فهرست مطالب

  • Volume:13 Issue: 1, 2019
  • تاریخ انتشار: 1398/01/21
  • تعداد عناوین: 17
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  • Hossein Sepahvand, Mina Mokhtari Hashtjini, Mahmood Salesi, Hedayat Sahraei, Gila Pirzad Jahromi * Page 1

      Context: Post-traumatic stress disorder (PTSD) is a chronic psychiatric disorder that occurs as a result of an accident or life-threatening event. The purpose of our study was to examine the prevalence of PTSD in the Iranian population from 2000 to 2015 through a meta-analysis of the published studies to review the epidemiologic evidence of PTSD after disasters and wars and to examine PTSD determinants. Evidence Acquisition: The electronic databases including PubMed, Embase, Web of Science, Magiran, etc. were explored to find related papers. Two authors independently reviewed and extracted data via an extraction sheet, and disagreements were resolved by holding a meeting with a third author. Meta-analysis was performed using “metaprop” command in STATA 11 software. Studies with < 25 participants were excluded from our analysis.

    Results

    Ultimately, 47 studies were included in this meta-analysis. Primary PTSD was investigated in 44 studies and secondary PTSD in six studies. Forty studies investigated natural PTSD and five studies technical PTSD. PTSD related to childbirth, job, earthquake, war, burn, accident, and rape events were investigated in seven, six, nine, nine, two, two, and two studies, respectively, and their pooled prevalence were 25%, 30%, 58%, 47%, 40%, 11%, and 74%, respectively.

    Conclusion

    The results revealed that the burden of PTSD among the Iranian population exposed to wars and disasters is high. PTSD was correlated with a range of factors including demographic and background factors and characteristics of the event exposure.

    Keywords: Disasters, Iran, Post-traumatic Stress Disorder, Prevalence, War
  • Hamid Mohsenabadi, Mohammad Javad Shabani, Zahra Zanjani * Page 2
     
    Background
    In recent years, application and practice of mindfulness-based interventions to reduce adolescent psychological problems are increasing. Therefore, it is necessary to design and study tools that measure mindfulness and its effects.
    Objectives
    One of the available tools to measure mindfulness in adolescents is the mindfulness attention awareness scale for adolescents (MAAS-A). The current study aimed at examining the factor structure and reliability of a Persian version of this scale and investigating the relationship between mindfulness and anxiety.
    Methods
    The current descriptive, cross sectional and psychometric study was conducted on 354 students from Kashan city, Iran, selected via the cluster sampling method in 2017. The exploratory factor analysis (EFA) by the principle component analysis method, the confirmatory factor analysis (CFA), and the relationship between mindfulness and anxiety were conducted to examine the validity of the MAAS-A. To calculate the reliability of the MAAS-A, Cronbach’s alpha and test-retest reliability (four-week interval) were employed. The statistical analysis was performed with SPSS version 19.0 and AMOS-22.
    Results
    The results of the EFA suggested two factors for this scale labeled as “acting with attention and awareness” and “attention to the present moment”. The CFA confirmed the two-factor model of the 14-item scale (the root mean square error of approximation (RMSEA) 90% confidence interval (CI) = 0.001 - 0.06). The reliability of this scale was good (α = 0.81, retest reliability = 0.86) and the correlation between mindfulness and anxiety was negative and significant (r = -0.43, P < 0.01). Also, this relationship was significant in females (r = -0.44, P < 0.01) and males (r = -0.46, P < 0.01).
    Conclusions
    According to the results of the current study, the MAAS-A was a reliable and valuable scale to measure the mindfulness of adolescents. The results of correlation between mindfulness and anxiety meant that by increasing mindfulness, the anxiety reduced in adolescents.
    Keywords: Adolescent, Anxiety, Factor Structure, MAAS-A, Mindfulness, Validity
  • Sobhan Rezaee, Sara Esmizadeh, Abbas Deilamizade, Alireza Noroozi, Hamed Ekhtiari * Page 3
     
    Background
    Drug addiction treatment (DAT) is a dynamic market influenced by customers’ requests and regulating policies. With about 6000 active clinics nationwide, there is insufficient data regarding the trend of DAT market in Iran. However, these treatment centers advertise their services in daily newspapers providing an indirect manner for their market analysis.
    Objectives
    The current study was the second phase of the authors’ longitudinal study on evaluating DAT network in Tehran. The current study was designed to provide an outline of treatment services, along with communicative and economic aspects of these centers through tracking their advertisements in newspapers.
    Methods
    A trend study was conducted in two time points, May 2009 and November 2012, and reviewed all relevant advertisements in the daily newspapers in a one-month period, in Tehran. After content analysis of the advertisements, the data collection was finalized with telephone-structured interviews.
    Results
    In 2009, sixty-six clinics advertised for their services, using 383 codes to introduce their centers (43%) and treatment menus (57%). Three years later, in 2012, ninety-nine clinics advertised their services a 33% increase. They used 923 codes (140% growth) to introduce their centers (64%) and advertise treatment menus (36%). Regarding their treatment menus, there was a wide range of treatment choices, including common and broad categories of care center (i.e., outpatient and inpatient), and treatment modalities (detoxification to maintenance with methadone, buprenorphine, and naltrexone). Based on the results, methadone maintenance therapy (MMT) remains as the most popular treatment in Tehran offered by 85% of the centers. On average, it costs 1,185,270 Rials (US$37.03) per month, a 16% increase in three years. In 2009, there was no code regarding methamphetamine in the ads, but in 2012, about 43% of centers included the related code in their ads, reflecting the market response to rapidly growing methamphetamine addiction in Iran.
    Conclusions
    Longitudinal trend analysis of DAT market using newspaper advertisements, as an indirect, but rapid and feasible method, provides a dynamic picture of drug treatment network. It showed that opioid maintenance therapy still continues its services in the market, and treatment services likewise grow in response to methamphetamine crisis in Iran.
    Keywords: Advertisements, Drug Use Disorders, Treatment, Interrupted Time Series Analysis, Methamphetamine, Methadone, Iran
  • Nader Jafari Balalami*, Alireza Khalilian, Mana Par, Tahereh Zargarnataj Page 4
     
    Background
    In terms of family psychological health, emotional intelligence (EQ) and marital adjustment are issues, which should not be overlooked. However, a few studies have been conducted to experiment and evaluate the impact of EQ skill-based training on couples’ marital adjustment.
    Objectives
    The aim of this pilot study was to assess the effect of EQ components on marital adjustment among university students.
    Methods
    The study utilized a quasi-experimental design with married couples (N = 60) from Mazandaran University aged 22 to 29 years old. The experimental group (30 married couples) participated in a training course on emotional intelligence skills and the other 30 couples did not do so. Measures of emotional intelligence and marital adjustment were completed by the participants. Pre and post training tests, Bar-On emotional intelligence test, and Har Mohan-Singh marital adjustment questionnaire were completed by both groups. The Paired t-test was used in order to evaluate the effectiveness of the training course.
    Results
    Participants’ data showed that the training course had an impact on EQ as well as marital adjustment. Data analysis showed that conducting the training course had significant impact on the experimental group (P < 0.001). Analysis of the data approved that training had an impact on the students’ marital adjustment in the experimental group (P < 0.001).
    Conclusions
    Considering the significant positive relationship between EQ and marital adjustment, the EQ competencies can be utilized as a fundamental and effective component in improving and reinforcing satisfactory marital relationships. Therefore, interpersonal relationship and marital relationship between each couple can be improved through an emotional intelligence skill–based training course.
    Keywords: Emotional Intelligence, Marital, Adjustment, Students, Iran
  • Saeed Dehnavi *, Ali Zadeh Mohammadi, Marjan HassaniRaad Page 5
     
    Background
    Multiple sclerosis (MS) is one of the most common chronic and progressive central nervous system ailments that is considered as a disabling and traumatizing disease.
    Objectives
    The goal of the present study was to investigate the effectiveness of psychodrama based on unity-oriented approach on the sense of coherence of MS patients.
    Methods
    This was a quasi-experimental research, which included pre-test, post-test, and follow-up design with a control group. Using a convenience sampling method, 20 individuals were selected from among females with MS who had visited the Iranian MS Society. The subjects were randomly placed into two experiment and control groups. The experiment group participated in a 12 session unity-focused psychodrama therapy plan for six weeks, whereas the control group received no intervention. For data collection, the Flensborg-Madsen’s Sense of Coherence Questionnaire was used. The data was analyzed using ANOVA with repeated measures.
    Results
    The results revealed that there is a significant difference between two groups’ sense of coherence scores in post-test and follow-up stages (P < 0.05).
    Conclusions
    As seen in the findings, the unity-oriented psychodrama can be used as an effective treatment to enhance the sense of coherence among MS patients. Unity-oriented approach helps the patients integrate with the universe and define their bitter experiences. It also facilitates better patient acceptance through understanding a sense of connectivity to the coherent world and offers a sense of immorality to the MS patients.
    Keywords: MS, Multiple Sclerosis, Psychodrama, Sense of Coherence, Unity-Oriented
  • Seyde Shahrbanoo Daniali, Firoozeh Mostafavi Darani, Elahe Tavassoli, Atefe Afshari, Farideh Forouzande, Ahmad Ali Eslami * Page 6
     
    Background
    Co-morbid depression in patients with chronic disease is associated with weak self-care and high complications.
    Objective
    The study aimed to determine the relationship of self-care behaviors and the kind of chronic disease with depression in adults with chronic disease in Isfahan, Iran.
    Methods
    This cross-sectional study was conducted in government healthcare centers. A total of 483 eligible consent respondents participated from March 2015 to June 2015. The “Stanford self-management questionnaire” and the patient health questionnaire (PHQ-9) were used for the assessment of self-management behaviors and depression. Data were analyzed using the SPSS 17 software.
    Results
    The prevalence of depression in participants was 14.7%. There was a significant relationship between self-management behaviors such as physical activity (P < 0.05) and medication adherence (P < 0.001), and depression. The risk of depression was greater in rheumatoid arthritis disease patients (OR = 4.41, 95% CI (0.47 - 5.38), P > 0.001) and skeletal disease patients (OR = 1.70, 95% CI (1.03 - 2.77), P < 0.05) than in other chronic disease patients.
    Conclusions
    We found a negative association between depression and self-care activities in Iranian patients with chronic diseases. Psychological treatment for depression should be considered to improve the prognosis of chronic diseases.
    Keywords: Depression, Chronic Disease, Medication Adherence, Exercise, Nutritional Status, Self-Management
  • Parisa Samadi, Raziyeh Maasoumi, Mehrdad Salehi, Mohammad Arash Ramezani, Shahnaz Kohan * Page 7
     
    Background
    Sexual desire has biological, individual, interpersonal, and social dimensions. The question raised here is whether being a woman or a man influences sexual desire or whether gender differences contribute to it.
    Objectives
    This study aimed at exploring married women’s and men’s experiences regarding the concept of sexual desire.
    Methods
    This study conducted by a qualitative design and with a thematic analysis method. Data were collected using semi structured-interviews (with an equal number of men and women) chosen through a purposeful sampling method. After being conducted, each interview was transcribed verbatim and read several times to achieve the sense of the whole and then, the key terms were highlighted as codes. After the initial classification of the codes, subthemes and main themes gradually appeared.
    Results
    Two main themes were developed as follows: “feeling of arousal with the goal of achieving orgasm” and “individual conditions and relational skills strengthening sexual desire.”
    Conclusions
    Participants considered physical, psychological, and interpersonal dimensions of sexual desire. They mostly intended sexual intercourse and orgasm during the feeling of sexual desire. The skills of couples to interact with each other and physical and psychological readiness for an individual to have sexual relationships strengthened sexual desire. Any evaluation and treatment in the field of sexual desire should be comprehensive and consider all contextual, individual, and interpersonal aspects of each society.
    Keywords: Hypoactive Sexual Desire Disorder, Iran, Qualitative Research
  • Alireza Azimpour, * Zohreh Derakhshan, Susan Ghanbari Page 8
     
    Background
    According to the criteria of personality disorders, some disorders, especially the antisocial personality disorder, can be characterized by the hypo-morality and some disorders, especially the obsessive-compulsive personality disorder, can be characterized by the hyper-morality. It seems that both the hyper-morality and the hypo-morality have linkages to different aspects of psychopathology.
    Objectives
    To better understand the issue, the current study aimed to compare individuals with high and low moral identity in the tendencies to all personality disorders and some other mental disorders.
    Methods
    From a database that had been gathered from 212 undergraduate university students, 30 students that had the highest moral identity and 24 students that had the lowest moral identity were selected to complete Millon clinical multiaxial inventory-III. The data of the two groups were compared by the multiple analysis of variance statistical method.
    Results
    The findings indicated that students with the highest moral identity had only higher tendency to the obsessive-compulsive personality disorder while students with the lowest moral identity had higher tendencies to the antisocial personality disorder, narcissistic personality disorders, and somatoform disorders. Nevertheless, in the tendencies to other disorders, a significant difference was not found.
    Conclusions
    The findings indicated that both very low and very high moral identity might be related to some psychopathological traits. It is in coordination with the emphasis of some philosophers such as Aristotle on the importance of sobriety or the doctrine of the mean for constituting the virtues and the theories of some psychiatrists such as Freud about the role of inflammation of superego in shaping some neurotic reactions. There may be some implications for preventing from both wastage and extremism in educating the moral identity.
    Keywords: Antisocial Personality Disorder, Mental Disorders, Moral Identity, Obsessive-Compulsive Personality Disorder, Personality Disorders
  • Elham Ebrahimi, Afsane Farouee Firoozi * Page 9
     
    Background
    Children are first educated in their families. Parents by adapting different parenting styles consciously and in most cases unconsciously teach their children important educational doctrines.
    Objectives
    This study aimed to determine the impacts of parenting style and perceived childhood attachment on children’s concept of God. In this descriptive correlational study, 375 students of Islamic Azad university of Birjand were selected via multi-stage sampling.
    Materials and Methods
    The subjects completed the questionnaires related to parenting style, perceived parental attachment, and concept of God. The obtained model was a good fit for the data, and the psychological pattern revealed that controlling parenting style (insecure mother-child attachment) promotes dependence on God and encourages the perception of God as a controller. Also, supportive parenting via forming parent-child attachments (insecure father-child attachment) could predict the child’s view of God as a controller.
    Results
    Good parenting style was not directly correlated with the perception of God; however, it could improve one’s positive perception of God through increasing or decreasing attachment to parents. In addition, poor and rejecting parenting style both directly and indirectly affects the concept of God by increasing children’s mistrust toward parents and decreasing dependence on God.
    Conclusions
    Uncaring, rejecting parenting style is more remarkable in decreasing positive attitudes toward God, compared to authoritative parenting style.
    Keywords: Parenting Style, Perceived Attachment to Parents, Perception of God
  • Hadis Yousefi, Mohammad Ghaderi Rammazi *, Abbas Abolghasemi, Kouros Divsalar Page 10
     
    Background
    Today, opioid use is recognized as a global concern, threatening people’s physical and mental health.
    Objectives
    This study was conducted to investigate the effects of self-control training on emotional wellbeing and opioid craving among men with opioid use disorder.
    Methods
    In this quasi experimental study, the sample included all men with opioid use disorder, who were admitted to drug treatment centers of district 6, Tehran, Iran during year 2015. Fifty subjects were initially selected, matched, and randomly assigned to experimental and control groups (25 cases per group). After a diagnostic interview, the subjects were asked to complete the pretests, including the cognitive emotion regulation questionnaire (CERQ), facial expression recognition test (FERT), emotional processing scale (EPS), toronto alexithymia scale (TAS), and craving beliefs questionnaire (CBQ). The experimental group participated in 10 weekly sessions of self-control training. A week after the intervention, both groups were tested using the same instruments. For data analysis, multiple analysis of variance (MANOVA) test was applied in SPSS version 18.
    Results
    Self-control training caused a significant increase in positive emotion regulation (P < 0.001), emotion recognition (P = 0.002), and emotion processing (P < 0.001), while reducing negative emotion regulation (P = 0.002), alexithymia (P < 0.001), and opioid craving in men with opioid use disorder (P < 0.001).
    Conclusions
    Self-control training exerts a significant effect on the improvement of emotional wellbeing in men with opioid use disorder and reduces their opioid craving.
    Keywords: Craving, Emotional Wellbeing, Iran, Opioid Use Disorder, Self-Control
  • Maryam Sadighpour, Abbas Ramezani Farani *, Banafsheh Gharraee, Mozhgan Lotfi Page 11
     
    Background
    The aim of the current study was to propose a model for body dissatisfaction, body comparison and internalization of appearance-related ideals as mediators of self-esteem, multidimensional perfectionism, perception of teasing, and perceived sociocultural pressures of body dysmorphic disorder symptoms.
    Methods
    This was a correlational study performed via structural equation modeling. The statistical population of the study consisted of 802 university students who were chosen via the multilevel cluster sampling method. The data collection tools included Yale-Brown obsessive-compulsive scale modified for body dysmorphic disorder, multidimensional body-self relations questionnaire, and Rosenberg self-esteem, multidimensional perfectionism, sociocultural attitudes towards appearance, body comparison, perception of teasing and perceived sociocultural pressure scales. For data analysis, structural equation modeling was used via Lisrel 8.5 software.
    Results
    Although the initial model was a poor fit to the data, the fit was improved after some modifications were made. There were some differences between the male and female models, but body dissatisfaction maintained a mediator role with respect to self-esteem and perceived sociocultural pressures of body dysmorphic disorder symptoms in both genders.
    Conclusions
    Findings of the current study proposed a comprehensive model regarding understanding of the structural interactions of various psychosocial factors of body dysmorphic disorder symptoms. Comprehending dynamics of the aforementioned factors is essential both in interventional and prophylactic approaches.
    Keywords: Body Dysmorphic Disorder, Body Image, Perfectionism, Self-Concept, Structural Equation Modeling
  • Shahrzad Mazhari *, Mahin Eslami Shahrbabaki, Ali Mohammad Pourrahimi, Hoda Faezi, Mohammad Reza Baneshi Page 12
     
    Background
    Reading habits are believed to have an important role in the association between number and space; however, the effect of the spatial numerical association of response codes (SNARC) as a casual involvement has not been fully documented.
    Objectives
    This study aimed to determine the SNARC effect in individuals with mixed-reading Persian language in which the text is read from right to left but the numbers are read from left to right. Moreover, because of the critical role of visuospatial attention in SNARC effect, which is impaired in patients with schizophrenia, the SNARC effect was also examined in a group of patients with schizophrenia.
    Methods
    Using number comparison tasks and parity judgment tasks, the SNARC effect was first examined in a group of Persian speaking university students and then in a group of Persian speaking schizophrenic patients.
    Results
    The results showed the standard SNARC effect in students with the mixed-reading habit. Moreover, the results revealed a comparable SNARC effect in schizophrenia patients and controls.
    Conclusions
    Our results suggested that the direction of reading of numbers might influence the relationship between numbers and space, not the direction of text reading. Also, the semantic representation of numbers is preserved in patients with schizophrenia.
    Keywords: Reading Direction, Schizophrenia, SNARC
  • Habibolah Khazaie, Ali Zakiei *, Mohsen Rezaei, Seyed Mehdi Hoseini, Mostafa Alikhani Page 13
     
    Background
    The role of emotion in the quality of sleep is very important.
    Objectives
    The present study aimed to investigate the mediating roles of repetitive negative thoughts in the relationship between sleep quality and each of emotional dysregulation and experiential avoidance.
    Methods
    This study was a cross-sectional study with random sampling method, which two groups of samples were selected (clinical sample and non-clinical sample, n1 = 120 and n2 = 200 people, respectively). Then after data collection, two models were designed and examined using the AMOS-2 software, path analysis, and structural equation modeling.
    Results
    The results of the present study revealed that in both samples, the standard coefficient of the experiential avoidance path to sleep quality was not significant through the repetitive negative thoughts, while the emotional deregulation path to sleep quality was significant through repetitive thoughts (β = 0.55, P < 0.001).
    Conclusions
    According to the results of the present study, it can be concluded that emotional dysregulation leads to reduced sleep quality when the level of repetitive negative thoughts is high.
    Keywords: Insomnia_Sleep Quality_EmotionsCopyright © 2019_Author(s). This is an open-access article
  • Steven A Koehler_Kazem Mohammad_Kourosh Holakouie_Naieni *_Roya Karimi_Yahia Zare Mehrjerdi_Jalal Karimi Page 14
     
    Background
    The use/abuse of drugs, both legally and illegally, is a worldwide public health problem, and has serious impacts on the individual, family, society, and crimes. In order to assess the scope of the drug use/abuse issue, it is critical, first, to determine the number of individuals using/abusing drugs, the epidemiological/demographic features of the using/abusing population, and the type of drugs used/abused. Currently, data on the prevalence and incidence of substance abuse in Iran cannot be directly obtained. We propose the next phase of determining the prevalence and incidence of drug abuse by introducing system thinking and system dynamics modeling to estimate the number of addicts, recreational drug users, and drug-related deaths.
    Objectives
    In this study, we evaluated a dynamical system approach to model drug-related deaths in the next 10 years in Isfahan province.
    Methods
    We proposed a general model for drug abuse that can easily be specified to study the dynamics of drug-related deaths.
    Results
    Based on the estimated parameters, we calculated the total population of Isfahan province, the future susceptible population of drug users/abusers, recreational users, and addicts, and the growth rates and death rates for the latter three groups for the years 2013 - 2023. These estimations were based on an epidemiological mathematical model to predict the proportions of drug abusers over the next ten years in Isfahan. As expected, this model shows an increase of about 10 folds in deaths related to drug abuse in addicts by 2023 and a 14% increase in the addict population in Isfahan province.
    Conclusions
    The dynamical system approach is suitable to address the dynamic complexity of many public health issues. It has the potential to integrate our awareness about multilevel causes of health and their template of action, reaction, and feedback, and to promote our knowledge about how policy interventions affect the health of communities and populations.
    Keywords: Dynamical System Approach, Drug Abuse, Epidemiology, Iran
  • Behnaz Enjezab, Mina Zarehosseinabadi *, Banafsheh Farzinrad, Ali Dehghani Page 15
     
    Background
    Menopause is a physiological alteration affecting women's quality of life. Mindfulness-based cognitive therapy (MBCT) as a psychological and non-pharmacological method can be effective to improve the quality of life in perimenopausal women.
    Objectives
    The present study was conducted to determine the effectiveness of MBCT on the quality of life in perimenopausal women.
    Methods
    This randomized controlled trial was conducted on 73 perimenopausal women from August 2017 to February 2018 in four health centers in Yazd. They were randomly divided into the intervention (n = 36) and control (n = 37) groups by using simple random sampling method; indeed, the random number table. The MBCT was given once a week to the intervention group over eight two-hour sessions and the control group received no intervention. The data collection instruments included a demographic questionnaire, Cooperman's index, and the menopause-related quality of life questionnaire, which were fulfilled by both groups before, immediately after, and one month after the completion of the intervention.
    Results
    In the intervention group, the mean score of quality of life and its dimensions (except for the sexual dimension) immediately and one month after the completion of the intervention showed a significant reduction compared with the control group (P < 0.001). Also, the improvement of the quality of life and its dimensions mean scores was significant in three intervals of the study in the intervention group (P < 0.001).
    Conclusions
    Given the effectiveness of MBCT in enhancing the quality of life in perimenopausal women, this method is recommended to be used as a supportive method for management of perimenopausal period
    Keywords: Mindfulness, Menopause, Quality of Life, Counseling
  • Fereshteh Pouyan, Mahnaz Akbari Kamrani, Mitra Rahimzadeh, Mansoreh Jamshidimanesh, Sara Esmaelzadeh–Saeieh * Page 16
     
    Background
    Preterm labor is the most stressful experience for mothers. Consultation by interpersonal psychotherapy (IPT) approach is a method to support mothers with pre-term labor. This study aimed to assess the effect of IPT oriented child birth education on adaption role and stress in mothers of infants admitted to the intensive care unit.
    Methods
    This randomized interventional study investigated 92 primiparous women with a newborn admitted to the newborn intensive care unit of Kamali Hospital. The sampling method was convenient and samples were randomly assigned to two groups of control and intervention by four blocks randomization method. In addition to routine care, the intervention group received three IPT counseling sessions. The data collection tool in this study was parental stress questionnaire and maternal role adaptation questionnaire.
    Results
    The results of repeated measure test indicated that the maternal stress score had a significant change over time (P < 0.001) with significant differences between the two groups (P < 0.001), and maternal role adaptation changed significantly over time (P < 0.001) with a significant difference between the two groups (P < 0.001).
    Conclusions
    Considering the impact of interpersonal psychotherapy-oriented child birth education on maternal stress and maternal role adaptation, as well as the limited duration and cost of this program and the possibility of training it by nurses and midwives, it is suggested to include this training program in routine interventions for mothers with a premature baby.
    Keywords: Stress, Maternal Behavior, Neonatal, Intensive Care Unit, Premature Birth