Identifying indicators and evaluation steps with suggestions for improving trauma care in Iran: experts' perspective

BACKGROUND

Trauma is one of the major causes of mortality across the world. Trauma patients have critical status and need timely, adequate, and organized care. The different consequences of trauma care among service centers around the world and even within a country revealed the need for careful evaluation. This study was designed and executed to collect experts' opinions on the evaluation steps, related indicators, and improvement strategies in trauma care.

METHODS

This qualitative study was based on a conventional content analysis approach. 2 focus group discussions (FGD) with 6 participants per FGD and 16 face-to-face in-depth interviews were conducted to collect the required information (from September 2018 to early 2019). Participants were selected through the purposive sampling method. The experts' viewpoints were classified by the main and sub themes.

RESULTS

Four basic themes extracted from the interviews and focus group discussions including, trauma care importance (sub-themes: the involved individuals' being young and productive and the effectiveness of trauma care); trauma care indicators (sub-themes: pre-hospital indicators, in-hospital indicators, and post-hospital indicators); stages of trauma care evaluation (sub-themes: evaluation prerequisites, finalization of indicators before the evaluation, determining evaluation time scope, determining evaluation dimensions, external and internal evaluation and use of evaluation results); trauma care improvement (sub-themes: balancing workload in trauma centers, enhancement of information system, considering extra-organizational dimensions in trauma care and empowerment of trauma care providers).

CONCLUSIONS

According to experts' viewpoints, trauma is a very important issue, because it involves young people. They believed that having indicators covering all aspects of care assist health managers and policymakers to understand under-standard performance. These indicators should be used in the form of a specific evaluation program and related to Iran context. Besides, reforming macro policies, planning, development of infrastructures, and education was some recommendations of experts to improve trauma care.

Identifying indicators and evaluation steps with suggestions for improving trauma care in Iran: experts' perspective

BACKGROUND

Trauma is one of the major causes of mortality across the world. Trauma patients have critical status and need timely, adequate, and organized care. The different consequences of trauma care among service centers around the world and even within a country revealed the need for careful evaluation. This study was designed and executed to collect experts' opinions on the evaluation steps, related indicators, and improvement strategies in trauma care.

METHODS

This qualitative study was based on a conventional content analysis approach. 2 focus group discussions (FGD) with 6 participants per FGD and 16 face-to-face in-depth interviews were conducted to collect the required information (from September 2018 to early 2019). Participants were selected through the purposive sampling method. The experts' viewpoints were classified by the main and sub themes.

RESULTS

Four basic themes extracted from the interviews and focus group discussions including, trauma care importance (sub-themes: the involved individuals' being young and productive and the effectiveness of trauma care); trauma care indicators (sub-themes: pre-hospital indicators, in-hospital indicators, and post-hospital indicators); stages of trauma care evaluation (sub-themes: evaluation prerequisites, finalization of indicators before the evaluation, determining evaluation time scope, determining evaluation dimensions, external and internal evaluation and use of evaluation results); trauma care improvement (sub-themes: balancing workload in trauma centers, enhancement of information system, considering extra-organizational dimensions in trauma care and empowerment of trauma care providers).

CONCLUSIONS

According to experts' viewpoints, trauma is a very important issue, because it involves young people. They believed that having indicators covering all aspects of care assist health managers and policymakers to understand under-standard performance. These indicators should be used in the form of a specific evaluation program and related to Iran context. Besides, reforming macro policies, planning, development of infrastructures, and education was some recommendations of experts to improve trauma care.

Developing safe community and healthy city joint model

BACKGROUND

Healthy city and safe community programs are the most common initiatives gaining increasing appeal in various communities to improve safety and health, independently. The aim of this study was to develop a joint application model of safe community and healthy city.

METHODS

A comprehensive literature review was conducted on healthy city and safe community programs using PubMed, Web of Science, Scopus and Science Direct and also related websites such as WHO regional offices in 2018. The preliminary list of joint model dimensions and topics were extracted and then assessed by the expert through two rounds of decision Delphi and four expert panel sessions. Eventually, the visual model was developed and approved by the experts.

RESULTS

Literature review resulted in the identification of 11 programs on safety and health promotion in the community of which 35 topics were extracted. After investigating the topics accordance, they were judged (correction, merging or eliminating) by experts through Delphi rounds and panel sessions. Eventually a joint model comprising 14 dimensions, 3 core principles and 4 values called "Safe and Health Promoting Community, SHPC_ model" was developed.

CONCLUSIONS

SHPC model provides a parallel and comprehensive view on safety and health topics in a community. The implementation of an integrated model could be one possible way to enhance the commitments on behalf of state and local government, and health system leaders to prioritize injuries and non-communicable disease prevention to address promotion, prevention, treatment and social consequences of mutual community-based interventions.

Forty years after Alma-Ata: how people trust primary health care?

BACKGROUND

Primary Health Care (PHC) was introduced as the first level of health services delivery after Alma-Ata declaration. However, after forty years, it needs to be more trustful to achieve its predefined objectives. Public trust in PHC is one of the neglected issues in the context. The aim of this study is to evaluate public trust in PHC in Iran.

METHODS

The present investigation is a household survey conducted in East Azerbaijan Province, Iran. Two-stage cluster sampling method with Probability Proportional to Size (PPS) approach was used. Totally, 1178 households were enrolled in the study. PHC trust questionnaire and Ultra-short version of Socio-Economic Status assessment questionnaire (SES-Iran) was used for data collection. Data were analyzed using STATA software (version 15) through descriptive statistics and linear regression.

RESULTS

The mean ± SD age of the participants was 41.2 ± 15.1 and most (53.7%) were female. Mean score of PHC trust was 56.9 ± 24.7 (out of 100). It was significantly different between residents of Tabriz (the capital of province) and other cities in the province (p < 0.001). Linear regression showed that younger age, gender, insurance type, being married, and households higher socio-economic status had a significant positive effect on PHC trust level with R² = 0.14383.

CONCLUSIONS

Public trust in PHC system in Iran needs to be improved. Individual variables had a small but key role in trust level. PHC trust cannot be only affected by individual's variables and experiences but also by health system and health providers' characteristics and public context in which PHC system exists. PHC trust level could be used as a public indicator in health systems especially in Low and Middle Income Countries (LMIC) to contribute in system strengthening policies at the national and international levels.

The priority setting of factors affecting a crash severity using the Analytic Network Process

Background:

The original step in reducing crash severity is recognition of the involved factors. The aim of this paper is to prioritize the factors affecting crashes severity. The current study was carried out in 2018 in Iran.

Methods:

The present cross-sectional study focuses on factors affecting the crash severity. Due to the compli-cated nature of traffic accidents, Multi-Criteria Decision-Making methods can be considered as an effective approach. In this work, the factors affecting a crash severity were identified and then attained factors were scored by ten traffic safety experts. To prioritize and weigh these factors, the Analytic Network Process method and Super Decisions program were used.

Results:

The results showed four main factors and 60 sub-factors in which the main factors in the order of priority were the safety (the most important sub-factor: speed over the upper limit), the other fac-tors (the most important sub-factor: road user type), the health (the most important sub-factor: drowsiness), and the environment (the most important sub-factor: slipping the road).

Conclusions:

In order to control the crash severity, the presented factors in this study could help traffic safety experts to prioritize and perform controlling actions.

Helmet use determinants and barriers among motorcyclists in world: systematic review

Background:

Road traffic injuries were introduced as leading cause of death worldwide and 1.2 million ‎people die due to them every year. Motorcyclists are at an increased risk because of their lack ‎of physical protection such as helmet makes them vulnerable to injury. This study aimed to ‎identify helmet use barriers and determinants.‎

Methods:

The information obtained in this review was retrieved from electronic databases such as ‎PubMed, Scopus, Science Direct and Web of knowledge databases using keywords. Moreover, ‎manual search of related journals were done. Also references of the selected articles were ‎reviewed to increase the chance of articles finding. Article screening was done using Endnote ‎X8.2. The inclusion criteria were articles with publishing date after 1995, reporting the barriers ‎or facilitators of helmet using. Conference abstracts and proceedings which had reported the ‎effects of helmet on accidents and with a publishing date before 1995 were excluded. ‎

Results:

Determinants of helmet use were identified and categorized in four categories as: Individual ‎and psychological factors (such as awareness and positive attitudes towards the compulsory use ‎of helmet, usefulness, older age, having accident background, experienced driving, and being ‎married), road-related factors (such as riding long distances and in urban roads), socio-‎economic factors (such as higher socio-economic condition and education). Another category of ‎determinants was other factors such as different climatic conditions, various motorcycle brands ‎and certain day of week which had different roles as helmet use determinant or barrier in ‎studies.

Conclusions:

Governmental and nongovernmental organization dealing with road traffic prevention should ‎ensure that standard helmets are made available and at affordable price to both motorcyclist and ‎passenger. Continuous education on the importance of helmet use to the community should be ‎addressed through media campaigns to improve the knowledge and attitude. However, ‎compatible helmets must be produced to overarch some barriers.‎

Keywords:

Helmet use, Motorcyclists, Determinants, Barriers, World

Safe and Health Promoting Community: Developing a Model

Background:

Healthy City and Safe Community programs are the most common initiatives gaining increasing appeal in various communities to improve safety and health, independently. The aim of this study is to develop a joint application model of safe community and healthy city. Here, we have tried an applied model development effort.

Methods:

A comprehensive literature review was conducted on healthy city and safe community programs in 2018. The preliminary list of joint model dimensions and topics were extracted and then assessed by the experts. Eventually, the visual model was developed and approved by the experts.

Results:

Totally, 35 safety and health promotion topics were extracted. After investigating the topics accordance, they were assessed by experts via two-rounds of Delphi study and panel sessions. Eventually a joint model comprising 14 dimensions, 3 core principles and 4 values called Safe and Health Promoting Community, SHPC_ model was developed.

Conclusions:

SHPC model provides a parallel and comprehensive view on safety and health topics in a community. The implementation of an integrated model could be one possible way to enhance the commitments on behalf of state and local government, and health system leaders to prioritize injuries and non-communicable disease prevention to address promotion, prevention, treatment and social consequences of mutual community-based interventions.

Keywords:

Safe Community, Healthy City, Joint application Model

Classification of Drugs Listed in Iranian Pharmacopoeia Based on Impact on Driving Performance

According to studies, drugs based on their Pharmaco-dynamics and pharmacokinetics can affect driving performance. There are clear conclusions about some medications and in other drugs have not yet reached definitive conclusions. There are two international experiences regarding the classification of drugs based on their impact on driving performance. These projects are DRUID (Driving Under the Influence of Drugs and medicines) and ICADTS projects. This study conducted to classify Iranian pharmacopeia according to drugs effects on driving performance. The projects divided the drugs used in the treatment of diseases into three categories in terms of traffic safety. The project first identified and explored similar experiences in the world by reviewing scientific resources. For the medicines that their effects were determined in the existing classifications, their impact category were extracted from DRUID and ICADTS systems. For drugs that have different categories in two systems or unidentified their effects on these classifications, Drug side effects, especially in areas of attention, cognition, sleep, vital signs were extracted from pharmacology and other related textbooks. With using appropriate keywords, the studies and evidences about these drugs effects on driving were assessed. At an expert meeting, with review of side effects and scientific evidences, the impact of these drugs on driving performance was determined. Finally, the effect of drugs on driving performance was classified into three groups with no or minimal, moderate and severe effects. Based on these classification results, a mobile application was designed and prepared for ordinary people. In this application, for any drug their effect category, side effects and prevention strategies were explained.

Crash Severity Assessment: Is There a Need for Revisiting the Current Indicators?

Background:

Methods:

Results:

Conclusions:

Keywords:

Analysis and classification of the road traffic health and safety mobile apps based on the Haddon’s matrix

Background:

Road traffic accidents have been one of the main causes of death worldwide. However, most of the crashes are both predictable and preventable. With the widespread use, mobile phone is considered as a major road safety risk. However, varieties of apps have recently been developed for improving the road traffic health and safety. Despite an increasing trend of these apps, there is no comprehensive analysis of their features and no taxonomy or classification of them based on the traffic safety theories or frameworks. The aim of this study was to explore characteristics of available mobile apps on the road traffic health and safety and classify them based on the Haddon’s Matrix.

Methods:

To conduct this research, a comprehensive and systematic review of the mobile applications developed for the road traffic health and safety was carried out through using the qualitative content analysis. Google Play was searched through using a combination of the keywords to retrieve the road traffic apps. In order to extract the app features, their description was examined, and their content was analyzed. Then they were classified in four main categories including Road Traffic Health & safety, Road Traffic Training, Road traffic Navigation, and Other Road Traffic apps. Finally, the Haddon’s matrix was applied to analyze and classify those mobile apps residing in two main categories of the traffic health & safety, and the traffic training. Haddon’s matrix is a relevant framework for structured analyses of traffic injury events. In the Haddon’s matrix, the contributions of human, vehicle/equipment and environmental factors to the injuries in the three phases pre-crash, crash and post-crash has been presented.

Results:

In this study, 916 mobile apps met the inclusion criteria and were included in the final analysis.19 subcategories were identified for classifying the included apps based on their features and functionalities. In total, 620 of the mobile apps were grouped on the basis of Haddon’s matrix. About 61.76% of these apps were categorized as the traffic health & safety group. Among the subcategories of the traffic health & safety group, the highest number of apps (194) was the real-time traffic alerting apps. Behavior based feed-backing subcategory was ranked the second among the traffic health and safety apps with 75 apps.

When the researchers applied factors and phases of Haddon’s framework for analyzing the apps, it was found that the Haddon’s factors have been taken into account in the apps grouped into two main categories of the apps including traffic training and traffic health & safety applications. The highest percentage of Haddon’s matrix factor considered for the intervention through the apps was related to the physical & social environment (23.69%) in the traffic training category. The features of 259 apps were classified in the Event/ Driving phase of Haddon’s matrix. Most of the apps in this phase was related to the real-time traffic alerting subgroup. These apps performed in real time while driving. The lowest number of the apps in driving phase was observed in the behavior based feed backing subcategory, which inform drivers about their driving behavior in real-time. Sixteen apps had features that categorized them in both Pre-event / Pre-driving and Event / Driving phases. In addition, 20 apps were found to have feature for intervening in both Event / Driving and Post-event / Post –driving phases. All 235 apps in the traffic training category were in pre-event/ pre-driving phase, which requires users to use these apps before driving.

Conclusions:

Applying Haddon’s matrix on analyzing and classifying the traffic health and safety apps revealed strengths and weaknesses of the existing related mobile apps in terms of the factors that must be considered for intervention toward prevention and reduction of road traffic accidents as the main public health issue.

Keywords:

Mobile apps, Traffic accident prevention apps, Traffic safety, Haddon matrix, Public health

Health services utilisation and responsiveness profiles in Iran: a provincial household study

Objective

The aim of this study was to describe health services utilisation and responsiveness in East Azerbaijan province, Iran.

Design

A cross-sectional household study as part of a larger research on primary healthcare system.

Setting

We carried out the study in East Azerbaijan Province, northwest Iran from July to September 2015.

Participants

A total of 1318 households were included.

Results

Most of the participating households had social security health insurance. Heart failure or hypertension care, general outpatient care and arthritis care were the most used services. High services cost and inadequate medicine and medical equipment were introduced to be the main barriers to health services utilisation in Tabriz and province representative sample (PRS), respectively. Health system responsiveness mean score (the maximum is 100) was 33.71±16.15 (95% CI 32.45 to 34.97) in Tabriz and 32.02±14.3 (95% CI 30.9 to 33.13) in PRS, which showed significant difference (p≤0.02).

Conclusions

Differences in the utilisation and responsiveness of health services and distribution of health resources were observed between Tabriz and PRS. Evidently, health system responsiveness in both Tabriz and PRS was at low level. The results demonstrate the need for changing resource distribution policies and employing reactive health policies to response the public health.

Predictive ability of underlying factors of motorcycle rider behavior: an application of logistic quantile regression for bounded outcomes

Background: The human factors are of great importance, especially Motorcycle Rider Behavior Questionnaire (MRBQ) and attention deficit hyperactivity disorder (ADHD) in motorbike riders in road traffic injuries. This study aimed to predict MRBQ score by ADHD score and the underlying predictors by the logistic quantile regression (LQR), as a new strategy.

Methods: In this cross-sectional study, 311 motorbike riders were randomly sampled by a clustering method in Bukan, northwest of Iran. The data were collected by MRBQ and ADHD standard surveys. To assess the relationship at all levels of MRBQ distribution, LQR in 5th, 25th, 50th, 75th and 95th quantiles of MRBQ score was utilized to assess the predictability of ADHDscore and its subscales in addition to the underlying predictors of MRBQ score. To do this, an unadjusted and as well as adjusted 4-step hierarchical modeling was used.

Results: Almost in all quantiles of MRBQ scores, direct and significant relationships were observed between MRBQ score and ADHD score and its subscales (coefficients: 0.02 to 0.10, all P < 0.05). Besides, the driving period (coefficients: -0.58 to -0.95, P < 0.05) and hour driving (coefficients: 0.42 to 0.52, P < 0.05) also came to be the significant predictors of MRBQ score.

Conclusion: ADHD score and driving parameters can be taken into the consideration when planning actions on the motorcycle rider behaviors at all levels of the MRBQ.

Efficacy of Citalopram on Acute Ischemic Stroke Outcome: A Randomized Clinical Trial

BACKGROUND AND PURPOSE

Ischemic stroke (IS) is one of the main causes of death and disability in the adult population, and recovery from it is a major health concern worldwide. The aim of the present study was to evaluate the effectiveness of citalopram on 3-mounth outcome of nondepressed acute IS patients.

METHODS

In a randomized, placebo-controlled clinical trial, 144 patients with acute IS were studied for 3 months. In one group, the patients received oral citalopram 20 mg (once daily), and in the other group, they received placebo. All patients received standard care, including physiotherapy. Patients with depression were excluded throughout the study. The primary outcome of the study was set to a 50% reduction in the 3-month National Institutes of Health Stroke Scale compared with the baseline scores (Clinical Trial Registration URL: http://www.irct.ir ; Unique identifier: IRCT201203192150N2).

RESULTS

The mean age of patients was 66.4 years. Of 144 eligible patients, 15 patients died (4 in the citalopram and 11 in the placebo group), and 21 patients did not complete the study follow-up period (10 in the citalopram and 11 in the placebo group). The primary outcome of the study was achieved in 57 patients (79%) in the citalopram and 39 patients (54%) in the placebo group ( P < .001), with risk ratio and number needed to treat of 2 (CI = 1.2-3) and 4 (CI = 2.5-8.6), respectively. No major adverse events were found in either group.

CONCLUSIONS

Citalopram is a safe and tolerable medication in patients with acute IS, which could improve the outcome in these patients.

Determinants and barriers of helmet use in Iranian motorcyclists: a systematic review

Background:

Helmet use by motorcyclists decreases the incidence and severity of an injury and its related death. Unfortunately, the helmet use rate is not in an acceptable level in Iran. This study aimed to systematically identify the determinants and barriers of helmet use among Iranian motorcyclists.

Methods:

A systematic search of literature was done using PubMed, Scopus, Science Direct and Web of knowledge databases for English literature and SID for Persian articles by specified keywords. Manual searching and reference of references were used to improve the articles identification. Articles published before 1995 and those which did not report the barriers and determinants of helmet use were excluded. Data were extracted using an extraction table.

Results:

Out of 49 retrieved articles, 13 articles were included in the study. Most of them (70%) had a cross-sectional design. Personal factors (such as older age, marital status and education) and motorcyclist's attitude and beliefs about the helmet effectiveness were reported as important determinants of helmet use. Helmet weight and its visual and audial limitation for motorcyclists were known as the main reported barriers to use a helmet.

Conclusions:

Interventions affecting the motorcyclists' attitude must be employed along with the legal interventions. Moreover, cost-effective engineering improvements in helmet production remain an important policy to improve the compliance of helmet use.

Positive Association Between Serum 25-Hydroxy-Vitamin D and Liver Enzymes Levels in Healthy Individuals: A Population-Based Study from Iran

Objective: The relationship between serum 25-hydroxy-vitamin D and within normal range liver enzymes in a population-based study in the northwest of Iran was investigated. Method: This cross-sectional study was comprised of 700 apparently healthy Iranian adults (287 men & 413 women) who participated in the major lifestyle promotion project (LPP) conducted in East Azarbaijan-Iran in 2015. The ultraviolet method and chemiluminescent immunoassay technology were respectively used for determination of the serum levels of liver enzymes (alanine aminotransferase (ALT) and aspartate aminotransferase (AST)) and 25-hydroxy-vitamin D. The one-way ANOVA and the linear regression analysis were used for statistical analysis. Results: There were not significant differences in mean ALT and AST levels regarding different serum 25-hydroxy- vitamin D status. In the unadjusted model, serum 25-hydroxy-vitamin D was significantly associated with ALT (p = 0.008). The participants in the fourth quartile of 25-hydroxy-vitamin D had significantly higher level of ALT compared with participants in the first quartile (p = 0.002). After adjustment for age, sex, BMI, waist circumference, fasting blood glucose, lipid profile, and dietary vitamin D, this association remained significant. For AST, in the unadjusted model, the association between serum 25-hydroxy-vitamin D and AST was marginally significant (p = 0.08). The participants in the third quartile of 25-hydroxy-vitamin D had significantly higher levels of AST compared with participants in the first quartile (p = 0.01). Conclusion: According to results, there was a positive association between 25-hydroxy-vitamin D and ALT in individuals without liver diseases. Additional prospective studies were needed to confirm this observation and also elucidate the underlying mechanisms.

The association between melasma and postinflammatory hyperpigmentation in acne patients

Background

Although, melasma is most prevalent among Asian young women, and also darkly pigmented individuals are particularly prone to developing post inflammatory hyperpigmentation, to the best of our knowledge, there are rare or no studies about the association of melasma and Post inflammatory hyperpigmentation.

Objectives

The aim of this study was to investigate how likely is a melasma patient to developed post inflammatory hyperpigmentation when compared to patients with inflammatory acne lesions who do not have melasma.

Patients and Methods

This comparative study was conducted on 400 participants, 200 subjects involved with pigmented lesions of melasma and inflammatory acne lesions and200 involved only with inflammatory Acne lesions without melasma. Melasma, acne and post inflammatory hyper pigmentation, if existed, were assessed by a dermatologist, and pigmentation depth was assessed by wood's lamp. Multivariate logistic regression analysis suitable for study design was used to assess the association between melasma and post-acne pigmentation.

Results

We found out that 24.1% of patients without melasma had post-acne pigmentation compared to 66.8% in melasma group (P < 0.001). The likelihood of observing post-acne pigmentation was found to be nearly six times more in melasma patients versus those without melasma. Association existed after controlling for possible confounders such as melanin score and time length of self-reported sun exposure, and acne severity score.

Conclusions

Melasma appears to increase the likelihood of post-acne pigmentation.

Evidence-based urology: how does a randomized clinical trial achieve its designed goals?

PURPOSE

To discuss the methodological considerations of a standard and applicable randomized clinical trial (RCT).

MATERIALS AND METHODS

Using a predefined strategy, we conducted systematic computerized search of the MEDLINE (1966 to 2011) and EMBASE (1980 to 2011) databases to identify all English language educational articles discussing the RCT methodological aspects. Full text versions of identified studies were reviewed in blinded fashion for key methodological and statistical characteristics.

RESULTS

Randomized clinical trials in surgery are the highest level of the primary research evidence in evidence-based medicine. There is increasing demand for implementation of RCTs in urological daily practice.

CONCLUSION

Randomized clinical trials' report should be absolutely clear, simple, and easy to understand with well-defined internal and external validity. Efforts should be made to design high quality RCTs in urology. There are substantial needs for urologists to their knowledge about RCT.