mustard gas can cause numerous complications in the skin , eye , gastrointestinal , and respiratory systems ( 1 ) .
physical and psychological disabilities can establish limitations in usual activities , occupational tasks , social actions , and the quality of life in chemical victims ( 3 ) .
quality of life is a broad concept that involves all of aspects of life including physical , social , and spiritual ( 4 ) .
health - promoting lifestyle is closely related to veterans physical and psychological health status and , therefore , to their quality of life .
health - promoting behaviors are defined as real human desires that propel individuals to maximize health , personal performance , and productive lives . according to pender et al . , health promotion is a dynamic and positive process that encompasses behaviors supporting a healthy lifestyle , including physical activity , dieting , spiritual growth , interpersonal relationships , health responsibility , and stress management .
they defined health - promoting behaviors as voluntary daily activities derived from environmental , demographical , and social variables and that such activities can affect one s health conditions .
in other words , a health - promoting lifestyle is a multi - dimensional pattern of voluntary behaviors needed for promoting one s health conditions , self- growth , and perfection ( 5 ) .
health promotion theories and models can facilitate establishing , maintaining , and improving healthy behaviors by predicting factors influencing risky behaviors ( 6 - 8 ) .
penders health promotion model ( hpm ) is a comprehensive and predictive model that can provide a theoretical framework to explore the factors influencing health - promoting behaviors . the first version of hpm was used as a framework to testing its capabilities in predicting a health - promoting lifestyle , but several constructs such as importance of health , definition of health , and perceived control of health
were deleted owing to lack of sufficient empirical evidence of predictive power and several constructs were added ; therefore , the model was revised ( 5 ) . in the revised model ,
the included concepts of health - promoting behavior are individual characteristics and experiences , behavior - specific cognitions and affects , and behavioral outcomes .
the concept of individual characteristics and experiences has direct and indirect effects ( through cognition and affects factors ) on behavior , and it includes personal factors and prior related behaviors .
the concept of behavior - specific cognitions and affects has a direct effect on behavior , and it includes constructs such as perceived benefits and barriers , perceived self - efficacy , activity - related affect , interpersonal influences , and situational influences .
pender tested his model in multiple studies and identified constructs such as personal factors ( perceived health status ) , perceived benefits and barriers , perceived self - efficacy , and interpersonal influences ( social support ) as the best predictors a health - promoting lifestyle ( 5 ) .
however , existing evidences indicate that the factors influencing each specific behavior should be assessed independently ( 9 ) .
research in iranian elders with several disabilities showed that social support was the most important determinant factor in performing day - to - day activities ( 10 ) . a study in persons with multiple sclerosis showed that enhancing social support , lowering barriers , and increasing specific self - efficacy for health behaviors results in improved health - promoting behaviors and quality of life ( 11 ) . in diabetic females with physical disability , the perceived self - efficacy , perceived benefits , and perceived health status are effective factors on physical activity behaviors and the perceived health status construct is an effective indirect factor influencing physical activity ( 12 ) .
veterans with numerous disabilities need to change to a health - promoting lifestyle , and although hpm clearly identifies the constructs leading to health - promoting behaviors , the relationships among the constructs are less clear .
therefore , the purpose of the current study was to investigate the direct and indirect relationships between hpm constructs and health - promoting behaviors in veterans , as well as the effectiveness of the model in predicting health - promoting behaviors .
in this cross sectional study , 276 moderate - to - severely affected chemical veterans living in ilam province were recruited between july and november 2014 via census sampling .
veterans more than 25 percent were categorized as moderate and severe based on the medical committee of department of veterans affairs ( dva ) .
the province has temperate climate in the north , and warm and semi - warm climate in the south .
the inclusion criteria included having suffered from moderate - to - severe levels of injury and having adequate physical health .
however , individuals who did not comply with the study procedures , not satisfied about participating in the study , or without permanent residence in ilam province were excluded from the study . for sampling ,
first , the complete list of chemicals veterans names and phone numbers was obtained from the department of veterans affairs ( dva ) .
then , through telephone contact , explanations regarding the targets , procedures , and confidential rules of the research were presented to potential study participants .
thereafter , if a veteran expressed desire to participate in the investigation , the researcher would visit their home to collect data .
then , they were requested to choose the best options as their answers to questions .
of the 276 referred veterans , six died , three were not able to respond to the questions , 15 submitted incomplete questionnaires , and 13 moved out of ilam .
therefore , finally , 239 veterans ( 86.6% response rate ) entered into the study .
a self - administered questionnaire , the health - promoting lifestyle profile ii ( hplp ii ) questionnaire , and five standard instruments regarding pender models constructs , including perceived health status , perceived benefits , perceived barriers , social support , and self - efficacy , were used to collect data .
all instruments were first translated by the primary investigator and then a bilingual person translated them back to english ; all differences were improved .
the translated instruments were reviewed by a group of iranian health education experts , and minor amendments were made to them .
prior to data collection , the questionnaires were tested for reliability in a sample of 50 chemical veterans . in this study , all questionnaires were reliable and the ranges of cronbach s alpha coefficients were 0.82 ( perceived health status)0.92 ( hplp ii ) .
the self - administered questionnaire queried age , gender , occupation , disability , type of injury , and militancy type .
the hplp ii included 52 questions , and all items are scored using a likert scale ranging from 1 ( never ) to 4 ( always ) .
this standard questionnaire for measuring health - promoting behaviors includes six dimensions , namely , health responsibility , physical activity , nutrition , spiritual growth , interpersonal relations , and stress management .
higher scores indicate more favorable conditions in veterans in terms of health - promoting behaviors . walker and collogues reported cronbach s alpha of 0.94 for this instrument ( 13 - 15 ) . in this study , for this instrument , we obtained cronbach s alpha of 0.92 , and content validity index ( cvi ) values in terms of simplicity , precision , and specificity were 0.91 , 0.97 , and 0.91 , respectively .
response categories for items vary from 2- to 6- point scales , and raw scores for items range from 1 to 6 .
physical domain scores range from 6 to 20 , and mental domain scores range from 6 to 27 .
reported cronbach s alpha of 0.73 for the physical health subscale and 0.72 for the mental health subscale in iranian people .
furthermore , explanatory factor analysis ( 16 ) and confirmatory factor analysis ( cfa ) indicated good fit validity for this tool ( 17 ) . given these previous evaluations of this questionnaire in iran , we did not validate it in the present study .
the standard multidimensional scale of perceived social support contains 12 items and assesses three subscales , namely , family , friends , and other significant individuals support .
the items are scored on a 7-point likert scale ranging from strongly disagree ( 1 point ) to strongly agree ( 7 points ) , and the total questionnaire score ranges from 12 to 84 .
psychometric studies have indicated good reliability (  = 0.91 ) . moreover , cronbach s alpha coefficient of this scale was 0.94 , which indicates good internal consistency ( 18 ) . in this study ,
the cvi values for simplicity , precision , and specificity were 0.93 , 0.96 , 0.91 , respectively , and cronbach s alpha was 0.87 , for this instrument .
the scales regarding perceived benefits of and perceived barriers to health - promoting behaviors comprised 26 and 18 questions , respectively .
alpha for the benefits and barriers scales were 0.82 and 0.60 , respectively ( 10 ) .
the cvi values for simplicity , precision , and specificity for the perceived benefits questionnaire were 0.99 , 0.96 , and 0.99 , respectively , while those for the perceived barriers questionnaire were 0.98 , 0.98 , and 0.91 .
furthermore , the reliability scores of the benefits and barriers scales were 0.91 and 0.88 , respectively , in this study . perceived self- efficacy has been defined as people s judgments on their own possibilities for indulging in health - promoting behaviors .
becker et al . designed this scale for measuring six dimensions of health - promoting behaviors .
the 26 items comprising this questionnaire are scored on a 4- point likert scale from never ( 1 point ) to always ( 4 points ) with the total score ranging from 26 to 104 .
its cvi values for simplicity , precision , and specificity were 0.99 , 0.98 , and 0.98 , respectively , which indicate its appropriateness of content validity .
the collected data were coded and entered into statistical package for social sciences ( spss ) version 18.0 .
path analysis was used for studying the direct and indirect effects of variables and for estimating the values of coefficients in the underpinning linear model .
this value was significant ( p = 0.04 ) ; therefore , a few of the variables ( such as age , social support , perceived benefits , and health status ) were non - normal and we used the robust maximum likelihood estimation procedure . a correlation matrix and an asymptotic covariance matrix were applied for model estimation .
chi - square (  ) , the adjusted goodness - of - fit index ( agfi ) , and root - mean - square error of approximation ( rmsea ) were used as model fit criteria .
the comparative bentler - bonett non - normed fit index ( nnfi ) was selected .
nnfi values equal to or greater than 0.90 are recommended as acceptable values for this measure .
t value was used for elimination of parameters in the path analysis , and the modification index was used for inclusion of additional parameters .
the aim of the study was verbally explained to the potential participants who met the inclusion criteria .
the participants were told that all information ( such as name , address , percentage of injury , etc . ) would be kept secret and anonymous .
the required permissions were obtained from the vice - chancellor of research , bushehr university of medical sciences , department of education in bushehr city , and department of veterans affairs .
furthermore , the study was approved by the university ethics committee with ethics number 20.71.208 .
in this cross sectional study , 276 moderate - to - severely affected chemical veterans living in ilam province were recruited between july and november 2014 via census sampling .
veterans more than 25 percent were categorized as moderate and severe based on the medical committee of department of veterans affairs ( dva ) .
the province has temperate climate in the north , and warm and semi - warm climate in the south .
the inclusion criteria included having suffered from moderate - to - severe levels of injury and having adequate physical health .
however , individuals who did not comply with the study procedures , not satisfied about participating in the study , or without permanent residence in ilam province were excluded from the study . for sampling ,
first , the complete list of chemicals veterans names and phone numbers was obtained from the department of veterans affairs ( dva ) .
then , through telephone contact , explanations regarding the targets , procedures , and confidential rules of the research were presented to potential study participants .
thereafter , if a veteran expressed desire to participate in the investigation , the researcher would visit their home to collect data .
then , they were requested to choose the best options as their answers to questions .
of the 276 referred veterans , six died , three were not able to respond to the questions , 15 submitted incomplete questionnaires , and 13 moved out of ilam .
therefore , finally , 239 veterans ( 86.6% response rate ) entered into the study .
a self - administered questionnaire , the health - promoting lifestyle profile ii ( hplp ii ) questionnaire , and five standard instruments regarding pender models constructs , including perceived health status , perceived benefits , perceived barriers , social support , and self - efficacy , were used to collect data .
all instruments were first translated by the primary investigator and then a bilingual person translated them back to english ; all differences were improved .
the translated instruments were reviewed by a group of iranian health education experts , and minor amendments were made to them .
prior to data collection , the questionnaires were tested for reliability in a sample of 50 chemical veterans . in this study , all questionnaires were reliable and the ranges of cronbach s alpha coefficients were 0.82 ( perceived health status)0.92 ( hplp ii ) .
the self - administered questionnaire queried age , gender , occupation , disability , type of injury , and militancy type .
the hplp ii included 52 questions , and all items are scored using a likert scale ranging from 1 ( never ) to 4 ( always ) .
this standard questionnaire for measuring health - promoting behaviors includes six dimensions , namely , health responsibility , physical activity , nutrition , spiritual growth , interpersonal relations , and stress management .
higher scores indicate more favorable conditions in veterans in terms of health - promoting behaviors .
walker and collogues reported cronbach s alpha of 0.94 for this instrument ( 13 - 15 ) . in this study , for this instrument , we obtained cronbach s alpha of 0.92 , and content validity index ( cvi ) values in terms of simplicity , precision , and specificity were 0.91 , 0.97 , and 0.91 , respectively . the perceived health status questionnaire is a 12-item scale covering physical and mental health .
response categories for items vary from 2- to 6- point scales , and raw scores for items range from 1 to 6 .
physical domain scores range from 6 to 20 , and mental domain scores range from 6 to 27 .
reported cronbach s alpha of 0.73 for the physical health subscale and 0.72 for the mental health subscale in iranian people .
furthermore , explanatory factor analysis ( 16 ) and confirmatory factor analysis ( cfa ) indicated good fit validity for this tool ( 17 ) . given these previous evaluations of this questionnaire in iran , we did not validate it in the present study .
the standard multidimensional scale of perceived social support contains 12 items and assesses three subscales , namely , family , friends , and other significant individuals support .
the items are scored on a 7-point likert scale ranging from strongly disagree ( 1 point ) to strongly agree ( 7 points ) , and the total questionnaire score ranges from 12 to 84 .
moreover , cronbach s alpha coefficient of this scale was 0.94 , which indicates good internal consistency ( 18 ) . in this study ,
the cvi values for simplicity , precision , and specificity were 0.93 , 0.96 , 0.91 , respectively , and cronbach s alpha was 0.87 , for this instrument .
the scales regarding perceived benefits of and perceived barriers to health - promoting behaviors comprised 26 and 18 questions , respectively .
alpha for the benefits and barriers scales were 0.82 and 0.60 , respectively ( 10 ) .
the cvi values for simplicity , precision , and specificity for the perceived benefits questionnaire were 0.99 , 0.96 , and 0.99 , respectively , while those for the perceived barriers questionnaire were 0.98 , 0.98 , and 0.91 .
furthermore , the reliability scores of the benefits and barriers scales were 0.91 and 0.88 , respectively , in this study .
perceived self- efficacy has been defined as people s judgments on their own possibilities for indulging in health - promoting behaviors .
becker et al . designed this scale for measuring six dimensions of health - promoting behaviors .
the 26 items comprising this questionnaire are scored on a 4- point likert scale from never ( 1 point ) to always ( 4 points ) with the total score ranging from 26 to 104 .
its cvi values for simplicity , precision , and specificity were 0.99 , 0.98 , and 0.98 , respectively , which indicate its appropriateness of content validity .
the collected data were coded and entered into statistical package for social sciences ( spss ) version 18.0 .
path analysis was used for studying the direct and indirect effects of variables and for estimating the values of coefficients in the underpinning linear model .
this value was significant ( p = 0.04 ) ; therefore , a few of the variables ( such as age , social support , perceived benefits , and health status ) were non - normal and we used the robust maximum likelihood estimation procedure . a correlation matrix and an asymptotic covariance matrix were applied for model estimation .
chi - square (  ) , the adjusted goodness - of - fit index ( agfi ) , and root - mean - square error of approximation ( rmsea ) were used as model fit criteria .
the comparative bentler - bonett non - normed fit index ( nnfi ) was selected .
nnfi values equal to or greater than 0.90 are recommended as acceptable values for this measure .
t value was used for elimination of parameters in the path analysis , and the modification index was used for inclusion of additional parameters .
the aim of the study was verbally explained to the potential participants who met the inclusion criteria .
the participants were told that all information ( such as name , address , percentage of injury , etc . ) would be kept secret and anonymous .
the required permissions were obtained from the vice - chancellor of research , bushehr university of medical sciences , department of education in bushehr city , and department of veterans affairs .
furthermore , the study was approved by the university ethics committee with ethics number 20.71.208 .
in total , 239 chemical veterans entered into the study with mean age of 51.17  8.87 years .
most veterans were 25% veteran ( 52.3% , n = 125 ) , 27.6% ( n = 66 ) were 30% , 9.6% ( n = 23 ) were 35% , and 9.2% ( n = 22 ) had 40% or higher percent of veteran . in this study ,
43.9% ( n = 105 ) of the subjects were chemical veterans , 13.4% ( n = 32 ) were physico - chemical veterans , 37.7% ( n = 90 ) were neuro - chemical veterans , and 4.6% ( n = 12 ) had all aforementioned afflictions .
of these , 44.4% ( n = 106 ) were voluntary participants in combat situations , 32.6% ( n = 78 ) were soldiers , and 23% ( n = 51 ) were military personnel .
of all the participants , 35.1% ( n = 84 ) were employed , 34.7% ( n = 83 ) were pensioners , and 29.8% ( n = 109 ) had other jobs .
average responses to the five constructs and the hplp ii are summarized in table 1 .
the results ( according to mean values obtained ) demonstrate that the participants in this study had poor of hplp .
moreover , the veterans perceived medium levels of health status , self - efficacy , and perceived barriers related to hplp .
accordingly , positive associations were found between hplp and all constructs , except perceived barriers .
therefore , the veterans who had higher perceived barriers were reported to have poorer hplp .
the original hypothesized model did not fit the data well (  = 147.72 , df = 6 , p = 0.000 , rmsea = 0.32 ( 0.28 - 0.36 ) , nnfi = 0.44 , gfi = 0.89 , agfi = 0.17 ) .
path analysis revealed that some coefficients were significant and others were not . after considering the results of the original model and the related theoretical issues ,
the model was modified by removing non - significant coefficients one - by - one between demographic factors and model constructs .
the fit indices indicated improvement of the modified model over the original model (  = 13.78 , df = 18 , p = 0.743 , rmsea = 0.00 ( 0.00 - 0.04 ) , nnfi = 0.98 , gfi = 0.94 , agfi = 0.89 ) .
critical n ( hoelter s index ) in this model was 601.94 , which suggests that sample size cutoff for testing the model was more than satisfied .
the coefficients between the variables were improved , and all paths in the modified model were significant .
fit indices such as gfi and agfi indicated good fit of the model ( values > 0.9 ) ( table 3 ) . according the results , among personal factors , perceived health status had the most effect on hplp with factor loading of 0.15 . the variables age and occupation did not have direct or indirect effects on hplp and were omitted from the model . in this study , among the model constructs , the factor with the most effect on hplp was social support with the highest factor loading of 0.382 .
the results indicate that all constructs , except perceived barriers , positively influenced hplp , and perceived benefit had no effect on hplp .
the pathways across personal factors , constructs , and hplp are shown in figure 1 .
direct and indirect influences of the personal factors and model constructs on hplp are summarized in table 4 .
abbreviations : barr , barrier ; percent , disability percentage ; se , self - efficacy ; ss , social support ; veteran , militancy ; veteran type , type of injury .
in this study , we aimed to identify the direct and indirect factors affecting health - promoting behaviors in chemical veterans based on the hpm . in this study ,
the mean scores of health - promoting behaviors in veterans was lower than that shown in harooni;s study , which was conducted among the elderly in dena province ( 20 ) .
the results of the present study are consistent with the findings of several studies ( 10 , 21 - 24 ) , indicating the inappropriate status of health - promoting behavior in veterans .
the results show that hpm as a theoretical framework for this study is a poor predictor of health - promoting lifestyle in chemical veterans ( r = 15% ) . in this study
, no correlation was observed between the individual characteristics and experiences of veterans regarding health - promoting lifestyles .
however , all demographic variables , except age and occupation , had indirect effects on health - promoting behaviors .
one study showed only housing status was associated with quality of life ( 25 ) .
consistent with this study , other studies have shown personal factors have no significant direct effects on hplp subscales ( 26 - 28 ) .
similar to the findings of several studies ( 29 , 30 ) , our findings show that perceived health status was the most important predictor of hplp of veterans , so individuals with better perceived health indulged in more health - promoting behaviors .
this study showed that all structures , except perceived barriers , had positive effects on health - promoting behaviors .
in addition , among the model constructs , perceived benefits had no effect on health - promoting behaviors and this result is in contradiction with the findings of a few other studies . in an iranian study among elderly people , perceived benefits was shown to have a direct effect on health - promoting behaviors . moreover ,
this construct had direct effects on oral health behavior and on the use of hearing protection devices ( 31 , 32 ) .
in the present study , the impact of perceived benefits was covered by other constructs , so it was removed from the model . in accordance with some studies perceived barrier constructhad negative and indirect effect on health - promoting behaviors through social support construct ( 10 , 33 ) . in other study , perceived barriers showed negative but direct effect on using of hearing protection behavior ( 12 , 34 ) . in this study ,
similar to the findings of a previous study ( 34 ) , perceived self - efficacy had indirect effects on health - promoting behaviors through social support and perceived barriers , but in several other studies , self - efficacy had both direct and indirect effects ( 10 , 11 , 35 ) , and in other studies , this construct had only direct effects ( 28 , 32 , 33 ) .
therefore , all studies showed a relationship between self - efficacy and health - promoting behaviors .
as shown in the present study , perceived social support was the most powerful predictor of health - promoting behaviors .
in several studies ( 11 , 25 , 28 , 34 - 37 ) , social support , too , had a direct effect on health - promoting behaviors and quality of life .
however , in one study among pregnant women ( 38 ) , social support was not a significant predictor of health - promoting behavior .
this contradiction may be owing to women s condition , indicating that these people are influenced by other factors to improve their health - related behaviors .
it can be concluded that to ensure the spread of health - promoting lifestyles in chemical veterans , it is necessary to increase social support . to this end , we should educate a variety of sources , including friends , family , and significant people to create support required to indulge in health - promoting behaviors .
additionally , veterans should be educated about strategies for overcoming barriers by using a variety of promoting self - efficacy strategies . due to several problems and disabilities such as respiratory disorders in veterans ,
furthermore , similar studies on chemical veterans are limited , so comparing the findings of this study with those of other studies was difficult . further research on veterans should be conducted in the near future . despite the limitations of the present study , given that it was conducted only in ilam province , the same study can be conducted in other provinces .
furthermore , in the present study , only veterans with moderate to severe disabilities were included to avoid bias in the results .
nonetheless , the use of hpm as a theoretical framework and the census sampling procedure were strong points of this study .
it can be concluded that to ensure the spread of health - promoting lifestyles in chemical veterans , it is necessary to increase social support . to this end , we should educate a variety of sources , including friends , family , and significant people to create support required to indulge in health - promoting behaviors .
additionally , veterans should be educated about strategies for overcoming barriers by using a variety of promoting self - efficacy strategies .
due to several problems and disabilities such as respiratory disorders in veterans , questionnaire fulfillment was difficult .
furthermore , similar studies on chemical veterans are limited , so comparing the findings of this study with those of other studies was difficult . further research on veterans should be conducted in the near future . despite the limitations of the present study , given that it was conducted only in ilam province , the same study can be conducted in other provinces .
furthermore , in the present study , only veterans with moderate to severe disabilities were included to avoid bias in the results .
nonetheless , the use of hpm as a theoretical framework and the census sampling procedure were strong points of this study .
 backgroundhealth - promoting behaviors can enhance physical and mental health among individuals with disability , particularly veterans.objectivesthe current study aimed to examine both one - way direct and indirect effects of the factors of the health promotion model ( hpm ) on health - promoting behaviors in chemical veterans from ilam province in iran.materials and methodsthis cross - sectional study was conducted in 2014 . in this study , 239 moderate - to - severe chemical veterans from illam province supported by the veterans affairs department of ilam were evaluated via census sampling . 
 data including health - promoting behaviors , perceived self - efficacy , perceived barriers and benefits , perceived social support , and perceived health status were collected using standard questionnaires.resultsthe results show that the hpm is a poor predictor of the health - promoting lifestyles of chemical veterans ( r2 = 15% ) . social support ( factor loading = 0.38 ) 
 is the strongest predictor of health - promoting behaviors and it influences such behaviors directly , while perceived barriers ( factor loading = -0.11 ) and perceived self - efficacy ( factor loading = 0.02 ) indirectly predict behavior through social support.conclusionsperceived social support is the most important factor that influences health - promoting behaviors . increasing social support by enhancing self - efficacy and decreasing perceived barriers can improve health - promoting behaviors among veterans . 
1. Background
2. Objectives
3. Materials and Methods
3.1. Study Design
3.2. Instruments and Measures
3.3. Data Analysis
3.4. Ethical Principles
4. Results
5. Discussion
5.1. Conclusions
5.2. Limitations