The effect of COVID-19 on utilization of chronic diseases services

OBJECTIVES

The aim of the present study is to evaluate the impact of Covid-19 on utilization of chronic diseases services.

METHODS

Interrupted time-series design was used to examine the utilization of chronic diseases services before and during the Covid-19 pandemic among hospitals in Iran. Chronic obstructive pulmonary disease (COPD), asthma, type 2 diabetes, heart failure, and chemotherapy were selected as a proxy to indicate the impact of Covid-19 on utilization of chronic diseases services. Data were collected in 24 sites from 12 months before the onset of Covid-19 (from March 2019 to February 2020) to 12 months during the Covid-19 pandemic (February 2020 to March 2021).

RESULTS

A total of 7,039,378 services were provided, of which 51.92% were provided for women and 62.73% for >65 age group. A sudden decrease was observed in monthly utilization of services during the Covid-19 pandemic; ranging from 13.91 (95% CI = -21.73, 6.10, P = 0.001) for chemotherapy to 606.39 (95% CI = -1040.72, 172.06, P = 0.009) for heart failure services per 100 thousand population. A decrease was observed in COPD services; 15.28 services compared with the period before Covid-19. Subsequently, the monthly utilization trends of asthma, type 2 diabetes, and chemotherapy services increased significantly (P < 0.05).

DISCUSSION

Although chronic diseases are a factor in more severe form of Covid-19, their failure to seek diagnostic, prevention and treatment services has somewhat complicated the issue.

Is the surge in cesarean section rates during the COVID-19 pandemic truly substantiated?

BACKGROUND

Cesarean section (C-section) rates, deemed a critical health indicator, have experienced a historical increase. The advent of the COVID-19 pandemic significantly impacted healthcare patterns including delays or lack of follow-up in treatment and an increased number of patients with acute problems in hospitals. This study aimed to explore whether the observed surge is a genuine consequence of pandemic-related factors.

METHODS

This study employs an Interrupted Time Series (ITS) design to analyze monthly C-section rates from March 2018 to January 2023 in Kurdistan province, Iran. Segmented regression modeling is utilized for robust data analysis.

RESULTS

The C-section rate did not show a significant change immediately after the onset of COVID-19. However, the monthly trend increased significantly during the post-pandemic period (p < 0.05). Among primigravid women, a significant monthly increase was observed before February 2020 (p < 0.05). No significant change was observed in the level or trend of C-section rates among primigravid women after the onset of COVID-19.

CONCLUSION

This study underscores the significant and enduring impact of the COVID-19 pandemic in further increasing the C-section rates over the long term, the observed variations in C-section rates among primigravid women indicate that the COVID-19 pandemic had no statistically significant impact.

Socioeconomic inequality in unmet outpatient healthcare needs among people living in urban informal settlements in Sanandaj city, Iran

BACKGROUND

The growing trend of informal settlements is a serious humanitarian crisis. Unmet need for health care services is an indicator to measure the state of equality and access to healthcare services. This study, for the first time in Iran, examined the prevalence of unmet needs for outpatient healthcare services and related socioeconomic inequalities among residents of informal settlements in Sanandaj city.

METHODS

This cross-sectional study was conducted on informal settlements of Sanandaj city with a sample size of 1345 people. Data were collected using a questionnaire. Multivariate logistic regression was used to determine significant predictors of unmet needs for healthcare services. Concentration index (C) and concentration curve (CC) were calculated to measure inequality in the prevalence of unmet needs for healthcare services.

RESULTS

The prevalence of unmet needs for outpatient healthcare services was 31.7%. Financial and physical barriers were the most common reasons for not using the needed services. The highest unmet need was related to dental (80.6%) and rehabilitation services (78.8%). Being elderly with about 2.3 times (OR: 2.37, 95% CI: 1.19-4.75), not having a job with about 1.7 times (OR: 1.70, 95% CI: 1.13-2.57) and having a low economic status with about 4 times (OR: 4.46, 95% CI: 2.39-9.70) increased the odds of experiencing unmet need for outpatient healthcare services. The value of concentration index showed that unmet need for outpatient healthcare services was significantly concentrated among people with lower economic status (C= -0.330, 95% CI: -0.432 to -0.227).

CONCLUSION

The unmet need is high among people living in informal settlements of Sanandaj city and a significant part of the residents of these settlements does not have access to required healthcare services. Regardless of the needs of people living in these settlements, who constitute a large population of Iran, access to universal health coverage is not possible in such areas. Removing the identified obstacles and causes behind the unmet needs requires the interdisciplinary participation of all actors, including the government, the nation, and civil society.

Socioeconomic Inequality in Screen Time, Phone, and Tablet Use among Iranian Adolescents: Results of A National Study

Background

Excessive screen time has been associated with a variety of negative health outcomes. We aimed to evaluate screen time and phone and tablet use in Iranian adolescents and their relation to the socioeconomic status of adolescents' families in 2018.

Methods

This descriptive-analytical study was carried out on 10-12-year-old adolescents from Kurdistan, Fars, and Markazi provinces. Cluster sampling was used for sampling. Data were collected by completing demographic questionnaires, calculating the BMI of adolescents and phone and tablet use, screen time, and socioeconomic status of the families. We used linear and logistic regression to estimate the final model. The concentration index was used to measure inequality and the Oaxaca decomposition to examine the different determinants of the inequality.

Results

1590 adolescents (52.58% boys) were enrolled in our study. Screen time activities were significantly higher in boys, older adolescents, higher BMIs, more educated mothers, and 35< year-old fathers (P < 0.05). The use of mobile phones and tablets was significantly higher among boys, ten-year-olds, families with four or fewer members, higher BMIs, adolescents with higher levels of parental education, and more educated mothers (P < 0.05). In addition, the concentration index for screen time activities (C = 0.083) and phone and tablet use (C = 0.536) showed that screen time and phone and tablet use activities were higher in adolescents with high socioeconomic status.

Conclusion

Screen time, phone and tablet use were higher in adolescents with high socioeconomic status. Also, many other factors like gender, age, BMI, parents' education and age can affect screen time, phone and tablet use in adolescents.

An assessment of the relationship between national rates of Covid-19 incidence and mortality as reported to an international comparison database: An ecological study

Background and Aims

Making a judgment only based on formal national reports can be misleading. We aimed to assess the relationship between countries' development indicators and reported coronavirus disease 2019 (Covid-19)-related incidences and death.

Methods

Covid-19 related incidence and death cases were extracted from the updated Humanitarian Data Exchange Website on October 8, 2021. Univariable and multivariable negative binomial regression were utilized to investigate the relationship between development indicator and incidence and mortality from Covid-19 by calculating the Incidence rate ratio (IRR), mortality rate ratio (MRR), and fatality risk ratio (FRR).

Results

Very high human development index (HDI) compared with low HDI (IRR:3.56; MRR:9.04), the proportion of physicians (IRR:1.20; MRR:1.16), besides extreme poverty (IRR:1.01; MRR:1.01) were independently correlated with the mortality and incidence rate of Covid-19. Very high HDI and population density were inversely correlated with the fatality risk (FRRs of 0.54 and 0.99). The cross-continental comparison shows Europe and the North Americas, had significantly higher incidence and mortality rates with IRR of 3.56 and 1.84 as well as MRRs of 6.65 and 3.62, respectively. Also, they inversely correlated with the fatality (FRR:0.84 and 0.91, respectively).

Conclusion

A positive correlation between the fatality rate ratio based on countries' development indicators and the reverse for the incidence and mortality rate was found. Developed countries with sensitive healthcare systems can diagnose infected cases as soon as possible. Also, the mortality rate of Covid-19 will be accurately registered and reported. Due to more access to diagnostic tests, patients are diagnosed at the initial stages and will have a better opportunity to receive treatment. This leads to higher reports of incidence/and/or mortality rates and lower fatality of COVID-19. In conclusion, more Covid-19 incidence and mortality cases in developed countries can result from a more comprehensive care system and a more accurate recording procedure.

Has Iran achieved the goal of reducing the prevalence of households faced with catastrophic health expenditure to 1%?: A national survey

Background and Aims

One of the goals of the Islamic Republic of Iran is to reduce the prevalence of catastrophic health expenditures among Iranian households to 1% by the end of the sixth 5-year development plan (2016-2021). This study was conducted to evaluate the level of access to this goal in the final year of this program.

Methods

A national cross-sectional study was conducted on 2000 Iranian households in five provinces of Iran in 2021. Data were collected through interviews using the World Health Survey questionnaire. Data from households whose health care costs were more than 40% of their capacity to pay were included in the group of households with catastrophic health expanditure (CHE). Determinants of CHE were identified using univariate and multivariate regression analysis.

Results

8.3% of households had experienced CHE. The variables of being a female head of household (odd ratio [OR] = 2.7), use of inpatient (OR = 1.82), dental (OR = 3.09), and rehabilitation services (OR = 6.12), families with disabled members (OR = 2.03) and low economic status of the households (OR = 10.73) were significantly associated with increased odds of facing CHE (p < 0.05).

Conclusion

In the final year of the sixth 5-year development plan, Iran has not yet achieved its goal of "reducing the percentage of households exposed to CHE to 1%." Policymakers should pay attention to factors increasing the odds of facing CHE in designing interventions.

Burden of COVID‐19 disease in Kurdistan province in west of Iran using disability‐adjusted life years

Background and Aims

During the coronavirus disease 2019 (COVID‐19) pandemic, about seven million people were infected with the disease, of which more than 133,000 died. Health policymakers need to know the extent and magnitude of the disease burden to decide on how much to allocate resources for disease control. The results of this investigation could be helpful in this field.

Methods

We used the secondary data released by the Kurdistan University of Medical Sciences between February 2020 to October 2021 to estimate the age‐sex standardized disability‐adjusted life years (DALY) by the sum of the years of life lived with disability (YLD) and the years of life lost (YLL). We also applied the local and specific values of the disease utility in the calculations.

Results

The total DALY was estimated at 23316.5 and 1385.5 per 100,000 populations The YLD and YLL constituted 1% and 99% of the total DALY, respectively. The DALY per 100,000 populations was highest in the men and people aged more than 65 years, but the prevalence was the highest in people under the age of 40.

Conclusions

Compared to the findings of the “burden of disease study 2019,” the burden of COVID‐19 in Iran is ranked first and eighth among communicable and noncommunicable diseases, respectively. Although the disease affects all groups, the elderly suffer the most from it. Given the very high YLL of COVID‐19, the best strategy to reduce the burden of COVID‐19 in subsequent waves should be to focus on preventing infection in the elderly population and reducing mortality.

Assessing performance of the Healthcare Access and Quality Index, overall and by select age groups, for 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Health-care needs change throughout the life course. It is thus crucial to assess whether health systems provide access to quality health care for all ages. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019), we measured the Healthcare Access and Quality (HAQ) Index overall and for select age groups in 204 locations from 1990 to 2019.

METHODS

We distinguished the overall HAQ Index (ages 0-74 years) from scores for select age groups: the young (ages 0-14 years), working (ages 15-64 years), and post-working (ages 65-74 years) groups. For GBD 2019, HAQ Index construction methods were updated to use the arithmetic mean of scaled mortality-to-incidence ratios (MIRs) and risk-standardised death rates (RSDRs) for 32 causes of death that should not occur in the presence of timely, quality health care. Across locations and years, MIRs and RSDRs were scaled from 0 (worst) to 100 (best) separately, putting the HAQ Index on a different relative scale for each age group. We estimated absolute convergence for each group on the basis of whether the HAQ Index grew faster in absolute terms between 1990 and 2019 in countries with lower 1990 HAQ Index scores than countries with higher 1990 HAQ Index scores and by Socio-demographic Index (SDI) quintile. SDI is a summary metric of overall development.

FINDINGS

Between 1990 and 2019, the HAQ Index increased overall (by 19·6 points, 95% uncertainty interval 17·9-21·3), as well as among the young (22·5, 19·9-24·7), working (17·2, 15·2-19·1), and post-working (15·1, 13·2-17·0) age groups. Large differences in HAQ Index scores were present across SDI levels in 2019, with the overall index ranging from 30·7 (28·6-33·0) on average in low-SDI countries to 83·4 (82·4-84·3) on average in high-SDI countries. Similarly large ranges between low-SDI and high-SDI countries, respectively, were estimated in the HAQ Index for the young (40·4-89·0), working (33·8-82·8), and post-working (30·4-79·1) groups. Absolute convergence in HAQ Index was estimated in the young group only. In contrast, divergence was estimated among the working and post-working groups, driven by slow progress in low-SDI countries.

INTERPRETATION

Although major gaps remain across levels of social and economic development, convergence in the young group is an encouraging sign of reduced disparities in health-care access and quality. However, divergence in the working and post-working groups indicates that health-care access and quality is lagging at lower levels of social and economic development. To meet the needs of ageing populations, health systems need to improve health-care access and quality for working-age adults and older populations while continuing to realise gains among the young.

FUNDING

Bill & Melinda Gates Foundation.

The impact of COVID-19 pandemic on hospital admissions for nine diseases in Iran: insight from an interrupted time series analysis

BACKGROUND

Associations between the COVID-19 pandemic and hospitalizations have not been studied Iran. This study aimed to examine the impact of the COVID-19 pandemic on hospital admissions for nine categories of disease in seven public hospitals in Kermsnahah city, the capital of Kermsnahah province, in the west of Iran.

METHODS

Data on monthly hospitalization rates (number of hospitalizations per 100,000 population) were collected for nine categories of disease for a period of 40 months (23 months before and 17 months after the COVID-19 outbreak in Iran) from the health information systems of all seven public hospitals in Kermanshah city. Categories of disease included those related to pregnancy, childbirth and the puerperium period, neoplasms, diseases of the digestive, respiratory, circulatory, genitourinary and nervous systems, mental and behavioural disorders, and infectious and parasitic diseases. Population data were extracted from the Statistics Centre of Iran. An interrupted time series analysis with segmented regression was used to examine the impact of COVID-19 on hospital admissions.

FINDINGS

Average monthly hospitalization rates fell for all nine categories of disease included in the study after the onset of the pandemic, with overall rates of 85.5 per 100,000 population in the period before the COVID-19 outbreak and 50.4 per 100,000 population after the outbreak began. The relative reduction in hospitalizations for the nine diseases was 56.4%. Regression analysis of monthly data indicated a sharp decrease in hospitalisations during the first month after the COVID-19 outbreak, which was statistically significant for all diseases (p < 0.001). After the initial reduction following onset of the pandemic, significant increases were observed for some diseases, including neoplasms (increase of 3.17 per 100,000 population; p < 0.001), diseases of the digestive system (increase of 1.17 per 100,000 population; p < 0.001) and diseases related to pregnancy, childbirth and the puerperium period (increase of 1.73 per 100,000 population). For other categories of disease, rates significantly declined, including infectious and parasitic diseases (decrease of 2.46 per 100,000 population; p < 0.001). Hospitalization rates did not increase to pre-pandemic levels for any disease, with the exception of those related to pregnancy, childbirth and the puerperium period.

CONCLUSIONS

Our study indicated that the COVID-19 pandemic had a significantly negative effect on hospitalizations in Iran. Although use of hospital care has gradually increased post-outbreak, it has yet to return to normal levels.

Prevalence of elective cosmetic surgery and its relationship with socioeconomic and mental health: A cross-sectional study in west of Iran

Background and Aims

The aim of this study was to investigate the prevalence and desire towards performing elective cosmetic surgery and its relationship with socioeconomic, mental, and spiritual health in Sanandaj, the capital of Kurdistan province in the west of Iran.

Methods

This cross‐sectional descriptive‐analytical study was performed on 492 subjects in Sanandaj using multistage sampling method. Data collection tools included two checklists and two questionnaires. Data analysis was performed using the Chi‐square test and multiple logistics regression model by the help of SPSS software version 20.

Results

The mean (standard deviation) age of participants was 32.58 (9.67) years. The prevalence of cosmetic surgery and the desire to perform it were 12.8% (n = 63) and 19.1% (n = 94), respectively. The most common type of cosmetic surgery was rhinoplasty with 5.5% (n = 27). The prevalence of symptoms of mental disorders among people with cosmetic surgery and people willing to perform cosmetic surgery was significantly higher than all subjects (p < 0.001). Female gender (odds ratio [OR] = 1.98; 95% confidence interval [CI]: 1.06–3.68) and having mild (OR = 3.01 95% CI: 1.06–3.68) and moderate to severe symptoms of mental disorder (OR = 7.59; 95% CI: 3.90–14.75) were among the influential variables on performing cosmetic surgery.

Conclusion

Both the prevalence and desire towards performing cosmetic surgery are high in Sanandaj and this needs the attention of health policy makers. Designing targeted interventions with an emphasis on the findings of this study is proposed to reduce these practices.

Unmet health care needs among pregnant women during COVID-19 pandemic and its determinants in Kurdistan province, Iran: A cross-sectional study

Background and Aims

The aim of this study was to assess unmet needs for health care and its determinants during COVID-19 pandemic among pregnant women in Iran.

Methods

This cross-sectional study was performed among pregnant women in Kurdistan province in 2020 with a sample size of 800 people who were selected by multistage sampling method. Data were collected using a structured questionnaire that was completed through interviews. Also, multiple logistic regression was used to determine the relationship between independent variables and outcome variable. Statistical tests were performed using Stata software package.

Results

The highest unmet needs for health care were related to dental services with 66%, rehabilitation services with 58.6%, and psychological services with 43.2% and the lowest were related to hospital services with 12%, midwifery services with 15.6%, and physician visit services with 39.1%. The most important reasons for unmet needs for health care were fear of getting COVID-19 and the cost of the services. The variables of age group and spouse education for physician visit services; age group for midwifery services; age group, education and employment status for dental services; age group, supplementary insurance and economic status for rehabilitation services; and age group and economic status for psychological services were significantly associated with unmet needs for health care (p < 0.05).

Conclusion

A significant percentage of health care needs of pregnant women was unmet, for which the fear of getting COVID-19 and financial barriers were the main reasons.

Knowledge, attitudes, practices and fear of COVID-19 among Iranians: A quick online survey

To control COVID-19, several strategies were proposed in Iran since the start of the outbreak. The number of reported infected people and its consequent death toll herald relative inadequacies in the quality and extent of the measures in curbing the COVID-19 transmission cycle. This study was conducted to investigate knowledge, attitude, precautionary practices and degree of fear related to COVID-19 in a sample of Iranian population. This study was conducted among 457 residents of Kurdistan Province, Iran, through social networks and social media (WhatsApp and Telegram). Knowledge, attitude and practice and fear of COVID-19 were collected using valid tools. Multiple logistic regression and multivariate linear regression analyses were used to identify factors associated with binary outcome attitudes, practices and continuous variables knowledge and fear of COVID-19, respectively. The mean (SD) age of participants was 37.86 (10.42); of them, 252 (55.1%) were men, and more than two-thirds were married (74.8%). About 10% of the respondents were in believed that COVID-19 could create a type of social stigma. Level of knowledge about COVID-19 in 77.8% of the study attendees was acceptable, and 352 of them (70%) were confident that the virus would eventually be successfully controlled in the world, but only 252 of the attendants (50%) had confidence about successful control of COVID-19 in Iran. Applying multiple logistic regression, knowledge (OR: 1.18, p = 0.028) and fear (OR: 1.04, p = 0.028) of COVID-19 were associated with positive attitude towards controllability of COVID-19. Gender (OR: 1.96, p = 0.012), sources of information (OR: 5.00, p = 0.005) and knowledge (OR: 1.27, p = 0.006) were also indicated association with taking precautionary practices to control COVID-19. Further studies are recommended to boost level of knowledge, strengthen positive attitude and ameliorate behavioural pattern for successful control of COVID-19 in Iran.

The Burden of Cardiovascular Diseases in the Kurdistan Province, Iran, from 2011 through 2017

Background: Calculating the burden of diseases is essential for their monitoring. The burden of cardiovascular diseases in Kurdistan Province has not been reported. This study aimed at calculating the burden of cardiovascular diseases in the Kurdistan Province from 2011 through 2017. Methods: In this cross-sectional study, incidence data were extracted from registration systems. The methods of the World Health Organization (WHO) were employed to calculate disability-adjusted life years (DALYs) of cardiovascular diseases in the Kurdistan Province. DALYs were calculated by summing the years of life lost (YLLs) and the years of life lived with disability (YLDs) for sex, age group, and year. Results: The burden of cardiovascular diseases increased from 18569.1 DALYs in 2011 to 34929.8 DALYs in 2017. The highest increase and the largest decrease in DALY according to the all age-standardized DALYs index were related to acute myocardial infarction and heart failure in women, respectively. The highest DALYs in both sexes were in the age group of over 80 years. Conclusion: The burden of cardiovascular diseases is increasing in the Iranian province of Kurdistan. It is, therefore, essential to implement appropriate and adequate interventions such as lifestyle modification, extensive screening, public education promotion, and operational plan development. We hope our results will aid decision-makers in performing urgent interventions.

Cohort profile: Dehgolan prospective cohort study (DehPCS) on non-communicable diseases in a Kurdish community in the west of Iran

The Dehgolan Prospective Cohort Study (DehPCS) was conducted to examine and identify risk factors for the most prevalent non-communicable diseases (NCDs). In addition, in order to examine participants’ health status, socioeconomic status, behavioral factors, nutritional status, and environmental exposures, the DehPCS collected, analyzed, and stored blood, urine, nail, and hair samples to conduct genetic studies and identify biomarkers and other biological determinants of NCDs. In total, 3,996 adults aged 35 to 70 from the general population participated in the study from February 2018 to March 2019. Of them, 43.7% were women. The first follow-up wave was conducted with 3,995 participants. Information on a wide range of variables was collected, including on socioeconomic status, lifestyle, nutritional status, habits, physical examination findings, medication use, and medical history. Proxy variables such as body mass index, metabolic equivalent task score, wealth index, and macronutrients and micronutrients were calculated. The most common self-reported diseases in descending order were kidney stones, hypertension, and fatty liver. The prevalence of diabetes and hypertension was 9.3% and 33.4%, respectively. All data, samples, and measurements will be collected again at 5-year intervals. Thus, it will be possible to examine time-dependent changes in the risk factors of NCDs. The DehPCS can be used to study the relationships among genetics, lifestyle, socioeconomic status, and environmental risk factors and the most prevalent NCDs in case-cohort studies using a nested case-control design that will be applied to the cohort infrastructure. Researchers can also submit pre-proposals via the following web address: http://c.ddrc.ac.ir/persianaccess/Account/Login.

Physician induced demand for knee replacement surgery in Iran

BACKGROUND

The structure of the Iranian health system has raised this hypothesis that a part of the Knee Replacement Surgery (KRS) services are provided due to Physician-Induced Demand (PID).

METHODS

This paper used an unbalanced individual panel data covering the steady-state 15,729 KRSs performed by 995 surgeons provided by the Armed Forces Insurance Organization at the provincial level over the 60 months (2014-2018). We use a generalized method of moment's system (GMM-SYS) to obtain consistent and asymptotically efficient estimates, which provide a vital instrument for our dynamic panel data.

RESULTS

The outcomes show that with unequal increasing orthopedic surgeons to population ratio, both the number and size of KRS services were increased significantly at a 1 % level. Given that the positive elasticity obtained for the service size was significantly larger than the number of services, the findings give strong support for the existence of PID in the Iran system for KRS care. Also, the raw and population-adjusted number of KRS, cost, and the surgery per active physician increased significantly at the monthly province level.

CONCLUSIONS

This is the first time that the existence of PID in the Iranian health system is investigated using approved econometric models. The findings indicate that the health system structure has been provided the conditions for aggressive, costly, and high-risk services such as KRS to be exposed to PID.

Unmet dental care need in West of Iran: determinants and inequality

Purpose

The purpose of this study was to assess the self-perceived need, seeking and use of dental care and its main determinants in Kurdistan province, Iran.

Design/methodology/approach

A total of 1,056 adults in Kurdistan province were included in this cross-sectional study. Multistage sampling approach was used to select the samples. Data on sociodemographic characteristics, economic status, self-perceived need, seeking and use of dental care were collected using a self-administrated questionnaire. Multivariate logistic regression model was used to assess factors affecting the use of dental care. In addition, socioeconomic inequality relating to dental care needs and use of dental care were examined using concentration curve and concentration index.

Findings

In this study, unmet dental care need was 62.7%. There was a perceived need for dental care among 13.7% (n = 145) of the participants in the past month, with only 39.3% (n = 57) seeking the care. The most important reasons for unmet dental care need were “Could not afford the cost” and “Insurance did not cover the costs.” Multivariate logistic regression showed that supplementary insurance status and household economic status were identified as main determinants affecting dental care-seeking behavior. The result of concentration index revealed that seeking dental care was more concentrated among the rich, whereas the perceived dental care need is more prevalent among the poor.

Originality/value

This study demonstrated that the prevalence of unmet dental care needs is high in the study setting. Also, financial barrier was identified as the main determinant of unmet dental care needs.

The Burden of Cancer in a Sample of Iranian Population

Background: We aimed at estimating the burden of cancer in Kurdistan Province, western Iran during 2011-2017. Methods: In this cross-sectional study, incidence data extracted from the cancer registry system and death data were extracted from the system of registration and classification of causes of death of Kurdistan Province. We applied the WHO’ methods to calculate the disability-adjusted life year (DALYs). Results: The burden of cancer increased from a DALYs of 12309 in 2011 to 13969 in 2017, the YLL from 11644 in 2011 to 12951 in 2017 and the YLD from 665 in 2011 to 1018 in 2017. The top five cancers, according to DALYs (%) in both sex during 2011-2017 were: stomach (25%), lung (14%), liver (9%), esophagus (6%), and colon (6%). The most burden of cancer related to gastrointestinal tract (54% vs. 45%). Totally, more than 25% of DALYs were related to stomach cancer. Conclusion: The increasing DALYs of cancer in Kurdistan Province is one of the major public health concerns as in most developed countries. More than half of the burden of cancer in the Kurdistan Province is related to gastrointestinal tract. Stomach cancer, is accounting for more than 25% of the burden in both sexes. Urgent policy, management and public health measures such as general education, screening, early detection and effective treatment are recommended to reduce the burden of cancers and especially gastrointestinal tract malignancies.  

Catastrophic health expenditures for children with disabilities in Iran: A national survey

OBJECTIVE

The aim of this study was to investigate the percentage of households with disabled children aged 0-8 years who had faced catastrophic health expenditures (CHEs) due to the health costs of these children in Iran.

METHODS

This cross-sectional study was carried out on 2000 households with disabled children aged 0-8 years in five provinces of Iran in 2020. Data were collected using the World Health Survey questionnaire and face-to-face interview. Determinants of CHE were identified using logistic regression.

RESULTS

32.7% of households with disabled children had faced CHE. Head of household being female (Adjusted OR = 18.89, 95%CI: 10.88-29.42), poor economic status of the household (Q1: Adjusted OR = 20.26, 95% CI, 11.42-35.94; Q2: Adjusted OR = 8.27, 95%CI, 4.45-15.36; Q3: Adjusted OR = 13.88, 95%CI, 7.89-24.41), lack of supplementary insurance by a child with disabilities (Adjusted OR = 6.13, 95%CI, 3.39-11.26), having a child with mental disability (Adjusted OR = 2.71, 95%CI, 1.60-4.69), and type of basic health insurance (having Iranian Health Insurance: Adjusted OR = 2.20, 95%CI, 1.38-3.49; having Social security insurance: Adjusted OR = 1.66, 95%CI, 1.06-2.61) significantly increased the chances of facing CHE.

CONCLUSION

A significant percentage of households with disabled children had faced CHE because of their disabled child's health costs. The key determinants of CHE should be considered by health policy-makers in order to more financial protection of these households.

Assessing unmet health-care needs of the elderly in west of Iran: A case study

Purpose

The purpose of this study is to investigate the status of perceived need, seeking behavior and utilization of health services in the elderly population of Sanandaj (west of Iran).

Design/methodology/approach

This is a cross-sectional study conducted on 800 elderly people in Sanandaj. Subjects were selected using multistage sampling and data were collected using self-report questionnaires. A multivariate logistic model with odds ratios (ORs) was used to determine the relationship of independent variables with seeking perceived need. Also, the concentration index was used to measure the inequality in using health services.

Findings

The perceived need for outpatient (during the last 30 days) and inpatient health-care services (during the past 12 months) was 69.7% and 29.7%, respectively. Among them, the unmet need for outpatient and inpatient health-care services was 46.6% and 17%, respectively. Having health insurance (adjusted OR 12.08; 95% confidence interval [CI] 1.04–140.11), middle economic status (adjusted OR 5.18; 95% CI 1.30–20.51) and being in an age group of 65–70 years (adjusted OR 7.60; CI 1.42–40.61) increased the chance of seeking inpatient care. Also, being in an age group of 60–65 years (adjusted OR 0.41; 95% CI 0.18–0.95) reduced the chance of seeking outpatient care. There was also a pro-rich inequality in using outpatient health services.

Originality/value

The elderly population suffers from unmet health-care needs, especially in outpatient services. The most important reason for not seeking outpatient and inpatient services was financial barriers and self-medication, respectively. So, designing targeted policies and interventions to address barriers in the conversion of need to demand in the elderly population is essential.

The health-related quality of life in Iranian patients with COVID-19

Background

COVID-19 is a public health emergency with a high mortality rate and it reduces the patient’s Health-Related Quality of Life (HRQoL) significantly. This effect is measured in the current study.

Methods

In a cross-sectional study in Iran, 320 randomly selected treated patients from COVID-19 were studied. To collect the required data, we applied a questionnaire that included socio-demographic factors, clinical characteristics, and questions on the patients’ HRQoL. Time trade-off (TTO) approach was used to measure the lost HRQoL attributed to COVID-19. Besides, we applied a two-limit Tobit regression model to determine the effects of the socio-demographic factors on patients’ health utility and the visual analogue scale approach was used to estimate the perceived total current health status.

Results

The overall mean (SE) and median (IQR) of the health utility values were 0.863 (0.01) and 0.909 (0.21) respectively. These values for the traders (those who were willing to lose a part of their remaining time of life to avoid the disease) were estimated at 0.793 (0.01) and 0.848 (0.17), respectively. The lowest amount of utility value belonged to the elderly (mean (SE) = 0.742 (0.04); median (IQR) = 0.765 (0.42)) and those living in rural areas (mean (SE)) = 0.804 (0.03); median (IQR) = 0.877 (0.30)). The univariate analysis showed that age, place of residence, and household size had a statistically significant effect on health utility. Moreover, findings of the regression analysis indicated that the participants’ age and hospitalization status were the key determinants of COVID-19 health utility value.

Conclusion

COVID-19 is associated with a substantial and measurable decrease in HRQoL. This decline in HRQoL can be directly compared with that induced by systemic health states.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06170-z.

Comparing the properties of the EQ-5D-5L and EQ-5D-3L in general population in Iran

BACKGROUND

Little information exists on properties of EQ-5D-5L (the 5L hereafter) compared to the EQ-5D-3L (the 3L hereafter) measures in the context of Iran. This study aims to compare the measurement properties of the two versions of the EQ-5D (the 3L vs. the 5L) using data obtained from general population in Iran.

METHODS

A total of 886 adults aged 18 years and above from September to November 2020 participated in this cross-sectional analysis. The required data collected using self-administered and-standard questionnaire and multistage sampling method was used to select the samples. The 3L and 5L measures compared in terms of celling effect, distribution and redistribution pattern, feasibility, convergent validity, know-groups validity and informativity.

RESULTS

From September to November 2020, 886 adults (mean aged = 44.6 years; 55% male and 87.1% married) included in the study. The study indicated that the 5L had lower celling effects compared to the 3L (45% vs. 46%). A better convergent validity and known-groups validity was found for the 5L version compared to the 3L and significantly stronger association found between the 5L measure with both the Visual Analogue Scale and the 5-point health status scale. The 5L index score showed higher relative efficiency (RE) in 9 of 11 condition (mean RE = 1.36). Compared to the 3L, the 5L classification system had higher Shannon index (H') in all dimensions: mobility (0.52 vs. 0.40), self-care (0.23 vs. 0.20), usual activities (0.61 vs. 0.47), pain/discomfort (1.19 vs. 0.89) and anxiety/depression (1.22 vs. 0.47).

CONCLUSION

The study demonstrated that the measurement properties of 5L version in terms of celling effects, convergent validity, known-groups validity, RE and informativity similar or better than the 3L among general population; suggesting the use of 5L in the context of Iran. Hence, we suggested the use of the 5L in economic evaluation, clinical and public health studies in Iran.

Evaluating the quality of care for patients with type 2 diabetes mellitus based on the HbA1c: A national survey in Iran

Objective

The present study was conducted to evaluate the quality of care for type2 diabetic patients based on the HbA1c in Iran.

Materials and methods

This cross-sectional study was conducted in 2019 among patients with type 2 diabetes in Iran. The data were collected through a three-part questionnaire including demographic information, disease-related records, and HbA1C status of patients. Multiple logistic regression was used to investigate the relationship between the outcome variable (HbA1c status) and the independent variables in Stata 12.

Results

The mean HBA1c was 8.01 ± 1.76% among 1,198 diabetic patients, and more than 66% of them had HBA1c above 7%, i.e. they had uncontrolled blood sugar levels. HBA1c has the highest average among people with more than 10 years of diabetes (8.47 ± 1.77%), self-employed people (8.36 ± 1.94%), illiterate people or those with elementary education (8.13 ± 1.76%) and people with poor economic status (8.12 ± 1.79%). Also, in the final model, people with more than 10 years of disease history had the highest prevalence of HBA1C > 7 with a chance ratio of 3.28 (P < 0.001, 95%CI: 2.37–4.53) and followed by illiterate people or those with elementary education with a chance ratio of 1.6 (P = 0.020, 95%CI: 1.08–2.39) compared to those with high school diploma or academic education.

Conclusion

The prevalence of adverse HBA1c in 66% of the studied subjects indicates an inappropriate status of diabetes control in Iran. This indicates the poor quality of services provided to the diabetics. This is a warning sign and requires appropriate interventions to improve the quality of services provided to diabetic patients.

The Burden of Stroke in Kurdistan Province, Iran From 2011 to 2017

OBJECTIVES

The aim of this study was to calculate the burden of stroke in Kurdistan Province, Iran between 2011 and 2017.

METHODS

Incidence data extracted from the hospital information system of Kurdistan Province and death data extracted from the system of registration and classification of causes of death were used in a cross-sectional study. The World Health Organization method was used to calculate disability-adjusted life years (DALYs).

RESULTS

The burden of stroke increased from 2453.44 DALYs in 2011 to 5269.68 in 2017, the years of life lost increased from 2381.57 in 2011 to 5109.68 in 2017, and the years of healthy life lost due to disability increased from 71.87 in 2011 to 159.99 in 2017. The DALYs of ischaemic stroke exceeded those of haemorrhagic stroke. The burden of disease, new cases, and deaths doubled during the study period. The age-standardised incidence rate of ischaemic stroke and haemorrhagic stroke in 2017 was 21.72 and 20.72 per 100 000 population, respectively.

CONCLUSIONS

The burden of stroke is increasing in Kurdistan Province. Since health services in Iran are based on treatment, steps are needed to revise the current treatment services for stroke and to improve the quality of services. Policy-makers and managers of the health system need to plan to reduce the known risk factors for stroke in the community. In addition to preventive interventions, efficient and up-to-date interventions are recommended for the rapid diagnosis and treatment of stroke patients in hospitals. Along with therapeutic interventions, preventive interventions can help reduce the stroke burden.

Socioeconomic inequalities in tobacco, alcohol and illicit drug use: evidence from Iranian Kurds

BACKGROUND

The associations between socioeconomic status (SES) and tobacco use, alcohol consumption and drug use are poorly understood in the Islamic Republic of Iran.

AIMS

To measure education- and wealth-related inequalities in cigarette smoking, hookah smoking, illicit drug use and alcohol consumption in Kermanshah Province, Islamic Republic of Iran.

METHODS

We used baseline data from the Ravansar Noncommunicable Disease (RaNCD) study. The study collected information on socioeconomic and demographic characteristics, cigarette and hookah smoking, alcohol consumption and illicit drug use of 10 015 adults aged ≥ 35 years between 2014 and 2016. The relative concentration index and absolute concentration index were used to measure education- and wealth-related inequalities in cigarette smoking, hookah smoking, illicit drug use and alcohol consumption.

RESULTS

Cigarette smoking was concentrated among less-educated and less-wealthy men and women. Similarly, illicit drug use was concentrated among lower-SES men. In contrast, hookah smoking and alcohol consumption were more prevalent among higher-SES men.

CONCLUSIONS

There were education- and wealth-related inequalities in tobacco, alcohol and illicit drug use in the west of the Republic of Iran. Future studies should aim to identify the main socioeconomic determinants of these inequalities in Kermanshah Province and generally in the Islamic Republic of Iran.

The prevalence of physical inactivity in Iranian adolescents and the impact of economic and social inequalities on it: results of a National Study in 2018

BACKGROUND

This study aims to determine the prevalence of physical inactivity in Iranian adolescents aged 10-12 years and the impact of socioeconomic inequality on it.

METHODS

In this descriptive study, the study population consisted of 10-12 years old adolescents from an Iranian population from Kurdistan, Fars and Markazi provinces in 2018. The sample size was 1590 individuals. The sampling method was cluster sampling. Data was collected using demographic questionnaire, modifiable activity questionnaire (MAQ) and socioeconomic questionnaire. Cut points on the MAQ for light activity, moderate activity and heavy activity were MET< 3, MET = 3-6 and MET> 6, respectively. Linear and logistic regression were used to estimate the final model and the Oaxaca analysis method was applied. All analyses were performed in Stata/SE 14.0.

RESULTS

Of the 1590 participants, 52.82% were male. The results showed that 25.79% of the subjects were physically inactive and 7.30% engaged in moderate physical activity during the week. The average physical activity during 1 week was more in boys than in girls (P-value< 0.05). Adolescents of mothers with secondary and high school education were more likely to have physical inactivity than mothers with a high school diploma or higher (AOR: 1.35, 95% CI: 1.02-1.77). The concentration index was -.11, indicating a greater concentration of physical inactivity in adolescents with low socioeconomic levels.

CONCLUSION

One-fourth of the study population had physical inactivity in this age group. Socioeconomic levels, parental literacy, and sex of adolescents were associated with the level of physical activity.

Patterns of sexual behaviors and related factors among prisoners in Iran: results from a national survey in 2015

PURPOSE

The purpose of this paper is to determine patterns of sexual behaviors and related factors among prisoners in Iran, 2015.

DESIGN/METHODOLOGY/APPROACH

This cross-sectional study was a part of a bio-behavioral surveillance survey conducted on 6,200 prisoners in 26 prisons in Iran. The subjects were selected through multi-stage sampling. Questionnaires and interviews were used to collect data on participant's demographics and history of sexual behaviors. Using STATA-12 software, the collected data were analyzed through descriptive statistics, and crude and adjusted logistic regression.

FINDINGS

A total of 5,508 prisoners with a response rate of 88.8 percent participated in this study. Of all prisoners, 55 percent (n=3,027) had a history of "unsafe sex in the lifetime" of whom 53.4 percent (n=1,549) never used condoms during unsafe sex in the lifetime. Based on the results of multivariate analysis, risk factors for "unsafe sex in lifetime" were the following: higher level of education (AOR=1.79, CI: 1.41-2.28), being single (AOR=1.32, CI: 1.18-1.47), unemployed before imprisonment (AOR=1.45, CI: 1.06-1.97), having history of previous imprisonment (AOR=1.31, CI: 1.17-1.47) and history of drug use in the lifetime (AOR=1.53, CI: 1.35-1.75).

ORIGINALITY/VALUE

Prisoners are high-risk groups that are prone to practice unsafe sex. Prisoners who are single, unemployed before imprisonment, a drug user, with a higher level of education and with a history of imprisonment are likely to be sexually active in their lifetime. Thus, they are a priority for receiving suitable interventions.

Assessing horizontal equity in health care utilization in Iran: a decomposition analysis

Background

Despite the goal of horizontal equity in Iran, little is known about it. This study aimed i) to assess socioeconomic inequality and horizontal inequity in the healthcare utilization; and ii) to explore the contribution of need and non-need variables to the observed inequalities.

Methods

This study used national cross sectional dataset from Utilization of Health Services survey in 2015. Concentration Index (C), Concentration Curve (CC) and Horizontal Inequity index (HI) were calculated to measure inequality in inpatient and outpatient health care utilization. Decomposition analysis was used to determine the contribution of need and non-need factors to the observed inequalities.

Result

Results showed the pro-poor inpatient services in both rural (C = − 0.079) and non-rural areas (C = − 0.096) and the pro-rich outpatient services in both rural (C = 0.038) and non-rural (C = 0.007). After controlling for need factors, HI was positive and significant for outpatient services in rural (HI = 0.039) and non-rural (HI = 0.008), indicating that for given need, the better off especially in rural make greater use of outpatient services. The HI was pro-poor for inpatient services in both rural (HI = − 0.068) and non-rural (HI = -0.090), was significant only in non-rural area. Non-need factors were the most important contributors to explain inequalities in the decomposition analysis.

Conclusion

Disentangle the different contribution of determinants, as well as greater HI in rural areas for outpatient and in non-rural areas for inpatient services, provide helpful information for decision makers to re-design policy and re-distribute resource allocation in order to reduce the socioeconomic gradient in health care utilization.

Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries, 2000-17: analysis for the Global Burden of Disease Study 2017

BACKGROUND

Across low-income and middle-income countries (LMICs), one in ten deaths in children younger than 5 years is attributable to diarrhoea. The substantial between-country variation in both diarrhoea incidence and mortality is attributable to interventions that protect children, prevent infection, and treat disease. Identifying subnational regions with the highest burden and mapping associated risk factors can aid in reducing preventable childhood diarrhoea.

METHODS

We used Bayesian model-based geostatistics and a geolocated dataset comprising 15 072 746 children younger than 5 years from 466 surveys in 94 LMICs, in combination with findings of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, to estimate posterior distributions of diarrhoea prevalence, incidence, and mortality from 2000 to 2017. From these data, we estimated the burden of diarrhoea at varying subnational levels (termed units) by spatially aggregating draws, and we investigated the drivers of subnational patterns by creating aggregated risk factor estimates.

FINDINGS

The greatest declines in diarrhoeal mortality were seen in south and southeast Asia and South America, where 54·0% (95% uncertainty interval [UI] 38·1-65·8), 17·4% (7·7-28·4), and 59·5% (34·2-86·9) of units, respectively, recorded decreases in deaths from diarrhoea greater than 10%. Although children in much of Africa remain at high risk of death due to diarrhoea, regions with the most deaths were outside Africa, with the highest mortality units located in Pakistan. Indonesia showed the greatest within-country geographical inequality; some regions had mortality rates nearly four times the average country rate. Reductions in mortality were correlated to improvements in water, sanitation, and hygiene (WASH) or reductions in child growth failure (CGF). Similarly, most high-risk areas had poor WASH, high CGF, or low oral rehydration therapy coverage.

INTERPRETATION

By co-analysing geospatial trends in diarrhoeal burden and its key risk factors, we could assess candidate drivers of subnational death reduction. Further, by doing a counterfactual analysis of the remaining disease burden using key risk factors, we identified potential intervention strategies for vulnerable populations. In view of the demands for limited resources in LMICs, accurately quantifying the burden of diarrhoea and its drivers is important for precision public health.

FUNDING

Bill & Melinda Gates Foundation.

Estimating utility value for female genital mutilation

BACKGROUND

Female genital mutilation/cutting (FGM/C) is a clear violation of women's rights and can have adverse and irreversible health effects as well. Worldwide, more than 200 million women and girls have undergone FGM/C. Utility value of FGM/C has not been estimated yet, so we designed this study to extract the health utility value of FGM/C for the first time in the world.

METHODS

In a cross-sectional study in Iran, 125 girls and women who underwent FGM/C procedure were examined by the trained midwives in order to determine its type. In addition, a questionnaire was completed for identifying the socio-demographic factors and extracting the health utility of these individuals. Health utility was measured using Time Trade-off method and also to determine the effects of the socio-demographic factors on the health utility a two-limit censored regression model was applied.

RESULTS

The mean and median of the health utility of women with FGM/C were 0.971 (SE: 0.003) and 0.968 (IQR: 1-0.95), respectively. Number of non-traders was 58 (46.4%) who reported perfect health utility. However, the mean of health utility among traders was 0.946 (SE: 0.002). Only type 1 (Clitoridectomy) and type 2 (Excision) FGM/C were seen in this study. Women with Type 1 FGM/C had significantly lower health utility value (Mean: 0.968, Median: 0.957) than their type 2 counterparts (Mean: 0.987, Median: 1.00). Moreover, women in the age group of 31-45 years (Mean: 0.962, Median: 0.956), single (Mean: 0.950, Median: 0.954), divorced (Mean: 0.951, Median: 0.950), employed (Mean: 0.959, Median: 0.956), and with supplementary insurance (Mean: 0.962, Median: 0.950) had significantly lower health utility than their counterparts.

CONCLUSION

FGM/C affects physical and psychological well-being of these individuals, resulting in a lack of personal and marital satisfaction, which ultimately leads to a 3% reduction in their health related quality of life. Therefore, preventing from this practice is very important and should be considered by health system policy makers more than before.

Can judgments according to case fatality rate be correct all the time during epidemics? Estimated cases based on CFR in different scenarios and some lessons from early case fatality rate of coronavirus disease 2019 in Iran

Background: The new Coronavirus disease (COVID-19) was first identified in China in 2019. Case fatality rate (CFR) indicator of the disease is one of the most important indices noticed by experts, policymakers, and managers, based on which daily evaluations and many judgments are made. CFR can change during epidemics. This study aimed to estimate the actual number of COVID-19 cases in Iran and to calculate the early CFR for the disease based on official statistics. Methods: This was a descriptive study whose data were obtained from the website of the Ministry of Health and Medical Education of Iran from February 20, 2020 until March 26, 2020. CFR has been obtained by dividing the total number of deaths by the total number of confirmed cases at one point in time. In this study, the actual number of COVID-19 cases in Iran was estimated based on the mortality model in 4 scenarios. Excel 2013 software was used to analyze the data. Results: According to the findings of this study, In Iran, until March 26, 2020, a total of 27 017 people have been infected by COVID-19 and 2077 died of it. However, CFR indicator had a descending trend in Iran: 100%, 18.6%, 8.8%, 3.3%, 6.9%, and 7.7% on days 1, 5, 10, 20, 30, and 35, respectively. The actual number of COVID-19 cases in Iran was estimated to be 4 789 454, 2 873 673, 1 436 836, and 718418 as of March 26, 2020 according to the 4 scenarios, respectively. Conclusion: In emerging epidemics, CFR indicator must not be used as a basis to judge the performance of a health system unless that epidemic condition has been clarified. Moreover, it is suggested that in the outbreak of an epidemic, specifically emerging diseases, CFR must not be the base of judgment. Making judgments, specifically in the outbreak of emerging epidemics, based on fatality rate can lead to information bias. It is also possible to estimate the total number of patients based on the CFR in circumstances where little information is available on the disease.

Incidence and Intensity of Catastrophic Health-care Expenditure for Type 2 Diabetes Mellitus Care in Iran: Determinants and Inequality

BACKGROUND

The present study aimed to assess the prevalence and intensity of catastrophic health-care expenditures (CHE) relating to type 2 diabetes mellitus care and inequality in facing such expenditures in Iran.

METHODS

A total of 1065 type 2 diabetes patients were included in this cross-sectional study. A multistage sampling method was used to select the samples. Data on sociodemographic characteristics, economic status, health and diabetic costs were collected using a self-constructed questionnaire. We used capacity to pay (CTP) of households to calculate the incidence of CHE due to diabetic care at four different thresholds. The mean positive overshoot (MPO) and overshoot were used to assess the intensity of CHE. The relative concentration index and slope index of inequality (SII) were used to measure socioeconomic-related inequalities in incidences of CHE. In addition, decomposition methods were used to identify the main factors affecting observed inequality in CHE.

RESULTS

The incidence of CHE at the 10, 20, 30, and 40% of CTP thresholds for type 2 diabetes mellitus care was 57.5, 28.9, 16.5, and 11.4%, respectively. The results of CI and SII indices for CHE due to diabetic care indicated that the incidence of CHE was more prevalent among patients with lower socioeconomic groups. The decomposition analysis showed that the socioeconomic status, marital status and gender of patients were the main factors contributing to socioeconomic inequality in incidence of CHE among the poor.

CONCLUSION

Our study demonstrated that the incidence and intensity of CHE due to diabetic care were relatively high, particularly among socioeconomically disadvantaged patients. Modification to the present health care financing strategies is recommended in order to protect lower socioeconomic groups against the financial burden of diabetic care.

Global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017

BACKGROUND

Understanding the patterns of HIV/AIDS epidemics is crucial to tracking and monitoring the progress of prevention and control efforts in countries. We provide a comprehensive assessment of the levels and trends of HIV/AIDS incidence, prevalence, mortality, and coverage of antiretroviral therapy (ART) for 1980-2017 and forecast these estimates to 2030 for 195 countries and territories.

METHODS

We determined a modelling strategy for each country on the basis of the availability and quality of data. For countries and territories with data from population-based seroprevalence surveys or antenatal care clinics, we estimated prevalence and incidence using an open-source version of the Estimation and Projection Package-a natural history model originally developed by the UNAIDS Reference Group on Estimates, Modelling, and Projections. For countries with cause-specific vital registration data, we corrected data for garbage coding (ie, deaths coded to an intermediate, immediate, or poorly defined cause) and HIV misclassification. We developed a process of cohort incidence bias adjustment to use information on survival and deaths recorded in vital registration to back-calculate HIV incidence. For countries without any representative data on HIV, we produced incidence estimates by pulling information from observed bias in the geographical region. We used a re-coded version of the Spectrum model (a cohort component model that uses rates of disease progression and HIV mortality on and off ART) to produce age-sex-specific incidence, prevalence, and mortality, and treatment coverage results for all countries, and forecast these measures to 2030 using Spectrum with inputs that were extended on the basis of past trends in treatment scale-up and new infections.

FINDINGS

Global HIV mortality peaked in 2006 with 1·95 million deaths (95% uncertainty interval 1·87-2·04) and has since decreased to 0·95 million deaths (0·91-1·01) in 2017. New cases of HIV globally peaked in 1999 (3·16 million, 2·79-3·67) and since then have gradually decreased to 1·94 million (1·63-2·29) in 2017. These trends, along with ART scale-up, have globally resulted in increased prevalence, with 36·8 million (34·8-39·2) people living with HIV in 2017. Prevalence of HIV was highest in southern sub-Saharan Africa in 2017, and countries in the region had ART coverage ranging from 65·7% in Lesotho to 85·7% in eSwatini. Our forecasts showed that 54 countries will meet the UNAIDS target of 81% ART coverage by 2020 and 12 countries are on track to meet 90% ART coverage by 2030. Forecasted results estimate that few countries will meet the UNAIDS 2020 and 2030 mortality and incidence targets.

INTERPRETATION

Despite progress in reducing HIV-related mortality over the past decade, slow decreases in incidence, combined with the current context of stagnated funding for related interventions, mean that many countries are not on track to reach the 2020 and 2030 global targets for reduction in incidence and mortality. With a growing population of people living with HIV, it will continue to be a major threat to public health for years to come. The pace of progress needs to be hastened by continuing to expand access to ART and increasing investments in proven HIV prevention initiatives that can be scaled up to have population-level impact.

FUNDING

Bill & Melinda Gates Foundation, National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH.

Drug use and risk behaviour profile, and the prevalence of HIV, hepatitis C and hepatitis B among people with methamphetamine use in Iran

BACKGROUND

Stimulants substances use, particularly methamphetamine use, is increasing globally, including in Iran. This study assessed the drug use and risk behaviour profile, and prevalence of HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV) among a large population using methamphetamine as their primary drug in Iran.

METHODS

This cross-sectional study was conducted in eight provinces of Iran. Individuals using methamphetamine for ≥3 months during the past three years, with no life-time history of injecting opioid drugs were enrolled. Drug use and risk behaviour data were collected through interviews. Blood samples were tested for HIV antibodies (HIV Ab), HCV antibodies (HCV Ab), and HBV surface antigen (HBs Ag).

RESULT

Among 567 participated, 84% were men and mean age was 36 years. Smoking with pipe was the most common method of methamphetamine use (53%), while 13% had a history of injecting methamphetamine, among whom 30% shared needles or syringes. Among those having sex during intoxication phase (n = 270), 48% never used condom. The prevalence of HIV Ab, HCV Ab and HBs Ag was 6.7% (95%CI: 4.7-9.1), 19.4% (95%CI: 16.2-22.9) and 1.4% (95%CI: 0.6-2.7), respectively. Age ≥ 30 years (adjusted OR [aOR]: 2.10, 95%CI: 1.18-3.76), lower education (high school vs. tertiary education, aOR: 13.95, 95%CI: 1.90-102.60), and injecting methamphetamine (aOR: 1.92, 95%CI 1.10-3.35) were significantly associated with HCV exposure. No factor was found associated with HIV infection. Among those reporting no potential injecting or sexual risk factors, 19.8% and 6.8% have HCV Ab positive and HIV Ab positive, respectively.

CONCLUSION

High prevalence of injecting and sexual risk behaviours, HIV infection and HCV exposure were found among individuals using methamphetamine as their primary drug, demonstrating them as an emerging population at risk of HIV and HCV in Iran. Targeted screening and harm reduction programs for this population are required.

Mapping 123 million neonatal, infant and child deaths between 2000 and 2017

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2-to end preventable child deaths by 2030-we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000-2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.

Frequency and potential causes of medication errors from nurses’ viewpoint in hospitals affiliated to a medical sciences University in Iran

Purpose

The purpose of this paper is to investigate the prevalence of medication errors (MEs) and the factors affecting them among nurses of hospitals affiliated to Kurdistan University of Medical Sciences (KUMS) in 2016.

Design/methodology/approach

This is a cross-sectional and descriptive-analytic study. In total, 503 nurses were selected using census method from six hospitals affiliated to KUMS. A self-constructed questionnaire was employed to collect information on nurses’ socio-demographic characteristics (6 items), the prevalence and type of MEs (21 items) and their perceptions about the main causes of MEs (40 items). Data were collected from August 15 to October 15, 2016. In addition, nonparametric and linear regression tests were used to describe the descriptive statistics and analyze the data.

Findings

The response rate was 73 percent and the monthly reported MEs per nurse was 6.27±11.95. Giving medication at non-scheduled time (28.4 percent), giving multiple oral medications together (22.4 percent) and giving painkillers after operation without physician’s prescription (15.3 percent) were three types of repetitive MEs, respectively. Gender, work experience, and having a second job affected the total number of MEs. “Long and unconventional nursing shifts,” “changing the dosage of medications for patients under observation due to multiple consultations and different doctors’ orders” as well as “failure to give feedback about the causes of errors to nurses by supervisors” were the three prioritized factors for MEs.

Originality/value

There is a need to reduce MEs in order to improve patient safety. It seems that in order to reduce MEs, systemic and managerial reforms such as reducing the working hours and workload of nurses, giving feedback about the causes of MEs to nurses, and using initiatives to reduce the stress in nurses are necessary.

Catastrophic health expenditure and its determinants in households with gastrointestinal cancer patients: evidence from new health system reform in Iran

Purpose

The right to health for all people means that everyone should have access to the needed healthcare services without suffering from severe financial hardship. The purpose of this paper is to investigate the prevalence as well as the effective factors on facing catastrophic health expenditures (CHE) among gastrointestinal cancer patients and families in Kurdistan province in west of Iran after the implementation of Health Transformation Plan (HTP).

Design/methodology/approach

A cross-sectional study was carried out on 189 households with gastrointestinal cancer patients in Kurdistan province in 2018. Data were collected using World Health Survey questionnaire. A method developed by World Health Organization with the threshold of 40 percent household’s capacity to pay was used in order to measure the proportion of households facing CHE. Also, logistic regression was applied for identifying the effective factors on household’s exposure to CHE. Data were analyzed using STATA version 13.

Findings

Almost 73 percent (72.7 percent) of the households (n=117) faced the CHE. Not having supplementary health insurance (adjusted odds ratio (AOR): 3.8; 95% confidence interval: 1.3–10.8 (and having low socio-economic status (AOR: 7.1; 95% CI: 1.8–28.1) were the significant factors affecting the households’ exposure to CHE. In total, 57 and 1 percent of the studied households reported that having a gastrointestinal cancer patient at home had a significant effect on refraining from using health services by other family members.

Originality/value

The proportion of the studied households facing CHE was very high. This may indicate the weakness of health system as well as health insurance or the weakness of HTP in financial protection of fragile population.

Effects of the Health Transformation Plan on caesarean section rate in the Islamic Republic of Iran: an interrupted time series

Background

In recent decades, the rate of caesarian section (C-section) has increased in the Islamic Republic of Iran. A reform in the Iranian health system - the Health Transformation Plan (HTP) - was launched in 2014 in which one of the objectives of HTP is decreasing the rate of C-section.

Aims

This study aimed to assess the effects of the Health Transformation Plan (HTP) on the C-section rate in the Islamic Republic of Iran.

Methods

This study was an interrupted time series analysis that used segmented regression analysis to assess the immediate and long-term effects of the HTP on C-section rate in two groups of hospitals affiliated and not affiliated to the Ministry of Health and Medical Education (MoHME) in Kurdistan province. Study samples were selected using the data on monthly C-section rate collected over a period of four years.

Results

We observed significant decreases in C-section rate immediately after the HTP in both groups of hospitals by 0.0629 and 0.0013, respectively (P < 0.05). In the long run, we observed no significant decrease in the regression slope of C-section rate in both groups.

Conclusions

The implementation of HTP decreased the C-section rate. However, the reduction does not meet expectations.

Past, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995-2050

BACKGROUND

Comprehensive and comparable estimates of health spending in each country are a key input for health policy and planning, and are necessary to support the achievement of national and international health goals. Previous studies have tracked past and projected future health spending until 2040 and shown that, with economic development, countries tend to spend more on health per capita, with a decreasing share of spending from development assistance and out-of-pocket sources. We aimed to characterise the past, present, and predicted future of global health spending, with an emphasis on equity in spending across countries.

METHODS

We estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three categories-government, out-of-pocket, and prepaid private health spending-and estimated development assistance for health (DAH) from 1990 to 2018. We estimated future scenarios of health spending using an ensemble of linear mixed-effects models with time series specifications to project domestic health spending from 2017 through 2050 and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private, and out-of-pocket health spending, and DAH. Estimates are reported in 2018 US dollars, 2018 purchasing-power parity-adjusted dollars, and as a percentage of gross domestic product. We used demographic decomposition methods to assess a set of factors associated with changes in government health spending between 1995 and 2016 and to examine evidence to support the theory of the health financing transition. We projected two alternative future scenarios based on higher government health spending to assess the potential ability of governments to generate more resources for health.

FINDINGS

Between 1995 and 2016, health spending grew at a rate of 4·00% (95% uncertainty interval 3·89-4·12) annually, although it grew slower in per capita terms (2·72% [2·61-2·84]) and increased by less than $1 per capita over this period in 22 of 195 countries. The highest annual growth rates in per capita health spending were observed in upper-middle-income countries (5·55% [5·18-5·95]), mainly due to growth in government health spending, and in lower-middle-income countries (3·71% [3·10-4·34]), mainly from DAH. Health spending globally reached $8·0 trillion (7·8-8·1) in 2016 (comprising 8·6% [8·4-8·7] of the global economy and $10·3 trillion [10·1-10·6] in purchasing-power parity-adjusted dollars), with a per capita spending of US$5252 (5184-5319) in high-income countries, $491 (461-524) in upper-middle-income countries, $81 (74-89) in lower-middle-income countries, and $40 (38-43) in low-income countries. In 2016, 0·4% (0·3-0·4) of health spending globally was in low-income countries, despite these countries comprising 10·0% of the global population. In 2018, the largest proportion of DAH targeted HIV/AIDS ($9·5 billion, 24·3% of total DAH), although spending on other infectious diseases (excluding tuberculosis and malaria) grew fastest from 2010 to 2018 (6·27% per year). The leading sources of DAH were the USA and private philanthropy (excluding corporate donations and the Bill & Melinda Gates Foundation). For the first time, we included estimates of China's contribution to DAH ($644·7 million in 2018). Globally, health spending is projected to increase to $15·0 trillion (14·0-16·0) by 2050 (reaching 9·4% [7·6-11·3] of the global economy and $21·3 trillion [19·8-23·1] in purchasing-power parity-adjusted dollars), but at a lower growth rate of 1·84% (1·68-2·02) annually, and with continuing disparities in spending between countries. In 2050, we estimate that 0·6% (0·6-0·7) of health spending will occur in currently low-income countries, despite these countries comprising an estimated 15·7% of the global population by 2050. The ratio between per capita health spending in high-income and low-income countries was 130·2 (122·9-136·9) in 2016 and is projected to remain at similar levels in 2050 (125·9 [113·7-138·1]). The decomposition analysis identified governments' increased prioritisation of the health sector and economic development as the strongest factors associated with increases in government health spending globally. Future government health spending scenarios suggest that, with greater prioritisation of the health sector and increased government spending, health spending per capita could more than double, with greater impacts in countries that currently have the lowest levels of government health spending.

INTERPRETATION

Financing for global health has increased steadily over the past two decades and is projected to continue increasing in the future, although at a slower pace of growth and with persistent disparities in per-capita health spending between countries. Out-of-pocket spending is projected to remain substantial outside of high-income countries. Many low-income countries are expected to remain dependent on development assistance, although with greater government spending, larger investments in health are feasible. In the absence of sustained new investments in health, increasing efficiency in health spending is essential to meet global health targets.

FUNDING

Bill & Melinda Gates Foundation.

Workplace violence against physicians and medical students in west part of Iran

Purpose

The purpose of this paper is to survey the prevalence of exposure to workplace violence (WPV) including physical violence, verbal abuse, bullying as well as its related factors among physicians and medical students attending teaching hospitals of Kurdistan University of Medical Sciences (KUMS).

Design/methodology/approach

This is a descriptive analytic as well as a cross-sectional study which was carried out on all physicians (general and specialists) and medical students attending teaching hospitals of KUMS in 2014. Overall, 400 participated in this study and data were gathered using a standard questionnaire. Then, data were analyzed using SPSS 20, χ2 and Fisher’s exact tests as well as univariate and adjusted logistic regression.

Findings

The prevalence of physical violence, verbal abuse and bullying among medical students was reported 4.5, 59 and 0.8 percent, respectively. In addition, the prevalence of these violence among general practitioners was 6.9, 72.4 and 0 percent, respectively. Moreover, 11.5, 42.3 and 3.8 percent of specialists had experienced physical violence, verbal abuse and bullying, respectively. Patients and their relatives were the main sources of the violence. Based on the results of multivariate logistic regression, male sex (AOR=2.60, CI: 1.56–4.32) and having shift work (AOR=3.13, CI: 1.67–5.84) were the most significant risk factors for total WPV.

Originality/value

The WPV experienced by physicians and medical students attending teaching hospitals of MUK is high. Health sector authorities should develop and implement proper strategies and interventions aiming at reducing or preventing from incidence of WPV.

The impact of health transformation plan on hospitalization rates in Iran: An interrupted time series

OBJECTIVE

The study aims to assess the impact of health transformation plan (HTP) as a major health system reform on hospitalization rate in Iran. Health transformation plan adopted different measures to increase the coverage of basic health insurance, increase the quality of outpatient visit care, improve and expand the family physician program, expand health services to suburban areas, reduce out-of-pocket (OOP) payments for inpatient services, and update tariffs to more realistic ones.

METHODS

We selected Kurdistan province, a province that was not a patient referral hub, for the collection of monthly hospitalization data over a period of 50 months. Interrupted time series (ITS) analysis was carried out, and segmented regression analysis was employed to assess the abrupt (or short-term) and gradual (or long-term) effects of HTP on hospitalization rate.

RESULTS

Although before the intervention, there was no significant increase or decline in hospitalization rate in the Kurdistan province, after the implementation of HTP, a significant increase in the intercept and slope of hospitalization rate was observed (P < 0.001).

CONCLUSION

Health transformation plan has improved the utilization of hospitalization care services in a province that historically had been suffering from underutilized hospital services.

National action plan of the Islamic Republic of Iran for combating antimicrobial resistance during 2016 - 2021

Background: Antimicrobial resistance (AMR) is one of the most important threats to health worldwide. Therefore, the World Health Organization (WHO) have invited countries around the world to work together to inhibit AMR, and all the member states are expected to prepare a national plan for tackling AMR by 2017. This project was aimed to prepare the National Action Plan of the Islamic Republic of Iran for combating antimicrobial resistance (NAP-IRIAMR) during 2016 to 2021. Methods: In this article, the literature and available documents were reviewed to identify key stakeholders. Moreover, interviews, brain storming sessions, and meetings with key stakeholders were held to determine NAP-IRIAMR objectives, strategies, policies, and indicators for monitoring and evaluation. To reach consensus and make a conclusion, participants' views and comments were analyzed using Delphi method and expert panel. Results: In this national action plan for combating AMR, 13 key stakeholders were identified and 5 objectives were set: (1) raising public awareness and increasing trainings on AMR, (2) continuous monitoring of AMR, (3) preventing the spread of microorganisms resistant to antimicrobials, (4) promoting the rational use of antimicrobials, (5) promoting research and development in the field of AMR. Conclusion: The NAP-IRIAMR was prepared for the years 2016- 2021. Intersectoral cooperation is needed to combat AMR. It is expected that implementing the NAP-IRIAMR and reaching the determined goals will help overcome the problems related to AMR.

The impact of health sector evolution plan on hospitalization and cesarean section rates in Iran: an interrupted time series analysis

Objective

To investigate the effect of the health sector evolution plan (HSEP) on hospitalization and cesarean section (C-section) rates in Kermanshah province in the western region of Iran.

Design

Interrupted time series analysis.

Setting

Hospital care system in Kermanshah province.

Study Participants

Fifteen hospitals affiliated to Ministry of Health and Medical Education (MoHME) in Kermanshah province.

Intervention(s)

Health sector evolution plan.

Main Outcome Measures

Hospitalization rate and C-section rate.

Results

We observed a statistically significant increase in the hospitalization rate (12.9 hospitalizations per 10 000 population, P < 0.001) in the first month after the implementation of the HSEP. Compared with the monthly trend in hospitalization rate before the intervention, we found a significant increase of 0.70 hospitalizations per 10 000 population (P < 0.001) in monthly trend in hospitalization rate after the HSEP. Although the proportion of C-section from total deliveries decreased by 11% (P = 0.044) in the first month after the implementation of the HSEP, the proportion of C-section from total deliveries increased at the rate of 0.0017% (P = 0.001) per month during post-intervention period.

Conclusion

We found an increase in the hospitalization rate after the intervention of HSEP. Although the C-section rate in the first month after the HSEP decreased, we observed an increasing trend in C-section rate over the study period; this implies that the HSEP did not promote vaginal delivery in Iran, which is outlined as one of the objectives of the intervention.

Out-of-Pocket and Informal Payment Before and After the Health Transformation Plan in Iran: Evidence from Hospitals Located in Kurdistan, Iran

BACKGROUND

One of the objectives of the health transformation plan (HTP) in Iran is to reduce out-of-pocket (OOP) payments for inpatient services and eradicate informal payments. The HTP has three phases: the first phase (launched in May 5, 2014) is focused on reducing OOP payments for inpatient services; the second phase (launched in May 22, 2014) is focused on primary healthcare (PHC) and the third phase utilizes an updated relative value units for health services (launched in September 29, 2014) and is focused on the elimination of informal payments. This aim of this study was to determine the OOP payments and the frequency of informal cash payments to physicians for inpatient services before and after the HTP in Kurdistan province, Iran.

METHODS

This quasi-experimental study used multistage sampling method to select and evaluate 265 patients discharged from hospitals in Kurdistan province. The study covered 3 phases (before the HTP, after the first, and third phases of the HTP). Part of the data was collected using a hospital information system form and the rest were collected using a questionnaire. Data were analyzed using Fisher exact test, logistic regression, and independent samples t test.

RESULTS

The mean OOP payments before the HTP and after the first and third phases, respectively, were US$59.4, US$17.6, and US$14.3 in hospital affiliated to the Ministry of Health and Medical Education (MoHME), US$39.6, US$33.7, and US$13.7 in hospitals affiliated to Social Security Organization (SSO), and US$153.3, US$188.7, and US$66.4 in private hospitals. In hospitals affiliated to SSO and MoHME there was a significant difference between the mean OOP payments before the HTP and after the third phase (P<.05). The percentage of informal payments to physicians in hospitals affiliated to MoHME, SSO, and private sector, respectively, were 4.5%, 8.1%, and 12.5% before the HTP, and 0.0%, 7.1%, and 10.0% after the first phase. Contrary to the time before the HTP, no informal payment was reported after the third phase.

CONCLUSION

It seems that the implementation of the HTP has reduced the OOP payments for inpatient services and eradicated informal payments to physician in Kurdistan province.