Development and Validation of a Bio-centric Acting questionnaire based on the Biocentric Health Management Theory

Development and Validation of a Bio-centric Acting questionnaire based on the Biocentric Health Management Theory | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and Validation of a Bio-centric Acting questionnaire based on the Biocentric Health Management Theory Vahid Delshad, Abbas Ebadi, Mariola Bidzan, Gholamreza Ghaedamini Harouni, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7739088/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : The bio-centric worldview is an approach based on human understanding and feeling of being a part of nature through affective experiences and ability to connect with life. The essence of biocentric-acting is life and the connection with the ‘holiness’ and ‘enjoyment’ of life. It seems that this sacred connection with life has been lost in many communities, especially among medical service workers, and the individual and widespread identity crisis that has resulted from the recent Covid-19 pandemic shows the necessity of re-establishing this connection. However, there is no standardized instrument for measuring Bio-centric Acting. This study aims to develop and assess, for the first time, the psychometric properties of biocentric-acting based on the bio-centric health management theory (BHMT) as a theoretical framework and to test it in an Iranian context. Methods : In this methodological study, items were extracted from relevant literature according to the specified objectives of the BHMT. The first draft of the biocentric-acting questionnaire for prehospital staff was designed based on BHMT with the Hybrid concept development approach (HCDA). Then, the psychometric properties, including face content and construct validity as well as reliability, were analyzed. Results : All explored items were categorized as antecedent, attribute, or consequence based on the HCDA. Subsequently, 131 items related to attributes were chosen for further analysis in the study. In the following step, face and content validity of the questionnaire were assessed by 11 prehospital staff and 29 experts. A total of 81 items were retained for Exploratory Factor Analysis (EFA) with 300 prehospital staff. Finally, 34 items related to Biocentric Acting were arranged into 3 factors: 1 – Self-relationship and Communication with Nature; 2 – Relationship to Others; and 3 – Individual Turmoil. Conclusion : This biocentric-acting questionnaire was developed in the Iranian context to assess prehospital staff acting based on the BHMT. It is recommended that this instrument be adopted using BHMT for other occupations and different contexts, to develop a full BHMT scale, especially for workers who have been engaged in the response to the pandemic, in order to assess the consequences of COVID-19. Psychometric assessment Validity Reliability Bio-centric Acting Emergency Medical Services Figures Figure 1 Figure 2 Introduction Humans are experiencing some form of borderline personality disorder, with increasing stress, depression and chronic fatigue syndromes that arise from the confusion of modern life, destroying their health and their ability to relate. As such, a paradigm shift from the egocentric anthropocentric (human-centred) worldview to a bio-centric (life-centred) one is required in all areas of science and life, as Figure 1 shows below this paradigm shift. This would ensure the co-existence of people and nature, allowing them to respect their own inner disposition and the life that is inherent to it, and allowing others to do the same (Stueck, n.d.). Humans are experiencing some form of borderline personality disorder, with increasing stress, depression and chronic fatigue syndromes that arise from the confusion of modern life, destroying their health and their ability to relate. As such, a paradigm shift from the egocentric anthropocentric (human-centred) worldview to a bio-centric (life-centred) one is required in all areas of science and life, as Figure 1 shows below this paradigm shift. This would ensure the co-existence of people and nature, allowing them to respect their own inner disposition and the life that is inherent to it, and allowing others to do the same (Stueck, n.d.). The bio-centric orientation is described by Rolando Toro as that of a ‘relationship human and the ecological human’ (Toro, 2010). In Western culture, it is vital to restore the feeling for the ‘sanctity of life’ and for the ‘enjoyment of life’ as it is described in the theory of Biodanza and the biocentric principles of Toro (2010), because this attitude is having been forgotten. Developing affectivity, expanded cognition, and the expansion of ethical awareness should become an absolute priority (Toro, 2004, 2005, 2010). Also, the work of Schweitzer et al. (999), Naess (2013) and Cavalgante and Wagner (n.d.) has focused on ethical principles and the need to protect life. Based on this and further theoretical biocentric frameworks, the Biocentric Health Management Theory (BHMT) was developed and scientifically investigated by Stueck during the COVID-19 Crisis (2021). In this context, BHMT was called Pandemic Management Theory (Stueck, 2021, n.d.). One of the main claims of BHMT is that humans need to radically change their relationship with nature and the living elements therein, from seeing it purely in terms of its instrumental value to recognizing nature as a living community that has inherent value that must be protected and cooperated with. In the BHMT, the bio-centric worldview is an approach based on human understanding and feeling of being a part of the community of living beings (nature), recognized through affective experiences. This happens by connecting with human inner nature through orientation towards its biological and psychological life-centred biocentric core-activities (e.g., autoregulation and autopoiesis) and expressing authentically life-protecting biopsychological system-elements, for instance instincts, feelings, and all behavioural aspects of life in a continuous affective relationship with others and nature. This intra- and interpersonal feeling-based and experience-based connection and the increase of sensibility by using the proposed methods of bio-centric action (see next section) leads to a dissolution of bio-centric borders, namely: anxieties about life, empathic connection, expression of feelings about nature, to a wider perception of and connection with the sanctity and holiness of life, and to an increase of ethical consciousness and aesthetic recognition of being a part of nature and the universe, rather than obsessively attempting to dominate them. BHMT is an approach that uses the laws that govern and protect life to guide pedagogical and methodological models in education, medicine, politics, economics, work, and psychology. The bio-centric approach of the BHMT orients various areas of action, not only in personal health but also in collective health, social policies, and inclusive models of coexistence of the human community (Benatti et al., 2020). In addition to the work of Toro (2010), it is also based on the biocentric approach of Morin and Freire (1991), the radical constructivism and autopoiesis of Maturana and Varela (2010), on chronobiopsychology (Balzer & Stueck, 2021; Stueck, n.d.), and the scientific evaluations of Biodanza (Marcus, 2021). Bio-centric fields of action and BHMT The BHMT describes 6 fields of action to develop a life-protecting ethic, as table-1 shows below The essence and aim of bio-centric acting in these 6 fields is life itself and the connection with the ‘holiness’ and ‘enjoyment’ of life. Table-1: Six Biocentric acting Scale and its Subscales based on BHMT Scale Sub scales 1-Affective Communication to myself, to others and to all living elements Affective, feeling based, connections between humans and them self Affective connection to other humans Affective connection to all living elements 2-Experience of Lively Corporeality Connection of wildness and instinctiveness of Life 3-Contact with healthy identity and inner orientation Development of inner orientation self-reflexion in feedback Internal detachment of dependencies Identity through affective encounters in feedback Maintaining autonomy, self- actualization and creative expression 4-Experience and Expression of Life Potentials Stimulating the joy of Living and the feeling of liveliness Development of Life Sense and Trust Experiential Integration subjective construction of knowledge 5-Expanded awareness and connection to the wholeness Experience of “implicate orders” (Bohm), “ent-anglements” (Zeilinger), Wholeness 6-Ethical environmental action and ecological awareness of nature Ethical behaviour Ecological awareness Ecological strategies with biocentric approach This sacred connection has been lost in many cultures, and the recent COVID-19 crisis has led to individual and widespread identity crises, showing the necessity of re-establishing this connection. Stueck described 2 possible ways that the BHMT can work in the 6 fields. The Penguin Way – from the head to the body –- is one of the possible ways ( Stueck, 2015). This connection can be gained by methodologies that focus on experiential learning on an emotional, rather than an intellectual, level. This can be done with the use of experiential methods like the Biodanza to develop an aesthetic and ethical attitude and affective integration with life ( Toro, 2010). Toro emphasized on the need for humans to live within a natural and cosmic network as relationship-oriented and ecological humans. Much work has been done on the Biodanza theory (Maturana & Varela, 1980; Maturana, 2011; Maturana & Verden-Zöller, 2008; Toro, 2010; Stueck & Villegas, 2008; Stueck, n.d.). The other way in the BHMT model is from the body to head (the so-called Polar Bear Level), and describes methods that focus on the verbal-reflexive aspect of biocentric connections (e.g., respectful communication based on nonviolent communication; Rosenberg, 1965; Röhr et al., 2020; Schoppe & Stück, 2012) This Polar Bear–Penguin Paradigm secures the balance between the emotion-focused affective regulation and the reflexive level of autoregulation (Stueck, 2015). There are many other possibilities for work in biocentric fields of action (Stueck, n.d.). The Biocentric Health-Management Theory can be applied with both children and adults, and can be used in work environments and in educational and health-related fields, for example the School of Empathy (Stueck, 2013), the TANZPRO-Biodanza program for children (Stueck & Villegas, 2017), and Respectful communication (Röhr et al., 2020). Biocentric limits: Biocentric limits have an impact on a person's attitude to life (liveliness and vitality), well-being, and mental and physical health. Consequences of abnormal sensations are susceptibility to infections, depression, and hyperactivity. When the connection with life is lost, and depression and exhaustion occur alongside hyposensitivity states, an individual can no longer sets limits on work behaviours and may attempt to make contact with the outside world (hyperactivity), although a physiological passivity in the sense of increased inhibition might already indicate withdrawal (Stueck, n.d.). Hence, it is essential to clarify the function of every job, using a standard tool to achieve this goal. The prehospital system plays a vital role in the health system network through rapid patient transport and aims to provide proper treatment in the appropriate place and time by deploying available resources (Delshad et al., 2016). This crucial operation needs well-performing staff to manage stressful situations (Delshad et al., 2020). On the other hand, studies have shown that prehospital functions need improvement due to their critical situation (Koslowsky et al., 2013; Heydari et al., 2014; Dadashzadeh & Rahmani, 2017). It is worth mentioning that the principal investigator in the present study has more than 5 years working in this field and has personally experienced stressful situations. The present study therefore aims to improve the function of prehospital staff and assess their acting based on reliable and valid tools. Theoretical Foundation of the Bio-centric Acting Scale B ased on the work of Toro (2010) and other researchers like Maturana, the psychometric properties of mental health evaluated by Becker, and BHMT, Stueck (2021) developed a questionnaire to measure biocentric acting. This battery is part of a psychometric instrument for the analysis of risk management (Stueck et al., 2019). This battery was shortened, adapted to Iranian culture and validated in the present study (see Table 1). The Bio-centric Acting questionnaire was developed based on the BHMT as an independent instrument that is part of a battery. In health and psychological sciences, a battery consists of independent tools, and as such, each instrument is scored separately (Flanagan et al., 2013), but the findings are interpreted together. Objectives This study aims to develop an instrument to evaluate Bio-centric Acting based on the BHMT using the hybrid concept development approach (HCDA; Schwartz-Barcott & Kim, 2000) to examine the primary psychometric properties of the instrument (face validity, content validity, reliability, intraclass correlation coefficient). Methods In the first phase of this methodological study, indicators were extracted by a literature review. In order to prepare the questionnaire, a purposeful search was carried out about biocentric function. A thorough literature search was performed using keywords such as ‘biocentric’, ‘function’, ‘acting’, ‘field of action’, ‘health management’, and ‘life-centered’ on scientific databases. Relevant studies were carefully examined and items were extracted from the studies and listed in the first draft. This item pool was carefully reviewed by the research team regarding the extent of its coverage and relevance to the specified objectives of the BHMT. For some subscales, there were standard questionnaires, but the number of items was greater than those of the standard questionnaires. To date, it has been used to study a wide variety and range of concepts. An item pool was developed and categorized based on the HCDA into antecedents, attributes, and consequences by an expert panel in 3 focus group meetings in Iran and was approved in 4 virtual meetings on Skype between Iranian and German research members (Rivaz et al., 2019). After panel approval, the questionnaire was forward- and backward-translated according to the WHO guidelines (WHO, 2020). The psychometric properties, including face validity, content, construct validity, and reliability, were evaluated. Validity: Face validity To access face validity, a cognitive interview was conducted with the prehospital staff. In this step, participants of diverse ages, experience, and education levels were asked to comment on the difficulty, appropriateness, and clarity of the items. Based on the comments received, some items were changed and clarified (Rose et al., 2009). Content validity Content validity was assessed using both qualitative and quantitative methods. In the qualitative content validity assessment, questionnaires were sent to experts who were selected from among the experts who participated in the questionnaire development – prehospital staff trainers, prehospital staff experts with more than 10 years of working experience, psychologists, psychiatrists, psychiatric nurses, and emergency health managers (with at least MSc degrees) – to assess the appropriateness of the wording, grammar, item allocation, and scaling of the items. Quantitative content validity was assessed using the content validity ratio (CVR). For CVR calculations, electronic forms of the questionnaire were sent to experts for evaluation. CVR values greater than 0.40 based on Lawshe’s table were considered acceptable (Lawshe, 1975). Reliability The reliability of the tool was assessed using internal and external consistency tests. The internal consistency of the tool was evaluated using Cronbach’s alpha and the external reliability was evaluated using the test-retest method. For reliability assessment, 42 prehospital staff completed the questionnaire twice at a 10-day interval. The intraclass correlation coefficient (ICC) values of the questionnaire and its subscales were calculated using the two-way mixed effects method. Acceptable Reliability was considered as ICC values greater than 0.75 (Shoukri, 2010). Cronbach’s alpha values were calculated for the tool and its subscales. Values greater than 0.7 were considered acceptable (Mayers, 2013). Developing Bio-centric Acting questionnaire scoring The tool was scored on 5, 7, and 10-point Likert type scales from 5 to 1, and negatively-worded items were reverse scored (i.e., from 1 to 5). The standard 0–100 scoring scale was applied after the weight of each item was determined. The raw scores of the questionnaire were converted to 0–100 scores using the linear transformation equation (Ibrahim & Madian, 2011). Construct validity assessment: The construct validity was evaluated via EFA. The rule of thumb states that samples greater than 300 are appropriate for most EFAs (Harrington, 2009). Eligibility criteria were the same as those explained in the qualitative phase (Nulty, 2008). EFA was performed to extract the latent constructs. Sample appropriateness was evaluated via the Kaiser-Meyer-Olkin (KMO) test and Bartlett’s test of sphericity. KMO values of 0.7–0.8 and 0.8–0.9 were interpreted as acceptable and large sample sizes, respectively (Nia et al., 2014). Then, latent constructs extracted through likelihood and varimax rotation. Factor loading was set at 0.5 or greater and, thus, items with communalities lower than 0.5 were removed from factor analysis (Samitsch, 2014). Statistical data analysis SPSS version 22 was used for data analysis. The data were presented in termsof descriptive statistics, including mean, standard deviation, standard error of measurement, and frequencies. Moreover, statistical analyses were performed using paired t -tests, Cronbach’s alpha, and ICC. Ethical considerations This project was approved by the ethics committee of the University of Social Welfare and Rehabilitation Sciences (code: IR.USWR.REC.1398.145). Written informed consent was obtained from all participants. Moreover, the researchers took steps to ensure confidentiality and that no harm was done to the participants. Results After the first draft of the instrument developed from literature review studies was completed, the panel of experts carefully examined the items in regards to the extent of their coverage and their relevance to the specified objectives of the BHMT. Categorization: Items were categorized by experts into three dimensions: antecedent, attribute, and consequences using the Hybrid model, and 131 items in the attribute dimension were selected by the expert panel for further evaluation. Face and Content Validity The face validity of the instrument was assessed by 11 prehospital staff and some items were edited and simplified due to ambiguity. In this stage, 21 items were revised for clarity. For content validity assessment, electronic forms of the questionnaire were sent to 80 experts to assess the essentiality of the items. Forty-one experts answered the questionnaire. About 12 participants also answered the questionnaire but the responses were not rich enough and were excluded. Finally, 29 experts were included. CVR values greater than 0.332 based on the Lawshe table were considered acceptable (Hyrkäs et al., 2003). The CVR range for all the items was between 0.37 and 1. Ultimately, 48 items that had a CVR of < 0.37 were removed. Also, 44 items were removed through validity assessment, and 81 items were retained in the final draft. Reliability The Cronbach’s alpha coefficient of the tool was 0.89 and the intraclass correlation coefficient of the test-retest results was 0.78. In this stage, 36 acceptable responses were selected based on quality and answer time. ICC values greater than 0.75 were considered to constitute acceptable reliability. Cronbach’s alpha values were also calculated for the tool and its subscales and values greater than 0.7 were considered acceptable. (Table-2) Table 2. Intraclass Correlation Coefficient, Cronbach’s Alpha Values for the scales Scale ICC Cronbach’s Alpha Number of Items Affective Communication 0.85 0.79 25 Experience of Lively Corporeality 0.69 0.73 9 Contact with healthy identity 0.76 0.71 20 Experience and Expression of Life Potentials 0.66 0.86 11 Expanded awareness and connection to the wholeness 0.75 0.69 4 Ethical environmental action and ecological awareness 0.10 0.81 3 Bio-centric boundary 0.86 0.89 9 Total 0.780c 0.895 81 The above table shows the ICC, Cronbach’s alpha, and the number of items for each scale. Arranging the factors in order of relevance to competency yielded the following results: Affective Communication had the highest ICC and Ethical Environmental Action had the lowest, although its total ICC and Cronbach’s Alpha were in the acceptable range. Construct Validity: In Table 3, the Kaiser-Meyer-Alkin index (KMO) is equal to 0.900 and Bartlett’s sphericity test at 5016.181 (at the level of p < 0.001) was significant. Therefore, it can be concluded that the implementation of factor analysis based on the correlation matrix in the study sample (300 people) can be justified. Table-3 KMO and Bartlett sphericity test (BT) bio-centric Acting Instrument KMO and Bartlett's Test Kaiser-Meyer-Olkin Measure of Sampling Adequacy. .900 Bartlett's Test of Sphericity Approx. Chi-Square 5016.181 df 561 Sig. .000 A total of 34 items with specific variances were divided into 3 factors with variances of 28.487, 9.402, and 4.676. These factors explained 42.56% of the total variance in stress outcomes, which is almost acceptable (Table 4) Table 4. General explained variance of the Bio-centric Acting Instrument Total Variance Explained Factor Initial Eigenvalues Extraction Sums of Squared Loadings Rotation Sums of Squared Loadings a Total % of Variance Cumulative % Total % of Variance Cumulative % Total 1 10.235 30.103 30.103 9.686 28.487 28.487 8.467 2 3.769 11.085 41.188 3.197 9.402 37.889 7.029 3 2.137 6.285 47.474 1.590 4.676 42.565 5.186 4 1.466 4.311 51.784 5 1.318 3.877 55.661 6 1.057 3.108 58.769 7 1.001 2.943 61.713 8 .946 2.783 64.496 9 .863 2.539 67.035 10 .829 2.437 69.472 11 .763 2.244 71.716 12 .722 2.124 73.839 13 .700 2.059 75.899 14 .660 1.943 77.841 15 .611 1.799 79.640 16 .593 1.743 81.383 17 .543 1.598 82.981 18 .522 1.537 84.517 19 .498 1.463 85.981 20 .489 1.439 87.419 21 .468 1.378 88.797 22 .433 1.274 90.071 23 .399 1.173 91.244 24 .376 1.104 92.349 25 .360 1.060 93.408 26 .322 .948 94.357 27 .318 .937 95.293 28 .292 .858 96.151 29 .258 .760 96.910 30 .249 .731 97.642 31 .237 .696 98.338 32 .205 .604 98.942 33 .195 .572 99.514 34 .165 .486 100.000 Extraction Method: Maximum Likelihood. a. When factors are correlated, sums of squared loadings cannot be added to obtain a total variance. After examining the internal consistency of the items, it appears that the Bio-centric Acting Instrument has three factors, but the contribution of the first factor to the total variance of the variables was more significant and distinct from the other factors. The slope of the graph almost disappears after the second factor. (Figure-2) Based on the psychometry, 34 items related to Bio-centric Acting were formed into 3 factors. The first factor, Self-relationship and Communication with Nature, contained 15 items, the second factor, Relationship to Others, contained 11 items, and the third factor, Individual Turmoil, contained 8 items. Discussion The instrument developed in this study is based on 6 subscales of Bio-centric Acting; Affective Communication, Experience of Lively Corporeality, Contact with Healthy Identity, Experience and Expression of Life Potentials, Expanded Awareness and Connection to Wholeness, and Ethical Environmental Action and Ecological Awareness. All of these subscales had acceptable validity and reliability except the Ethical Environmental Action and Ecological Awareness subscale. However, in the final version, just 34 items in 3 subscales were retained; based on BHMT, an expert panel named them: 1 – Self-relationship and Communication with Nature; 2 – Relationship to Others; and 3 – Individual Turmoil. This instrument was part of a whole battery which was developed to evaluate psychobiological health Prehospital staff work for long hours under stressful conditions and often witness the agonies, physical destruction, and psychological devastation of victims (Koslowsky et al., 2013). Therefore, accurate and timely identification of stressors and maintaining preparedness to cope with them are crucial tasks for keeping staff effective (Moradi et al., 2016). The development of a valid and reliable tool is thus essential for the assessment of Bio-centric Acting in prehospital staff. Previous studies have shown that the development of assessment tools is important for pre-hospital emergency staff because of their important role (Benatti et al., 2020). Also, the rate of exposure to stressors is moderately high among emergency medical staff. Thus, identifying the rate of exposure of emergency medical staff to stressors can help prevent burn out and improve their functioning (Dadashzadeh & Rahmani, 2017). The questionnaire developed in this study can be an initial step towards the assessment of Bio-centric Acting in stressful professions such as prehospital staff. Avraham et al. (2014) have investigated the bio-mental-social health of pre-hospital emergency personnel. They found that work stress has a profound effect on the relationships of emergency personnel with others, which is in line with the results of the present study. According to Nino et al. (2020), physical, psychosocial, biological, and personal characteristics differ between individuals. Factors such as increased mental workload, job fatigue, and lack of communication can have negative effects on psychological and social factors. In line with this study, they emphasized the importance of communication and relationships with others. Similarly, a study by Drake et al., (2017) examined the health of prehospital emergency staff based on the bio-psycho-social model and found that improved bio-psycho-social health increases efficiency and effectiveness. Although this study mentioned efficiency and effectiveness improvements and is similar to the current study, it differs from our study in that it also focuses on patient care and costs. To promote public health, it is necessary to focus on the provision of pre-hospital services, appropriate policymaking, foresight, adoption of a systemic view, as well as to develop comprehensive research programs and roadmaps (Bahadori et al., 2016). The Bio-centric Acting instrument makes it possible to collect data about prehospital staff. In this study, a Bio-centric Acting questionnaire was developed which can be crucial for assessing and promoting Bio-centric acting. Other scholars can also adapt the tool to other cultures and to other contexts and professions (Delshad et al., 2020). Regarding scoring and interpretation in batteries, each instrument is scored, but the findings should be interpreted as a health profile battery, which will be explored in a subsequent study which is currently underway (Safrit & Wood, 1987; Flanagan et al., 2013) Conclusion The instrument developed in this study has acceptable psychometric properties. The findings will be useful for policy makers and planners who aim to improve functioning among prehospital staff. It can be used to guide improved regulations for prehospital staff and also in other professions. Furthermore, the results will be helpful for exploring the process of bio-centric functioning in other similar occupations, such as firefighters, emergency department workers, and rescue service workers. Therefore, it should be emphasized again that this article aims to develop a part of battery comprising other instruments and to review literature based on bio-centric health management theory compatible with Iranian culture in the population of pre-hospital technicians. Strengths and Limitations: To the best of our knowledge, this is the first study to apply the hybrid concept of a life-centered paradigm to study bio-centric acting among prehospital staff, who work in high stress environments. Also, the study was an international cross-cultural study between Germany and Iran, and the research team included one policy-maker with more than 20 years working experience in this field (Prof. Marcus Stueck). On the other hand, the reluctance and/or refusal of some staff to collaborate in the construct validity assessment is the most important limitation of this study. Moreover, this study is part of an ongoing study (PhD dissertation), and data acquisition was slower than normal due to the COVID-19 pandemic. Abbreviations Bio-centric health management Theory (BHMT) Hybrid concept development approach (HCDA) Exploratory Factor Analysis (EFA) Bio-centric Acting (BA) Content validity ratio (CVR) Intra class correlation coefficient (ICC) Declarations Ethics approval and consent to participate: This PhD project was evaluated positively by the Ethical Committee and approved by the Health in Emergency and Disaster research center of the University of Social Welfare and Rehabilitation (Approval ID: IR.USWR.REC.1398.145 Approval Date: 2019.11.25), Iran. Written consent to participate was evaluated and approved by the ethical committee as a standard form in the USWR university (this project is being carried out in Iran, and the consent letter is in Farsi).The study was conducted in accordance with the Declaration of Helsinki Consent for publication Not applicable. Availability of data and materials: Not applicable. Competing interests: The authors declare that they have no conflicts of interest. Funding : The work was not supported by funds and has not received external funding. Authors' contributions VD: Conceptualization, methodology, investigation, formal analysis, writing - original draft, project administration. AE: Methodology, validation, writing - review and editing. MB: Resources, writing - review and editing. GGH: Formal analysis, writing - review and editing. HRKH: Supervision, writing - review and editing, funding acquisition. MS: Conceptualization, theoretical framework, writing - review and editing. All authors read and approved the final manuscript. Acknowledgements Not applicable in this phase of study. Study status This is an ongoing study and participant recruitment has not been completed at the time of submission. Authors’ information VD is a paramedic who has been working in EMS for 6 years, has an MSc in Nursing Education, and is a PhD in Health in Emergency and Disaster in USWR, Iran and DPFA Germany. He is so interested in making connections between Psychobiological concepts and emergency and disaster medicine, with international collaboration. MS, PhD and Hab. in Psychology and Professor in DPFA, Academy of Work and Health Leipzig, Germany. AE, PhD in Nursing and Professor in Behavioral Sciences Research Center, Life-style institute, Baqiyatallah University of Medical Sciences, Tehran, IR Iran. GhGh, PhD and Assosiate professor in Social Welfare Management Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. HRKh, PhD, Post-doctoral research fellowship in Emergency and disaster Health, Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. MB, PhD in Psychology and Professor in Institute of Psychology, University of Gdansk, Gdansk, Poland. References Avraham, N., Goldblatt, H., & Yafe, E. (2014). Paramedics’ experiences and coping strategies when encountering critical incidents. 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Rosenberg self-esteem scale (RSE). Acceptance and Commitment Therapy. Measures Package , 61 (52), 18. Safari, S., Rahmati, F., Baratloo, A., Motamedi, M., Forouzanfar, M. M., Hashemi, B., & Majidi, A. (2015). Hospital and pre-hospital triage systems in disaster and normal conditions; a review article. Iranian Journal of Emergency Medicine , 2 (1). Safrit, M. J., & Wood, T. M. (1987). The test battery reliability of the health-related physical fitness test. Research Quarterly for Exercise and Sport , 58 (2), 160–167. Samitsch, C. (2014). Data quality and its impacts on decision-making: How managers can benefit from good data . springer. Schoppe, S., & Stück, M. (2012). Wertschätzende Kommunikation in Kindertagesstätten. Prävention Und Gesundheitsförderung , 7 (4), 229–236. Schwartz-Barcott & Kim, H. S., D. (2000). An expansion and elaboration of the hybrid model of concept development. Concept Development in Nursing : Foundations, Techniques, and Applications . Shoukri, M. M. (2010). Measures of interobserver agreement and reliability . CRC press. Stück, M. (2013). School of Empathy: Introduction and first results. Beiträge Zur Pädagogischen Und Rehabilitationspsychologie. Historical and Cross-Cultural Aspects of Psychology, Hrsg. von Evelin Witruk, Frankfurt Am M.: Peter Lang . Stueck, M. (n.d.). The Pandemic Management Theory. COVID-19 and biocentric development. Health Psychology Report. https://doi.org/https://doi.org/10.5114/hpr.2021.103123 Stueck, Marcus. (2015). How Penguins & Polar Bears got together. Fundamentals of a School of Empathy and a Complete Science. Europeo-Latnoamericano , 31. Stueck, Marcus, Delshad, V., Roudini, J., Khankeh, H., Ranjbar, M., Reschke, K., Villegas, A., Balzer, H.-U., Matthews, G., & Sack, U. (2019). Health Cube with School of Empathy and Stress Reduction for Iranian Drivers New Tools for Traffic Psychology and Biocentric Health Management in Iran. Modern Care Journal , 16 (2). Stueck, Marcus, & Villegas, A. (2017). Evidence-Based BIODANZA Programmes for Children (TANZPRO-Biodanza) in Schools and Kindergartens. The Oxford Handbook of Dance and Wellbeing , 77. Toro, R. (2004). The Biocentric Principle. Unpublished Material. International Biocentric Foundation (IBF), Biodanzaschule Leipzig . Toro, R. (2005). The Biocentric Education. Unpublished Material. International Biocentric Foundation (IBF), Biodanzaschule Leipzig . Toro, Rolando. (2010). Das System Biodanza . Tinto-Verlag. Wade, D. T., & Halligan, P. W. (2017). The biopsychosocial model of illness: a model whose time has come . SAGE Publications Sage UK: London, England. WHO. (2020). tools guideline (Process of translation and adaptation of instruments) . World Health Organization. https://www.who.int/substance_abuse/research_tools/translation/en/ Additional Declarations No competing interests reported. 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Sciences","correspondingAuthor":false,"prefix":"","firstName":"Abbas","middleName":"","lastName":"Ebadi","suffix":""},{"id":532937528,"identity":"8a1eec98-7b5a-43fc-8a6f-5df08686c28a","order_by":2,"name":"Mariola Bidzan","email":"","orcid":"","institution":"University of Applied Sciences in Elbląg","correspondingAuthor":false,"prefix":"","firstName":"Mariola","middleName":"","lastName":"Bidzan","suffix":""},{"id":532937529,"identity":"97124802-549e-41ab-a4df-550d46c7ccf9","order_by":3,"name":"Gholamreza Ghaedamini Harouni","email":"","orcid":"","institution":"University of Social Welfare and Rehabilitation Sciences","correspondingAuthor":false,"prefix":"","firstName":"Gholamreza","middleName":"Ghaedamini","lastName":"Harouni","suffix":""},{"id":532937530,"identity":"b3ce5880-f5be-44bf-a5bd-3a1032fe3fa0","order_by":4,"name":"Hamidreza Khankeh","email":"data:image/png;base64,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","orcid":"","institution":"Berlin Institute of Health at Charité","correspondingAuthor":true,"prefix":"","firstName":"Hamidreza","middleName":"","lastName":"Khankeh","suffix":""},{"id":532937531,"identity":"9262f668-af1f-40c1-8c01-9fbd96196774","order_by":5,"name":"Marcus Stueck","email":"","orcid":"","institution":"DPFA 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14:08:54","extension":"json","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":8296,"visible":true,"origin":"","legend":"","description":"","filename":"946d44c53b304291bb6184e1384d1e3e.json","url":"https://assets-eu.researchsquare.com/files/rs-7739088/v1/385686711585268f13d0cf62.json"},{"id":94867457,"identity":"603a2e2b-0908-4491-90e0-11ce503ef2d0","added_by":"auto","created_at":"2025-10-31 14:08:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":861124,"visible":true,"origin":"","legend":"\u003cp\u003ePyramid model of anthropocentrism vs. network model of bio-centric cooperation ( Stueck, n.d.)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7739088/v1/a9725c1007ebb692322f9577.png"},{"id":94867448,"identity":"470c701f-4472-4666-8809-9096b772d259","added_by":"auto","created_at":"2025-10-31 14:08:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":137102,"visible":true,"origin":"","legend":"\u003cp\u003eScree Plot of Factor Number\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7739088/v1/f3b8c70de2cb0d88141ca99e.png"},{"id":104553388,"identity":"e15baa7d-8da3-43b7-a5ea-dfd198e878e2","added_by":"auto","created_at":"2026-03-13 08:42:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2556868,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7739088/v1/2f1e348c-d6c7-4f83-a6ba-525d4ef9c7bd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and Validation of a Bio-centric Acting questionnaire based on the Biocentric Health Management Theory","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHumans are experiencing some form of borderline personality disorder, with increasing stress, depression and chronic fatigue syndromes that arise from the confusion of modern life, destroying their health and their ability to relate. As such, a paradigm shift from the egocentric anthropocentric (human-centred) worldview to a bio-centric (life-centred) one is required in all areas of science and life, as Figure 1 shows below this paradigm shift. This would ensure the co-existence of people and nature, allowing them to respect their own inner disposition and the life that is inherent to it, and allowing others to do the same (Stueck, n.d.).\u003c/p\u003e\n\u003cp\u003eHumans are experiencing some form of borderline personality disorder, with increasing stress, depression and chronic fatigue syndromes that arise from the confusion of modern life, destroying their health and their ability to relate. As such, a paradigm shift from the egocentric anthropocentric (human-centred) worldview to a bio-centric (life-centred) one is required in all areas of science and life, as Figure 1 shows below this paradigm shift. This would ensure the co-existence of people and nature, allowing them to respect their own inner disposition and the life that is inherent to it, and allowing others to do the same (Stueck, n.d.).\u003c/p\u003e\n\u003cp\u003eThe bio-centric orientation is described by Rolando Toro as that of a \u0026lsquo;relationship human and the ecological human\u0026rsquo; (Toro, 2010). In Western culture, it is vital to restore the feeling for the \u0026lsquo;sanctity of life\u0026rsquo; and for the \u0026lsquo;enjoyment of life\u0026rsquo; as it is described in the theory of Biodanza and the biocentric principles of Toro (2010), because this attitude is having been forgotten. Developing affectivity, expanded cognition, and the expansion of ethical awareness should become an absolute priority (Toro, 2004, 2005, 2010). Also, the work of Schweitzer et al. (999), Naess (2013) and Cavalgante and Wagner (n.d.) has focused on ethical principles and the need to protect life. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on this and further theoretical biocentric frameworks, the Biocentric Health Management Theory (BHMT) was developed and scientifically investigated by Stueck during the COVID-19 \u0026nbsp;Crisis (2021). In this context, BHMT was called Pandemic Management Theory (Stueck, 2021, n.d.). One of the main claims of BHMT is that humans need to radically change their relationship with nature and the living elements therein, from seeing it purely in terms of its instrumental value to recognizing nature as a living community that has inherent value that must be protected and cooperated with. In the BHMT, the bio-centric worldview is an approach based on human understanding and feeling of being a part of the community of living beings (nature), recognized through affective experiences. This happens by connecting with human inner nature through orientation towards its biological and psychological life-centred biocentric core-activities (e.g., autoregulation and autopoiesis) and expressing authentically life-protecting biopsychological system-elements, for instance instincts, feelings, and all behavioural aspects of life in a continuous affective relationship with others and nature. This intra- and interpersonal feeling-based and experience-based connection and the increase of sensibility by using the proposed methods of bio-centric action (see next section) leads to a dissolution of bio-centric borders, namely: anxieties about life, empathic connection, expression of feelings about nature, to a wider perception of and connection with the sanctity and holiness of life, and to an increase of ethical consciousness and aesthetic recognition of being a part of nature and the universe, rather than obsessively attempting to dominate them.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBHMT is an approach that uses the laws that govern and protect life to guide pedagogical and methodological models in education, medicine, politics, economics, work, and psychology. The bio-centric approach of the BHMT orients various areas of action, not only in personal health but also in collective health, social policies, and inclusive models of coexistence of the human community (Benatti et al., 2020). In addition to the work of Toro (2010), it is also based on the biocentric approach of Morin and Freire (1991), the radical constructivism and autopoiesis of Maturana and Varela (2010), on chronobiopsychology (Balzer \u0026amp; Stueck, 2021; Stueck, n.d.), and the scientific evaluations of Biodanza (Marcus, 2021).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBio-centric fields of action and BHMT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe BHMT describes 6 fields of action to develop a life-protecting ethic, as table-1 shows below The essence and aim of bio-centric acting in these 6 fields is life itself and the connection with the \u0026lsquo;holiness\u0026rsquo; and \u0026lsquo;enjoyment\u0026rsquo; of life.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable-1: Six\u0026nbsp;Biocentric acting Scale and its Subscales based on BHMT\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"696\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSub scales\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e1-Affective Communication to myself, to others and to all living elements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eAffective, feeling based, connections between humans and them self\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eAffective connection to other humans\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eAffective connection to all living elements\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e2-Experience of Lively Corporeality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eConnection of wildness and instinctiveness of Life\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e3-Contact with healthy identity and inner orientation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eDevelopment of inner orientation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eself-reflexion in feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eInternal detachment of dependencies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eIdentity through affective encounters in feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eMaintaining autonomy, self- actualization and creative expression\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e4-Experience and Expression of Life Potentials\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eStimulating the joy of Living and the feeling of liveliness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eDevelopment of Life Sense and Trust\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eExperiential Integration subjective construction of knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e5-Expanded awareness and connection to the wholeness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eExperience of \u0026ldquo;implicate orders\u0026rdquo; (Bohm), \u0026ldquo;ent-anglements\u0026rdquo; (Zeilinger), Wholeness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e6-Ethical environmental action and ecological awareness of nature\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eEthical behaviour\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eEcological awareness\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eEcological strategies with biocentric approach\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThis sacred connection has been lost in many cultures, and the recent COVID-19 crisis has led to individual and widespread identity crises, showing the necessity of re-establishing this connection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStueck described 2 possible ways that the BHMT can work in the 6 fields. The Penguin Way \u0026ndash; from the head to the body \u0026ndash;- is one of the possible ways ( Stueck, 2015). This connection can be gained by methodologies that focus on experiential learning on an emotional, rather than an intellectual, level. This can be done with the use of experiential methods like the Biodanza to develop an aesthetic and ethical attitude and affective integration with life ( Toro, 2010). Toro emphasized on the need for humans to live within a natural and cosmic network as relationship-oriented and ecological humans. Much work has been done on the Biodanza theory (Maturana \u0026amp; Varela, 1980; Maturana, 2011; Maturana \u0026amp; Verden-Z\u0026ouml;ller, 2008; Toro, 2010; Stueck \u0026amp; Villegas, 2008; Stueck, n.d.).\u003c/p\u003e\n\u003cp\u003eThe other way in the BHMT model is from the body to head (the so-called Polar Bear Level), and describes methods that focus on the verbal-reflexive aspect of biocentric connections (e.g., respectful communication based on nonviolent communication; Rosenberg, 1965; R\u0026ouml;hr et al., 2020; Schoppe \u0026amp; St\u0026uuml;ck, 2012) This Polar Bear\u0026ndash;Penguin Paradigm secures the balance between the emotion-focused affective regulation and the reflexive level of autoregulation (Stueck, 2015).\u003c/p\u003e\n\u003cp\u003eThere are many other possibilities for work in biocentric fields of action (Stueck, n.d.). The Biocentric Health-Management Theory can be applied with both children and adults, and can be used in work environments and in educational and health-related fields, for example the School of Empathy (Stueck, 2013), the TANZPRO-Biodanza program for children (Stueck \u0026amp; Villegas, 2017), and Respectful communication (R\u0026ouml;hr et al., 2020).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBiocentric limits:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBiocentric limits have an impact on a person\u0026apos;s attitude to life (liveliness and vitality), well-being, and mental and physical health. Consequences of abnormal sensations are susceptibility to infections, depression, and hyperactivity. When the connection with life is lost, and depression and exhaustion occur alongside hyposensitivity states, an individual can no longer sets limits on work behaviours and may attempt to make contact with the outside world (hyperactivity), although a physiological passivity in the sense of increased inhibition might already indicate withdrawal \u0026nbsp;(Stueck, n.d.). Hence, it is essential to clarify the function of every job, using a standard tool to achieve this goal. \u0026nbsp;The prehospital system plays a vital role in the health system network through rapid patient transport and aims to provide proper treatment in the appropriate place and time by deploying available resources (Delshad et al., 2016). This crucial operation needs well-performing staff to manage stressful situations (Delshad et al., 2020). On the other hand, studies have shown that prehospital functions need improvement due to their critical situation (Koslowsky et al., 2013; Heydari et al., 2014; \u0026nbsp;Dadashzadeh \u0026amp; Rahmani, 2017). It is worth mentioning that the principal investigator in the present study has more than 5 years working in this field and has personally experienced stressful situations. The present study therefore aims to improve the function of prehospital staff and assess their acting based on reliable and valid tools.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheoretical Foundation of the Bio-centric Acting Scale\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003eased on the work of Toro (2010) and other researchers like Maturana, the psychometric properties of mental health evaluated by Becker, and BHMT, Stueck (2021) developed a questionnaire to measure biocentric acting. This battery is part of a psychometric instrument for the analysis of risk management (Stueck et al., 2019). This battery was shortened, adapted to Iranian culture and validated in the present study (see Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Bio-centric Acting questionnaire was developed based on the BHMT as an independent instrument that is part of a battery. In health and psychological sciences, a battery consists of independent tools, and as such, each instrument is scored separately (Flanagan et al., 2013), but the findings are interpreted together.\u003cbr\u003e\u0026nbsp;Objectives\u003cbr\u003e\u0026nbsp;This study aims to develop an instrument to evaluate Bio-centric Acting based on the BHMT using the hybrid concept development approach (HCDA; Schwartz-Barcott \u0026nbsp;\u0026amp; Kim, 2000) to examine the primary psychometric properties of the instrument (face validity, content validity, reliability, intraclass correlation coefficient).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eIn the first phase of this methodological study, indicators were extracted by a literature review. In order to prepare the questionnaire, a purposeful search was carried out about biocentric function. A thorough literature search was performed using keywords such as \u0026lsquo;biocentric\u0026rsquo;, \u0026lsquo;function\u0026rsquo;, \u0026lsquo;acting\u0026rsquo;, \u0026lsquo;field of action\u0026rsquo;, \u0026lsquo;health management\u0026rsquo;, and \u0026lsquo;life-centered\u0026rsquo; on scientific databases. Relevant studies were carefully examined and items were extracted from the studies and listed in the first draft. This \u0026nbsp;item pool was carefully reviewed by the research team regarding the extent of its coverage and relevance to the specified objectives of the BHMT. For some subscales, there were standard questionnaires, but the number of items was greater than those of the standard questionnaires. To date, it has been used to study a wide variety and range of concepts. An item pool was developed and categorized based on the HCDA into antecedents, attributes, and consequences by an expert panel in 3 focus group meetings in Iran and was approved in 4 virtual meetings on Skype between Iranian and German research members (Rivaz et al., 2019). After panel approval, the questionnaire was forward- and backward-translated according to the WHO guidelines (WHO, 2020). The psychometric properties, including face validity, content, construct validity, and reliability, were evaluated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eValidity:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFace validity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo access face validity, a cognitive interview was conducted with the prehospital staff. In this step, participants of diverse ages, experience, and education levels were asked to comment on the difficulty, appropriateness, and clarity of the items. Based on the comments received, some items were changed and clarified (Rose et al., 2009).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContent validity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContent validity was assessed using both qualitative and quantitative methods. In the qualitative content validity assessment, questionnaires were sent to experts who were selected from among the experts who participated in the questionnaire development \u0026ndash; prehospital staff trainers, prehospital staff experts with more than 10 years of working experience, psychologists, psychiatrists, psychiatric nurses, and emergency health managers (with at least MSc degrees) \u0026ndash; to assess the appropriateness of the wording, grammar, item allocation, and scaling of the items. Quantitative content validity was assessed using the content validity ratio (CVR). For CVR calculations, electronic forms of the questionnaire were sent to experts for evaluation. CVR values greater than 0.40 based on Lawshe\u0026rsquo;s table were considered acceptable (Lawshe, 1975).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReliability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe reliability of the tool was assessed using internal and external consistency tests. The internal consistency of the tool was evaluated using Cronbach\u0026rsquo;s alpha and the external reliability was evaluated using the test-retest method. For reliability assessment, 42 prehospital staff completed the questionnaire twice at a 10-day interval. The intraclass correlation coefficient (ICC) values of the questionnaire and its subscales were calculated using the two-way mixed effects method. Acceptable Reliability was considered as ICC values greater than 0.75 (Shoukri, 2010). Cronbach\u0026rsquo;s alpha values were calculated for the tool and its subscales. Values greater than 0.7 were considered acceptable (Mayers, 2013).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeveloping Bio-centric Acting questionnaire scoring\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe tool was scored on 5, 7, and 10-point Likert type scales from 5 to 1, and negatively-worded items were reverse scored (i.e., from 1 to 5). The standard 0\u0026ndash;100 scoring scale was applied after the weight of each item was determined. The raw scores of the questionnaire were converted to 0\u0026ndash;100 scores using the linear transformation equation (Ibrahim \u0026amp; Madian, 2011).\u003c/p\u003e\n\u003cp\u003eConstruct validity assessment:\u003c/p\u003e\n\u003cp\u003eThe construct validity was evaluated via EFA. The rule of thumb states that samples greater than 300 are appropriate for most EFAs (Harrington, 2009). Eligibility criteria were the same as those explained in the qualitative phase (Nulty, 2008).\u003c/p\u003e\n\u003cp\u003eEFA was performed to extract the latent constructs. Sample appropriateness was evaluated via the Kaiser-Meyer-Olkin (KMO) test and Bartlett\u0026rsquo;s test of sphericity. KMO values of 0.7\u0026ndash;0.8 and 0.8\u0026ndash;0.9 were interpreted as acceptable and large sample sizes, respectively (Nia et al., 2014). Then, latent constructs extracted through likelihood and varimax rotation. Factor loading was set at 0.5 or greater and, thus, items with communalities lower than 0.5 were removed from factor analysis (Samitsch, 2014).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical data analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSPSS version 22 was used for data analysis. The data were presented in termsof descriptive statistics, including mean, standard deviation, standard error of measurement, and frequencies. Moreover, statistical analyses were performed using paired \u003cem\u003et\u003c/em\u003e-tests, Cronbach\u0026rsquo;s alpha, and ICC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was approved by the ethics committee of the University of Social Welfare and Rehabilitation Sciences (code: IR.USWR.REC.1398.145). Written informed consent was obtained from all participants. Moreover, the researchers took steps to ensure confidentiality and that no harm was done to the participants.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAfter the first draft of the instrument developed from literature review studies was completed, the panel of experts carefully examined the items in regards to the extent of their coverage and their relevance to the specified objectives of the BHMT.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCategorization:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eItems were categorized by experts into three dimensions: antecedent, attribute, and consequences using the Hybrid model, and 131 items in the attribute dimension were selected by the expert panel for further evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFace and Content Validity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe face validity of the instrument was assessed by 11 prehospital staff and some items were edited and simplified due to ambiguity. In this stage, 21 items were revised for clarity. For content validity assessment, electronic forms of the questionnaire were sent to 80 experts to assess the essentiality of the items. Forty-one experts answered the questionnaire. About 12 participants also answered the questionnaire but the responses were not rich enough and were excluded. Finally, 29 experts were included. CVR values greater than 0.332 based on the Lawshe table were considered acceptable (Hyrk\u0026auml;s et al., 2003). The CVR range for all the items was between 0.37 and 1. Ultimately, 48 items that had a CVR of \u0026lt; 0.37 were removed. Also, 44 items were removed through validity assessment, and 81 items were retained in the final draft.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReliability\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The Cronbach\u0026rsquo;s alpha coefficient of the tool was 0.89 and the intraclass correlation coefficient of the test-retest results was 0.78. In this stage, 36 acceptable responses were selected based on quality and answer time. ICC values greater than 0.75 were considered to constitute acceptable reliability. Cronbach\u0026rsquo;s alpha values were also calculated for the tool and its subscales and values greater than 0.7 were considered acceptable. (Table-2)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eIntraclass Correlation Coefficient, Cronbach\u0026rsquo;s Alpha Values for the scales\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"615\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eICC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCronbach\u0026rsquo;s Alpha\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Items\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAffective Communication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.85\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.79\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e25\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience of Lively Corporeality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.69\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.73\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContact with healthy identity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.76\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.71\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience and Expression of Life Potentials\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.66\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.86\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e11\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExpanded awareness and connection to the wholeness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.75\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.69\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthical environmental action and ecological awareness\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.81\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBio-centric boundary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.86\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.89\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 387px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.780c\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.895\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e81\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe above table shows the ICC, Cronbach\u0026rsquo;s alpha, and the number of items for each scale. Arranging the factors in order of relevance to competency yielded the following results: Affective Communication had the highest ICC and Ethical Environmental Action had the lowest, although its total ICC and Cronbach\u0026rsquo;s Alpha were in the acceptable range.\u003c/p\u003e\n\u003cp\u003eConstruct Validity:\u003c/p\u003e\n\u003cp\u003eIn Table 3, the Kaiser-Meyer-Alkin index (KMO) is equal to 0.900 and Bartlett\u0026rsquo;s sphericity test at 5016.181 (at the level of \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001) was significant. Therefore, it can be concluded that the implementation of factor analysis based on the correlation matrix in the study sample (300 people) can be justified.\u003c/p\u003e\n\u003cp\u003eTable-3 KMO and Bartlett sphericity test (BT) bio-centric Acting Instrument\u0026nbsp;\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 624px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKMO and Bartlett\u0026apos;s Test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 416px;\"\u003e\n \u003cp\u003eKaiser-Meyer-Olkin Measure of Sampling Adequacy.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e.900\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eBartlett\u0026apos;s Test of Sphericity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eApprox. Chi-Square\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e5016.181\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e561\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eSig.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eA total of 34 items with specific variances were divided into 3 factors with variances of 28.487, 9.402, and 4.676. These factors explained 42.56% of the total variance in stress outcomes, which is almost acceptable (Table 4)\u003c/p\u003e\n\u003cp\u003eTable 4. General explained variance of the Bio-centric Acting Instrument\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"699\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" style=\"width: 699px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Variance Explained\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003eFactor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 266px;\"\u003e\n \u003cp\u003eInitial Eigenvalues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 277px;\"\u003e\n \u003cp\u003eExtraction Sums of Squared Loadings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003eRotation Sums of Squared Loadings\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 68px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 98px;\"\u003e\n \u003cp\u003e% of Variance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003eCumulative %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 79px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 98px;\"\u003e\n \u003cp\u003e% of Variance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 99px;\"\u003e\n \u003cp\u003eCumulative %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e10.235\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e30.103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e30.103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e9.686\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e28.487\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e28.487\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e8.467\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e3.769\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e11.085\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e41.188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e3.197\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e9.402\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e37.889\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e7.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e2.137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e6.285\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e47.474\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e1.590\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e4.676\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e42.565\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e5.186\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e1.466\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e4.311\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e51.784\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e1.318\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e3.877\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e55.661\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e1.057\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e3.108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e58.769\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e1.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e2.943\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e61.713\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.946\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e2.783\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e64.496\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.863\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e2.539\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e67.035\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.829\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e2.437\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e69.472\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.763\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e2.244\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e71.716\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.722\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e2.124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e73.839\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.700\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e2.059\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e75.899\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.660\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e1.943\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e77.841\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.611\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e1.799\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e79.640\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.593\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e1.743\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e81.383\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.543\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e1.598\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e82.981\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.522\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e1.537\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e84.517\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.498\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e1.463\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e85.981\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.489\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e1.439\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e87.419\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.468\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e1.378\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e88.797\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.433\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e1.274\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e90.071\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.399\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e1.173\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e91.244\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.376\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e1.104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e92.349\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.360\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e1.060\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e93.408\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.322\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e.948\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e94.357\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.318\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e.937\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e95.293\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.292\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e.858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e96.151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.258\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e.760\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e96.910\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.249\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e.731\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e97.642\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e.696\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e98.338\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e.604\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e98.942\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e.572\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e99.514\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e.165\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e.486\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e100.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 699px;\"\u003e\n \u003cp\u003eExtraction Method: Maximum Likelihood.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 699px;\"\u003e\n \u003cp\u003ea. When factors are correlated, sums of squared loadings cannot be added to obtain a total variance.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAfter examining the internal consistency of the items, it appears that the Bio-centric Acting Instrument has three factors, but the contribution of the first factor to the total variance of the variables was more significant and distinct from the other factors. The slope of the graph almost disappears after the second factor. (Figure-2)\u003c/p\u003e\u003cp\u003eBased on the psychometry, 34 items related to Bio-centric Acting were formed into 3 factors. The first factor, Self-relationship and Communication with Nature, contained 15 items, the second factor, Relationship to Others, contained 11 items, and the third factor, Individual Turmoil, contained 8 items.\u003c/p\u003e\n"},{"header":"Discussion","content":"\u003cp\u003eThe instrument developed in this study is based on 6 subscales of Bio-centric Acting; Affective Communication, Experience of Lively Corporeality, Contact with Healthy Identity, Experience and Expression of Life Potentials, Expanded Awareness and Connection to Wholeness, and Ethical Environmental Action and Ecological Awareness.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAll of these subscales had acceptable validity and reliability except the Ethical Environmental Action and Ecological Awareness subscale. However, in the final version, just 34 items in 3 subscales were retained; based on BHMT, an expert panel named them: 1 \u0026ndash;\u0026nbsp;Self-relationship and Communication with Nature; 2 \u0026ndash; Relationship to Others; and 3 \u0026ndash; Individual Turmoil. This instrument was part of a whole battery which was developed to evaluate psychobiological health \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrehospital staff work for long hours under stressful conditions and often witness the agonies, physical destruction, and psychological devastation of victims (Koslowsky et al., 2013). Therefore, accurate and timely identification of stressors and maintaining preparedness to cope with them are crucial tasks for keeping staff effective (Moradi et al., 2016). The development of a valid and reliable tool is thus essential for the assessment of Bio-centric Acting in prehospital staff.\u003c/p\u003e\n\u003cp\u003ePrevious studies have shown that the development of assessment tools is important for pre-hospital emergency staff because of their important role (Benatti et al., 2020). Also, the rate of exposure to stressors is moderately high among emergency medical staff. Thus, identifying the rate of exposure of emergency medical staff to stressors can help prevent burn out and improve their functioning (Dadashzadeh \u0026amp; Rahmani, 2017). The questionnaire developed in this study can be an initial step towards the assessment of Bio-centric Acting in stressful professions such as prehospital staff.\u003c/p\u003e\n\u003cp\u003eAvraham et al. (2014) have investigated the bio-mental-social health of pre-hospital emergency personnel. They found that work stress has a profound effect on the relationships of emergency personnel with others, which is in line with the results of the present study.\u003c/p\u003e\n\u003cp\u003eAccording to Nino et al. (2020), physical, psychosocial, biological, and personal characteristics differ between individuals. Factors such as increased mental workload, job fatigue, and lack of communication can have negative effects on psychological and social factors. In line with this study, they emphasized the importance of communication and relationships with others. Similarly, a study by Drake et al., (2017) examined the health of prehospital emergency staff based on the bio-psycho-social model and found that improved bio-psycho-social health increases efficiency and effectiveness. Although this study mentioned efficiency and effectiveness improvements and is similar to the current study, it differs from our study in that it also focuses on patient care and costs.\u003c/p\u003e\n\u003cp\u003eTo promote public health, it is necessary to focus on the provision of pre-hospital services, appropriate policymaking, foresight, adoption of a systemic view, as well as to develop comprehensive research programs and roadmaps (Bahadori et al., 2016). The Bio-centric Acting instrument makes it possible to collect data about prehospital staff. In this study, a Bio-centric Acting questionnaire was developed which can be crucial for assessing and promoting Bio-centric acting. Other scholars can also adapt the tool to other cultures and to other contexts and professions (Delshad et al., 2020). Regarding scoring and interpretation in batteries, each instrument is scored, but the findings should be interpreted as a health profile battery, which will be explored in a subsequent study which is currently underway (Safrit \u0026amp; Wood, 1987; Flanagan et al., 2013)\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe instrument developed in this study has acceptable psychometric properties. The findings will be useful for policy makers and planners who aim to improve functioning among prehospital staff. It can be used to guide improved regulations for prehospital staff and also in other professions. Furthermore, the results will be helpful for exploring the process of bio-centric functioning in other similar occupations, such as firefighters, emergency department workers, and rescue service workers. Therefore, it should be emphasized again that this article aims to develop a part of battery comprising other instruments and to review literature based on bio-centric health management theory compatible with Iranian culture in the population of pre-hospital technicians.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo the best of our knowledge, this is the first study to apply the hybrid concept of a life-centered paradigm to study bio-centric acting among prehospital staff, who work in high stress environments. Also, the study was an international cross-cultural study between Germany and Iran, and the research team included one policy-maker with more than 20 years working experience in this field (Prof. Marcus Stueck). On the other hand, the reluctance and/or refusal of some staff to collaborate in the construct validity assessment is the most important limitation of this study. Moreover, this study is part of an ongoing study (PhD dissertation), and data acquisition was slower than normal due to the COVID-19 pandemic.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBio-centric health management Theory (BHMT)\u003c/p\u003e\n\u003cp\u003eHybrid concept development approach (HCDA)\u003c/p\u003e\n\u003cp\u003eExploratory Factor Analysis (EFA) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBio-centric Acting (BA)\u003c/p\u003e\n\u003cp\u003eContent validity ratio (CVR)\u003c/p\u003e\n\u003cp\u003eIntra class correlation coefficient (ICC)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis PhD project was evaluated positively by the Ethical Committee and approved by the Health in Emergency and Disaster research center of the University of Social Welfare and Rehabilitation (Approval ID: IR.USWR.REC.1398.145 Approval Date: 2019.11.25), Iran.\u003c/p\u003e\n\u003cp\u003eWritten consent to participate was evaluated and approved by the ethical committee as a standard form in the USWR university (this project is being carried out in Iran, and the consent letter is in Farsi).The study was conducted in accordance with the Declaration of Helsinki\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThe work was not supported by funds and has not received external funding.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVD: Conceptualization, methodology, investigation, formal analysis, writing - original draft, project administration. AE: Methodology, validation, writing - review and editing. MB: Resources, writing - review and editing. GGH: Formal analysis, writing - review and editing. HRKH: Supervision, writing - review and editing, funding acquisition. MS: Conceptualization, theoretical framework, writing - review and editing. All authors read and approved the final manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Not applicable in this phase of study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy status\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This is an ongoing study and participant recruitment has not been completed at the time of submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVD is a paramedic who has been working in EMS for 6 years, has an MSc in Nursing Education, and is a PhD in Health in Emergency and Disaster in USWR, Iran and DPFA Germany. He is so interested in making connections between Psychobiological concepts and emergency and disaster medicine, with international collaboration.\u003c/p\u003e\n\u003cp\u003eMS, PhD and Hab. in Psychology and Professor in DPFA, Academy of Work and Health Leipzig, Germany.\u003c/p\u003e\n\u003cp\u003eAE, PhD in Nursing and Professor in Behavioral Sciences Research Center,\u0026nbsp;Life-style institute,\u0026nbsp;Baqiyatallah University of Medical Sciences, Tehran, IR Iran.\u003c/p\u003e\n\u003cp\u003eGhGh, PhD and Assosiate professor in Social Welfare Management Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.\u003c/p\u003e\n\u003cp\u003eHRKh, PhD, Post-doctoral research fellowship in Emergency and disaster Health, Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMB, PhD in Psychology and Professor in Institute of Psychology, University of Gdansk, Gdansk, Poland.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAvraham, N., Goldblatt, H., \u0026amp; Yafe, E. (2014). Paramedics\u0026rsquo; experiences and coping strategies when encountering critical incidents. \u003cem\u003eQualitative Health Research\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(2), 194\u0026ndash;208.\u003c/li\u003e\n\u003cli\u003eBahadori, M., Ghardashi, F., Izadi, A. R., Ravangard, R., Mirhashemi, S., \u0026amp; Hosseini, S. M. (2016). Pre-hospital emergency in Iran: A systematic review. \u003cem\u003eTrauma Monthly\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(2).\u003c/li\u003e\n\u003cli\u003eBenatti, B., Albert, U., Maina, G., Fiorillo, A., Celebre, L., Girone, N., Fineberg, N., Bramante, S., Rigardetto, S., \u0026amp; Dell\u0026rsquo;Osso, B. (2020). What happened to patients with obsessive compulsive disorder during the COVID-19 pandemic? A multicentre report from tertiary clinics in northern Italy. \u003cem\u003eFrontiers in Psychiatry\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e, 720.\u003c/li\u003e\n\u003cli\u003eCavalcante, R., \u0026amp; Wagner, C. 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Tinto-Verlag.\u003c/li\u003e\n\u003cli\u003eWade, D. T., \u0026amp; Halligan, P. W. (2017). \u003cem\u003eThe biopsychosocial model of illness: a model whose time has come\u003c/em\u003e. SAGE Publications Sage UK: London, England.\u003c/li\u003e\n\u003cli\u003eWHO. (2020). \u003cem\u003etools guideline (Process of translation and adaptation of instruments)\u003c/em\u003e. World Health Organization. https://www.who.int/substance_abuse/research_tools/translation/en/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Psychometric assessment, Validity, Reliability, Bio-centric Acting, Emergency Medical Services","lastPublishedDoi":"10.21203/rs.3.rs-7739088/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7739088/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: The bio-centric worldview is an approach based on human understanding and feeling of being a part of nature through affective experiences and ability to connect with life. The essence of biocentric-acting is life and the connection with the ‘holiness’ and ‘enjoyment’ of life. It seems that this sacred connection with life has been lost in many communities, especially among medical service workers, and the individual and widespread identity crisis that has resulted from the recent Covid-19 pandemic shows the necessity of re-establishing this connection. However, there is no standardized instrument for measuring Bio-centric Acting. This study aims to develop and assess, for the first time, the psychometric properties of biocentric-acting based on the bio-centric health management theory (BHMT) as a theoretical framework and to test it in an Iranian context.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: In this methodological study, items were extracted from relevant literature according to the specified objectives of the BHMT. The first draft of the biocentric-acting questionnaire for prehospital staff was designed based on BHMT with the Hybrid concept development approach (HCDA). Then, the psychometric properties, including face content and construct validity as well as reliability, were analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: All explored items were categorized as antecedent, attribute, or consequence based on the HCDA. Subsequently, 131 items related to attributes were chosen for further analysis in the study. In the following step, face and content validity of the questionnaire were assessed by 11 prehospital staff and 29 experts. A total of 81 items were retained for Exploratory Factor Analysis (EFA) with 300 prehospital staff. Finally, 34 items related to Biocentric Acting were arranged into 3 factors: 1 – Self-relationship and Communication with Nature; 2 – Relationship to Others; and 3 – Individual Turmoil.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: This biocentric-acting questionnaire was developed in the Iranian context to assess prehospital staff acting based on the BHMT. It is recommended that this instrument be adopted using BHMT for other occupations and different contexts, to develop a full BHMT scale, especially for workers who have been engaged in the response to the pandemic, in order to assess the consequences of COVID-19.\u003c/p\u003e","manuscriptTitle":"Development and Validation of a Bio-centric Acting questionnaire based on the Biocentric Health Management Theory","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-31 14:08:17","doi":"10.21203/rs.3.rs-7739088/v1","editorialEvents":[{"type":"communityComments","content":1}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"63b95f4e-ca58-4db6-92ea-897b2a51ced5","owner":[],"postedDate":"October 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-13T08:41:29+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-31 14:08:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7739088","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7739088","identity":"rs-7739088","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}