1. Introduction
Hemophilia is an inherited genetic disorder. In this disorder, severe and spontaneous bleeding may occur because of an insufficient blood-clotting factor in the body. Depending on the shortage of coagulation factor in the blood, the severity of the disease will be different (DeKoven et al., 2014; Iannazzo et al., 2017). Commonly, the bleeding happen into the joint spaces (hemarthrosis), especially in the knees, ankles, and elbows. It also causes intracranial and postoperative bleeding (Hosseini et al., 2014). Frequent and severe bleeding, movement limitations and other complications will eventually result in emotional and life-threatening problems (Chen et al., 2015). Because of their special medical care (Jafari, Mohtashami, Alaee Karahroudi, Mansouri, & Rassouli, 2016).
The normal activities of the patients and even their family members and people around them will be significantly and negatively affected (Sidonio, Holot, & Cooper, 2017). On the other hand, drugs side-effects, immobilization, frequent absences from school and school dropout (Cassis, Querol, Forsyth, Iorio, & Board, 2012), economic costs imposed on individuals and society (Poon, Doctor, & Nichol, 2014; Rezende et al., 2017; Sondik, Madans, & Gentleman, 2010), infection with hepatitis B, C viruses and some special treatments that result in inappropriate physical appearances in many patients lead to disturbances in feeling good and well-being, and affect the quality of the patients’ relationships with others (Klein & Nimorwicz, 1982). 
Considering that the most part of the Iran health care subsidy is spent on the patients with hemophilia and one-fifth of the total cost of importing medicine are allocated to hemophilia patients, it is one of the most expensive diseases in Iran. Given that the majority of hemophiliacs living in the country’s distant provinces and challenged with the medicines shortage in addition to above-mentioned problems, the Life expectancy of students with hemophilia is unfortunately short (Dorgalaleh, Dadashizadeh, & Bamedi, 2016; Karimi & Haghpanah, 2015). 
In recent years, psychologists have investigated the structure of hope and believe that hope is one of the foundational principles of mental power and balance of human minds (Griggs, 2017; Shorey, Snyder, Yang, Lewin, & Psychology, 2003). Psychologists believe that hope can improve several aspects of life such as mental health, education, work, and personal meaning. There are three fundamental factors in creating hope as a positive feeling. These three factors included goals, pathways, and agency (Snyder, & Lopez, 2009). Snyder that studied the phenomenology of hope, believed that those people with the ability to develop and self-optimize these components are hopeful people (Snyder, Lopez, & Pedrotti, 2010). Although numerous studies have been so far conducted to investigate neurological signs and complications of hemophilia, there are few studies on psychological problems that can cause or exacerbate cognitive diseases in hemophilic patients (Dehghan & Memarian, 2013).
Sporadic studies have been conducted in this area around the world and demonstrated that a high percentage of hemophilia patients suffer from depression, anxiety, and moderate to severe stress (Ghavidel Heydari, Shirazi, & Sanagouyemoharer, 2018; Poormansouri, Ahmadi, Shriati, & Keikhaei, 2016). By studying the prevalence of major depressive disorder and negative behavioral patterns in children and adolescents with hemophilia, those who were randomly selected, it was found that 36% of them had at least a death wish once in the past 6 months (Ghanizadeh & Balich‐Jahromi, 2009). Therefore, psychological support and mental health protection are critical for helping children and adolescents with this chronic disease (Torres‐Ortuño, Cid‐Sabatel, Barbero, & García‐Dasí, 2017). Positive psychotherapy is a cognitive psychological strategy and one of the practical approaches that can be effective to obviate psychological problems of hemophilia, considering the age and characteristics of the patients (Thorn, 2017). 
Research studies have shown that it is possible to train children and adolescents to learn the required skills to implicate optimism and reality-based positive thinking according to their psychological problems and to manage the mental tensions and problematic situations (Seligman & Csikszentmihalyi, 2014; Stewart, Watson, Clark, Ebmeier, & Deary, 2010). positive psychotherapy refers to using positive thinking interventions to deal with depression by encouraging positive emotions, raising the level of positive engagement in life, and increasing the meaning of life (Falakaflaki & Malekitabar, 2016). These people would like to pay more attention to their merits and resources, rather than the possibility of failure and problems (Ji, Holmes, & Blackwell, 2017; Khodabakhsh, Khosravi, & Zarrinpour, 2015).
Studies show a direct and significant relationship between optimism and Life expectancy that increase the levels of hope (Conoley & Conoley, 2009). Hutz, Midgett, Pacico, Bastianello and Zanon (2014) conducted research entitled “the relation of hope, optimism, self-esteem, mental well-being and personality” and found out a direct and significant relationship between optimism and hope for life, mental well-being, and self-esteem. Furthermore, Lyonotope study results indicate that positive psychological interactions can increase hope, perceived social support, and the ability to cope with social stress in individuals (Leontopoulou, 2015). 
Previous studies have examined the effectiveness of optimism in Life expectancy, in other words, there are several studies conducted to shed light on the efficacy of positive psychotherapy on different groups that have psychological problems (Johnson & Wood, 2017; Meyer, Johnson, Parks, Iwanski, & Penn, 2012). Given the chronic nature of hemophilia, short Life expectancy index, and its most patients as children and teenagers, it is easy to imagine the myriad of the problems and significant economic burden on the healthcare system that would be created by psychological complications of this disease. The present study seeks to answer the question of if positive psychotherapy training can improve the Life expectancy of hemophilic students.

2. Methods
In this study, we investigated the impact of positive psychotherapy on Life expectancy in three stages of Pre-test, post-test, and follow-up in a quasi-experimental research with an experimental and a control group. The statistical population included 70 students from the Hemophilia Center of Zahedan City, Iran in 2016-2017. Of this group, 56 students who agreed to participate in this study were selected and randomly assigned to an experimental (n=28) and a control group (n=28). 
Inclusion criteria were diagnosis of hemophilia based on medical diagnostic tests available in medical records, living in Zahedan, studying at senior elementary or junior high school, being able to cooperate and implement the program, not dealing with any other diseases except hemophilia based on a physician’s opinion and medical records (some patients with asthma, kidney failure, and so on were excluded from study) and finally, not taking part in any other psychological interventions. In this study, we followed the CONSORT flow diagram illustrated in Figure 1. In this study, we follow positive psychotherapy protocol developed by Seligman and are presented in Table 1 (Seligman & Csikszentmihalyi, 2014).
Children’s Hope Scale Questionnaire: Snyder (1991) developed this questionnaire to measure the amount of hope. It has 12 items in which 8 items are used in calculating the hope index and 4 other items are deviating phrases that are not included in the rating. The range of this test score is 0 to 4 and higher scores represent a greater Life expectancy and vice versa (Snyder, 2000; Kermani, Khodapanahi, & Mahmoud, 2011).
This project was done with the consideration of ethical issues. For each participant in the study, a meeting was held between the study administrator, the student and their parents for 30 minutes. In this session, we provided clear explanations about the research objectives, the method of research, a brief presentation of positive psychotherapy protocol and the pros and cons of the treatment. In addition, we introduced some research in these domains in which positive psychotherapy helped the individuals to manage the psychological complications of their disease more effectively. At the end of this meeting, we asked from parents and the students to sign the consent forms. 

 

 

3. Results
The sample consisted of 56 students with hemophilia in the age range of 10 to 25 years old. Detailed demographic characteristics of the samples and sampling flow diagram are presented in Table 2 and Figure 1, respectively.
The results of Table 3 indicate that the Life expectancy scores in the experimental group in the post-test and follow-up stage significantly increased in comparison with the control group (P<0.05). The post-test mean scores presented in Table 4 have moderated for covariates effect in different states of conducted tests and the result indicates that the covariate effect has been removed effectively.
The results of Table 5 indicate a significant difference between the mean of post-test score (F1,25=6.22, P<0.05, ή2=0.10] and follow-up scores (F1,28=12.04, P<0.001, ή2=0.30). Obviously, the mean scores of post-test and follow-up of the experimental group were significantly higher in the Life expectancy than in the control group. Given the ETA in the post-test and follow-up phases, it can be concluded that these changes are due to the effect of the independent variable (positive psychotherapy training).

4. Discussion
The purpose of this study was to investigate the effectiveness of positive psychotherapy in Life expectancy of students suffered from hemophilia. The results of Table 3 indicate a significant difference between the mean scores of Life expectancy in Pre-test compared with the post-test and follow-up scores of the experimental group. 

 

 

 

Obviously, the mean score of the Life expectancy in the post-test in the experimental group was significantly higher than that in the control group. These results are in concordance with the previous studies (Hutz et al., 2014; Leontopoulou, 2015; Sezgin & Erdogan, 2015; Terni, 2015; Weinberg, Besser, Zeigler-Hill, & Neria, 2016). 
Researchers found a direct and significant relation between optimism and Life expectancy, well-being and self-esteem (Hutz et al., 2014). In another research, Sezgin and Erdogan (2015) showed that optimism and hope are positive and significant predictors of self-efficacy and academic achievement. Considering the results presented in Tables 3 and 4, positive psychotherapy has a stable effect. In addition, the results suggested that performing reminder sessions could consolidate and enhance the effect of positive psychotherapy.
The basic element of positive psychotherapy intervention is training participants to focus on positive emotions and resources. In other words, by increasing the positive excitements in an optimized way, the correct and positive feedbacks to a difficult situation increases (Horney et al., 2011). One of the important properties of positive psychotherapy training is that the person can take its advantages without the need for a psychologist which confirms the effectiveness of this therapeutic approach in the follow-up phase (Layous, Chancellor, Lyubomirsky, Wang, & Doraiswamy, 2011). In addition, it will increase the pleasure and comfort of the patient’s life. 

 

 

 

 

While additional research is absolutely necessary for this subject, the current study provides some clinical and practical implications. The results of this study highlighted the efficacy of positive psychotherapy method to increase the Life expectancy score in students suffering hemophilia. Results of our study suggest the implication of positive psychotherapy strategies to enhance life quality index and alleviate complications of hemophilia patients as an example of chronic disease. Using positive psychotherapy for students with hemophilia could improve psychological complications of hemophilia e.g. test anxiety as one of the main problems in the academic life of these patients (Ghavidel Heydari et al., 2018). We emphasize using this method by psychotherapists, caregivers, and medical staffs. Furthermore, planning to educate this method to caregivers and medical staff will improve their ability to help patients with hemophilia and psychologically manage their problems.
Regardless of how much treatment of hemophilia could be effective, patients, their families, and specialists agree that living with this disease can be difficult and frustrating. Therefore, increasing the Life expectancy has a direct and positive effect on improving the quality of life in these patients. In general, according to the study results and other similar studies, attention to new approaches of psychology and psychotherapy such as positive psychotherapy and training this method to psychology staffs can be effective in the treatment of various disorders that have psychological complications. Our results show that positive psychotherapy can be valuable in increasing Life expectancy and well-being in patients with chronic diseases. This study has limitation in terms of its sample size, so future studies are needed to support the obtained results. 

Ethical Considerations
Compliance with ethical guidelines
All ethical principles were considered in this article. The participants were informed about the purpose of the research and its implementation stages; they were also assured about the confidentiality of their information; Moreover, They were allowed to leave the study whenever they wish, and if desired, the results of the research would be available to them.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors contributions
Carring out the experiment and writing the manuscript: Mahbobe Ghavidel Heydari, Mahmoud Shirazi, Gholam Reza Sanagouyemoharer; Planning and supervising: Mahmoud Shirazi; and Designing, implementation of the research and analyzing: Gholam Reza Sanagouyemoharer.

Conflict of interest
The authors declare no conflict of interest.

Acknowledgements
The authors would like to express Ms. Salmanian, the head of Zahedan Hemophilia Society. Our sincere thanks also go to Rahgoshaye Elm va Pajohesh Institute advisors for their helpful comments for conducting this study.




References