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Structural Equation Modeling of Bio-centric acting and health in Iranian EMS

This study developed and psychometrically validated the three-dimensional Biocentric Acting Questionnaire (BAQ) for Iranian pre-hospital emergency staff, demonstrating its reliability and significant predictive relationship with stress and physiological health parameters.

Original authors: Vahid Delshad, Abbas Ebadi, Mariola Bidzan, Gholamreza Ghaedamini Harouni, Hamidreza Khankeh, Marcus Stuck

Published 2026-08-07

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CC BY 4.0

Original authors: Vahid Delshad, Abbas Ebadi, Mariola Bidzan, Gholamreza Ghaedamini Harouni, Hamidreza Khankeh, Marcus Stuck

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

The Invisible Shield: Why Your Connection to Life Matters

Imagine your mind and body as a high-performance car. For decades, mechanics (scientists and doctors) have focused almost entirely on fixing the broken parts: the flat tires of stress, the cracked engines of burnout, and the sputtering pistons of anxiety. They've built excellent tools to measure how much damage a car has taken. But what if the secret to a smooth ride isn't just about fixing the damage, but about how the car is tuned to the road it's driving on?

This is where a fascinating idea called "Biocentric Health" comes in. Think of it as a shift in perspective. Instead of seeing humans as the only important things in the universe (like the driver who thinks the car is the only thing that matters), this theory suggests we are part of a giant, living network. It proposes that our health depends on three special connections: how we treat ourselves, how we connect with other people, and how we feel about nature. When these connections are strong, they act like a super-shield, helping us bounce back from the bumps and potholes of a tough job. The big question researchers have been asking is: Can we actually measure this "super-shield" in people who face the most dangerous roads of all, like emergency medical workers?

The Mission: Building a New Compass for Heroes

In this study, a team of researchers from Iran, Germany, and Poland decided to build a new tool to measure this "super-shield" specifically for the brave men and women who work in Iran's pre-hospital emergency services (EMS). These are the paramedics and technicians who rush into life-threatening situations, often working long shifts and seeing terrible accidents. The researchers wanted to create a questionnaire called the Biocentric Acting Questionnaire (BAQ). Their goal wasn't just to ask "Are you stressed?" but to ask "How connected do you feel to life, nature, and others?"

To build this tool, they started with a massive pile of 131 potential questions. They acted like editors cutting a long movie down to its best scenes. They asked experts to check if the questions made sense, then tested them on real emergency workers. They split a group of 585 workers into two teams: one team helped them discover the hidden patterns in the answers (a process called Exploratory Factor Analysis), and the other team helped them confirm those patterns were real (Confirmatory Factor Analysis). Finally, they used a complex computer model (Structural Equation Modeling) to see how this new "connection score" related to stress and physical health.

What They Found: The Three Pillars of Connection

The researchers discovered that the BAQ works like a three-legged stool, holding up a person's health. These three legs are:

Self and Nature: How well you understand your own feelings and feel connected to the natural world.
Relationship to Others: How well you connect with and help other people.
Individual Turmoil: This is the "broken leg" of the stool. It measures feelings of restlessness and emotional chaos. Interestingly, the more of this turmoil a person has, the lower their "bio-centric" score.

When they tested the tool, it showed it was reliable. The internal consistency score was 0.895, which is like a very high grade on a test, meaning the questions consistently measure the same thing. They also checked it again 10 days later, and the results stayed steady (a score of 0.78), proving it wasn't just a fluke.

The Big Reveal: Connection Saves Lives

The most exciting part of the study was seeing how this "connection score" actually affected the workers' bodies. The researchers used a sophisticated model to trace the path from stress to health. They found that when workers faced high external stress (like heavy workloads), their ability to connect with life dropped. But here is the magic: the study found a very strong link between having a high "bio-centric" score and having better physical health.

Specifically, the model showed a path coefficient of 0.89 between the BAQ score and physiological status. In plain English, this means that workers who felt more connected to themselves, others, and nature reported significantly better physical health, including their blood pressure, heart rate, and oxygen levels. It suggests that this "life-centered" way of acting isn't just a nice feeling; it acts like a biological buffer, helping the body stay calm even when the job is chaotic.

The Caveats: A Work in Progress

While the results are promising, the researchers are careful not to call this a magic cure-all. They admit that their model wasn't a perfect fit for the data (the fit scores were a bit lower than the ideal, around 0.81 instead of 0.90), which is common when testing a new idea in a new culture for the first time. Also, because they only looked at one moment in time, they can't say for sure that feeling connected causes better health, only that they happen together.

Furthermore, the study mostly included men (97.9% of the participants), which reflects the reality of the Iranian emergency workforce but means we don't know yet if this tool works exactly the same way for women or in other countries. The researchers also noted that the physical health data was mostly self-reported, though they did double-check some of it on-site.

The Takeaway

This paper successfully built the first-ever tool to measure "bio-centric acting" for emergency workers in Iran. It suggests that focusing on positive connections—to oneself, to others, and to nature—might be a powerful way to protect the health of those who save lives. While more research is needed to refine the tool and test it in different groups, the study offers a hopeful new direction: maybe the best way to heal our heroes isn't just to treat their stress, but to strengthen their connection to the living world around them.

Technical Summary: Structural Equation Modeling of Bio-centric Acting and Health in Iranian EMS

Problem Statement
Pre-hospital Emergency Medical Services (EMS) personnel globally face high levels of occupational stress, secondary traumatic stress, and burnout, leading to adverse mental and physical health outcomes. While existing instruments effectively measure deficits such as stress and burnout, there is a lack of validated tools grounded in salutogenic (resource-oriented) frameworks that assess positive health resources. Specifically, the Biocentric Health Management Theory (BHMT), which posits that optimal health arises from affective connections with oneself, others, and nature, has not been operationalized into a validated instrument for pre-hospital emergency staff. Furthermore, no culturally adapted, Persian-language tool exists to assess "bio-centric acting" within the Iranian context, limiting the application of BHMT-based interventions in this region.

Methodology
This study employed a multi-method psychometric research design conducted in Tehran, Iran, between December 2020 and June 2021. The research followed three distinct phases:

Instrument Development: Using the Hybrid Concept Development Approach (HCDA), an initial pool of 131 items was generated through literature review, adaptation of the German "Health Cube Battery," and expert panel consensus. Items were refined through face validity testing (cognitive interviews with 11 staff) and content validity assessment (29 experts using Lawshe's Content Validity Ratio). This process reduced the item pool to 81 items for the initial Exploratory Factor Analysis (EFA).
Psychometric Validation: A total of 585 pre-hospital EMS staff participated. The sample was split into two groups: 300 participants for EFA and 263 for Confirmatory Factor Analysis (CFA) and Structural Equation Modeling (SEM).
- EFA: Used maximum likelihood extraction with varimax rotation to identify the underlying factor structure.
- CFA: Tested the fit of the EFA-derived three-factor model using indices including $\chi^2/df$ , CFI, NFI, GFI, and RMSEA.
- SEM: Examined the predictive validity of the Biocentric Acting Questionnaire (BAQ) by modeling relationships between stress sources (internal/external), workload, BAQ scores, and physiological parameters (blood pressure, heart rate, oxygen saturation).
Reliability Assessment: Internal consistency was measured via Cronbach's $\alpha$ , and temporal stability was assessed using a 10-day test-retest Intraclass Correlation Coefficient (ICC).

Key Contributions

Development of the BAQ: The study successfully developed the Biocentric Acting Questionnaire (BAQ), the first instrument specifically designed to measure bio-centric acting based on BHMT for pre-hospital emergency staff.
Cross-Cultural Adaptation: The paper provides the first psychometrically validated Persian version of a BHMT-based instrument, addressing a critical gap in non-Western emergency health research.
Methodological Rigor: The study utilized a comprehensive validation pipeline (HCDA $\rightarrow$ Translation $\rightarrow$ Face/Content Validity $\rightarrow$ EFA $\rightarrow$ CFA $\rightarrow$ SEM) with a large sample size exceeding minimum requirements for factor analysis.
Integration of Physiological Data: Unlike many psychological studies, this research integrated self-reported and audited physiological parameters into the structural model to test the embodiment of bio-centric acting.

Results

Factor Structure: EFA revealed a three-factor structure explaining 42.6% of the total variance:
1. Self-Relationship and Communication with Nature: Capturing intra-personal vitality and connection to the natural environment.
2. Relationship to Others: Reflecting interpersonal empathy and social support.
3. Individual Turmoil: Representing the absence of bio-centric functioning (e.g., restlessness, emotional dysregulation).
Model Fit: CFA yielded marginal fit indices (CFI = 0.810, RMSEA = 0.053). The authors note these are acceptable for early-stage validation in a new cultural context, though below ideal thresholds (CFI $\ge$ 0.90).
Reliability: The total scale demonstrated good internal consistency (Cronbach's $\alpha$ = 0.895) and good test-retest reliability (ICC = 0.78).
Structural Equation Modeling: The SEM confirmed predictive validity. Key findings included:
- External stress positively predicted workload, which negatively predicted BAQ scores.
- Internal stress predicted negative stress consequences, which also negatively predicted BAQ scores.
- BAQ strongly predicted physiological status ( $\beta$ = 0.89, $p$ < 0.001), indicating that higher bio-centric acting scores are associated with better physiological health markers.

Significance and Claims
The paper claims that the BAQ is a valid and reliable tool for assessing bio-centric acting in Iranian pre-hospital emergency staff. The study establishes that bio-centric acting is not merely a subjective psychological state but is significantly associated with objective physiological parameters, supporting the BHMT premise that life-centered connections influence neuroendocrine and autonomic systems.

The authors position the BAQ as a resource-oriented alternative to traditional deficit-focused stress assessments. They suggest its utility for:

Workforce Monitoring: Identifying staff at risk for burnout and poor health.
Intervention Design: Creating targeted programs (e.g., nature-based team building, empathy training) to strengthen the three BAQ dimensions.
Evaluation: Measuring the effectiveness of health interventions in emergency services.

The authors remain modest regarding the study's limitations, acknowledging the cross-sectional design (precluding causal inference), the predominantly male sample (97.9%), the reliance on self-reported physiological data (due to pandemic constraints), and the fact that the study was conducted exclusively in Tehran. They emphasize that while the three-factor structure is theoretically coherent, the model fit indices suggest the need for further refinement and validation in more diverse, gender-balanced, and multi-site populations.