor and delivery. a total of 78 nurses from public and private hospitals in erbil governorate participated in the study. structured questionnaires and an observational checklist were used to collect data and used spss version 26 was used to analyze it. result: nurse’s knowledge (n=27, 50.0%), (n=9, 37.5%) in public and private hospitals was at a good level, and they had a positive attitude (n=32, 59.3%) in public hospitals and a positive attitude (n=14, 58.3%) in private hospitals. but had a fair practice (n=19, 35.18%) in public hospitals and good practice (n=10, 41.7%) in private hospitals towards labor pain and non-pharmacological pain management. this is due to the lack of time, inadequate staff and the great workload of the staff. conclusion: this survey showed that the knowledge of most of the nurses was at a good level, but it was weak in items such as (cold therapy, acupuncture and acupressure technique), as well as majority of them do the following practices: relaxation technique, give psychological support and, ensure that women's relatives are there during the entire labor process; and they do not use other types of non pharmacological pain reliving method like: hypnosis, ice packs, intradermal water block. it is required to design a pain-relieving non-pharmacological training course for nurses. keywords: labor pain; non-pharmacological; nurses. shahla shkak shareef; department of nursing, college of nursing, hawler medical university, kurdistan regioniraq. (correspondence: shahlashkak89@gmail.com) tiran jamil piro; department of nursing, college of nursing, hawler medical university, kurdistan regioniraq. 34 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 20/06/2022 accepted: 21/08/2022 published: 30/5/2023 mailto:shahlashkak89@gmail.com?subject=shahlashkak89@gmail.com https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article pregnancy is one of the most crucial and wonderful times in a mother's life. it finishes with the birth of a baby during the labor phase. labor pain is one of the most terrible experiences. because it is an inevitable aspect of the birth process, this pain is unique from others. it is not a sign of injury or tissue damage; it declines naturally, is regular and consistent, eventually becomes tight, and leads to a wonderful event, childbirth. some delivery positions are more painful than others, such as lying on your back. changing postures and being mobile throughout labor might help to alleviate discomfort. amniotomy, vaginal examinations, and monitoring can all cause discomfort by restricting a woman's movement or generating concern analgesics are now seldom used for pain management during delivery due to maternal and newborn complications, and non-drug and complementary medicine options are growing more prominent [1].labor ache is a horrible, complicated, and highly personalized experience that includes either sensory or emotional elements. the way the woman handles childbirth and how it manifests physically and mentally might affect how much pain she experiences. for women of all races and cultures seeking services for childbirth in hospitals, pain management may be of the highest significance and a crucial part of therapy. many women may benefit from the midwifery style of treatment since it highlights the usual natural process of labor and delivery in low-risk pregnancies and encourages the use of nonpharmacological approaches [2].true labor starts when the female has bloody flow, her membranes tear, and she has severe uterine contractions that produce cervical effacement and dilation. the specific pathophysiology that causes this to happen is unknown. it is essential to identify between real and fake labor. a characteristic of the first one is the onset of uterine contractions every three to five minutes, lasting 20 to 60 seconds, at regular intervals. when labor begins, uterine contractions do not stop, and the uterine cervix dilates as a result. inconsistent contractions and cervical dilatation, often known as braxton-hicks contractions, are the markers of false labor. in particular, for nulliparous women, false contractions become more frequent during the 31st week of pregnancy, generating confusion and concern [3].abdominal pains, pelvic pain, and backache are common symptoms of labor pain. women who have gone through labor recall the high intensity of the pain and categorize it as mild, moderate, or severe, with the severity rising from the start of contractions to full dilation of the cervix pain during labor can be either physiological or psychological/emotional. fear, uncertainty, and a lack of knowledge can all exacerbate emotional pain. even though it won't fix the issue, childbirth education is a good strategy to address it. the lower uterine segment and cervix dilate in the early stages of labor, which causes pain. the fetus' descent down into the birth canal produces distension and tearing of tissues in the vagina and perineum in the late first and second phases of labor, resulting in discomfort. dilation and labor could be slowed down, which would make them more painful if the woman holds her breath and attempts to fight off the contractions. the woman's posture is crucial during the childbirth process [4].suffering throughout delivery should be seen as a real phenomenon that poses no harm to a mother's pregnancy; nonetheless, most of these events rely on the assistance of midwives during labor pain. individual characteristics of midwives, such as years of work or 35 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article to music, and using breathing techniques. some other therapies include hydrotherapy, acupressure, acupuncture, massage, hypnosis, aromatherapy, hot and cold applications, and transcutaneous electrical nerve stimulation. a more therapeutic approach will help lower the pain threshold or divert attention away from the discomfort of childbirth [9].around the world, medication therapies are commonly used during labor and delivery. despite the fact that epidural analgesia is regarded to be a good painkiller, it is not always associated with a positive delivery experience. furthermore, this sort of pain therapy is expensive, can impair women's sense of competence, lengthen the second stage of labor, and increase the likelihood of subsequent interventions (such as instrumental birth or cesarean surgery) [10].nonpharmaceutical, psychological, and physiological treatments are the three main categories of childbirth pain management treatments. non-pharmacological pain relief methods provide several benefits, such as inexpensive, no harm to the woman, her baby, or the course of the birth and no interruption with labor, and even being pleasurable for the mother and fetus. the nurse's primary key responsibilities are to find the issues of the woman in labor, provide appropriate information about different modalities of pain relief during labor, assist the women in labor in ventilating all of their doubts through interpersonal interactions, assist the women in labor in choosing the appropriate modality for effective pain relief, and to effectively apply alternative modalities of pain management throughout the first phase of labor, thereby reducing the risk of complications [11]. experience and the number of births performed, may impact or effect on labor pain evaluation and management methods [5].healthcare practitioners must assist women with pain management during childbirth [6].moms were attended by experienced women, most generally known as traditional birth attendants, in the centuries past, and monitoring was held at their homes. the carers performed prayers, created herbal mixtures, and utilized charms to help lessen the discomfort of contractions [7].proper delivery practices are those that are closely linked to the humanization phase of obstetric care. these should include, among other things, autonomy, respect for women's and families' rights, empathic support for health professionals, encouragement to adopt noninvasive and non-pharmacological pain relief methods, freedom of position, and clinical practice based on current evidence, according to who recommendations [8].since the dawn of time, humans have been aware of pain and have attempted to manage it in various ways. there are two main approaches for alleviating and controlling pain during childbirth. pharmacological therapies are typically expensive and have undesirable side effects. pharmacological therapy is used to alleviate pain. it’s a common practice found in many nations across the world. the most common prescriptions are analgesic drugs like entonox, epidural analgesia, diamorphine, tramadol, and pethidine.physically, the pain would be reduced, but the mothers' psychological and emotional wellbeing would be overlooked. receiving opioid pain relievers such as pethidine is one alternative for pharmacological pain treatment. also, non-pharmacological therapies are used to control pain. some techniques include changing positions, movement, and progressive muscle relaxation, which can happen through yoga, listening 36 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article in erbil governorate, a cross-sectional study was conducted in public and private hospitals. data were collected by using a non-probability (purposive sample) technique. the inclusion criteria composed all nurses working in delivery room and exclusion criteria included the nurses who had at least one year of experience in delivery room. data was collected through an observational checklist and format for a questionnaire. the questionnaire consists of 4 parts. part one includes sociodemographic characteristics and professional background of the nurses this part contains information like (age, marital status, academic qualification, length of experience in the delivery room, working shift, satisfaction in the workplace, participation in a non-pharmacological pain management training course, the number of mothers who are responsible by the nurse at the same shift, and types of pain management during labor for reliving labor pain). part two related nurses’ knowledge of labor and non-pharmacological pain management during labor by 40 items assessed. the total average means of all items is about 2.47 of a standard deviation 0.53, so the statistical analysis revealed that the means value of all items was more than the standard of study value ≥2.34. this part revealed a high acceptance rate, and this shows the high level of all the questions about the knowledge of nurses about labor pain and management. the queistonerie was scored by following the scoring protocol by providing a corresponding letter relating to the chosen answer for frequency of consumption ranging from 1(i don’t know), 2 (incorrect), 3(correct).part three related to nurses’ practices about different methods of non-pharmacological pain management during labor and was assessed by 27 items scored likert scales, which is about 27 items reached a low degree. the total average means of all items is about 1.55 of a standard division of 0.35, so the statistical analysis revealed that the means value of all items was less than the standard of study value 2.34. this part revealed a low acceptance rate, and this shows the low level of all the questions about the practices of nurses regarding applying nonpharmacological pain methods in the delivery room. part four related to an attitude of nurses regarding pain management during labor, assessed by 22 items, which about 22 items reached a high degree. the total average means of all items is about 2.81 with standard division 0.44, so the statistical analysis revealed that the means value of all items was more than the standard of study value ≥2.34. this part revealed a high acceptance rate, and this shows the high level of all the questions about the attitude of nurses regarding pain management during labor .the study's limitation was covid-19 pandemic. in general, people handled the situation delicately and avoided getting too near to one another [28]. the study was accepted by the nursing ethical committee of hawler medical university college of nursing on7 october 2021 number 109, and official authorization was acquired from the ministry of health's director of health in erbil. the respondents' rights and confidentiality were protected throughout the study. they were informed and explained the goal of the study as well as the confidentiality of the information through a verbal permission process. data analysis: statistical package for social science (spss) version 25 was used to analyze and organize the data. the mean and standard divisions for determining the acceptance rate of participants. 37 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 38 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1 revealed that most of the sample members were in public hospitals within the category of 39-49 years old, the highest percentage (35.2%), and in private hospitals shows that most of the participants of the sample study were within the category of 28-38 with a percentage of (41.6%). the majority of the sample of the study in both areas (public, private) hospitals was in married marital status, which is about (70.4%, 70.8%). most of the sample members in public and private hospitals at the level of education hold a secondary school of nursing degree, with a percentage of (25.9% , 25.0%).regarding working shifts in public and private hospitals, the result indicates that the majority of them working in the circulating formwork is about (35.2% , 29.2%). as for the working experience in delivery rooms in public hospitals, it indicated that most of the participants were in the category 1020 years, which was about (55.6%), which indicates the hospitals focused on highly experienced nurses. as for the working experience in delivery rooms in private hospitals, it indicated that most of the participants were in the category of less than 10 years, which was about (70.8%). according to the results of the study in public hospitals, hours per day, we have two groups close to each other, and most of them work less than 10 hours a day, which was about (38.9%), while other parts work more than 15 hours a day, with a percentage of (37%).the working hour per day in private hospitals shows the majority of them work more than 15 hours a day which was about (45.8%). results variables public private f (%) f (%) age group 18-27 6 (11.1) 1 (4.2) 28-38 17 (31.5) 10 (41.6) 39-49 19 (35.2) 7 (29.2) 50 above 12 (22.2) 6 (25.0) marital status single 12 (22.2) 5 (20.8) married 38 (70.4) 17 (70.8) widowed 3 (5.6) 1 (4.2) divorced 1 (1.9) 1 (4.2) academic qualification training course 4 (7.4) 4 (16.7) primary school of nursing 6 (11.1) 0 (0) secondary school of nursing 14 (25.9) 6 (25.0) secondary school of nursing department (midwifery) 8 (14.8) 5 (20.8) diploma of nursing 8 (14.8) 2 (8.3) diploma of nursing department (midwifery) 10 (18.5) 1 (4.2) college of nursing 3 (5.6) 3 (12.5) college of nursing department (midwifery) 1 (1.9) 3 (12.5) working shift morning 12 (22.2) 5 (20.8) evening 8 (14.8) 3 (12.5) night shift 15 (27.8) 4 (16.7) circulating 19 (35.2) 7 (29.2) working experience in delivery room < 10 18 (33.3) 5 (20.8) 10-20 30 (55.6) 17 (70.8) > 20 6 (11.1) 7 (29.2) working hours per day < 10 21 (38.9) 8 (33.4) 10-15 13 (24.1) 5 (20.8) > 15 20 (37.0) 11 (45.8) total 54 (100) 24 (100) table 1 :socio-demographic characteristics of study sample in public and private hospitals https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 39 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2 revealed that the majority of nurses in public were satisfied with working in the delivery room, which is about (98.1%). table 3 shows that all of the nurses were satisfied with working in the delivery room, which is about (100%). as a result of the study sample, the majority of nurses did according to the study sample, all nurses did not participate in any training course about pain . management of labor, with a percentage (100%). not participate in any training course about pain management of labor, with a percentage (95.8%), while one nurse participated in the training course 5 years ago. table 2: personal information in the public hospitals items f (%) are you satisfied with working in delivery room? yes 53 (98.1) no 1 (1.9) total 54 (100.0) did you participate in training course about pain management of labor? no 54 (100.0) how many mothers are you responsible for at the same time in your working shift? less than 5 11 (20.4) 5-10 35 (64.8) more than 10 8 (14.8) total 54 (100) do you apply any pain management methods for women in labor? yes 54 (100.0) table 3: demographic information in the private hospitals items f (%) are you satisfied with working in delivery room? yes 24 (100) did you participate in training course about pain management of labor? yes 1 (4.2) no 23 (95.8) a. if yes, when did you participate in such training course? 23 (95.8) 5 years ago 1 (4.2) b. if yes, how much time did it long? 1 day 1 (4.2) total 24 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 40 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4 shows levels of nurses' responses in the public and private hospitals regarding knowledge of nurses about labor pain and management and practices of nurses regarding applying non-pharmacological pain methods in the delivery room. the result in public hospitals was as follows: (50%) of nurses were at a good level, while (16.7%) were at a fair level, and (33.3%) of them were at a poor level, and in private hospitals knowledge of nurses about labor pain and management was as follows: table 5 shows the response levels of public and private hospital nurses regarding nurses' attitudes toward labor pain management as follows: (59.3%) nurses were at the positive level and (40.7%) were at the (37.5%) of nurses were at a good level, while (33.33%) were at a fair level, and (29.16%) of them were at a poor level. the performance of nurses in public hospitals regarding the use of non-medicinal pain methods in the delivery room is as follows: 31.48% at a good level, 35.18% at a fair level and (33.33%) at a poor level, also in private hospitals using non-medicinal pain methods in the delivery room, it was as follows: (41.7%) of nurses were at good level, (25.0 %) at the appropriate level and 33.3% at a poor level. negative level. while in private hospitals, the results of nurses' attitudes about pain management during labor were as follows: (58.3%) of nurses at good level and (41.7%) at negative level table 4: levels of the knowledge, and practices in the public and private hospitals table 5: levels of the attitude in the public and private hospital overall level public hospitals private hospital good fair poor good fair poor f (%) f (%) f (%) f (%) f (%) f (%) knowledge of nurses about labor pain and management 27(50) 9(16.7) 18 (33.3) 9(37.5) 8(33.33 ) 7 (29.16) practices of nurses regarding applying non pharmacological pain methods in delivery room 17 (31.48) 19 (35.18) 18 (33.3) 10 (41.7) 6(25.0) 8(33.3) overall level public hospitals private hospital positive negative positive negative f (%) f (%) f (%) f (%) attitude of nurses regarding pain management during labor 32 (59.3) 22 (40.7) 14 (58.3) 10 (41.7) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 41 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 6 shows the comparisons between variables knowledge, practice, and attitude in public hospitals and the private hospital. the results were as follows: the mean value of public hospitals was 2.44, and for private hospitals was 2.55 for items regarding knowledge of nurses about labor pain and management. while public hospitals were 1.46 and for private hospitals were 1.76 for items related to practices of nurses regarding applying non-pharmacological pain this study revealed that nurses’ knowledge of labor and pain management in public and private hospitals was at a good level. these results were congruent with a study carried out on 87 nurses and midwives done by [24] in ibadan, nigeria, which revealed moderate knowledge about labor pain management among their study participants. also, the finding of the present study is supported by using a simple random sampling study done by [14] among 209 professional nurses, who revealed that nurses had adequate knowledge about non -pharmacological pain management. while these results are not consistent with the result of a previous study done by[18] in egypt on 88 healthcare providers demonstrated that healthcare professionals are more or less familiar with several of the non-pharmacological methods, this result disagrees with the study done by [19] among 246 nurses who reported that methods in the delivery room, and the mean value of public hospitals was 2.80 while the private hospitals were 2.84 for items regarding the attitude of nurses regarding pain management during labor. the result revealed that the knowledge, practice, and attitude in the private hospitals were better and higher compared to the knowledge, practice, and attitude in the public hospitals, with the exception of the sample size difference in these two sectors. nurses did not have adequate knowledge. regarding the practices of nurses in private hospitals, it indicated that the majority of nurses had good practice. this may be due to adequate space, staff, and equipment. it comes along with a study done by [21] in ethiopia on 336 skilled attendants who, revealed that more than half of the study participants had good practice. this is similar to a crosssectional study carried out by [22] in ethiopia among 464 healthcare professionals. while the finding of the present study in public hospitals shows that the majority of nurses had fair practice, the possible reasons may be inadequate staff, lack of time, lack of training on nonpharmacological pain management, incorporation of physicians with nurses or nurses with mothers, and lack of staff, this finding is similar to a cross-sectional study done by [20] among 420 obstetric table 6: differences between overall level variables knowledge, practice, and attitude in the public hospitals and the private hospitals variables public hospitals n private hospitals n mean std. deviation mean std. deviation knowledge 2.44 0.527 54 2.55 0.494 24 practice 1.46 0.283 54 1.76 0.288 24 attitude 2.80 0.440 54 2.84 0.366 24 discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 42 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. care providers in hawassa, also finding comes along with study done in ethiopia by [13] which revealed that poor practice during labor pain management. moreover, the results of the present study are supported by [17] in egypt, who found that about half of the respondents didn’t use nonpharmacological methods. the finding of the present study in public hospitals is that more than half of nurses had a fair attitude towards non-pharmacological pain management during labor. the current study's findings are similar to a previous study done by [17] in ethiopia on 169 nurses, which revealed that the majority of nurses have an unfavorable attitude towards nonpharmacological pain management methods. in private hospitals, it shows that more than half of nurses had a good attitude. this result agrees with the result of a previous descriptive study which was done by [23] in ethiopia on 299 obstetric caregivers who found that the majority of the study participants had a positive attitude toward labor pain relief methods, and this comes along with a study done by [24] who studied 233 skilled attendants in tigry region. in this study, the contrasts between knowledge, attitude, and practice were found in both public and private hospitals. the results were as follows: the mean value of public hospitals was 2.44 and for private hospitals were 2.55 for items regarding knowledge of nurses about labor pain and management. while public hospitals were 1.46 and for private hospitals were 1.76 for items related to practices of nurses regarding applying non-pharmacological pain methods in the delivery room, and the mean value of public hospitals were 2.80 while the private hospitals were 2.84 for items regarding the attitude of nurses regarding pain management during labor. it comes along with a study done by [21] in ethiopia, which revealed that skilled birth attendants who were working at private primary hospitals were 6.55 times more likely to have good knowledge about labor pain removing methods as compared to skilled birth attendant working at public primary hospitals, this result is similar to the study done by [18] among 88 health-care providers in abha, saudi arabia, which are agreement with the result of the present study in private hospitals and disagreement with the result of present study in public hospitals. toward the practice of nurses applying nonpharmacological work in the labor world revealed that poor practice in public hospitals compared with private hospitals. this comes along with a study done by [13] in gamo and gofa zones that found that practice of non-pharmacological labor pain management was poor in public health facilities; also this finding is similar to a descriptive study done by[27] on 120 nurses at makkah el-mukarramah. the result of the present study in private hospitals indicated a positive attitude and good practice of nursing staff regarding non-pharmacological methods .this is supported by cross-sectional study done by[26] on 299 f obstetric caregivers working at labor ward in public health centers of the east gojjam zone, amhara region, ethiopia, which demonstrated that obstetric caregivers who had a positive attitude toward managing labor pain were 2.45 times more likely to use labor pain management methods than those who had a negative attitude for labor pain management. this result is supported by a study done by [16] in ethiopia who found that nurses with a favorable attitude to non-pharmacology pain management methods were statistically significantly associated with good practice of non-pharmacology pain management. also, the finding is supported by a study done in ethiopia by [13] on 272 skilled attendants who revealed that https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 43 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. respondents who had favorable attitudes towards labor pain management were 2.82 times more likely to do good practice than others. moreover, the results of the present study is supported by [20] in hawassa city on 305 obstetric care providers who found that a favorable attitude towards labor pain management, were 2.97 times more likely to practice labor pain management compared to their counterparts. the study concluded that the majority of the nurses in public and private hospitals were with the mean age of 42.00 years old, most of them married, in secondary school, satisfied with working in a delivery room, and did not participate in a training course about pain management of labor. the overall usage of labor pain management strategies by nurses in public hospitals was poor. nurse’s knowledge, practice and attitude had shown statistical significance association with age, level of education and years of experience. hiring nurses who are graduates from the college of nursing, especially (department) of midwifery. [1] fadhil s. effect of non-pharmacological pain management methods on reduction the duration of labor stages in primigravida women at al-elwyia maternity teaching hospital.iraqi national journal of nursing specialties. 2019; 32(1):31–8. [2] ramasamy p, kwena am, emarah a, kangethe s. knowledge, attitude, practice and barriers to educational implementation of non-pharmacological pain management during labor in selected hospitals, kenya. central african journal of public health. 2018; 4(1): 20-26. [3] butkus sc, editor.maternal-neonatal nursing made incredibly easy!.third edition. philadelphia: wolters kluwer health/lippincott williams & wilkins; 2015. p.314. [4] konlan kd, afaya a, mensah e, suuk an, kombat di.non-pharmacological interventions of pain management used during labour; an exploratory descriptive qualitative study of puerperal women in adidome government hospital of the volta region, ghana. reprod health. 2021; 18(1):1–11. [5] aziato l, kyei aa, deku g. experiences of midwives on pharmacological and nonpharmacological labour pain management in ghana. reprod health. 2017; 14(1):1–8. [6] getu aa, getie sa, gela gb, maseresha ea, feleke be, muna am.non-pharmacological labor pain management and associated factor among skilled birth attendants in amhara regional state health institutions, northwest ethiopia. reprod health. 2020; 17(1):1–8. [7] osório smb, silva júnior lg da, nicolau aio.assessment of the effectiveness of non -pharmacological methods in pain relief during labor. northeast network nursing journal. 2014; 15(1): 174-184 [8] oliveira ps de, couto tm, gomes np, campos lm, lima ktr dos s, barral fe. best practices in the delivery process: conceptions from nurse midwives. revista brasileira de enfermagem. 2019; 72(2):455–62. [9] mahmood k. labour and birth experiences and awareness of pain relief among kurdish women. [phd thesis]. university of sheffield; 2016. [10] thomson g, feeley c, moran vh, downe s, oladapo ot. women’s experiences of pharmacological and non-pharmacological pain relief methods for labour and childbirth: a qualitative systematic review.reprod health. 2019;16(1):1–20. [11] boateng ea, kumi lo, diji aka. nurses and midwives’ experiences of using nonpharmacological interventions for labour pain management: a qualitative study in ghana. bmc pregnancy childbirth. 2019; 19(1):1–10. [12] ojerinde eze o, onibokun a, akpa o m. knowledge and practice of pain management among nurses in labour wards in ibadan, nigeria. african journal of midwifery and women's health. 2016;10(3):132–7. [13] wassihun b, alemayehu y, gultie t, tekabe b, gebeyehu b. non-pharmacological labor pain management practice and associated factors among skilled attendants working in public health facilities in gamo and gofa zone, southern ethiopia: a cross-sectional conclusion references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 44 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. study.plos one. 2022; 17(4):e0266322. [14] jira l, weyessa n, mulatu s, alemayehu a. knowledge and attitude towards nonpharmacological pain management and associated factors among nurses working in benishangul gumuz regional state hospitals in western ethiopia, 2018. journal of pain research. 2020;13:2917–27. [15] nuriy lahm, ahmed hm. nurse/midwives’ practices during labor and delivery in maternity teaching hospital in erbil city. erbil journal of nursing and midwifery. 2018;1(1):23– 32. [16] zeleke s, kassaw a, eshetie y. nonpharmacological pain management practice and barriers among nurses working in debre tabor comprehensive specialized hospital, ethiopia. plos one. 2021;16(6):e0253086. [17] mousa o, abdelhafez a, abdelraheim a, yousef a, abdelghany a, el gelany s. perceptions and practice of labor pain-relief methods among health professionals conducting delivery in minia maternity units in egypt. obstetrics and gynecology international. 2018;2018:1–6. [18] almushait m, ghani ra. perception toward non-pharmacological strategies in relieving labor pain: an analytical descriptive study. journal of natural sciences research. 2014;4 (2): 2224-3186. [19] yava a, çicek h, tosun n, özcan c, yildiz d, dizer b. knowledge and attitudes of nurses about pain management in turkey. international journal of caring sciences. 2013;6 (3):494-505. [20] wakgari n, mekonnen m, lema b, negasu a, lulu b, abebe e. labour pain management practices among obstetric care providers in hawassa city, ethiopia. african journal of midwifery and women's health. 2020;14 (2):1–12. [21] solomon et, kassie fy, mekonnen dg, mihret ms, abate at, dessie aa. knowledge, attitude, and practice towards labor pain management and associated factors among skilled birth attendants working at hospitals found in central, west, and north gondar zones, northwest ethiopia, 2019: a multicenter cross-sectional study. pain research and management. 2021;2021:1-9. [22] eyeberu a, debela a, getachew t, dheresa m, alemu a, dessie y. obstetrics care providers attitude and utilization of nonpharmacological labor pain management in harari regional state health facilities, ethiopia. bmc pregnancy childbirth. 2022;22(1):1-9. [23] bishaw ka, sendo eg, abebe ws. knowledge and use of labour pain relief methods and associated factors among obstetric caregivers at public health centers of east gojjam zone, amhara region, ethiopia: a facility based crosssectional study. bmc pregnancy childbirth. 2020;20 (1):1-9. [24] sahile e, yemaneh y, alehegn a, nigussie w, salahuddin m, yekoye a, gebeyeh n. practice of labour pain management methods and associated factors among skilled attendants working at general hospitals in tigray region, north ethiopia: hospital based cross-sectional study design. health science journal. 2017;11(4):1-7. [25] tekletsadik ea, desta aa, workneh bs. knowledge, attitude, and associated factors towards nonpharmacological pain management among nurses working at amhara region comprehensive specialized hospitals, ethiopia. critical care research and practice.2021; 2021:1–11. [26] bishaw ka, sendo eg, abebe ws. knowledge, and use of labour pain relief methods and associated factors among obstetric caregivers at public health centers of east gojjam zone, amhara region, ethiopia: a facility based crosssectional study. bmc pregnancy childbirth.2020;20 (1): 1-9. [27] ali hs. ibrahim y. mohamed e. nonpharmacological pain management: nurses’ knowledge, attitudes and practices in selected hospitals at makkah elmukarramah. life science journal;2(10):19. [28] yılmaz v, ameen ss. the role of local government in combating the crisis of covid-19 pandemic in erbil–iraq. route educational & social science journal. 2021; 8(6): 78-92. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.07 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article knowledge practice and lifestyle among pregnant women regarding nausea and vomiting in primary health care centers in erbil city abstract background and objectives: nausea and vomiting during pregnancy affect pregnant women to varying degrees. over the years, a large number of modalities have been used to deal with debilitating conditions and the health state of pregnant women. the study aimed to find the prevalence of nausea and vomiting among pregnant women in the first trimester and to study the effect of an educational program on their knowledge and practices regarding complementary and alternative medicine to reduce nausea and vomiting in the first trimester. methods: a quasi experimental study was conducted from january 2022 to july 2022 among pregnant women who had nausea and vomiting who attended eight primary health care centers in erbil city. the purposive sampling method was used to select 200 pregnant women. the rhodes index test was used to assess the rate of nausea and vomiting. results: the prevalence of nausea and vomiting among pregnant women in the first trimester was 68% in erbil city. the largest proportion of the participants (46.3%) belonged to the age group 25-34 years. the median of the participants' knowledge score before the intervention was 3, while it significantly increased to 14 after the intervention (p<0.001). the median of their lifestyle score increased significantly from 0 before the intervention to 32 after the intervention (p<0.001). conclusion: the prevalence of nausea and vomiting among the pregnant women, their complaint about this condition, and their knowledge, practice, and lifestyle regarding nausea and vomiting before and after and experienced changed significantly for the better. keywords: knowledge; practice; lifestyle, nausea; vomiting; pregnant women. shaymaa sameer maqsood; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. (correspondence: shaymaa.maqsood@hmu.edu.krd) ibrahim hasan mustafa; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. 57 received: 07/04/2023 accepted: 18/06/2023 published: 30/05/2025 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:(correspondence:%20dara.albanna@hmu.edu.krd) mailto:shaymaa.maqsood@hmu.edu.krd?subject=shaymaa.maqsood@hmu.edu.krd%20 mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.07 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article during pregnancy, which is a natural event, women's body undergoes numerous changes.[1] due to the physiological changes during pregnancy, required for fetal development, pregnant women experience various signs and symptoms.[2] nausea and vomiting are most commonly complained about by pregnant women during the early trimester. in spite of the fact that nausea and vomiting of pregnancy (nvp) might happen any time during pregnancy, it is usually called morning sickness.[3] pregnant women experience nvp, or morning sickness, from the 6th gestational week of pregnancy until the end of the 16th gestational week. [4,5] it is reported that 63% of pregnant women experience nvp during the 1st and 2nd trimesters of pregnancy, which is similar to nvp prevalence in early pregnancy.[6] if nausea and vomiting are not treated early, pathological problems will occur due to decreased fluid in the body which in turn leads to increased blood concentration and consequent decreased blood circulation, resulting in bad effects on the growth and development of the fetus.[7] although pregnant women die due to nvp in rare cases, the probability is still quite high.[8] due to maternal system changes during pregnancy, pregnant women need to get adapted both psychologically and physically.[9] nausea and vomiting during pregnancy can only be treated by consuming drugs; however, drug consumption has unfavorable impacts on the growth and development of the fetus.[10] for this purpose, complementary medicine, particularly herbal remedies, is used all over the world. [11] pregnant women can easily be negatively affected by the side effects of drugs; therefore, the safety of herbal therapies is particularly significant for them. pregnancy can progress more as a result of consuming herbal supplements. disorders caused by pregnancy, such as gastro-esophageal reflux, nausea, and vomiting, are treated by consuming herbal medicine. [12,13] as reported by the media and pregnant women, herbal use is recommended during pregnancy by pharmacists, natural or alternative medicine practitioners, and health care providers. [14,15,16] using herbal medicines has an important role in managing both minor and major illnesses. [17] complementary therapies, including herbal or traditional plants like ginger and peppermint oil, can be utilized to decrease nausea and vomiting during early pregnancy. [18] as pointed out by the national center for complementary and alternative medicine (nccam), complementary and alternative medicine (cam) is a wide domain of treatment resources that include all practices, modalities, and health systems. [19] according to the news published in the british medical journal in 1996, there was a remarkable increase in worldwide use of complementary medicine. [20,21] in addition, there has been a remarkable rise in the use of complementary and alternative medicine in australia, the united states, and europe over the past decade. [20,22] cams are broadly used all over the world. [23] different diseases and conditions in various populations are nowadays treated using herbal medicine. [24] moreover, pregnant women from different countries and with different backgrounds have been reported by numerous published studies to consume herbal medicine. [25] for a remarkable number of pregnant women, family and friends are the main sources to obtain information about the use of herbal medicine during pregnancy. [26] a significant number of pregnant women consume herbal medicine although they do not have any knowledge related to such medicine. [27] it is well documented that because of nausea and vomiting during pregnancy, the number of pregnant 58 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.07 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article in the data collection session, age between 18 and 40 years, healthy pregnant women, singleton pregnancy, and ability to communicate. women with a history of infertility, those with a medical and surgical history, and those who were faced with any matter causing them to abandon the study were excluded. a questionnaire was used to collect data on the pregnant women`s demographics, including age, level of education, and occupation. obstetric data on gravida, para, abortion, and gestational age based on the first day of the last menstrual period and first ultrasound were also gathered through the questionnaire. another section of the questionnaire was related to dietary consumption and daily life, which consisted of a four-item scale that measured the daily routine for pregnant women during the first trimester in which the responses to the items were scored based on an ordinal scale of three points varying from always 2, sometimes 1, to never 0. [29]in addition, another data collection instrument was used: rhodes index score was used for no nausea and vomiting to severe nausea and vomiting. this scale consisted of 8 questions asking about the daily frequency of vomiting, the amount of vomiting, nausea and retching duration and quantity, and distress for each episode of nausea, vomiting, and dry retching. the questions focused on the first day of the assessment. the practice section of the data collection instrument consisted of five aspects, including the instruction about how to use the complementary and alternative medicine, and determined to three groups. moreover, the knowledge items included knowledge about nausea and vomiting, the source of relevant information, the source of hearing about complementary and alternative medicine, harm to the fetus, and how to decrease nausea and vomiting during pregnancy. the validity of this scale has been women who seek medical attention, medications, and even herbal medicine is increasing. [28]to the best of our knowledge, no data exists on the consumption of herbal medicine and supplements among pregnant women in erbil city. in this regard, the present study was conducted to find the prevalence of nausea and vomiting among pregnant women in the first trimester, and to study the effect of an educational program on their knowledge and practices regarding complementary and alternative medicine to reduce nausea and vomiting in the first trimester. the present study was conducted using a quasi-experimental design from january 2022 to july 2022. to estimate the prevalence of nausea and vomiting among pregnant women in the first trimester in eight primary health care centers in the kurdistan region. before the start of the project, a pilot study was carried out. epi info was used to estimate the size of the study sample for the prevalence of nausea and vomiting using this information: population size 31833, confidence interval 95%, expected frequency 85, and margin of error 5, and the sample was 200 pregnant women. pregnant women with nausea and vomiting during their first trimester were selected as the study sample. also, the sample size of quasi-experimental assessment of knowledge and practice of nausea and vomiting among pregnant women for this purpose was selected based on the ps program power and sample size calculation version 7.2.4.0 entering the confidence (ci), power, and proportion. the sample size was estimated to be one hundred twenty-three pregnant women for prepost instruction. the inclusion criteria were the women's ability to participate 59 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.07 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article calculated through cronbach's alpha (α=0.8).[30]after the pregnant women were provided with information about the aim of the study, they filled out consent forms. the approval of the study was obtained from the ethics committee of hawler medical university no. 123 (dated 7-102021) and the authorities of the managements of the health and primary health care centers. in addition, all pregnant women were given a copy of the education resources and were required to participate in the program. spss (version 25.0) was employed to analyze the collected data. for this purpose, descriptive and inferential statistics were utilized to calculate frequency, percentage, mean, median, and standard deviation. in addition, the wilcoxon signedrank test, fisher's exact test, and chi-square test were utilized. a p-value of less than or equal to 0.05 was considered statistically significant. as revealed by the results of the present study, the prevalence of nausea and vomiting among pregnant women during the first trimester was 68 %. according to the results of the study regarding the sociodemographic characteristics of all pregnant women who participated in this study, the largest proportion (46.3%) of the sample belonged to the age group 25-34 years. also, only around one-third (29.3%) of the sample were college graduates, and 30.9% were graduates of primary schools. moreover, the majority (77.2%) of the women were unemployed. in addition, the prevalence of obesity was 13.8% (table 1). the results also indicated that the highest percentage (58.5 %) of the women was multigravida and 43.9% were nulliparous. more than one quarter (26.8%) of the women had a history of abortion. approximately two-thirds (64.2%) were in their 6-8 weeks of gestational age (table 2). 60 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results table 1. basic characteristics of the study basic characteristics no. (%) age (years) < 25 44 (35.8) 25-34 57 (46.3) ≥ 35 22 (17.9) education level illiterate 3 (2.4) primary school 38 (30.9) secondary school 26 (21.1) institute 20 (16.3) college or higher 36 (29.3) occupation student 8 (6.5) unemployed 95 (77.2) skilled manual workers 20 (16.3) bmi (kg/m2) <25 52 (42.3) 25-29 54 (43.9) ≥30 17 (13.8) table 2: obstetric history of the study obstetric history no. (%) gravidity primigravida 42 (34.1) multigravida 72 (58.5) grand multigravida 9 (7.3) parity nulliparous 54 (43.9) primiparous 34 (27.6) multiparous 34 (27.6) grand multiparous 1 (0.8) abortion no 90 (73.2) yes 33 (26.8) gestational age (weeks) 6-8 79 (64.2) 9-12 44 (35.8) total 123 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.07 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article 61 acupressure groups increased significantly from 0 to 5 (in the pyridoxine and capsule ginger groups) and from 0 to 10 in the acupressure group (p-value <0.001). it is worth mentioning that 5 and 10 scores are the maximum scores of the mentioned scales (table 3). without bringing anything up; however, the groups were not significantly different in this regard (p-value <0.176). the estimated amount of throwing up was small in the majority (77.2%) of the women, and the groups were not significantly different in this regard (p-value <0.440). it was also observed that 51.2% of the women felt great-severe distress due to retching, nausea, and vomiting; however, the differences between the groups were not significant for these three mentioned items (p-value <0.065) (table 4). table 3 shows that the median of the knowledge score was 3, while it increased significantly to 14 after (p-value<0.001). the median lifestyle score increased significantly from 0 before to 32 after the program (p-value <0.001). the median practice score of pyridoxine, capsule ginger , and as indicated in table 4, around 51.2% of the women in the pyridoxine and capsule ginger groups had felt nausea 4-7 times during the previous day, while 26.8% in the acupressure group had (p=0.036). it was also seen that all of the women remained nauseated for 1-3 hours during the previous day. the majority (94.3%) of the women of the whole sample had a history of vomiting 1-3 times during the previous 24 hours, and the groups were not significantly different in this regard (p-value <0.697). around one-third (34.1%) of the women had a history of retching or dry heaves copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: scores of knowledge, lifestyle and practice before and after the educational program. pre-scores post-scores scores of: sd median sd median p-value* knowledge 0.95 3.00 0.00 14.00 < 0.001 life-style 0.13 0.00 1.61 32.00 < 0.001 practice (pyridoxine group) 0.00 0.00 0.00 5.00 < 0.001 practice (capsule ginger group) 0.00 0.00 0.00 5.00 < 0.001 practice (acupressure) 0.00 0.00 0.00 10.00 < 0.001 *by wilcoxon-signed rank test. the results 0 of each median and sd based on the some questions just during first trimester that author created not related whole lifestyle also practices its related to some specific questions https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.07 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article 62 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: assessment of pregnancy unique quantification of emesis rhodes index by the program method at day zero. pyridoxine ginger capsule acupressure total p-value in the past 24 hours, how many times you felt nauseated? 1-3 times 20 (48.8) 20 (48.8) 30 (73.2) 70 (56.9) 4-7 times 21 (51.2) 21 (51.2) 11 (26.8) 53 (43.1) 0.036** in the past 24 hours, how many hours you remained nauseated or sick? 1-3 hours 41 (100.0) 41 (100.0) 41 (100.0) 123 (100.0) n/a in the past 24 hours, how many times you have thrown up? 1-3 times 40 (97.6) 38 (92.7) 38 (92.7) 116 (94.3) 4-7 times 1 (2.4) 3 (7.3) 3 (7.3) 7 (5.7) 0.697* in the past 24 hours, how many times do have period of retching or dry heaves without bringing anything up? 1-3 times 23 (56.1) 27 (65.9) 31 (75.6) 81 (65.9) 4-7 times 18 (43.9) 14 (34.1) 10 (24.4) 42 (34.1) 0.176** in the past 24 hours, the estimated amount of threw up was? small 34 (82.9) 29 (70.7) 32 (78.0) 95 (77.2) moderate 7 (17.1) 10 (24.4) 9 (22.0) 26 (21.1) large 0 (0.0) 2 (4.9) 0 (0.0) 2 (1.6) 0.440* in the past 24 hours, did you feel distress from retching or dry heaves? mild-moderate 22 (53.7) 14 (34.1) 24 (58.5) 60 (48.8) great-severe 19 (46.3) 27 (65.9) 17 (41.5) 63 (51.2) 0.065** in the past 24 hours, did you feel distress from vomiting or throwing up? mild-moderate 22 (53.7) 14 (34.1) 24 (58.5) 60 (48.8) great-severe 19 (46.3) 27 (65.9) 17 (41.5) 63 (51.2) 0.065** in the past 24 hours, did you feel distress from nausea/sickness in your stomach? mild-moderate 22 (53.7) 14 (34.1) 24 (58.5) 60 (48.8) great-severe 19 (46.3) 27 (65.9) 17 (41.5) 63 (51.2) 0.065** total 41 (100) 41 (100) 41 (100) 123 (100) **by chi square test. *by fisher’s exact test. n/a: not applicable. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.07 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article this finding is in line with those of another study, which reported that 88.9% of those who could read and write consumed complementary.[31]however, these findings are not in agreement with those of a study carried out in australia, in which women with higher educational levels consumed complementary more. such discrepancy might be due to the fact that the practices followed in australia differ from those of other countries. [33]a large number of pregnant women consume herbs quite frequently; therefore, they need to be provided with a suitable source of relevant information. [34] to the best of our knowledge, the present study is the first investigation which has had a specific focus on the consumption of herbal medicine and supplements during pregnancy in erbil city, kurdistan region of iraq. the results of the current study demonstrated that limited number of the pregnant women used herbal supplements. this finding is in line with those of the study carried out by zaki and albarraq (2014), ho reported that only 4.6% of the pregnant women used herbal supplements during their pregnancy.[35] the pregnant women who participated in the present study mentioned that they needed complementary medicine practices. this finding is in line with those reported in the study by al-faris (2008), in which 86.9% of the women outlined their need for practices. [36] in an epidemiological study of herbal medicines carried out in italy, 1,044 randomly selected women were studied. the results showed that, 47.0% of them used at least one herbal product during pregnancy.[37]such differences in the women's knowledge, experience, and practice of using complementary medicine can be attributed to discrepancies in the advancement of health systems across the countries and scarcity in the availability and access of medical services. [38] nausea and vomiting are a common complaint during pregnancy, and awareness of this discomfort and subsequent adherence to the management may alleviate the burden of this complaint. this is the first study conducted in erbil city, kurdistan region, iraq aimed at assessing the prevalence of nausea and vomiting among pregnant women during the first trimester, which was 68 %. before the implementation of the program, the pregnant women's scores of knowledge, practice, and lifestyle regarding complementary and alternative medicine were low. as emphasized by the results, the pregnant women did not have the habit of consuming supplements during pregnancy. however, these scores increased significantly after the program. after their participation in the program, there was a remarkable increase in the pregnant women's use of complementary medicine and alternative medicine during their first trimester. unlike this finding, the results of another study showed that the rate of using complementary among the pregnant women was high. as indicated by the results of that study, 97.5% of the participating women were previously aware. this high score of knowledge about complementary was related to the role of the media, friends, relatives, and family. [31] moreover, these findings of the present study are not in agreement with those of some studies conducted in the usa, which reported high consumption of complementary among middle-aged groups. [32] discrepancy between the findings of the current study and other studies can be related to differences between the participants regarding their occupational, educational, and cultural standards. according to the results of the current study, women with lower educational levels had higher scores for using complementary medicine. 63 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.07 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article [7] wulandari da , kustriyanti d , aisyah r. minumanjahehangatuntukmengurangi emesis gravidarumpadaibuhamil di puskesmasnalumsarijepara.journalsmartkebidanan.2 019; 6(1): 42.https://doi.org/10.34310/ sjkb.v6i1.246. [8] world health organization. hyperemesis gravidarum: current perspectives. international journal of women’s health. 2014 :6: 719–725.doi: 10.2147/ijwh.s37685. [9] rahmawati na, rosyidah t, marharani a. hubunganpelaksanaansenamhamildenganketidaknyamananibuhamil trimester iii di bidanpraktekmandirisupadmi, kundenbulu, sukoharjo. involusijornalilmukebidanan. 2016; 7(12):42-50.: http:// dx.doi.org/10.32497bangunrekaprima.v5i1.1 404. [10] viljoen e, visserj ,koen n, musekiwa a. a systematic review and meta-analysis of the effect our and safety of ginger in the treatment of pregnancy-associated nausea and vomiting. nutritional journal .2014; (19):1320.doi: 10.1186/1475-2891-13-20. [11] dabaghian fh .knowledge of pregnant women about the efficacy and safety of herbal medicine and their practice during pregnancy .complementary medicine journal.2012;2 (3): 246-256. http://cmja.arakmu.ac.ir/ article-1-149-en.html [12] hemminki e, mantyranta t, malin m, koponen p. a survey on the use of alternative drugs during pregnancy. scand journal social medicine. 1991; 19(3): 199 204.doi: 10.1177/140349489101900310. [13] forster d, denning a, wills g, bolger m , mccarthy e. herbal medicine use during pregnancy in a group of australian women. bmc pregnancy childbirth.2006; 6: 21 30.doi:10.1186/1471-2393-6-21. [14] hepner dl, harnett m, segal s, camann w, bader a, tsen l. herbal use in parturients. an international journal of obstetrics and gynecology. 2002;94:690–3.doi: 10.1097/00000539-200203000-00039 [15] maats f, crowther c. patterns of vitamin, mineral and herbal supplement use prior to and during pregnancy. australian and newzeland journal of obstetetrics and gynecology .2002;42:4946.doi.org/10.1177/0310 057x19845786 [16] nordeng h, havnen g. use of herbal drugs in pregnancy: a survey among 400 norwegian women. pharmacoepidemioly& drug safety.2004;13:371–80. doi:10.1002/pds.945 as shown by the results of the current study, a remarkable number of pregnant women were consuming and including supplement products and herbal medicines as a part of their maternity care. it was also concluded that a large number of the participating women could have access to sufficient knowledge about consuming complementary medicine. these findings can be utilized by policymakers and health professionals as a reference for the use of in previous mention during pregnancy. the authors report no conflicts of interest or sources of financial support. [1] suryaningrumkc ,titisari i , mediawati m. hubunganantara status gravidadanusiaibudengankejadian emesis gravidarum. jurnalilmukesehatan. 2018; 7(2): 12–20 doi.org/10.32831/jik.v7i2.213. [2] kjeldgaard hk, vikanesa, benth js, junge c, garthus-niegel s, eberhard-gran m.the association between the degree of nausea in pregnancy and subsequent posttraumatic stress.archiveswomens mental health. 2019; 22(4):493-501.doi.org/10.1007/s00737-0180909. [3] fatwa t. pengaruh rebusan jahe terhadap keluhan mual muntah ibu hamil. jurnal medika hutama.2020; 2(1): 48–59. https://jurnalmedikahutama.com/index.php/ jmh/article/view/77. [4] wahyuningsih s. buku ajar keperawatanmaternitas .bondowoso .2019 ; 188: doi :978602-51757-9-4 [5] ramdhaniip,ayudiaf.pengaruhpemberianmi numanjahe (zingiber officinale var. rubrum) terhadappenurunan emesis gravidarum trimester pertama. jurnalilmukesehatan. 2019;3(2): 97. doi.org/10.33757/jik.v3i2.231 [6] kallen b, lundberg g, aberg a. relationship between vitamin use, smoking and nausea and vomiting of pregnanacy. actaobstetriciaetgynecologicascandinavica .2003;82:916 -920.:doi:10.1034/j.1600-0412.2003.00307 64 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.07 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article [28] close c, sinclairm, liddlesd, madden e , mccullough j e , hughes c .a systematic review investigating the effectiveness of complementary and alternative medicine (cam) for the management of low back and/ or pelvic pain (lbpp) in pregnancy. journal of advance nursing research.2014; 70 (8): 1702 –1716. doi:10.1111/jan.12360 [29] crozier sr, inskip hm, godfrey km, cooper c,robinsonsm. nausea and vomiting in early pregnancy: effects on food intake and diet quality .maternal and child nutrition. 2017 ; 13(4): 123-.89. doi: 10.1111/mcn.12389 [30] pakniat h, memarzadeh mr, azh n, mafi m, ranjkesh f. comparison of the effect of chamomile, ginger and vitamin b6 on treatment of nausea and vomiting in pregnancy: a randomized clinical trial.the iranian journal of obstetrics, gynecology and infertility 2018;21(8):47-54. doi: 10.22038/ ijogi.2018.11969 [31] elolemy at, albedaham. public knowledge, attitude and practice of complementary and alternative medicine in riyadh region, saudi arabia.oman medical journal.2012;( 27) 1: 20-26. available from :available from :doi 10. 5001/omj.2012.04 [32] mohamed h, abdin j. “knowledge, attitude and practice of complementary and alternative medicine (cam) among pregnant women: a preliminary survey in qatar.” middle east journal of family medicine.2010;(7)10:5 –14.doi: 10.1155/2021/8829313 [33] ni h, simile c, hardy am. utilization of complementary and alternative medicine by united states adults: results from the 1999 national health interview survey. medical care 2002;40(4):353358.doi:10.1097/00005650-20020400000011 [34] hashem fd , abdollahi mf, shojaeia,kianbakht s (ph.d.)4, zafarghandi n, goushegir a. use and attitude on herbal medicine in a group of pregnant women in tehran. journal of medicinal plants. 2012; 41(11): 22-33. doi: 20.1001.1.2717204.2012.11.41.3.9 [35] zaki nm, albarraq aa. use, attitudes and knowledge of medications among pregnant women: a saudi study. saudi pharmaceutical journal. 2014; 22 (5):419–428. doi:10.1016/j.jsps.2013.09.001 [17] barnes j. quality. efficacy and safety of complementary medicines: fashions, facts and the future. part1. regulation and quality.british journal of clinical pharmacology l. 2003;55(3):226–33.doi: 10.1046/j.13652125.2003.01810.x [18] somoyani, ni ketut. literature review: terapi komplementer untuk mengurangi mual muntah pada masa kehamilan. journal ilmiah kebidanan. the journal of midwifery.2020; 8(1):10–17. doi.org/10.33992/ jik.v8i1.1193 [19] national center for complementary and alternative medicine (nccam).: http:// nccam.nih.gov/. [20] goldbeck-wood s, dally m. complementary medicine is booming worldwide. bmj 2007;313:131–3. doi:10.1093/ecam/nen031 [21] world health organization. fact sheet no 134: traditional medicine. 2013.:http:// www.who.int/mediacentre/factsheets/ fs134/en/index.html. [22] forster da, denning a, wills g, bolger m, mccarthy e. herbal medicine use during pregnancy in a group of australian women. bmc pregnancy childbirth .2006;19:21. doi: 10.1186/1471-2393-6-21 [23] posadzki p, watson lk, alotaibia,ernst e. . prevalence of use of complementary and alternative medicine (cam) by patients/ consumers in the uk: systematic review of surveys.clinicalmedecine. 2013;13 (2): 126– 131. doi: 10.7861/clinmedicine.13-2-126 [24] yang pr, shih wt , chu yh, chen pc , wu cy .frequency and co-prescription pattern of chinese herbal products for hypertension in taiwan: a cohort study. bmc complementary and alternative medecine. 2015;15 (1):1: doi.org/10.1186/s12906-015-0690-8 [25] holst l,wright d , nordengh, haaviks. use of herbal preparations during pregnancy: focus group discussion among expectant mothers attending a hospital antenatal clinic in norwich uk. complementary therapy of clinical prectice. pract.2009;15 (4): 225– 229.doi: 10.1016/j.ctcp.2009.04.001. [26] john lj, shantakumarin.herbal medicines use during pregnancy: a review from the middle east. oman medical journal. 2015;30 (4): 229.doi:10.5001/omj.2015.48 [27] nordengh ,havnen gc. use of herbal drugs in pregnancy: a survey among 400 norwegian women. pharmacoepidemioly &drug safety. 2004; 13(6): 371–380. doi:10.1002/ pds.945 65 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.07 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article [36] zaffani s, cuzzolin l, benoni g. herbal products: behaviors and beliefs among italian women. pharmacoepidemioly& drug safety. 2006; 15: 354-9.doi:10.1002/pds.1190 [37] ni h, simile c, hardy am. utilization of complementary and alternative medicine by united states adults: results from the 1999na-tional health interview survey. medical care.2002; 40:353-358. doi:10.1097/00005650-200204000-00011. [38] al-faris ea,al-rowaisn , mohamed ag ,alrukbanm o ,al-kurdia, al-noor et al. prevalence and pattern of alternative medicine use: the results of a household survey. annals of saudi medecine. 2008;28 (1):4-10. doi:10.5144/0256-4947.2008. 66 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article knowledge and satisfaction for patients undergoing coronary angiography at surgical specialty hospital cardiac center in erbil city abstract background and objectives: patients' satisfaction is a vital indicator of the quality of health care. nevertheless, current data on determinants of satisfaction in invasive procedures for the cardiac patients are deficient. accordingly, this study aims to assess the knowledge and satisfaction level of patients who undergoing coronary angiography. methods: a descriptive/cross-sectional study design was carried out among 350 coronary heart disease patients who performed coronary angiography at the surgical specialty hospital cardiac center in erbil city. the study begins from of january 2023 to the 7th of august 2023. the data was collected via using a questionnaire which included patients' characteristic data, knowledge about coronary angiography and patient satisfaction questionnaire. the collected data were analyzed via the frequency and percentages, mean and standard deviation, also the researcher used the chi-square, independent t-test and oneway analysis of variance (anova) also binary logistic regression analyses were performed. results: presented higher service satisfaction scores were found in younger patients, male, more educated, and with high monthly income respectively, the overall degree of satisfaction with coronary angiography care was 57.4 % while 42.6 % of the patients were dissatisfied with coronary angiography care, the factors affecting patient dissatisfaction were lack of patient trust (p-value =0.027, or=0.499), not ensuring privacy during the procedure (p-value 0.003, or=0.447), unacceptable waiting time for admission (p-value <0.001, or=5.857) and high costs procedure (p-value <0.001, or=4.052). conclusion: more than half of patients are satisfied with coronary angiography care despite most of them having inadequate knowledge. keywords: knowledge; satisfaction; coronary angiography. chnar salahaddin qadir: department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq (correspondence: chnar.qadir@hmu.edu.krd) 94 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 16/08/2023 accepted: 19/11/2023 published: 30/11/2023 mailto:chnar.qadir@hmu.edu.krd?subject=chnar.qadir@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article henceforth coronary heart disease (chd) is one most common causes of mortality worldwide, annually, is estimated 17.9 million lives. more than four out of five chd deaths are due to heart attacks and stroke, and one-third of these deaths occur prematurely in people under 70 years of age [1]. in iraq, the number of chd is increased and considered as a health problem according to data provided the iraqi ministry of health in the hospitals morbidity it was shown that 65% increase in hospital admission due to coronary heart disease [2]. thus, the coronary angiography (cag) is considered as a gold standard diagnostic procedure to identify the function of the heart, structural disorders, and main blood vessels. the coronary angiography is an imaging method that requires the insertion or introduce of the contrast media into the catheter into arterial or selected blood vessels. also, it used to detect the coronary artery structure and assess the intensity or grade of lesions from atherosclerosis [3]. therefore nowadays, it has become evident that the care of hospitalized patient’s with the heart disease doesn’t regarded as merely as a preventing from the complication of the disease and inadequate to the management of the illness but too includes evaluate of needs for the establishment of a higher level in quality care [4]. the health care services, patients' satisfaction have become the most important and challenging competitive elements. health care providers are presumed to offer both high quality of care and exceed clients' expectancy while being price conscious and effective [5].cardiovascular diseases trajectory affects not only the patient but their family members, community and relationships with others too [6]. patients who attend cardiac clinics need to have information, from those who experience and suffer from psycho-social needs, moreover, they regularly need significant management concerning medication [7]. realizing the experience of patient gives the healthcare provider the chance to improve a higher level of patient satisfaction. the most important and the key indicator of the improvement in quality of care and delivery, health system consistency, reliability and well-being is patients’ satisfactions [8]. the level of patient satisfaction in iraq is expected to be worse [9], probably for the reason that the health care systems undeveloped have an inadequate capacity in offering appropriate and more effective health care also insufficient support to the health institutions. noticeably, there is an inadequate number of healthcare professionals to increase the number of patients. moreover, the insufficient availability of drugs and laboratory investigations lead to more burden. in the end, the patient's trust, keeping privacy, waiting time, patients teaching markedly affected patients’ satisfaction. thus, and due to the mentioned facts the study aimed to determine patients’ satisfaction and knowledge level toward coronary angiography care and factors associated with dissatisfaction. the present study was a cross-sectional design which was carried out on patients with coronary heart disease (chd) who performing coronary angiography at cardiac center in erbil city. the current study started at the beginning of january 2023 to 7th august 2023. an ethical approval from the ethical committee was taken from hawler medical university at the college of nursing. in the study areas, the investigator carefully chosen the participants and asked them to contribute to the study. the sample was present and aware of the study’s purposes, and the voluntary character of their involvement, 95 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article distributed into two categories based on the knowledge score: inadequate knowledge 50% and adequate knowledge >50% [11]. the final section of the questionnaire is about patients' satisfaction, which was measured by psq18 scale, is a standard patient satisfaction questionnaire [12]. seven different categories for evaluation include various domains of satisfaction (2 items) of general satisfaction, (4 items) of technical quality, (2 items) of interpersonal aspect, (2 items) of communication, (2 items) of financial aspect, (2 items) of time spending, and (4 items) of accessibility and convenience. answers for each item were based on 5 choices, the likert scale 5-point rating for measuring level of satisfaction was used on a range from (strongly disagree to strongly agree). a scale from 1 to 5 was used to calculate the mean of the scores. the overall satisfaction scale score was divided into two main categories: satisfaction (equal to or above the mean) and dissatisfaction (below the mean). the total scores for items involved in each domain were displayed and calculated as the mean. through using this formula like [mean∗100/5], it was transferred into a percentage level of satisfaction. to analyze the data from spss software version 27 was used. a significant level that is less than or equal to 0.05 is considered. to describe the variables of frequency and percentages and to analyze the quantitative data, the mean and standard deviation were used. also, one-way analysis of variance, the chi-square and independent ttest, and additionally, binary logistic regression were performed (dependent variables). the level or grade of patient satisfaction as measured through using the stander tools (psq-18 scale) score (the dependent/outcome variable) and the independent factors (patient’s trust, fear of the procedure, privacy during the procedure, and the researcher informed all patients was taken confidentiality and privacy in their responses. they were told that they might reject or end up participating at any time without no experiencing any consequences. the total sample was (n=350) coronary heart disease patients and was carefully chosen with a purposive sampling method according to the inclusion criteria of the study. the participants of this study were patients who were ready and want to participate in the study, adult patients diagnosed with coronary heart disease, who need coronary angiography for the first time, and being conscious. while the exclusion criteria were patients who had unstable conditions, receiving any other invasive procedure and unable to give consent. the simple formula was used to calculate the suitable sample size in the prevalence study at duhok heart center, kurdistan-iraq, who examined clinically diagnosed cad patients who underwent coronary angiography (cag); n=z2p (1−p)/d2. where n is the sample size, z is the statistic corresponding to the level of confidence, p is the expected prevalence or proportion, and d is corresponding to the effect size, sample size 3.841*0.31*0.69/0.0025= 328 [10]. the questionnaire contains three parts. the first part which consisted of the general information (demographical data) which includes (age, gender, educational level, occupational status, monthly income, residency and cigarette smoking). the second part was to determine the knowledge of patients about coronary angiography, which included (21 items), pre-coronary angiography (8 items), intra-coronary angiography (4 items) and post-coronary angiography (9 items). the patient responds to each item with the right answer (one score) and for the wrong answer (zero scores), the total maximum score is 21. the overall level of knowledge has been 96 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article waiting time for admission, high costs procedure, procedure explanation, discomfort and irritability) the adjusted odd s’ ratio was used to comparing, the influence of factors on the outcome/consequence dissatisfaction. table 1. description of demographic information of coronary heart disease patients. a total of 350 coronary heart disease patients visited surgical specialty hospitalcardiac center to perform coronary angiography. the minimum age of participants in the study is 31 years and maximum was more than 60 years old and the mean age with a standard deviation of the sample was 58.97±8.99, the highest percentage of studied coronary heart disease patients were male, (54%) were uneducated, (24.9%) was governmentally employed, 56% their insufficient monthly income, (68.6%) coming from urban, 54.3% was non -smoker, concerning patient’s knowledge about coronary angiography (61.9%) had inadequate knowledge while (39.1%) of them had adequate knowledge. in regard, the severity of the number of coronary artery stenosis, a higher proportion of (48%) had moderate (50 % to 69 %) of the coronary artery was obstructed. regarding the result of coronary angiography, a higher percentage of (57.7%) were diagnosed as percutaneous coronary intervention and (18.3%) of the coronary artery bypass graft. 97 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results table 1. demographical data of coronary heart disease patients variables n (%) age group (years) 31-45 72(20.6) 46-60 84(24.6) >60 194(54.4) gender male 214(61.1) female 136(38.9) level of education uneducated 189(54) educated 161(46) occupation governmental employed 87(24.9) self-employed 80(22.9) unemployed 29(8.3) retired 34(9.7) housewife 120(34.3) monthly income insufficient 196(56) sufficient 154(44) residency urban 240(68.6) rural 110(31.4) cigarette smoking non-smoker 190(54.3) current smoker 52(14.9) ex-smoker 108(30.9) patients’ knowledge about coronary angiography adequate knowledge 137(39.1) inadequate knowledge 213(61.9) coronary artery severity of stenosis mild (<50%) 105(30) moderate (50%–69%) 168(48) severe (≥70%) 77(22) therapeutical options pci 202(57.7) cabg 64(18.3) omt 84(24) pci (percutaneous coronary intervention); cabg (coronary artery bypass graft), omt (optimal medical therapy) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 98 were dissatisfied with technical quality (52.6%), interpersonal aspect (56%), communication (56.3%), and financial aspect (53.1%) respectively. while (50.9%) of them were satisfied with accessibility and convenience domain in general, the highest percentage of satisfaction was (57.4%) of patients satisfied with coronary angiography care whereas (42.6%) of them wquality (p-value=0.037) interpersonal aspect (p-value=0.013), communication (p -value<0.001) and in accessibility and convenience (p-value=0.023), whereas there was no statistically significance found in the domain of financial aspect (p-value =0. 217), time spent with doctor (p-value =0.880).ere dissatisfied. copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. the rating and scoring of study participants on each domain of the level of patient satisfaction were shown in [table 2]. the high proportion (63.7%) was taken in the general satisfaction domain, compared to the domain that measures the amount of time spent with the physician, with health care personnel, which had a lower percentage (41.1%). moreover, more than half a percentage of those table 3. display compares patient’s knowledge regarding coronary angiography and satisfaction, patients who had adequate knowledge significantly had more satisfaction than those who had inadequate knowledge in the general satisfaction domain (p-value <0.001), technical table 2. description of patient satisfaction in different domains domains of satisfaction dissatisfied n(%) satisfied n(%) general satisfaction 127(36.3) 223(63.7) technical quality 184(52.6) 166(47.4) interpersonal aspect 196(56.0) 154(44.0) communication 197(56.3) 153(43.7) financial aspect 186(53.1) 164(46.9) time spending 206(58.9) 144(41.1) accessibility and convenience 172 (49.1) 178(50.9) overall satisfaction 149(42.6) 201(57.4) table 3. comparison patient’s knowledge of coronary angiography and satisfaction domains of satisfaction inadequate knowledge adequate knowledge mean difference p-value general satisfaction 2.16±1.38 2.82±1.66 -0.66 <0.001 technical quality 2.44±1.35 2.77±1.51 -0.33 0.037 interpersonal aspect 2.24±1.25 2.64±1.55 -0.40 0.013 communication 2.01±1.24 2.59±1.54 -0.58 <0.001 financial aspect 2.86±1.09 3.04±1.49 -0.18 0.217 time spending 2.45±1.57 2.75±1.68 -0.30 0.880 accessibility and convenience 2.57±1.43 2.95±1.57 -0.38 0.023 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 99 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4. distribution the level of satisfaction of coronary heart disease patient with demographic information, the result indicates that younger patients (53.90±17.99) are more satisfied than older patients (41.78±20.82). in regard gender male patients, (54.25±20.63) significantly had higher level of satisfaction than female (43.80±20.09).the study found that participants who were educated (53.32±20.75) revealed highest levels of patient satisfaction with coronary angiography care when compared to uneducated persons (41.45±19.26). participants who had insufficient monthly income (43.82±19.78) expressed lower satisfaction than patients with sufficient salary (51.04±21.26). in regard [table 5] the findings show that factors associated with patient dissatisfaction in coronary angiography care, it has been found that there was a significant association between dissatisfaction with coronary angiography care, partial inpatient trust (61.4%, p-value <0.001), inadequate privacy during the procedure (64.5%, p-value <0.001), disagreeing waiting time for admission (52.5%, p-value <0.001), high costs of procedure (49.6%, p-value <0.001), inadequate explanation about the procedure (55.1%, p-value <0.001).table 6. summarizes the logistic regression of factors affecting ratings on the lower satisfaction were constructed to evaluate the association among selected variables and dissatisfaction with coronary angiography care. the variables chosen in the model were based on the bivariate analysis. the factors were put into the model discomfort and irritability, patient trust, fear of the procedure, inadequate privacy, waiting time for admission, high costs procedure and not explaining the procedure were put into the model. model fit was measured by the likelihood ratio statistic (χ2= 7.66, p=0.006) and the hosmer and leme show test (χ2= 16.57, p=0.35), the variability observed in the target variable is explained by the regression mode was r2 = 35.2%. patients who lacked of trust half times more chance of being dissatisfied with coronary angiography care than full patient trust, patients with poor keeping privacy during the procedure were nearly half time more likely to report dissatisfaction than those with only keeping privacy during the procedure. compared to those who were disagreement with waiting time for admission status, nearly 6 times more likely is associated with dissatisfaction. additionally, the person who reported high costs of procedures had 4 times more likelihood of being dissatisfied with health care service than those who agree with cost of angiography procedures. finally, patients who had an inadequate explanation about the procedure had a 1.61 times further probability of have dissatisfied with health care services than those who received an adequate explanation. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 100 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4. comparison of demographical data and patients’ satisfaction demographic data n satisfaction mean ±sd p-value age group (years) 31-45 72 53.90±17.99 <0.001 46-60 84 48.25±19.54 >60 194 41.78±20.82 gender male 214 54.25±20.63 <0.001 female 136 43.80±20.09 level of education uneducated 189 41.45±19.26 <0.001 educated 161 53.32±20.75 occupation governmental employed 87 50.24±19.11 0.105 self-employed 80 49.21±22.28 unemployed 29 38.38±20.33 retired 34 49.00±23.93 housewife 120 47.21±20.10 monthly income insufficient 196 43.82±19.78 <0.001 sufficient 154 51.04±21.26 residency urban 240 49.24±20.74 0.068 rural 110 44.85±21.04 table 5. factors influencing of patients’ dissatisfaction in coronary angiography care factors total dissatisfied n(%) satisfied n(%) pvalue discomfort and irritability yes 156 (44.6) 70(44.9) 86(55.1) 0.435 no 194(55.4) 79(40.7) 115(59.3) patient’s trust lack 83(23.7) 51(61.4) 32(38.6) <0.001 full 267(76.3) 98(36.7) 169(63.3) fear from procedure no 65(18.6) 23(35.4) 42(64.6) 0.194 yes 285(81.4) 126 (44.2) 159(55.8) privacy during procedure inadequate 141(40.3) 91(64.5) 50(35.5) <0.001 adequate 209(59.7) 58(27.8) 151(72.2) waiting time for admission unacceptable 263(75.1) 138(52.5) 125(47.5) <0.001 acceptable 87(24.9) 11(12.6) 76(87.4) high costs of procedure yes 270(77.1) 134(49.6) 136(50.4) <0.001 no 80(22.9) 15(18.8) 65(81.3) procedure explanation yes 178(50.9) 98(55.1) 80(44.9) <0.001 no 172(49.1) 51(29.7) 121(70.3) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article discussion 101 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. nowadays, diagnostic and therapeutic methods for coronary heart disease has been changed quickly. in our country, the health care staff number per patient is low and that causes a reduction in the time of examination, marking numerous difficulties. in these situations, it is not easy to perform and work more professionally and efficiently as health staff. the majority of heart disease patients have no information on coronary angiography, and inadequate knowledge about cardiovascular diseases. the present finding shows more than half the percentage of the study sample was satisfied with healthcare facilities in the domain of general satisfaction, while less than half the percentage of patients were satisfied in the domain of time spent with healthcare personnel, technical quality, interpersonal aspects and communication and financial aspect. it is comparable with a study done in in jeddah saudi arabia show that more than three-quarter of patients satisfied with health care services [13]. likewise, the present study comes along with a descriptive study carried out on 340 heart disease patients at tengku ampuan rahimah hospital, in malaysia, the study revealed that who revealed that most of the patient satisfaction were regarded the health service factors, particularly general satisfaction, convenience and accessibility," while dissatisfaction regarding the orientation of doctors, particularly the "time spent with the doctor," "interpersonal behaviors" and "communication" during counselling [14]. the present study shows that most of the patients had inadequate knowledge regarding coronary angiography care. it was aligned with the present study findings of studies [15, 16] which were conducted in cologne, germany and peshawar, pakistan respectively. it was indicated that the participants did not have sufficient knowledge about the coronary angiography. it might be due to lack of patient education before performing coronary angiography. also, the present study demonstrated that patients’ who had adequate knowledge significantly had more satisfaction than those who had inadequate the knowledge, and this was supported by study results that aimed of evaluating the conveying methods of information concerning the coronary table 6. determinants of patient dissatisfaction in coronary angiography care factors p-value or 95% c.i. for or discomfort and irritability yes 0.324 0.771 0.461 1.292 no ref patient’s trust lack 0.027 0.499 0.27 0.923 full ref fear from procedure yes 0.492 1.274 0.638 2.545 no ref privacy during procedure inadequate 0.003 0.447 0.261 0.766 adequate ref waiting time for admission unacceptable <0.001 5.857 2.706 12.675 acceptable ref high costs procedure yes <0.001 4.052 2.026 8.106 no ref procedure explanation yes 0.077 1.613 0.95 2.739 no ref r2 = 35.2%, χ2= 7.66, p-valve=0.006 hosmer and leme show test χ2= 16.57, p=0.35 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 102 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. to have higher levels of satisfaction with coronary angiography care as in comparison to uneducated patients. the study results in parallel with a prior study done [23] which is identified that people with higher levels of educational background were more satisfied with their medical performance in the clinical setting. this may be because the participants with higher education levels are more familiar with what the hospital offers than participants with lower levels of education. the results, here, are corroborate with [24], who found that patient education level was associated with satisfaction with care. the higher education contributes to greater responsiveness to health system care and services, ultimately leading to greater satisfaction. in addition, to what mentioned above, another study, found that educated people were statistically significant, and gained a higher score of satisfaction in healthcare facilities, also, displayed that higher satisfaction rate in psq-18 with hospital services and with the staff’s behavior [13].the participants who had insufficient monthly income expressed lower satisfaction than participants with sufficient income, high scores of satisfaction were noted and reported in people who had sufficient salary for daily needs. the result come along with another study conducted in 2015 which its result displays that there was a significant difference between satisfaction rates in patients towards health system and services and their monthly income [25]. also, the findings come along with a study that indicated that insufficient salaries, dissatisfaction with lower health perception, and people were significant predictions of satisfaction rates with the health care system and service [26].in this study, the factor affecting patients’ dissatisfaction among all participants, was unacceptable due to the time for angiography and it was showed that most of the heart disease patients weren’t well alert angiography procedures [17]. another by study showed that deficiency in patients’ aware of in what manner the coronary angiography was performed and essential cares earlier and directly after that leads the patients’ to dissatisfy, and the patients can’t tolerate adherence to essential care as needed and it may causes an rise in vascular access complications which are related to the procedure [18]. the findings of the current study revealed that the patient satisfaction with demographic data indicates that younger patients are more satisfied than older ones, this result is aligned with the findings of previous studies in malaysia [14] china [19], and rawalpindi in pakistan [20] which are respondents of the mentioned studies who were aged fifty years, and more are about two times and a half less satisfied with outpatient clinics services than younger age groups. this the result of study demonstrations that the male patients significantly had higher satisfaction than the females, here the findings are in line with an earlier report [21] which revealed that the female patients who were more likely to have poorer coronary heart disease experience, dissatisfaction and low perception of their health care services compared with male patients. these findings are important to the public health hence they implications and require more research to understanded the sex‐definite differentiations of quality in health care, providing, and eventually health consequences. also, it was agreed with other previous findings of studies done in malaysia [14] and nigeria [22] exhibited male patients were more satisfied while in comparison to their counterparts, it also, revealed that male patients were more satisfied in general satisfaction and time spent with the physician. the study found that the educated patients showed https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article conclusion references 103 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. admission, this results was supported by another studies done by [13,27] was acknowledged that there were no enough times and method to communicate with the clinicians and physicians as a significant aspect in their lesser of satisfaction rating with health care facilities. also, in their study [28] showed that the patients’ satisfaction rating and scores were undesirably correlated to the ready and waiting time. likewise, this result is consistent with a study which was done in the united states, the study revealed that shorter time in waiting for care was associated with enhancing and improved satisfaction rates [29].the present study reported that the patients’ trust in doctors who had chances to be fully satisfied with health care system. this finding is similar to an earlier study done by [30] displayed that patient empathy and trust was a positive correlation with patient satisfaction. also, the result of the study in line with the study done by [31] who reports that patients completely influenced their satisfaction in coronary angiography care by experience and confidence among the health care providers. furthermore, it has come along reported that, making sure privacy and confidentiality for essential services which is provided by the hospital had statistical be significance for patient satisfaction. moreover, healthcare providers should offer the highest level of privacy there to improve the level of satisfaction for patients with heart diseases [32]. the current study concluded that younger age, female, educated and sufficient monthly income exhibited higher service satisfaction scores in comparison to patients who aged more than sixty years, male, uneducated and insufficient monthly income, respectively. in coronary heart disease, a higher level of satisfaction rating and scoring in the domain of general satisfaction in comparison to the domain had a lower rating in measures of the amount of time spent with health care personnel. moreover, more than half a percentage of those were dissatisfied with the technical quality, interpersonal aspect, communication, and financial aspect, respectively. whereas patients were satisfied with the domain accessibility and convenience. in general, most of the patients were satisfied with coronary angiography. to sum up, patients who had adequate knowledge significantly had more satisfaction than those who had inadequate knowledge about coronary angiography. the author reports no conflict of interest. [1] world health organization cardiovascular disease. (2021). available from: https:// www.who.int/health-topics/cardiovasculardiseases#tab=tab-1 [2] jabber m, dheyaa i, abdulmahdi k, awda g. nurses’ knowledge about coronary artery disease in al-nasiriyah city. wiadomosci lekarskie. 2022; 75(4 p1):853-856.doi: 10.36740/wlek202204119. [3] hinkle jl and cheever kh. brunner and suddarth’s textbook of medical-surgical nursing.14th ed. usa. philadelphia. wolters kluwer. 2018; p.1929-1931. [4] polikandrioti m, babatsikou f. "information to coronary disease patients." health science journal. 2013;7(1), pp. 3-10. [5] ferrel b, virani r, paice j. "statewide efforts to improve palliative care in critical care settings." american association of critical care nurse, 2010; 30 (6), pp. 40-45. [10] . [6] wilson tm, peng z, clark ra, tirimacco r. cardiac rehabilitation and secondary prevention: assessing patient satisfaction. british journal of cardiac nursing 2018; 13 (3):135-141 doi:10.12968/ bjca.2018.13.3.135 [7] lai vkw, lee a, leung p, chiu ch, ho km, gomersall cd, et al. patient and family satisfaction levels in the intensive care unit after elective cardiac surgery: study protocol for a randomized controlled trial of a conflict of interest https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 104 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. preoperative patient education intervention. british medical journal open. 2016; 6:e011341. doi:10.1136/bmjopen-2016011341. [8] ali s, chessex c, bassett-gunter r, grace sl. patient satisfaction with cardiac rehabilitation: association with utilization, functional capacity, and heart-health behaviors. patient preference and adherence. 2017;11, 821– 830. https://doi.org/10.2147/ppa.s120464. [9] jadoo s aa, yaseen sh m, al-sammarrie mam, mahmood a sh. patient satisfaction in outpatient medical care: the case of iraq. journal of ideas in health. 2020;3(2):176-182 https://doi.org/10.47108/jidhealth. [10] mohammad am, jehangeer hi, shaikhow sk. prevalence and risk factors of premature coronary artery disease in patients undergoing coronary angiography in kurdistan, iraq. bmc cardiovascular disorders. 2015; 15, 155. https://doi.org/10.1186/s12872-015-0145-7. [11] haroon sh a. a study to evaluate the effectiveness of information booklet on knowledge regarding coronary angiography among 3rd year g.n.m. students in selected nursing school at vijayapur, karnataka. international journal of advances in nursing management. 2021; 9(4):385-8. doi: 10.52711/2454-2652.2021.00089. [12] aljarallah na, almuqbil m, alshehri s, khormi ams, alreshaidan rm, alomran fh, et al. satisfaction of patients with health care services in tertiary care facilities of riyadh, saudi arabia: a cross-sectional approach. front public health. 2023; 13;10:1077147. doi: 10.3389/fpubh.2022.1077147. pmid: 36711344. [13] alsayali, m m, al-sahafi a, mandoura n, usman shah h b, abdul rashid o a, alsharif k, et al. “patients' satisfaction after primary health care centers' integration with ministry of health hospitals, jeddah.” journal of epidemiology and global health. 2019; 9,(2) 135-142. doi:10.2991/jegh.k.190522.001. [14] ganasegeran k, perianayagam w, abdul manaf r, ali jadoo sa, al-dubai sar. patient satisfaction in malaysia’s busiest outpatient medical care. scientific world journal. 2015; 2015:1–6. doi: 10.1155/2015/714754. [15] eran a, erdmann e, er f. informed consent prior to coronary angiography in a real world scenario: what do patients remember? plos one. 2010; 5(12): e15164. doi: https:// doi.org/10.1371/journnaal.pone.001516.. [16] shaheen n, muhammad d, habibullah g, khattak iu. association between knowledge and anxiety level among patients undergoing coronary angiography in tertiary care hospitals of peshawar.. critical care innovations. 2022; 5(1): 15-23. doi: 10.32114/cci.2022.5.1.15.23. [17] pietura r, kucharska-pietura k, szymanska a. informed consent for angiography and endovascular treatment. przeglad lekarskia. 2004; 61(7):794-6. [18] najafi-kalyani m, jamshidi n, abbaszadeh a. poster effectiveness of video education on comfort and tolerability of patients undergoing coronary angiography. european journal of cardiovascular nursing. 2010; 9 (1 suppl):16. [19] yan z, wan d, li l. patient satisfaction in two chinese provinces: rural and urban differences. journal of the international society for quality in health care. 2011; 23 (4): 384–389. https://doi.org/10.1093/ intqhc/mzr03. [20] afzal m, rizvi f, azad ah, rajput am, khan a, tariq n. effect of demographic characteristics on patient’s satisfaction with health care facility. journal of postgraduate medical institute. 2014; 28(2):154–60. https:// jpmi.org.pk/index.php/jpmi/article/ view/1528. [21] okunrintemi v, valero-elizondo j, patrick b, salami j, tibuakuu m, ahmad, s., et al. gender differences in patient-reported outcomes among adults with atherosclerotic cardiovascular disease. journal of the american heart association. 2018; 7(24), e010498. https://doi.org/10.1161/ jaha.118.010498 [22] bener a, ghuloum s. gender difference on patients’ satisfaction and expectation towards mental health care. nigerian journal of clinical practice. 2013;16(3), 285–291. https://doi.org/10.4103/11193077.113448. [23] senitan m, gillespie j. health-care reform in saudi arabia: patient experience at primary health-care centers. journal of patient experience. 2020; 7(4), 587–592. https:// doi.org/10.1177/2374373519872420. [24] karaca a, durna z. patient satisfaction with the quality of nursing care. nursing open. 2019; 4;6(2):535-545. doi: 10.1002/ nop2.237. pmid: 30918704; pmcid: pmc6419107. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 105 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [25] al-hussein ra, khaleel ma. "assessment of patients satisfaction regarding nursing care provided at general hospitals in al-najaf city." kufa journal for nursing sciences. 2015; 18; 5 (3): pp. 26-27. [26] lee s, godwin op, kim k, lee e. predictive factors of patient satisfaction with pharmacy services in south korea: a cross-sectional study of national level data. plos one. 2015; 5;10(11):e0142269. doi: 10.1371/ journal.pone.0142269. pmid: 26540165; pmcid: pmc4634764. [27] chandra s, ward p, mohammadnezhad m. factors associated with patient satisfaction in outpatient department of suva subdivisional health center, fiji, 2018: a mixed method study. front public health. 2019; 2;7:183. doi: 10.3389/fpubh.2019.00183. pmid: 31312630; pmcid: pmc6614334. [28] bleustein c, rothschild db, valen a, valatis e, schweitzer l, jones r. wait times, patient satisfaction scores, and the perception of care. the american journal of managed care. 2014 may;20(5):393-400. pmid: 25181568. [29] lerner, justin e, and gabriel robles. “perceived barriers and facilitators to health care utilization in the united states for transgender people: a review of recent literature. journal of health care for the poor and underserved. 2017; 28,1 127-152. doi:10.1353/hpu.2017.0014. [30] lan yl, yan yh. the impact of trust, interaction, and empathy in doctor patient relationship on patient satisfaction. journal of nursing and health studies. 2017; 2:2. https:// doi.org/10.21767/2574-2825.1000008. [31] chang cs, chen sy, lan yt. service quality, trust and patient satisfaction in interpersonal-based medical service encounters. bmc health services research. 2013;13:22. https://doi.org/10.1186/1472-6963-13-22. [32] asamrew n, endris aa, tadesse m. level of patient satisfaction with inpatient services and its determinants: a study of a specialized hospital in ethiopia. journal of environmental and public health. 2020; 2473469. https://doi.org/10.1155/2020/2473469. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.11 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article assessment of hearing loss effects on speech difficulties by speech audiometry abstract background and objective: the basic audiological exam includes speech audiometry as a necessary component. the study aimed to assess the effects of hearing loss on speech difficulty in kurdish populations in compared to a healthy control group. in addition, the study aimed to establish a kurdish speech audiometry. material and methods: the case-control study analyzed 100 patients, divided into two groups 50 with hearing loss and 50 with normal hearing assessed by speech audiometry. the initial clinical interviews with the cases were conducted at zakho general hospital in zakho city in the period from november 20th, 2021, to april 10th, 2022. examination of the ear canal are performed as the first steps in a basic audiological evaluation, pure tone audiometry and speech audiometry. all of the research's variables were covered by a questionnaire that was developed for the study. results: the comparisons of sound recognition between the patients for the right, left, and bilateral ears. there is a highly significant of the healthy controls compared with patients with hearing loss. sound recognition threshold in the right ear, with 3 (25%) at 60db, left ear 10 (83.33%) and bilateral ears 6 (15.79%) at 40db in the patients. and 0 (0%) in the healthy controls. conclusion: the patients with hearing loss has significantly higher rates of speech difficulty compared to the healthy controls. the lists of word can be used as a guide for identification of hearing loss to the kurdish populations. observed across the two monosyllabic and polysyllabic word lists. and the lack of differences between speech reception thresholds (srts) and pure tone audiometry (ptas). identifying the underlying causes and potential interventions for individuals experiencing hearing loss. keywords: pure tone audiometry; speech audiometry test; hearing loss; sound detection threshold; sound recognition threshold. ronahi ibrahim ali; department of nursing, college of nursing, duhok university, duhok, kurdistan region, iraq. (correspondence: ronahi.ibrahim9@gmail.com) ronak taher ali; college of medicine, hawler medical university, erbil, kurdistan region, iraq. 98 received: 14/02/2023 accepted: 14/05/2023 published: 30/11/2025 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:ronahi.ibrahim9@gmail.?subject=ronahi.ibrahim9@gmail. mailto:ronahi.ibrahim9@gmail.com?subject=ronahi.ibrahim9@gmail.com mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.11 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article speech audiometry is an essential part of audiological diagnostics and clinical measurements [1]. typically consists of determining the speech recognition threshold (srt), the word recognition score (wrs) is established in quiet and, preferably, also in noise [2]. speech is a particularly human tool for the expression of emotion, exchange of thoughts, and conveyance of information [3]. humans require speech perception and comprehension in order to communicate normally. many individuals with hearing loss say that they have difficulty understanding speech in everyday circumstances [4]. speech audiometry is typically used to calculate the speech recognition threshold (srt). conducting listening trials, which frequently have the goal of determining the (srt), are the gold standard for evaluating these algorithms. i.e., the signal-to-noise ratio (snr) at which a particular proportion (often 50%) of words are identified. speech audiometry tests were not introduced until the 1950s, and standardized test materials are still in short supply [3], [5]. the word recognition score (wrs) is the most crucial and widely utilized component of speech audiometry in current diagnostic audiology, word recognition testing is one of the most important procedures. when the words are delivered in a standardized context and the presentation level is at a suprathreshold level, it measures one's capacity to reliably recognize a list of spoken words (i.e., pure tones are audible above the lowest feeling level) that is loud enough to provide the best results in terms of recognition [6]. many additional languages, including japanese, make use of the wrs., [7]. turkish, [8] and arabic. in the egyptian press, word lists in arabic have been reported, iraqi, [9]. saudi [10] , jordanian, [11], and other studies. previous jordanian have found no significant variations in wrs in normal hearing jordanians depending on ear or gender characteristics at the pleasant feeling level [12]. regardless, the most used technique for measuring auditory perception is pta due to the fact that it gauges a listener's openness to sound rather than their functioning hearing abilities, speech perception may not always be predicted with precision by pure tone audiometry [13]. individual hearing qualities vary, and hearing is limited by age. because hearing loss cases due to noise are on the rise, in addition to ear injury caused by electronic equipment and media development, noise induced deafness is steadily increasing among young college students [14]. this is a case-control study, patients who underwent speech audiometry to evaluate the effects of hearing loss on speech difficulties were divided in to two groups study group and control group. the study group comprised patients diagnosed with hearing loss, while the control group consisted of individuals who were healthy, without any reported hearing complaints. the population of this study was the patients who were assessed with the effects of hearing loss on speech difficulties by speech audiometry at the audiology center in zakho city. the patients had different socio-demographic characteristics within zakho city. the clinical center of audiology / speech audiometry is the only tertiary specialized center for diagnostic and therapeutic services for audiology / speech audiometry patients in zakho city. in this case-control study, the patients who were assessed with the effects of hearing loss on speech difficulties by speech audiometry were included. the patients were then divided into two groups, the first one involved those who were diagnosed with 99 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.11 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article general directorate of health and the selected hospital administrations in zakho city. the researcher collected the data through direct conversations with patients by using a pre-designed questionnaire. the information was taken from the patient's face-to-face interview technique. additionally, the filling of the questionnaire for each patient took around 30–45 minutes. the patients have been informed that all data would be confidential and would only be used for research purposes initial clinical interviews with all subjects were conducted at zakho general hospital. examination of the ear canal are performed as the first steps in a basic audiological evaluation, speech audiometry, pure tone audiometry (250-8000 hz), and (speech recognition index (sri) and speech reception threshold (srt), likewise acoustic immittance techniques. the individuals wore headphones while undergoing speech audiometry. a clinician-diagnosed middle ear pathology was ruled out with immittance audiometry. all operations were performed with headphones, a free field audiometry amplification device, and an inter acoustics two-channel digital audiometer model, which were completed in an audiometric booth. following the initial audiological examination, we used kurdish speech audiometry (ksa) (appendix e and f ). the data collection process was handled by an audiologist with normal hearing. in the monitor room, a loudspeaker that was crystal clear allowed the audiologist to hear the participant's answer. if a participant properly repeated a word, the audiologist would put a checkmark next to it. the audiologist recorded the participant's incorrect words on the data collection form. the audiologist would put an x on the information gathering form if the patient was unable to say it again and made no response. each participant's pure tone audiometry (pta) rounded to the hearing loss and the second group involved those who were healthy without any complaints or changes in their hearing were determined. finally, the study included 100 individuals of both genders aged 18-30 years. the participants were divided into two groups: control group (cg), 50 healthy young adults with no hearing complaints or changes, and no systemic diseases; and study group (sg), 50 patients with a diagnosis of hearing loss, matched to the control group for age and gender. the cg was recruited through posters hanging on the walls of the medical college and through invitations made to the persons accompanying the patients, while the sg subjects were recruited at the educational hospital & private hospital on the kurdistan region. the inclusion criteria state that individuals between the ages of 18-30 with normal hearing or any type of hearing loss can participate. however, individuals under 18 or over 30 years old, those with autism, and deaf and mute patients are excluded. the ethical approval of the current study was obtained from the ethical committee at the duhok general directorate of health and the scientific committee of the duhok college of nursing formally approved the study proposal dated 24th – october 2021 as a reference number: 24102021-10 -1 (appendix a). to make it easier for researchers to do their investigation, a formal request for consent was prepared for zakho general hospital. following the explanation of the study's goal for the students and patients, an oral verbal agreement form was collected from those who took part; they were given the option to cease or resume their participation at any time. they received a guarantee that all information would be kept confidential. additionally, participation in this study was entirely optional, and participants were free to withdraw at any moment. after getting permission from the duhok 100 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.11 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article nearest 5 db hl, was computed at 0.5, 1, 2, 4, and 8 khz. each word list's pi functions throughout all topic areas was created using the wrss recorded from -10 to 55 db sl (pta) in 5 db increments. the data collection and follow-up for this study took place over a span of six months, from november 20th, 2021, to april 10th, 2022. the overall study period extended from october 24th, 2021, to august 4th, 2023. based on the plot of swedish speech banana as shown in (figure 2.1) the value at the local maximum of the power spectral density, as noticed, corresponds to each phoneme frequency. the difference between the intensity at the local maxima of power spectral density is what defines each phoneme's intensity specifically [15]. in this study the new words recognition lists created in kurdish has a total of 2000 potential possibilities when all available combinations are used. we preliminarily construct a kst (kurdish speech test) from 28 initial consonants, 22 vowels, and 3 tones. the remaining 196 words were created after absurd and improper terms were eliminated. a total of 96 words for the polysyllabic list and 100 words for the monosyllabic list were included in each of the two phonemically balanced lists. due to their vocalic characteristics and classification as semivowels, the two glide consonants (i.e., )/ غ/were left out of the list of consonants. in order to diagnose and cure speech disorders, speech tests using phrase materials are performed, such as choosing the optimal amplification methods, as opposed to speech tests using word stimuli, which are designed for diagnostic purposes. different consonants are represented by various kurdish letters depending on their position in a word. kurdish consonants are shown in (table 2.1.). kurdish also uses four more letters, including /( ژ(ʒ/), )/͡چtʃ/), )/گg/), and )/پp/). the persian alphabet makes use of them, but the original arabic letters do not have them. however, in rare instances, the two consonants are seen, which, for instance, has a consonant printed twice, )/ڵ ا وەڵ wɑɫɫɑɫ/, which stands “swearing” in english. 101 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. figure 2.1: frequency in cycles per second [15]. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.11 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article 102 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2.1.: consonants in kurdish ipa sorani kurmanji word examples in sorani examples of english words analysis b ب b (bał باڵwing) b = "buy" p پ p (pan پانwide) p = "peek" t ت t (taj تاجcrown) t = "time" d د d (dar دارtree) d = "deer" k ک k (koka کۆکەcough) c = "cat" g گ g (ga گاbull) g = "green" q ق q (qûł قووڵdeep) english but sounds deeper in the throat in similar to k ʔ ا ' (âzad ئازادfree) "uh-oh" in middle sound f ف f (fil فیلelephant) f = "fire" v ڤ v (vela ڤێالvela) v = "velocity" s س s (sûr سوورred) s = "spring" z ز z (zirjan زریانhurricane) z = "zinc" x خ kh (khrap خرابbad) german"bach" in similar to ch ʕ ع ` (irâq عراقiraq) pharyngeal (like arabic "ain") "the sound is conveyed in arabic words; it is absent in kurdish terms" ɣ غ gh (gaz غازgas) voiced but, similar to soundع normally pronounced [x] ʃ ش sh (shin شیblue) sh = "shape" ʒ ژ zh (zhyan ژیانlife) ge = "garage" ʧ چ ch (châk چاکgood) ch = "chicken" ʤ ج j (jwân جوانbeautiful) j = "juice" ħ ح ḥ (hoshtr حوشتcamel ) more guttural than the english h depending on the area, used frequently in iraqi dialects h ھ h (hiwa ھیواhope) h = "hole" m م m (mâr مارsnake) m = "mine" n ن n (nân نانbread) n = "north" w و w (wiłât والتcountry) w = "wave" j ى y (yusif یوسفjosef) y = "yard" ɾ ر r (firyad فریادrescuer) r = "lord" r ڕ ř, rr (řewi ڕێویfox) like spanish trilled r l ل l (lew لێوlip) (front of the mouth l = "light" ɫ ڵ ł (sâł ( ساڵyear) (back of the mouth l = "all" https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.11 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article descending run is over. on the other hand, ascending methods start below the estimated threshold, where the patient cannot repeat the words, and then present subsequent blocks of test words at progressively higher hearing levels. this procedure is repeated until the patient correctly repeats a certain number of words, at which point the ascending run is terminated as show in (figure 2.2.) 103 after determining hearing thresholds through calculating pure tone average (pta) from air conduction thresholds at 0.5, 1 and 2 khz by pure-tone audiometer, determine wrs monaurally in the better ear at several intensities through speech audiometer (path medical gmbh germany) by using monosyllable words lists through monitored live voice (mlv) with the microphone at a distance of about 15cm distance from the tester’s lips which are covered by paper or mask to avoid lipreading. the typical vu meter has a range that goes from –20 db to +10 db relative to the calibration point at 0 db. later, count the number of words that are correctly identified and convert to the percentage of the number of words presented (whole word score).each group is tested by one half list at different intensity levels beginning at a speech level of 10 db and increasing this level step-wise by an intensity of 10 db until 60 db when the subject reached maximum score in order to obtain the performance-intensity function and to assess internist intelligibility differences. it is generally accepted that the srt is the lowest hearing level at which a patient can repeat 50%of spondee words, but there are many ways to nd this point and no single technique is universally accepted. most srt testing methods share several common features even though their specie c characteristics can vary widely. the most common characteristic is that several spondee words are presented to the patient one at a time at the same hearing level. the descending methods begin presenting these blocks of test words above the estimated srt so that the patient is initially able to repeat them, and then pressent subsequent blocks of spondee words at progress snively lower hearing levels. this process is repeated until the patient misses a certain number of words; at which time the copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. figure 2. 2 :examples of measuring the srt with (a) descending [16], (b) ascending [17], and (c) ascending (asha1979) methods. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.11 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article table 5.2 presents the correlation between the patients with hearing loss and healthy controls regarding hearing loss in the right, left, and bilateral ears, as well as the types and duration of the problem. there is a lower significant of the healthy controls in terms of right ear snhl 0 (0%) compared to the patients 22 (44%), as well as chl with 5 (10%) in the patient and 0 (0%) in the healthy controls, and mixed hl there is a highly significant in left ear. additionally, there is a highly significant in the duration of the problem between the patient and healthy controls, specifically for durations of 01-11 months ago 24 (48%) for the patient, and durations of 5 years is 11 (22%) for the patient compared to healthy controls 0(0%). the general information of the patients and healthy controls were presented in mean (sd) or number (%). hearing issues of patients with hearing loss and healthy controls were presented in number and percentage. comparisons of degree of hearing loss between patients and controls were examined in an independent ttest. the significant level of difference was examined with a p-value of less than 0.05. the statistical calculations were performed in jmp pro 14.3.0 (jmp®, version 14.3.0. sas institute inc., cary, nc, 1989– 2023.) there are some limitations which faced the investigator during the period of study, some participant gets dizziness and vertigo during test. participants who provided their consent completed the questionnaire, which typically took approximately 45 minutes to finish. the study ensured strict confidentiality and the data collected will be solely utilized for research purposes. the average age of participants in the study group was 23.34 years (4.76%), while in the control group, it was 20.20 years (1.12%). among the sample population, approximately 66% of the study group and 52% of the control group were male, whereas 34% of the study group and 48% of the control group were female. 104 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results table 5. 1: demographic characteristics between the patient and healthy controls demographic characteristics patient (n=50) health controls (n=50) age mean (sd) 33 (66) 17 (34) 23.34 (4.76) 20.20 (1.12) gender no (%) male female 33 (66) 17 (34) 26 (52) 24 (48) table 5. 2: comparisons of types and duration of hearing loss between patient and healthy controls hearing loss no (%) patients (n=50) healthy controls (n=50) hearing problem of right ear normal snhl chl mhl 22 (44) 22 (44) 5 (10) 1 (2) 50 (100) 0 (0) 0 (0) 0 (0) hearing problem of left ear normal snhl chl mhl 7 (14) 34 (68) 2 (4) 7 (14) 50 (100) 0 (0) 0 (0) 0 (0) hearing problem of bilateral ears normal snhl chl mhl 0 (0) 19 (82.61) 2 (8.70) 2 (8.70) 50 (100) 0 (0) 0 (0) 0 (0) duration of hearing problem no problem 1-3 weeks ago 1-11 months ago 1-5 years ago 5 years and over 0 (0) 3 (6) 24 (48) 12 (24) 11 (22) 50 (100) 0 (0) 0 (0) 0 (0) 0 (0) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.11 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article table 5.4 show that there is a strongly significant of the patient with hearing loss in term of sound detection threshold in right ear of detected threshold about 31 (62%) for patient compared to the healthy control 5 (10%). and also, there is a significantly high of the patient in left ear sound detection threshold for not detected threshold is 19 (38%) compared to the healthy control 45 (90%). while there is a lower significant of the healthy control in bilateral ears sound detection threshold about 45% detection and 5% not detected threshold compared to the patient with hearing loss as show in. table 5.3 and in figure 4.1 shows the comparisons of speech issue sound detection thresholds between the patient and healthy controls for the right, left, and bilateral ears. it is a significantly high of the study compared with healthy controls in the right ear sound detection threshold (sd = 82.06 (15.83) patient and (sd = 96.8 (3.35) detection threshold (sd = 82.58 (14.73) patient compared with (sd = 97.6 (2.19) healthy controls. additionally, there is a significant difference in the bilateral ears’ sound detection threshold (sd = 97.47 (5.20) patient and (sd = 99.91 (0.60) healthy controls. healthy controls. similarly, there is a widely significant in the left ear sound 105 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 5. 3: comparisons of sound detection threshold between patient and healthy controls speech issue mean (sd) patient (n=50) health controls (n=50) sound detection threshold rt ear 82.06 (15.83) 96.8 (3.35) sound detection threshold lt ear 82.58 (14.73) 97.6 (2.19) sound detection threshold bilateral ears 97.47 (5.20) 99.91 (0.60) figure 5. 1: sound detection threshold between patients with hearing loss and healthy controls table 5. 4: detection of sound between patients and healthy controls speech issue no (%) patients (n=50) health controls (n=50) sound detection threshold rt ear detected not-detected 31 (62.00) 19 (38.00) 5 (10.00) 45 (90.00) sound detection threshold lt ear detected not-detected 31 (62.00) 19 (38.00) 5 (10.00) 45 (90.00) sound detection threshold bilateral ears detected not-detected 19 (38.00) 31 (62.00) 45 (90.00) 5 (10.00) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.11 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article a strongly significant in the left ear sound recognition threshold, with 10 (83.33%) in the patients and 0 (0%) in the healthy controls at 40db. additionally, there is a highly significant in the bilateral ears’ sound recognition threshold, with 6 (15.79%) in the patients and 0 (0%) in the healthy controls at 40db. sound recognition thresholds and hearing loss. these differences could be attributed to various factors such as underlying medical conditions, exposure to loud noise, or other individual characteristics. in agreement with the previous study, the current study, the average age in the patient with hearing loss was 23.34 years (4.76%), and in the healthy controls, it was 20.20 years (1.12%). approximately 66% of the patient and 52% of the healthy controls were male, while 34% of the patient and 48% of the healthy controls were female. and in the [11] patient indicating that there were no differences in performance between male and female participants in the study. the previous study included 15 healthy controls (2 males, 13 females, age 33-66 years, median age 51 years) and 15 patient table 5.5 shows the comparisons of sound recognition between the patients for the right, left, and bilateral ears. there is a lower significant of the healthy controls compared with patients with hearing loss in the right ear sound recognition threshold, with 3 (25%) in the patients and 0 (0%) in the healthy controls at 60db. similarly, there is the main findings of this study show that there is a higher significant difference in patient compared to the healthy controls in the sound detection threshold for speech issues in the right, left, and bilateral ears, as well as in sound recognition for bilateral ears. additionally, there is a higher significant difference in hearing loss for the right and left ears. factors strongly associated with the patient group compared to healthy controls include age, male gender, and hearing problems in the right ear, left ear, and bilateral ears. furthermore, there is a strongly significant in the duration of the hearing problem, specifically about 0111 months ago. based on the results presented in this study, there are highly significant differences observed between the patient and healthy controls in terms of 106 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion table 5. 5: comparisons of sound recognition between patient and healthy controls sound recognition no (%) patient (n=50) healthy controls (n=50) sound recognition threshold rt ear 20db 40db 60db 7 (58.33) 2 (16.67) 3 (25) 0 (0) 0 (0) 0 (0) sound recognition threshold lt ear 20db 40db 2 (16.67) 10 (83.33) 0 (0) 0 (0) sound recognition threshold bilateral ears 20db 30db 40db 60db 85db 25 (65.79) 3 (7.89) 6 (15.79) 3 (7.89) 1 (2.63) 50 (100) 0 (0) 0 (0) 0 (0) 0 (0) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.11 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article the word lists need to be tested on the population for which the test is intended in order to establish a more accurate test. similar to the current study, in bansal et al., 2016 study, out of cases, (44.55%) had snhl (bilateral [67.95%]; unilateral [32.04%]) which was the most common type of hearing impairment among patients complaining of hl. this study had incidence of pure usnhl in 19.32% cases of snhl, which is higher than other studies. the higher incidence may be because of difference between the total populations being considered. while in the current study out of cases 50% had snhl (bilateral – [19 (82.61%)]; unilateral – [34 (68%)] there is a highly significant difference between the study and control groups. in line with the previous study, the [21] study’s shows that the word recognition scores in english were significantly lower than the word recognition scores in cantonese for both the normalhearing (p < 0.0001) and hearing-impaired groups (p < 0.0001). on the other hand, while the english scores of the hearingimpaired group are significantly lower than those of the normal-hearing group (p = 0.003), there was no significant difference between the groups when tested in cantonese (p = 0.19). in other words, the effect of hearing impairment was greater when tested in the second language than in the native language. but in current studies shows the comparisons of word recognition scores in kurdish sound detection thresholds between the patient and healthy controls for the right, left, and bilateral ears. there is a highly significant difference between the patient and healthy controls in the right ear sound detection threshold (patient sd = 82.06 (15.83) and (health controls sd = 96.8 (3.35). similarly, there is a high significant difference in the left ear sound detection threshold (patient sd = 82.58(14.73) and (4 males, 11 females, age 34-72 years, median age 52 years) participants in the nh group showed an average score of 58% (sd = 4.3), while the average score for the hi group was 59% (sd = 3.8), a levene's test for equality of variances showed no significant difference in variance (p = 0.405) and a two-sided independent samples t-test for equality of means showed no significant difference in means (p = 0.334) between groups [18]. recent studies have supported current findings indicating that there is a lower significant of the healthy controls in terms of right ear chl with 5 (10%) in the patient and 0 (0%) in the healthy controls. in privies study show that the participant with chl had significantly lower correct responses than individuals with normal hearing for both sides. the results suggest reduced auditory temporal processing ability in adults with chl compared to normal hearing subjects. therefore, developing a clinical protocol to evaluate auditory temporal processing in this population is recommended [19]. in contrast to the findings of this study shows the comparisons of sound recognition between the patient for the right, left, and bilateral ears. there is a significant difference in the left ear sound recognition threshold, with 10 (83.33%) in the patients and 0 (0%) in the healthy controls at 40db. additionally, there is a significant difference in the bilateral ears sound recognition threshold, with 6 (15.79%) in the patients and 0 (0%) in the healthy controls at 40db. in the [20] study shows that at 40 db sl (above the srt) level, normal hearing subjects attained maximum speech identification scores when compared to hearing impaired subjects using both word lists and was statistically significant (p = 0.001). hence, it can be concluded that there is a significant difference in the performance of individuals with normal hearing and those with hearing impairment. suggested that 107 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.11 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article studies revealed that the difference between normal hearingand hearingimpaired listeners was significant [p = 0.003]. the apparent difference between the two groups is supported by a significant interaction between hearing status and “static” versus “illusion” stimulus condition [p < 0.001]. these findings are argued to be primarily the result of (a) a change in dynamic binaural sensitivity and (b) high-frequency hearing loss affecting the audibility of pinna cues [25]. the current study compares the ear hearing loss between the patient and healthy controls for both the right and left ears. there is a highly significant in the right ear sn hearing loss, with 22 (44%) in the patients and 0 (0%) in the healthy controls. consistent with the privies study, two subjects presented with a bilateral mixed hearing loss, the other two with a unilateral mixed hearing loss all the implanted subjects reached an srt value below 65 db, indicating that, at conversation level in quiet, more than 50% of the words could be understood. for this reason, some problems at the interposed skin level can be foreseen, especially in those patients undergoing a retro auricular incision after multiple middle ear surgeries [26]. the current study shows that the mixed hl there is a highly significant in bilateral and unilateral hearing loss. in contrast to the findings of the present study, [27] found no significant difference in the factors of duration between the two groups (p = 0.624) [27]. the possible reason for this non-significant difference may be attributed to emotional and functional dimensions in their study. however, in the current study, a highly significant difference was observed in the duration of the problem between the patient and healthy controls, specifically for durations of 01-11 months ago 24 (48%) for the patient, and durations of 5 years is 11 (22%) for the patient compared to healthy controls (0%). (health controls sd = 97.6(2.19). additionally, there is a significantly high difference in the bilateral ear’s sound detection threshold (patient sd = 97.47(5.20) and (health controls sd = 99.91(0.60). previously published studies [22] show the differences in detection or recognition between the categories is highly significant. is to ensure participants are presented with at least one, preferably two or more, sounds from each category. this will result in more useful data from an equal number of participants. while the current study shows that there is a highly significant in the sound recognition threshold in the patient compared to the healthy controls at 40db. as in this study, other literature has confirmed that these measures were also significantly correlated to high-frequency hearing loss (p < 0.001, p = 0.031, p = 0.010). srt and spatial advantage were also significantly correlated to lowfrequency hearing loss (p < 0.001, p = 0.009). however, srt was significantly correlated with both low-frequency hearing loss (p = 0.007) and high-frequency hearing loss (p = 0.012). talker advantage, which is a measure of the benefit gained from access to pitch cues, was significantly correlated with high-frequency hearing loss (p = 0.003). alternatively, it could be argued that the absence of an age effect in this study is because of the different materials and maskers used in the study design [23]. quiet thresholds were found to vary between 16 and 41.5db spl and were not significantly correlated with age (r2 = 0.05, p > 0.05), although quiet speech thresholds were significantly correlated with the average pure-tone thresholds at the two ears. correlations were stronger for the average of three lowto midfrequency thresholds (5, 1, 2 khz: r2 = 0.62, p < 0.0001) than for three midto high-frequency thresholds (1, 2, 4 khz: r2 = 0.52, p < 0.0001) [24], numerous 108 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.11 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article conclusion references numerous studies revealed that lunner, 2003 shows the correlations between hearing loss and speech reception were significant (r0.470.49). as well as the [28], shows four of the correlations between speech test and reading span score were significant (r0.37-0.56). and [29] shows the visual text-reception threshold was significantly correlated with the auditory speech-reception thresholds in both static and modulated noise (r0.54-0.54). which is often taken as a measure of working memory and predicts performance on a wide range of cognitive tasks. while the current study shows that there is a significant difference between hearing loss and speech recognition threshold. this study showed that the patients with hearing loss has significantly higher rates of speech difficulty and other audiorelated issues compared to the healthy controls. in addition, the study showed that the established guideline can be used as a guide for identification of hearing loss to the kurdish populations. based on the study, the current study has significant implications for the field as it contributes to improving audiological diagnostic and rehabilitation services in the kurdistan region/iraq. by conducting thorough validation experiments, the authors propose that the developed word recognition test lists can be universally applied across different countries, indicating their broad applicability in diverse cultural and linguistic contexts. overall, the results suggest that the developed speech materials are suitable for clinical testing of speech audiometry in the specific population, as evidenced by the consistent performance observed across the two monosyllabic word lists and the lack of differences between speech reception thresholds (srts) and pure tone averages (ptas). these findings 109 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. recommendation: highlight the importance of further research to identify the underlying causes and potential interventions for individuals experiencing hearing loss. additionally, these results emphasize the need for regular hearing screenings and interventions to prevent and manage hearing impairments in the population. further investigation and analysis are needed to determine the specific causes and implications of these findings. the created kurdish speech test lists should be standardized in kurdistan region /iraq, and depended on the ministry of health in kurdistan region /iraq. further research is needed to explore the relationship between hearing loss and speech difficulty and quality of life (that includes aspects related to physical, mental, social, and environment interactions. providing this group of patients with counseling services in order to help them obtaining social and psychological adjustment. [1] t. nuesse, b. wiercinski, t. brand and i. holube, "measuring speech recognition with a," trends in hearing, vol. 23, pp. 114, 2019. [2] j. punch and . b. rakerd, "evaluation of a protocol for integrated speech audiometry," american journal of audiology, vol. 28, no. 1, pp. 26-36, 2019. [3] x. ma, b. mcpherson and l. ma, "chinese speech audiometry material: past, present, future," hearing balance and communication, vol. 11, no. 2, pp. 52-63, 2013. [4] b. j. parmar , . s. l. rajasingam, . j. k. bizley and . d. a. vickers, "factors affecting the use of speech testing in adult audiology," american journal of audiology, vol. 31, no. 3, pp. 528-540, 2022. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.11 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article 110 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [5] j. roßbach, . b. kollmeier and b. t. meyer, "a model of speech recognition for hearingimpaired listeners based on deep learning," the journal of the acoustical society of america, vol. 151, no. 3, p. 1417–1427, 2022. [6] s. l. nissen , r. w. harris , l.-j. jennings , d. l. eggett and h. buck , "psychometrically equivalent mandarin bisyllabic speech discrimination materials spok discrimination materials spoken by male and f y male and female t emale talkers," international journal of audiology, vol. 44, no. 7, pp. 379-390, 2005. [7] s. sakamoto, t. yoshikawa, s. amano, y. suzuki and t. kondo, "new 20-word lists for word intelligibility test in japanese," international conference on spoken language processing, icslp, pp. 2158-2161, 2006. [8] y. k. kemaloğlu, . g. ş. kamışlı and . g. mengü, "phonemic analysis of turkish monosyllabic word lists used for speech discrimination word recognition tests," kulak burun bogaz ihtis derg, vol. 27, no. 4, pp. 198-207, 2017. [9] h. a. alusi, r. hinchcliffe, b. ingham, j. j. knight and c. north, "arabic speech audiomentry," vol. 13, no. 3, pp. 212-230, 1974. [10] a. a. ashoor and t. prochazka, "saudi arabic speech audiometry," audiology, vol. 21, no. 6, pp. 493-508, 1982. [11] s. n. garadat, . k. j. abdulbaqi and . m. a. haj-tas , "the development of the university of jordan word recognition test," vol. 56, no. 6, pp. 424-430, 2017. [12] a. m. and w. , "speech audiometry: arabic word recognition test for adults," kent state university, 2021. [13] k. c. de sousa , . d. w. swanepoel, d. r. moore, . h. c. myburgh and c. smits, "improving sensitivity of the digits-in-noise test using antiphasic stimuli," ear and hearing , vol. 41, no. 2, pp. 442-450, 2020. [14] s.-h. jeung, b.-m. jin and k.-y. hyun, "college students’ hearing ability through pure tone," international journal of innovative science, engineering & technology, vol. 2, no. 7, pp. 220-226, 2015. [15] n. klangpornkun, c. onsuwan, c. tantibundhit and p. pitathawatchai, "predictions from "speech banana" and audiograms: assessment of hearing deficits in thai hearing loss patients," the journal of the acoustical society of america, vol. 134, no. 5, pp. 1-11, 2013. [16] j. b. chaiklin and i. m. ventry, "spondee threshold measurement: a comparison of 2 and 5-db methods," journal of speech and hearing disorders, vol. 29, no. 1, pp. 47-59, 1964. [17] j. b. chaiklin, j. f. and r. f. dixon, "spondee thresholds measured in ascending 5-db steps," journal of speech and hearing research, vol. 10, no. 1, pp. 141-145, 1967. [18] t. koelewijn, n. j. versfeld and s. e. kramer, "effects of attention on the speech reception threshold and pupil response of people with impaired and normal hearing," hearing research, vol. 354, pp. 56-63, 2017. [19] a. bayat, m. farhadi, h. emamdjomeh, n. saki , g. mirmomeni and f. rahim , "effect of conductive hearing loss on central auditory functionefeito da perda auditiva condutiva na função auditiva central," brazilian journal of otorhinolaryngology, vol. 83, no. 2, pp. 137-141, 2017. [20] m. a. dias, u. devadas and b. rajashekhar, "development of speech audiometry material in goan konkani language," language in india, vol. 15, no. 2, pp. 268-280, 2015. [21] s. h. marinova-todd, c. k. siu and l. m. jenstad, "speech audiometry with non-native english speakers: the use of digits and cantonese words as stimuli," canadian journal of speech-language pathology and audiology, vol. 35, no. 3, pp. 220-227, 2011. [22] c. pals, "detection and recognition threshold of sound sources in noise," faculty of science and engineering., 2008. [23] h. glyde, s. cameron, h. dillon, l. hickson and m. seeto, "the effects of hearing impairment and aging on spatial processing," ear and hearing, vol. 34, no. 1, pp. 15-28, 2013 [24] f. j. gallun, a. c. diedesch, s. d. kampel and k. m. jakien, "independent impacts of age and hearing loss on spatial release in a complex auditory environment," frontiers in neuroscience, vol. 7, 2013. [25] w. o. brimijoin and m. a. akeroyd , "the effects of hearing impairment, age, and hearing aids on the use of self-motion for determining front/back location," journal of the american academy of audiology, vol. 27, no. 7, p. 588–600, 2016. [26] m. barbara , m. perotti, b. gioia, l. volpini and s. monini, "transcutaneous boneconduction hearing device: audiological and surgical aspects in a first series of patients with mixed hearing loss," acta otolaryngol, vol. 133, no. 10, pp. 1058-1064, 2013. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.11 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article 111 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [27] j. li, . z. qiu, y. qiu, . l. li , . y. zheng, . f. zhao, x. huang, m. liang, . y. li , . y. cai and . y. ou, "prognostic factors influencing the tinnitus improvement after idiopathic sudden sensorineural hearing loss treatment," otol neurotol, vol. 43, no. 6, pp. e613-e619, 2022. [28] m. rudner, c. foo, j. rönnberg and t. lunner, "phonological mismatch makes aided speech recognition in noise cognitively taxing," ear and hearing, vol. 28, no. 6, pp. 879 -892, 2007. [29] a. a. zekveld, e. l. j. george, s. e. kramer, s. t. goverts and . t. houtgast, "the development of the text reception threshold test: a visual analogue of the speech reception threshold test," journal of speech, language, and hearing research, vol. 50, no. 3, pp. 576-584, 2007. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.14 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article job satisfaction among nurses who work in the oncology unit in erbil city abstract background and objectives: job satisfaction refers to a person's overall assessment of their employment, whether good or bad. oncology nursing practitioners routinely witness the suffering, misery, and death of others while working long hours in understaffed units and with a high emotional commitment. it is crucial to evaluate how happy these specialists are in their highly specialized field. this study is aimed at evaluating the job satisfaction among nurses who work in the oncology unit in erbil city. methods: a descriptive cross-sectional study was conducted among 31 nurses working in the oncology ward at rizgary in the city of erbil in the kurdistan region of iraq, from november 2022 to april 2023. non-probability purposive sampling is used to collect relevant study samples. the study sample is assessed using a questionnaire consisting of two parts. result: according to the study, half (48.4%) of oncology nurses were dissatisfied about their pay and benefits, although the majority were just mildly unhappy. 54.8% of respondents had no unhappiness with workdays, while 32.3% expressed moderate satisfaction with work hours. the majority expressed no opinion regarding career advancement; however, there was moderate satisfaction with professional relationships (54.8%), social engagement (51.6%), and part-time jobs (41.9%). overall, the results show that job satisfaction is moderate, with neutrality prevalent in the majority of job-related factors. conclusion: the study concluded that factors such as gender, age, education, and work experience can influence job satisfaction among oncology nurses. dissatisfaction was moderate regarding salary, vacation benefits, and the benefits package. keywords: job satisfaction; nurses; oncology wards; sociodemographic factors. goran noori saleh; department of nursing, tishk international university, erbil, kurdistan region, iraq. dara abdulla al-banna; department of nursing, tishk international university, erbil, kurdistan region, iraq. hanan azad ahmed; department of nursing, tishk international university, erbil, kurdistan region, iraq. (correspondence: hanan.azad@tiu.edu.iq) 133 received: 20/07/2025 accepted: 17/09/2025 published: 30/11/2025 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:?subject=%20 mailto:.azad@tiu.edu.iq%20) mailto:azad@tiu.edu.iq?subject=azad@tiu.edu.iq%20 mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.14 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article job satisfaction is influenced by how much people like or loathe their jobs. it is also viewed as a collection of viewpoints on the job's numerous facets, such as salary, the nature of the workgroup, organizational dynamics, and working conditions. because of this, job pleasure and dissatisfaction can both occur in a variety of workplace settings [1]. there is a correlation between enhanced patient outcomes and increased levels of work satisfaction among nurses [2]. several factors are believed to influence the job satisfaction of nurses, such as their workload, support, occupational safety, relationships with supervisors and coworkers, and organizational structure [3]. the development of staff, the suitability of nurse staffing, the independence of nurses, their participation in policy-making, and the backing of supervisors for new ideas were significantly influenced by relationship management and the linkages between physicians and nurses, as well as dispute resolution. consequently, these factors are closely associated with nurses’ job satisfaction [4]. nurses provide patient assessments, give treatments and prescriptions, monitor symptoms and side effects, record nursing care and interventions, educate patients and their families, and offer support. furthermore, their collaborative contributions with other healthcare professionals and patients should not be underestimated [5]. oncology nurses operate in a setting that entails the handling of intricate diseases with unfavorable outcomes, technological advancements, and frequent interactions with patients who are experiencing pain, suffering, and nearing the end of their lives. based on data from previous research, these issues have played a substantial role in causing work dissatisfaction, stress, and burnout among oncology nurses [6].therefore, the disparity between the need for oncology nurses and the availability of such nurses has increased the likelihood of nurses encountering unfavorable consequences, ultimately impacting the standard of treatment in a detrimental manner [7]. concerns about nurses' job satisfaction have long existed in healthcare systems, especially in underdeveloped nations. research from pakistan shows that a large number of nurses are unhappy with their working conditions, particularly with regard to salary and recognition. this kind of discontent can have a detrimental effect on retention, performance, and motivation, which in turn can lower the standard of patient care. therefore, it is crucial to comprehend the elements that affect nurses' job happiness in order to enhance workforce stability and healthcare results. [8]. this study aims to investigate the impact of organizational support, workload, salary and benefits, and compare job satisfaction levels with those working in other healthcare settings, with the ultimate goal of suggesting strategies to assess the job satisfaction among oncology nurses. a crosssectional study design was conducted among nurses who are working at the oncology unit in rizgary teaching hospital in erbil city. the study was carried out from november 2022 to april 2023. the study sample included 31 nurses (representative sample) who are working in oncology unit at rizgary teaching hospital in erbil city, kurdistan region of iraq. a nonprobability, purposive sampling is used to collect the relevant study samples. all nurses in the oncology unit who are willing to participate and have at least one year of work experience were recruited in this study. a questionnaire, as a tool of data collection, was used and had two parts. part one consists of 134 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.14 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article approval. for informal oral consent, it was taken from all participants after a detailed explanation about the purpose of the study and giving a guarantee that their personal information would be saved and secured. in addition to the above, the researchers told each participant that this is a voluntary work and that they can leave at any time even if the process is not completed. the data were analyzed by statistical software (statistical package for social science-spss v.26) through using descriptive statistical analysis (frequency and percentage). within this study, "job opportunities" is a term that refers to the social and career aspects of the nursing work environment that may have some effect on job satisfaction. they include career development opportunities, participation in research, publication, working with peers, socialization, and flexible work hours. these aspects were assessed as subscales of the multidimensional job satisfaction scale, which is a measure of the extent to which certain domains such as salary, benefits, working conditions, and job opportunities are contributory to nurses' overall level of satisfaction. the data represents the sociodemographic characteristics of a sample of 31 oncology nurses. the sample includes 15 females and 16 males. the majority of the sample, 67.7%, are within the age range of 30 to 39 years old. more than half of the participants were married (64.5%) and had a bachelor's degree (51.6%). in terms of work experience, the majority of participants had experience ranging from 11 to 15 years (30.0%) and 16 to 20 years (30.0%). 10.0% of respondents had 1 to 5 years of experience, whereas nearly onequarter (23.3%) had 6 to 10 years. only 3.3% of participants had worked for 21–25 years and 26–30 years as well. none of the sociodemographic characteristics of nurses, which included age, years of experience, gender, marital status, and education level; part two consists of the items regarding job satisfaction. for assessing job satisfaction, several items had been used. the multidimensional job satisfaction scale is an in-depth tool that helps assess the distinct factors contributing to an individual’s satisfaction at work. instead of assessing job satisfaction as a single global construct, the scale recognizes a number of broader categories that influence how employees view their job. these categories usually relate to autonomy, collegial and supervisory interactions, professional stature, accountabilities at work, organizational norms and compensation, and sometimes consider external environment factors related to external colleagues or support staff. the scale employs likert-type items to determine the importance individuals assign to various dimensions and their level of satisfaction within each dimension. [9] it is used one of the versions of the professional satisfaction index, which utilized paired comparisons and attitude scales to derive adjusted component scores [10]. a validated six-factor model offered a culturally adapted model using confirmatory factor analysis. these multidimensional tools offered a fuller picture of how an employee perceives workplace satisfaction and helped researchers and administrators identify focused areas for organizational improvement and employee care and support. in the job satisfaction scale,1 coded for very dissatisfied, 2 for moderately dissatisfied, 3 for neither satisfied nor dissatisfied, 4 for moderately satisfied, and 5 for very satisfied. the data was collected through direct (face-to-face) interviews. for ethical considerations, the proposal was approved by the scientific committee from the faculty of nursing at tishk international university to obtain formal 135 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.14 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article participants had a postgraduate degree, as shown in table 1. the findings indicate that none of the nurses were very dissatisfied or very satisfied with their salary and vacation benefits. however, a large number of nurses were however, half of the nurses (45.2%) were neither dissatisfied nor satisfied with their benefits package. as for hours worked, none of the nurses were extremely dissatisfied, but 22.6% were moderately dissatisfied and 41.9% were neither dissatisfied nor satisfied. meanwhile, 32.3% of the participants were moderately satisfied with their working hours, and only 3.2% were very satisfied. overall, the results show that job satisfaction needs to be improved for nurses working in oncology wards, particularly in salary and holiday benefits, as reflected in table 2. as far as the benefits package is concerned, there were not many nurses (6.5%) who were extremely dissatisfied, but almost a quarter (25.8%) who were moderately dissatisfied. nearly half of the nurses (48.4%) were neither dissatisfied nor satisfied with their salary and vacation benefits moderately dissatisfied with their salary (19.4%) and vacation benefits (12.9%). 136 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table1: sociodemographic characteristics of nurses working in the oncology unit sociodemographic characteristics samples (n. 31) f. (%) gender female 15 (48.5) male 16 (51.5) age group (year) 20-29 7 (22.6) 30-39 21 (67.7) ≥ 40 3 (9.7) marital status single 11 (35.5) married 20 (64.5) educational level diploma 15 (48.4) bachelor’s degree 16 (51.6) year of experience 1-5 3 (10) 6-10 7 (23.3) 11-15 9 (30.0) 16-20 9 (30.0) 21-25 1 (3.3) 26-30 1 (3.3) table 2: employee satisfaction by work-related factor very dissatisfied moderately dissatisfied nor dissatisfied moderately satisfied very satisfied f. (%) f. (%) f. (%) f. (%) f. (%) salary 0 (0) 6 (19.4) 15 (48.4) 10 (32.3) 0 (0) vacation 0 (0) 4 (12.9) 15 (48.4) 12 (38.7) 0 (0) benefits package (insurance, retirement) 2 (6.5) 8 (25.8) 14 (45.2) 7 (22.6) 0 (0) hours of the work 0 (0) 7 (22.6) 13 (41.9) 10 (32.3) 1 (3.2) flexibility in scheduling your hours 0 (0) 6 (19.4) 21 (67.7) 4 (12.9) 0 (0) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.14 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article 137 in terms of opportunities to interact professionally with other disciplines, more than half of nurses (54.8%) were moderately satisfied, followed by 19.4% who were neither dissatisfied nor satisfied, and 12.9% who were very satisfied or moderately dissatisfied. only 4 nurses (12.9%) reported being very dissatisfied. regarding opportunities to interact with faculty of the college of nursing, 48.4% of the nurses were neither dissatisfied nor satisfied, followed by 25.8% who were moderately dissatisfied, 22.6% who were moderately satisfied, and only 1 nurse (3.2%) who was very satisfied. no nurses reported being very dissatisfied. when it comes to opportunities to belong to department and institutional committees, less than half of nurses (41.9%) were neither dissatisfied nor satisfied, followed by 35.5% who were moderately satisfied, 19.4% who were moderately dissatisfied, and only 1 nurse (3.2%) who was very dissatisfied. in terms of opportunities for career advancement, the majority of nurses (67.7%) reported being neither dissatisfied nor satisfied, followed by 29% who were moderately satisfied, and only 1 nurse (3.2%) who was moderately dissatisfied. no nurses reported being very satisfied or very dissatisfied. regarding opportunities to participate in nursing research, 38.7% of the nurses were moderately satisfied, followed by 29% who the data represents the levels of satisfaction of nurses who work in oncology units with various aspects of their job opportunities. the data represent nurses’ satisfaction with different aspects of job opportunities, including professional growth, research participation, and workplace interactions. these factors were evaluated as part of the multidimensional job satisfaction assessment to determine how such opportunities contribute to overall job satisfaction among oncology nurses. for each aspect, the percentages of nurses who reported being very dissatisfied, moderately dissatisfied, not dissatisfied, moderately satisfied, and very satisfied are presented. according to the results, the majority of nurses were not dissatisfied with their opportunities to work straight days, with 54.8% reporting no dissatisfaction, followed by moderately satisfied at 25.8%, and moderately dissatisfied at 9.7%. however, 9.7% of nurses reported being very dissatisfied with this aspect. in terms of opportunities for parttime work, 41.9% of nurses reported being moderately satisfied, while 29% were not dissatisfied and 16.1% were moderately dissatisfied. 12.9% of nurses reported being very satisfied, while none reported being very dissatisfied. regarding social contact opportunities at work, half of nurses (51.6%) reported being moderately satisfied, followed by 29% who were not dissatisfied, and 19.4% who were very satisfied. none of the nurses reported being dissatisfied with this aspect of their job. similarly, for social contact opportunities with colleagues after work, less than half of nurses (45.2%) were moderately satisfied, followed by 29% who were not dissatisfied and 25.8% who were very satisfied. none of the nurses reported being dissatisfied with this aspect of their job, as shown in figure 1 in a bar graph. copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. figure 1. different opportunities for the job https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.14 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article in terms of weekends off per month, the majority of nurses (74.2%) reported being neither satisfied nor dissatisfied, while 6.5% were moderately dissatisfied and 19.4% were moderately satisfied. there were no nurses who reported being very dissatisfied or very satisfied. regarding flexibility in scheduling weekends off, 38.7% of nurses were neither satisfied nor dissatisfied, while 35.5% were moderately dissatisfied, 19.4% were moderately satisfied, and 6.5% were very satisfied. no nurses reported being very dissatisfied. for compensation for working weekends, 38.7% of nurses were neither satisfied nor dissatisfied, 41.9% were moderately dissatisfied, 16.1% were moderately satisfied, and 3.2% were very dissatisfied. none of the nurses reported being very satisfied. regarding maternity leave time, 38.7% of nurses were neither satisfied nor dissatisfied, 32.3% were moderately satisfied, 25.8% were very dissatisfied, and 3.2% were moderately dissatisfied. no nurses reported being very satisfied. for childcare facilities, 45.2% of nurses were neither satisfied nor dissatisfied, 29% were 138 were neither dissatisfied nor satisfied, 16.1% who were very dissatisfied or very satisfied, and 5 nurses (16.1%) who were moderately dissatisfied. finally, when it comes to opportunities to write and publish, the majority of nurses (32.3%) were neither dissatisfied nor satisfied, followed by 35.5% who were moderately dissatisfied, 12.9% who were very dissatisfied, 11 nurses (35.5%) who were moderately satisfied, and only 1 nurse (3.2%) who was very satisfied, as shown in figure 1.2. in terms of their immediate supervisors, only 3.2% of the participants reported being very dissatisfied, while 35.5% reported being moderately satisfied and 9.7% reported being very satisfied. however, a significant proportion of participants reported being moderately or very dissatisfied with their immediate supervisor (22.6% and 29%, respectively). when it comes to nursing peers, no participants reported being very dissatisfied, but 9.7% reported being moderately dissatisfied. the majority of the participants (48.4%) reported being moderately satisfied with their nursing peers, while 12.9% were very satisfied. regarding the physicians they work with, none of the participants reported being very or moderately dissatisfied. however, a considerable proportion of participants reported being neither satisfied nor dissatisfied (38.7%). similarly, 22.6% of the participants reported being very satisfied with the physicians they work with, as shown in figure 3. copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. figure 2. the different opportunities for the job figure 3. satisfaction with workplace interpersonal relations https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.14 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article of nurses were moderately satisfied, 41.9% were neither satisfied nor dissatisfied, 12.9% were very satisfied, and none of the nurses were very dissatisfied or moderately dissatisfied. regarding the amount of responsibility, 61.3% of nurses were moderately satisfied, 16.1% were neither satisfied nor dissatisfied, 22.6% were very satisfied, and none of the nurses were very dissatisfied or moderately dissatisfied. finally, for control over work conditions, 41.9% of nurses were moderately satisfied, 35.5% were neither satisfied nor dissatisfied, 22.6% were very satisfied, and none of the nurses were very dissatisfied or moderately dissatisfied, as shown in table 3. moderately satisfied, 22.6% were moderately dissatisfied, and 3.2% were very dissatisfied. none of the nurses reported being very satisfied. regarding the method of care delivery used in the unit, 41.9% of nurses were moderately dissatisfied, 41.9% were neither satisfied nor dissatisfied, 6.5% were moderately satisfied, and 6.5% were very satisfied. only 3.2% of nurses were very dissatisfied. regarding control over what goes on in the work setting, 51.6% of nurses were moderately satisfied, 29% were neither satisfied nor dissatisfied, 19.4% were moderately dissatisfied, and none of the nurses were very dissatisfied or very satisfied. for recognition of work from peers, 45.2% 139 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: distribution of satisfaction among the nurses working in oncology wards very dissatisfied moderately dissatisfied nor dissatisfied moderately satisfied very satisfied f. (%) f. (%) f. (%) f. (%) f. (%) weekends off per month 0 (0) 2 (6.5) 23 (74.2) 6 (19.4) 0 (0) flexibility in scheduling your weekends off 0 (0) 11 (35.5) 12 (38.7) 6 (19.4) 2 (6.5) compensation for working weekends 1 (3.2) 13 (41.9) 12 (38.7) 5 (16.1) 0 (0) maternity leave time 8 (25.8) 1 (3.2) 12 (38.7) 10 (32.3) 0 (0) childcare facilities 1 (3.2) 7 (22.6) 14 (45.2) 9 (29) 0 (0) the delivery of care method used on your unit (e.g. functional, team, primary) 1 (3.2) 13 (41.9) 13 (41.9) 2 (6.5) 2 (6.5) control over what goes on in your work setting 0 (0) 0 (0) 9 (29) 16 (51.6) 6 (19.4) recognition of work from peers 0 (0) 0 (0) 13 (41.9) 14 (45.2) 4 (12.9) your amount of responsibility 0 (0) 0 (0) 5 (16.1) 19 (61.3) 7 (22.6) your control over work conditions 0 (0) 0 (0) 11 (35.5) 13 (41.9) 7 (22.6) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.14 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article education, age, and work experience had a strong role in determining the job satisfaction of nurses employed in jordan. the study revealed no statistically significant correlation between sociodemographic factors, such as gender and marital status, and job satisfaction. another study conducted by [13] investigated the influence exerted by sociodemographic factors on the job satisfaction of nurses employed in south africa. the study established that age, education level, and work experience years were powerful predictors of job satisfaction, while variables such as gender and marriage status were insignificant predictors. relative to these studies, the current study concluded that variables such as gender, age, marriage status, education level, and work experience were all powerful determinants of job satisfaction among oncology ward nurses. however, observe that the sample used in this study was very small, which may limit the generalizability of findings [12, 13, 14], carried out research into job satisfaction among oncology nurses in china and confirmed the same results regarding dissatisfaction with pay and benefits. overall, 59.4% of nurses reported dissatisfaction with their salary, and 50.6% reported dissatisfaction with their benefits. in terms of job satisfaction, the research found that nurses with greater levels of education and work experience were more job-satisfied. the study indicated that heavy workloads and extended working hours negatively impact job satisfaction. another study by [15] investigated job satisfaction among oncology nurses in brazil and found that job satisfaction was positively correlated with the level of education, compensation, and job security. the study also found that nurses who reported greater work-related social support and autonomy reported greater job satisfaction. the study, however, found that workload, inadequate staffing, and job satisfaction is a key component of nurses’ overall well-being and is closely linked to retention, productivity, and job performance. in the case of oncology unit nurses, job satisfaction is even more important given the nature of their work and how it can be emotionally demanding. the findings of this study have important implications for nursing practice and can serve as a foundation for creating interventions to increase job satisfaction among nurses working in oncology wards. if it is understood what aspects of job satisfaction are important for this group of nurses, interventions can be tailored to improve their well-being, work performance, and general job satisfaction. findings of this study have important implications for nursing practice and can help inform future efforts to improve the allocation of nursing resources in oncology units. understanding job satisfaction among nurses is crucial in ensuring that patients receive appropriate care and that nurses are working in roles that suit their skills and qualifications. sociodemographic factors, such as gender, age, marital status, and educational level, can play an important role in shaping job satisfaction among nurses working in oncology units. this is supported by [11], who found that personal and demographic characteristics influenced nurses' stress levels and job satisfaction in cancer settings. for example, variations in education level or years of experience can influence nurses’ job responsibilities and tasks. additionally, factors such as marital status and age may impact the availability of nurses to work certain shifts or take on certain responsibilities. there have been several studies that have investigated the role of sociodemographic factors in shaping job satisfaction among nurses. one piece of research conducted by [12] found that 140 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.14 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article a month, or else they are not concerned with how much they are getting. as far as planning weekends off for themselves, higher percentages of nurses were not satisfied at the 35.5% rate with moderate dissatisfaction. this could be read to mean that perhaps nurses do not feel that they are in charge of planning weekends off themselves. regarding receiving pay for working weekends, a high percentage of nurses were highly or moderately dissatisfied. nurses may feel they are not fairly compensated for the additional work assigned during weekends. regarding the duration of maternity leave, a greater number of nurses reported being very dissatisfied, indicating that they may perceive the time off following childbirth as inadequate. finally, regarding childcare facilities, more nurses were moderately or very dissatisfied. this may show that nurses may not feel that they have adequate childcare facilities to utilize, which may impact their work performance. overall, this information indicates that there is some potential for improvement in many aspects of job satisfaction among nurses. those include pay for working on weekends, maternity leave duration, and availability of childcare facilities. in erbil city, there are two public teaching hospitals specializing in oncology: rizgary teaching hospital and nanakali teaching hospital. however, nanakali teaching hospital did not permit us to collect data for this study, resulting in a limited sample size, as we only gathered data from all staff members working in the oncology ward at rizgary teaching hospital. inadequate resources negatively affected job satisfaction. this study emphasizes the need for healthcare organizations to address areas such as compensation, benefits, workload, and resources to improve job satisfaction among nurses. if we place in comparison what we have discovered in this research as shown in figures 1,2, and 3 with other research, e.g., the systematic reviews of [16] and [17], who identified factors influencing job satisfaction of nurses, e.g., workload, remuneration, and communication with colleagues. [18] conducted a literature review on job satisfaction among nurses and concluded that it is a complex and multifaceted concept which may be influenced by environmental, organizational, and individual factors. drawing a comparison of research on oncology ward nurses with these other studies, there can be an identification of similarities and differences. for example, the study on nurses working in cancer wards determined that the majority of nurses were satisfied with career development opportunities, whereas the systematic reviews conducted by [16] and [17] determined that pay and opportunities for advancement were primary motivators of job satisfaction among nurses. in the same way, the study among oncology ward nurses concluded that possibilities for social interaction with others in the workplace and with coworkers outside of work were generally satisfactory, which is consistent with the study of [18] that coworker and supervisor relationships can be a major factor in job satisfaction. it is noteworthy that, among all the factors listed, no nurses reported being very satisfied. this means that there is scope to improve in all these dimensions. when it comes to weeks off a month, the majority of nurses responded neither satisfied nor dissatisfied. this could imply that they may not have a specific preference for any particular number of weekends off 141 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.14 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article increase career advancement: nurses with greater education levels were found to experience higher job satisfaction levels. there should be motivation for career growth among nurses in health care organizations. foster supportive work environments: nurses who feel supported and valued in the work environment are more likely to have greater job satisfaction. healthcare organizations must foster supportive work environments by providing opportunities for collaboration and teamwork, valuing and rewarding nurses for their hard work (e.g., with money, a letter of gratitude, or grant opportunities), and promoting open communication and respect for cultures. [1] culibrk j, delic m, mitrovic s, culibrk d. job satisfaction, organizational commitment and job involvement: the mediating role of job involvement. front psychol. 2018;9:132. doi: 10.3389/fpsyg.2018.00132. [2] al-dwaikat tn, rababah hh, al-hammouri mm, chghriwat mn. the relationship between work-related stress and job satisfaction among nurses in jordan. j nurs manag. 2019;27(7):1458–66. doi: 10.1111/ jonm.12781. [3] hamdan m, hamra aa. burnout among workers in emergency departments in palestinian hospitals. bmc health serv res. 2017;17(1):407. doi: 10.1186/s12913-0172306-9 [4] de simone s, planta a, cicotto g. the role of job satisfaction, work engagement, selfefficacy and agentic capacities on nurses' turnover intention and patient satisfaction. bmc health serv res. 2018;18(1):227. doi: 10.1186/s12913-018-3013-z [5] zareifar s, haghpanah s, beigipour z, hosseini s, molavi ma, naderi m. job satisfaction and stress levels of nurses working in oncology wards; a multicenter study. galen med j. 2017;6(2):128–35. doi: 10.31661/ gmj.v6i2.722. [6] specchia ml, cozzolino mr, carini e, di pilla a, galletti c, ricciardi w, et al. leadership styles and nurses’ job satisfaction. results of a systematic review. int j environ res public health. 2021;18(4):1552. the study found that oncology nurses in rizgary hospital experience moderate overall job satisfaction, with neutrality prevailing across most job-related factors. while nurses reported satisfaction with professional relationships, responsibility, and control over work conditions, dissatisfaction was notable regarding salary, vacation benefits, and overall benefits packages. demographic factors such as age, gender, education, and years of experience influenced satisfaction levels. career advancement, research participation, and academic collaboration opportunities were limited, and issues such as weekend compensation and scheduling flexibility were identified as concerns. these findings suggest that improving compensation, benefits, professional development opportunities, and supportive management practices could enhance job satisfaction, reduce turnover, and promote higher-quality care for oncology patients. drawing on the study’s findings, the following recommendations can be made. health care organizations, such as the ministry of health and relevant policymakers, should increase salaries and benefits to recruit and retain high-quality nurses. improve working conditions: a significant proportion of nurses reported dissatisfaction with their work schedules in the study. in addition to providing flexible schedules that enable nurses to manage their personal and professional lives, healthcare facilities should seek to enhance working conditions by strategically expanding their workforce in order to reduce staffing shortages. by reducing excessive workloads, minimizing overtime, and improving overall job satisfaction, hiring more nurses can improve patient care and retain qualified personnel. 142 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion references recommendations https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.14 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article med j islam repub iran. 2017;31:130. doi: 10.22038/mjiri.2017.9255 [18] al sabei sd, labrague lj, miner ross a, karkada s, albashayreh a, al masroori f, et al. nursing work environment, turnover intention, job burnout, and quality of care: the moderating role of job satisfaction. j nurs scholarsh. 2020;52(1):95-104. doi: 10.1111/jnu.12528. doi: 10.3390/ijerph18041552 [7] kaiser ja, westers jb. nursing teamwork in a health system: a multisite study. j nurs manag. 2018;26(5):555-562. doi: 10.1111/ jonm.12582. [8] sallam m, al-salahat k, nofal a. job satisfaction and burnout among oncology nurses in jordan: a cross-sectional study. ann med surg (lond). 2022;78:103756. doi: 10.1016/ j.amsu.2022.103756 [9] morais bx, pedro cmp, dalmolin gl, silva am. professional satisfaction of nursing workers from a service of hematologyoncology. revista rene. 2018;19:e3165. doi: 10.15253/2175-6783.2018193165 [10] aloisio ld, gifford wa, mcgilton ks, borschneck a, estabrooks ca, rycroftmalone j, et al. factors associated with job satisfaction among care aides in residential long-term care: a cross-sectional study. int j nurs stud. 2021;116:103372. doi: 10.1016/ j.ijnurstu.2021.103891 [11] haghpanah s, zareifar s, beigipour z, hosseini s, molavi m a, naderi m. job satisfaction and stress levels of nurses working in oncology wards; a multicenter study. galen medical journal. 2017;6(2):e722. doi:10.31661/gmj.v6i2.722 [12] al‐hamdan z, manojlovich m, tanima b. jordanian nursing work environments, intent to stay, and job satisfaction. j nurs scholarsh. 2017;49(1):103–10. doi: 10.1111/ jnu.12265. [13] moyo i, gwele ns. job satisfaction and its associated factors among nurses in a public hospital in south africa. j nurs manag. 2022;30(2):496-503. doi: 10.1111/ jonm.13506. [14] zhang yy, han wl, qin w, yin hx, zhang cf, kong c, et al. extent of compassion satisfaction, compassion fatigue and burnout in nursing: a meta-analysis. j nurs manag. 2018;26(7):810–9. doi: 10.1111/jonm.12589 [15] da silva vr, de s velasque l, tonini t. job satisfaction in an oncology nursing team. rev bras enferm. 2017;70(5):988–95. doi: 10.1590/0034-7167-2016-0422. [16] isfahani p, sarzehi t. job satisfaction among nurses in hospitals of iran: a systematic review and meta-analysis. pajouhan sci j. 2019;17(4):1–8. doi: 10.52547/psj.17.4.1. [17] shahri sss, ghashghaee a, behzadifar m, bragazzi nl, behzadifar m, mousavinejad n, et al. depression among iranian nurses: a systematic review and meta-analysis. 143 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article psychological distress in diabetic and myocardial infarction patients in erbil citycomparative study abstract background and objectives: psychological distress refers to a range of negative emotional experiences, such as anxiety, depression, and stress. diabetes mellitus and myocardial infarction are two medical conditions that can have a significant impact on an individual's psychological well-being. therefore, the study aimed to assess and compare psychological distress among diabetes mellitus and myocardial infarction patients in erbil city. methods: a quantitative, comparative study design was conducted on 100 patients whom 50 of them were diabetes mellitus patients at layla qasim health center and the other 50 were myocardial infarction patients at the cardiac centre in erbil city. the data was collected from 20th april 2022 till 24th may 2023. results: the result showed that less than half of myocardial infarction patients were old adults which is 42% between 57-68 years, married, illiterate and living in urban. on the other hand, less than half of diabetes mellitus patients were middle-aged adults, which is 42% between 45-56 years, married illiterate and living in urban. the ranges of the genders are equal with 50% being male and 50% being female. also, more than half of myocardial infarction patients are non-smokers 52%, and 34% are smokers. in contrast, less than half of diabetes mellitus patients are 40% nonsmokers, and 20% are smokers. conclusions: the majority of diabetic mellitus patients had a moderate level of depression. at the same time, anxiety and stress were extremely severe, and most patients with myocardial infarction had an extremely severe level of depression, anxiety and stress. keywords: psychological distress; diabetes mellitus; myocardial infarction; patients. mosleh saber kareem; department of nursing, college of nursing, hawler medical university, erbil, iraq. (correspondence: mosleh.kareem@hmu.edu.krd) muhammad hasan awla; department of nursing, college of nursing, hawler medical university, erbil, iraq. dlzar sadeeq anwar; department of nursing, college of nursing, hawler medical university, erbil, iraq. iman saleh azeez; department of nursing, college of nursing, hawler medical university, erbil, iraq. sideeq sadir ali; department of nursing, college of nursing, hawler medical university, erbil, iraq. 193 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 24/06/2023 accepted: 19/11/2023 published: 30/11/2023 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article psychological distress is a common mental health problem in the community. it is a state of emotional suffering typically characterized by symptoms of depression, anxiety and stress. patients with chronic diseases may experience negative emotions, such as depression. it is an unpleasant or emotional feeling that affects the functional capacity of individuals; psychological distress interferes with activities of daily living and easily results in negative views of one's self, others, and the environment around them [1]. psychological distress is largely defined as a state of emotional suffering characterized by symptoms of depression, stress and anxiety [2]. stress is a state of mental or emotional strain or tension that results from adverse or demanding circumstances [3]. anxiety is the most common, or frequently occurring, mental disorder, which is characterized by restlessness and disturbance of thinking and behavior [4]. depression is the most common mental health condition in the general population, characterized by sadness, loss of interest or pleasure, disturbed sleep or appetite, feelings of tiredness, and poor concentration [5]. diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves. the most common is type 2 diabetes, usually in adults, which occurs when the body becomes resistant to insulin or doesn't make enough insulin. in the past three decades the prevalence of type 2 diabetes has risen dramatically in countries of all income levels [6]. a heart attack, also called a myocardial infarction, happens when a part of the heart muscle does not get enough blood. the more time that passes without treatment to restore blood flow, the greater the damage to the heart muscle. coronary artery disease (cad) is the main cause of heart attacks. a less common cause is a severe spasm, or sudden contraction, of a coronary artery that can stop blood flow to the heart muscle [7].depression is recognized as an independent risk factor for the development of myocardial infarction. the prevalence of psychological distress among mi patients is high, with depression existing in 70.7% of patients and anxiety symptoms (24%) [8]. also, the prevalence of psychological distress in patients with dm ranges from 18 % to 52 % globally [9]. myocardial infarction (mi) is a serious and potentially life-threatening disease, that has often been associated with significant anxiety and depression in patients. it causes substantial morbidity and mortality [10]. the estimated prevalence of depression in patients with chronic diseases ranges from 9.3 to 25% and patients with chronic diseases such as hypertension, coronary heart disease, and diabetes have a high incidence of depression. the depression and the cardiovascular risk are strongly correlated and many patients with chronic diseases have mental disorders, such as depression, because of the long-term nature of the disease and its impact on quality of life [11]. anxiety after a myocardial infarction (mi) is common. most of the mi patients showed ahigh level of anxiety immediately after the diagnosis of the disease both in western and eastern countries, namely; australia, england, japan, south korea, and the united states. similarly, in a study of the norwegian population with mi, a higher level of anxiety in the initial phase (20%) was reported [12]. some studies have reported that patients with diabetes are almost twice as likely to suffer from anxiety and depression as the general population and between 20% and 40% of people with t2dm experience feelings of anxiety, depression and stress [13]. around 14% of people with diabetes have diagnosable general anxiety disorder and up to 194 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article centre in erbil city. the study was conducted from 12th april 2023 to 20th june 2023 and the data was collected from 20th april 2022 to 24th may 2023. the data was collected through a questionnaire that consisted of two parts: part one: sociodemographic data (age, gender, marital status, occupational status, religion, living area, economic status, level of education, sleep quality, smoking state and high blood pressure) part two; depression, anxiety and stress scale 21 items (dass-21) is a set of three self-report scales designed to measure the emotional states of depression, anxiety and stress. each of the three dass-21 scales contains 7 items, divided into subscales with similar content. the rating scale is as follows: (0, 1, 2, and 3): 0 did not apply to me at all. 1 applied to me to some degree, or some of the time. 2 applied to me to a considerable degree or a good part of time. 3 applied to me very much or most of the time. scales the dass yields three subscale scores for depression, anxiety, and tension/stress. dass anxiety = 2 + 4 + 7 + 9 + 15 + 19 + 20 dass depression = 3 + 5 + 10 + 13 + 16 + 17 + 21 dass stress = 1 + 6 + 8 + 11 + 12 + 14 +18 recommended cut-off scores for conventional severity labels (normal, moderate, severe) are as follows: scores on the dass21 will need to be multiplied by 2 to calculate the final score [15]. 40% have subsyndromal elevated anxiety levels. an emerging body of literature suggests that stress has a role in the etiology of type 2 diabetes mellitus (t2dm) both as a predictor of new-onset t2dm and as a prognostic factor in people with existing t2dm [14].according to the researcher’s expectations in our society, psychological distress affects the immune system and the patient’s health condition and thus leads to chronic diseases, especially diabetes and myocardial infarction. therefore, researchers attempted to evaluate psychological distress among patients with diabetes and myocardial infarction in the city of erbil and identify the main points between patients with diabetes and myocardial infarction. the present study is a quantitative, comparative study conducted to assess psychological distress (depression, anxiety, and stress) among diabetic and myocardial infarction patients in erbil city. the formal arrangement was taken from the college of nursing / scientific committee, also took permission from layla qasim health center, hawler teaching hospital, rizgary teaching hospital and surgical specialty hospital-cardiac centre. the sample of the study was estimated at 100 patients from both diabetes meletus (dm) and myocardial infarction (mi) (50 diabetic and 50 mi patients) in erbil city, at the same time, 12 patients with dm and 11 patients with mi refused to participate in the present study. regarding the inclusion criteria, there were diabetic and myocardial infarction patients of both genders and over the age of eighteen years old, while the exclusion criteria were; patients who had cancer or mental problem. the settings of the study were from layla qasim health center, hawler teaching hospital, rizgary teaching hospital and surgical specialty hospital-cardiac 195 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article the research followed the most recent version of the declaration of helsinki, and the study received ethics approval from the human research ethics committee at the hawler medical university/ college of nursing under the code 10. the data was analyzed using the statistical package for social sciences (spss, version 26), using two statistical analyses: frequency and percentage descriptive data analysis, and independent samples t-test, mean difference, 95% confidence interval of the difference mean and standard deviation for comparative between both types of disease. for comparative analysis between mean of diabetic and myocardial infarction used a p-value of ≤ 0.05 was considered statistically significant. the demographics of 100 patients with both myocardial infarction and diabetes mellitus are displayed in table 1. the table also displays divinations among mi and dm patients with varying ages, genders, socioeconomic backgrounds, and quality of sleep. the ages of the participants ranged from 33 to 69. patients aged 57 to 68, they made up the largest age group (42%) of those diagnosed with a myocardial infarction. the next tier, comprising 30% of the total, included those aged 45–56. ages 69 and up accounted for 26% of those with the third stage of mi. the incidence of mi was lowest in those aged 3344 (2%). in contrast, 42% of people with dm fell within the age range of 45-56. between the ages of 57 and 68 made up the next tier, representing 28%. people aged 69 and up had type 3 diabetes, representing around 16% of the population. the smallest percentage, 14%, came from ages 33 to 44. the mean age and standard deviation in mi were 61.54 ± 9.842 and in dm was 55.60± 10.087. both males and females made up 50% of the mi and dm patient populations. participants' marital status varied widely; for example, among those with mi, 90% were married, and 10% were widowed. in contrast, the majority of people with diabetes were married. in addition, 14% were either widowed. patients with mi were more likely to live in an urban region (84%) than in a rural area (16%). moreover, 92% of type 2 diabetes patients were city dwellers, whereas only 8% were residents of rural areas. concern the level of education, of participants were largely illiterate (46%), with only 14% able to read and write. while 22% had completed high school, 8% had completed middle school, and 10% had completed colleges or universities. patients with diabetes mellitus had the following educational attainment levels: (50%) do not know how to read or write, while (6%) do. 24% have only completed elementary school, 18 % have completed middle school, and 2% have completed high school and college). in table 1. shows that just 28% of the mi participants were actively employed, while 72% were not, and 0% were retired. cases of dm included people who were either working (14%), not working (76%), or retired (10 %). the table also includes the income of each person based on their profession. most heart attack patients (84%), of them had high incomes (4%), had low incomes, (12%) fell within the middle class. regarding the economic status of the study sample, had 2% had a very high income, the majority of them had somehow income, and 30 % were poor in economic statutes. regarding the participant’s personal health conditions, the table also shows some other criteria regarding their health. the quality of sleep reported by those with a mi was as follows: patients were more likely to report good sleep quality (64%), fewer sleep problems (18%), and shorter sleep duration (18%). however, just 26% of dm patients reported poor sleep quality, 34% 196 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article 197 shared a common religious background: they were all muslims. last but not least, the table details whether or not any participants suffered from any additional chronic diseases. 54% of mi patients were disease-free, whereas nearly half had hypertension. asthma affected 2% of the population. despite this, more than half of the diabetic individuals 64 % were otherwise healthy. hypertension affected 34% whereas asthma affected only 2%. copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. reported sleeping difficulties, and 64% reported getting enough sleep. this table shows the percentage of smokers and nonsmokers within our patient population. there were more non-smokers (52%) than smokers (34%), passive smokers (8%) than smokers (34%), and former smokers (6%) among mi patients. while 40% of dm patients were never smokers, 18% were non-smokers, 20% were never active smokers, and 22% were never active exsmokers. patients with both mi and dm table 1: socio demographic characteristics of study participants. socio demographic characteristics myocardial infarction diabetes mellitus frequency (n=50) percentage (%) frequency percentage (n=50) (%) age group (years) 33-44 1 (2) 7 (14) 45-56 15 (30) 21 (42) 57-68 21 (42) 14 (28) >69 13 (26) 8 (16) m ± sd 61.54 ± 9.842 55.60 ± 10.087 gender male 25 (50) 25 (50) female 25 (50) 25 (50) marital status single 0 (0) 0 (0) married 45 (90) 42 (84) divorce 0 (0) 1 (2) widowed 5 (10) 7 (14) residential area urban 42 (84) 46 (92) rural 8 (16) 4 (8) level of education illiterate 23 (46) 25 (50) read and write 7 (14) 3 (6) primary school 11 (22) 12 (24) secondary school 4 (8) 9 (18) institute and college 5 (10) 1 (2) occupational status employment non-employed 14 36 (28) (72) 7 38 (14) (76) retirement 0 (0) 5 (10) economic status high income 2 (4) 1 (2) middle income 42 (84) 34 (68) low income 6 (12) 15 (30) sleep quality good sleep quality 32 (64) 20 (40) difficulty sleeping 9 (18) 17 (34) short sleep 9 (18) 13 (26) smoking pattern non-smoker 26 (52) 20 (40) passive smoker 4 (8) 9 (18) smoker 17 (34) 10 (20) ex-smoker 3 (6) 11 (22) religion muslim 50 (100) 50 (100) other chronic disease non hypertension 27 22 (54) (44) 32 17 (64) (34) asthma 1 (2) 1 (2) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article moderate (4%), normal (6%) and mild (10%)-while (14%) of dm patients had extremely high levels of anxiety. contrarily, the anxiety levels of mi patients varied widely, with 2 percent of them reporting normal anxiety, 6 percent reporting mild anxiety, 20 percent reporting moderate anxiety, 8 percent reporting severe anxiety, and 64 percent reporting the highest levels of anxiety. the levels of stress among dm patients were as follows: 10 % of the patients experienced both normal and moderate levels of stress. only 2% of them had a severe level of stress; meanwhile, more than half (60%) had extremely severe stress. on other hand, the levels of stress among mi patients are also different; the normal to mild level were 2% and 6%. 20% had moderate stress levels, 24% had a severe level and highest level was extremely severe level of stress among mi patients was 48%. 198 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2 displays the prevalence of depression, anxiety, and stress among individuals with diabetes and myocardial infraction (mi). five categories-normal, mild, moderate, severe, and extremely severe are used to categorize the severity of depression. less than half of the study sample had diabetes mellitus and 34% had moderate levels of depression. the lowest level of depression was 14% and it showed both mild and severe symptoms, while 16% of them had a normal level of depression. among the patients, 22% had an extremely severe depression. the levels of depression among mi patients were as follows: 8 % of them had a normal and mild depression, 30 % had a moderate level of depression, 6 % had severe level, and 48 % had an extremely severe level, which was the highest percentage among them. in table 2, the levels of anxiety were also displayed. most dm patients (66%), who had extremely high levels of anxiety , had the lowest levels— table 2: depression, anxiety and stress level among diabetic and myocardial infarction patients frequency (n=50) percentage (%) frequency (n=50) percentage (%) level of depression normal mild 8 7 (16) (14) 4 4 (8) (8) moderate 17 (34) 15 (30) severe 7 (14) 3 (6) extremely severe 11 (22) 24 (48) level of anxiety normal 3 (6) 1 (2) mild 5 (10) 3 (6) moderate 2 (4) 10 (20) severe 7 (14) 4 (8) extremely severe 33 (66) 32 (64) level of stress normal 7 (14) 3 (6) mild 5 (10) 1 (2) moderate 7 (14) 10 (20) severe 1 (2) 12 (24) extremely severe 30 (60) 24 (48) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article anxiety among mi patients, which are 10.56, while the deviation is 9.163, the confidence of the interval of the difference lower is -0.404 and higher is 4.804 as the p value is 0.096. additionally, the results of overall stress levels among dm patients are 18.20, and total stress levels among mi patients are 16.92, as shown in the table. also, the deviation is 11.305, the lower confidence interval for the difference is 1.933, and the higher confidence interval is 4.493, with a p value of 0.425. myocardial infarction patients, and both of these investigations revealed that the patients had poor or insufficient sleep [17]. in table 2, depression, anxiety, and stress levels were listed for diabetic and myocardial infarction patients. the majority of diabetic patients had moderate levels of depression, which was inconsistent with a quantitative cross-sectional study about the relationship between depression, anxiety, and stress symptoms and glycemic control in diabetes mellitus patients, which found that most patients were suffering. a study revealed the high prevalence of depression among mi patients [8]. supports the finding that the majority of patients with this condition had highly severe levels table 3 compares the averages for diabetes and myocardial infraction and displays the overall levels of stress, anxiety, and depression. the average level of depression in dm patients is 10.28, while the average level of depression in mi patients is 13.52, with a standard deviation of 9.755. and the lower and upper limits of the confidence interval for the difference are 6.012 and -0.468, respectively, while the p value is 0.023, which means that statistically was significant. regarding the total levels of anxiety among dm patients, which are 12.76, and the total levels of in this study, psychological discomfort is compared between diabetic and myocardial infarction patients in erbil city. the majority of the patients were between the ages of forty-five and fifty-six in the first part of the age group distribution. this result was in agreement with a case-control study about the high prevalence of depressive, anxious, and stress symptoms among diabetes mellitus patients, which revealed that the majority of patients fell within these age ranges [13].the majority of patients reported having good sleep quality, but two studies contradicted one study's findings among type 2 diabetes patients in the united states [16]. another study looked at sleep disturbances in 199 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: comparative between mean of diabetic and myocardial infarction total level of dass mean std. deviation 95% confidence interval of the difference t-value p-value lower upper depression dm 10.28 9.755 -6.012 -0.468 -2.348 0.023 depression-mi 13.52 anxiety – dm 12.76 9.163 -0.404 4.804 1.698 0.096 anxiety-mi 10.56 stress – dm 18.20 11.305 -1.933 4.493 0.801 0.427 stress-mi 16.92 discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article the majority of diabetic mellitus patients were had a moderate level of depression, while anxiety and stress were extremely severe, the majority of patients who had myocardial infarction had an extremely severe level of depression, anxiety and stress. about the comparative level of psychological distress among diabetic mellitus (dm) and myocardial infarction (mi) patients, the results showed a difference between them in that the dm level of depression was lower than that of mi, but the level of stress and anxiety in dm was higher than that of mi patients. [1] doglikuu bd, abdulai a, yaseri m, shakibazadeh e, djazayery a and mirzae k. do interactions between patients’ psychological distress and adherence to dietary recommendation predict glycemic control among persons with type2 diabetes in ghana. life style medicine article. 2021; 1(1): 4-2. doi:10.1002/lim2.22 [2] drapeau a, marchand a, prevost db. epidemiology of psychological distress. mental illnesses understanding prediction and control.2012; 5 (2): 105-6. doi: 10.5772/30872 [3] surwit rs, schneider ms, feinglos mn. stress and diabetes mellitus. diabetes care journal. 1992; 15 (10): 1413-22. doi.org/10.2337/diacare.15.10.1413 [4] adwas aa, jbireal jm, azab ae. anxiety: insights into signs, symptom, etiology, pathophysiology and treatment. east african scholars journal of medical sciences. 2019; volume 2, issue10. www.easpublisher.com [5] lim gy, tam ww, lu y, ho cs, zhang mw. prevalence of depression in the community from 30 countries between 1994 and 2014. scientific reports journal.2018; 8:2861. doi:10.1038/s41598-018-21243-x [6] world health organization. diabetes mellitus. 2023. https://www.who.int/ [7] centers for disease control and prevention. hart attacks symptoms, risk, and recovery. 2022. https://www.cdc.gov/heartdisease/ heart_attack.htm [8] vaswani d. psychological stress in myocardial infarction patients. india journal cardiac disease women.2020; 5 (1): 34-5. doi.org/ of depression. according to the results of a quantitative cross-sectional study conducted in iran about the prevalence of depression, anxiety, and stress disorders in elderly people living in khoy, 74% of elderly people in the khoy county had severe anxiety [18]. the majority of patients who were suffering from diabetes and myocardial infarction had extremely severe levels of anxiety, the study found. regarding the level of stress in both diseases, it was determined that the patients had extremely high levels of stress. this finding was similar to that of the study about oxidative stress as the primary cause of acute myocardial infarction in diabetics, which established that stress is the primary factor in myocardial infarction (mi) in diabetics and has the worst prognosis [19]. the comparative levels of stress, anxiety, and depression between diabetic and myocardial infarctions were discussed in table 3, which was the last one. it demonstrated that there were significant differences in patients' levels of depression, anxiety, and stress between these two diseases, such that the level of depression among dm patients is lower than the level of depression among mi patients. however, the conclusion was contradicted by two other studies [20], [21]. which established that the level of depression in both diseases is lower than anxiety and stress. the overall levels of worry and stress among dm patients are higher than the overall levels among mi patients. therefore, in order to effectively provide psychological therapy to mi and dm patients, it is necessary to take into account their psychological needs. 200 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.20 erbil j. nurs. midwifery, vol. 6, no. (2), nov 2023 original article (3):258. doi.org/10.1037/aap0000147 [17] johansson i, karlson bw, grankvist g, brink e. disturbed sleep, fatigue, anxiety and depression in myocardial infarction patients. european journal of cardiovascular nursing. 2010 ;9 (3), p. 175-180. doi: 10.1016/ j.ejcnurse.2009.12.003 [18] babazadeh t, sarkhoshi r, bahadori f, moradi f, shariat f. prevalence of depression, anxiety and stress disorders in elderly people residing in khoy, iran (2014-2015). journal of research in clinical medicine. 2016 ;4 (2):122-128. doi: 10.15171/jarcm.2016.020 [19] filippo cd, cuzzocrea s, rossi f, marfella r. and d'amico m. oxidative stress as the leading cause of acute myocardial infarction in diabetics. cardiovascular drug reviews journal. 2006; 24(2):77-87. doi: 10.1111/j.15273466.2006. 00077.x [20] norlund f, lissaker c, wallter j, held c, ollson emg. factors associated with emotional distress in patients with myocardial infarction: results from the swedeheart registry. european journal of preventive cardiology 2018; 25(9). doi: 10.1177/2047487318770510 [21] qui s, sun h, liu y, kanu js, li r, yu y et al. prevalence and correlates of psychological distress among diabetes mellitus adults in the jilin province in china: a crosssectional study. peer journal. 2017; 10 (3): 5-11. doi: 10.7717/peerj.2869 10.1055/s-0040-1708575 [9] pearson s, wills k, woods m and warnecke e. effects of mindfulness on psychological distress and hba1c in people with diabetes. mindfulness journal. 2018; 9 (2): 1615-6. doi.org/10.1007/ s12671-018-0908-1 [10] sarkar s, chadda rk, kumar n and narang r. anxiety and depression in patients with myocardial infarction: findings from a center in india. general hospital psychiatry journal. 2012; 34(2): p.160-166. doi.org/10.1016/ j.genhosppsych.2011.09.016 [11] ma y, xiang q, yan ch, liao h, wang j. relationship between chronic diseases and depression: the mediating effect of pain. bmc psychiatry journal. 2021; 436 (36). doi.org/10.1186/s12888-021-034283 [12] panthee b and kritpracha c. anxiety and quality of life in patients with myocardial infarction. nurse media journal of nursing.2011; 1(1): p.105115.doi.org/10.14710/ nmjn.v1i1.750 [13] bener a, oaa al-hamaq a and e dafeeah. high prevalence of depression, anxiety and stress symptoms among diabetes mellitus patients. the open psychiatry journal. 2011; volume, 5(1). doi: 10.2174/1874354401105010005 [14] hackett ra and steptoe a. type 2 diabetes mellitus and psychological stress a modifiable risk factor. nature reviews endocrinology journal. 2017; 13(9): p.54760. doi: 10.1038/nrendo.2017.64 [15] henry jd, crawford jr. the short-form version of the depression anxiety stress scales (dass-21). construct validity and normative data in a large non-clinical sample. british journal of clinical psychology. 2005; 44 (2): 227-39. doi.org/10.1348/014466505x29657 [16] seaton va, narcisse mr, subica am, long cr, matthews ee, mcelfish pa. sleep quality partially mediates the association between type 2 diabetes and psychological distress in native hawaiian and pacific islander adults in the united states. asian american journal of psychology. 2019;10 201 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.11 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article patient satisfaction with the quality of nursing care in public and private hospitals in erbil city abstract background and objectives: patient satisfaction is an essential parameter in assessing the quality of care and healthcare facility performance and the most important competitive advantage of the government and private hospitals. the study aims to investigate patients’ satisfaction regarding the quality of nursing care in both public and private hospitals. methods: a quantitative, comparative study was conducted among 330 patients (165 from public hospitals and 165 from private hospitals) in erbil city from october 2023 to february 2024. data were collected through structured interviews using a standardized questionnaire and analyzed using descriptive and inferential statistics via the statistical package for the social sciences. results: among the 330 patients surveyed, the majority were aged 18 to 39 years (55.8%), predominantly female (65.5%) and married (75.2%). notably, 50.3% had been hospitalized over four times in public hospitals. patients reported their health status as fair (38.8% before hospitalization), with 64.2% transferred from other facilities. in private hospitals, 100% of patients had single occupancy in their rooms. satisfaction scores for nursing care were significantly higher in private hospitals compared to public ones (p < 0.001). significant associations were observed between sociodemographic factors and nursing care satisfaction (p < 0.001), with gender showing no significant association (p = 0.819). conclusions: the study concludes that patients in private hospitals exhibit strong satisfaction with the quality of nursing care compared to those in public hospitals. this highlights the importance of addressing disparities in nursing care quality between hospital types to enhance overall patient satisfaction and healthcare outcomes. keywords: patient satisfaction; quality of nursing care; public hospitals; private hospitals. ali taher mohammedameen; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. (correspondence: ali.mohammedameen@hmu.edu.krd) azzadin kamal mahmod; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. yousif bakr omar; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. haval mohammed qadir; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. sideeq sadir ali; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. burhan ezzadin sabir; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. 115 received: 19/05/2022 accepted: 22/10/2024 published: 30/11/2024 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:ali.mohammedameen@hmu.edu.krd mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.11 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article patient satisfaction with nursing care is a critical part of healthcare quality assessment, directly affecting patient outcomes, adherence to treatment plans, and overall healthcare delivery. it measures the patient’s perception to which extent they are satisfied with receiving healthcare from their healthcare provider. [1] the quality of nursing care includes several features that contribute to providing the highest care to patients, such as effectiveness, efficiency, patient safety, best patient outcomes, and effective communication by addressing patients' physical, psychological, emotional, sociocultural, and spiritual aspects of care needs competently, resulting in the best possible outcomes. [2, 3] providing holistic nursing care rather than physical nursing care only increased the patient’s level of satisfaction. as such, exploring the relationship between holistic care and patient satisfaction becomes imperative for optimizing healthcare delivery and improving patient-centered outcomes. [4]access to quality nursing care is a fundamental human right that significantly impacts patient well‐being. [5] one of the measurement methods to assess the quality of nursing care is by assessing patients' level of satisfaction. it can be improved by providing proper nursing care. [6, 7] a study conducted in erbil city in 2021 compared patient satisfaction levels between private and public hospitals. the research findings revealed a significant disparity in satisfaction levels, with patients in private hospitals being approximately 10 times more satisfied with overall healthcare services compared to those in public hospitals. this result underscores the importance of examining differences in patient experiences between healthcare sectors and highlights potential areas for improvement within the public healthcare system. factors contributing to higher satisfaction rates in private hospitals may include shorter wait times, perceived higher quality of care, more personalized attention, and better amenities. [8]lack of understanding of patients’ perception regarding the level of satisfaction with adult nursing care provided in private and public hospitals; the main part of hospital care is nursing care, and there is a critical gap in understanding healthcare quality. to compare satisfaction levels between these two types of hospitals, this study aims to provide insights to assess and compare the level of patient satisfaction with the adult nursing care provided by public and private hospitals in erbil city. this investigation holds significance for healthcare providers, administrators, and policymakers, as it can inform strategies to enhance the quality of nursing care delivery and improve overall patientsatisfaction. a quantitative, comparative study was designed to assess patients' satisfaction with the quality of adult nursing care in private and public hospitals in erbil city from october 2023 to february 2024. the sample size for this study was determined using a standard formula based on power analysis to detect statistically significant differences in patient satisfaction between public and private hospitals. with nearly 2250 patients admitted monthly to public hospitals, key parameters were established: a confidence level of 95% (with a z-value of approximately 1.96), a margin of error of 5% (0.05), and an estimated proportion (p) assumed to be 0.5 to maximize variability. using these parameters, the initial sample size was calculated with the formula n=z2*p*(1−p)/ e2. substituting the values, the calculation yielded approximately 384.16. to account for the finite population size [32] of 2250, the sample size was adjusted. 116 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.11 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article socio-demographic characteristics, while part ii employed the "patient satisfaction with nursing care quality questionnaire (psncqq)" developed by laschinger et al. [9]. this questionnaire was originally developed by a multidisciplinary research team and was adapted from “the patient judgments of hospital quality (pjhq)” questionnaire. prior assessments of reliability, as indicated by cronbach coefficients, have consistently demonstrated high values. the scoring of the questionnaire involves calculating a general satisfaction score for each patient by summing the scores for all items and dividing by the total number of items. this process yields a single average score that reflects the patient’s overall satisfaction with the nursing care received. ethical approval was initially obtained from the ethics committee at the college of nursing, hawler medical university (approval no. 5, january 21, 2024). subsequently, official permission was secured from the general directorate of health for data collection in public hospitals. for private hospitals, an official request was made by the university through administrative channels to obtain permission from each hospital's administrative department. additionally, verbal consent was obtained from each patient before data collection. the collected data were analyzed using descriptive statistics to calculate frequency and percentage distributions. additionally, for finding the mean difference, the t-test was used, and for finding the level of significance, the mann-whitney u test (because they were not normally distributed) was employed to compare variables between groups. all statistical analyses were conducted using the statistical package for social sciences (spss), version 23. the adjustment helps maintain the statistical validity of the study. without this correction, the results may be skewed, leading to incorrect conclusions about the population. using the formula nadjusted=n/1+ (n−1)/n [33], resulting in an adjusted sample size of about 328.6. ultimately, the study recruited a total of 330 patients, with 165 from public hospitals and 165 from private hospitals. this sample size calculation, based on a 5% margin of error and a 95% confidence level, ensured sufficient statistical power for the study, facilitating meaningful comparisons of patient satisfaction across hospital types. patients were selected from most of the public hospitals in erbil city, including rizgary teaching hospital, hawler teaching hospital, maternity teaching hospital, west emergency hospital, and east emergency hospital. in this study, a total of seven private hospitals were initially identified as eligible candidates for inclusion, namely paky hospital, serdem private hospital, zheen international hospital, cmc private hospital, mehrabani surgical hospital, hawler private hospital, and zanko hospital. however, five private hospitals were selected for participation to maintain confidentiality and impartiality without singling out any specific institution. the selection process was conducted based on factors such as accessibility, patient volume, and diversity of services offered. by including a diverse representation of private hospitals, the study aims to comprehensively compare private and public hospitals regarding the quality of adult nursing care in erbil city while ensuring fairness and confidentiality. this study included adult patients aged 18 years and older, regardless of gender. patients who were unconscious or had significant mental health issues were excluded to ensure valid responses. data were collected through structured interviews utilizing a two-part questionnaire. part i captured 117 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.11 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article table 1 shows the socioeconomic characteristics of patients in both private and public hospitals. in terms of age distribution, the majority of patients in both hospital types were young adults aged between 18 and 39 years, comprising 55.2% in private hospitals and 55.8% in public hospitals. middle-aged adults (40-59 years) accounted for 30.9% in private hospitals and 25.5% in public hospitals, while old adults (60-99 years) constituted 13.9% in private hospitals and 18.8% in public hospitals. the mean age and standard deviation for patients in private hospitals were 39.47 ± 15.857 years, whereas in public hospitals they were 40.62 ± 16.797 years. regarding gender distribution, more patients were females in both private (58.2%) and public (65.5%) hospitals. the majority of patients in both hospital types were married, comprising 75.2% in private hospitals and 73.3% in public hospitals. regarding time of hospitalization, the majority of patients in private hospitals (39.4%) were admitted only once in the past two years, whereas in public hospitals, the majority (50.3%) were hospitalized over four times, likely due to the high cost of private hospitals. before hospitalization, most patients in private hospitals (38.8%) reported their health status as fair, while in public hospitals, a slightly lower percentage (33.9%) reported fair health status. in terms of admission manner, a significant proportion of patients in both private (64.2%) and public (53.3%) hospitals were transferred from another facility. lastly, in private hospitals, the majority of patients (100%) stayed alone in their rooms, whereas in public hospitals, the majority (79.4%) stayed with more than one other person. 118 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result variable private hospitals n=165 public hospitals n=165 n (%) n (%) age group (years) 18-39 young adult 91 (55.2) 92 (55.8) 40-59 middle-aged adult 51 (30.9) 42 (25.5) 60-99 old-adult 23 (13.9) 31 (18.8) m ± sd 39.47 ± 15.857 40.62 ± 16.797 gender male 69 (41.8) 57 (34.5) female 96 (58.2) 108 (65.5) marital status single 23 (13.9) 28 (17) married 124 (75.2) 121 (73.3) divorced 4 (2.4) 2 (1.2) widowed 14 (8.5) 14 (8.5) table 1: socioeconomic characteristics of patients in private and public hospitals https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.11 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article 119 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: socioeconomic characteristics of patients in private and public hospitals variable private hospitals n=165 public hospitals n=165 n (%) n (%) times of hospitalization during the past 2 years only once 65 (39.4) 38 (23) twice 23 (13.9) 27 (16.4) 3 times 14 (8.5) 11 (6.7) 4 times 10 (6.1) 6 (3.6) over 4 times 53 (32.1) 83 (50.3) overall patient’s health before hospitalization excellent 1 (0.6) 0 (0) good 39 (23.6) 22 (13.3) fair 64 (38.8) 56 (33.9) poor 44 (26.7) 58 (35.2) very poor 16 (9.7) 29 (17.6) unsure 1 (0.6) 0 (0) manner of admission toward admitted through the emergency department 20 (12.1) 67 (40.6) transferred from another facility 106 (64.2) 88 (53.3) admitted through patient registration/to the unit directly 36 (21.8) 8 (4.8) admitted after day procedure or test 1 (0.6) 2 (1.2) others 2 (1.2) 0 (0) the number of patients in a room for most of the hospital stay by yourself 165 (100) 30 (18.2) with another patient 0 (0) 4 (2.4) with 2 or more patients 0 (0) 131 (79.4) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.11 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article private hospitals, a total of 90.3% of respondents in this setting reported being “excellent” and “very good.” in contrast, only 21.8% of patients in public hospitals fell into the same categories. the data reveal that a significant proportion of public hospital patients, 41.2%, reported a “good”, 28.5% were “fair”, and 8.5% were “poor”. therefore, the total percentage in those similar lower categories was 9.7% among private hospitals. the mean satisfaction score in private hospitals was 4.678 with a standard deviation of 0.451, whereas in public hospitals, the mean satisfaction score was lower at 3.478 with a standard deviation of 0.682. this finding underscores the importance of hospital type in influencing patient satisfaction with nursing care. 120 table 2 shows the overall level of satisfaction reported by patients, showing a notable disparity between private and public hospitals. patients in private hospitals exhibited higher levels of satisfaction with nursing care, with 79.4% expressing being 'excellent.' conversely, a mere 7.9% of them in public hospitals expressed that they were “excellent” regarding the quality of nursing care. in addition to the high percentage of “excellent” patients in table 3 shows the comparative analysis of patient satisfaction with the quality of nursing care between private and public hospitals. the results indicate a very highly significant difference between the two types of hospitals (p-value <0.001), with patients in private hospitals reporting notably significantly higher satisfaction levels. copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: overall patients’ satisfaction with the quality of nursing care in private and public hospitals overall satisfaction setting of hospitals total private n=165 public n=165 n (%) n (%) excellent 131 (79.4) 13 (7.9) 144 (43.64) very good 18 (10.9) 23 (13.9) 41 (12.41) good 13 (7.9) 68 (41.2) 81 (24.55) fair 2 (1.2) 47 (28.5) 49 (14.85) poor 1 (0.6) 14 (8.5) 15 (4.55) total 165 (100) 165 (100) 330 (100) table 3: comparative between public and private hospitals regarding patients’ satisfaction with the quality of nursing care total mean of patients’ satisfaction public mean ±sd private mean ±sd mean difference 95% confidence interval of the difference p-value (sig.) lower upper 3.491± 0.698 4.678± 0.451 1.187 1.060 1.314 2344.5* < 0.001 (vhs)** * mann-whitney u test ** very high significant difference https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.11 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article ed-admitted patients reported “very good” or “excellent” satisfaction, whereas those admitted through patient registration or elective procedures reported much higher levels of satisfaction. a very significant relationship was found between roomsharing and satisfaction (p < 0.001). patients who were in a room alone or with one other person reported higher satisfaction levels, with 68.2% of these patients rating their experience as “excellent”. conversely, patients who shared rooms with multiple individuals reported lower satisfaction, with only 8.4% rating their care as “excellent”. table 4 reveals the association between the levels of patients’ satisfaction with some variables of socio-demographic data. the age group 18-39 years reported the highest level of “excellent” satisfaction, with 39.3% of patients indicating they were highly satisfied. in comparison, 25.9% of patients in the same age group rated their experience as “very good”. for the older age groups (40-59 and 60-99 years), satisfaction levels decrease, with fewer patients reporting “very good” or “excellent” are used. the relationship between age and satisfaction was found to be statistically significant (p = 0.029), indicating that younger patients tend to express higher levels of satisfaction. gender did not show a significant relationship with patient satisfaction (p = 0.819), as the levels of satisfaction between male and female patients were fairly comparable. however, slightly more females reported “very good” or “excellent” satisfaction than males, but the difference was not statistically significant. marital status was significantly associated with satisfaction (p = 0.020). married patients were more likely to report “very good” or “excellent” satisfaction, with 44.9% of married patients indicating high satisfaction, compared to lower satisfaction among single individuals, with only 33.3% of single patients reporting similarly high levels of satisfaction. the number of times a patient had been hospitalized significantly impacted satisfaction (p = 0.003). patients who had been hospitalized more than four times reported the lowest satisfaction levels, with only 33.8% rating their care as “very good” or “excellent”. on the other hand, those hospitalized only once were more likely to report high satisfaction (52.4%).patients admitted through the emergency department (ed) or transferred from another facility showed significantly lower satisfaction levels (p < 0.001). only 17.2% of 121 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.11 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article 122 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: association between level of patients’ satisfaction with some variables of socio-demographic data variables level patients’ satisfaction pvalue (sig.) poor n (%) fair n (%) good n (%) very good n (%) excellent n (%) age group (years) 18-39 11 (6) 39 (21.3) 42 (23) 19 (10.4) 72 (39.3) 0.029 s 40-59 4 (4.3) 5 (5.4) 25 (26.9) 12 (12.9) 47 (50.5) 60-99 0 (0) 5 (9.3) 14 (25.9) 10 (18.5) 25 (46.3) gender male 4 (3.2) 18 (14.3) 34 (27) 12 (9.5) 58 (46) 0.819 ns female 11 (5.4) 31 (15.2) 47 (23)) 29 (14.2) 86 (42.2) marital status single 4 (7.8) 9 (17.6) 13 (25.5) 8 (15.7) 17 (33.3) 0.02 hs married 10 (4.1) 37 (15.1) 59 (24.1) 29 (11.8) 110 (44.9) divorced 0 (0) 0 (0) 1 (16.7) 0 (0) 5 (83.3) widowed 1 (3.6) 3 (10.7) 8 (28.6) 4 (14.3) 12 (42.9) times of hospitalization only once 5 (4.9) 9 (8.7) 14 (13.6) 21 (20.4) 54 (52.4) 0.003 hs twice 4 (8) 8 (16) 14 (28) 2 (4) 22 (44) 3 times 1 (4) 6 (24) 0 (0) 4 (16) 14 (56) 4 times 1 (6.3) 1 (6.3) 5 (31.3) 1 (6.3) 8 (50) over 4 times 4 (2.9) 25 (18.4) 48 (35.3) 13 (9.6) 46 (33.8) manner of admission toward admitted through the ed 11 (12.6) 30 (34.5) 19 (21.8) 12 (13.8) 15 (17.2) <0.001 vhs transferred from another facility 4 (2.1) 17 (8.8) 54 (27.8) 25 (12.9) 94 (48.5) admitted through patient registration 0 (0) 2 (4.5) 6 (13.6) 3 (6.8) 33 (75) admitted after day procedure 0 (0) 0 (0) 2 (66.7) 0 (0) 1 (33.3) others 0 (0) 0 (0) 0 (0) 1 (50) 1 (50) the number of patients in a room by yourself 3 (1.5) 18 (9.2) 21 (10.8) 20 (10.3) 133 (68.2) <0.001 vhs with another patient 0 (0) 1 (25) 2 (50) 1 (25) 0 (0) with 2 or more patients 12 (9.2) 30 (22.9) 58 (44.3) 20 (15.3) 11 (8.4) ns= not significant relationship s= significant relationship hs= high significant relationship vhs= very high significant relationship https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.11 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article the study's investigation into overall patient satisfaction with nursing care revealed notable disparities between private and public hospitals. the majority of participants in private hospitals reported excellent levels of satisfaction, whereas those in public hospitals expressed a good level of satisfaction. these findings are in line with studies by alhusban m. and abualrub r. [21] and mulugeta et al. [22]. conversely, lotfi et al. [11], found that most patients were fair with nursing care in specific hospital wards. karaca a. and durna z. [12], found that the patients were more satisfied, which means very good with the nursing care from a private hospital in istanbul turkey. koç et al. [23], indicate that patients were generally moderately satisfied with the care they received. the study done by yusefi et al. [3] in shiraz, tehran, revealed that the total quality of nursing care from the patient’s perspective was moderate. thapa s, and joshi a. [16] in nipal, the finding revealed that the majority (51 %) of patients had poor satisfaction with the quality of nursing care provided; in this study, the good level equals moderate level because the researcher used five likert scales. the comparison between public and private hospitals regarding patient satisfaction further substantiates these disparities. the study identified a highly significant difference in satisfaction levels, with patients in private hospitals expressing higher satisfaction rates. these findings agree with hepsiba r. and bhattacharjee t. [24] in india, dinsa et al. [25] in ethiopia, and khattak et al. (2012) in pakistan. similarly, sharma s. and kamra p. [26] observed differing nursing care practices between public and private hospitals. additionally, mutiarasari et al. (2021) reported higher satisfaction levels among patients treated in private hospitals compared to public hospitals. this is supported by ali s. [27], who observed differing in this study, the participants predominantly comprised younger adults, with similar distributions observed in both private and public hospitals (55.2% and 55.8% respectively). additionally, the majority of the study samples were female and married, and the results align with previous studies conducted by al-khafaji z and al-hussein i. [10], lotfi et al. [11], karaca a. and durna z. [12], and goes et al. [13]. concerning the frequency of hospitalization over the past two years, the findings revealed that while the majority of participants in private hospitals were hospitalized only once, those in public hospitals experienced hospitalization over four times more frequently. this result corroborates the findings of studies conducted by findik et al. [14], eyasu et al. [15], and thapa s. and joshi a. [16] which revealed that most patients in private hospitals were hospitalized only once, compared with those in public hospitals. the study also found that the overall health status of patients in private hospitals before hospitalization was predominantly fair. this finding is consistent with research conducted by alsaqri s. [17] in ha’il city, saudi arabia. furthermore, a significant proportion of participants were transferred from another hospitalization facility, which supports the findings of milutinović et al. [18]. in terms of room arrangements, while most patients in public hospitals shared rooms, all participants in private hospitals stayed alone in their rooms. this trend is similarly observed in studies by akhtari-zavare et al. [19] in tehran most cases were admitted in general wards, and alharbi, et al. [20] in saudi arabia, more than half of the participants shared a hospital room with others, and nearly half had a family member with them during their hospitalization. 123 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.11 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article [1] manzoor f, wei l, hussain a, asif m, shah sia. patient satisfaction with health care services; an application of physician's behavior as a moderator. international journal of environmental research and public health. 2019;16 (18). doi: 10.3390/ ijerph16183318. [2] stavropoulou a, rovithis m, kelesi m, vasilopoulos g, sigala e, papageorgiou d, et al. what quality of care means? exploring clinical nurses' perceptions on the concept of quality care: a qualitative study. clinic and practice. 2022;12 (4):468-81. doi: 10.3390/clinpract12040051. [3] yusefi ar, sarvestani sr, kavosi z, bahmaei j, mehrizi mm, mehralian g. patients' perceptions of the quality of nursing services. bmc nursing. 2022;21 (1):131. doi: 10.1186/s12912-022-00906-1. [4] rajabpour s, rayyani m, mangolian shahrbabaki p. the relationship between iranian patients’ perception of holistic care and satisfaction with nursing care. bmc nursing. 2019;18 (1):48. doi: 10.1186/s12912-0190374-7. [5] fuseini ag, bayi r, alhassan a, atomlana ja. satisfaction with the quality of nursing care among older adults during acute hospitalization in ghana. nursing open. 2022;9 (2):1286-93. [6] aiken lh, sloane dm, ball j, bruyneel l, rafferty am, griffiths p. patient satisfaction with hospital care and nurses in england: an observational study. bmj open. 2018;8 (1):e019189. doi: 10.1136/bmjopen-2017019189. [7] gishu t, weldetsadik ay, tekleab am. patients' perception of quality of nursing care; a tertiary center experience from ethiopia. bmc nursing. 2019;18:37. doi: 10.1186/ s12912-019-0361-z. [8] qadir do, qader ss, al-banna da, rasool aa, shakor jk. patient’s satisfaction with health care services in erbil city/iraq. erbil journal of nursing and midwifery. 2021;3 (2):119 25. doi: 10.15218/ejnm.2020.14. [9] laschinger hs, hall lm, pedersen c, almost j. a psychometric analysis of the patient satisfaction with nursing care quality questionnaire: an actionable approach to measuring patient satisfaction. journal of nursing care quality. 2005;20 (3):220-30. doi: 10.1097/00001786-200507000-00006. nursing care practices between public and private hospitals. additionally, mutiarasari et al. [28] in indonesia reported higher satisfaction levels among patients treated in private hospitals compared to public hospitals. regarding the association between the levels of patients’ satisfaction with some variables of socio-demographic data related to the quality of nursing care, the study identified significant associations with all variables the biographical data of the patients in both (private and public) hospitals except gender, which did not show a significant relationship with patient satisfaction. these findings are consistent with charalambous et al. [29] in cyprus, siraj s. and arifa s. [30] in srinagar, jammu and kashmir, india, and sachdeva s. and kaur h. [31] in new delhi hospital, india, who observed similar trends in patient satisfaction and sociodemographic factors. however, the study found no significant associations between sociodemographic characteristics and nursing care quality in either public or private hospitals, which is consistent with findings by eyasu et al. [15] and al-khafaji z. and al-hussein i. [10] in their examination of nursing care practices. the quality of nursing care significantly influences patient satisfaction in both private and public hospitals in erbil city. this study concluded that staff nurses in private hospitals provide higher-quality nursing care compared to those in public hospitals. patients’ satisfaction levels were higher in private hospitals; the difference was statistically significant. from the study, it has been clear that in private and public hospitals, patient satisfaction was positively associated with some sociodemographic variables related to nursing care. finally, the quality of nursing care in public hospitals should be improved. 124 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.11 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article [20] alharbi hf, alzahrani ns, almarwani am, asiri sa, alhowaymel fm. patients' satisfaction with nursing care quality and associated factors: a cross-section study. nursing open. 2023;10 (5):3253-62. doi: 10.1002/ nop2.1577. [21] alhusban ma, abualrub rf. patient satisfaction with nursing care in jordan. journal of nursing management. 2009;17 (6):749-58. doi: 10.1111/j.1365-2834.2008.00927.x. [22] mulugeta h, wagnew f, dessie g, biresaw h, habtewold td. patient satisfaction with nursing care in ethiopia: a systematic review and meta-analysis. bmc nursing. 2019;18 (1):27. doi: 10.1186/s12912-019-0348-9. [23] koç z, sağlam z, şenol m. patient satisfaction with the nursing care in hospital. turkiye klinikleri journal of medical sciences. 2011;31 (3):629-40. doi: 10.5336/ medsci.2009-16413. [24] hepsiba rp, bhattacharjee t. a comparative study to assess the level of patient satisfaction on quality of nursing care among parturients admitted in government and private hospitals at lucknow. annals of the romanian society for cell biology. 2021;25 (7):31-41. [25] dinsa k, gelana deressa b, beyene salgedo w. comparison of patients satisfaction levels toward nursing care in public and private hospitals, jimma, ethiopia. nursing: research and reviews. 2022:177-89. doi: 10.2147/nrr.s380630. [26] sharma sk, kamra pk. patient satisfaction with nursing care in public and private hospitals. nursing & midwifery research journal. 2013;9 (3):130-41. doi: 10.1177/0974150x2013030. [27] ali ss. quality of immediate postoperative nursing care for patients in public and private hospitals in erbil city, iraq-comparative study. erbil journal of nursing and midwifery. 2020;3 (2):126-35. doi: 10.15218/ ejnm.2020.15. [28] mutiarasari d, demak ipk, bangkele ey, nur r, setyawati t. patient satisfaction: public vs. private hospital in central sulawesi, indonesia. gaceta sanitaria. 2021;35:s186-s90. doi: 10.1016/j.gaceta.2021.07.012. [29] charalambous m, sisou g, talias ma. assessment of patients' satisfaction with care provided in public and private hospitals of the republic of cyprus: a comparative study. international journal of caring sciences. 2018;11 (1):125. [10] al-khafaji zaa, al-hussein iqk. patient's satisfaction with nursing care in emergency department at public hospital in al-najaf al -ashraf governorate. global scientific journal. 2018;6 (11). [11] lotfi m, zamanzadeh v, valizadeh l, khajehgoodari m. assessment of nurse–patient communication and patient satisfaction from nursing care. nursing open. 2019;6 (3):1189-96. doi: 10.1002/nop2.316. [12] karaca a, durna z. patient satisfaction with the quality of nursing care. nursing open. 2019;6 (2):535-45. doi: 10.1002/nop2.237. [13] goes m, oliveira h, lopes m, fonseca c, pinho l, marques m. a nursing caresensitive patient satisfaction measure in older patients. scientific reports. 2023;13 (1):7607. doi: 10.1038/s41598-023-338059. [14] findik uy, unsar s, sut n. patient satisfaction with nursing care and its relationship with patient characteristics. nursing & health sciences. 2010;12 (2):162-9. doi: 10.1111/j.1442-2018.2009.00511.x. [15] eyasu kh, adane aa, amdie fz, getahun tb, biwota ma. adult patients’ satisfaction with inpatient nursing care and associated factors in an ethiopian referral hospital, northeast, ethiopia. advances in nursing, 2016, 6308617, 7 pages, 2016. doi: 10.1155/2016/6308617. [16] thapa s, joshi a. patients’ satisfaction with quality nursing care at teaching hospital, chitwan. journal of nursing and health science (iosr-jnhs). 2019;8 (3):71-5. doi:10.9790/1959-0803077175. [17] alsaqri s. patient satisfaction with quality of nursing care at governmental hospitals, ha’il city, saudi arabia. journal of biology, agriculture and healthcare. 2016;6 (10):128-42. [18] milutinović d, simin d, brkić n, brkić s. the patient satisfaction with nursing care quality: the psychometric study of the serbian version of psncq questionnaire. scandinavian journal of caring sciences. 2012;26 (3):598-606. doi: 10.1111/j.14716712.2012.00969.x. [19] akhtari-zavare m, abdullah my, hassan sts, said sb, kamali m. patient satisfaction: evaluating nursing care for patients hospitalized with cancer in tehran teaching hospitals, iran. global journal of health science. 2010;2 (1):117. 125 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.11 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article [30] siraj ss, arifa s. a comparative study to assess the quality of nursing care rendered by staff nurses and the level of satisfaction perceived by patients in selected wards of selected government and private hospitals of srinagar, kashmir. ip journal of paediatrics and nursing science. 2022;5 (2):62-73. doi: 10.18231/j.ijpns.2022.011. [31] sachdeva s, kaur h. a study to assess the patient satisfaction regarding treatment and care in emergency department of new delhi hospital, india. nursing & care open access journal. 2018;5 (6):357-60. doi: 10.15406/ ncoaj.2018.05.00173. [32] thompson, s. k. (2012). sampling. third edition. john wiley & sons. (url: https:// scholar.google.com/scholar? hl=en&as_sdt=0%2c5&q=sampling% 2c+3rd+edition&btng=) page 11-13. [33] althubaiti a. sample size determination: a practical guide for health researchers. j gen fam med. 2023; 24: 72–78. doi: 10.1002/ jgf2.600 (url: https:// onlinelibrary.wiley.com/doi/full/10.1002/ jgf2.600) 126 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.03 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article effect of serum lipid profile and renal functions during pregnancy and its associated diseases in sulaimanyah / kurdistan region abstract background and objective: the physiological function of the kidneys poses significant challenges during pregnancy, impacting maternal and fetal health. understanding the interplay between renal functions and serum lipid profiles is crucial for managing maternal health. this study aims to investigate serum lipid profiles and their association with renal function in pregnancy and compare them with non-pregnant status. the objective of this study was to conduct a prospective analysis of blood lipid concentration, namely lipoprotein, as well as the rates of urea and creatinine, in pregnant women, and thereafter compare these measurements with those of non-pregnant women. methods: a casecontrol study was conducted on pregnant women in sulaimanyah/ kurdistan. both serum lipid profile tests, including triglycerides, cholesterol, and lipoprotein levels, and renal function markers, such as serum creatinine, urea, and estimated glomerular filtration rate, were measured at various stages of pregnancy. data was analyzed by the statistical package for the social sciences version 22.0 to identify correlations between serum lipid profile, renal function, and pregnancy outcomes. results: this study highlights significant positive correlations of low-density lipoprotein with gestation age, cholesterol, triglyceride, and high-density lipoprotein, alongside strong negative correlations with total serum bilirubin and creatinine in pregnancy. this correlation was not found in non-pregnant status. additionally, estimated glomerular filtration rate exhibits strong positive correlations with cholesterol and low-density lipoprotein and negative correlations with total serum bilirubin and creatinine.in non-pregnant individuals, estimated glomerular filtration rate moderately correlates with random blood sugar while strongly correlating negatively with urea and creatinine.mean ± standard deviation of urea and creatinine were significantly higher in non-pregnant women while cholesterol and estimated glomerular filtration rate were significantly high among pregnant women. conclusion: this study highlighted notable metabolic disparities between pregnant and non-pregnant women, particularly in terms of lipid profiles and renal function. changes in hormone levels during pregnancy can elevate lipid profiles and renal function, and these metabolic and hormonal changes could affect kidney function indicators. keywords: renal function (rf); pregnancy; estimated glomerular filtration rate (egfr); serum lipid profile (slp). azad mohammed aziz ahmed; department of nursing, darbandikhan technical institute, sulaimani polytechnic university, sulaimani, kurdistan region, iraq. (correspondence: azad.aziz@spu.edu.iq) amjad mahmood qadir; department of general science, college of basic education, university of halabja, halabja, kurdistan region, iraq. jamal kareem shakor; department of nursing, darbandikhan technical institute, sulaimani polytechnic university, sulaimani, kurdistan region, iraq. musa zorab; department of physics, college of science, university of halabja, kurdistan region, iraq. 20 received: 21/03/2024 accepted: 03/11/2024 published: 30/05/2025 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:azad.aziz@spu.edu.iq?subject=azad.aziz@spu.edu.iq mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.03 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article it is well-recognized that pregnancy causes significant bodily changes. in addition to raising the need for metabolic fuels for the growing fetus and the development of its supporting structures, it also alters hormone levels in the body, which may affect the lipid profile throughout the course of the pregnancy's many trimesters. examination of serum lipid profiles throughout the initial three months of pregnancy can potentially forecast the occurrence and intensity of pre-eclampsia [1]. the anabolic phase during early pregnancy stimulates lipogenesis and promotes the accumulation of fat in anticipation of the rapid growth of the fetus in late pregnancy [2]. insulin resistance causes an increase in lipolysis, which results in a greater flow of fatty acids to the liver. this, in turn, stimulates the production of very low-density lipoproteins (ldls) and leads to higher concentrations of triglycerides (tg). due to a reduction in the functioning of lipoprotein lipase, very low-density lipoprotein (vldl) persists in the bloodstream for an extended period, resulting in the buildup of lowdensity lipoprotein (ldl). elevated levels of ldl are linked to the progression of atherosclerosis [3]. disordered lipid metabolism also appears to have a significant role in the development of pregnancy-induced hypertension (pih). the correlation between blood lipids and gestational proteinuria hypertension strongly indicates that lipid profile analysis can be used as a diagnostic tool [4]. throughout a typical pregnancy, there is an increase in plasma triglyceride and cholesterol levels, which eventually return to normal as the pregnancy advances. pregnancy-induced hormonal fluctuations impact lipid metabolism. endogenous female sex hormones exert a substantial impact on serum lipids. during pregnancy, there is an elevation in hepatic lipase activity and a reduction in lipoprotein lipase activity [5]. another study's conclusion likewise confirmed a consistent positive correlation between high levels of maternal tg and the likelihood of pre-eclampsia [6, 7]. conversely, hyperlipidemia is considered a natural occurrence during pregnancy. multiple studies have noticed a significant increase of 50 to 60% in cholesterol levels and a substantial increase of 100 to 200% in tg levels during uncomplicated pregnancy [8]. furthermore, there appears to be a correlation between various pregnancy problems and the presence of extra lipid abnormalities and impaired renal function [9]. additionally, more than half of renal function can be lost before the level of blood creatinine exceeds 120 µmol/l [10]. pregnant women with serum creatinine levels exceeding 124 µmol/l are at a higher risk of experiencing a faster deterioration in kidney function and having a worse pregnancy outcome. when managing pregnant women with chronic kidney disease, it is important to consider various aspects to reduce the negative impact of pregnancy on the mother's kidney function and the resulting repercussions on the fetus. in addition, it is noteworthy that a significant number of individuals suffering from kidney disease and experiencing very minor impairment exhibit an unexpected rise in glomerular filtration rate (gfr) during pregnancy [11]. prior research has indicated a potential link between lipid metabolism and renal function during pregnancy. prior research has utilized serum creatinine as a marker for impaired rf. the categorization of renal impairment was based on the following criteria: mild, moderate, or severe [12, 13]. finding the correlation of lipid profile with duration of pregnancy, particularly in those women who have the associated kidney problems, could help pregnancy outcome, mother’s health, and 21 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.03 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article general hospital. the serum was then separated from the rest of the blood by subjecting it to centrifugal force at a speed of 3000 rpm for 3 minutes and repeating it three times. gather specimens of females, encompassing both expectant and non-expectant individuals, from various age groups residing in urban areas. a subset of female patients has presented with comorbidities including hypertension, thyroid dysfunction, diabetes mellitus, hepatic disorders, and renal disorders. then, with the assistance of laboratory expert staff, all necessary tests were performed in the laboratory department of darbandikhan shahid tofiq general hospital for all pregnant women participating in our research according to our study plan. serum lipid profile (slp) the enzymatic colorimetric test method for quantifying cholesterol in human serum is conducted using the biochemical analyzer biolis 30i apparatus. the hydrolysis of cholesterol esters by cholesterol esterase yields free cholesterol and fatty acids. cholesterol undergoes oxidation, catalyzing the conversion of cholesterol to cholest-4-en-3one and hydrogen peroxide. in the presence of peroxidase, the produced hydrogen peroxide oxidatively couples with phenol and 4-aminophenazone, forming a red quinone-imine dye. the intensity of the dye's color is directly proportional to the cholesterol concentration, measured at 500 nm. t.g. is enzymatically measured in serum via a series of coupled reactions, hydrolyzing triglycerides to produce glycerol. glycerol is then oxidized by glycerol oxidase with hydrogen peroxide, a reaction product measured similarly to cholesterol absorbance measured at 500 nm. high-density lipoprotein is detected using the direct method without specimen pretreatment. initially, ldl, vldl particles, and chylomicrons generate free cholesterol, which, through an enzymatic reaction, fetal growth. lipid profiles such as ldl, tg and tc could be used as indicators to assess a healthy pregnancy and fetal growth. this study aimed to prospectively examine the blood lipid concentration, namely lipoprotein, as well as the urea and creatinine rates, in pregnant women and compare them with those of non-pregnant women. this was case-control study conducted from august 22, 2022, until december 25, 2022. fifty pregnant women and sixty-four non-pregnant women would enroll for obstetric care at the general health laboratory of sulaimanyah/darbandikhan shahid tofiq general hospital. these women face various health issues during pregnancy, such as kidney function disease and elevated levels of serum lipid profiles. the study aims to evaluate the correlation between blood lipid concentrations, specifically lipoprotein, as well as the rates of urea and creatinine in pregnant and non-pregnant individuals. this paper would prospectively analyze these values. also, to identify the most influential factors among pregnancy duration in weeks, age, and bmi. collection of blood samples blood samples were taken from 50 pregnant women and 64 nonpregnant women in both the maternity and laboratory departments of darbandikhan shahid tofiq general hospital in northern iraq. the study received approval from the ethics centre committee at sulaimani polytechnic university. subsequently, written informed consent was obtained from each participant. the participants were provided with the opportunity to voluntarily withdraw from the research based on their preferences. five millilitres of venus blood were utilized for all tests. the blood was collected in a simple polyethylene tube and allowed to coagulate at room temperature in laboratory department of darbandikhan shahid tofiq 22 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.03 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article produces hydrogen peroxide. the generated peroxide undergoes a peroxidase reaction with n, n-bis(4-sulphobutyl)-mtoluidine-disodium (dsbmt), resulting in a colorless product. subsequently, specific detergents solubilize hdl-cholesterol. in conjunction with the action of cholesterol oxidase (co) and cholesterol esterase (ce), peroxidase (pod) and 4-aminoantipyrine (4 -aap) develop a colored reaction proportionate to hdl-cholesterol concentration. absorbance is measured at 600 nm. ldlcholesterol is calculated from measured values of total cholesterol, triglycerides, and hdl-cholesterol according to the relationship: [ldl-cholesterol] = [total chol] [hdl-chol] [tg]/5, where [tg]/5 estimates vldl-cholesterol, with all values expressed in mg/dl. renal function test (rft) creatinine is an in vitro assay used to precisely measure the concentration of creatinine in human serum using the biochemical analyzer biolis 30i apparatus. this enzymatic method relies on the conversion of creatinine with the assistance of creatininase, creatinase, and sarcosine oxidase to glycine, formaldehyde, and hydrogen peroxide. catalyzed by peroxidase, the liberated hydrogen peroxide reacts with 4aminophenazone and htiba to form a quinone imine chromogen. the intensity of the color of the formed quinone imine chromogen is directly proportional to the creatinine concentration in the reaction mixture. this coloration, indicative of the creatinine concentration in the specimen, is measured at 550 nm. blood urea is assessed by a kinetic method based on the specific action of urease, which hydrolyzes urea into ammonium ions and carbon dioxide. ammonium ions then react with chloride and salicylate to form a blue-green complex. this coloration, proportional to the urea concentration in the specimen, is measured at 340 nm. data analysis the results of this investigation were displayed in a table using the statistical software for social sciences (spss) version 22.0. descriptive analysis was conducted on the mean and standard deviation of a biochemical indicator for both pregnant and non-pregnant women. a t-test was then used to see if there were any significant differences between the two groups. pearson correlation has been done to figure out each relationship between the duration of pregnancy and para and biochemical indicators in pregnant and nonpregnant women differently. a multiple linear regression model was constructed to identify the characteristics that are indicative of high cholesterol in pregnant women. a p-value of less than 0.05 was used to determine statistical significance. and egfr has been measured using the following formula: egfr = 175 × (scr) ^-1.154 × (age) ^-0.203 × (0.742). exclusion criteria: women aged more than 50 years were excluded from the analysis. ethical concerning this study has been done with the general health laboratory of sulaimanyah/ darbandikhan shahid tofiq general hospital. the authorization letter was taken from the nursing department, darbandikhan technical institute, sulaimani polytechnic university. all patients were provided with a clear explanation of the study's objectives, and consent letters were obtained from all participants. table 1 demonstrated that the mean age (35.54±8.7), urea (23.94±8.08), and creatinine (0.57±0.128) were significantly higher in non-pregnant women compared with pregnant women. while the mean of cholesterol (182.53±36.94), hdl (54.28±11.67), and egfr (158.34±44.40) were significantly high among pregnant women (p-value<0.05). 23 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.03 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article 24 correlation with tsb (r = -0.405, p < 0.01) and creatinine (r = -0.967, p-value < 0.001). the study also found a significant moderate correlation of cholesterol with tg (r = 0.399, p-value < 0.01) and hdl (r = 0.385, p-value < 0.01), and serum creatinine had a significant correlation with the tsb (r = 0.475, p-value < 0.001). the correlation of random blood sugar was close to being significant with the tg (r = 0.285, p-value < 0.05). table 2 indicates that ldl has a significant positive correlation with the women‘s gestation age (r = 0.354, p-value < 0.01), cholesterol (r = 0.802, p-value < 0.001), tg (r = 315, p-value <0.05.), and hdl (r = 0.454, p-value< 0.001), and a strong negative correlation with tsb (r = -0.431, p-value = 0.002) and creatinine (r = -0.413, p-value < 0.01). similarly, the study found a strong correlation of egfr with cholesterol (r = 0.305, p-value < 0.05) and ldl (r = 0.449, p -value < 0.001) and a strong negative copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: mean of biochemical indicators in pregnant and non-pregnant women variables non-pregnant women meant and standard deviation (n=44) pregnant women mean and standard deviation (n= 49) p-value age 35.54±8.7 29.24± 6.2 < 0.001 tsb 0.66±0.22 0.59±0.21 0.148 diabetes 108.79±30.32 110.81±31.93 0.756 urea 23.94±8.08 18.34±5.90 < 0.001 creatinine 0.57±0.128 0.50±0.139 0.011 cholesterol 162.29±34.81 182.53±36.94 0.008 tg 171.13±69.76 194.46±45.32 0.057 hdl 49.25±8.97 54.28±11.67 0.023 ldl 96.45±26.25 102.14±30.93 0.344 egfr 127.48±32.33 158.34±44.40 < 0.001 table 2: correlation of biochemical indicators and gestational age in pregnant women control variables age & para age of pregnancy in weeks tsb diabetes urea creatinine cholesterol tg hdl ldl tsb -0.045 p-value 0.762 diabetes 0.237 0.180 p-value 0.105 0.221 urea -0.043 -0.031 -0.084 p-value 0.771 0.836 0.569 creatinine -0.242 0.475 -0.155 0.196 p-value 0.097 0.001 0.293 0.182 total cholesterol 0.279 -0.254 0.217 -0.040 -0.265 . p-value 0.055 0.081 0.138 0.789 0.069 . tg 0.173 -0.052 0.284 -0.235 -0.020 0.399 p-value 0.239 0.728 0.050 0.107 0.894 0.005 . hdl 0.239 -0.250 -0.095 0.186 -0.186 0.385 -0.072 . p-value 0.102 0.086 0.523 0.206 0.206 0.007 0.626 . ldl 0.354 -0.431 0.123 -0.251 -0.413 0.802 0.315 0.454 p-value 0.014 0.002 0.406 0.085 0.004 0.000 0.029 0.001 . egfr 0.216 -0.405 0.138 -0.257 -0.967 0.305 0.003 0.166 0.449 p-value 0.140 0.004 0.350 0.078 < 0.001 0.035 0.981 0.261 < 0.001 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.03 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article serum creatinine also has a significant positive correlation with urea level (r = 0.300, p-value < 0.05) and a negative correlation with random blood sugar (r = -0.394, pvalue < 0.001). cholesterol also has a significant moderate correlation with tg (r = 0.364, p-value < 0.01). creatinine, age, hdl, and egfr. the regression model has shown a significant coefficient of ldl and urea with cholesterol. the model shows that urea and ldl indicate 1.398 % and 0.913 % variances in cholesterol levels, respectively. 25 table 3 shows the correlation coefficient among biochemical indicators and gestational age of pregnancy. the study has shown a moderate positive correlation of egfr with random blood sugar (r = 0.434, p-value < 0.001) and a negative strong to moderate correlation with urea (r = 0.365, p-value < 0.01) and creatinine (r = 0.916, p-value < 0.001). table 4 demonstrate a linear regression model of multiple variables with the cholesterol level in pregnant women. the linear regression model has explored a 70 % variance in cholesterol level, significantly explained by para, ldl, diabetes, bmi, urea, and age of pregnancy in weeks, tg, copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: correlation of biochemical indicators and gestational age in non-pregnant women. control for age. non-pregnancy women diabetes urea creatinine cholesterol tg hdl ldl egfr tsb 0.073 0.066 -0.115 -0.083 -0.001 -0.183 -0.077 0.177 p-value 0.570 0.609 0.370 0.518 0.994 0.151 0.551 0.165 diabetes -0.145 -0.394 -0.105 0.022 -0.132 -0.034 0.434 p-value 0.256 0.001 0.414 0.862 0.304 0.792 0.000 urea 0.300 0.069 -0.086 -0.050 0.107 -0.365 p-value 0.017 0.592 0.503 0.695 0.402 0.003 creatinine -0.076 -0.065 -0.121 -0.167 -0.916 p-value 0.554 0.610 0.345 0.190 0.000 cholesterol 0.364 0.180 0.715 0.062 p-value 0.003 0.158 0.000 0.627 tg -0.251 0.126 0.008 p-value 0.047 0.324 0.952 hdl 0.053 0.118 p-value 0.679 0.355 ldl 0.132 p-value 0.302 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.03 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article correlation with protein excretion products such as tsb and creatinine. gestational age has more indicated the lipid profile. this finding has been proven by many other studies. tc, tg, and ldl have been increasing with gestational age [16, 17]. a study has confirmed that there is an association between lipid profile and uric acid in preeclampsia and dyslipidemia and raised uric acid levels are symptoms of preeclampsia in nullipara pregnant women in their third trimester [18]. this study could not find a significant association between urea and lipid profiles in pregnant women. among pregnant women, the current study has indicated that ldl has a significant positive correlation with the woman’s gestation period, cholesterol, tg, and hdl, and a strong negative correlation with tsb, and creatinine. the study also found a significant moderate correlation between cholesterol and tg and hdl, and serum creatinine had a significant the objective of this study was to determine the metabolic differences in lipid profile and kidney function between pregnant and non-pregnant individuals. pregnancy status was known by a high level of lipid profile and a decreased level of urea and creatinine. the latest research has shown that the mean urea and creatinine levels were significantly decreased in pregnant women, whereas the average levels of cholesterol, hdl, and egfr were observed to be significantly high. another study has confirmed that tc, tg, ldl-c, hdl-c, and egfr all increase significantly during pregnancy. pregnant women exhibited decreased levels of urea, creatinine, and uric acid. [14, 15]. lower levels of urea, creatinine, and uric acid in pregnancy are mostly related to high renal blood flow and gfr in pregnant women [15]. compared to non-pregnant status, in pregnancy status, the metabolism of biochemical profiles such as ldl and tc has a high 26 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: coefficient linear regression of cholesterol predictor variables unstandardized coefficients standardized coefficients t-value p-value 95.0% confidence interval for b b std. error beta lower bound upper bound (constant) -125.245 107.770 -1.162 0.252 -343.415 92.924 tg 0.163 0.084 0.202 1.954 0.058 -0.006 0.332 hdl 0.138 0.336 0.043 0.409 0.685 -0.543 0.818 ldl 0.913 0.148 0.764 6.178 0.000 0.614 1.212 diabetes 0.130 0.108 0.113 1.211 0.233 -0.087 0.348 urea 1.398 0.615 0.223 2.276 0.029 0.154 2.642 creatinine 124.263 92.882 0.470 1.338 0.189 -63.766 312.293 egfr 0.377 0.300 0.452 1.257 0.216 -0.230 0.985 age 0.414 0.576 0.080 0.719 0.477 -0.752 1.580 gestational period in weeks -0.124 0.306 -0.038 -0.405 0.688 -0.744 0.496 bmi 0.217 0.614 0.031 0.353 0.726 -1.027 1.460 para -1.298 3.203 -0.042 -0.405 0.688 -7.783 5.187 discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.03 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article variables. the linear regression model has explored a 70 % variance in cholesterol level, which is significantly explained by para, ldl, diabetes, bmi, urea, age of pregnancy in weeks, tg, creatinine, age, hdl, and egfr. the regression model has shown a significant coefficient of ldl and urea with cholesterol [24]. the model has shown that urea and ldl indicate a 1.398% and 0.913% variance in cholesterol levels, respectively. a lipid profile can help predict the risk of gestational diabetes [25, 26], while the current study could not find a significant correlation between lipid profile and random blood sugar [27]. to sum up, this study highlights notable metabolic disparities between pregnant and non-pregnant women, namely in terms of lipid profiles and kidney function. in pregnant women, ldl shows significant positive correlations with gestation age, cholesterol, tg, and hdl, alongside strong negative correlations with tsb and creatinine. moreover, egfr demonstrates strong positive associations with cholesterol and ldl and negative correlations with tsb and creatinine, while moderate correlations exist between cholesterol and tg as well as hdl. serum creatinine also exhibits a significant correlation with tsb. conversely, in non-pregnant individuals, egfr moderately correlates with random blood sugar but strongly negatively correlates with urea and creatinine. serum creatinine shows a significant positive correlation with urea and a negative correlation with random blood sugar, while cholesterol displays a significant moderate correlation with tg. these findings emphasize the complexity of biomarker interactions and their implications for health in diverse physiological contexts. correlation with the tsb. other studies have found that serum levels of uric acid, creatinine, and blood urea indicate the pre -eclamptic status of pregnant women [19]. in this study, urea and creatinine were significantly decreased in pregnant women [20], and creatinine and tsb were negatively correlated with ldl [21]. among non -pregnant women, tsb and serum creatinine did not have a significant correlation with ldl [22]. decreased levels of tsb and serum creatinine in pregnant women are related to kidney function during pregnancy, which leads to an increase in egfr and the excretion of proteins such as creatinine and tsb. in addition, during pregnancy, physiological adaptations occur to support fetal growth and development; these adaptations can affect renal function and lipid metabolism, leading to changes in the correlation between egfr and cholesterol/ldl [23].similarly, the study found a strong positive correlation between egfr and cholesterol and ldl, but this correlation was not significant among nonpregnant women. among non-pregnant women, this study has shown a moderately positive correlation of egfr with random blood sugar and a strong to moderately negative correlation with urea. this correlation was not found among pregnant women. normally, during pregnancy, egfr increases by 50%, which also leads to a substantial decrease in serum creatinine, urea, and uric acid values [20]. overall, the combination of increased renal blood flow, hormonal influences, and changes in lipid metabolism, physiological adaptations, and gestational hypertensive disorders can lead to a strong positive correlation between egfr and cholesterol/ ldl during pregnancy, whereas this correlation may not be as significant among non -pregnant women due to differences in hormonal and physiological status. a high cholesterol rate is indicated by several 27 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.03 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article [4] devi, s.a., study of serum lipid profile in second trimester as a predictor for pregnancy induced hypertension in rajarajeswari medical college and hospital. 2019, master thesis rajiv gandhi university of health sciences (india). [5] casado, m.e., l. huerta, a. marcos-díaz, a.i. ortiz, f.b. kraemer, m.a. lasunción, et al., hormone-sensitive lipase deficiency affects the expression of sr-bi, ldlr, and abca1 receptors/transporters involved in cellular cholesterol uptake and efflux and disturbs fertility in mouse testis. biochimica et biophysica acta (bba)-molecular and cell biology of lipids, 2021. 1866(12): p. 159043.https:// doi.org/10.1016j.bbalip.2021.15904. [6] jiang, z.g., s.c. robson, and z. yao, lipoprotein metabolism in nonalcoholic fatty liver disease. journal of biomedical research, 2013. 27(1): p. 1.https://doi.org/10.755 2fjbr.27.20120077 [7] huggins, c.e., a.p. james, m.p. bonham, k.m. clark, and s.d. lee, postprandial lipemia and the relationship to health, in advances in dietary lipids and human health. 2022, elsevier. p. 193-209. https:// doi.org/10.1016/b978-0-12-823914-8.00019 -7 [8] della porta, m., fatty acids unsaturation and oxidative stress in membrane function, pregnancy, and metabolic syndrome. doctoral thesis 2021. [9] bonassi, s. and m. fenech, micronuclei and their association with infertility, pregnancy complications, developmental defects, anaemias, inflammation, diabetes, chronic kidney disease, obesity, cardiovascular disease, neurodegenerative diseases and cancer. the micronucleus assay in toxicology chapter .4 2019.https:// doi.org/10.1039/9781788013604-00038 [10] zhao, l., s. li, and y. gao, efficacy of statins on renal function in patients with chronic kidney disease: a systematic review and meta-analysis. renal failure, 2021. 43(1): p. 718 -728. https:// doi.org/10.1080/0886022x.2021.1915799 [11] turi, v.-r., c.t. luca, d. gaita, s. iurciuc, i. petre, m. iurciuc, et al., diagnosing arterial stiffness in pregnancy and its implications in the cardio-renal-metabolic chain. diagnostics, 2022. 12(9): p. 2221. https:// doi.org/10.3390/diagnostics12092221 conflicts of interest: the authors declare that they have no conflicts of interest. in this manuscript, all tables have been authored by us. the authors have signed a welfare statement at the nursing department at the sulaimani polytechnic university. the authors signed the ethical consideration’s approval. ethical clearance: our work has been approved by the scientific and ethical committee at the sulaimani polytechnic university. all authors of this study participated equally in all stages of the writing process; they also reviewed and approved the submission of this work. the authors would like to thank the sulaimani polytechnic university, darbandikhan technical institute, nursing department, general health laboratory of sulaimanyah/ darbandikhan shahid tofiq general hospital, and all patients for their support and collaboration in providing data for this research. [1] majhi, b., role of lipid profile in early second trimester for prediction of pre-eclampsia. international journal of reproduction, contraception, obstetrics and gynecology, 2021. 10(8): p. 3101-3106. https:// doi.org/10.18203/2320-1770.ijrcog20212962 [2] zeng, z., f. liu, and s. li, metabolic adaptations in pregnancy: a review. annals of nutrition and metabolism, 2017. 70(1): p. 59-65. https://doi.org/10.1159/000459633 [3] quiroga, a.d. and r. lehner, pharmacological intervention of liver triacylglycerol lipolysis: the good, the bad and the ugly. biochemical pharmacology, 2018. 155: p. 233241.https://doi.org/10.1016/ j.bcp.2018.07.005 28 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. acknowledgement author’s declaration author’s contribution statement references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.03 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article [20] cheung, k.l. and r.a. lafayette, renal physiology of pregnancy. advances in chronic kidney disease, 2013. 20(3): p. 209214.https://doi.org/10.1053/ j.ackd.2013.01.012. [21] cai, a., s. qi, z. su, h. shen, y. yang, w. cai, et al., a pilot metabolic profiling study of patients with neonatal jaundice and response to phototherapy. clinical and translational science, 2016. 9(4): p. 216-220. https://doi.org/10.1111/cts.12401 [22] yun, h.j., s.r. ryoo, j.-e. kim, y.j. choi, i. park, g.-t. shin, et al., trabecular bone score may indicate chronic kidney disease-mineral and bone disorder (ckd-mbd) phenotypes in hemodialysis patients: a prospective observational study. bmc nephrology, 2020. 21: p. 1-10. https://doi.org/10.1186/s12882 -020-01944-0 [23] al-ghazali, b.s., b.a. hashim, and a. habib, calcium and phosphate excretion in preeclampsia, as markers of severe disease. medical journal of babylon, 2010. 9(4): p. 755-3. [24] hannawi, s., h. hannawi, f. alokaily, and i. al salmi, variables associated with subclinical atherosclerosis among rheumatoid arthritis patients of gulf cooperative council countries. saudi medical journal, 2020. 41 (2): p. 128.https://doi.org/10.15537% 2fsmj.2020.2.24900. [25] barat, s., a. ghanbarpour, z. bouzari, and z. batebi, triglyceride to hdl cholesterol ratio and risk for gestational diabetes and birth of a large-for-gestational-age newborn. caspian journal of internal medicine, 2018. 9(4): p.368.https://doi.org/10.22088% 2fcjim.9.4.368. [26] wang, c., w. zhu, y. wei, r. su, h. feng, l. lin, et al., the predictive effects of early pregnancy lipid profiles and fasting glucose on the risk of gestational diabetes mellitus stratified by body mass index. journal of diabetes research, 2016. 2016.https:// doi.org/10.1155/2016/3013567. [27] biadgo, b., s.m. abebe, h.w. baynes, m. yesuf, a. alemu, and m. abebe, correlation between serum lipid profile with anthropometric and clinical variables in patients with type 2 diabetes mellitus. ethiopian journal of health sciences, 2017. 27(3): p. 215226.https://doi.org/10.4314/ejhs.v27i3.3 [12] silbert, b.i., the pharmacology and oxidative stress effects of frusemide in acute kidney injury. the university of western australia. master thesis 2018 [13] lady aqnes kurniawati, l., m. muhammad ilham aldika akbar, b. budi utomo, and a. aditiawarman, risk factor of preeclampsia in a secondary indonesian hospital: a casecontrol study. indian journal of forensic medicine & toxicology, 2021. 15(3): p. 34743482.https://doi.org/10.37506/ ijfmt.v15i3.15839 [14] wu, l., q. wu, q. li, s. cao, y. zhang, y. liu, et al., consecutive reference intervals for biochemical indices related to serum lipid levels and renal function during normal pregnancy. bmc pregnancy and childbirth, 2022. 22(1): p. 642.https://doi.org/10.1186/ s12884-022-04960-0 [15] gao, y., j. jia, x. liu, s. guo, and l. ming, trimester-specific reference intervals of serum urea, creatinine, and uric acid among healthy pregnant women in zhengzhou, china. laboratory medicine, 2021. 52(3): p. 267272. [16] jovandaric, m.z., s. babic, m. raus, and b. medjo, the importance of metabolic and environmental factors in the occurrence of oxidative stress during pregnancy. international journal of molecular sciences, 2023. 24(15): p. 11964.https://doi.org/10.3390/ ijms241511964 [17] jo, y.s., j.y. cheon, j.w. ahn, y. kim, and g.s.r. lee, pentraxin 3 and lipid profile status in pregnancy. journal of obstetrics and gynaecology, 2017. 37(6): p. 727730.https:// doi.org/10.1080/01443615.2017.1291596 [18] agarwal, v., b.k. gupta, a. vishnu, and j. kiran, association of lipid profile and uric acid with pre-eclampsia of third trimester in nullipara women. journal of clinical and diagnostic research: jcdr, 2014. 8(7): p. cc04. https://doi.org/10.7860%2fjcdr%2f2014% 2f7901.4533. [19] tesfa, e., a. munshea, e. nibret, d. mekonnen, m.a. sinishaw, and s.t. gizaw, maternal serum uric acid, creatinine and blood urea levels in the prediction of pre-eclampsia among pregnant women attending anc and delivery services at bahir dar city public hospitals, northwest ethiopia: a case-control study. heliyon, 2022. 8(10).https:// doi.org/10.1016/j.heliyon.2022.e11098. 29 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 erbil j. nurs. midwifery, vol. 6, no. (2), nov. 2023 original article non-pharmacologic pain management knowledge and barriers among nurses in erbil hospitals abstract aim of the study: pain management is a multidisciplinary approach for easing suffering and improving the patients’ quality of life and nurses play a significant role in providing pain assessment and treatment. non-pharmacological pain management is any intervention intended to improve health or well-being that does not involve the use of any drugs or medicine. this study aimed to assess the nurses’ knowledge and their barriers regarding non-pharmacologic pain management. methods: a descriptive cross-sectional study was carried out at hawler, rizgary and nanakaly teaching hospitals in medical and oncology wards on a non-probability purposive sample of 100 nurses who worked in the above wards. the data was collected from the end of december to the end of february 2020 through self-reports by nurses using a constructive single choice questionnaire. each correctly answered item was recorded as 1 and the incorrect one as 0. results: the higher percentages of nurses, including males aged between (30-39) years, institute graduates, and experienced in jobs between (1-10) years. 69% of nurses have a moderate level of non-pharmacologic pain management, and, 47% of nurses have not applied non-pharmacological pain management in hospitals. only 16% of them applied, and 37% sometimes applied, psychological and physical methods of non-pharmacologic pain management were more applied by 29% and 23% respectively by nurses than other methods. nurses had many barriers to using non-pharmacological pain management, like nursing workload and lake of protocol for pain management. conclusion: this study concluded that the majority of nurses have a fair (moderate) level of knowledge about non-pharmacological pain management and applied by only 16 % of nurses. nurses have many barriers to using non-pharmacological pain management. keywords: pain management; non-pharmacologic pain management; knowledge; barriers. ronak nematala hussain; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq (correspondence: ronak.hussain@hmu.edu.krd). 106 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 31/03/2023 accepted: 12/07/2023 published: 30/11/2023 mailto:ronak.hussain@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 erbil j. nurs. midwifery, vol. 6, no. (2), nov. 2023 original article pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage the international association for the study of pain (iasp) [1, 2]. pain is a responsive mechanism to protect from damage. many studies describe pain as the fifth vital sign that health professionals monitor and manage when caring for patients [3, 4]. pain is feeling, and only a person without pain is a happy person. in physiotherapy, more physical modalities are used for the treatment of subacute and chronic pain [5].nonpharmacological therapy as any intervention intended to improve health or wellbeing that does not involve the use of any drugs or medicine [6]. these therapies help the standard pharmacologic treatment in pain management. while medications are being used for treating the somatic (physiological and emotional) dimension of the pain, non-pharmacologic therapies aim to treat the affective, cognitive, behavioral and socio-cultural dimensions of the pain [7]. non-pharmacologic management is a number of effective interventions for pain. these may be used alone for mild to moderate pain, or in combination with drug therapy for more severe pain [8]. the use of non-pharmacological pain relief techniques has been found to be effective with fewer side effects and complications associated with them also diminishes pain perception by reducing intensity and increasing pain tolerance, reduces painrelated distress, strengthens coping abilities, and gives the patient and family a sense of control over pain [9].nonpharmacologic interventions include cognitive behavioral therapy, relaxation therapy, biofeedback, patient education, selfmanagement, and social support interventions. these types of interventions aim to change behavior, cognitions, and emotions by targeting the psychosocial processes that are implicated in the perceptions and responses to pain. here, good nursing care plays a pivotal or central role. nurses are not the only healthcare workers who are responsible for relieving patients’ pain; they also play a key role in managing patients’ pain [10, 11].because of the extensive prevalence of chronic pain, the major impact it has on quality of life and the many benefits of non-pharmacologic methods of pain management in relieving pain, therefore this method needs to be explored further. the barriers keeping nurses from using them need to be explored. nurses' knowledge of nonpharmacological pain management needs to be assessed, and any deficits identified need to be corrected, so patients have access to other options to manage their pain more effectively. the study aimed to assess non-pharmacologic pain management knowledge among nurses and potential barriers related to management. a quantitative descriptive cross-sectional study design was used to assess nurses’ knowledge about non-pharmacologic pain management in hawler, rizgary and nanakaly teaching hospitals in erbil city. the sample study included a nonprobability purposive sample, including all nurses who worked in medical wards during the period of data collection from 21 december 2020 to the end of february 2020. data were collected through the nurses’ self-report method by using a constructed questionnaire that was based on an extensive review of relevant literature. the questionnaire consisted of three parts, which included part i: sociodemographic characteristics of the nurses, which include setting, gender, age, level of education, and experience in the job. part ii consisted of the nurse's knowledge of non-pharmacologic pain management. 107 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 erbil j. nurs. midwifery, vol. 6, no. (2), nov. 2023 original article part iii included the barriers to the application of non-pharmacologic pain management. prior to data collection, formal permission was obtained from the ethical approval of the ethical committee at the college of nursing and official permission was obtained from the erbil directorate of health. nurses’ using a constructive single choice questionnaire, each correctly answered item was recoded as 1 and the incorrect one as 0. data were analyzed through the spss (statistical package for science service) for windows v.21 for statistical data analysis, which includes descriptive statistical analysis (frequency, percentage, mean of percentage, which is calculated by the sum of percentages divided by a number of items and chi-square to find out the association between nurses’ non-pharmacologic pain management and some of the sociodemographic variables like setting, age, level of education. the p value of each test ≤ 0.05 is considered statistically significant. table 1 represents socio-demographic characteristics of nurses’ distribution: 41% of nurses were within the age group (3039) years, 33% of them within (20-29) years, 51% of nurses were males and 49% of them females. concerning level of education, 57% of nurses were institute graduates, and bachelor was 23%. about setting, 38% of nurses were from rizgary teaching hospital, 36% were from hawler teaching hospital and 26% were from nanakaly teaching hospital. regarding experience in the job, 51% of nurses were between (1-9) years of experience, and 30% were between (11-19) years. 108 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results table-1. socio-demographic characteristics of the nurses (n.100) socio-demographic characteristics of nurses f. (%) 1. age of nurses 20-29 33 (33) 30-39 41 (41) 40-49 17 (17) 50-59 9 (9) 2. gender of nurses male 51 (51) female 49 (49) 3. level of education preparatorynurse 20 (20) institute 57 (57) bachelor 23 (23) 4. setting of nurses hawler teaching hospital 36 (36) rizgary teaching hospital 38 (38) 5. nanakaly teaching hospital 26 (26) 6. experience in job years 1 – 9 51 (51) 10-19 30 (30) 20 – 29 15 (15) 30-40 4 (4) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 erbil j. nurs. midwifery, vol. 6, no. (2), nov. 2023 original article table 2 shows from q1 to q6, regarding nurses' knowledge about pain assessment. the results show that 44.83 of nurses define pain and assess it correctly and % 72 of nurses answer correctly to the question about the knowledge of the signs and symptoms of pain. regarding nurses' knowledge of non-pharmacologic pain management from q7-q18, it shows the table 3 reveals to overall levels of nurses' knowledge. most nurses, 69% have moderate. overall mean of percentages, and % 57.3 of nurses answered correctly and % 42.7 answered incorrectly. for most of the nurses, 83% correctly answered on massaging as a pain reliever, with 17% incorrect. the lowest percentages of knowledge about on non-pharmacologic pain management (tens) were 0.30 and 0.15, respectively. knowledge, 22% have poor knowledge and 9% of nurses have good knowledge. 109 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2 : nurse’s knowledge about non-pharmacologic pain management (no.100) nurse knowledge about pain and non-pharmacologic pain management incorrect answer correct answer f. f. definition of pain 44 56 nurses have the right to assess the pain of the patients. 47 53 ideal time for pain assessment 76 24 the frequency of use of the pain assessment in the 24-hour tool is. 89 11 sign and symptom of pain 28 72 according to nursing process pain assessment is provided in which steps? 47 53 overall mean of percentages 55.17 44.83 pain can be managed without drug 25 75 chronic pain can be managed without drug 56 44 by pharmacologic and non-pharmacologic can manage or relief pain 33 67 having idea about non-pharmacologic pain management 37 63 social method is non-pharmacologic pain management 53 47 transcutaneous electrical nerve stimulation (tens) a method of non-pharmacologic pain management 70 30 definition of tens 85 15 deep breath exercise is relaxation technique for pain management 29 71 according to situation (cold or heat application-massage) is more effective nonpharmacologic pain management 29 71 massage is the most effective method to getting the attention away from the pain 49 51 massaging use method of stroking, kneading, and rubbing can relieve pain 17 83 the benefits of using non-pharmacological pain management is 29 71 over all mean of percentages 0.42.7 0.57.3 table 3: overall nurses’ levels of knowledge about non-pharmacologic pain management overall nurses’ levels of knowledge f. (%) poor knowledge 22 (22) moderate knowledge 69 (69) good knowledge 9 (9) total 100 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 erbil j. nurs. midwifery, vol. 6, no. (2), nov. 2023 original article 110 of 47% of nurses did not apply, 37% of them with some times applied, and 16% always applied. while the other 20% used none pharmacologic methods of pain management, while cognitive behavior method is used by 8% of nurses. having a nursing workload and 14% of having a lack of protocol of pain management barriers. copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4 shows the implementation of non -pharmacologic pain management by nurses in the hospitals. a high percentage table 5 shows that a higher percentage% 29 of the nurses used the psychological method, 23% used the physical method, 20% of them used all of the methods of none pharmacologic pain management, table 6 shows that the higher percentages, 47% of nurses' barriers, are within all the above barriers, followed by 17% table 4 non pharmacologic pain management method applied in the hospitals applied of non-pharmacologic pain management by nurses f. (%) no 47 (47) some time 37 (37) yes 16 (16) table 5: methods of none pharmacologic pain management applied by the nurses methods of none pharmacologic pain management that apply by the nurses f. (%) physical method 23 (23) psychological method 29 (29) cognitive behavior method 8 (8) all above 20 (20) none of above 20 (20) table 6: barriers to using non-pharmacological pain management. barriers to using non-pharmacological pain management f. (%) 1 . lack of the protocol of pain management 14 (14) 2 . nurses' unwillingness and patient instability 8 (8) 3 . inadequate motivation 8 (8) 5 . nursing workload 17 (17) 6 . nurses' lack of knowledge 6 (6) 7 . all the above barriers 47 (47) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 erbil j. nurs. midwifery, vol. 6, no. (2), nov. 2023 original article 111 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 6.1 shows the nurses' opinion about providing actions that minimize the barriers of applying non-pharmacologic pain management in hospitals. 49% of nurses minimize those barriers through item of table 7 shows that there were significant associations between the setting and age of nurses with applying non-pharmacologic pain management in the hospital at p.value 0.046, 0.048 respectively. managing pain without drug were applied more by nurses from hawler teaching hospital than nanakaly and rizgary teaching hospiapplying all of the above actions, followed by 16% of them within caregiver training to minimize barriers and 15% by enhancing patient by staff and family. elder. also, there is a significant association between nurses’ knowledge of nonpharmacologic pain management with their educational level; the higher their level of education (bachelor), the more knowledgeable they are about nonpharmacologic pain management at p-value 0.003, respectively. table 6.1: actions that provide to minimize the barriers. the following actions to minimize the barriers f. (%) enhance patient by staff and family 15 (15) enhance patient by himself 4 (4) provide good environment 9 (9) caregiver training 16 (16) caring according to hospital policy 7 (7) all of the above way 49 (49) table 7 :association between some of the nurses’ sociodemographic characteristics with their nonpharmacologic pain management setting of nurses hawler teaching hospital rizgary teaching hospital nanakaly teaching hospital total 1. appling non-pharmacologic pain management in the hospitals no 12 21 14 47 some time 19 13 5 37 yes 5 4 7 16 total 36 38 26 p. 0.046 nurses’ age (years) 20-29 30-39 40-49 50-90 2. appling non-pharmacologic pain management no 8 23 11 5 47 some time 1 8 11 4 4 37 yes 7 7 2 0 16 total 3 3 41 17 9 p.0.048 3. nurses’ level of education prep-nurse institute bachelor total knowledge about non-pharmacologic pain management un known 8 16 2 26 poor 4 6 1 11 good 16 13 11 40 very good 8 3 12 23 total 36 38 26 p. 0.003 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 erbil j. nurs. midwifery, vol. 6, no. (2), nov. 2023 original article management methods. however, the current study finding is lower compared with the result of the study [15] in zimbabwe bindura hospital, which had a mean knowledge score of 64.5%.in current study, 69% of nurses had a fair level of overall nurse's knowledge about nonpharmacologic pain management; this is due to the fact that more than half of nurses have within medium level of education. this result, along with results of bindura hospital and united states studies [15, 16] and nigerian study [17], revealed that nurses have adequate knowledge about non-pharmacological methods for pain control. however, lower, compared with another study of the western part of ethiopia, 78.1% correctly answered the item [18].the present result disagree with the result of a previous study [19] conducted in bangladesh they indicated that nurses with poor level of knowledge and whereas the level of practice was moderate in the current study near than half of nurses not apply non-pharmacological method of pain management this may be related to the hospitals system and inadequate facilities to use non-pharmacological methods and excess workload this result in consistent with the results of the turkey article study [20] that reviewed about 35 turkish and english studies which included 13 of these studies were master’s thesis and 11 of these were doctoral thesis and research articles the most research was done in 2016 and 2017. they stated that nurses have never used or limited used nonpharmacological methods in pain management. in addition the current result disagree with the results of turkey study [4] and study [21] in egypt they mentioned that majority of nurses were restricted or didn’t apply non-pharmacological pain management practices for their patients. furthermore the result of the study [12] in jordan supported current study result they it is the first study done in erbil, even in iraq, on the nurses' knowledge regarding non-pharmacological pain management; therefore, the goal of this study is to assess nurses' knowledge of nonpharmacological pain management and their barriers among chronic disease patients in erbil. in this study, the results show that the higher percentage of nurses were from rizgary teaching hospitals, males, aged from 30-39 years, married, medical institute graduates, having less than ten years of experience; this result disagrees with the result of the previous study [12] done on jordanian nurses which revealed that the majority of the nurses were females, more than half of the respondents belonged to the age group of 26-30 years old, majority of the respondents had professional experiences between 6 10 years and (86.8%) of respondents had a bachelor degree. the current study findings regarding nonpharmacological pain assessment and management sub-items revealed that nearly half (%44.83) of the nurses answered the questions correctly. it may be related to a need for more protocols for pain management and nurses' workload in the hospitals. this finding is consistent with the egypt study [13], which revealed that nurses' pain assessment and management among critically ill patients needed a better level of practice. regarding nurses’ knowledge of non-pharmacological pain management, results of this study show that 57.3 % of the overall mean percentages of nurses had correctly answered; this may relate to the fact that the majority of nurses institute graduate within middle level of education. this result is consistent with the results of ethiopian studies [14, 2] which revealed that 53.3% and 51.2% of nurses, respectively, had good knowledge of non-pharmacological pain 112 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 erbil j. nurs. midwifery, vol. 6, no. (2), nov. 2023 original article non-pharmacological pain management were lack of time (54.2%), excessive workload (51.2%), and lack of knowledge of some of the various alternative measures (38.9%). furthermore the most common barriers that prevents nurses using nonpharmacological pain management for patients in the three saudian hospitals (1, 2& 3) supported the current result by stated their barriers were the lack of time (55%, 62.5%, 15% respectively), then followed by unwillingness of patients (5%, 25%, 7.5% respectively) [ 23]. regarding association between applying of non-pharmacologic pain management with setting and age of nurses there was significant association at p.value 0.046, 0.048 respectively. nanakaly teaching hospital more applying of nonpharmacologic pain management than hawler and rizgary teaching hospitals, and the younger nurses more applied nonpharmacologic pain management than orders; this may relate to younger nurses more familiar and beneficiary about using internet and mass media than older. there were a positively relationship between nurses’ knowledge on non-pharmacologic pain management with their educational level at p.value 0.003, this result supported by nigerian and saudian studies [17, 23] which finds that there is significant relationship between the nurses’ knowledge with their educational level and years of practice regarding use of alternative pain relief measures. while the results disagree with the egypt study which stated that there is no significant relationship between nurses’ knowledge as well as practices with their age, years of experience [13]. also current results disagree with the result from tehran, iran [24].they stated that nurse’s educational level, and their work experiences were not significantly associated with the non-pharmacological pain management. stated nurses tended to have a moderate practices of pain management (mean = 4.968; standard deviation = 1.310). concerning the methods of nonpharmacological pain management that were applied by nurses in this study, the results show that nurses mostly applied the psychological and physical methods. this result is supported by the result of the nigerian study [17], which found that nurses were more aware (85.7%) of the physical methods of non-pharmacological pain control when compared to psychological (49.8%) methods. furthermore regarding using methods of nonpharmacological pain management in current study the results congruent with the results of brazil review article study [22] in 2017 they revealed that from the nonpharmacological measures that can be employed by nurses are patient orientations with regard to emotional support, and massage, relaxing massage, heat or cold application, measures that can be implemented by nurses. in relating to barriers of non-pharmacological pain management in this study the present result show that nurses have many barriers such as lack of protocol of pain management, nursing workload, nurses unwilling and patient instability, lack of motivation to use non-pharmacology pain management methods and poor nurses knowledge, this results supported by the result of ethiopian study [14] which stated that based on nurses response barriers were around 121 (71.6%) of nurses were had fatigue, 121 (71.6%) nurses in adequate motivation, about three fourth 125(74.0%) within heavy nurses’ workload, 122(72.2%) conflict and unwillingness to use nonpharmacological pain management,125 (74.0%) multiple responsibility of nurses. in addition the current result agree with the results of nigerian study [17] which indicated their barriers of 113 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 erbil j. nurs. midwifery, vol. 6, no. (2), nov. 2023 original article [6] sintler ne. the benefits of nonpharmacological interventions for individuals with dementia: a systematic review. master of social work clinical research. msw clinical research paper. catherine university sophia. 2017. pp.1-30 available from: https://sophia.stkate.edu/ msw_papers/802. [7] demir y. non-pharmacological therapies in pain management, pain management current issues and opinions, 2012. available from: http://www.intechopen.com/books/ pain-management-current-issues-andopinions/non-pharmacological therapies-inpain-management. [8] donna d. ignatavicius, m. linda workman, cherie rebar.medical-surgical nursing ebook: concepts for interprofessional collaborative care nine edition. 2018 united state. elsevier. p.69. [9] mwanza e, gwisai rd, munemo c. knowledge of non-pharmacological method of pain management among nurses at bindura hospital zimbabwe. pain research and treatment. volume 2019, | https:// doi.org/10.1155/2019/2703579. [10] gokhale sg and gokhale s. nonpharmacological methods for pain management. research gate. jp guniper .nurse health care. opinion, 2017. 4 (4). p.p 1-2. doi:10.19080/jojnhc.2017.04.555642. [11] bashar i. alzghoul1 & abdullah na. pain management practices by nurses: an application of the knowledge, attitude and practices (kap) model. canadian center of science and education. global journal of health science.2016. vol. 8, no. 6. pp.; 154-60. doi: 10.5539/gjhs.v8n6p154. [12] ali, n. s., w. y. morsy, and m. n. badr, "critical care nurses’ knowledge and practices regarding pain assessment and management at cairo university hospitals", egyptian nursing journal, 2015. vol. 10, issue 7, pp. 28 -38 | https:// doi.org/10.1155/2020/4893707. [13] s zeleke, a kassaw, y eshetie. research article non-pharmacological pain management practice and barriers among nurses working in debre tabor comprehensive specialized hospital, ethiopia. plos one journals. 2021.16 (6). pp; 1-11 [14] manwere a, chipfuwa t, mukwamba mm, chironda g. knowledge and attitudes of registered nurses towards pain management of adult medical patients: a case of bindura controlling pain is very important and necessary to comfort and relieve patient complaints, increase the quality of life, reduce complications and allow individuals to perform everyday activities. in this study, nurses have moderate knowledge and practices regarding nonpharmacologic pain management. there was a positively strong relation between nurses' knowledge of non-pharmacologic pain management with their level of education. there is no conflict of interest reported by the authors [1] cohen m, quintner j, van rysewyk s. reconsidering the iasp definition of pain. pain reports 2018. doi: 10.1097/ pr9.0000000000000634. [2] jira l, weyessa n, mulatu s, alemayehu a. knowledge and attitude towards nonpharmacological pain management and associated factors among nurses working in benishangul gumuz regional state hospitals in western ethiopia. journal of pain research. 2020; 13: https:// doi.org/10.2147/jpr.s265544. [3] theodosopoulou e. vazourakis f. filintras i. gkika d. dimitrakaki p. galanis p.chadzopulu a. patients and nurses attitude towards pain management with alternative methods. progress health sciences.2011 (cited in 14th feb 2020). vol 1. (2). pp; 5-10. [4] karabulut n, gürçayır d, aktaş yy. nonpharmacological interventions for pain management used by nursing students in turkey. kontakt, elsevier 2016; 18(1); pp;23 -31 [5] ramova e, ramov l. non pharmacological treatment of pain with physical therapy modalities and alternative medicine methods. 2/4 res arthritis bone study. 2018.1 (4). pp; 1-4 114 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.12 erbil j. nurs. midwifery, vol. 6, no. (2), nov. 2023 original article 115 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [15] moceri jt, drevdahl dj. nurses’ knowledge and attitudes toward pain in the emergency department. journal of emergency nursing. 2014; 40(1):6–12. [16] nwaneri, a., ndubuisi, i., anarodo, a., okoronkwo, i. and offor, e., 2018. nurses’ knowledge and level of utilisation of non– pharmacological pain control for othorpaedic patients in enugu nigeria. international journal of nursing science, 8(4), pp.61-66. [17] woldehaimanotte, saketa y, zeleke a, gesesew h, woldeyohanes t. knowledge and attitude: a survey among nurses in 23 health institutions in western nigeria. [18] international journal of nursing science 2018, 8(4): 61-66 2014; 20(3):254–60.25. doi: 10.5455/gmj-30-157196. [19] basak s , petpichetchian w, kitrungrote l. knowledge and attitudes of nurses and their practices regarding post-operative pain management in bangladesh. the 2nd international conference on humanities and social sciences april 10th, 2010 faculty of liberal arts, prince of songkla university palliative care_007.pp;1-12. [20] yaban zs. review article usage of nonpharmacologic methods on postoperative pain management by nurses: sample of turkey. international journal of caring sciences.2019. 12 (1) pp: 529541. [21] khalil ns. critical care nurses’ use of nonpharmacological pain management methods in egypt. applied nursing research. 2018; 44:33–8. doi: 10.1016/ j.apnr.2018.09.001. [22] oliveira junior nj, oliveira sb, migowski er amd riegel. nurses’ role in the nonpharmacological pain treatment in cancer patients. review article. rev dor. são paulo, 2017; 18(3):261-5. doi 10.5935/1806 -0013.20170112 [23] ali hs, ibrahim y, mohamed e. nonpharmacological pain management: nurses’ knowledge, attitudes and practices in selected hospitals at makkah el-mukarramah. life science journal. 2013; 2(10); pp; 1327-35. . http://www.lifesciencesite.com [24] kia z, allahbakhshian m , ilkhani m , nasiri m, allahbakhshian a. nurses’ use of nonpharmacological pain management methods in intensive care units: a descriptive cross-sectional study. elsevier ltd. complementary therapies in medicine. 2021. 58 pp; 1-5https://doi.org/10.1016/ j.ctim.2021.102705. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.13 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article students’ perspective about current teaching method in college of nursing at hawler medical university abstract background and objectives: the current teaching method in the college of nursing is mainly lecture, which plays a vital role for teaching and learning nursing students. the purpose of this study was to assess the students' opinions regarding the current teaching methods at the hawler medical university college of nursing. methods: a cross-sectional descriptive study was carried out at the college of nursing in the erbil, kurdistan region, iraq. the study involved 414 nursing and midwifery students. a non-probability-convenience sample method was utilized to enroll 414 nursing students who completed a questionnaire to examine their views on the current teaching method at the college of nursing. results: the vast majority of the study sample were female students, and while more than half of them are aged between 21 and 24 years old (56.8%) with an average of 21 years. the findings indicate that the majority of students (63.53%) sometimes expressed an agreement with the effectiveness of the teaching methods. the result indicated that a significantly higher proportion of females report being "sometimes" satisfied with the current teaching methods, accounting for 85.6% of responses in this category, similarly compared to only 14.4% from males. conclusion: most students believed that the current teaching approach used in the nursing education program significantly contributed to students’ increased academic success. key words: teaching method; students; nursing education; perspective. dlzar sedeeq anwer; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. (correspondence: dlzar.anwer@hmu.edu.krd) abubakir majeed saleh; department of community medicine, hawler medical university, erbil, kurdistan region, iraq. nursing department, faculty of nursing, tishk international university, erbil, kurdistan region, iraq. vian afan naqshbandi; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. 124 received: 16/01/2025 accepted: 22/04/2025 published: 30/11/2025 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:dlzar.anwer@hmu.edu.krd)?subject=dlzar.anwer@hmu.edu.krd)%20%20%20%20%20 mailto:dlzar.anwer@hmu.edu.krd)?subject=dlzar.anwer@hmu.edu.krd)%20%20%20%20%20 mailto:dlzar.anwer@hmu.edu.krd) mailto:dlzar.anwer@hmu.edu.krd)?subject=dlzar.anwer@hmu.edu.krd)%20%20%20%20%20 mailto:dlzar.anwer@hmu.edu.krd)?subject=dlzar.anwer@hmu.edu.krd)%20%20%20%20%20 mailto:dlzar.anwer@hmu.edu.krd)?subject=dlzar.anwer@hmu.edu.krd)%20%20%20%20%20 mailto:dlzar.anwer@hmu.edu.krd) mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.13 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article one way to enhance nursing education is to determine the effect of teaching methods on nursing students’ achievements and teaching effectiveness at nursing colleges. delivering nursing education through the traditional lecture format, on the other hand, is criticized for its emphasis on the learners' passive receipt of knowledge rather than learning to think critically [1]. at hawler medical university's college of nursing, lectures are the primary teaching modality used nowadays. a teacher who speaks continually in front of a class about a given subject or topic is said to be using a lecture teaching approach. the size of the group might range from 20 to 1000. delivering the entire subject matter is the instructor's responsibility. it is among the most traditional teaching strategies still in use in schools, colleges, and universities across a range of subject areas. the foundation of the lecture style of instruction is that the instructor imparts knowledge to the students before they engage with the material themselves. traditional lecturing or teaching methods are other names for the lecture style of instruction. since the traditional lecture style is a passive learning approach, many educators and researchers think it has no greater impact on students' cognitive growth. it does not allow students to participate in the learning process. [2].a widely used teaching method is the lecture. it works well for teaching specific facts and fundamental abilities since the information is delivered in an understandable and straightforward way. it also works well for introducing learners to new subjects or topics. it is utilized to introduce new content that is not yet published in books or print. it is seen to be an effective way to deliver information to a big class of students. large groups of people can also be presented with a lot of knowledge through lectures. it is the most effective approach to use when the facts or issues are contradictory or unclear; the lecture technique is the most effective approach to employ when time is limited. the lecture technique works best when oral presentations are the most effective way to learn a subject. lectures organize, clarify, and explain complex ideas. lectures challenge preconceived notions and learning habits; they generate excitement and drive for additional study; and the lecturer has complete control over the whole course. for pupils who lack creativity and innovation, the lecture poses minimal danger. therefore, for students who learn best by listening, the lectures are appealing [3].many teaching methods are available in the educational process, especially in university, for example, the bologna process, the traditional method process and small group discussion. in kurdistan, different universities exist, including governmental and private ones. according to the ministry of higher education and scientific research, the teacher-centered approach was the core of education among universities in the past. the system was the traditional teaching method: transferring information from the teacher to the learners in theoretical classes and applying it in practical ones. but nowadays, most of the universities use a student-centered approach by using new teaching methods such as teamwork or group work, self-assessment, and peer assessment as a means of deeper learning in the education cycle [4]. importance of the studythis study is important because researchers want to know or evaluate whether the current teaching method, as a teaching method, is effective, engaging, and well-received by students at the college of nursing.aims of the studyto determine the perspective of the students about the current teaching method in the college of nursing at hawler medical university. 125 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.13 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article form prepared by the researchers for the purpose of studying. the form consisted of 2 parts. part 1 referred to socio demographic characteristics of the students, including age, sex, residence, type of secondary school, students’ stage, and department. part 2 assessed the students’ perspective about the current teaching method, containing 18 principal items. each item was rated 5 for regularly, 4 for sometimes, 3 for rarely, 2 for never and 1 for do not know. a common approach is to set a midpoint cutoff: high frequency (positive) → mean ≥ 4.0 (regularly/sometimes), moderate frequency → mean 3.0 – 3.9 (rarely), low frequency (negative) → mean < 3.0 (never/do not know). categorization of mean scores using the scale mean score range is 4.0 – 5.0 for high frequency (regularly/sometimes), 3.0 – 3.9 for moderate frequency (rarely), and 1.0 – 2.9 for low frequency (never/do not know). if an item’s mean score is 4.5, it falls in the highfrequency category. if the mean score is 3.2, it falls under moderate frequency. a mean score of 2.4 is classified as low frequency. the statistical package for social sciences (spss, v23) was utilized to analyze the data. cronbach's alpha, which gauges a construct's internal consistency, was used to conduct a reliability test. for this metric, a reliability "alpha" of 0.60 is the suggested minimum acceptable level [5]. using the chi-square test because their p-values are higher than the significant level of α =0.05. cronbach’s alpha was calculated to assess the internal consistency of the data, serving as a reliability measure. a coefficient of 0.60 or above is recommended for exploratory research, with reliability classified as excellent (≥0.90), high (0.70– 0.90), moderate (0.50–0.70), or low (≤0.50). while reliability is essential, it must be paired with validity for meaningful results. in this study, the 18-item scale for teaching methods achieved a cronbach’s a cross-sectional study was conducted in order to investigate students’ perspectives about the current teaching method at the college of nursing. the study was conducted at the college of nursing/hawler medical university, which is a public university in erbil city, located in the north of iraq. it is also a capital of kurdistan. a nonprobability-convenience sample (n=414) of students was used in this study. the sample consists of 414 students from the college of nursing. the g power sample size calculator was used to determine the required sample size for conducting the study. to determine the appropriate sample size for a finite population of 841 individuals, we use the standard sample size formula for surveys. giving a 95% confidence level (z=1.96z = 1.96z=1.96), an expected proportion of 50% (p=0.5p = 0.5p=0.5), and a margin of error of 5% (e=0.05e = 0.05e=0.05), the calculation involves plugging these values into the formula. after performing the necessary computations, the required sample size is found to be 264. this means that to achieve statistically significant results while maintaining the specified confidence level and margin of error, a survey should include at least 264 respondents from the population. n = 841 # population size z = 1.96 # z-score for 95% confidence level p = 0.5 # expected proportion e = 0.05 # margin of error the second, third, and fourth stages of the students from the college of nursing were included. first-stage students were excluded because they do not have enough experience with the current teaching method. the study was carried out from 1st september to 15th november 20242024. the data was collected through a questionnaire 126 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.13 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article alpha of 0.743, indicating high reliability and ensuring the credibility of the findings. [6] [7] [8].the questionnaire form about the current teaching method was sent to ten nursing faculty experts in order to review the items of the questionnaire form. each expert returned their comments and suggestions about the questionnaire form. after that, the researchers carefully reviewed their comments and feedback and corrected and edited the items of the questionnaire form accordingly. formal ethical approval from the ethical committee of the college of nursing/ hawler medical university was received by researchers on june 06, 2024 with the number of 2410. before they agreed to take part willingly, the participants in the study were made aware of the research's goals. additionally, the respondents were assured that their responses would remain anonymous and be utilized just for academic investigation. the responders filled out the questionnaires and handed them in to the researcher. most of the responders are female (85.5%) while more than half of them are aged between 21 and 24 years old, because 56.8% are 21 years old on average. the percentage of students coming from public secondary school (84.5%) is higher than the percentage from private school (15.5%) while most of them are studying in the fourth grade (41.1%). more than half of the students are living in urban (54.6%) followed by suburban (22.9%), and rural (22.5%) respectively, since most of them are staying at home (63%). the percentage of participating students who were studying at the nursing department (56.8%) were higher than those who were studying at the midwifery department (43.2%). among the items analyzed, do teachers provide students with a written syllabus (course book) for each course? standing out with the highest mean score of 4.239, indicating a strong level of agreement or satisfaction with the aspect it addresses. in contrast, the question about the library providing you with educational aids such as digital library and internet access recorded the lowest mean score of 2.879, suggesting relatively lower satisfaction or agreement. the overall mean score for this set of questions is calculated at 3.735, with a standard deviation of 0.450, reflecting moderate variability in the responses. 127 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result table 4.1: descriptive statistics for demographic questionnaire variables n (%) sex male 60 (14.5) female 354 (85.5) age 18 20 164 (39.6) 21 24 235 (56.8) 24 + 15 (3.6) secondary school private 64 (15.5) public 350 (84.5) staying home 261 (63.0) dorm 153 (37.0) resident rural 93 (22.5) suburban 95 (22.9) urban 226 (54.6) student stage second 108 (26.1) third 136 (32.9) fourth 170 (41.1) department nursing 235 (56.8) midwifery 179 (43.2) are you satisfied with the current teaching methods in the college? yes 162 (39.1) no 252 (60.9) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.13 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article 76 * percentage of agreement copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4.2: students’ perspective about the current teaching methods do not know never rarely sometimes regularly mean sd * % n (%) n (%) n (%) n (%) n (%) lecture is the main method of teaching in the college? 3 (0.7) 21 (5.1) 42 (10.1) 219 (52.9) 129 (31.2) 4.087 0.82 81.74 teachers are using different teaching strategies during teaching process? 2 (0.5) 43 (10. 4) 96 (23.2) 219 (52.9) 54 (13) 3.676 0.85 73.53 teachers encourage discussion with students during teaching. 2 (0.5) 10 (2.4) 63 (15.2) 187 (45.2) 152 (36.7) 4.152 0.80 83.04 how often teachers are using teaching aids (audiovisual aids) during teaching: 15 (3.6) 32 (7.7) 93 (22.5) 139 (33.6) 135 (32.6) 3.838 1.08 76.76 \ do teachers update their lecture according to the feedbacks of the students? 22 (5.3) 83 (20) 128 (30.9) 125 (30.2) 56 (13.5) 3.266 1.09 65.31 \ how often teachers update their lectures 34 (8.2) 40 (9.7) 108 (26.1) 190 (45.9) 42 (10.1) 3.401 1.06 68.02 \ do teachers provide students with a written syllabus (course-book) for each course? 8 (1.9) 22 (5.3) 46 (11.1) 125 (30.2) 213 (51.4) 4.239 0.98 84.78 q8: the whole planned written curriculum is implemented during the course? 14 (3.4) 29 (7) 66 (15.9) 195 (47.1) 110 (26.6) 3.865 1.00 77.29 q9: the library provides you with educational aids such as digital library and internet access. 23 (5.6) 17 3 (41. 8) 92 (22.2) 83 (20) 43 (10.4) 2.879 1.12 57.58 q10: the library provides you with educational aids such as textbooks and journals 17 (4.1) 93 (22. 5) 103 (24.9) 118 (28.5) 83 (20) 3.379 1.16 67.58 q11: facilities such as (classrooms or halls, projector, labs, simulators, etc) needed for proper teaching in the college are available? 8 (1.9) 36 (8.7) 78 (18.8) 164 (39.6) 128 (30.9) 3.889 1.00 77.78 q12: the current mid-term and final examination meet learning objectives as summative evaluation: 16 (3.9) 59 (14. 3) 71 (17.1) 179 (43.2) 89 (21.5) 3.643 1.09 72.85 q13: lecturer deliver lectures with great interest. 6 (1.4) 37 (8.9) 103 (24.9) 198 (47.8) 70 (16.9) 3.698 0.90 73.96 q14: lecturers easily found outside of class time. 10 (2.4) 74 (17. 9) 113 (27.3) 134 (32.4) 83 (20) 3.498 1.08 69.95 q15: lecturers interested in student achievement and giving feedback on student progress. 11 (2.7) 61 (14. 7) 102 (24.6) 185 (44.7) 55 (13.3) 3.512 0.99 70.24 q16: lecturers are prepared to answer questions. 7 (1.7) 26 (6.3) 44 (10.6) 170 (41.1) 167 (40.3) 4.121 0.95 82.42 q17: does the lecturer give enough time and space for students to ask questions? 8 (1.9) 22 (5.3) 49 (11.8) 167 (40.3) 168 (40.6) 4.123 0.95 82.46 q18: lecturers give course contents and framework at the beginning of each lecture. 19 (4.6) 20 (4.8) 63 (15.2) 167 (40.3) 145 (35) 3.964 1.05 79.28 overall 3.735 0.45 74.70 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.13 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article times, there is room for improvement to enhance regular approval. the finding of the study showed that there is a statistically significant association between nursing students' responses (never, rarely, sometimes, and regularly) and the variables of gender, stage of study, and satisfaction with the current teaching methods because their p-values (0.043, <0.001, and <0.001) are less than the significant level of α =0.05. environment. also, students in the fourth stage report the highest percentage of being "sometimes" satisfied with the current teaching methods, accounting for 48.7% of responses in this category. this is noticeably higher compared to students in the third stage, who make up 27.8%, and those in the second stage, who represent 23.6%. these findings suggest that satisfaction with the teaching methods tends to increase as students’ progress to higher stages of their education. then, the percentage of students who are "sometimes" satisfied with the current teaching methods (36.9%) is less than the percentage of students who are not satisfied (63.1%). however, the percentage of students who are 129 the findings indicate that the majority of students (63.53%) sometimes expressed an agreement with the effectiveness of the teaching methods. this is followed by 21.5% of students who rarely agreed, 13.53% who regularly agreed, and a small fraction (1.4%) who reported never agreeing with the current teaching methods. these percentages reflect varying levels of satisfaction, highlighting that while most students find the methods acceptable at for instance, the result indicates that a significantly higher proportion of females report being "sometimes" satisfied with the current teaching methods, accounting for 85.6% of responses in this category, compared to only 14.4% from males. similarly, the percentage of females who express being "regularly" satisfied is even higher, at 94.6%, while males account for just 5.4% in this category. these findings highlight a notable gender disparity in satisfaction levels, with females consistently reporting higher agreement with the effectiveness of the teaching methods than their male counterparts. this trend may point to gender-specific perceptions or experiences within the educational copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. figure 4.1 : overall percentage about the current teaching methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.13 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article 130 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. "regularly" satisfied with the current teaching methods (73.2%) is significantly higher compared to those who are not regularly satisfied (26.8%). this indicates that while occasional satisfaction is evenly split, there is a stronger trend toward regular satisfaction among the respondents. on the other hand, there is no statistically significant difference between nursing students' responses (never, rarely, sometimes, and regularly) and each of the (age, secondary school, staying, resident, and department) variables separately. table 4.3 : association between nursing students response (never, rarely, never, and regularly) with demographic question using chi-square test variables overall total chisquare p-value never rarely sometimes regularly sex male n 0 19 38 3 60 8.164 0.043 (%) (0) (21.3) (14.4) (5.4) (14.5) female n 6 70 225 53 354 (%) (100) (78.7) (85.6) (94.6) (85.5) age 18 20 n 3 47 89 25 164 2.343 0.126 (%) (50) (52.8) (33.8) (44.6) (39.6) 21 24 n 3 40 162 30 235 (%) (50) (44.9) (61.6) (53.6) (56.8) 24 + n 0 2 12 1 15 (%) (0) (2.2) (4.6) (1.8) (3.6) secondary school private n 0 12 44 8 64 1.747 0.627 (%) (0) (13.5) (16.7) (14.3) (15.5) public n 6 77 219 48 350 (%) (100) (86.5) (83.3) (85.7) (84.5) staying home n 5 60 162 34 261 2.157 0.540 (%) (83.3) (67.4) (61.6) (60.7) (63) dorm n 1 29 101 22 153 (%) (16.7) (32.6) (38.4) (39.3) (37) resident rural n 1 17 65 10 93 3.708 0.716 (%) (16.7) (19.1) (24.7) (17.9) (22.5) suburban n 1 20 63 11 95 (%) (16.7) (22.5) (24.0) (19.6) (22.9) urban n 4 52 135 35 226 (%) (66.7) (58.4) (51.3) (62.5) (54.6) student stage second n 0 29 62 17 108 25.157 <0.001 (%) (0) (32.6) (23.6) (30.4) (26.1) third n 5 39 73 19 136 (%) (83.3) (43.8) (27.8) (33.9) (32.9) fourth n 1 21 128 20 170 (%) (16.7) (23.6) (48.7) (35.7) (41.1) department nursing n 4 56 141 34 235 3.035 0.386 (%) (66.7) (62.9) (53.6) (60.7) (56.8) midwifery n 2 33 122 22 179 (%) (33.3) (37.1) (46.4) (39.3) (43.2) satisfied in current teaching methods yes n 1 23 97 41 162 35.74 <0.001 (%) (16.7) (25.8) (36.9) (73.2) (39.1) no n 5 66 166 15 252 (%) (83.3) (74.2) (63.1) (26.8) (60.9) total n 6 89 263 56 414 (%) (100) (100) (100) (100) (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.13 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article deepened their perspectives, and demonstrated enthusiasm. [11].according to the outcome of the current study, it showed that the percentage of students who are "sometimes" satisfied with the current teaching methods (36.9%) is less than the percentage of students who are not satisfied (63.1%). cooperative learning and traditional learning methods in theoretical classes have been compared in an iranian study on nursing students' ability to communicate with patients in practical settings. the findings indicated that there was no significant difference between the two groups' pre-teaching intervention communication skills scores, but there was a significant difference between the two groups' post-teaching intervention interaction skills and problem follow-up subscale scores. it is advised to increase nursing students' participation in arguments by implementing active teaching strategies that can offer the chance for improved communication skills, as this study shows that cooperative learning is an effective way to improve and increase nursing students' communication skills, particularly in the interactive skills and follow-up the problems subscale [12]. the majority of students thought that the nursing education program's present teaching methodology had a significant part in raising students' academic achievement. the findings show that, in comparison to their male counterparts, a much larger percentage of females say they are "sometimes" satisfied with the existing teaching methods. the present study indicated that the students agreed that their teachers provide the students with a written syllabus (course book) for each course. the findings showed that the majority of students (63.53%) sometimes expressed an agreement with the effectiveness of the current teaching methods. a study, on the opinions of students on nursing education was carried out in jordan. the findings showed that the course material and instructional strategies were comprehensive, wellstructured, and easy to understand. emphasis was placed on online resources and teachers who are well-prepared, wellorganized, and make efficient use of class time. conversely, the most common factor that adversely impacted pupils' learning was a noisy atmosphere [9].the finding of the current study mentioned that most of the students (43.2%) responded that they sometimes agree that the current midterm and final examination meet learning objectives in the current teaching method. additional research conducted in hong kong has verified that evaluation techniques can affect nursing students' learning strategies. a deep learning technique may benefit from assessments that measure comprehension rather than memorization [10]. the result of this research identified that most of the students responded that (52.9%) sometimes their teachers were able to use different teaching strategies during their teaching process. another study, on how instructional context influences nursing students' adoption of a deep learning strategy, was carried out in japan. according to the study's findings, students were more likely to embrace the deep approach to learning when teachers actively engaged their attention, supported learning activities, gave them explanations that helped them understand, imparted knowledge that broadened and 131 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion conclusion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.13 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article [7] zhong, y., xu, t., dong, r., lyu, j., liu, b., chen. the analysis of reliability and validity of the it-mais, mais and muss. international journal of pediatric otorhinolaryngology. 2017; 96, 106-110. doi.org/10.1016/j.ijporl.2017.03.006. [8] vaske jj, beaman j, sponarski cc. rethinking internal consistency in cronbach's alpha. leisure sciences. 2017; 39(2):163-173. doi.org/10.1080/01490400.2015.1127189 [9] ahmed mz, touama h, rayan a. students' perspectives about nursing education. american journal of educational research. 2015;3(3):288-91. doi:10.12691/education3-3-6 [10] leung sf, mok e, wong d. the impact of assessment methods on the learning of nursing students. nurse education today. 2008;28(6):711-719.doi:10.1016/ j.nedt.2007.11.004. [11] takase m, imai t, niitani m, okada m. teaching context contributing to nursing students' adoption of a deep approach to learning. journal of professional nursing. 2019; 35(5):379-388. doi:10.1016/ j.profnurs.2019.04.006 [12] baghcheghi n, koohestani hr, rezaei k. a comparison of the cooperative learning and traditional learning methods in theory classes on nursing students' communication skill with patients at clinical settings. nurse education today. 2011; 31(8): 877-82. doi: 10.1016/j.nedt.2011.01.006. limitations of the study and recommendations the geographic area that just encompasses hawler medical university and the college of nursing is the limitation of the study. it is advised to conduct additional study with the addition of other colleges of nursing in iraqi kurdistan. the authors declared that there is no conflict of interest in this study. [1] hala o, al-mostafa o, hasheesh ma. traditional versus nontraditional methods of teaching: the impact on nursing teaching effectiveness and student’s achievements at nursing colleges. an-najah university journal for research. (2011); 5(1), 256-257. doi:10.35552/0247-025-001-010. [2] muhammad h. a critical review on blended learning versus traditional lecture method. international journal of learning and teaching. (2021); 13(2), 62-76. doi: 10.18844/ ijlt.v13i2.5668. [3] marmah aa. students’ perception about the lecture as a method of teaching in tertiary institutions. views of students from college of technology education. international journal of education and research. (2014); 2(6), 601-612. doi:10.1016/j.sbspro.2014.01.1445 [4] salih mm, chaqmaqchee za. attitudes of university students in kurdistan region of iraq towards different methods of evaluation. journal of arts, literature, humanities and social sciences. 2021; 69: 283-298. doi.org/10.33193/jalhss.69.2021.536. [5] hussey i, alsalti t, bosco f, elson m, arslan r. an aberrant abundance of cronbach’s alpha values at .70. advances in methods and practices in psychological science. 2025;8(1). doi:10.1177/25152459241287123 [6] taber ks. the use of cronbach’s alpha when developing and reporting research instruments in science education. research in science education. 2018;48(6): 1273-1296. doi.org/10.1007/s11165-016-9602-2 132 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conflict of interst reference https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article factors associated with poor quality of life in lung cancer patients undergoing chemotherapy in erbil city abstract background and aims: lung cancer is one of the most prevalent types of cancer in the world, and the aim of the study was to determine the quality of life. and its related factors in lung cancer patients undergoing chemotherapy. methods: a descriptive cross-sectional study design was conducted in iraq in 2022 on 100 cancer patients undergoing chemotherapy who were randomly collected in rizgary teaching hospital and nanakaly hospital for blood disease and cancer. the instrument used for data collection consisted of demographic and medical data (age, gender, educational level, marital status, occupation, economic status, residency, cigarette smoking, family history, stages of lung cancer, and types of lung cancer), another section was the functional assessment of cancer therapy-lung questionnaire (fact-l), specifically designed for the measurement of quality of life in patients with lung cancer. categorical data were presented as frequency and percentage and the mean± sd was calculated for continuous data, independent t-test, and chi-square test was also used; binary logistic regression was run to determine the effect of the predictors on poor quality of life in lung cancer patients a p-value ≤0.05 was considered statistically significant. results: the overall quality of life was poor (59%), the mean± sd for functional assessment of cancer therapy lung cancer subscale (fact-l) was 66.19 ± 10.54, and trial outcome index (toi) was 39.77±5.51, the following variables were associated with a poor quality of life: age >50 (p-value =0.020, or= 2.47), female (p-value =0.006, or= 3.02), uneducated (p-value =0.0005, or= 1.86), ex-smoker (p-value =0.040, or= 2.14), insufficient income (p-value =0.037, or= 2.69). conclusion: the quality of life of lung cancer was lower in physical well-being, functioning well-being, and lung cancer subscale compared to social/family well-being, and emotional well-being, as generally, the quality of life of most lung cancer patients was poor. keywords: quality of life; functional assessment of cancer therapy lung cancer subscale; chemotherapy. dler hamad ismael; department of nursing, college of nursing, hawler medical university, kurdistan regioniraq. (correspondence: dler.ismael@hmu.edu.krd) 74 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 03/03/2023 accepted: 29/05/2023 published: 30/5/2023 mailto:dler.ismael@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article lung cancer is a popular malignancy and the most predictable cause of death worldwide. according to the world health organization an estimated 2.21 million new patients and the mortality rate was 1.8 million cases in 2020 [1]. remarkably unfavorable outcomes are estimated in developing countries where with inadequate healthcare services, there is increased exposure to risk factors such as environmental, and economic factors, and lifestyles changed to western lifestyles [2]. in iraq, there is increasing in the incidence of cancer and death, despite implemented of national cancer registries and control program since 1974, according to the latest estimates from the international agency for research reported number of cancer in new cases was >25,000, and cancer-related deaths was14,000 in 2018 (3). the earliest reported cancer incidence rates in erbil, duhok and sulaymaniyah were 50.0 and 61.5, and 61.7 cases/100,000 individuals, respectively [4]. quality of life (qol) is one of the most familiar health issues for cancer patients. qol is multidimensional and includes the emotional, social, and physical activities of patients.the value of quality of life has to be highly considered, because of the extreme symptom burden and commonly restricted life expectancy [5]. as a result of the advancement in medical science and continuing development of treatment, the survival rate of patients with cancer has been estimated longer. this has resulted in a continued interest in studying the health-related quality of life (hrqol) of cancer survivors. so, there is a subsequent need to satisfy cancer patients' needs, enabling them to live healthy life [6]. cancer impacts patients’ quality of life (qol) in the whole domain. the deterioration in the qol begins with the identification of cancer and persists with the advancing nature of the treatment. chemotherapy is one of the well-known treatment choices for patients to fight cancer [7], as well. these treatment effects also have severe unwanted effects on the patient’s quality of life. moreover, patients who received chemotherapy treatment for a longer time to get the preferred effect and require regular hospital admission for disease treatment, which causes a further burden on cancer patients [8]. there are several factors impacting the quality of life of lung cancer patients undergoing chemotherapy such as age, gender, marital status, education levels, pathological types, family income, and metastasis the independent factors affecting the deterioration of their quality of life [9], there is no study in the literature reporting on the quality of life of lung cancer patients among the kurdish population. the objective of the present study was to assess the factors associated with poor quality of life of lung cancer patients undergoing chemotherapy. a descriptive cross-sectional study design was performed on 100 lung cancer patients collected successively in oncology units at both rizgary teaching hospitals and nanakaly hospital for blood disease and cancer in erbil city. the sample of the study was lung cancer patients according to the inclusion criteria were asked to participate in the study in two oncology regional units in erbil city. before starting the study, approvals were taken from the college of nursing /hawler medical university and hospital authorities for the conduct of the study. the researcher obtained ethical from; they were assured about data confidentiality informed consent was obtained from all participants before starting interviews with them. the researcher was aware of research ethics therefore patients’ dignity, values, and 75 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article lung cancer subscale. the toi is described for the measurement of functional outcomes. a 5-point likert-type scale asked patients to respond to each item with a score of 0–4, where not at all=0, a little bit=1, somewhat = 2, quite a bit=3, and very much=4. the total fact-l score is the summation of the 5 subscale scores and ranges from 0 to 136 and the toi score array between (0 to 84). the lung cancer subscale applied a 5-point likert scale to patient responses to measure the intensity of lung cancer symptoms rated as non = 0, mild= 1, moderate = 2, marked= 3 and severe= 4). all statistical analyses using (spss software version 26), descriptive and inferential statistical tests were performed. categorical data were presented as frequency and percentage distribution, and the mean± sd was calculated for continuous data. independent t-test and chi-square test were also used. binary logistic regression models were used to find and predict factors affecting the quality of life in lung cancer patients ,p-value equal or less than 0.05 was considered statistically significant. among the total of 100 patients with lung cancer in table 1 the findings indicated that, the mean age of patients was 54.25± 8.13 and the highest percentage was 75% more than 50 years old, and 70% of them were male. regarding educational level, nearly half of them 46% were uneducated, and most of them were married. regarding occupational status 54% of them were unemployed, also more than half of the participants were insufficient family income accounting for 61%, and most of them were living in a rural area 65%. in addition, the table showed that the highest percentage 73% of the participant was ex-smoker, about 18% had a positive family history, and most of the samples had stage iii of security may impact during data collection. the participants of this study were lung cancer patients, according to a statistical specialist, the sample size was determined to be 100 patients by this statistical formula marked n=z² pq/d² ( z =1.96, p= 0.067, q= 0.933, d= 0.05) , to obtain accurate data and a representative sample a purposive sampling method was used to select the samples: patients who were willing to participate in the study, age over 18 years, confirmation of the lung cancer diagnosis by an oncologist, undergoing chemotherapy and kurdish speaker. the patients excluded were unwillingness to participate in the study, newly diagnosed patients with lung cancer, uncooperative patients, being treated with psychotropic medication, and patients who have severe illness with serious complications and unstable. data were collected between february 2022 and december 2022 through face-to-face interviews. the instrument consisted of demographical characteristics and medical data (age, gender, educational level, marital status, occupation, economic status, residency, cigarette smoking, family history, stages, and types of lung cancer). the second part was the functional assessment of cancer therapygeneral questionnaire (fact-g) widely used to measure the quality of life in cancer patients, it was established by a group of oncology specialists [10]. in addition, the lung cancer subscale (lcs) to the fact-g, together create (fact-l) which is specifically designed for lung cancer. it contains 34 items that assess five primary dimensions of qol: physical well-being (pwb; 7 items), functional well-being (fwb; 7 items), emotional well-being (ewb; 6 items), and social/family wellbeing (sfwb; 7 items). lung cancer subscale (lcs 7 items). the trial outcome index (toi) calculates the total of the physical well-being, functional. well-being, and 76 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article lung cancer 57%, regarding types of lung cancer, adenocarcinoma was the highest percentage 44%, followed by squamous cell carcinoma 35%, small-cell carcinoma 11%, and large-cell carcinoma 9% respectively. moreover, table 1 shows a significant association between quality of life and age (p=0.003), gender (p=0.005), level of education (p=0.001), family income (p=0.001), residency, (p=0.047), cigarette smoking(p=0.005) and stage of lung cancer (p=0.001), while there was no significant found between quality of life with marital status (p=0.187 ), occupation (p=0.310), family history (p=0.743) and types of lung cancer (p=0.300). 77 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: association between quality of life and variables of the study demographic and medical data quality of life (fact-l) p-value poor n(%) good n(%) total n(%) age ≤50 4(16.0) 21(84.0) 25(25) 0.003 >50 37(49.3) 38(50.7) 75(75) gender male 35(50.0) 35(50.0) 70(70) 0.005 female 24(80.0) 6(20.0) 30(30) level of education uneducated 28(60.9) 18(39.1) 46(46) 0.001 educated 13(24.1) 41(75.9) 54[(54) marital status married 37(39.4) 57(60.6) 94(94) 0.187 widowed 4(66.7) 2(33.3) 6(6) occupation employed 10(62.5) 6(37.5) 16(16) 0.310 retired 9(64.3) 5(35.7) 14(14) unemployed 17(31.5) 37(68.5) 54(54) housewife 5(31.3) 11(68.8) 16(16) family income insufficient 44(72.1) 17(27.9) 61(61) 0.001 sufficient 24(61.5) 15(38.5) 39(39) residency urban 22(33.8) 43(66.2) 35(35) 0.047 rural 19(54.3) 16(45.7) 65(65) cigarette smoking non-smoker 5(18.5) 22(81.5) 27(27) 0.005 ex-smoker 36(49.3) 37(50.7) 73(73) family history no 33(40.2) 49(59.8) 82(82) 0.743 yes 8(44.4) 10(55.6) 18(18) stage of lung caner stage iii 9(15.8) 48(84.2) 57(57) 0.001 stage iv 32(74.4) 11(25.6) 43(43) types of lung cancer large-cell carcinoma 1(11.1) 8(88.9) 9(9) 0.300 small-cell carcinoma 4(36.3) 7(63.3) 11(11) squamous cell carcinoma 16(44.4) 20(55.6) 35(35) adenocarcinoma 19(43.1) 25(56.8) 44(44) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 78 index (toi) was 39.77±5.5. also, the results demonstrate that the quality of life domains was lower in physical well-being 13.74 ± 3.02 functioning well-being 13.15 ± 4.12, lung cancer subscale 12.88 ± 3.54, compared to other domains of social/family well-being 14.29 ± 4.48, emotional well-being 12.13 ± 3.23. higher social well-being (16.84±4.15 to 12.37±3.72), better emotion status (14.91±6.09 to 10.04±5.51), well improved functioning status (14.65±4.64 to 12.02±3.29), better able to control lung cancer symptoms (14.09±2.86 to 11.28±3.67) consequently. copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2 shows the mean score for quality of life domains was a low mean score ≤ 2 which is considered a poor qol while a mean score of more than 2 is a good qol [10], the analysis of the qol revealed a mean total score of functional assessment of cancer therapy lung cancer subscale (fact-l) was 66.19 ± 10.54, trial outcome comparison of quality of life of scores according to stages of lung cancer as shown [in table 3]. the quality of life mean score was significantly higher in stage iii lung cancer compared to stage iv, patients with stage iii lung cancer had better physical well being (14.44±3.33 to 13.21±2.67), table 2. quality of life scores in lung cancer patients undergoing chemotherapy quality of life domains min max mean ± sd/ total mean ± sd/ scale physical well-being 7.00 21 13.74 ± 3.02 1.96 ± 0.43 social/family well-being 5.00 21 14.29 ± 4.48 2.04 ± 0.64 emotional well-being 1.00 24 12.13 ± 3.23 2.02 ± 1.03 functioning well-being 7.00 21 13.15 ± 4.12 1.88 ± 0.59 lung cancer subscale 5.00 21 12.88 ± 3.54 1.84 ± 0.50 trial outcome index 1.89 57 39.77 ± 5.51 1.89 ± 0.26 fact-l score qol 47.0 99 66.19 ± 10.54 1.95 ± 0.31 table 3: comparison of quality of life of scores according to stages of lung cancer quality of life stage of lung cancer iii iv mean difference t. test p-value mean±sd mean±sd physical well-being 14.44±3.33 13,21±2,67 -1.23 -2.05 0.043 social well-being 16.84±4.15 12,37±3,72 -4.46 -5.66 0.001 emotional well-being 14.91±6.09 10,04±5,51 -4.87 -4.18 0.002 functioning well-being 14.65±4.64 12,02±3,29 -2.63 -3.31 0.001 lung cancer subscale 14.09±2.86 11.28±3,76 -2.80 -3.61 0.001 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 79 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. a logistic regression model was constructed to assess the association between selected variables of study as predictors and poor quality of life (fact-l), as shown in [table 4]. variables chosen in the model were based on the bivariate analysis of age, gender, level of education, residency, smoking, and economic status were put into the model. model fit was measured by the likelihood ratio statistic (χ2= 3.26, pxvalue=0.004) and the hosmer and leme figure 1 shows a comparison of quality of life sores each scale in male and female lung cancer patients, the male reported higher mean scores compared to females in physical well-being (pwb), social/family show test (χ2= 4.67, p=0.69), the variability observed in the target variable is explained by the regression mode was r2 = 49.1%. the following variables were associated with a poor quality of life: age >50 (p-value =0.020, or= 2.47), female (p -value =0.006, or= 3.02), uneducated (pvalue =0.0005, or= 1.86), ex-smoker (pvalue =0.040, or= 2.14), insufficient family income (p-value =0.037, or= 2.69). well-being (sfwb), emotional well-being (ewb), functioning well-being (fwb) lung cancer subscale (lcs), functional assessment of cancer therapy-lung (qol-factl). table 4: factors associated with poor quality of life (fact-l) variables p-value or 95% ci lower upper age /year ≤50 ref. >50 0.020 2.47 1.31 11.8 gender male 0.006 3.02 1.68 10.5 female ref. level of education uneducated 0.005 1.86 1.62 7.58 educated ref. residency urban ref. rural 0.095 2.23 0.85 7.47 cigarette smoking non-smoker ref. ex-smoker 0.040 2.14 1.06 8.04 family income insufficient 0.037 2.69 0.91 7.94 sufficient ref. figure 1: changes fact-l total score in male and female patients https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 80 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. also, [figure 2] shows the lung cancer subscale of symptoms the highest percentage of lung cancer patients had severe difficulty breathing 43%, poor appetite 41%, cancer is one of the main problems throughout the world. it is frequently increasing day by day, and many cancer patients need to improve their quality of life. it is detected that the incidence of cancer in old age raised continuously, as older age may itself be an important risk factor due to certain physiologic changes that go along with the ageing process, in addition to the presence of a variety of comorbidities, and adverse effects associated with the medications for chronic disease [11, 12]. the results show the mean age of the patients was 54.25± 8.13 and the main proportion of the age group of lung cancer patients was more than 50 years old, and about 70% were male that significant association with the quality of life, which agree with a study conducted in an oncology center in hilla city, 2019 which revealed that most of the participants were men, their cough 40%, shortness of breath 38%, chest tightness 34%, and other symptoms 49% unclear thinking was marked and 39% moderate weight loss. age 60 years and above (13). also, in the current study supported by a study done in egypt most of the sample was male, which might reflect the higher smoking rate and industrial and environmental pollutant exposures among males in these countries, in the current study, males had a better quality of life than female similar to the existing literature, also showed that the females gender was significantly associated with the poor qol[14, 15] . higher education has been displayed to have a positive effect on survival for cancer patients. in current study, the highest percentage of samples were illiterate and had a significant association with quality of life this agrees with the study shows that education is one factor that positively affects qol. moreover, patients who completed primary or further education were observed to have better social and physical figure 2. lung cancer symptoms intensity for patients undergoing chemotherapy discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 81 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. functions [16, 17]. in this study, most of the participants were living in rural areas, which was supported by a study that reported lung cancer more frequently caused death in rural areas [18]. insufficient monthly income accounted for significantly associated with the quality of life in comparison with a study that has shown that individual income measures are significantly and independently associated with cancer risk factors, quality of life, and survival [19]. cigarette smoking appears to be a risk factor that influences the quality of life of patients with lung cancer [20] in this study demonstrated that patients who smoked previously are three times more at risk for developing lung cancer than non-smokers and had significant impacts on quality of life. patients with stage iii lung cancer had significantly better physical well-being, higher social well-being, emotional status, well-improved-functioning status, and better ability to control lung cancer symptoms which agrees with a study done in turkey when considering the stage of the tumor, the scale scores varied significantly in all dimensions among patients with stage iii cancer [21] . in addition, the study done in china by [22] found that stage iv lung cancer patients had lower all domains of fact-l scores than stage iii patients. the current study focused on patients with advanced-stage lung cancer, the highest percentage of symptoms perceived by patients were severe in difficulty breathing, poor appetite, cough, shortness of breath, and chest tightness, which was supported by a study in the case of small cell lung cancer, the most frequent symptoms were cough, dyspnea, pain and weight loss [23], in other instances, which seems to be similar to the results of another study in sweden showed that the symptom burden in lung cancer patients, the most prominent symptoms were dyspnea., fatigue., coughing., insomnia., and appetite loss [24]. the analysis of the qol revealed a mean total score of the functional assessment of cancer therapy lung cancer subscale (fact-l) was 66.19 ± 10.54, trial outcome index (toi) was 39.77±5.51. whereas a study done in germany shows that fact-l total score was 86 ±21.5, and toi 50.5 ±14.9 [25]. furthermore, this study seems to be the most impacted in our study samples in physical well-being and functioning well-being, which lowers scores compared to social/family well-being, and emotional well-being that comes along with previous studies done in usa, germany, and france [26, 27]. the present study was carried out on a limited sample and the generalization of the results should be done with caution, selecting an available sampling method according to the type of study due to the diversity and metastasis of cancers. moreover considering important variables such as types of treatment including radiotherapy and surgery and the presence of other diseases associated with cancer were other limitations that affected the outcome of the study in summary, lung cancer patients had lower quality of life in physical well-being, functioning well-being, and lung cancer subscale, compared to social/family wellbeing, and emotional well-being. in general, the quality of life of most lung cancer patients was poor the authors declare that they have no competing interests. not applicable. conclusion conflicts of interest funding https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 82 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [1] wong mcs, lao xq, ho kf, goggins wb, tse sla. incidence and mortality of lung cancer: global trends and association with socioeconomic status. sci rep 7, 14300 2017; doi:org/10.1038/s41598-017-14513-7 [2] fitzmaurice c, abate d, abbasi n, abbastabar h, abd-allah f, abdel-rahman o et al. global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted lifeyears for 29 cancer groups, 1990 to 2017: a systematic analysis for the global burden of disease study. jama oncol. 2019; 5, 174968. doi: 10.1001/jamaoncol.2019.2996. [3] bray f, ferlay j, soerjomataram i, siegel rl, torre la, jemal a. global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca cancer j clin. 2018; 68(6):394-24. doi: 10.3322/caac.21492 [4] khoshnaw n, mohammed ha, abdullah da. patterns of cancer in kurdistan results of eight years cancer registration in sulaymaniyah province-kurdistan-iraq. asian pac j cancer prev. 2015;16(18):8525-31. doi: 10.7314/ apjcp.2015.16.18.8525. [5] reale ml, de luca e, lombardi p, marandino l, zichi c, pignataro d, et al . quality of life analysis in lung cancer: a systematic review of phase iii trials published between 2012 and 2018. lung cancer. 2020; 139:47-54. doi: 10.1016/j.lungcan.2019.10.022. epub 2019 oct 31. [6] ravasco p. nutrition in cancer patients. j clin med. 2019; 8(8):1211. doi: 10.3390/ jcm8081211. [7] fitch kv and pyenson bs. cancer patients receiving chemotherapy: opportunities for better management; 2010 available from https://us.milliman.com/en/insight/ research / health/ cancer-patients-receivingchemotherapy-opportunities-for-bettermanagement/ [8] rashid ya, ghafoor za, masood n, mehmood t, awan s,ansar t, et al. psychosocial impact of cancer on adult patients. j pak med assoc. 2012;62(9):905-9. pmid: 23139973. [9] bovero a, sedghi na, opezzo m, botto r, pinto m, ieraci v, et al. dignity-related existential distress in end-of-life cancer patients: prevalence, underlying factors, and associated coping strategies. psychooncology. 2018;27:2631–2637. doi: 10.1002/ pon.4884. [10] cella d, chang ch. a discussion of item response theory and its applications in health status assessment. med care. 2000;38(9 suppl):ii66-72. doi: 10.1097/00005650-200009002-00010. [11] torre la, siegel rl, jemal a. lung cancer statistics. adv exp med biol. 2016;893:119. doi: 10.1007/978-3-319-24223-1_1. [12] kim hj, choi cm, kim sg. the younger patients have more better prognosis in limited disease small cell lung cancer. tuberc respir dis. 2016;79:274–281 doi: 10.4046/ trd.2016.79.4.274 [13] al-khateeb z, mahdi l. prevalence of lung cancer in al najaf governorate registered in middle euphrates oncology center during 2019 and 2020. j fac med bagdad . 2022 ;64(1):22-30. doi:org/10.32007/ jfacmedbagdad. 6411887 [14] akl ym, emam rh, sabry im, ali aa. clinico‑pathological profileof bronchogenic carcinoma cases presented to chest department, cairouniversity in the last 10 years. egypt j chest dis 2013;62:705‑12. doi.org/10.1016/j.ejcdt.2013.09.019. [15] chagani p, parpio y, gul r, jabbar aa. quality of life and its determinants in adult cancer patients undergoing chemotherapy treatment in pakistan. asia pac j oncol nurs. 2017 apr-jun;4(2):140-146. doi: 10.4103/2347-5625.204499. [16] evans cj, trudeau e, mertzanis p, marquis p, peña bm, wong j, et al . development and validation of the pain treatment satisfaction scale (ptss): a patient satisfaction questionnaire for use in patients with chronic or acute pain. pain. 2004;112 (3):254-266. doi: 10.1016/ j.pain.2004.09.005. [17] guvencli m, yalniz e, komurcuoglu b, erbaycu ae 2, karakurt g the impact of chemotherapy on the eortc qlq-c30 and lc-13 quality of life scales in patients with lung cancertepecik eğit hast derg. 2021; 31(3): 344-354 | doi: 10.5222/ terh.2021.73626 [18] atkins gt, kim t, munson j. residence in rural areas of the united states and lung cancer mortality. disease incidence, treatment disparities, and stage-specific survival. ann am thorac soc. 2017;14(3):403411. doi: 10.1513/annalsats.201606469oc. reference https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.09 erbil j. nurs. midwifery, vol. 6, no. (1), may 2023 original article 83 copyright ©2022 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [19] toubat o, atay sm, kim aw, ding l, farias aj, ebner pj etal. disparities in guidelineconcordant treatment for pathologic n1 non-small cell lung cancer. ann thorac surg. 2020;109:1512-20. doi: 10.1016/ j.athoracsur.2019.11.059 [20] dimunová l, dankulincova v, zuzana m, jana b, relationship between quality of life of lung cancer patients and smoking. central european journal of nursing and midwifery.2018; 9. 812. doi:10.15452/ cejnm.2018.09.0009 [21] aydoğan b, göksel t, erbaycu a, öz a, pinar c, gürsul k, etal. the psychometric properties and clinical use of the turkish version of the functional assessment of cancer therapy–lung (fact-l) scale. j basic clin health sci 2019; 3:139-144 .doi.org/10.30621/ jbachs.2019.652 [22] zhang z, chen a, xie f, li x, hu g, lin g. low prognostic nutrition index predicts poorer quality of life in late-stage lung cancer. ann palliat med. 2020;9(6):3976-3984. doi: 10.21037/apm-20-1892. [23] ruano-raviña a, provencio m, calvo de juan v, carcereny e, moran t, rodriguez-abreu d, etal . lung cancer symptoms at diagnosis: results of a nationwide registry study. esmo open. 2020;5(6):e001021. doi: 10.1136/ esmoopen-2020-001021. [24] larsson m, ljung l, johansson bb. healthrelated quality of life in advanced non-small cell lung cancer: correlates and comparisons to normative data. eur j cancer care (engl). 2012 ;21(5):642-9. doi: 10.1111/j.13652354.2012.01346.x. epub 2012 apr 23. [25] kuon j, vogt j, mehnert a, alt-epping b, van oorschot b, sistermanns j et al. symptoms and needs of patients with advanced lung cancer: early prevalence assessment. oncol res treat. 2019;42(12):650-659. doi: 10.1159/000502751. epub 2019 oct 21. [26] iyer s, roughley a, rider a, taylor-stokes g. the symptom burden of non-small cell lung cancer in the usa: a real-world crosssectional study. support care cancer. 2014;22(1): 181–7. doi: 10.1007/s00520-013 -1959-4. epub 2013 sep 12. [27] iyer s, taylor-stokes g, roughley a. symptom burden and quality of life in advanced non-small cell lung cancer patients in france and germany. lung cancer. 2013 aug; 81(2): 288–93. doi: 10.1016/j.lungcan.2013.03.008. epub 2013. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.18 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article unveiling the veil of mortality: investigating the multifaceted causes and consequences of sudden deaths through post-mortem perspectives in erbil city abstract background and objective: percutaneous sudden death is still a great concern to humankind since it still affects a large population across the globe and has many causes and risk factors. this paper looks at the various contributing factors to sudden deaths in erbil, iraq, focusing on examining gender differences and family predisposition. methodology: using proper and extensive research methods, this research afforded data from fifty different persons of different ages. the assessment comprised sex, age, cause of death, previous co1morbidity, and family anamneses in addition to qualitative and quantitative semesters with relatives and time-sequential analysis of risk factors. results: mores findings show that smoking and alcohol use are influential risks because of their correlation with health risks at a statistical level. as for stress, obesity and poor sleep do not have very sharp relations, while poverty and lack of risk factors are statistically insignificant, which could mean that they are only correlated at all but could be coincidental. most observable gaps are on gender: unfortunately, male gender is more vulnerable and affected by lifestyle diseases more than their female counterparts. using the obtained results of the analysis, it becomes possible to state that myocardial infarction and atherosclerosis are quite frequent health issues, which are predominantly observed during the night and related to family tendencies. conclusion: the findings of this research also stress on the importance of smoking and gender differences related to sudden death that demand more careful consideration of the public health approaches , including genetic testing, modification in lifestyle and modification of the environment and so on. it demonstrates the relation between the rates of sudden death and myocardial infarction and atherosclerosis at night and the necessity for further study of circadian rhythm. emphasis is placed on the position of forensic experts to establish the causes of death, especially in erbil, iraq pointing towards a systematized procedure towards bringing down sudden death incidences across the globe. keywords: sudden death; smoking; obesity; gender risks; circadian rhythms. dilman azad hassan; department of nursing, faculty of nursing, tishk international university and college of medicine, hawler medical university, erbil, kurdistan region, iraq. (correspondence: dilman.hassan@hmu.edu.krd) 190 received: 05/04/2024 accepted: 27/11/2024 published: 30/11/2024 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:dilman.hassan@hmu.edu.krd mailto:dilman.hassan@hmu.edu.krd?subject=dilman.hassan@hmu.edu.krd%20 mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.18 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article death incidents always occur throughout the year and affect families as well as people around the globe , causing so much emotional stress, let alone the imbalance of families and communities that are affected. such deaths not only interfere with the lives of those involved, but they also have consequences for the rest of society. easy identification of the many factors that are in some way linked to sudden deaths and their impact on people’s lives is essential for prevention, improvement of health outcomes and better ways to support those who are bereaved. fringe events are the sudden and natural cardiac accidents, suicides, and even homicides. cardiovascular diseases are considered to be the main contenders for increased rates of sudden deaths that cause considerable rates of deaths worldwide [1, 6]. khan et al.,conducted a study in saudi arabia whereby they established the prevalence of scd and noted that this was alarmingly high; therefore , they called for effective measures to be taken in order to deal with this problem [2]. besides, the process components, including air pollution, occupational risks, and chemical use, have also been shown to raise the mortality levels [2, 3]. these factors are aggravating of preexisting diseases and have high potential risks for several population groups. this brings to the issue of sudden deaths, and a variety of socioeconomic factors can greatly influence this condition. patient-care disparities that emerge from inequalities in the distribution of the healthcare, educational, and resource systems imply that high rates of otherwise avoidable sicknesses result in unanticipated mortality [4, 5]. for instance, the study has shown that it is computed that death due to sudden cardiac arrest is higher amongst the people with lower socioeconomic status, which shows that the social determinants of health should also be targeted. this study endeavours to shed light on the multifactorial factors that surround the phenomenon of deaths in a specific postmortem examination view. through the examination of autopsy results, case notes, and forensic investigations ,the research will determine the causes of sudden deaths and the contributing factors that surround them. by way of this more global perspective, we will try to establish a better understanding of other ramifications of sudden deaths on people and their environment. equally important is getting to know the consequences of sudden deaths, as in these circumstances the mental state and the economic wellbeing of survivors may be negatively impacted [7, 8]. that can help avoid the deterioration of long-lasting consequences these tragedies trigger and increase the overall community’s coping capacity. it is with this view that this study hopes to enrich the existing literature and guide strategies for prevention and mitigation of sudden deaths as key health trends of interest [9 and 10]. 1. study design, setting, and duration (2019-2023): study design, setting, and duration (2019-2023): 50 cases of sudden deaths in this study were topics of a retrospective cohort that was investigated carefullyby the department of forensic medicine at rezkar hospital in erbil, iraq, for the period of 2019-2023. the selected cases do cover a vast age range from 15 months to 70 years; this would mean that the study obtained a diverse population that would capture all the necessary demography that is relevant to an understanding of the complexity of sudden deaths.2. strategic case selection and sample determination: the choice of cases of sudden death was conducted with 191 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.18 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article to find statistically significant relations for enhancing the comprehension with regard to these risk factors and the idea of how they are related to sudden death [16].6. obesity measurement technique: obesity was defined using body mass index (bmi) which remains one of the most valid measures of obesity. bmi was computed by dividing an individual’s weight in kilograms by the square of height in meters (bmi = kg/m²). participants were categorized according to the world health organization's classifications for obesity:, which are classified as as; underweight (bmi<18. 5), normal weight (bmi < 25), overweight (bmi 25-29. 9) and obesity (bmi ≥ 30). such standardized measurement was possible to apply in order to evaluate the relation between obesity and sudden death in a consistent manner.7. integrated quantitative and qualitative family interviews: besides, the assessment based on the reorganization of 50 medical records, the qualitative interviews with the relatives of the deceased patient were carried out. this approach was developed in an effort to somewhat attempt to obtain a genuine picture of the family relational aspect, consumption patterns and practices involving diet and exercise, and : the inheritable profile, which encompassed the cases of sudden death. the study applied clear and precise phenomenological research methods, the phenomenological research designs derived qualitative data from the study; the data set signifies profoundrooted family perception about suddendeath events [17].8. dynamic longitudinal analysis of risk factor evolution: for examining the trends and shifts of risk factors for sudden deaths from the year 2019 to the year 2023, a big-scale long-term cohort study was done, as several of them are chronic and dynamic in nature and several of them are long-term risk factors associated with sudden deaths with regard to a high level of rigor and using thorough procedures which included, amongst others, peculiar criteria such as age, gender and overall ascertainable causes of deaths. thus, the variability of the results is also magnified due to the variation of age of the participants, which, though, diversifies the study findings [11]. this means that sample size restricts some certain interpretation of the outcomes to reduce risks of making wrong conclusions concerning the cause of sudden death.3. advanced family history analysis: a review of each case family history was done separately to undoubtedly link the families’ health history with the risk factors and proven causes of sudden death. in this important step, the main purpose was to reveal potential genetic and hereditary causes that could potentially increase the risk of sudden death in erbil’s population [12,13]. through such relations , the study aims at explaining the heritable risks that may contribute to causes of sudden deaths.4. in-depth temporal analysis of death circumstances: in-depth temporal analysis of death circumstances: conducting a temporally expansive study for each case, pre-mortem and postmortem information was accrued with the view to demystify the key chronology and socio-environmental circumstances associated with each sled event. this integrative assessment was attempted to assess specific changes in lifestyle, other health events, and proximate events leading to these sudden deaths [14,15].5. sophisticated risk factor-cause correlation analysis: sophisticated risk factor-cause correlation analysis: the study systematically analysed the connection between the common risk factors, including smoking, alcohol consumption, obesity, poor sleep, stress, and low ses, with the exact types of mortality deaths in the light of the context of erbil within the years of 2019-2023. this analysis was planned so that it wanted 192 copyright ©2024the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.18 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article this, they were very much involved in documenting the temporal trends of these risk factors and their regression analysis of changes in the predictor on occurrences of sudden death.9. rigorous ethical oversight and data privacy: teaching is highly ethical where matters concerning data privacy are effectively followed from set standards. as to the participants being involved in the research, the high level of ethical research standards and the close concern with participants’ privacy was attended to by ensuring participants’ identities were kept anonymous where they or their families’ medical information and experiences were identified. for this purpose, permission was sought and obtained from the relevant institutional review boards, hence improving the ethical intention of the proposed research.10. contrast, analysis with advanced statistics using spss 29. the analysis of this study used the statistical package for social sciences (spss) at the 29 and more version. the study used complex statistics to compare all complexities and consistencies within data sets. this involved the use of chi-square tests, logistic regression models, and survival analysis as the means of evaluating and confirming the strength of the relationship between the risk factors, family history dispositions, and incidences of sudden deaths. 11. expert consultations for validation and insight: the consultation with the experts for the confirmation and information when: the study also included focus group discussions with a panel of medical and forensic physicians from rezkar hospital with the aim of getting more views on the various complex factors that lead to sudden deaths. use of consultation in engaging news and journal articles was useful in these consultations because it was contributing to a study, which was statistically coherent and clinically relevant.12. adaptive feedback mechanism for continuous refinement: the adaptive feedback mechanism to make constant improvements: the feedback process was used throughout the study to determine the strengths and weaknesses of the process while it was ongoing from the feedback of various parents, doctors, community workers, and especially families with such children. this dynamic approach assisted in maintaining a certain level of the study’s relevance to the emerging new developments and, thus, enhanced the study’s efficiency in handling a phenomenon of sudden deaths in erbil. table 1 demonstrates the cross-tabulation of some of the risk factors and their outcomes as concerning a specific health outcome. this is done through the help of frequencies, percentages, and the results of the chi-square test. thus, smoking and alcohol consumption levels are found to be the most significant risk factors that are present in this study as evidenced by their low p-values. these risk variables are considered to be the most prominent global risk variables most linked to the risk. the confidence of the links between obesity and stress is less than that of the smoking and alcohol intake, even if the p-values of the latter two components are slightly higher. however, there is strong evidence that levels of stress are related to obesity. traditional standards for statistical significance (p < 0. 05) are not met by such variables as insufficient sleep, poverty, and the absence of other documented risk factors. thus, it remains unclear whether there are any links with the health resultthey could only be due to chance, as this implies. the p-values by the stars are aligned such that it will be easily appreciated by the reader when high or low significance levels are achieved. a better rating means more cases that speak against the h0 and we recall that h0 states that no relationship exists. 193 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.18 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article 194 one would also want to note that renal failure is, apparently, more frequent in females, which contrasts with the general tendency observed. this is an important area to shed light on. there may be gender disparities in mortality that have not been explored; however, the presence of deaths that resulted from unspecified causes confirms such a possibility. still, it is possible to assume that there are latent differences in mortality rate between males and females. such accumulation of data offers insights into the disparities in mortality in different diseases according to gender as well as the contributed effects of certain individual lifestyles on the overall health status. thus, it can be stated that it is specific therapies and more research that are required to address the issues mentioned above. this is because of this event, the annual latin grammy awards were held to celebrate artists of latin american origin. the data in table 2 give an idea of these disparities and reveal fairly large gender differences in the mortality rates from many of these causes. as it can be seen in this table, the discrepancies are real in that they reflect information generated from the data. that is evidenced by the following variances. this is due to various causes, including smoking, alcohol consumption, atherosclerosis, myocardial infarction, renal failure and other reasons that have not been well elucidated. a statistically significant difference is a key figure that speaks about such differences. a p-value below 0. 05 denotes statistical significance. based on the results above, it is quite reasonable to assume that men are more vulnerable to various kinds of risk than women. this is due to the fact that men have a higher risk of smoking-related mortality, and disease of atherosclerosis and myocardial infarction in addition to alcohol intake, as compared to the female gender. furthermore, male consumers have been found to consume the alcohol more than the females. copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: distribution lifestyle risk factors and sudden death in erbil risk factor frequency (n) percentage (%) chi-square test (p-value) smoking 22 (44) 0.002 hs alcohol consumption 12 (24) 0.015 s obesity 7 (14) 0.050 s poor sleep 6 (12) 0.080 ns stress 8 (16) 0.037 s poverty 3 (6) 0.110 ns no identified risk factor 10 (20) 0.200 ns table 2. prevalence and statistical significance of various causes of death by gender cause of death prevalence among males (%) prevalence among females (%) p-value smoking (44) (22) <0.05* atherosclerosis (36.11) (14.29) <0.05* myocardial infarction (mi) (27.78) (7.14) <0.05* alcohol consumption (24) (12) <0.05* renal failure (11.11) (21.43) <0.05* unknown causes (11.11) (21.43) <0.05* https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.18 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article are due to renal failure, and 16% are from other reasons; these are far less common. there is no statistically significant correlation with the sample population for renal failure and other causes, with p-values of 0.150 and 0.200, respectively. evidence from this study indicates that while heart attacks and atherosclerosis are major problems for this population, renal failure and other variables do not play a major role in these problems. are connected with renal failure as well as other causes also do not show highly defined temporal trends, and incidents are distributed throughout numerous time frames. furthermore, the significance of these alignments is not even near, being 0.10 and 0. 25 respectively, in the comparable populations. in aggregate, the results of the research have shown the necessity to conduct further scientific investigation of the timing characteristics of deaths related to renal failure and other diseases. moreover, the findings made it possible to state that attention should be paid to temporal factors, which might help explain the instances of sudden death due to myocardial infarction and atherosclerosis. 195 table 3 shows a description of the frequency of different health conditions in the population that was sampled. among the many causes of heart disease, the results show that atherosclerosis accounts for 46% of all cases and myocardial infarction for 28%. with p-values of 0.045 for myocardial infarction and 0.030 for atherosclerosis, respectively, the statistical analysis shows that both conditions are significantly correlated with the sample population. in comparison, 10% of cases the following table 4 offers some ideas of the timing of unexpected fatalities, which can be associated with a number of factors concerning the time of their occurrence. attacks of acute myocardial infarction are given special causation along with the diseases like atherosclerosis and renal failure and many more. atherosclerosis and myocardial infarction also have an interesting pattern; while both manifestations are more frequent during the night and in the morning, besides, they have variable data during the day. both of these are other unsuspected causes of death which are associated with atherosclerosis. since, in view of the assessments madeby comparing the coefficients obtained and the sensitivity of the tests performed, the p-value turned out to be less than 0. 05, it is possible to consider the assessment of a potential relationship between the events listed above and certain times of the day. at the same time, the unforeseen mortalities that copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3.distribution and statistical significance of sudden death causes cause number of cases proportion of total significance level myocardial infarction (mi) 14 (28) 0.045 s atherosclerosis 23 (46) 0.030 s renal failure 5 (10) 0.150 ns other causes 8 (16) 0.200 ns total 50 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.18 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article it is less in the case of family predisposition, where there are 4 cases of renal failure and 6 cases for other reasons. a relatively weaker genetic linkage is suggested by the other associated p-values of 0. 200 and 0. 200 and 150 for these situations, respectively, as shown in the table below. these observations also illustrate how family medical histories are crucial in identifying the root of autopsied sudden deaths, including myocardial infarction and atherosclerosis. evidence given in smoking-related morbidity and mortality in the framingham heart study [18]. this continuous situation clearly indicates that there is a need to eradicate the prevalence of smoking, as its association with sudden cardiac events has already been well documented. in addition, there are gender differences as well, where males are found to be more vulnerable to diseases associated with alcohol x table 5 also suggests that causes of scd have heritable disposition since they are inclined to be transmitted down the generations. the statistics indicate that there are a number of family predisposition cases with regard to atherosclerosis and mi – eight cases of mi and ten cases of atherosclerosis, respectively. these diseases run in the families based on the information presented in these data and p-values of 0 which are less than the levels of significance. 035 and 0. 050, respectively. the holistic synthesis of the results from the latest study with the previous studies offers spectacular understanding of the multifaceted connection between the risky behavioral and genetic factors and other large health determinants of sudden death. smoking is still a well-documented risk factor which was present in 44% of cases of deaths recorded as sudden (p=0. 002); again, observations corroborate 196 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4: temporal distribution of sudden deaths by cause : in sample with overall statistical significance cause of sudden death morning (6am-12pm) (n) afternoon (12pm-6pm) (n) evening (6pm-9pm) (n) night (9pm-6am) (n) unknown (n) overall p-value myocardial infarction (mi) 3 3 2 6 0 < 0.05 s atherosclerosis 6 7 3 7 0 < 0.05 s renal failure 3 1 1 0 0 0.10 ns other causes 4 2 2 3 1 0.25 ns table 5: the family link: exploring familial predisposition cause of sudden death familial predisposition reported (n) familial predisposition not reported (n) unable to ascertain (n) p-value myocardial infarction (mi) 8 5 1 0.035 s atherosclerosis 10 12 1 0.050 s renal failure 2 3 0 0.200 ns other 4 3 1 0.150 ns discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.18 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article medical systems in responding to sudden fatalities [23,24].one of the features of this discourse is the role of forensic experts, which is not mentioned often, especially in such places as erbil in iraq. they are indispensable to finding solutions to the workflow that connects medical tests with precise determinations of the cause of death. there is a need to enhance the roles of such experts within the health system since they help in offering important information about mortality trends in order to aid health policies. the effects of one’s mode of living, one’s blood, and one’s health on death in a sudden are described in detail. preventing smoking is one of the important areas in the world’s public health services because the hazard factor has been around for quite some time now. this requirement is supported by the most fundamental research, including the framingham heart study, as evidence that smoking poses a major threat to the cardiovascular systems and a high threat to unknown death. men’s health treatments are very appropriate in mitigating the high incidence of smoking and alcohol-related diseases in the male community thus, there is a need to do research on circadian rhythms because atherosclerosis and myocardial infarction fatalities are on the increase at night. in preventive measures, timing is very essential. obesity in particular makes it even harder to establish resolution because the factors that contribute to the rate of sudden death depend on gender. in particular, biological, behavioral, and social models should be taken into consideration during treatment of the condition. a proper reaction is required in this case, as the primary cause of death is multifactorial. this approach challenges the prevailing epidemiological power-based risk and substance smoking. this means there is a gender-specific vulnerability that requires gendered health interventions; and therefore gender should be recognized as a vital contributor to health differences. further, the rise in the number of deaths, particularly during the night, by myocardial infarction and atherosclerosis also draws the need to further understand the circadian effects. eckart et al. (2011) observed these temporal patterns in the same way and further stressed these patterns while discussing the effective planning of preventive measures [20].obesity is one of the key factors that amplify gender-specific consequences of risk factors of sudden death. the current study yielded significant correlations with atherosclerosis and myocardial infarction similar to the observation made by christensen et al. 2009,who recommended integrated intercession since both biological, behavioral, and socioeconomic factors influence the two diseases [21]. renal failure and other chronic diseases causing scd are multifactorial, which poses a problem to the application of current risk assessment tools. this complexity requires a holistic multi-disciplinary public health approach that goes a step further than the elimination of risky behaviours, diet and genetic testing and environmental management [22].the discussion of this paper brings into light the need to promote multidimensional approaches to public health as recommended by who in 2017. more so, such initiatives need to be underpinned by gender differences, time and genetic factors. such a strategy offers hope on minimizing the risk factor associated with sudden death as a result of its multiple causes on the international level. furthermore, this form of evaluation acknowledges the relevance of the economic disparities, emotional issues, and poor heritage information on family 197 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.18 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article [1] nofal hk, abdulmohsen mf, khamis ah. incidence and causes of sudden death in a university hospital in eastern saudi arabia. emhj-eastern mediterranean health journal 2011; 17: 665–670. [2] world health organization. icd-10 version: 2010. other sudden death, cause unknown [internet]. 2010 [cited 2023 feb 10]. available from: https://icd.who.int/ browse10/2010/en#/i00-i99. [3] pelemo o, sabageh d, komolafe a. an autopsy review of sudden unexpected natural deaths in a suburban nigerian population. popul health metr 2014; 12: 26. [4] mashali a, el dine f, ahmed r. the application of the international classification of diseases among autopsy cases of sudden death in tripoli, libya. j forensic crime investig 2018; 2: 102. [5] jitta udnoon, thamrong chirachariyavej, vichan peonim. sudden unexpected deaths in different age groups at ramathibodi hospital, bangkok, thailand: a retrospective autopsy study during 2003-2007. southeast asian journal of tropical medicine and public health [internet]. 2009 [cited 2024 dec 15];40(1):162–8. available from: https:// mahidol.elsevierpure.com/en/publications/ sudden-unexpected-deaths-in-different-agegroups-at-ramathibodi-h [6] basso c, burke m, fornes p, gallagher pj, de gouveia rh, sheppard m, et al. guidelines for autopsy investigation of sudden cardiac death. virchows archiv. 2007 oct 20;452 (1):11–8. [7] reniers g, araya t, schaap a, kumie a, kebede d, nagelkerke n, et al. monitoring cause-specific adult mortality in developing countries: a comparison of data sources for addis ababa and its implications for policy and research. social science & medicine. 2005 nov;61(9):1952–7 [8] hatanaka k, nakamura n, kojima m, ando k, irie s, maki bunno, et al. methotrexateassociated lymphoproliferative disorders mimicking angioimmunoblastic t-cell lymphoma. pathology research and practice. 2009 jul 24;206(1):9–13. [9] escoffery ct, shirley se. causes of sudden natural death in jamaica: a medicolegal (coroner’s) autopsy study from the university hospital of the west indies. forensic science international. 2002 sep;129(2):116–21. assessment paradigms while setting a stake into environmental, behavioural, and even genetic approaches that are inherent in holistic health interventions. in an address released in 2017, who made several general recommendations on why these conclusions should be integrated into the practice of health. significant additional reductions in the rate of ‘‘out of nowhere’’ deaths require a more comprehensive strategy that targets sex, time and genetics. going by this technique, there could be a minimal number of deaths that were not expected to occur, and the health care system could be personalized to suit patients’ needs. talented forensic professionals are in demand, and this is especially.in erbil – iraq, where they identify why a person dies. the common one is the total disconnection of medical examination to the cause of death diagnosis. health ecosystems to be recognized and assisted is much better cognizance. this is why a comprehensive postmortem approach that is more than what a common protocol calls for is required for the purposes of postmortem observations in the event of an assigned death. environmental treatments, behavioural changes, and genetic tests demand better information on gender differences, time and genetic characteristics. worldwide besd mortality could be lowered due to an interprofessional approach, improved sunders, and ses by employing forensic learning. the complexity of the interaction of sudden death factors may be better controlled with this informed approach, thus enhancing the intervention and prevention efforts. 198 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.18 erbil j. nurs. midwifery, vol. 7, no. (2), nov 2024 original article [20] pelli h, lappalainen-lehto r, piironen a, sand j, nordback i. risk factors for recurrent acute alcohol-associated pancreatitis: a prospective analysis. scandinavian journal of gastroenterology. 2008 jan;43(5):614– 21. [21] kourkoumpetis t, sood g. pathogenesis of alcoholic liver disease: an update. clin liver dis. 2019;23(1):71–80. doi:10.1016/ j.cld.2018.09.002. [22] zhao p, wang jg, gao p, et al. sudden unexpected death from natural diseases: fifteen years’ experience with 484 cases in seychelles. j forensic leg med. 2016;37:33–8. doi:10.1016/j.jflm.2015.08.009. [23] orlien sms, sandven i, berhe nb, et al. khat chewing increases the risk for developing chronic liver disease: a hospital-based casecontrol study. hepatology. 2018;68(1):248– 57. doi:10.1002/hep.29702. [24] orlien sm, berhe nb, morgan my, et al. khat-related liver disease in sub-saharan africa: neglected, yet important. lancet glob health. 2019;7(3):e300–1. doi:10.1016/s2214-109x(19)30020-2. [10] akinwusi p, komolafe, adeomi, olayemi. pattern of sudden death at ladoke akintola university of technology teaching hospital, osogbo, south west nigeria. vascular health and risk management. 2013 jun;333. doi: 10.1016/s0379-0738(02)00268-2. pmid: 12243880. [11] none vanrajsinh k rathva, none rajeshkumar r bhoot. assessment of sudden natural deaths in medico-legal autopsies at tertiary care teaching hospital. indian journal of forensic medicine & toxicology. 2023 oct 16;17(4):25–9. [12] choukimath drsm, naik drmm. causes of sudden death autopsy review in a tertiary referral center. tropical journal of pathology and microbiology. 2020 dec 31;6(8):481– 5. [13] zanjad np, nanadkar sd. study of sudden unexpected deaths in medico-legal autopsies. journal of indian academy of forensic medicine 2006; 28: 27–30. [14] tiemensma m, burger eh. sudden and unexpected deaths in an adult population, cape town, south africa, 2001-2005. south african medical journal. 2012 jan 27;102 (2):90. [15] azmak ad. sudden natural deaths in edirne, turkey, from 1984 to 2005. medicine, science and the law. 2007 apr;47(2):147–55. [16] andrés e, león m, cordero a, magallón botaya r, magán p, luengo e, et al. factores de riesgo cardiovascular y estilo de vida asociados a la aparición prematura de infarto agudo de miocardio. revista española de cardiología. 2011 jun;64(6):527–9. [17] kumar v, san kp, idwan a, shah n, hajar s, norkahfi m. a study of sudden natural deaths in medico legal autopsies in university malaya medical centre (ummc), kuala lumpur. journal of forensic and legal medicine. 2007 apr;14(3):151–4. [18] engdahl j, holmberg m, karlson bw, luepker r, herlitz j. the epidemiology of out -of-hospital “sudden” cardiac arrest. resuscitation. 2002 mar;52(3):235– 45.doi:10.1016/s0300-9572(01)00315-8. [19] kawasaki y, tsuchida a, sasaki t, yamasaki s, kuwada y, murakami m, et al. irsogladine malate up-regulates gap junctional intercellular communication between pancreatic cancer cells via pka pathway. pancreas. 2002 nov;25(4):373–7. 199 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.05 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article evaluation of pulmonary function test in post-covid-19 patients abstract background and objectives: sars-cov-2 emerged, leading to a global pandemic with significant morbidity and mortality. lung injury is prevalent, raising concerns about long-term complications. current data indicate persistent pulmonary function issues, particularly diffusion capacity, in survivors. critical care needs and risk factors for poor outcomes are identified, but the full impact of post-covid syndromes remains inadequately defined. further research is essential to understand the long-term consequences of covid-19. this study aims to evaluate pulmonary function tests in postcovid-19 patients. methods: a quantitative study was conducted on 74 post-covid-19 patients in erbil, iraq, evaluating demographic and clinical characteristics. data were collected via questionnaires and analyzed using spss, ensuring participant confidentiality and voluntary participation throughout the research process. results: the study analyzed 74 post-covid-19 patients, revealing demographics such as 55.4% aged 54-69 and a male predominance (63.5%). common symptoms included cough (66.2%) and shortness of breath (73%). half had high systolic blood pressure, and significant associations were found between severity and factors like age, spo2, and pulmonary function tests. conclusion: spirometry patterns significantly correlate with the severity of post-covid-19 symptoms, suggesting their value as prognostic markers. however, the study found no significant link between spirometry patterns and comorbidities, indicating a need for further research to explore these relationships and their implications for patient management. keywords: pulmonary function test; spirometry patterns; post-covid-19; sars-cov-2. hemin khalid saber; department of medicine, college of medicine, hawler medical university, erbil, kurdistan region, iraq. baghawan ahmed osthman; department of medicine, college of medicine, hawler medical university, erbil, kurdistan region, iraq. dara abdulla al-banna; department of nursing, faculty of nursing, tishk international university, erbil, kurdistan region, iraq. (correspondence: dara.albanna@hmu.edu.krd) 37 received: 15/02/2025 accepted: 14/03/2025 published: 30/05/2025 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:(correspondence:%20dara.albanna@hmu.edu.krd) mailto:(correspondence:%20dara.albanna@hmu.edu.krd)?subject=(correspondence:%20dara.albanna@hmu.edu.krd) mailto:(correspondence:%20dara.albanna@hmu.edu.krd)?subject=(correspondence:%20dara.albanna@hmu.edu.krd) mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.05 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article in late 2019, a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (sars-cov-2), emerged in wuhan, china, and has since spread globally, infecting more than 200 million people. the clinical course of infection appears to be extremely variable, from asymptomatic to severe pneumonia with multiorgan failure requiring critical care. more than 1,122,036 people are known to have died following infection, but data on morbidity in survivors are scarce. lung injury is a predominant feature of acute sars-cov-2 infection, and understanding the longer-term implications is critical given the number of affected patients. there is currently little known about the post-infectious long-term complications from the severe acute respiratory syndrome coronavirus two (sars-cov2), with much extrapolated from severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers) pandemics during the 2003 and 2012, respectively (zhao. et al, 2020; ngia, et al., 2010).the extrapolated data has shown that there are long-term reductions in pulmonary function, as measured by pulmonary function testing (pft), most significantly for diffusion capacity for carbon monoxide (dlco) for up to two years after infection (hui. et al., 2005; ong. et al., 2004; park, jun, and kim, 2018) [3,4,5,6,7]. approximately 1 in 7 hospitalized patients with covid-19 in the united kingdom required critical care admission, the majority for management of ards (drake. et al., 2021). the onset of covidards in the second week post-symptomonset (at declining viral loads) and response to immunomodulation suggests pathogenic immune dysregulation. given the unprecedented scale of the covid-19 pandemic, even a low event rate may have a significant population-level impact (morbidity, late mortality). most descriptions of post-covid syndromes stipulate symptom duration for > 3 months (munblit, o’hara, akrami, perego, olliaro, needham, 2022). clinically significant ild refers to > 10% lung parenchymal changes on chest computed tomography (ct). a consensus definition and the true burden of post-covid19-ild have not yet been determined. pc-ild should be considered in patients with persistent respiratory symptoms (e.g., cough and dyspnea) 3 months post-covid-19 symptom-onset, and patients with > 10% ct changes should be monitored. accumulating data suggests that while the majority of scans show improvement, at 12 months the prevalence of (non-progressive) fibrosis is  ~ 10% in hospitalized patients, particularly in severe disease and older age (ong. et al., 2004). several clinical features and comorbidities are associated with a poor prognosis and a higher risk of mortality from covid-19. these include pre-existing health problems such as hypertension, diabetes, cardiovascular disease, obesity, cancer, chronic kidney, liver, and lung diseases, and older age, male sex, smoking, and race (richardson. et al., 2020; docherty. et al., 1985; sze. et al., 2020; sanchez-ramirez and mackey, 2020). whether these risk factors are also predictors of longer-term outcomes from covid-19 is currently unclear.the most common radiological pattern of acute infection with sars-cov-2 is of bilateral ground-glass opacification with or without consolidation in a subpleural distribution, and a radiological and histological pattern of organizing pneumonia pattern is described in many cases (zhao, zhong, xie, yu, and liu, 2020). radiological findings alter as the disease progresses, but persistent computed tomographic (ct) imaging abnormalities beyond day 14 of symptoms and up to day 37 have been reported (pan. et al., 2020; wang. 38 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.05 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article obtained permission from the scientific and ethical committees at the college of medicine, hawler medical university. on 4th june 2022. the other official permission from the erbil directorate of health and the administrative units of the teaching hospitals was obtained. this study includes 74 patients. a sample of post-covid -19 patients was recruited in this study based on a convenience (purposeful) sampling technique, according to the inclusion and exclusion criteria. ages more than 18 years, both genders, with good communication were included. this study was carried out from november 2022 to april 2023. the duration of the data collection was around four months. a questionnaire was designed, and it consisted of two main parts. part one included demographic and clinical characteristics. part two included laboratory and non-laboratory investigations of sbp, dbp, spo2, pr, temp, pmh, crp, d. dimer, ldh, wbcs, pulmonary function tests, forced vital capacity, and the ratio of fev1/fvc. the data was collected through a direct interview method (face-to-face) with the patients. informal oral consent was obtained from each participant. the researchers promised to keep the participant’s information confidential and use this data for this study only, then explained the purpose of this study to each participant. in addition to the above, the researchers told each participant that this is voluntary work, and they could leave at any time even if the process is not completed. the data was analyzed through statistical software (statistical package for science service-spss v.26) which includes descriptive statistical analysis as frequency and percentage and inferential statistical analysis including pearson correlation, chisquare, and fisher’s exact tests. the pvalue is considered significant if it is less than or equal to 0.05. et al., 2020). however, no data exist as to the natural history of inflammatory infiltrates during recovery from sars-cov-2 or the utility of any treatment in patients with persistent inflammatory interstitial lung disease (ild) following infection with coronavirus. however, corticosteroids are the mainstay of treatment for organizing pneumonia of other causes (cordier, 2000), and when used acutely in the management of acute respiratory distress syndrome (ards) caused by sars-cov-2 they have been associated with a reduction in mortality (horby. et al., 2020; sterne. et al., 2020). whether pc-ild should be divided into binary “inflammatory” and “fibrotic” categories based on radiological patterns remains controversial, given the ambiguity of some features (e.g., irregular lines), absence of histological correlates, uncertain course, and likelihood of reversibility. persistent ground-glass changes may indicate fine/immature fibrosis rather than inflammation, and fibrotic-like changes may be capable of regression and remodeling, albeit at a slower rate. idiopathic pulmonary fibrosis (ipf) is the archetypal fibrotic ild (f -ild), but most existing ild syndromes are thought to reside on an overlapping fibroinflammatory spectrum, e.g., hypersensitivity pneumonitis, an exaggerated aeroantigen-induced immune response, and rheumatic-associated ild. this arbitrary stratification into predominant fibrotic or inflammatory phenotypes may have therapeutic and prognostic implications (although targeted treatments may be used concurrently), with potential extrapolation to pc-il (mehta, ivan, rosas, and singer, 2022). a quantitative, descriptive study design was conducted on post-covid-19 patients at the medical wards in rizgary and hawler teaching hospitals in erbil city in the kurdistan region of iraq. the researchers 39 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.05 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article table 1 shows the demographic and clinical characteristics of the post-covid-19 patients. regarding the age group, more than half of the study sample in the age group between 54-69 years old (55.4%) and others are between 22-37 and 38-53 years old (17.6% and 27% respectively). about 63.5% were male and 36.5% female. regarding the symptoms, 66.2% had a cough, 32.4% had a fever, and 73% had a shortness of concerning blood pressure, half of the patients have high systolic blood pressure (50%) and only 35.1% have high diastolic blood pressure. about 81.1% of covid-19 patients suffer from hypoxemia. the highest percentage of the study samples have tachycardia (64.9%) with normal body temperature (40.5%) and only 28.4% have hypothermia. breathing. concerning the past medical history, the highest percentage have other diseases (37.8%), while 6.8% of the participants have copd and only 2.7% have asthma, the rest of them have no past medical history (52.7%). about 66.2% were nonsmokers, the smokers were 10.8% and exsmokers 21.6% with only one case of passive smoker. the highest percentage of the study sample have high crp (77%), high d. dimer (62.2%), normal ldh (48.6%), normal wbc (66.2%), low forced expiratory volume in one second (58.1%), low forced vital capacity (63.5%), more than normal ratio of fev1/fvc (98.6%), with normal pattern (71.6%). 40 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: demographic and clinical characteristics demographic and clinical characteristics f. (%) age groups (years) 22-37 13 (17.6) 38-53 20 (27) 54-69 41 (55.4) sex male 47 (63.5) female 27 (36.5) cough no 25 (33.8) yes 49 (66.2) fever no 50 (67.6) yes 24 (32.4) shortness of breath no 20 (27) yes 54 (73) others no 13 (17.6) yes 61 (82.4) past medical history none 39 (52.7) asthma 2 (2.7) copd 5 (6.8) others 28 (37.8) smoking no smoker 49 (66.2) smoker 8 (10.8) ex-smoker 16 (21.6) passive-smoker 1 (1.4) results https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.05 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article 41 moderate and severe (28.4% and 25.7% respectively). regarding the severity, the highest percentage was mild (43.2%) followed by copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: laboratory and non-laboratory investigations of post-covid-19 patients laboratory and non-laboratory investigations f. (%) sbp low systolic blood pressure 4 (5.4) normal systolic blood pressure 33 (44.6) high systolic blood pressure 37 (50) dbp low diastolic blood pressure 4 (5.4) normal diastolic blood pressure 44 (59.5) high diastolic blood pressure 26 (35.1) spo2 hypoxemia 60 (81.1) normal spo2 14 (18.9) pr bradycardia 0 (0) normal pulse rate 26 (35.1) tachycardia 48 (64.9) temp hypothermia 21 (28.4) normal body temperature 30 (40.5) hyperthermia 23 (31.1) crp normal crp 17 (23) high crp 57 (77) d. dimer normal d dimer 28 (37.8) high d dimer 46 (62.2) ldh low ldh 22 (29.7) normal ldh 36 (48.6) high ldh 16 (21.6) wbc leukopenia 20 (27) normal wbc 49 (66.2) leukocytosis 5 (6.8) forced expiratory volume in one second low fev1 43 (58.1) normal fev1 30 (40.5) high fev1 1 (1.4) forced vital capacity low fvc 47 (63.5) normal fvc 24 (32.4) high fvc 3 (4.1) fev1/fvc airflow limitation 1 (1.4) normal fev1/fvc 0 (0) more than normal 73 (98.6) pattern normal 53 (71.6) obstructive 3 (4.1) restrictive 18 (24.3) table 3: severity severity f. (%) mild 32 (43.2) moderate 21 (28.4) severe 19 (25.7) critical 2 (2.7) total 74 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.05 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article concerning the association between investigations and severity, there is a significant association between spo2, pr, d. dimer, wbc, pulmonary function tests, and forced vital capacity with the severity (pvalue ≤ 0.05). the other associations are non-significant (p-value > 0.05). 42 concerning the association between demographic and clinical characteristics with the severity, there is a very highly significant association between age groups and sob with the severity (p-value < 0.001). the other associations are nonsignificant (p-value > 0.05). copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4. association between demographic and clinical characteristics with severity demographic and clinical characteristics severity p-value mild moderate severe critical f. (%) f. (%) f. (%) f. (%) age groups (years) 22-37 10 (76.9) 2 (15.4) 1 (7.7) 0 (0) < 0.001 vhs 38-53 15 (75) 2 (10) 3 (15) 0 (0) 54-69 7 (17.1) 17 (41.5) 15 (36.6) 2 (4.9) sex male 19 (40.4) 16 (34) 11 (23.4) 1 (2.1) 0.550 ns female 13 (48.1) 5 (18.5) 8 (29.6) 1 (3.7) cough no 14 (56) 6 (24) 4 (16) 1 (4) 0.349 ns yes 18 (36.7) 15 (30.6) 15 (30.6) 1 (2) fever no 21 (42) 17 (34) 12 (24) 0 (0) 0.107 ns yes 11 (45.8) 4 (16.7) 7 (29.2) 2 (8.3) sob no 15 (75) 2 (10) 1 (5) 2 (10) < 0.001 vhs yes 17 (31.5) 19 (35.2) 18 (33.3) 0 (0) others no 9 (69.2) 3 (23.1) 1 (7.7) 0 (0) 0.169 ns yes 23 (37.7) 18 (29.5) 18 (29.5) 2 (3.3) pmh none 20 (51.3) 9 (23.1) 9 (23.1) 1 (2.6) 0.620 ns asthma 1 (50) 1 (50) 0 (0) 0 (0) copd 2 (40) 3 (60) 0 (0) 0 (0) others 9 (32.1) 8 (28.6) 10 (35.7) 1 (3.6) smoking no smoker 23 (46.9) 12 (24.5) 14 (28.6) 0 (0) 0.149 ns smoker 5 (62.5) 2 (25) 0 (0) 1 (12. 5) ex-smoker 3 (18.8) 7 (43.8) 5 (31.3) 1 (6.3) passivesmoker 1 (100) 0 (0) 0 (0) 0 (0) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.05 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article 43 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 5: association between investigations with the severity investigations severity p– value mild moderate severe critical f. (%) f. (%) f. (%) f. (%) sbp low systolic blood pressure 0 (0) 2 (50) 2 (50) 0 (0) 0.148 ns normal systolic blood pressure 20 (60.6) 6 (18.2) 6 (18.2) 1 (3) high systolic blood pressure 12 (32.4) 13 (35.1) 11 (29.7) 1 (2.7) dbp low diastolic blood pressure 1 (25) 1 (25) 2 (50) 0 (0) 0.348 ns normal diastolic blood pressure 24 (54.5) 11 (25) 8 (18.2) 1 (2.3) high diastolic blood pressure 7 (26.9) 9 (34.6) 9 (34.6) 1 (3.8) spo2 hypoxemia 18 (30) 21 (35) 19 (31.7) 2 (3.3) < 0.001 vhs normal spo2 14 (100) 0 (0) 0 (0) 0 (0) pr bradycardia 0 (0) 0 (0) 0 (0) 0 (0) 0.002 hs normal pulse rate 18 (69.2) 7 (26.9) 1 (3.8) 0 (0) tachycardia 14 (29.2) 14 (29.2) 18 (37.5) 2 (4.2) temp hypothermia 8 (38.1) 6 (28.6) 6 (28.6) 1 (4.8) 0.306 ns normal body temperature 17 (56.7) 9 (30) 4 (13.3) 0 (0) hyperthermia 7 (30.4) 6 (26.1) 9 (39.1) 1 (4.3) crp normal crp 10 (58.8) 5 (29.4) 2 (11.8) 0 (0) 0.320 ns high crp 22 (38.6) 16 (28.1) 17 (29.8) 2 (3.5) d. dimer normal d dimer 19 (67.9) 3 (10.7) 4 (14.3) 2 (7.1) 0.001 vhs high d dimer 13 (28.3) 18 (39.1) 15 (32.6) 0 (0) ldh low ldh 10 (45.5) 6 (27.3) 6 (27.3) 0 (0) 0.271 ns normal ldh 16 (44.4) 11 (30.6) 9 (25) 0 (0) high ldh 6 (37.5) 4 (25) 4 (25) 2 (12.5) wbc leukopenia 8 (40) 7 (35) 5 (25) 0 (0) 0.010 s normal wbc 24 (49) 14 (28.6) 10 (20.4) 1 (2) leukocytosis 0 (0) 0 (0) 4 (80) 1 (20) pulmonary function low fev1 7 (16.3) 15 (34.9) 19 (44.2) 2 (4.7) < 0.001 vhs normal fev1 24 (80) 6 (20) 0 (0) 0 (0) high fev1 1 (100) 0 (0) 0 (0) 0 (0) forced vital capacity low fvc 10 (21.3) 16 (34) 19 (40.4) 2 (4.3) < 0.001 vhs normal fvc 20 (83.3) 4 (16.7) 0 (0) 0 (0) high fvc 2 (66.7) 1 (33.3) 0 (0) 0 (0) fev1fvc airflow limitation 1 (100) 0 (0) 0 (0) 0 (0) 0.722 ns normal fev1/fvc 0 (0) 0 (0) 0 (0) 0 (0) more than normal 31 (42.5) 21 (28.8) 19 (26) 2 (2.7) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.05 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article pattern, all of the associations are non-significant (p -value > 0.05). concerning the association between demographic and clinical characteristics and the spirometry 44 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 6: association between demographic and clinical characteristics and the spirometry pattern demographic and clinical characteristics spirometry pattern p-value normal obstructive restrictive f. (%) f. (%) f. (%) age groups (years) 22-37 11 (84.6) 0 (0) 2 (15.4) 0.367 ns 38-53 16 (80) 0 (0) 4 (20) 54-69 26 (63.4) 3 (7.3) 12 (29.3) sex male 34 (72.3) 3 (6.4) 10 (21.3) 0.329 ns female 19 (70.4) 0 (0) 8 (29.6) cough no 17 (68) 1 (4) 7 (28) 0.870 ns yes 36 (73.5) 2 (4.1) 11 (22.4) fever no 39 (78) 2 (4) 9 (18) 0.182 ns yes 14 (58.3) 1 (4.2) 9 (37.5) sob no 15 (75) 1 (5) 4 (20) 0.854 ns yes 38 (70.4) 2 (3.7) 14 (25.9) pregnancy no 53 (71.6) 3 (4.1) 18 (24.3) constant yes 0 (0) 0 (0) 0 (0) sbp low systolic blood pressure 3 (75) 0 (0) 1 (25) 0.775 ns normal systolic blood pressure 25 (75.8) 2 (6.1) 6 (18.2) high systolic blood pressure 25 (67.6) 1 (2.7) 11 (29.7) dbp low diastolic blood pressure 3 (75) 0 (0) 1 (25) 0.987 ns normal diastolic blood pressure 32 (72.7) 2 (4.5) 10 (22.7) high diastolic blood pressure 18 (69.2) 1 (3.8) 7 (26.9) spo2 hypoxemia 41 (68.3) 3 (5) 16 (26.7) 0.388 ns normal spo2 12 (85.7) 0 (0) 2 (14.3) temp hypothermia 15 (71.4) 2 (9.5) 4 (19) 0.371 ns normal body temperature 23 (76.7) 1 (3.3) 6 (20) hyperthermia 15 (65.2) 0 (0) 8 (34.8) pmh none 29 (74.4) 0 (0) 10 (25.6) 0.244 ns asthma 2 (100) 0 (0) 0 (0) copd 4 (80) 1 (20) 0 (0) others 18 (64.3) 2 (7.1) 8 (28.6) crp normal crp 16 (94.1) 0 (0) 1 (5.9) 0.069 ns high crp 37 (64.9) 3 (5.3) 17 (29.8) d. dimer normal d dimer 19 (67.9) 1 (3.6) 8 (28.6) 0.799 ns high d dimer 34 (73.9) 2 (4.3) 10 (21.7) smoking no smoker 35 (71.4) 2 (4.1) 12 (24.5) 0.860 ns smoker 5 (62.5) 1 (12.5) 2 (25) ex-smoker 12 (75) 0 (0) 4 (25) passive-smoker 1 (100) 0 (0) 0 (0) ns* non-significant https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.05 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article significant association between spirometry pattern and the severity (p-value < 0.001). between spirometry pattern and the comorbidities (p-value 0.244). from acute infection, a phenomenon reported in several studies (carfì et al., 2020; huang et al., 2021). comparing these findings with existing literature, several similarities and differences emerge. for instance, while our study reports a high prevalence of cough and shortness of breath, huang et al. (2021) found a similar pattern of respiratory symptoms in their cohort of post-covid-19 patients. however, the prevalence of fever in our study appears lower than reported by carfì et al. (2020), suggesting potential variations in symptom presentation across different patient populations or study methodologies. elevated blood pressure, hypoxemia, tachycardia, and abnormal biomarker levels x concerning the association between spirometry pattern with the severity, there is a very highly regarding the association between the spirometry pattern and the comorbidities, there is a nonsignificant association the age distribution in this study demonstrates a predominance of patients between 54-69 years old, comprising 55.4% of the sample, which aligns with previous research indicating a higher susceptibility to severe covid-19 outcomes among older individuals (rothan and byrareddy, 2020). additionally, a higher proportion of males (63.5%) compared to females (36.5%) was observed, consistent with prior observations of covid-19's disproportionate impact on males (jin et al., 2020). symptomatology among post-covid-19 patients reveals a significant prevalence of cough (66.2%), fever (32.4%), and shortness of breath (73%), reflecting the persistence of respiratory symptoms even after recovery 45 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 7: association between spirometry pattern and severity severity spirometry pattern p-value normal obstructive restrictive f. (%) f. (%) f. (%) mild 28 (87.5) 2 (6.3) 2 (6.3) < 0.001 vhs* moderate 19 (90.5) 0 (0) 2 (9.5) severe 6 (31.6) 1 (5.3) 12 (63.2) critical 0 (0) 0 (0) 2 (100) vhs* very highly significant table 8: association between the spirometry pattern and comorbidities pmh spirometry pattern p-value normal obstructive restrictive f. (%) f. (%) f. (%) none 29 (74.4) 0 (0) 10 (25.6) 0.244 ns asthma 2 (100) 0 (0) 0 (0) copd 4 (80) 1 (20) 0 (0) others 18 (64.3) 2 (7.1) 8 (28.6) ns* non-significant discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.05 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article (williamson et al., 2020), the association between symptoms like cough and fever with severity may vary depending on factors like disease prevalence, population demographics, and study design. the association between investigative parameters and the severity of post-covid-19 symptoms. parameters such as spo2, pulse rate (pr), d. dimer, white blood cell count (wbc), and pulmonary function tests (fev1 and fvc) demonstrate a significant association with severity (p-value ≤ 0.05). this suggests that abnormalities in these parameters may serve as valuable indicators of disease severity and could aid in risk stratification and clinical decision-making. a significant association between spirometry patterns and the severity of post-covid -19 symptoms. notably, a very highly significant association (p-value < 0.001) was observed, indicating that the type of spirometry pattern exhibited by patients is strongly correlated with the severity of their symptoms. specifically, patients with mild or moderate symptoms predominantly displayed normal or obstructive spirometry patterns, while those with severe or critical symptoms were more likely to exhibit restrictive patterns. this suggests that spirometry patterns could serve as valuable indicators of disease severity in postcovid-19 patients, aiding clinicians in risk stratification and prognostication. a nonsignificant association (p-value 0.244) between spirometry patterns and comorbidities among post-covid-19 patients. despite trends indicating that patients with comorbidities such as asthma and copd tend to exhibit obstructive spirometry patterns, while those with other comorbidities display varied patterns, the lack of statistical significance suggests that spirometry patterns may not be strongly influenced by comorbidities alone in this cohort. further research is warranted to elucidate the interplay between comorbidities (e.g., crp, d. dimer) indicate persistent systemic inflammation and cardiovascular involvement in post-covid-19 patients (nalbandian et al., 2021; libby et al., 2021). pulmonary function tests reveal a high prevalence of airflow limitation and restrictive patterns, indicative of lingering respiratory impairments post-recovery (george et al., 2020). when compared with similar investigations, our findings corroborate the persistence of cardiovascular and respiratory sequelae post-covid-19. for instance, nalbandian et al. (2021) reported a similarly high prevalence of abnormal cardiac biomarkers and pulmonary dysfunction in their study cohort. however, differences in the prevalence of specific abnormalities may reflect variations in patient demographics, disease severity, or follow-up duration across studies. the distribution of severity among post-covid-19 patients, with mild cases being the most prevalent (43.2%), followed by moderate (28.4%) and severe (25.7%) cases. this distribution underscores the heterogeneity in symptom presentation and the need for tailored management strategies based on the severity of symptoms. the association between demographic/clinical characteristics and the severity of post-covid-19 symptoms. notably, age groups and shortness of breath (sob) exhibit a highly significant association with severity (p-value < 0.001), suggesting that older age and the presence of sob may predispose individuals to more severe outcomes. other associations, such as sex, cough, fever, past medical history, and smoking status, appear nonsignificant, indicating that these factors may not independently predict the severity of post-covid-19 symptoms in this cohort. comparing these findings with existing literature can provide further insights. for instance, while age has consistently been identified as a significant predictor of covid-19 severity in numerous studies 46 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.05 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article [4] docherty ab, harrison em, green ca, hardwick he, pius r, norman l, et al. features of 20 133 uk patients in hospital with covid-19 using the isaric who clinical characterisation protocol: prospective observational cohort study. bmj. 2020 may 22;369. https://doi.org/10.1136/bmj.m1985. [5] drake tm, riad am, fairfield cj, egan c, knight sr, pius r, et al. characterisation of in -hospital complications associated with covid-19 using the isaric who clinical characterisation protocol uk: a prospective, multicentre cohort study. the lancet. 2021 jul 17;398(10296):223-37. https:// doi.org/10.1016/s0140-6736(21)00799-6 [6] george pm, wells au, jenkins rg. pulmonary fibrosis and covid-19: the potential role for antifibrotic therapy. the lancet respiratory medicine. 2020 aug 1;8(8):807-15. https://doi.org/10.1016/s2213-2600(20) 30225-3 [7] horby p, lim ws, emberson jr. recovery collaborative group dexamethasone in hospitalized patients with covid-19-preliminary report. n engl j med. https:// doi.org/10.1056/nejmoa2021436 [8] huang c, huang l, wang y, li x, ren l, gu x, et al. 6-month consequences of covid-19 in patients discharged from hospital: a cohort study. the lancet. 2023 jun 17;401 (10393):e21-33. https://doi.org/10.1016/ s0140-6736(20)32656-8 [9] hui ds, wong kt, ko fw, tam ls, chan dp, woo j, et al. the 1-year impact of severe acute respiratory syndrome on pulmonary function, exercise capacity, and quality of life in a cohort of survivors. chest. 2005 oct 1;128(4):2247-61. https://doi.org/10.1378/ chest.128.4.2247 [10] jin jm, bai p, he w, wu f, liu xf, han dm, et al. gender differences in patients with covid-19: focus on severity and mortality. frontiers in public health. 2020 apr 29;8:545030. https://doi.org/10.3389/ fpubh.2020.00152 [11] libby p, lüscher t. covid-19 is, in the end, an endothelial disease. european heart journal. 2020 aug 21;41(32):3038-44. https:// doi.org/10.1093/eurheartj/ehaa623 [12] lorent n, weygaerde yv, claeys e, fajardo ig, de vos n, de wever w, et al. prospective longitudinal evaluation of hospitalised covid-19 survivors 3 and 12 months after discharge. erj open research. 2022 apr 1;8 (2).https://doi.org/10.1183/23120541.00004 -2022 and spirometry patterns in post-covid-19 patients. these findings align with emerging research suggesting that spirometry can serve as a valuable tool for assessing disease severity and guiding clinical management in post-covid-19 care. previous studies have also highlighted the utility of spirometry in identifying respiratory impairments and predicting clinical outcomes in covid-19 patients (george et al., 2020; torres-castro et al., 2021). however, the association between spirometry patterns and comorbidities warrants further investigation, as it may have implications for personalized treatment approaches and longterm management strategies in postcovid-19 care. in conclusion, spirometry patterns exhibit a significant association with the severity of post-covid-19 symptoms, highlighting their potential utility as prognostic markers in clinical practice. while the association between spirometry patterns and comorbidities appears non-significant in this study, further research is needed to elucidate the complex interplay between these factors and their implications for patient management. [1] bradley bt, maioli h, johnston r, chaudhry i, fink sl, xu h, et al. histopathology and ultrastructural findings of fatal covid-19 infections in washington state: a case series. the lancet. 2020 aug 1;396(10247):320-32. https://doi.org/10.1016/s0140-6736(20) 31305-2 . [2] carfì a, bernabei r, landi f. persistent symptoms in patients after acute covid-19. jama. 2020 aug 11;324(6):603-5. https:// doi:10.1001/jama.2020.12603 [3] cordier jf. organising pneumonia. thorax. 2000 apr 1;55(4):318-28. https:// doi.org/10.1136/thorax.55.4.318 47 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.05 erbil j. nurs. midwifery, vol. 8, no. (1), may2025 original article hospitalized with covid-19 in the new york city area. jama. 2020 may 26;323(20):20529. https://doi.org/10.1001/jama.2020.6775 [23] rothan ha, byrareddy sn. the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak. journal of autoimmunity. 2020 may 1;109:102433. https:// doi.org/10.1016/j.jaut.2020.102433 . [24] sanchez-ramirez dc, mackey d. underlying respiratory diseases, specifically copd, and smoking are associated with severe covid19 outcomes: a systematic review and metaanalysis. respiratory medicine. 2020 sep 1;171:106096. https://doi.org/10.1016/ j.rmed.2020.106096 [25] sterne ja, murthy sw, diaz jv, slutsky as, villar jw, angus dc, et al. who rapid evidence appraisal for covid-19 therapies (react) working group. association between administration of systemic corticosteroids and mortality among critically ill patients with covid-19: a meta-analysis. jama. 2020 oct 6;324(13):1330-41. https:// doi.org/10.1001/jama.2020.17023 [26] sze s, pan d, nevill cr, gray lj, martin ca, nazareth j, et al. ethnicity and clinical outcomes in covid-19: a systematic review and meta-analysis. e clinical medicine. 2020 dec 1;29. https://doi.org/10.1016/ j.eclinm.2020.100630 [27] torres-castro r, vasconcello-castillo l, alsina-restoy x, solis-navarro l, burgos f, puppo h, et al. respiratory function in patients post-infection by covid-19: a systematic review and meta-analysis. pulmonology. 2021 jul 1;27(4):328-37. https:// doi.org/10.1016/j.pulmoe.2020.10.013 [28] wang y, dong c, hu y, li c, ren q, zhang x, et al. temporal changes of ct findings in 90 patients with covid-19 pneumonia: a longitudinal study. radiology. 2020 aug;296 (2):e55-64. https://doi.org/10.1148/ radiol.2020200843 [29] williamson ej, walker aj, bhaskaran k, bacon s, bates c, morton ce, et al. factors associated with covid-19-related death using opensafely. nature. 2020 aug 20;584 (7821):430-6. https://doi.org/10.1038/ s41586-020-2521-4 [30] zhao w, zhong z, xie x, yu q, liu j. relation between chest ct findings and clinical conditions of coronavirus disease (covid-19) pneumonia: a multicenter study. american journal of roentgenology. 2020 may;214 (5):10727.https:doi.org/10.2214ajr.20.22976 [13] lu r, zhao x, li j, niu p, yang b, wu h, et al. genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. the lancet. 2020 feb 22;395(10224):565-74. https:// doi.org/10.1016/s0140-6736(20)30251-8 . [14] mehta p, rosas io, singer m. understanding post-covid-19 interstitial lung disease (ild): a new fibroinflammatory disease entity. intensive care medicine. 2022 dec;48(12):1803 -6. https://doi.org/10.1007/s00134-02206877-w [15] munblit d, o'hara me, akrami a, perego e, olliaro p, needham dm. long covid: aiming for a consensus. the lancet respiratory medicine. 2022 jul 1;10(7):632-4. https:// doi.org/10.1016/s2213-2600(22)00135-7 [16] nalbandian a, sehgal k, gupta a, madhavan mv, mcgroder c, stevens js, et al. postacute covid-19 syndrome. nature medicine. 2021 apr;27(4):601-15. https:// doi.org/10.1038/s41591-021-01283-z [17] ngai jc, ko fw, ng ss, to kw, tong m, hui ds. the long‐term impact of severe acute respiratory syndrome on pulmonary function, exercise capacity and health status. respirology. 2010 apr;15(3):543-50. https:// doi.org/10.1111/j.1440-1843.2010.01720.x [18] ong kc, ng ak, lee lu, kaw g, kwek sk, leow ms, et al. pulmonary function and exercise capacity in survivors of severe acute respiratory syndrome. european respiratory journal. 2004 sep 1;24(3):436-42. https:// doi.org/10.1136/thx.2004.030205 [19] ong kc, ng aw, lee ls, kaw g, kwek sk, leow mk, et al. 1-year pulmonary function and health status in survivors of severe acute respiratory syndrome. chest. 2005 sep 1;128 (3):1393-400. https://doi.org/10.1378/ chest.128.3.1393 [20] pan f, ye t, sun p, gui s, liang b, li l, et al. time course of lung changes at chest ct during recovery from coronavirus disease 2019 (covid-19). radiology. 2020 jun;295(3):71521.https://doi.org/10.114radiol.2020200370 [21] park wb, jun ki, kim g, choi jp, rhee jy, cheon s, et al. correlation between pneumonia severity and pulmonary complications in middle east respiratory syndrome. journal of korean medical science. 2018 jun 6;33(24). https://doi.org/10.3346/jkms.2018.33.e169 [22] richardson s, hirsch js, narasimhan m, crawford jm, mcginn t, davidson kw, et al. presenting characteristics, comorbidities, and outcomes among 5700 patients 48 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.05 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article risk factors associated with suicidality in erbil city abstract background and objectives: suicide is an intentional attempt to end someone's life that results in death. suicidality comprises suicidal thoughts, plans, and actions. knowing the risk factors associated with suicide may help in its reduction. the study's aims were to ascertain the sociodemographic characteristics of suicidal patients and suicidalityassociated risk factors. methods: a retrospective case-control study recruited 60 participants aged between 18 and 53 years within eight months. sociodemographic characteristics, risk factors associated with suicide attempts among the studied samples such as personal, maltreatment during childhood, communityassociated risk factors, and suicide methods used. the data was analyzed through binary logistic regression. results: in total, there were (26.6%) cases in the age group 18-29; the majority of the recruits were female (38.3%); most of the participants had a university degree (23.33%), and (26.6%) had never married. regarding their occupational status, most of the patients had paid work, and populated urban areas. among positive suicide cases, (89.3%) had experienced previous suicide attempts, mental illness; such as depression, was present in (57.1%). about )50% (of the suicidal participants experienced physical abuse and maltreatment during childhood. binary logistic regression analysis showed that previous suicide attempts, mental illnesses such as depression, job problems or loss, and barriers to health care access p-value< 0.040, 0.008, 0.023, 0.043 had a highly significant association with suicide. conclusions: there was no association between the sociodemographic characteristics of suicidal and non-suicidal individuals. individuals with associated characteristics, such as a history of repeated suicide attempts and generalized anxiety disorders, require special consideration. mental illnesses, such as depression, job loss or problems, a previous suicide attempt, and barriers to health care were the highest risk factors. key words: suicidality; suicidal attempt; risk factors; suicidal ideation. ahmed ali rasool; department of nursing, hawler medical university, kurdistan region, erbil, iraq. (correspondence: ahmed.rasool@hmu.edu.krd) abdulqader hussein hamad; department of nursing, hawler medical university, kurdistan region, erbil, iraq. 46 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. received: 19/04/2023 accepted: 07/12/2023 published: 30/05/2024 mailto:ahmed.rasool@hmu.edu.krd mailto:ahmed.rasool@hmu.edu.krd?subject=ahmed.rasool@hmu.edu.krd%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20 mailto:ahmed.rasool@hmu.edu.krd mailto:ahmed.rasool@hmu.edu.krd?subject=ahmed.rasool@hmu.edu.krd%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.05 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article suicidality is the umbrella word for suicidal ideation, plans, and actions (si, sp, and sa) (1). according to posner et al. (2007), si stands for "thoughts or wishes about terminating one's own life," sp for "making preparations to end one's own life" (2), and sa for "taking acts to terminate one's own life (3). suicide has elevated to a global health concern in the twenty-first century. over 700,000 people take their own lives each year, according to estimates from the world health organization (who) regarding the age, gender, and socioeconomic condition of the people, differences exist between areas and nations. the most popular methods of suicide include hanging, self-poisoning with drugs and pesticides, and using weapons. most suicides globally are caused by psychiatric disorders (4). in korea, the most common suicide techniques varied between those who attempted suicide and those who succeeded, the most common means of suicide completion was hanging, whereas the most common way of suicide attempt was drug poisoning, and it was determined that drug poisoning, stabbing, and other chemical poisoning were less fatal than other suicide techniques (5).the suicide rate in iran varies between 2.2 and 19.53 per 100,000 individuals, with an average of 5.3 per 100,000. men commit suicide more frequently than women (6). the most common method of suicide in iran is hanging, followed by drug overdose (7). at an estimated 1.7 per 100,000 individuals, iraq's suicide rate is still far lower than that of western countries. the most common methods of suicide are poisoning, burning, hanging, and using weapons. although suicide and suicidality are likely underreported, they are on the rise in iraq. suicidal ideation, attempts, and behavior can be influenced by several demographic, psychological, and environmental factors (8). the effects of various sociodemographic factors on suicide have been examined in a few studies (9). generally, suicide deaths are more common in older males, but suicide attempts are more frequently reported in women (10).in adolescents, depression is considered a significant risk factor for suicidality. for instance, one study (11, 12) indicated that depression is linked to a fivefold increased risk for suicidal attempts (sa), even after adjusting for gender, age, race, and socioeconomic level. anxiety is a risk factor associated with suicide (3). according to frey et al. (2023), there were over 47,000 suicide deaths in the united states in 2019, with over 37,000 of those suicides occurring among people of working age 16–64 years (13). (si) suicidal ideation (sp) suicidal planning (sa) suicidal attempt the study was done by amin and malkhasian in 2019 revealed that the prevalence of suicide in erbil was 3.96 per 100000 in the years from 2015-2016, while in kurdistan overall it was 3.83 per 100000. they stated that the total number of deaths due to unnatural causes of homicide and suicide was 1888 in the years 2015-2017, and suicide consisted of 43% of these deaths, which makes it one of the leading causes of unnatural deaths (14). this study acknowledges the possibility of generalizability limitations beyond erbil city and sensitivity-related challenges such as underreporting and recall biases, and the possibility of underexplored relevant factors. future research could expand the study's scope to include multiple locations, utilize diverse data sources, and facilitate collaboration among researchers, mental health professionals, and policymakers to resolve these disparities. filling in these gaps will contribute to our understanding 47 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.05 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article the participants were notified that they were allowed to get expert assistance. the research followed the most recent version of the declaration of helsinki (the declaration of helsinki is a fundamental document establishing principles for conducting scientific research involving humans). following erase the spaces between words 1947, the world medical association (wma) published the first version of the declaration in 1964) (15), and the study received ethics approval from the human research ethics committee at the hawler medical university/ college of nursing. inclusion criteria included agreement to be the subject of the study, good personal communication, age ≥ 18 years, both sexes, and people with previous suicide attempts whereas the exclusion criteria were being children, nonverbal communication patients, anybody who refused participation, psychosis and substance abuse. the questionnaire of this study includes sociodemographic characteristics of the patients, risk factors associated with suicidality among the studied samples, methods of suicide attempts that the study sample used, assessment of the level of suicide risk (colombia suicide severity risk scale). the sociodemographic characteristics included age group, sex, level of education, marital status, occupational status, and residency area (appendix n 1).risk factors associated with suicidality among the studied samples were used to determine the risk factors associated with suicide. it is a tool of three questions that each of them has specific questionnaires and the main questions are about (personal, abuse, maltreatment during childhood, and community). the higher the numbers of cases associated with suicide, the worse the condition is (appendix n 2).the methods of suicide attempts that the study sample used as a tool comprised a set of nine questionnaires, whereas respondents provided of suicidality, provide direction for interventions, and support efforts to reduce suicide rates and promote mental health in erbil city and beyond. the aim of this study is to investigate the demographics of suicidality in erbil city and to identify the complex risk factors associated with an increased likelihood of suicide attempts. by examining the interplay of variables such as age, gender, socioeconomic status, mental health conditions, social isolation, adverse life events, and access to mental health services. additionally, the study aims to shed light on the intricate dynamics underlying suicidal behavior. the findings will inform targeted prevention strategies, early intervention programs, and individualized mental health services in erbil city to alleviate the burden of suicidality and promote overall mental health. the present study was a retrospective case -control study that recruited 60 participants aged between 18 and 53. informed consent was obtained from all the participants. the tool is a standard questionnaire, and the method is a direct questionnaire (face to face) , which was filled out by the researcher and designed by the authors of the study on sociodemographic characteristics such as age, sex, level of education, marital status, occupational status, residency area, and socioeconomic status, which was known by giving them a questionnaire and then asking the participants orally, and risk factors associated with suicide attempts among the studied samples, such as personal maltreatment during childhood, community-associated risk factors, and suicide methods used. it has been attempted incorporate all the characteristics identified in the literature as potential risk factors for suicidality into the questionnaire. the time frame for this study was eight months. upon receiving the surveys, 48 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.05 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article responses of "yes" or "no" to assess their engagement with specific methods associated with suicidal attempts (appendix n 3). assessment of the level of suicide risk (cssrs) was used to determine the level of suicidal risk. this tool comprised a set of eight questionnaires, whereas respondents provided responses of "yes" or "no". a positive c-ssrs is a "yes" response to items 3, 4, 5 and 8. this tool has been used in many research studies with good reliability and validity (16) (appendix n 4). regarding validity and reliability, the questionnaire used in this study was in the kurdish language. firstly, the english version of this questionnaire, which had good reliability and validity, was translated into the kurdish language. then, for the validity and reliability of the kurdish version, it was given to 10 professors. moreover, two questionnaire tools were used (risk factors associated with suicidality among the studied samples, methods of suicide attempts that the study sample used, and assessment of the level of suicide risk (colombia suicide severity risk scale)), and they have been used in many research studies with good validity and reliability (16). • the official approval and licenses were obtained from the general director of health/ kurdistan region governorate (krg). • the letter of the introduction and the permission obtained to enter the research environment. • the aims of the study for all units were explained for all participants. • the freedom of the participants to participate in the study or to leave was considered. • oral informed consent from the participants to participate in the study was taken. • observing the principle of confidentiality of the information of the participants and using the code instead of the names of the participants in the questionnaire. • the official permissions were obtained from the ethics committee at the school of nursing /hawler medical university on 7/10/2021 the code number is ;137 there was not any barrier or limitation in the study. data are summarized and reported with the statistical package for social sciences (spss version 25.0) were used for data analysis. descriptive statistical analysis (frequency and percentage) and inferential statistical analysis of binary logistic regression (blr) were used to know the risk factors associated with suicide. by utilizing blr, the study aimed to create a predictive model, accounting for various categorical and continuous variables, to determine the relative importance and contribution of each risk factor in predicting suicidality in the population under study. a p-value was considered significant at the level of p ≤ 0.05 of the 60 cases, there were 16 males and 44 females. the subjects were divided into suicidal n= 32 and non-suicidal n=28 groups. among the suicidal group, 82.1% were female, and 17.9% were male. further details are presented in table (1). there was no significant difference between different age groups, male and female, level of education, marital status, occupational status and residency area of the suicidal and non-suicidal groups. a total of 64.2% controls, and 50% cases in the age group 18-29, more than half of the study samples were females 75% controls, and 71.8% cases, most of the participants had university degrees 75% controls, and 43.7% cases, 60.7% controls, 50% cases had never married. regarding their occupational status, 50% control, 31.2% cases had paid work, and n=29 control, n=22 cases inhabited urban areas. *not a comparable group and the sample size is small. 49 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. results https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.05 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article 50 planned or suicidal thoughts). furthermore, the time was so limited that getting a high number of cases was impossible in that determined time) copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. (as for the sample size, we highly appreciate the comment but we chose 60 because of the limited cases that we get in this society because there are not a lot of cases who can truly say that they had table 1: socio demographic characteristics of the studied samples sociodemographic characteristics suicidal groups p-value negative (n=32) positive (n=28) f. (%) f. (%) age group (years) 18-29 18 (56.3) 16 (57.1) 0.882 30-41 8 (25) 8 (28.6) 42-53 6 (18.7) 4 (14.3) sex male 11 (34.4) 5 (17.9) 0.149 female 21 (65.6) 23 (82.1) level of education cannot read and write 2 (6.3) 6 (21.4) 0.143 can read and write 2 (6.3) 5 (17.8) primary school graduated 0 (0) 1 (3.6) secondary school graduated 3 (9.4) 1 (3.6) high school graduated 4 (12.5) 1 (3.6) under-graduated 21 (65.5) 14 (50) marital status never married 17 (53.1) 16 (57.1) 0.400 married 13 (40.6) 11 (39.3) divorced 2 (6.3) 1 (3.6) occupational status paid work 14 (43.8) 10 (35.7) 0.729 self-employed (own business or farming) 7 (21.9) 6 (21.4) non-paid work (volunteer or charity) 1 (3.1) 1 (3.6) student 3 (9.4) 2 (7.1) keeping house/homemaker 4 (12.5) 6 (21.4) retired 1 (3.1) 0 (0) unemployed (health reason) 0 (0) 2 (7.1) unemployed (other reason) 2 (6.3) 1 (3.6) residency area urban 29 (90.6) 22 (78.6) 0.286 rural 1 (3.1) 4 (14.3) suburban 2 (6.3) 2 (7.1) the job has been classified according to (who). https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.05 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article physical abuse and maltreatment during childhood. other risk factors associated with suicide among suicidal participants were easy access to lethal means such as firearms or medications, as well as unsafe media portrayals of suicide, which occurred in 64.3%, and 67.9%. 51 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table (2) presents the risk factors associated with suicide attempts among the studied samples. among positive suicide cases, 89.3% had experienced previous suicide attempts, while mental illness, such as depression, was present in 57.1%. about 50% of the suicidal participants experienced table 2: risk factors associated with suicidality among the studied samples risk factors associated with suicide attempts among the study sample suicidal groups negative (n=32) positive (n=28) no yes no yes f. (%) f. (%) f. (%) f. (%) personal: previous suicide attempt 12 (37.5) 20 (62.5) 3 (10.7) 25 (89.3) mental illness, such as depression 25 (78.1) 7 (21.9) 12 (42.9) 16 (57.1) social isolation 22 (68.8) 10 (31.3) 13 (46.4) 15 (53.6) criminal problems 29 (90.6) 3 (9.4) 28 (100) 0 (0) financial problems 21 (65.6) 11 (34.4) 15 (53.6) 13 (46.4) impulsive or aggressive tendencies 22 (68.8) 10 (31.3) 24 (85.7) 4 (14.3) job problems or loss 22 (68.8) 10 (31.3) 22 (78.6) 6 (21.4) legal problems 28 (87.5) 4 (12.5) 27 (96.4) 1 (3.6) serious illness 30 (93.8) 2 (6.3) 28 (100) 0 (0) substance use disorder 29 (90.6) 3 (9.4) 24 (85.7) 4 (14.3) abuse maltreatment during childhood like: emotional 27 (84.4) 5 (15.6) 22 (78.6) 6 (21.4) physical 24 (75) 8 (25) 14 (50) 14 (50) sexual 30 (93.8) 2 (6.3) 26 (92.9) 2 (7.1) bullying 24 (75) 8 (25) 19 (67.9) 9 (32.1) family history of suicide 28 (87.5) 4 (12.5) 23 (82.1) 5 (17.9) relationship problems such as a break-up, violence, or loss 24 (75) 8 (25) 23 (82.1) 5 (17.9) sexual violence 32 (100) 0 (0) 28 (100) 0 (0) community: barriers to health care access 29 (90.6) 3 (9.4) 18 (64.3) 10 (35.7) cultural and religious beliefs such as a belief that suicide is good of a personal problem 26 (81.3) 6 (18.8) 21 (75) 7 (25) stigma associated with mental illness or help-seeking 25 (78.1) 7 (21.9) 20 (71.4) 8 (28.6) easy access to lethal means such as firearms or medications 14 (43.8) 18 (56.3) 10 (35.7) 18 (64.3) unsafe media portrayals of suicide 17 (53.1) 15 (46.9) 9 (32.1) 19 (67.9) someone in the community encourage for suicide 29 (90.6) 3 (9.4) 24 (85.7) 4 (14.3) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.05 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article attempts, mental illness such as depression, job problems or loss, and barriers to health care access p-value <0.040, 0.008, 0.023, 0.043 were highly significant and considered as main risk factors for suicidality. binary logistic regression analysis for the risk factors associated with suicidal thoughts and ideas was performed to identify risk factors of suicidality. eighteen covariates were selected as shown in table (3). of these, having previous suicide 52 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3: binary logistic regression analysis of risk factors associated with suicidal thoughts and ideas risk factors b s.e. wald df p-value odds ratio 95% c.i. lower upper previous suicide attempt 3.232 1.575 4.211 1 0.040 25.330 1.156 555.022 mental illness, such as depression 4.609 1.737 7.043 1 0.008 100.39 4 3.337 3020.004 social isolation 0.147 1.298 0.013 1 0.910 1.158 0.091 14.760 criminal problems -17.062 19839.3 < 0.001 1 0.999 < 0.001 < 0.001 financial problems 0.044 1.316 0.001 1 0.973 1.045 0.079 13.801 impulsive or aggressive tendencies -2.451 1.622 2.283 1 0.131 0.086 0.004 2.071 job problems or loss -5.991 2.640 5.150 1 0.023 0.003 < 0.001 0.442 legal problems -3.608 7.356 0.241 1 0.624 0.027 0.000 49491.93 serious illness -24.416 26836.6 < 0.001 1 0.999 < 0.001 < 0.001 substance use disorder -2.680 2.095 1.637 1 0.201 0.069 0.001 4.163 barriers to health care access 1.525 2.226 0.469 1 0.493 4.593 0.059 360.249 cultural and religious beliefs such as a belief that suicide is good of a personal problem 1.855 1.949 0.906 1 0.341 6.393 0.140 291.614 stigma associated with mental illness or help-seeking -0.424 1.525 0.077 1 0.781 0.655 0.033 13.017 easy access to lethal means such as firearms or medications -2.725 1.521 3.210 1 0.073 0.066 0.003 1.292 unsafe media portrayals of suicide 0.807 1.299 0.386 1 0.534 2.242 0.176 28.605 someone in the community encourage for suicide 1.366 1.638 0.696 1 0.404 3.920 0.158 97.111 barriers to health care access 4.880 2.416 4.079 1 0.043 131.69 1.155 15008.75 constant -2.435 1.451 2.816 1 0.093 0.088 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.05 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article many factors that contribute to it. it emphasizes the need to delve further into the phenomena by investigating risk variables outside sociodemographic, such as mental health, access to mental health treatments, cultural attitudes, and social support networks. the type of society and culture of the studied sample in my research would be the society and culture of erbil city itself. the studied sample refers to the individuals or participants from erbil city who was included in my study. therefore, the focus is on understanding the risk factors associated with suicidality within the specific societal and cultural context of erbil city and the individuals comprising the studied sample from that population. in this investigation, the constructed binary logistic regression models determined the risk factors associated with suicidality. almost three-fifths of percentage of suicide cases aged from eighteen to twentynine. this is in line with the findings of a related iranian study (20) which found that suicide rates are higher among younger subjects. these results suggest that younger age groups may be more vulnerable to suicide, potentially influenced by various risk factors and adverse life events. numerous risk factors have been identified, and it is thought that poor life events contribute to the emergence of suicide tendencies in young individuals (17). the present investigation discovered a statistically significant correlation between previous suicide attempts p-value= 0.040 and the suicidal ideas among the suicidal positive group. this result is consistent with that of a previous study (21) which reported the severity of suicidal ideation as a significant risk factor for suicide attempts. moreover, another study conducted in sulaimani city, kurdistan, iraq found that participants with a history of suicide attempts had a high incidence of suicidal ideation; thus the previous despite the fact that suicide is a complex human behavior, a variety of sociodemographic characteristics have been linked to a higher risk of suicidal behavior in various social and cultural contexts (17). regarding the sociodemographic characteristics of the participants of the present study, there were no significant differences p-value> 0.05 between different age groups, male and female, level of education, marital status, as well as occupational status and residency area of the suicidal and non-suicidal groups. these findings concur with those of a separate study conducted in erbil city, iraqi kurdistan, in which the level of suicide ideation was not significantly correlated with nearly all sociodemographic factors pvalue> 0.05 (18). drawing upon these findings, it can be inferred that sociodemographic characteristics alone may not be strong predictors of suicidality in the context of erbil city. the current results were also in concordance with the results of jha et al., (2023), in their study also, there were no significant relationships between being unmarried or low family income and suicide (19). this suggests that factors beyond sociodemographic, such as psychological, cultural, and social factors, might play a more prominent role in contributing to suicidality in this population. this is consistent with the findings of a similar study from iran (20) in which younger subjects account for a greater proportion of suicide cases. their results also showed that almost all the sociodemographic characteristics were non-significantly associated with suicide ideation p-value> 0.05. this study's findings, together with those from the current literature, highlight the need for gaining a deeper appreciation for the complexity of suicidality and the 53 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.05 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article suicide (26). for both men and women, a significant increase in the risk of suicide following a job loss was found to be associated with a prior dread of job loss (27). people who commit suicide are more likely to have died from job-related stress or financial difficulties than those who attempted suicide. (28). another study indicated that a reduction in work protection laws (29) and job loss increased the probability of suicide death among men (30). according to our knowledge, no previously published studies have examined the relationship between job loss and suicidality in our region. this is due to not taking suicide as an actual problem and not taking into great consideration. according to the study of cooper et al., (2015), only seventeen percent of those individuals who had lost their job took their lives within a month of job loss, and fifty percent died six months or longer after job loss. only two five percent of the ‘recessionrelated’ suicides were related to fears of job loss (31) which disagrees with our results. the present study results show that there was no correlation between the sociodemographic characteristics of the suicidal and non-suicidal groups. people who exhibit related symptoms, such as a history of repeated suicide attempts, need to receive extra care. mental illness, including depression, troubles at work or job loss, prior suicide attempts, and barriers to accessing health care, were the top risk factors. 54 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. attempts, if not managed, probably will lead to more aggressive actions (22). however, these results underscore the importance of addressing and managing previous suicide attempts to mitigate the risk of further escalation. depression is strongly related to both suicidal ideation and attempt, but little is known about the characteristics that increase the risk of suicide among people with depression (23). the current study found a highly statistically significant relationship between mental illness, such as depression (p= 0.008) and suicidal thoughts and ideas. therefore, more attention should be paid to people with mental illnesses, especially depression. this outcome is in line with those of dazzi et al. (2014), who found that suicidal thought is more substantially associated with depression severity than with its absence (24). the present study's findings are also in line with those of (21), showing that people who reported the highest levels of depression also had the highest rates of severe suicidal thoughts by four fifths of a percentage. thus, these findings emphasize the critical importance of addressing mental illness, particularly depression, as part of suicide prevention efforts. in addition, another analysis looked at how despair can lead to actions of self-harm. these findings are similar to previous ones showing that the degree of depression is a strong predictor of suicidality (25). a statistically significant correlation between job issues or loss was discovered in the current investigation p-value= 0.023, and the risk of suicidality. generally, this could be attributed to the difficulties and struggles that someone will face in their effort to live a good life. in the absence of a job, family problems will also increase, which may lead to suicidal ideation, attempt and a suicidal act. this result is similar to the previous studies that discovered a link between unemployment and conclusion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.05 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article [10] sáenz-aldea m, zarrabeitia mt, garcía blanco a, santurtún a. scrutinizing the profile and risk factors of suicide: a perspective from a case–control study focused on a northern region of spain. international journal of environmental research and public health. 2022;19 (23):15867. https://doi.org/10.3390/ ijerph192315867. [11] king ra, schwab-stone m, flisher aj, greenwald s, kramer ra, goodman sh, et al. psychosocial and risk behavior correlates of youth suicide attempts and suicidal ideation. journal of the american academy of child & adolescent psychiatry. 2001;40(7):837-46. https:// doi.org/10.1097/00004583-20010700000019. [12] park s-c, kim d. the centality of depression and anxiety symptoms in major depressive disorder determined using a network analysis. journal of affective disorders. 2020;271:19-26. https:// doi.org/10.1016/j.jad.2020.03.078. [13] frey jj, osteen pj, sharpe tl, mosby ao, joiner t, ahmedani b, et al. effectiveness of man therapy to reduce suicidal ideation and depression among working‐age men: a randomized controlled trial. suicide and life‐threatening behavior. 2023;53(1):137 -53. https://doi.org/10.1111/sltb.12932. [14] malkhasian aa, amin yk. pattern of suicide in kurdistan region/iraq in the past three years and methods of recognition. medical journal of tikrit university. 2019;25(2):64-73. [15] sawicka-gutaj n, gruszczyński d, guzik p, mostowska a, walkowiak j. publication ethics of human studies in the light of the declaration of helsinki–a mini-review. journal of medical science. 2022;91 (2):e700-e. https://doi.org/10.20883/ medical.e700. [16] chappell p, feltner de, makumi c, stewart m. initial validity and reliability data on the columbia–suicide severity rating scale. american journal of psychiatry. 2012;169(6):662-3. doi: 10.1176/ appi.ajp.2012.11111674 [17] poor fb, tabatabaei sm, bakhshani n-m. epidemiology of suicide and its associated socio-demographic factors in patients admitted to emergency department of zahedan khatam-al-anbia hospital. international journal of high risk behaviors & 55 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [1] nock mk, borges g, bromet ej, cha cb, kessler rc, lee s. the epidemiology of suicide and suicidal behavior. 2012. [2] posner k, oquendo ma, gould m, stanley b, davies m. columbia classification algorithm of suicide assessment (c-casa): classification of suicidal events in the fda’s pediatric suicidal risk analysis of antidepressants. american journal of psychiatry. 2007;164(7):1035-43. https:// doi.org/10.1176%2fappi.ajp.164.7.1035. [3] cai h, chow ih, lei s-m, lok gk, su z, cheung t, et al. inter-relationships of depressive and anxiety symptoms with suicidality among adolescents: a network perspective. journal of affective disorders. 2023;324:480-8. https://doi.org/10.1016/ j.jad.2022.12.093. [4] usul e, şan i̇, korkut s, kayıpmaz s, bekgöz b. analysis of suicide cases from ankara province: a 3-year emergency medical services experience. acta bio medica: atenei parmensis. 2022;93(2). https:// doi.org/10.23750/abm.v93i2.10357. [5] lim m, lee su, park j-i. difference in suicide methods used between suicide attempters and suicide completers. international journal of mental health systems. 2014;8(1):54. https://doi.org/10.1186/1752-4458-8-54. [6] razai d, ghadirzadeh mr, mahdavi sa, hasani j, nazari ssh. the suicide rate in the elderly population of iran between 2008 and 2014. journal of research in health sciences. 2020;20(1):e00471. https:// doi.org/10.34172/jrhs.2020.06. [7] shojaei a, moradi s, alaeddini f, khodadoost m, ghadirzadeh mr, khademi a. the association between completed suicides and season of the year in an iranian population. iranian journal of public health. 2013;42(3):293. [8] younis ms, lafta rk. suicide and suicidality in iraq: a systematic review. medicine, conflict and survival. 2023;39(1):48-62. https:// doi.org/10.1080/13623699.2023.2170580. [9] cano-montalbán i, quevedo-blasco r. sociodemographic variables most associated with suicidal behaviour and suicide methods in europe and america. a systematic review. the european journal of psychology applied to legal context, 2018, 10, 15-25 2018. http://dx.doi.org/https:// doi.org/10.5093/ejpalc2018a2. references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.05 erbil j. nurs. midwifery, vol. 7, no. (1), may 2024 original article [27] classen tj, dunn ra. the effect of job loss and unemployment duration on suicide risk in the united states: a new look using mass‐layoffs and unemployment duration. health economics. 2012;21(3):338-50. https://doi.org/10.1002/hec.1719. [28] dejong tm, overholser jc, stockmeier ca. apples to oranges?: a direct comparison between suicide attempters and suicide completers. journal of affective disorders. 2010;124(1-2):90-7. https:// doi.org/10.1016/j.jad.2009.10.020. [29] kim c, cho y. does unstable employment have an association with suicide rates among the young? international journal of environmental research and public health. 2017;14(5):470. https://doi.org/10.3390/ ijerph14050470. [30] blomqvist s, virtanen m, lamontagne ad, ll mh. perceived job insecurity and risk of suicide and suicide attempts: a study of men and women in the swedish working population. scandinavian journal of work, environment & health. 2022;48(4):293301. https://doi.org/10.5271% 2fsjweh.4015. [31] coope c, donovan j, wilson c, barnes m, metcalfe c, hollingworth w, et al. characteristics of people dying by suicide after job loss, financial difficulties and other economic stressors during a period of recession (2010–2011): a review of coroners ׳records. journal of affective disorders. 2015;183:98-105. https:// doi.org/10.1016/j.jad.2015.04.04 . 56 copyright ©2024 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. addiction. 2014;3(4). https:// doi.org/10.5812%2fijhrba.22637. [18] saeed ba. suicidal ideation among a group of depressed outpatients. zanco journal of medical sciences (zanco j med sci). 2017;21 (3):1907-14. https://doi.org/10.15218/ zjms.2017.050. [19] jha s, chan g, orji r. identification of risk factors for suicide and insights for developing suicide prevention technologies: a systematic review and meta-analysis. human behavior and emerging technologies. 2023;2023:3923097. https:// doi.org/10.1155/2023/3923097. [20] ghaleiha a, afzali s, bazyar m, khorsand f, torabian s. characteristics of hospitalized patients following suicide attempt in hamadan district, iran. oman medical journal. 2012;27(4). https://doi.org/10.5001% 2fomj.2012.75. [21] al-maani ma. suicidal ideation among patients suffering depression. middle east journal of psychiatry and alzheimers. 2015;84(1696):1-3. [22] abdulkarim am, muhsin ss. an investigation of the severity levels and risk factors of suicidal ideation among patients with major depressive disorder in sulaimani city, iraq/ kurdistan. pakistan journal of medical and health sciences. 2021;15(3):1048-51. [23] brådvik l. suicide risk and mental disorders. mdpi; 2018. p. 2028. https:// doi.org/10.3390/ijerph15092028. [24] dazzi t, gribble r, wessely s, fear nt. does asking about suicide and related behaviours induce suicidal ideation? what is the evidence? psychological medicine. 2014;44 (16):3361-3. https://doi.org/10.1017/ s0033291714001299. [25] handley t, rich j, davies k, lewin t, kelly b. the challenges of predicting suicidal thoughts and behaviours in a sample of rural australians with depression. international journal of environmental research and public health. 2018;15(5):928. https:// doi.org/10.3390/ijerph15050928. [26] milner a, page a, lamontagne ad. cause and effect in studies on unemployment, mental health and suicide: a meta-analytic and conceptual review. psychological medicine. 2014;44(5):909-17. https:// doi.org/10.1017/s0033291713001621. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.02 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article meconium-stained amniotic fluid and associated factors among women undergoing childbirth in maternity teaching hospital in erbil city abstract background and objectives: the purpose of this study was to identify the risk factors for meconium-stained amniotic fluid among women who delivered vaginally and were admitted to the delivery room at maternity teaching hospital in erbil city." methods: a descriptive case-control study was conducted in the labor ward of maternity teaching hospital in the kurdistan region, iraq. the study setting was the delivery room. a non-probability purposive sample included 342 mothers with singleton pregnancies: 171 cases with meconium-stained amniotic fluid and 171 controls with clear amniotic fluid. the data were analyzed using version 23 of the statistical package for the social sciences. results: the majority of women (82.7%) were illiterate, and more than half (58.2%) were multiparous. 57% of the newborns were male. approximately 18.7% of cases had caesarean sections compared to 5.3% in the control group, which is statistically highly significant (p-value < 0.001). additionally, about 30% of cases involving neonates were admitted to the neonatal intensive care unit, compared to just 1.8% in the control group, which is also statistically highly significant (p-value < 0.001). postdate (b coefficient: 2.487, 95% confidence interval: 4.686 to 30.854) and fetal distress (b coefficient: 3.048, 95% confidence interval: 5.662 to 78.393) were highly significantly associated with meconium-stained amniotic fluid. conclusion: there is a highly significant association between risk factors such as postdate and fetal distress in the case-control groups. the following factors did not significantly correlate with the case-control groups: preeclampsia, premature rupture of membranes, polyhydramnios, oligohydramnios, prolonged labor, induction of labor, or spontaneous labor. keywords: meconium stained; amniotic fluid; risk factors; delivery room. sazan bahram ahmed; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq. (correspondence: sazan.ahmed@hmu.edu.krd) srwa abdulrahman mustafa; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq madiha abbas muhammed; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq kazhan ibrahim mahmood; department of nursing, college of nursing, hawler medical university, erbil, kurdistan region, iraq awaz azeez saeed; department of midwifery, college of nursing, hawler medical university, erbil, kurdistan region, iraq. 11 received: 29/11/2023 accepted: 18/05/2024 published: 30/05/2025 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:sazan.ahmed@hmu.edu.krd?subject=sazan.ahmed@hmu.edu.krd mailto:sazan.ahmed@hmu.edu.krd?subject=sazan.ahmed@hmu.edu.krd mailto:sazan.ahmed@hmu.edu.krd mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.02 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article meconium is the first stool that is found in the intestine of the fetus from 14– 16 weeks gestation. meconium amniotic fluid (maf) occurs when there is a passage of the fetal colonic contents into the amniotic cavity (1). msaf can be found in 10– 20% of mothers during delivery across the world (2). though the passage of meconium could be physiological, it may become an environmental risk in the presence of fetal acidemia. the latter supervenes acutely and thus it is highly unpredictable and unpreventable (3). the exact causes of meconium-stained amniotic fluid are not clear (4). numerous factors are linked to meconium-stained amniotic fluid, including advanced maternal age, early rupture of the membranes, obstructed labor, induced labor, an unsettling heart rate pattern, pregnancy longer than 42 weeks, labor longer than 15 hours, pregnancy-induced hypertension, oligohydramnios, interpregnancy intervals shorter than two years, and a monthly family income of less than 5000 ethiopian birr (5). meconiumstained amniotic fluid results in short and long-term prenatal outcomes such as lower apgar score, respiratory distress, meconium aspiration syndrome (mas), neonatal sepsis (early onset neonatal sepsis and late -onset neonatal sepsis), and hyaline membrane disease. the meconium-stained amniotic fluid causes respiratory distress, specifically meconium aspiration syndrome, which results in morbidity and mortality of neonates (6). is beneficial for obtaining baseline rates of risk factors and identifying clues to the etiology of conditions this information is also helpful to plan and assess antenatal care for pregnant women, especially for high-risk populations. the main objectives of this study are to identify the main risk factors associated with the meconium-stained amniotic fluid in pregnant women and to find out the association between socio-demographical characteristics and obstetric characteristics of women in case-control groups. a descriptive case-control study was used to conduct this study. the study was carried out at the maternity teaching hospital in erbil city. this hospital is located on the main street of shaqlawa and has been established since 2004 in erbil city in the iraqi kurdistan region. the maternity teaching hospital consists of many departments, including emergency, in vitro fertilization, postpartum unit, postoperative unit, delivery unit, and neonatal intensive care unit (nicu). the study was conducted in the delivery unit. the duration of the study from 1st of february to 1st of october 2023.a non-probability purposive sample of 342 mothers with singleton pregnancies (171 cases and 171 controls) admitted to the delivery room at mth were respectfully asked to participate in the study. mothers were divided into two groups: the first group diagnosed with meconium amniotic fluid (maf) and the second group with clear amniotic fluid (caf). epi info 7 was used to determine the sample size by entering the total number of 3100 women who gave birth during three months in the delivery room in erbil city. the sample size was calculated using this method, yielding a 95% confidence level and a 5% margin of error. the calculation resulted in 342 samples. the inclusion criteria for this study were all pregnant mothers with singleton fetuses (not twin pregnancies) admitted to delivery room. additionally, the exclusion criteria were intrauterine fetal death (iufd), mothers with psychological problems, mothers with bloody amniotic fluid, and preterm birth.data were collected using a patient file records by the researchers and through 12 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.02 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article study, benefits, rights to privacy, rights to withdraw at any time, and that their information would be kept confidential and anonymous. the data were analyzed using the statistical package for the social sciences version 27 (spss). descriptive statistics were used to report frequency and percentages, regression analysis was used to explore the factors associated with meconium amniotic fluid (maf), and odds ratios (or) with 95% confidence intervals (95% ci) were calculated. the chi-square test was used to find the association between case and control groups. the association between sociodemographical and obstetrical characteristics of women and case control groups was illustrated in table 1. the analysis shows no statistically significant associations between the case control groups and the following variables: age category, residency place, and new-born sex. there were a significant statistical association between the case control groups and educational level (p-value=0.002). the majority (90.1%) of the case group was illiterate compared to 75.4% in the control group. there was also a significant statistically association between the case control groups and smoking status (p-value=0.037). the majority (99.4%, 95.3%) of the control and case groups were non-smokers, respectively. in addition, there were a significant statistical association between the case control groups and parity (p-value=0.014). the majority (63.7%) of the control group was multiparous and 52.6% of cases were multiparous. furthermore, there were a significant statistical association between the case control groups and access to prenatal care (p-value=0.005). fifty-five percent of the cases had no access to prenatal care compared to 39.8% of the control group. direct (face to face) interviews with pregnant women in the labor room who kindly accepted to participate in the study. the interviews were conducted in the delivery unit of mth. data collection started from the period 1st of february to 1st of may 2023. to avoid overcrowding, the researcher attended the hospital during the evening shift from 2 pm to 6 pm. the questionnaire format was categorized into three parts, including the following: part one: the socio-demographic characteristics of mothers such as age, level of education, residential area, occupation, income status, access to prenatal care and smoking.part two: women’s obstetrical history, including gestational age, parity, newborn sex, oligohydramnios, preeclampsia, gestational diabetes mellitus (gdm), abnormal placentation, placental abruption, chorioamnionitis, intrauterine growth restriction (iugr). part three: maternal comorbidities including overt diabetes mellitus, chronic hypertension, cardiovascular disease, thyroid dysfunction, drug addiction, hepatitis, anemia, infertility, and covid-19 at the time of admission). after constructing the questionnaire, it was sent to a number of experts in the fields of medicine, nursing, and biostatistics. the comments of experts were taken into consideration regarding clarity relevance, and adequacy to achieve the objectives, and the pilot study of 30 patients in the delivery room indicated that the tool was suitable for data collection. before data collection, formal permission was obtained from hawler medical university/college of nursing and maternity teaching hospital to conduct the study. ethical approval was obtained from the hawler medical university/nursing college. the code number was 5, and the date of approval was january 30, 2023. verbal informed consent was obtained from women before data collection, after explaining the purpose of the 13 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.02 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article compared to 5.3% in the control group and this is statistically highly significant at pvalue<0.001. in addition, regarding those babies who were admitted to nicu, around the association between risk factors and case-control groups is illustrated in table 2. the analysis reveals a significant association between postdate and case-control groups, as 28.1% of the cases were postdate compared to only 4.1% in the control group, and this is statistically highly significant at p-value < 0.001. in addition, around 29% of the cases had fetal distress compared to only 1.8% in the control 30% of the cases were admitted to nicu compared to only 1.8% in the control group. this is statistically highly significant at p-value<0.001. group, and this is statistically highly significant at p-value < 0.001. furthermore, there was a significant statistical association between the case-control groups and anemia (p-value = 0.021). around 19% of the cases had anemia compared to 9.9% in the control group. the analysis shows no significant statistical associations between the case-control groups and the following factors: spontaneous labor, induction 14 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 1: association between socio-demographical and obstetrical characteristics of women in both groups socio-demographic and obstetric variables case control total pvalue no. (%) no. (%) no. (%) age category (years) < 20 38 (22.2) 28 (16.4) 66 (19.3) 0.651 20-26 61 (35.7) 62 (36.3) 123 (36.0) 27-33 48 (28.1) 51 (29.8) 99 (28.9) 34-40 21 (12.3) 25 (14.6) 46 (13.5) > 40 3 (1.8) 5 (2.9) 8 (2.3) educational level illiterate 154 (90.1) 129 (75.4) 283 (82.7) 0.002 elementary 13 (7.6) 22 (12.9) 35 (10.2) high school/ diploma 2 (1.2) 12 (7.0) 14 (4.1) college 2 (1.2) 8 (4.7) 10 (2.9) residency place urban 133 (77.8) 139 (81.3) 272 (79.5) 0.421 rural 38 (22.2) 32 (18.7) 70 (20.5) smoking yes 8 (4.7) 1 (0.6) 9 (2.6) 0.037 no 163 (95.3) 170 (99.4) 333 (97.4) parity primipara 70 (40.9) 45 (26.3) 115 (33.6) 0.014 multipara 90 (52.6) 109 (63.7) 199 (58.2) grand multipara 11 (6.4) 17 (9.9) 28 (8.2) access to prenatal care yes 77 (45.0) 103 (60.2) 180 (52.6) 0.005 no 94 (55.0) 68 (39.8) 162 (47.4) current cesarean section yes 32 (18.7) 9 (5.3) 41 (12) <0.001 no 139 (81.3) 162 (94.7) 301 (88) admitted to nicu yes 51 (29.8) 3 (1.8) 54 (15.8) <0.001 no 120 (70.2) 168 (98.2) 288 (84.2) current newborn sex female 66 (38.6) 81 (47.4) 147 (43) 0.101 male 105 (61.4) 90 (52.6) 195 (57) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.02 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article 15 diabetes, iugr, chorioamnionitis, and chronic hypertension. of labor, prolonged labor, polyhydramnios, oligohydramnios, preeclampsia, premature rupture of membranes, pih, gestational copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2. association between risk factors and case control groups. risk factors case control total p-value no. (%) no. (%) no. (%) spontaneous labour yes 30 (17.5) 24 (14.0) 54 (15.8) 0.374 no 141 (82.5) 147 (86.0) 288 (84.2) post date (40-42 weeks) yes 48 (28.1) 7 (4.1) 55 (16.1) <0.001 no 123 (71.9) 164 (95.9) 287 (83.9) induction of labour yes 13 (7.6) 6 (3.5) 19 (5.6) 0.098 no 158 (92.4) 165 (96.5) 323 (94.4) prolonged labour yes 5 (2.9) 1 (0.6) 6 (1.8) 0.085 no 166 (97.1) 170 (99.4) 336 (98.2) fetal distress yes 49 (28.7) 3 (1.8) 52 (15.2) <0.001 no 122 (71.3) 168 (98.2) 290 (84.8) oligohydramnious yes 5 (2.9) 4 (2.3) 9 (2.6) 0.735 no 166 (97.1) 167 (97.7) 333 (97.4) preeclampsia yes 5 (2.9) 2 (1.2) 7 (2.0) 0.244 no 166 (97.1) 169 (98.8) 335 (98.0) anaemia yes 32 (18.7) 17 (9.9) 49 (14.3) 0.021 no 139 (81.3) 154 (90.1) 293 (85.7) prom yes 0 (0.0) 1 (0.6) 1 (0.3) 0.239 no 171 (100.0) 170 (99.4) 341 (99.7) iugr yes 2 (1.2) 0 (0.0) 2 (0.6) 0.095 no 169 (98.8) 171 (100.0 ) 340 (99.4) gestational diabetes yes 0 (0.0) 1 (0.6) 1 (0.3) 0.239 no 171 (100.0) 170 (99.4) 341 (99.7) chorioamnionitis yes 4 (2.3) 1 (0.6) 5 (1.5) 0.162 no 167 (97.7) 170 (99.4) 337 (98.5) chronic hypertension yes 3 (1.8) 3 (1.8) 6 (1.8) 1.000 no 168 (98.2) 168 (98.2) 336 (98.2) pih yes 2 (1.2) 1 (0.6) 3 (0.9) 0.558 no 169 (98.8) 170 (99.4) 339 (99.1) polyhydramnious yes 2 (1.2) 0 (0.0) 2 (0.6) 0.095 no 169 (98.8) 171 (100.0) 340 (99.4) post term (after 42 weeks) yes 2 (1.2) 0 (0.0) 2 (0.6) 0.095 no 169 (98.8) 171 (100.0) 340 (99.4) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.02 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article 2.686, 2.487, and 3.048, respectively, indicating that there are positive effects of these variables on the outcome variable. the odds of cases are 3.094 times greater for babies who were delivered by c/s (95% ci 1.038-9.220, p-value = 0.043). the odds of cases are 14.675 times greater for babies admitted to nicu (95% ci 13.77457.073, p < 0.001). in addition, the odds of cases are 12.024 times greater for babies born postdate (95% ci 4.686-30.854, pvalue < 0.001). furthermore, the odds of cases are 21.068 times greater for babies with fetal distress (95% ci 4.686-30.854, pvalue < 0.001). 16 in order to determine the degree of association between a range of risk factors and the case-control groups, a logistic regression analysis was conducted. table 3 shows the findings of this analysis. as illustrated in the table, nagelkerke r² is 0.513, which indicates that 51% of the variance is explained by the model. the data analysis shows no evidence of an effect of the level of education, smoking, parity, anemia, and access to antenatal care on the case and control groups. the b coefficients for c/s, nicu admission, postdate, and fetal distress are 1.129, copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 3. logistic regression analysis of risk factors and case control groups variable b coefficient wald odds ratio (95% ci) p value intercept -21.093 34.929 <0.001 educational level educational level 6.011 0.111 illiterate -0.879 0.965 0.415 (0.072 to 2.398) 0.326 elementary -0.410 0.173 0.664 (0.096 to 4.585) 0.678 high school/ diploma 1.345 1.062 3.837 (0.297 to 49.536) 0.303 smoking 2.108 3.161 0.566 (0.27 to 1.18) 0.075 parity parity 4.951 0.084 multipara -1.204 4.239 0.300 (0.095 to 0.944) 0.040 grand multiparous -0.742 1.735 0.476 (0.158 to 1.436) 0.188 access to prenatal care -0.449 2.192 0.638 (0.352 to 1.157) 0.139 cesarean section 1.129 4.109 3.094 (1.038 to 9.220) 0.043 admitted to nicu 2.686 15.027 14.675 (3.774 to 57.073) <0.001 post date 2.487 26.756 12.024 (4.686 to 30.854) <0.001 fetal distress 3.048 20.667 21.068 (5.662 to 78.393) <0.001 anemia 0.783 3.757 2.187 (0.991to 4.826) 0.053 overall % of correct classification 81.0 nagelkerke r2 0.513 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.02 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article 4.1% in the control group, and this is statistically highly significant at p-value < 0.001. this result was in agreement with the study performed by padmapriya in 2023 at dharmapuri, which showed that 26% of patients were at a gestational age of more than 40 weeks (10). the current study revealed that fetal distress is significantly associated with meconium-stained amniotic fluid. this finding was supported by the study conducted in northwest ethiopia by abate in 2021, which showed that fetal distress was nearly 22 times more likely to result in meconium-stained liquor (2). in addition, there was a statistically significant association between the case-control groups and anemia (p=0.021). around 19% of the cases had anemia compared to 9.9% in the control group (p=0.021). a similar study performed by seife and elias in 2022 showed that 38.6% of the cases had anemia compared to only 31.3% in the control group (11). spontaneous labor, induction of labor, prolonged labor, polyhydramnios, oligohydramnios, preeclampsia, premature rupture of membranes, pih, gestational diabetes, iugr, chorioamnionitis, and chronic hypertension were not significant in the current study. this finding was consistent with a study done in southest ethiopia by sorsa. it revealed that preeclampsia and oligohydramnios were not significant (12). another study, reported from northern ethiopia, contradicted this finding, showing that induced labor, prolonged labor, and premature rupture of membranes were significantly associated with meconium-stained amniotic fluid (13). the findings of the present study showed that the majority 52.6% of the cases and 63.7% of the control group were multiparous. there was a significant statistically association between the case-control groups and parity. this finding did not agree with a study done in kerala, india, which showed that 64.1% of the cases were primigravida and 66.7% of the controls were primigravida. therefore, parity was not statistically significant (7). additionally, there was a statistically significant association between the case-control groups and access to prenatal care. this finding was not consistent with a study conducted in ethiopia in 2024, which showed that the highest percentage of women attended antenatal checkups (8). another finding was that the majority of cases had c/s compared to a low percentage in the control group, and this is statistically highly significant. a similar study done in kerala, india in 2022 illustrated a higher incidence of caesarean section, with 50% delivered by caesarean section in the case group, whereas in the control group it was 44%. the indication for caesarean section in the study group was fetal distress, associated with abnormal fhr (9). in addition, regarding those babies who were admitted to nicu, around 30% of the cases were admitted to nicu compared to only 1.8% in the control group. this is statistically highly significant at pvalue < 0.001. a similar study in northwest ethiopia in 2021 revealed that the need for nicu care was higher in the meconium -stained amniotic fluid group babies than in the control group (2). the result of the current study shows that the association between risk factors and case-control groups was illustrated. the analysis reveals a significant association between postdate and case-control groups, as 28.1% of the cases were postdate compared to only 17 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.02 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article [3] smruthi, c., bhat, s., ashwini, m.s., kanta, s.r. and lepakshi, b.g., a clinical study of risk factors and pregnancy outcome in women with meconium-stained amniotic fluid in labour in a tertiary care centre. 2022. journal of cardiovascular disease research. 13 (5). available from: doi: downloads\documents\629f3819706506.2592326 5_2.pdf [4] gallo dm, romero r, bosco m, gotsch f, jaiman s, jung e., et al. meconium-stained amniotic fluid. american journal of obstetrics and gynecology. 2023 may 1;228(5): s115878. available from: doi: https:// doi.org/10.1016/j.ajog.2022.11.1283 [5] beyene, b.n., hirbaye, m., kebede, a. and balina, s., 2024. meconium-stained amniotic fluid and associated factors among mothers who gave birth at west guji zone public hospitals, oromia region, ethiopia: a crosssectional study. clinical epidemiology and global health. 29 (10). available from: doi: 10.1016/j.cegh.2024.101669. [6] nirmala c, thomas l, sujatha y. risk factors of meconium stained amniotic fluid-a case control study. international journal of clinical obstetrics and gynaecology. 2020;4 (2):157-60. available from: doi: https:// doi.org/10.33545/gynae.2020.v4.i2c.521. [7] sori d, belete a, wolde m. meconium stained amniotic fluid: factors affecting maternal and perinatal outcomes at jimma university specialized teaching hospital, south west ethiopia. gynecology and obstetrics journal (sunnyvale). 2016;6(394):2161-0932. doi: 10.4172/2161-0932.1000394. [8] tefera m, birhanu d, mihretie a, belete e, demis a, alemaw l. magnitude of meconium stained amniotic fluid and associated factors among women who gave birth in north shoa zone hospitals, amhara region, ethiopia 2024. plos one. 19(2): e0297654. https://doi.org/10.1371/ journal.pone.0297654. [9] sebastian g, ulahannan rt. pregnancy outcome of meconium-stained amniotic fluid in uncomplicated term pregnancies: a case control study. international journal of academic medicine and pharmacy. 022;4(5):432 -5. available from: doi: 10.47009/ jamp.2022.4.5.89. [10] padmapriya r, shanmugapriya n, shanmugapriya k, sukanya e. study on maternal risk factors and fetal outcome in deliveries with meconium-stained amniotic fluid. to conclude, 26% of the cases had thick meconium and more than a quarter of the cases (27.2%) were detected during the active phase of the labour. the majority of the study sample were post-date and had fetal distress in the case group compared to a low percentage in the control group. this means that the main risk factors were post-date and fetal distress, which were found to be highly significantly associated with meconium-stained liquor. maternal conditions like anemia were significantly associated with meconium-stained amniotic fluid (msaf). we should aim at treating anaemia in adolescent girls and women of reproductive age group before conceiving. during our antenatal checkups we should detect iugr and amniotic fluid volume while palpating. it is also recommended to detect maternal infections at term, such as vaginitis and utis, as they are risk factors for msaf. we should use a partogram or labor care guide by who to assess whether labor is progressing at the required rate and detect prolonged labor at the earliest, as prolonged labor is a risk factor for msaf. [1] shekari, m., jahromi, m.s., ranjbar, a. the incidence and risk factors of meconium amniotic fluid in singleton pregnancies: an experience of a tertiary hospital in iran. bmc pregnancy childbirth. 2, 930 (2022). available from: doi: https://doi.org/10.1186/ s12884-022-05285. [2] abate e, alamirew k, admassu e, derbie a. prevalence and factors associated with meconium-stained amniotic fluid in a tertiary hospital, northwest ethiopia: a crosssectional study. obstetric gynecology international journal. 021;2021:5520117. available from: doi: https:// doi.org/10.1155/2021/5520117. 18 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion recommendations references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.02 erbil j. nurs. midwifery, vol. 8, no. (1), may 2025 original article international journal of academic medicine and pharmacy. 2023;5(4):696-8. available from: doi: 10.47009/jamp.2023.5.4.138. [11] awqchew s., ezo e., determinants of meconium aspiration syndrome among neonates admitted to neonatal intensive care unit at nigist eleni mohammed memorial comprehensive specialized hospital, south ethiopia: unmatched case–control study. sage open medicine journal. 2022. 10 (1). available from: doi: https:// doi.org/10.1177/20503121221124693. [12] sorsa r, adugna t, kene k, abera d, dereje d, leta b, et al. determinants of meconiumstained amniotic fluid among women delivered at southwestern referral hospitals, southwest ethiopia: a multi-center casecontrol study. bmc pregnancy and childbirth. 2024 oct 14;24(1):672. available from: doi: https://doi.org/10.1186/s12884-02406867-4. [13] gebregziabher gt, hadgu fb, abebe ht. prevalence and associated factors of perinatal asphyxia in neonates admitted to ayder comprehensive specialized hospital, northern ethiopia: a cross-sectional study. international journal of pediatric. 2020;2020 (1):4367248. available from: doi: 10.1155/2020/4367248 19 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.12 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article female student’s knowledge and perception regarding polycystic ovarian syndrome at koya technical institute abstract background and objective: polycystic ovarian syndrome is the most common endocrine disease in women of reproductive age. it is one of the major reproductive health issues, and it is considered a significant health problem. institutional students represent the future of healthcare, equipped with essential knowledge that can be leveraged to educate their peers and patients, especially on this vital topic. this study aimed to determine female students' knowledge and perception regarding polycystic ovarian syndrome who are studying at koya technical institute, kurdistan, iraq. method: a quantitative, descriptive, cross-sectional study was conducted. the study was carried out at koya technical institute from october 1st, 2024, to december 25th, 2024, with convenience samples consisting of 393 female institutional students. the data were gathered through both an online link and a paper-based survey questionnaire and analyzed using spss software for statistical analysis, version 27. chi-square and fisher’s exact tests were used to determine the association between variables; a p-value ≤ 0.05 is considered statistically significant. result: in the present study, 393 samples participated; the mean age was 20.97 ±2.62, and more than half of the participants were in the 18-21 age group. 51.7% of the participants had fair knowledge. 44.3% had good knowledge, and only 4% had poor knowledge. 75.3% of the study samples had positive perceptions, and only 24.7% had negative perceptions, which revealed there is a significant association between the overall knowledge levels of study samples with socio-demographic characteristics of age (p -value = 0.032) and study year (p value = 0.04). conclusion: the findings of this study show that students had an adequate level of knowledge and positive perceptions regarding pcos and demonstrate a significant association between knowledge levels and both age and study year. in contrast, there is no significant association found between overall knowledge and marital status, residence, or department of study. keyword: polycystic ovarian syndrome; medical student; knowledge and perception. iman fadhil omar; department of midwifery, erbil medical technical institute, erbil polytechnic university, erbil, kurdistan region, iraq. (correspondence: iman.omer@epu.edu.iq ) gulala abubakr husein; department of nursing, college of nursing, raparin university, erbil, kurdistan region, iraq. zhyan hussein khdhir; department of nursing, college of nursing, raparin general directorate of health, ministry of health, erbil, kurdistan region, iraq. 112 received: 10/02/2025 accepted: 31/05/2025 published: 30/11/2025 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:.%20iman.omer@epu.edu.iq?subject=.%20iman.omer@epu.edu.iq mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.12 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article polycystic ovarian syndrome is a significant global health challenge and is classified as a multifaceted, heterogeneous endocrine disorder. it affects approximately 6–20% of women of reproductive age worldwide, representing a critical concern in public health [1]. this condition arises from an imbalance in female sex hormones, resulting in diverse clinical manifestations, including menstrual irregularities, ovarian cyst formation, infertility, and other systemic health complications. pcos is particularly prevalent among adolescents and young women, with an estimated prevalence of 5–10% among those in their reproductive years [2].the clinical presentation of pcos is highly variable, encompassing oligomenorrhea or amenorrhea, infertility, obesity, hirsutism, acne, acanthosis nigricans, and male-pattern alopecia. these features underscore its heterogeneity [3]. approximately 60% of individuals with pcos experience obesity and insulin resistance, while up to 40% develop diabetes by the age of 50. dyslipidemia is also a common comorbidity. cumulatively, these metabolic and endocrine abnormalities significantly elevate the risk of cardiovascular diseases, particularly among postmenopausal women with a history of pcos [4]. infertility is a notable complication, with anovulation attributed to pcos accounting for up to 73% of infertility cases. given its complexity, the accurate diagnosis and individualized management of pcos are imperative to mitigate its longterm health implications [5].the national health service (nhs) highlights that lifestyle interventions, particularly weight reduction, play a pivotal role in managing pcos. evidence suggests that even a modest weight loss of 5% can significantly improve symptomatology. pharmacological treatments, including progesterone-only or combined oral contraceptives, are frequently employed to restore menstrual regularity. furthermore, fertility challenges are addressed using agents such as clomiphene, letrozole, or metformin, often used off-label [6].cultural and societal barriers pose additional challenges to the effective management of pcos. in conservative societies, particularly in arab regions, discussions about reproductive health issues such as irregular menstruation, hirsutism, or low libido are often stigmatized. moreover, some traditional education systems exacerbate this knowledge gap by excluding comprehensive biology and anatomy education [7].existing literature on health-related knowledge, beliefs, and self-efficacy among women with pcos is limited and often contradictory. while some studies suggest that women with pcos exhibit distinct health perceptions compared to unaffected individuals, they consistently report poorer health outcomes and greater functional impairment [8].the increasing prevalence of polycystic ovarian syndrome is largely attributed to insufficient awareness and suboptimal lifestyle practices. addressing these gaps through early diagnosis, timely intervention, and comprehensive public education can significantly reduce the burden of pcos and its associated complications [9].female students in academic institutions represent a critical demographic for targeted polycystic ovarian syndrome education and awareness initiatives. as future mothers, their health literacy has the potential to shape the well-being of subsequent generations. ironically, many university students remain asymptomatic or unaware of their polycystic ovarian syndrome status until faced with reproductive challenges later in life. this highlights the need for focused research to evaluate their knowledge, attitudes, and perceptions 113 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. introduction https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.12 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article 15 questions about students’ knowledge of pcos. responses were evaluated as follows: correct = 1 and incorrect = 0. for items (1,2,3,4,5,6,7,9,14 and 15). for items (8,10,11,12 and 13) (which are vice versa): incorrect=1, correct=0 students’ responses to questions regarding poly cystic ovarian syndrome knowledge were divided into three categories and scored as follows: poor knowledge (1 to 5), fair knowledge (6 to 10), and good knowledge (11 to 15).the fourth part consisted of nine items evaluating the perceptions of the participants regarding polycystic ovarian syndrome. responses were ranked as follows: disagree = 1, neutral = 2, and agree =3. for items (1,2,3,4,5, and 10). for items (6,7,8 and 9) (which are vice versa): disagree =3, neutral=2 and agree=1. perceptions were divided into two categories and scored as follows: positive (20 to 30) and negative (10 to 19). the final part mentions the source of information from which the study samples obtained their information about polycystic ovarian syndrome, such as physicians, medical textbooks, magazines, television, etc. the content validity of the tools was evaluated by four experts from different specialties for instance (community health medicine, biostatistics, pediatrics of nursing and maternity nursing) across various universities in kurdistan. the experts assessed the tool for clarity of sentences, consistency, and content appropriateness, and no modifications were required. the reliability of the tools was also tested, with a cronbach's alpha of 0.75 for knowledge and 0.77 for perception. prior to data collection, formal permission was obtained from the ethical approval of the ethical committee at polytechnic university/erbil, erbil technical medical institute on 1st oct 2024. oral informed consent was obtained from the students before data collection, after the explanation of the purpose of the study, regarding polycystic ovarian syndrome. this study aimed to determine female students' knowledge and perception regarding polycystic ovarian syndrome who are studying at koya technical institute. a quantitative, descriptive cross-sectional study was conducted. the study was carried out at koya technical institute from october 1st, 2024, to december 25th, 2024, with convenience samples consisting of 393 of female students who were study in the departments such as nursing, midwifery, medical laboratory,and community health at koya technical institute. the study included the female institutional students who were willing to participate in the study; male and other departments were excluded from the study. the data were gathered through both an online link and a paper-based survey questionnaire. the survey was designed on an online platform and shared with students via social media such as viber ,whatsapp and messenger. additionally, hard copies were translated into the kurdish language and distributed to students during their free time (self-study hours) on campus by some of the researchers. a drop box was placed in the investigator’s office for collecting the completed forms. the survey was anonymous, and no personal information was collected. the online version was also shared with students through social media platforms. students were instructed to respond only once, either online or via the physical survey. the questionnaire consists of four parts. the first part included the socio-demographic characteristics of the study sample, such as age, residency, marital status, departments, and year of the study and the second part was related to reproductive information, such as regular menstrual cycles, intervals between each menstruation. the third part consisted of 114 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. methods https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.12 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article benefits, rights to privacy, and rights to withdraw at any time. the researchers have promised to keep the data information for confidentiality and anonymity. the data were analyzed using spss software for statistical analysis, version 27, to calculate descriptive statistical analysis (frequency and percentage). inferential statistical analysis (chi-square and fisher’s exact test) was used to determine the association between variables; the p-value ≤ 0.05 is considered statistically significant. table 1: in the present study, 393 participants took part, with a mean age of 20.97±2.62 years. more than half of the participants were in the 18-21 age group. the majority of the sample (86.5%) were single, and 41.2% of participants were enrolled in the midwifery department. over half (62.1%) were in the second stage of their studies. a significant portion (94.1%) of the students reported having no chronic diseases. table 2: regarding menstrual cycles, (65.5%) had regular cycles, while (34.5%) experienced irregular cycles. additionally, 57.0% of participants had menstrual intervals between 25-34 days, and 2.1% had a history of infertility. table 3 illustrates the students' knowledge of polycystic ovarian syndrome. according to the results, students demonstrated strong knowledge regarding the signs and symptoms, causes or diagnosis, and treatment of pcos. a majority of the participants (83.0%) were well-informed about pcos being diagnosed through ultrasound. additionally, four-fifths of the respondents (81.4%) recognized that an unusual amount of hair growth on different body parts is a symptom of pcos, and (80.4%) understood that obesity is a main cause of the condition. however, more than threefourths of participants (76.8%) were unaware that mood swings are a symptom of polycystic ovarian syndrome. table 4 presents the participants' perceptions of polycystic ovarian syndrome. the results show that students generally had a positive perception of the condition. more than two -thirds (66.5%) of students thought that polycystic ovarian syndrome can be managed through diet and exercise. additionally, (58.5%) of participants disagreed with the idea that polycystic ovarian syndrome is a permanent condition that cannot be cured. 55.7 % of the participants believed that polycystic ovarian syndrome patients require social support. moreover, (53.9%) of the respondents thought women who have polycystic ovarian syndrome can have children.while (36.4%) of students agreed that hirsutism caused by polycystic ovarian syndrome can lead to a decrease in social performance. 115 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. result table 1: socio-demographical data of the students regarding pcos n= 393 varibles f % -do you have regular menstrual cycle yes 257 (65.5) no 136 (34.5) -interval between menstruation (days) <25 d 90 (22.9) 25-34 d 224 (57.0) 35-60 d 52 (13.2) more than 60 d 27 (6.9) -having history of infertility yes 22 (2.1) no 28 (10.7) unmarried 343 (87.3) -if you are married are you using oral contraceptives yes 11 (2.8) no 39 (9.9) unmarried 343 (87.3) t total 393 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.12 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article 116 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 2: reproductive information of the students regarding pcos n= 393 variables subgroups f (%) age group 18-21 267 (67.9) 22-25 97 (24.7) 26-29 29 (7.4) marital status married 50 (12.7) single 340 (86.5) separated and divorced 3 (0.8) department nursing 144 (36.7) medical laboratory 63 (16.0) midwifery 162 (41.2) community health 24 (6.1) study year first stage 149 (37.9) second stage 244 (62.1) residence urban 190 (48.3) sub-urban 148 (37.7) rural 55 (14.0) having chronic disease yes 23 (5.9) -no 370 (94.1) table 3: knowledge of the study samples regarding pcos n=393 variables correct f. (%) incorrect f. (%) 1-in pcos there is an increased level of androgen hormone 227(57.8) 166(42.2) 2-cigarette smoking may cause pcos 154(64.6) 139(35.4) 3-obesity may cause pcos 316(80.4) 77(19.6) 4-insulin resistance (due to decrease insulin action in the body) may cause pcos 248(63.1) 145(36.9) 5-pcos may lead to anxiety and depression 326(83.0) 67(17.0) 6-unusual amount of hair growth on different body parts is a symptom of pcos 320(81.4) 73(18.6) 7-severe acne problems during the menstrual (periods) cycle are a symptom of pcos 263(66.9) 130(33.1) 8-mood swings is not a symptom of pcos(-) 302(76.8) 91(23.2) 9-pcos diagnosis can be confirmed by ultrasound 326(83.0 ) 67(17.0) 10-hair loss from the scalp more than normal is not a symptom of pcos(-) 238(60.4) 155(39.4) 11-specific blood tests cannot be used for diagnosis of pcos (-) 183(46.6) 210(53.4) 12-pcos is not lead to infertility (inability to have children) (-) 191(48.6) 202(51.4) 13-pcos is not curable(-) 140(35.6) 253(64.4) 14-anti-diabetic medications (metformin) may be used to treat pcos 227(57.8) 166(42.2) 15-weight loss is among the main treatment options for pcos 302(76.8) 91(23.2) (-) refers for negative statements https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.12 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article between marital status and overall knowledge of polycystic ovarian syndrome (p > 0.159). additionally, the findings revealed no significant relationship between medical departments, residence, and overall knowledge of polycystic ovarian syndrome, with p-values greater than 0.259 and 0.807, respectively. 117 table 5 presents the relationship between the age group of the study sample and their overall knowledge of poly cystic ovarian syndrome. the results indicate a significant relationship between the participants' age and academic year with their overall knowledge of polycystic ovarian syndrome (p-value = 0.032) and academic year (p-value = 0.04). however, no significant association was found copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. table 4:perception of the students regarding pcos n=393 variable agree f.(%) neutral f.(%) disagree f.(%) 1-pcos patients require social support. 219(55.7) 117(29.8) 57(14.5) 2pcos can be managed through diet and exercise. 261(66.5) 56(14.2) 76(19.3) 3-pcos patients have control over the disease . 218(55.5) 52(13.2) 123(31.3) 4-pcos patients need support and help from others. 224(57.0) 91(23.2) 78(19.8) 5-pcos patients can have children (women’s fertility). 212(53.9) 68(17.3) 113(28.8) 6-hirsutism due to pcos can decrease social performance(-) 143(36.4) 93(23.7) 157(39.9) 7-pcos patients have trouble associating with other people(-) 126(32.1) 114(29.0) 153(38.9) 8-pcos patients are depressed(-) 75(19.1) 69( 17.6) 249(63.3) 9-pcos is a permanent condition(-) 92(23.4) 7(18.1) 230(58.5) 10-pcos can be controlled. 182(46.3) 38(9.7) 173(44.0) (-) refers to negative statements table 5:the association of the overall knowledge of the study samples with some variables of sociodemographical data variables ----------------- age group poor knowledge ------------------- f.(%) fair knowledge --------------------- f.(%) good knowledge -------------------- f.(%) total --------------- f.(%) p-value ----------- 18-21 14(5.2) 135(50.6) 118 (44.2) 267(67.9) 22-25 1(1.0) 50(51.5) 46 (47.4) 97(24.7) 0.032 26-29 1(3.4) 18( 62.1) 10 (34.5) 29(7.4) marital status married 1(2.0) 26(52.0) 23(46.0) 50(12.7) 0.159 single 14(4.1) 176(51.8) 150(44.1) 340(86.5) separated and divorced 1(33.3) 1(33.3) 1(33.3) 3(0.8) study year first stage 14(5.7) 12(52.9) 10( 41.4) 244(62.1) 0.04 second stage 2(1.3) 74(49.7) 73(49.0) 149(37.9) department nursing 4(2.8) 73(50.7) 67(46.5) 144(36.6) medical laboratory 3(4.8) 38(60.3) 22(34.9) 63(16.1) 0.259 midwifery 9(5.6) 76( 46.9) 77(47.5) 162(41.2) community health 0(0.0) 16(66.7) 8(33.3) 24(6.1) residence urban 8(4.2) 92(48.4) 90(47.4) 190(48.3) sub-urban 6(4.1) 80(54.1) 62(41.9) 148(37.7) 0.807 rural 2(3.6) 31(56.4) 22(40.0) 55(14) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.12 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article had good knowledge, and only 4% had poor knowledge. regarding pcos, while (24.7%) had negative attitudes (57.8%) obtained information from television, (26.2%) from internet sources, (3.3%) from physicians, and (1.3%) from medical textbooks. figure 1 shows that 51.7% of all students had fair knowledge regarding polycystic ovarian syndrome, while 44.3% figure 2 indicates that (75.3%) of the study samples had positive perceptions figure 3: the figure demonstrates the respondents' sources for gaining and developing their knowledge regarding pcos. more than half of the study participants 118 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. figure 1: illustrates overall knowledge of study samples regarding pcos n=393. figure 2: illustrates overall perception of study samples regarding pcos n=393. figure 3: illustrates medical students, source of information regarding pcos. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.12 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article between (25 to 34) days. this finding is consistent with a study conducted in jordan, where more than one-third of the participants also had menstrual intervals within the (25 to 34) day range. [18].assessing the knowledge of students regarding polycystic ovarian syndrome adequate knowledge about polycystic ovarian syndrome is essential for students to develop a deeper understanding of polycystic ovarian syndrome and its complications. a recent study revealed that more than three-fourths (83.0%) of participants were aware that polycystic ovarian syndrome can be diagnosed via ultrasound. additionally, (83%) of students believed that polycystic ovarian syndrome could lead to anxiety and depression. a similar finding was reported by abu-taha m in a related study [19]. in a recent study, (81.4%) of participants were aware that one of the symptoms of polycystic ovarian syndrome is an unusual amount of hair growth on different body parts. a similar study reported the same finding. [18].in the current study, 80.4% of respondents recognized obesity as one of the main causes of pcos. this finding is comparable to a study conducted by noman ul haq in pakistan, where the majority of female students (87.1%) also identified obesity as a primary cause of polycystic ovarian syndrome. additionally, our results show that more than half of the participants (57.8%) obtained information about pcos through television, followed by internet sources (26.2%). in contrast, a cross-sectional study conducted at nepal medical college among final-year medical students found that most students had good knowledge of polycystic ovarian syndrome, with (76.5%) acquiring information from friends, (26%) from mass media, and only (9.5%) from healthcare professionals. this study emphasized that knowledge-sharing among medical students plays a crucial role in the socio-demographic characteristics of students regarding polycystic ovarian syndrome polycystic ovarian syndrome (pcos) is a complex and chronic endocrine disorder commonly diagnosed in women of reproductive age. it is associated with an increased risk of a range of complications, including hematologic, oncologic, metabolic, reproductive, and psychological issues. in 1935, stein and his colleagues were the first to identify a cluster of symptoms related to anovulation. they studied seven patients who experienced amenorrhea, excessive hair growth (hirsutism), and enlarged polycystic ovaries. their findings revealed that all seven patients resumed menstruation, and two were able to conceive after undergoing bilateral wedge resection of the ovaries [10]. this study aimed to gain a better understanding of students' knowledge and perceptions regarding polycystic ovarian syndrome. given that many women in our community are currently affected by polycystic ovarian syndrome, it is essential to assess how knowledgeable our students are about the condition, as they could play a key role in guiding the community and helping women manage it. our study revealed that more than half of the participants were between the ages of 18 and 21, the mean age of those studied being (±20.97). this aligns with a cross-sectional study conducted in the department of obstetrics and gynecology at a tertiary care center in southern india. the study involved 88 students aged between 18 and 22 years, with an average age of (21.4) years [11]. in our study, it was revealed that more than three-fourths of the participants were single (86.5%), which aligns with the findings of a similar study [11]. in the present study, more than half of the respondents reported having regular menstrual cycles, with intervals ranging 119 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.12 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article and related infertility among female students at isabella thoburn college in lucknow. their study reported that nearly half of the female students held a negative attitude toward polycystic ovarian syndrome [21].association between overall knowledge and some demographic characteristics: the knowledge scores among participants varied widely, and we identified a significant inverse association between age and overall knowledge among medical students (p-value = 0.032). this finding is consistent with a study conducted in pakistan by mehwish rizvi et al., which examined 646 undergraduate students and also reported a significant association between overall knowledge and age group. in our study, no significant association was found between marital status and overall knowledge. however, this contrasts with a descriptive study conducted at obstetric and gynaecological outpatient clinics in a health insurance hospital in minya governorate, which included 100 female participants. that study reported a significant association between overall knowledge and marital status (p-value = 0.02) [ 16].additionally, our study found a significant association between students' overall knowledge of polycystic ovarian syndrome and their year of study (p-value = 0.04). this finding aligns with a study conducted at south valley university, egypt, involving 260 female students, which reported similar studies [15].on other other hand another study conducted in egypt by redam et al., knowledge and attitude of late adolescent girls, regarding to polycystic ovarian syndrome, among 239 adolescent girls the result of the study indicated there was a significant association between overall knowledge and academic year the value of (p=0.008)[22].our recent study found no significant association between overall knowledge and residence or academic departments of medical students raising awareness [14].our study demonstrated that medical students had a fair overall knowledge of polycystic ovarian syndrome, with (57.7%) falling into this category. additionally, (44.3%) had good knowledge, while only (4%) of respondents exhibited poor knowledge. this may be attributed to the majority of participants showing an interest in receiving information about pcos. these findings are consistent with a study conducted in malaysia by hussin, s., & abd kadir, n. (2020), which found that most younger students had adequate knowledge, along with a positive perception and attitude toward polycystic ovarian syndrome [12]. on the other hand, another study conducted among adolescent girls used descriptive and inferential statistics to analyse the collected data. the results of the study revealed that before the intervention, only 22 adolescent girls (23.9%) had good knowledge of polycystic ovarian syndrome, 46 (50%) had average knowledge, and 24 (26.1%) had poor knowledge [21].assessment of perception of the participants regarding pcosour study revealed that more than half of the participants (55.7%) believed that patients with polycystic ovarian syndrome (pcos) require social support. additionally, twothirds (66.5%) of the participants assumed that pcos could be managed through diet and exercise. these findings align with those of a similar study [20].the current study showed (75.3%) of the study samples have a positive perception toward polycystic ovarian syndrome and only (24.7%) had a negative perception. this perception might be related to medical students living with that situation and a lot of women suffering with polycystic ovarian syndrome. on the contrary, this finding does not align with the research conducted by chauhan et al. (2021), who assessed the effectiveness of a structured teaching program on knowledge of polycystic ovarian syndrome 120 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.12 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article improved long-term health outcomes for women at risk of polycystic ovarian syndrome. in addition, a multidisciplinary approach that combines physiotherapy and psychological support is essential for enhancing health outcomes in women with pcos. none of the writers have any conflicts of interest or sources of financial support. [1] mohamed ra, taref nn, osman ne, keshta nha, alboghdady ma, marzouk mm, et al. effect of web-based health education on nursing students’ knowledge, adaptive healthy measures and attitudes regarding polycystic ovary syndrome: a randomized controlled trial. jornal of biomed cental nursing. 2024 jul 15;23(1):479. https:// doi.org/10.1186/s12912-024-02015-7 [2] b. s, nayak s. a study to assess the knowledge regarding pcos (polycystic ovarian syndrome) among nursing students at nuins. journal of health and allied sciences nu. 2016 sep;06(03):24–6. doi: 10.1055/s-0040-1708657 [3] haq n, khan z, riaz s, nasim a, shahwani r, tahir m. prevalence and knowledge of polycystic ovary syndrome (pcos) among female science students of different public universities of quetta, pakistan. imperial journal of interdisciplinary research. 2017;35(6):385–92. issn: 2454-1362, http://www.onlinejournal.in [4] mcgowan mp. polycystic ovary syndrome: a common endocrine disorder and risk factor for vascular disease. curr treat options cardio med. 2011 aug 1;13(4):289– 301. curr treat options cardio med 13, 289 –301 (2011). https://doi.org/10.1007/ s11936-011-0130-0 [5] stańczak na, grywalska e, dudzińska e. the latest reports and treatment methods on polycystic ovary syndrome. annals of medicine. 2024 dec 31;56(1):2357737. https:// doi.org/10.1080/07853890.2024.2357737 (p-value = 0.807 and 0.259). these findings are consistent with a study conducted among 192 medical students at a medical college. that study used a convenient sampling method and a pretested semistructured questionnaire to assess knowledge and awareness of polycystic ovarian syndrome [17]. in contrast, a study was carried out at the technical institute of nursing at benha university to evaluate the knowledge and attitudes of late adolescent girls towards polycystic ovarian syndrome. a purposive sample of 239 adolescent girls was used. the results indicated a highly significant correlation between overall knowledge and the area of residence (pvalue = 0.001) [23]. the findings of this study indicate that students possess a satisfactory level of knowledge and hold positive perceptions about pcos. television and the internet were identified as their primary sources of information, highlighting the necessity for greater involvement from healthcare professionals in educating young individuals. additionally, the study revealed a significant correlation between knowledge levels and both age and year of study. however, no notable association was found between overall knowledge and factors such as marital status, place of residence, or academic department. these findings underscore the importance of early detection and management of polycystic ovarian syndrome, emphasizing the need for targeted educational programs, particularly within academic institutions. future research should explore the effectiveness of structured awareness programs in enhancing students’ knowledge retention and preventive behaviours. bridging knowledge gaps, especially among healthcare professionals, could foster awareness and contribute to 121 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. conclusion conflict of interest references https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.12 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article [14] adhikari p, bhattarai j. knowledge, attitude and practice regarding polycystic ovarian syndrome (pcos) among final year medical students and interns in a medical college in kathmandu nepal. journal of diabetes and endocrinology association of nepal. 2023 aug 10;7(1):4-12. [15] maghraby ea, ahmed nt, ahmed aa, hassan mm. assessment of female nursing student's knowledge regarding polycystic ovarian syndrome at south valley university. assiut scientific nursing journal. 2022 nov 1;10 (33):170-7. [16] ali el. awareness of females regarding polycystic ovarian syndrome at outpatient clinics in minya health insurance hospital. helwan international journal for nursing research and practice. 2024 sep 1;3(7):16275. [17] aripin a, jaber rm, allias n, omar s, kamal nr, dwekat o. knowledge and attitudes towards polycystic ovary syndrome. african journal of reproductive health. 2022 apr 24;26(1):92-102. [18] abu‐taha m, daghash a, daghash r, abu farha r. evaluation of women knowledge and perception about polycystic ovary syndrome and its management in jordan: a survey‐based study. international journal of clinical practice. 2020 oct;74(10):e1355. [19] chemerinski a, cooney l, shah d, butts s, gibson-helm m, dokras a. knowledge of pcos in physicians-in-training: identifying gaps and educational opportunities. journal gynecological endocrinology. 2020 oct 2;36 (10):854-9. [20] upadhye jj, shembekar ca. awareness of pcos (polycystic ovarian syndrome) in adolescent and young girls. international journal reprod contracept obstet gynecol. 2017 jun 1;6(6):2297-301. [21] [21] srujana c, vasundhara r, miryani j. a study to assess the knowledge of nursing college students regarding polycystic ovarian syndrome in selected college at guntur district, andhra pradesh. international journal of advances in nursing management. 2018;6 (3):210-4. [22] papi g, haobijam j, devi lk. a study to assess the effectiveness of information booklet on knowledge regarding polycystic ovarian syndrome (pcos) among adolescent girls in selected higher secondary schools of east khasi hills, meghalaya. international journal of obstetrics and gynaecological nursing [6] rizvi m, islam mda, aftab mt, naqvi aa, jahangir a, ishaqui aa, et al. knowledge, attitude, and perceptions about polycystic ovarian syndrome, and its determinants among pakistani undergraduate students. journal plos one. 2023 may 25;18 (5):e0285284. https://doi.org/10.1371/ journal.pone.0318390. [7] pramodh s. exploration of lifestyle choices, reproductive health knowledge, and polycystic ovary syndrome (pcos) awareness among female emirati university students. international journal of women's health. 2020 oct 28:927-38 doi https:// doi.org/10.2147/ijwh.s272867. [8] lin aw, dollahite js, sobal j, lujan me. health-related knowledge, beliefs and selfefficacy in women with polycystic ovary syndrome. journal human reproduction. 2018 jan 1;33(1):91–100. https:// doi.org/10.1093/humrep/dex351 [9] sasikala r, shanmugham d, varghese j, saravanan d. a study of knowledge and awareness on polycystic ovarian syndrome among nursing students in a tertiary centre in south india. the new indian journal of obgyn. 2021;8(1):121–5. doi 10.21276/ obgyn.2021.8.1.23 [10] thabet h, alsharif f, garoot l, yousef m, almutairi l, kutbi r. the level of awareness of nursing students regarding polycystic ovarian syndrome in king abdulaziz university. assiut scientific nursing journal . 2021;9(26):172-181.doi:10.21608/ asnj.2022.99698.1242 [11] sasikala r, shanmugham d, varghese j, saravanan d. a study of knowledge and awareness on polycystic ovarian syndrome among nursing students in a tertiary centre in south india. the new indian journal of obgyn. 2021;8(1): 121–5. doi 10.21276/ obgyn.2021.8.1.23. [12] hussin sn, abd kadir nh. a study on knowledge, attitude and perception of polycystic ovary syndrome (pcos) among young students in higher educational institutions, perak. journal of social science advanced research. 2020 dec 29;1(2):160-81. [13] rizvi m, islam ma, aftab mt, naqvi aa, jahangir a, ishaqui aa, iqbal mz, iqbal ms. knowledge, attitude, and perceptions about polycystic ovarian syndrome, and its determinants among pakistani undergraduate students. journal plos one. 2023 may 25;18 (5):e0285284. 122 copyright ©2025 the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2025.12 erbil j. nurs. midwifery, vol. 8, no. (2), nov 2025 original article 123 copyright ©2025the author(s). this is an open access article which licensed under the terms and conditions of the creative commons attribution-noncommercial-sharealike 4.0 international license. it permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. 2024; 6(2): 123-129doi: https:// doi.org/10.33545/26642298.2024.v6.i2b.170 [23] mohamed reda a, ahmed hassan a, abdalla el sayed h, mohammed salama a. knowledge and attitude of late adolescent girls regarding polycystic ovarian syndrome. journal of nursing science benha university. 2022 jan 1;3(1):889-906.doi: 10.21608/ jnsbu.2022.215660. https://creativecommons.org/licenses/by-nc-sa/4.0/