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Tran CL, Choi KS, Kim S, Oh J. Individual and joint effect of socioeconomic status and lifestyle factors on cancer in Korea. Cancer Med 2023; 12:17389-17402. [PMID: 37489083 PMCID: PMC10501257 DOI: 10.1002/cam4.6359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/15/2023] [Accepted: 07/09/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND There is limited evidence on the individual and joint effect of socioeconomic status (SES) and unhealthy lifestyle on cancer. Therefore, this study aimed to examine the effects of these factors on cancer incidence and mortality. METHODS In this population-based cohort study, income was used as the proxy of SES. A combined unhealthy lifestyle score was obtained using data on smoking, alcohol consumption, physical activity, and body mass index. Hazard ratios were estimated using a Cox proportional hazards model. RESULTS The study included data on 8,353,169 participants (median follow-up period, 17 years). Although the association between low income and cancer incidence varied depending on cancer type, low income consistently increased the risk of cancer-related death with a social gradient. Unhealthy behaviors increased the risk of cancer incidence and mortality, except for thyroid and breast cancer in women and prostate cancer in men. Compared with the wealthiest and healthiest individuals, the poorest and unhealthiest men and women showed 2.1-fold (2.05-2.14) and 1.36-fold (1.31-1.41) higher risk of cancer-related death, respectively. The joint effect was most robust for lung, liver, head, and neck cancers in men and liver and cervical cancers in women; further, the effect was stronger with cancer-specific mortality than with incidence. CONCLUSION In conclusion, income and combined healthy lifestyle behaviors have individual and joint effects on cancer incidence and mortality. The effect varies by cancer type and sex.
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Affiliation(s)
- Chi Lan Tran
- Graduate School of Cancer Science and PolicyNational Cancer CenterGoyangSouth Korea
| | - Kui Son Choi
- Graduate School of Cancer Science and PolicyNational Cancer CenterGoyangSouth Korea
- National Cancer Control InstituteNational Cancer CenterGoyangSouth Korea
| | - Sun‐Young Kim
- Graduate School of Cancer Science and PolicyNational Cancer CenterGoyangSouth Korea
| | - Jin‐Kyoung Oh
- Graduate School of Cancer Science and PolicyNational Cancer CenterGoyangSouth Korea
- Division of Cancer PreventionNational Cancer CenterGoyangSouth Korea
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Russell B, Häggström C, Holmberg L, Liedberg F, Gårdmark T, Bryan RT, Kumar P, Van Hemelrijck M. Systematic review of the association between socioeconomic status and bladder cancer survival with hospital type, comorbidities, and treatment delay as mediators. BJUI COMPASS 2021; 2:140-158. [PMID: 35475135 PMCID: PMC8988826 DOI: 10.1002/bco2.65] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/30/2020] [Accepted: 11/30/2020] [Indexed: 12/11/2022] Open
Abstract
Objectives Materials and methods Results Conclusions
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Affiliation(s)
- Beth Russell
- Department of Translational Oncology and Urology Research School of Cancer and Pharmaceutical Sciences King's College London London UK
| | - Christel Häggström
- Department of Surgical Sciences Uppsala University Uppsala Sweden
- Department of Public Health and Clinical Medicine Umeå University Umeå Sweden
| | - Lars Holmberg
- Department of Translational Oncology and Urology Research School of Cancer and Pharmaceutical Sciences King's College London London UK
- Department of Surgical Sciences Uppsala University Uppsala Sweden
| | - Fredrik Liedberg
- Department of Urology Skåne University Hospital Malmö Sweden
- Institution of Translational Medicine Lund University Malmö Sweden
| | - Truls Gårdmark
- Department of Clinical Sciences Danderyd Hospital, Karolinska Institute Stockholm Sweden
| | - Richard T Bryan
- Institute of Cancer and Genomic Sciences The University of Birmingham Birmingham UK
| | | | - Mieke Van Hemelrijck
- Department of Translational Oncology and Urology Research School of Cancer and Pharmaceutical Sciences King's College London London UK
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Jackson DK, Li Y, Eskander MF, Tsung A, Oppong BA, Bhattacharyya O, Paskett ED, Obeng-Gyasi S. Racial disparities in low-value surgical care and time to surgery in high-volume hospitals. J Surg Oncol 2020; 123:676-686. [PMID: 33616989 DOI: 10.1002/jso.26320] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/07/2020] [Accepted: 11/16/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The objective of this study is to examine racial differences in receipt of low-value surgical care and time to surgery (TTS) among women receiving treatment at high-volume hospitals. METHODS Stage I-III non-Hispanic Black (NHB) and Non-Hispanic White (NHW) breast cancer patients were identified in the National Cancer Database. Low-value care included (1) sentinel lymph node biopsy (SLNB) among T1N0 patients age ≥70 with hormone receptor-positive cancers, (2) axillary lymph node dissection (ALND) in patients meeting ACOSOG Z0011 criteria, and (3) contralateral prophylactic mastectomy (CPM) with unilateral cancer. TTS was days from biopsy to surgery. Bivariate and logistic regression analyses were used to compare the groups. RESULTS Compared to NHWs, NHBs had lower rates of SLNB among women age ≥70 with small hormone-positive cancers (NHB 58.5% vs. NHW 62.2% p < .001) and CPM (NHB 26.3% vs. NHW 36%; p < .001). ALND rates for patients meeting ACOSOG Z0011 criteria were similar between both groups (p = .13). The odds of surgery >60 days were higher among NHBs (odds ratio, 1.77; 95% confidence interval, 1.64-1.91; NHW ref). CONCLUSIONS NHBs treated at high-volume hospitals have higher rates of surgical delay but are less likely to undergo low-value surgical procedures compared to NHW women.
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Affiliation(s)
| | - Yaming Li
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Mariam F Eskander
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Bridget A Oppong
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, Ohio, USA
| | - Oindrila Bhattacharyya
- Department of Economics, Indiana University Purdue University, Indianapolis, Indiana, USA
| | - Electra D Paskett
- Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, Ohio, USA
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Brewster R, Deb S, Pendharkar AV, Ratliff J, Li G, Desai A. The effect of socioeconomic status on age at diagnosis and overall survival in patients with intracranial meningioma. Int J Neurosci 2020; 132:413-420. [PMID: 32878534 DOI: 10.1080/00207454.2020.1818742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Intracranial meningiomas are the most common primary tumors of the central nervous system. How socioeconomic status (SES) impacts treatment access and outcomes for brain tumor subtypes is an emerging area of research. Few studies have examined the relationship between SES and meningioma survival and management with reference to relevant clinical factors, including age at diagnosis. We studied the independent effects of SES on receiving surgery and survival probability in patients with intracranial meningioma. METHODS 54,282 patients diagnosed with intracranial meningioma between 2003 and 2012 from the Surveillance, Epidemiology, and End Results (SEER) Program at the National Cancer Institute database were included. Patient SES was divided into tertiles. Patient age groups included 'older' (>65, the median patient age) and 'younger'. Multivariable linear regression and Cox proportional hazards model were used with SAS v9.4. Results were adjusted for race, sex, and tumor grade. Kaplan-Meier survival curves were constructed according to SES tertiles and age groups. RESULTS Meningioma prevalence increased with higher SES tertile. Higher SES tertile was also associated with younger age at diagnosis (OR = 0.890, p < 0.05), an increased likelihood of undergoing gross total resection (GTR) (OR = 1.112, p < 0.05), and a trend toward greater 5-year survival probability (HR = 1.773, p = 0.0531). Survival probability correlated with younger age at diagnosis (HR = 2.597, p < 0.001), but not with GTR receipt. CONCLUSION The findings from this national longitudinal study on patients with meningioma suggest that SES affects age at diagnosis and treatment access for intracranial meningiomas patients. Further studies are required to understand and address the mechanisms underlying these disparities.
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Affiliation(s)
- Ryan Brewster
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Sayantan Deb
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Arjun Vivek Pendharkar
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - John Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Gordon Li
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Atman Desai
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
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Lyle G, Hendrie GA, Hendrie D. Understanding the effects of socioeconomic status along the breast cancer continuum in Australian women: a systematic review of evidence. Int J Equity Health 2017; 16:182. [PMID: 29037209 PMCID: PMC5644132 DOI: 10.1186/s12939-017-0676-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 10/03/2017] [Indexed: 12/31/2022] Open
Abstract
Background Globally, the provision of equitable outcomes for women with breast cancer is a priority for governments. However, there is growing evidence that a socioeconomic status (SES) gradient exists in outcomes across the breast cancer continuum – namely incidence, diagnosis, treatment, survival and mortality. This systematic review describes this evidence and, because of the importance of place in defining SES, findings are limited to the Australian experience. Methods An on-line search of PubMed and the Web of Science identified 44 studies published since 1995 which examined the influence of SES along the continuum. The critique of studies included the study design, the types and scales of SES variable measured, and the results in terms of direction and significance of the relationships found. To aid in the interpretation of results, the findings were discussed in the context of a systems dynamic feedback diagram. Results We found 67 findings which reported 107 relationships between SES within outcomes along the continuum. Results suggest no differences in the participation in screening by SES. Higher incidence was reported in women with higher SES whereas a negative association was reported between SES and diagnosis. Associations with treatment choice were specific to the treatment choice undertaken. Some evidence was found towards greater survival for women with higher SES, however, the evidence for a SES relationship with mortality was less conclusive. Conclusions In a universal health system such as that in Australia, evidence of an SES gradient exists, however, the strength and direction of this relationship varies along the continuum. This is a complex relationship and the heterogeneity in study design, the SES indicator selected and its representative scale further complicates our understanding of its influence. More complex multilevel studies are needed to better understand these relationships, the interactions between predictors and to reduce biases introduced by methodological issues.
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Affiliation(s)
- Greg Lyle
- Centre for Population Health Research, Curtin University, Perth, Australia.
| | | | - Delia Hendrie
- School of Public Health, Curtin University, Perth, Australia
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Hung CL, Ou CY, Lai HC, Chen YT, Lee CC, Li SC, Su YC. High combined individual and neighborhood socioeconomic status correlated with better survival of patients with lymphoma in post-rituximab era despite universal health coverage. JOURNAL OF CANCER RESEARCH AND PRACTICE 2016. [DOI: 10.1016/j.jcrpr.2016.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Teng PR, Lin MJ, Yeh LL. Utilization of dental care among patients with severe mental illness: a study of a National Health Insurance database. BMC Oral Health 2016; 16:87. [PMID: 27585979 PMCID: PMC5009687 DOI: 10.1186/s12903-016-0280-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 08/15/2016] [Indexed: 11/10/2022] Open
Abstract
Background The oral health of patients with severe mental illness is poor, in general, and this may be attributed, in part, to inadequate dental care. This study investigated dental care utilization among patients with severe mental illness using a national representative sample. Methods This study used Taiwan’s National Health Insurance Research Dataset for 2009. Patients with the diagnosis of severe mental illness (ICD-9-CM: 290–298) were recruited as the study sample, and others comprised the control. Any visit to a dentist was defined as positive in terms of dental care utilization. Regression analyses were applied to determine the odds of dental care utilization for each diagnostic entity of severe mental illness, compared with the general population and controlling for potential covariates. Results Only 40 % of 19,609 patients with severe mental illness visited the dentist within 12 months. This was significantly lower than the dental visit rate of 48.3 % for the control population (odds ratio [OR] = .72, 95 % confidence interval [CI] = .69–.74; P <0.0001). The odds of dental care utilization differed among the severe mental illness diagnostic categories; e.g., the odds were lowest among those with alcohol psychoses (OR = .54, CI = .43–.68), senile dementia (OR = .55, CI = .52–.59) and other organic psychoses (OR = .58, CI = .52–.65), and highest among those with mood disorder (OR = .89, CI = .85–.94), with schizophrenic patients occupying a mid-level position (OR = .63, CI = .59–.67). Conclusions Patients with severe mental illness received less dental care than the general population. Health care providers and caregivers of patients with severe mental illness should encourage them to visit the dentist regularly, in order to improve the oral health of these vulnerable patient groups.
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Affiliation(s)
- Po-Ren Teng
- Department of Psychiatry, Chang Bing Show Chwan Memorial Hospital, No. 6, Lu-Gong Road, Lu-Gang Township, Changhwa County, Taiwan
| | - Miao-Jean Lin
- Department of Psychiatry, Chang Bing Show Chwan Memorial Hospital, No. 6, Lu-Gong Road, Lu-Gang Township, Changhwa County, Taiwan
| | - Ling-Ling Yeh
- Department of Healthcare Administration, Asia University, No. 500, Lioufong Rd, Wufeng, Taichung, 41354, Taiwan.
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Hauch A, Al-Qurayshi Z, Kandil E. The effect of race and socioeconomic status on outcomes following adrenal operations. J Surg Oncol 2015; 112:822-7. [PMID: 26525638 DOI: 10.1002/jso.24082] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 10/17/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Disparities following different operations exist. We seek to measure the effects of race/ethnicity and socioeconomic status on outcomes following adrenal surgery. METHODS Cross-sectional analysis of adrenal operations identified in the Nationwide Inpatient Sample (NIS) from 2003 to 2009. RESULTS A total of 7,537 procedures were included. Operations by high-volume surgeons had shorter length of stay (LOS) (3.4 days vs. 5.2 days, P < 0.001) and fewer complications (11.6% vs. 16.7%, P < 0.001). Hispanics were more likely to be operated on by low-volume surgeons [OR: 2.17, 95%CI: (1.33, 3.55)]. There were significant differences in LOS and cost among races/ethnicities, income categories, and insurance types (P < 0.05). Hispanics had longer LOS compared to Whites (P = 0.002) and their management was associated with a higher cost ($20,754.00 ± 1,478.40). Patients with either Medicaid [OR: 1.70, 95%CI: (1.30, 2.22)] or Medicare [OR: 1.86, 95%CI: (1.36, 2.54)] were more likely to have a LOS >5 days. CONCLUSIONS Racial and socioeconomic disparities exist; however, they are not solely related to access. A complex interplay between various racial, cultural, and socioeconomic factors likely influence outcomes in adrenal surgery.
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Affiliation(s)
- Adam Hauch
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Zaid Al-Qurayshi
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
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Casey MF, Gross T, Wisnivesky J, Stensland KD, Oh WK, Galsky MD. The Impact of Regionalization of Cystectomy on Racial Disparities in Bladder Cancer Care. J Urol 2015; 194:36-41. [DOI: 10.1016/j.juro.2015.01.076] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2015] [Indexed: 10/24/2022]
Affiliation(s)
| | - Tal Gross
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York
| | - Juan Wisnivesky
- Divisions of General Internal Medicine and Pulmonary and Critical Care, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - William K. Oh
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Matthew D. Galsky
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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Chang CM, Wu CC, Yin WY, Juang SY, Yu CH, Lee CC. Low socioeconomic status is associated with more aggressive end-of-life care for working-age terminal cancer patients. Oncologist 2014; 19:1241-8. [PMID: 25342317 DOI: 10.1634/theoncologist.2014-0152] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The relationship between low socioeconomic status (SES) and aggressiveness of end-of-life (EOL) care in cancer patients of working age (older than 18 years and younger than 65 years) is not clear. We assessed the association between aggressiveness of EOL care and differences in SES among working-age terminal cancer patients from Taiwan between 2009 and 2011. METHODS A total of 32,800 cancer deaths were identified from the Taiwan National Health Insurance Research Database. The indicators of aggressive EOL care (chemotherapy, more than one emergency room [ER] visit or hospital admission, more than 14 days of hospitalization, intensive care unit [ICU] admission, and death in an acute care hospital) in the last month of life were examined. The associations between SES and the indicators were explored. RESULTS Up to 81% of the cancer deaths presented at least one indicator of aggressive EOL care. Those who were aged 35-44 years and male, had low SES, had metastatic malignant disease, lived in urban areas, or were in hospitals with more abundant health care resources were more likely to receive aggressive EOL care. In multilevel logistic regression analyses, high-SES cancer deaths had less chemotherapy (p < .001), fewer ER visits (p < .001), fewer ICU admissions (p < .001), and lower rates of dying in acute hospitals (p < .001) compared with low-SES cancer deaths. CONCLUSION Working-age terminal cancer patients in Taiwan received aggressive EOL care. EOL cancer care was even more aggressive in those with low SES. Public health strategies should continue to focus on low-SES patients to provide them with better EOL cancer care.
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Affiliation(s)
- Chun-Ming Chang
- School of Medicine, Tzu Chi University, Hualian, Taiwan, Republic of China; Department of Surgery, Center for Clinical Epidemiology and Biostatistics, and Department of Otolaryngology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, Republic of China
| | - Chin-Chia Wu
- School of Medicine, Tzu Chi University, Hualian, Taiwan, Republic of China; Department of Surgery, Center for Clinical Epidemiology and Biostatistics, and Department of Otolaryngology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, Republic of China
| | - Wen-Yao Yin
- School of Medicine, Tzu Chi University, Hualian, Taiwan, Republic of China; Department of Surgery, Center for Clinical Epidemiology and Biostatistics, and Department of Otolaryngology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, Republic of China
| | - Shiun-Yang Juang
- School of Medicine, Tzu Chi University, Hualian, Taiwan, Republic of China; Department of Surgery, Center for Clinical Epidemiology and Biostatistics, and Department of Otolaryngology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, Republic of China
| | - Chia-Hui Yu
- School of Medicine, Tzu Chi University, Hualian, Taiwan, Republic of China; Department of Surgery, Center for Clinical Epidemiology and Biostatistics, and Department of Otolaryngology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, Republic of China
| | - Ching-Chih Lee
- School of Medicine, Tzu Chi University, Hualian, Taiwan, Republic of China; Department of Surgery, Center for Clinical Epidemiology and Biostatistics, and Department of Otolaryngology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan, Republic of China
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Hashemi SHB, Karimi S, Mahboobi H. Lifestyle changes for prevention of breast cancer. Electron Physician 2014; 6:894-905. [PMID: 25763165 PMCID: PMC4324293 DOI: 10.14661/2014.894-905] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 05/17/2014] [Accepted: 06/10/2014] [Indexed: 12/29/2022] Open
Abstract
Breast cancer is the second most common cause of death from cancer among women. Lifestyle changes are shown to be important in the prevention of breast cancer. Diet, physical activity, smoking, alcohol use, and vitamin and mineral use are key factors influencing the risk of breast cancer among women. Because these factors are related to each other, it is difficult to assess their individual roles in breast cancer. Some of these factors are alterable, meaning that women can decrease their risk for breast cancer by changing their behavior. Breast cancer is associated with a high rate of mortality and morbidity among women. Therefore, it is logical to try to find ways to decrease the risk of developing breast cancer. Lifestyle changes seem to be an easy, effective, and economical way to help prevention breast cancer. In women with a confirmed breast cancer diagnosis who are under radiotherapy treatment after undergoing a mastectomy, lifestyle changes are still very important. Some factors, such as smoking cessation and prevention of weight gain, may improve the long-term survival chances of these patients. Therefore, ways to increase women’s knowledge about the role of lifestyle changes in the prevention of breast cancer and in the survival of patients with diagnosed breast cancer should be considered and studied.
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Affiliation(s)
| | - Samieh Karimi
- Hormozgan fertility and infertility research center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Hamidreza Mahboobi
- Infectious and Tropical Diseases Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran ; B.A of psychology, Payam Noor University (PNU), Tehran, Iran
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