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1.  Barriers of Health News Producers’ Empowerment: A Qualitative Study in Iran 
Health Promotion Perspectives  2014;4(2):214-220.
Background: Studies show that raising news producers’ knowledge and skills are influential and necessary for promoting the quality of health news. This study aimed to investigate the barriers to implementing empowerment programs for news producers and to identify their respective solutions.
Methods: In this qualitative content analysis the opinion of 14 journalists, one translator, 10 editors or editors-in-chief of health news agencies were gathered through 12 in-depth interviews and 4 focus group discussions. Purposive sampling was done and interviews continued up to the point of saturation. Data were analyzed with Open Code software.
Results: The barriers to the implementation of empowerment programs were identified as: a) individual factors, b) deficiency of certain facilitators, and c) organizational and macro policymakings. Various solutions were suggested for the barriers respectively.
Conclusion: The implementation of empowerment programs for news producers requires a system approach toward its determinant factors. This will be more likely if measures at other concerned levels are also taken. Creating incentives on behalf of the news-producing organizations can also contribute to this end and create a suitable context for news producers. Training and empowerment alone will not be sufficient.
PMCID: PMC4300448  PMID: 25648827
Mass media; Health news; Health journalism; Empowerment; Qualitative research
2.  How can we establish more successful knowledge networks in developing countries? Lessons learnt from knowledge networks in Iran 
Formal knowledge networks are considered among the solutions for strengthening knowledge translation and one of the elements of innovative systems in developing and developed countries. In the year 2000, knowledge networks were established in Iran’s health system to organize, lead, empower, and coordinate efforts made by health-related research centers in the country. Since the assessment of a knowledge network is one of the main requirements for its success, the current study was designed in two qualitative and quantitative sections to identify the strengths and weaknesses of the established knowledge networks and to assess their efficiency.
In the qualitative section, semi-structured, in-depth interviews were held with network directors and secretaries. The interviews were analyzed through the framework approach. To analyze effectiveness, social network analysis approach was used. That is, by considering the networks’ research council members as ‘nodes’, and the numbers of their joint articles - before and after the network establishments - as ‘relations or ties’, indices of density, clique, and centrality were calculated for each network. In the qualitative section, non-transparency of management, lack of goals, administrative problems were among the most prevalent issues observed.
Currently, the most important challenges are the policies related to them and their management. In the quantitative section, we observed that density and clique indices had risen for some networks; however, the centrality index for the same networks was not as high. Consequently the attribution of density and clique indices to these networks was not possible.
Therefore, consolidating and revising policies relevant to the networks and preparing a guide for establishing managing networks could prove helpful. To develop knowledge and technology in a country, networks need to solve the problems they face in management and governance. That is, the first step towards the realization of true knowledge networks in health system.
PMCID: PMC4233097  PMID: 25354533
Knowledge network; Evaluation; Health management organization; Iran
3.  People’s trust in health news disseminated by mass media in Tehran 
Background: People are increasingly interested in health news. As a mass media, the ‘Islamic Republic of Iran Broadcasting’ (IRIB) has the highest number of target audiences. In Iran, some people follow health news via health programs on satellites and other means of communication. However, all of these programs do not live up to the standards of scientific evidence. In this study, we examined Tehran people’s trust in health news disseminated by the IRIB and other mass media outlets.
Methods: A cross-sectional study was conducted in Tehran. Through multistage sampling, 510 households proportional to size were randomly selected from five regions of Tehran including northern, eastern, western, southern and central regions. One person from each household completed the questionnaire through interviews. The questionnaire included questions on people’s level of trust in health news delivered by the IRIB, satellite programs, the internet and magazines. It also included demographic questions. The validity and reliability of the questionnaire was evaluated.
Results: Among the interviewees, 50.6% was female. The highest level of trust by the participants was observed in the IRIB (65.2%), and the lowest trust was observed in satellite news (43.4%); p< 0.001. The interviewees believed that the IRIB news broadcasters had more mastery over the subject than the ones in satellite channels (p< 0.001). The IRIB’s coverage of important and relevant health topics was also significantly perceived to be better than that of satellite news (p< 0.001). According to 83.5% of interviewees, the quality of health news had improved in the past 10 years. Fifty nine point eight percent of participants believed the quality and accuracy of the IRIB health news was monitored.
Conclusion: People’s higher level of trust in domestic news as compared to foreign sources and the better status of domestic sources in other areas such as precision in reporting, coverage of more important news, its delivery in lay language, the news broadcasters’ proficiency, and other cases - from the participants’ point of view - can highlight the significance of designing interventions for changing health behavior among domestic health news producers. Therefore, the results of this study can prove useful to health news policy makers in the IRIB.
PMCID: PMC4313454
Iran; News; Health
4.  Economic inequality in eye care utilization and its determinants: a Blinder–Oaxaca decomposition 
Background: The current study aimed to determine eye care utilization, to assess the role of economic inequality in the utilization of eye care services, and to identify its determinants in Shahroud, North of Iran.
Methods: Of the 6,311 invited people, 5,190 (82.24%) individuals aged 40 to 64 years old participated in the study. A history of a visit by an ophthalmologist or optometrist was considered as eye care utilization. The gap between low- and high-economic groups was decomposed into its determinants using the Oaxaca decomposition method.
Results: Among the participants, 16.32% [95% Confidence Intervals (CI)= 15.31–17.33%] had never been examined by an ophthalmologist or optometrist, and 30.94% (95% CI= 29.69–32.20%) had not undergone an eye examination in the past 5 years. This negative history was significantly higher among female subjects [Odds Ratio (OR)= 1.79, 95% CI= 1.51–2.14], the low-economic group (OR= 2.33, 95% CI= 1.90–2.87), the visually impaired (OR= 1.41, 95% CI= 1.05–1.90), and the uninsured (OR= 1.93, 95% CI= 1.45–2.58). The negative history of eye examination decreased with increasing in age (OR= 0.94, 95% CI= 0.93–0.96) and education (OR= 0.94, 95% CI= 0.92–0.96). In this study, 24.72% (95% CI= 22.30–27.14) of the low-economic group and 9.94% (95% CI= 8.75–11.14) of the high-economic group had no history of eye examination. Decomposition of the gap between the two economic groups showed that education and gender were the most important determinants of inequality.
Conclusion: A considerable percentage of adults, even those with visual impairment, do not receive appropriate eye care. There is a definite economic inequality in the community for which poverty per se could be the major cause.
PMCID: PMC4226620  PMID: 25396206
Eye; Health Status Disparities; Iran; Inequality
5.  Ethical Considerations of Community-based Participatory Research: Contextual Underpinnings for Developing Countries 
The nature of community-based participatory research (CBPR) poses distinctive ethical challenges. In the absence of organized guidelines, a remarkable amount of researchers’ time and energy will be spent tackling these ethical challenges. The study aimed to explore ethical issues and principles potentially arising when conducting CBPR.
This qualitative study conducted in CBPR Center of Tehran University of Medical Sciences. Required data were gathered through systematic literature review and semi-structured interviews. Representatives of community, academia, and nongovernmental organizations (NGOs) participated in our study. Ten interviews with representatives of partner organizations, four group interviews with academic staff, and four with representatives of community were conducted. Repeated thematic analysis was used to elicit ethics-related overarching themes from transcribed interviews. As recommendations, these themes were then organized into a set of CBPR-related ethical issues and principles.
Four CBPR ethical guidelines (including 173 articles) were selected from a systematic review. Overarching themes relating to ethical principles which emerged from interviews were as follows: Trust, transparency and accountability, equity and inclusion, power imbalance, tolerance and conflict management, and attention to cultural sensitivity. Practical principles that emerged included: Consensus rather than informed consent, ownership of data and research achievements, and sustainability and maintenance of relationships. According to findings and in comparison to international guidelines, the present study put more emphasis on cultural sensitivity and sustainability as CBPR ethical tangles.
Community-based participatory research ethical challenges are of the same kind in most parts of the world. However, some discrepancies exist that calls for local scrutiny. Future use and critic of current explored ethical issues and principles are highly encouraged.
PMCID: PMC4223954  PMID: 25400893
Community-based participatory research; ethics; ethical guideline
6.  Prevalence and associated factors of self-reported hypertension among Tehran adults in 2011: a population-based study (Urban HEART-2) 
Background: Hypertension is an important public-health challenge worldwide. The prevalence of hypertension greatly varies across countries. The aim of this study was to estimate the prevalence of self-reported hypertension and to determine related factors in a large random sample of Tehran population in 2011.
Methods: In this cross sectional study, 69173 individuals aged 25–64 years were selected using multistage cluster random sampling method. All participants were interviewed by trained personnel using standard questionnaires. Weighted prevalence and incidence rates were calculated and principle component analysis (PCA) was used to construct wealth index. Chi-square and odds ratio were used to assess associations in univariate analysis. Logistic Regression model was used in multivariate analysis.
Results: The prevalence of self-reported hypertension was 5.27% in total, 3.83% in men and 6.64% in women (p< 0.001). The annual incidence rate of self-reported hypertension was 6.87 per 1000; 5.26 in men and 8.43 in women (p< 0.001), obviously varied across various districts. In multivariate analysis, age, sex (woman), marital status (single), obesity and smoking were positively associated with prevalence of self-reported hypertension. Education level was negatively associated to hypertension. On the other hand, wealth status was not associated to self-reported hypertension.
Conclusion: Our study findings highlighted low awareness rates of hypertension among Tehran adults especially in men and younger people. Hence, we recommend public health strategies to improve health education programs. Moreover, programs to develop the surveillance system and screening programs to early detection of undiagnosed cases are urgently needed particularly in high risk population subgroups.
PMCID: PMC4301203  PMID: 25664306
Hypertension; Self-reporting; Prevalence; Tehran
7.  The Knowledge Translation Status in Selected Eastern-Mediterranean Universities and Research Institutes 
PLoS ONE  2014;9(9):e103732.
A serious worldwide effort to strengthen research based knowledge translation (KT) has begun in recent years and some countries, particularly developed ones, are trying to incorporate KT in their health and health research systems. Keeping in mind the recent economic depression and the need to perform more efficient research, we aimed to assess and compare the KT status of selected health research institutes in the Eastern Mediterranean Regions' countries, and to identify their strengths and weaknesses in the field.
After finding the focal points that would steer the focus group discussions (FGDs) and help complete the ‘Self Assessment Tool for Research Institutes’ (SATORI) tool, each focal point held two FGDs in which researchers, research authorities and other individuals specified in detail further in the study were held. The scores obtained by each institute were evaluated quantitatively, and the transcriptions were analyzed qualitatively with OpenCode software.
For ease of analysis the 50 items of the SATORI were classified into 7 main domains: ‘priority setting’, ‘research quality and timeliness’, ‘researchers’ KT capacities', ‘facilities and pre-requisites of KT’, ‘processes and regulations supporting KT’, ‘interaction with research users’, and ‘promoting and evaluating the use of knowledge’. Based on the scoring system, the strongest domain was ‘research quality and timeliness’. ‘Priority setting’ was the weakest domain of all. The remaining domains were more or less equal in strength and were not in a favorable state. The qualitative findings confirmed the quantitative findings.
The main problem, it seems, is that a KT climate does not exist in the region. And despite the difference in the contexts, there are many similarities in the region's institutes included in this study. Collaborative efforts can play a role in creating this climate by steering countries towards KT and suggesting regional strategic directions according to their needs.
PMCID: PMC4157749  PMID: 25197834
8.  The Extent of Inappropriate Use of Magnetic Resonance Imaging in Low Back Pain and its Contributory Factors 
Magnetic resonance imaging (MRI) is an expensive and commonly used technology with a variety of indications in patient diagnosis and treatments. The aim of this study is to identify a comprehensive list of indications and contraindications for MRI in patients with low back pain (LBP) and to determine the appropriateness of using this technology in these patients on the basis of this list.
A cross-sectional study was conducted in four radiographic centers in Tehran, Iran. A list of MRI indications and contraindications for LBP was developed by review of documents and expert panel. A pre structured checklist was designed and incorporated into a structured form. All 100 consecutive patients referring to four radiographic centers for performing MRI regarding LBP completed the questionnaire. Chi-square, Fisher's Exact Test and logistic Regression were used to assess statistical significance.
In this study, 187 patients (46.7%) had an indication for MRI, but 186 patients (46.5%) had no indication, 18 patients (4.5%) had indication and contraindication at the same time and nine patients (2.3%) had contraindication. Moreover, 71 patients (17.8%) underwent MRI for LBP during the past 2 years, of which 14 (19.7%) had normal results. Patients with complementary private insurance had a history of previous MRI about 20% more than other patients (P = 0.018). There was a statistically significant relationship between complementary private insurance coverage and number of MRI performed (P = 0.006).
About half of the patients referring to radiographic centers with LBP for MRI had no indication for this test.
PMCID: PMC4258662  PMID: 25489452
Appropriate use; contraindication; low back pain; indication; magnetic resonance imaging
9.  Children with Obesity Prioritize Social Support against Stigma: A Qualitative Study for Development of an Obesity Prevention Intervention 
Childhood obesity is a world-wide health problem and development of interventions to prevent or control it is a priority. Obesity is prevalent and on the increase among school-students in Iran, too. As the first step for development of an intervention, the current study was designed to complete our understanding of ideas, attitudes, beliefs, and preferences of primary school children in Tehran, Iran.
Twenty-seven primary school-students (11 boys, 16 girls) in grade-five, most of whom were overweight or obese, participated in four focus-group discussions (FGDs). All FGD notes were analyzed to find the main themes.
Nine themes in three main categories emerged after analysis. The themes in the category of barriers of losing weight included environmental, psychological and physiological barriers. Category of intervention components included nutrition improvement, physical activity promotion, social support and education. Setting and deliverer of the intervention were included in the intervention conditions category. The children proposed a multi-component approach for development of an intervention. They mentioned nutrition and physical activity improvement, social support and education as the main elements of an effective intervention.
The findings indicate that obese children need to be supported against different barriers of losing weight, mainly social barriers, especially humiliation by the community.
PMCID: PMC4258668  PMID: 25489443
Child; obesity; qualitative research; social support
10.  Are people in Tehran prepared for the family physician program? 
Upon successful experiences of family physician program in the rural regions, Iranian Ministry of Health and Medical Education (MOHME) made a decision to expand this program to urban areas. For this reason a pilot program were designated and some cities have been selected to determine dos and don’ts of performing family physician program in the cities. Various studies were published during this period demonstrating the advantages and disadvantages of family physicians’ care in these cities. After this process in 2012 and 2013 MOHME announced implementation of family physician program in Tehran. Our study investigated public attitudes, knowledge and practice about the newly introduced program.
This cross-sectional study was performed in Tehran during November to December 2012. A telephone survey was carried out using the Random Digit Dialing (RDD) method and data was gathered by a researcher designed questionnaire. A total of 386 residents aged 18 years and over participated in the study. To compare the differences between various groups’ knowledge scores data were analyzed performing Chi-square test, t-test, ANOVA, and logistic regression by SPSS software version 17, to find factors that affected individuals’ agreement with the program.
Among all samples 214(57.4%) knew about the program and almost 120(85.1%) of these aware people were planning to participate in the program. Television and Radio were the major information resources. After adjusting for Educational status, Access to Internet and Socio Economic Status(SES) those people who didn’t have any kind of health coverage systems(Health insurance) were most likely to accept the program and agree with that[OR= 2.38(1.05-5.38)].
The fact that despite low levels of information, most of aware people intend to enroll in the new program reveals that expanding informative programs would bring more participation and involvement among community.
PMCID: PMC4258677  PMID: 25489446
Family medicine; family physician; family practice
11.  Challenges for Better thesis supervision 
Background: Conduction of thesis by the students is one of their major academic activities. Thesis quality and acquired experiences are highly dependent on the supervision. Our study is aimed at identifing the challenges in thesis supervision from both students and faculty members point of view.
Methods: This study was conducted using individual in-depth interviews and Focus Group Discussions (FGD). The participants were 43 students and faculty members selected by purposive sampling. It was carried out in Tehran University of Medical Sciences in 2012. Data analysis was done concurrently with data gathering using content analysis method.
Results: Our data analysis resulted in 162 codes, 17 subcategories and 4 major categories, "supervisory knowledge and skills", "atmosphere", "bylaws and regulations relating to supervision" and "monitoring and evaluation".
Conclusion: This study showed that more attention and planning in needed for modifying related rules and regulations, qualitative and quantitative improvement in mentorship training, research atmosphere improvement and effective monitoring and evaluation in supervisory area.
PMCID: PMC4154287  PMID: 25250273
Dissertation; Research; Supervision; Iran
12.  Application of Capture-Recapture for Fine-tuning Uncertainties About National Maternal Mortality Estimates 
Maternal mortality ratio (MMR) is one of the main indicators of the millennium development goals and its accurate estimation is very important for the countries concerned. The objective of this study is to evaluate the applicability of capture-recapture (CRC) as an analytical method to estimate MMR in countries.
We used the CRC method to estimate MMR in Iran for 2004 and 2005, using two data sources: The maternal mortality surveillance system and the National Death Registry (NDR). Because the data registry contains errors, we defined three levels of matching criteria to enable matching of cases between the two systems. Increasing the matching level makes the matching criteria less conservative. Because NDR data were missing or incomplete for some provinces, we calculated estimates for two conditions: With and without missing/incomplete data.
According to the CRC method, MMR in 2004 and 2005 were 33 and 25 in the best-case scenarios respectively and 86 and 59 in the worst-case scenarios respectively. These estimates are closer to the ones reported by United Nations Agencies published in 2010, 38 and Hogan's study, 30 in 100,000 live births in 2005.
The MMR estimation by CRC method is slightly different from the international studies. CRC can be considered as a cost-effective method, in comparison with cross-sectional studies or improvement of vital registration systems, which are both costly and difficult. However, to achieve accurate estimates of MMR with CRC method and decrease the uncertainty we need to have valid databases and the absence of such capacities will limit the applicability of this method in developing countries with poor quality health databases.
PMCID: PMC4050684  PMID: 24932395
Capture-recapture; epidemiologic methods; Iran; maternal mortality
13.  Indications and Overuse of Computed Tomography in Minor Head Trauma 
Computed Tomography (CT) is a useful diagnostic technology, particularly in accident and emergency departments.
To identify a comprehensive list of indications for application of CT in patients with minor head trauma (MHT) and to determine appropriateness of its use on the basis of this list.
Materials and Methods:
A cross-sectional study was conducted in three Imaging centers in Tehran. A panel of experts developed a list of CT indications for MHT by reviewing documents. A pre-structured checklist was designed and incorporated into a structured form. Four hundred consecutive patients referring to three imaging centers for performing CT due to MHT completed the questionnaire.
Of 400 patients who underwent CT after MHT, 187 (46.8%) patients had Glasgow coma scale (GCS) score of 13 or 14 at two hours post-trauma and 37 (19.8%) of these patients did not have any indication of imaging. In addition, 213 (53.2%) patients had GCS score of 15 out of which 110 (51.6%) patients did not have any indication of imaging. Patients with a GCS score of 15 had a noticeably lower proportion of abnormal CT results in comparison to patients with a GCS score of 13 or 14, (odds ratio, 19.07; 95% confidence interval, 6.74-54.00; and P < 0.001). There was a statistically significant association between abnormal CT results and the presence of indications including vomiting, dangerous mechanism of injury, visible signs of trauma above the clavicles, signs of skull base fracture, and suspected skull fracture (P < 0.001).
On average, about 37% of the patients with MHT referring to the emergency departments had no indication of CT and approximately 86.5% of CT results were normal. Improving this situation can result in a significant saving in health care costs.
PMCID: PMC4082513  PMID: 25031853
Tomography, X-Ray Computed; Craniocerebral Trauma; Indication; Abnormal
14.  Inequality of Leprosy Disability in Iran, Clinical or Socio-Economic Inequality: An Extended Concentration Index Decomposition Approach 
Despite significant reduction in global disease prevalence, leprosy still has a high rate of disability while its determinants are unfair and many of them are amendable. The objective of this study was to measure inequality of disability in leprosy in Iran.
This was a cross-sectional study (2006-2007) on all living people affected by leprosy registered in W. Azerbaijan province health center, Western North of Iran. The outcome of the study was the socio-economic inequality considering presence or absence of grade 2 disability (G2D) based on the WHO classifications. An extended concentration index decomposition approach was used for analysis.
Among 452 cases, 65.3% were male and 67% were affected by the multi bacillary type. Overall G2D was 65.3%. The estimated Concentration Index was −0.0782, showing presence of pro-poor socio-economic inequality of G2D, while extended CI estimation (ѵ = 5) was −0.163. Achievement index with coefficient (ѵ = 5) revealed that G2D mean was 16% more than classic mean in the poorest group. The result of decomposition of the existing inequality revealed that, some of the determinants such as receiving mono-therapy, education, urbanization, and bacillus calmette guerin (BCG) vaccination had shared contribution (67.4%, 61.8%, 59.2%, and 57.5% respectively).
This study provided new perspective for the health system to leprosy control considering the significant gap between rich and poor (inequality) regarding G2D disability, and its effective elements in socio-economic strata. Some effective actions can be considered to reduce the scale of existing inequality.
PMCID: PMC4018589  PMID: 24829728
Disability; inequality; Iran; leprosy
15.  Reliability and Validity Assessment of Mizaj Questionnaire: A Novel Self-report Scale in Iranian Traditional Medicine 
In Iranian Traditional Medicine, mizaj (temperament) plays a key role in preventive, therapeutic and lifestyle recommendations. A reliable self-reported scale for mizaj identification is critically needed to introduce ITM into the official medical and health care system especially in the case of designing national preventive protocols.
The present study aimed to design a preliminary self-administered mizaj questionnaire and assessed its reliability and validity in Iran.
Patients and Methods
In this cross-sectional study, a questionnaire with 52 items was designed based on mizaj-related indices. Subsequent to content and face validity assessment, using qualitative and quantitative method, 47 items remained. Based on the non-randomly sampling, the test-retest reliability of each question and internal consistency of the questionnaire was examined by the participation of 35 volunteers. The reliable version questionnaire was filled up by 52 volunteers wherein they were divided into warm/cold and wet/dry groups based on their mizaj which was predetermined by a team of expert practitioners. Logistic regression analysis was performed for validity process between the experts’ assessment of mizaj and each of the items in the questionnaire that resulted to the final ten-item questionnaire divided into two subscales. By using ANOVA and post Hoc with Dunnet statistics, the optimum cut-off points were defined and their sensitivity and specificity was assessed.
The weighted kappa coefficients of the 39 items were between 0.40 and 0.82 showing their acceptable reliability and the Cronbach’s α coefficient was 0.71 showing the internal consistency. The sensitivity and specificity of the final questionnaire cut-off points were 65% and 93% for the warm group, 52% and 97% cold group, 53% and 67% dry group and finally 53% and 76% wet group.
Our results suggested that many of the designed questions according to the literature’s mizaj identification indices had satisfactory reliability and the final ten-item questionnaire could discriminate the different groups of mizaj, therefore, this can be used as the first version of a brief self-report mizaj estimating scale.
PMCID: PMC4005447  PMID: 24829785
Medicine; Traditional; Unani; Temperament; Questionnaires; Reproducibility of Results
16.  Commercialization of biopharmaceutical knowledge in Iran; challenges and solutions 
The objective of this study was to investigate the application of the university research findings or commercialization of the biopharmaceutical knowledge in Iran and determine the challenges and propose some solutions.
A qualitative study including 19 in-depth interviews with experts was performed in 2011 and early 2012. National Innovation System (NIS) model was employed as the study design. Thematic method was applied for the analysis. The results demonstrate that policy making, regulations and management development are considered as fundamental reasons for current commercialization practice pattern. It is suggested to establish foundation for higher level documents that would involve relating bodies and provide them operational guidelines for the implementation of commercialization incentives.
Policy, regulations and management as the most influential issue should be considered for successful commercialization. The present study, for the first time, attempts to disclose the importance of evidence input for measures in order to facilitate the commercialization process by the authorities in Iran. Overall, the NIS model should be considered and utilized as one of the effective solutions for commercialization.
PMCID: PMC3974067  PMID: 24568555
Knowledge translation; Biopharmaceutical research; Facilitators and barriers
17.  Comparing dietary patterns of depressed patients versus healthy people in a case control protocol 
BMJ Open  2014;4(2):e003843.
Major depressive disorder is the leading cause of disability around the world. Because of the high rate of medication discontinuation by patients and the risk of recurrence, factors such as nutrition could be useful for the prevention or treatment of depression. The relationship between depression and dietary patterns has been reported in a few studies but with controversial results. Therefore, we have decided to study the possible effects of cultural, social, racial, geographic and environmental conditions on this relationship in an Iranian population.
Methods and analysis
In our case control protocol, 110 cases and 220 controls will be individually matched based on age, sex and area of residence. New cases of depression, based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), will be recruited from two psychiatric clinics in Tehran. Interviewers will then go to each patient's home and invite qualified individuals to participate in the study as controls. Food intakes of all participants will be obtained by semiquantitative food frequency questionnaires covering the past year; these will be transformed into actual food intake (g/day). Dietary patterns will be determined by the principal components method. Conditional logistic regression, as a multivariate analysis, will be used for assessing the relationship between dietary patterns and depression, taking into consideration the potential role of different variables. The results may help to identify differences in dietary patterns between depressed and healthy people.
Ethics and dissemination
The study protocol has been approved by ethics committee of Tehran University of Medical Sciences. At the beginning of the study, a written informed consent form will be signed and dated by subjects and investigators. The results will be published in due time.
PMCID: PMC3927997  PMID: 24525387
Epidemiology; Nutrition & Dietetics
18.  Constructing Pragmatic Socioeconomic Status Assessment Tools to Address Health Equality Challenges 
A key challenge for equality evaluation and monitoring, mainly in developing countries, is assessing socioeconomic status (SES) of individuals. This difficulty along with low technical competency, have resulted in many health information collected in these countries which are devoid of suitable SES indices. However, simplifying data collection requirements for estimating economic parameters seems to guarantee their wide adoption by survey and health information system (HIS) designers, resulting in immediate production of equity-oriented policy-relevant information. The goal of this study is obtaining adequate number of variables, which their combination can provide a valid assessment of SES in Iranian population.
The data source was Living Standards Measurement Study of Iran (2006). Data of 27,000 households on the ownership of 33 household assets was used for this analysis. Households of this study were divided into 5 groups in terms of SES status using principle component analysis. Then selection was made among the 33 variables so that a combination with minimum necessary number for obtaining SES status is reached. Agreement of the new combination (including minimum number of variables) with full variable combination (including all 33 variables) was assessed using weighted kappa.
A minimum set of six variables including having kitchen, bathroom, vacuum cleaner, washing machine, freezer and personal computer could successfully discriminate SES of the population. Comparing this 6 item-index with the whole 33 item-index revealed that 65% of households were in the same quintiles, with a weighted kappa statistics of 0.76. For households in different quintiles, movement was generally limited to one quintile, with just 2% of households moving two or more quintiles.
The proposed simple index is completely applicable in current Iran's society. It can be used in different survey and studies. The development is quite simple and can be done on a yearly basis using the updated National level data. Having such standardized simplified and up to date SES indices and incorporating them into all health data sources can potentially ease the measurement and monitoring of equity of health services and indices.
PMCID: PMC3915472  PMID: 24554991
Equality; Iran; socioeconomic status measurement
19.  Cost Effectiveness of Malaria Interventions from Preelimination through Elimination: a Study in Iran 
Malaria still is considered as a public health problem in Iran. The aim of the National Malaria Control Department is to reach the elimination by 2024. By decreasing the number of malaria cases in preelimination phase the cost effectiveness of malaria interventions decreases considerably. This study estimated the cost effectiveness of various strategies to combat malaria in preelimination and elimination phases in Iran.
running costs of the interventions at each level of intervention was estimated by using evidence and expert opinions. The effect of each intervention was estimated using the documentary evidence available and expert opinions. Using a point estimate and distribution of each variable the sensitivity was evaluated with the Monte Carlo method.
The most cost-effective interventions were insecticide treated net (ITN), larviciding, surveillance for diagnosis and treatment of patients less than 24 hours, and indoor residual spraying (IRS) respectively, No related evidence found for the effectiveness of the border facilities.
This study showed that interventions in the elimination phase of malaria have low cost effectiveness in Iran like many other countries. However ITN is the most cost effective intervention among the available interventions.
PMCID: PMC4289510  PMID: 25629064
Malaria; prevention and control; Iran; cost effectiveness; IRS; ITN
20.  Knowledge translation in Iranian universities: need for serious interventions 
The aim of this study was to assess the status of knowledge translation (KT) in Iranian medical science universities in order to assess the strengths and weaknesses of the most important organizations responsible for producing knowledge in the country.
The KT activities were assessed qualitatively and quantitatively in nine universities using the Self-Assessment Tool for Research Institutes.
The strengths and weaknesses of universities were determined using seven main themes: priority setting; research quality and timeliness; researchers’ KT capacities; interaction with research users; the facilities and prerequisites of KT; the processes and regulations supporting KT; and promoting and evaluating the use of evidence.
The quantitative and qualitative results showed that the Iranian universities did not have an appropriate context for KT. There were significant shortcomings in supportive regulations, facilities for KT activities, and the level of interaction between the researchers and research users.
The shortcomings in KT were mostly in the area of stewardship and policymaking (macro level), followed by planning and implementation at the universities. In order to strengthen KT in Iran, it should occupy a prominent and focused role in the strategies of the country’s health research system.
PMCID: PMC3835863  PMID: 24225146
22.  How to Implement Clinical Practice Guidelines in Iran 
Evidence-based medicine would come to the result by evidence-based implementation. Clinical Practice Guidelines (CPG) as one of the evidence-based knowledge products requires appropriate interventions after being produced to be applied.
The aim of this qualitative study was to identify the strategies for application of CPGs produced in Iran.
Materials and Methods:
The purposive snowball sampling was performed and it continued until reaching the theoretical saturation. In-depth semistructured individual interviews and Focus Group Discussion (FGD) were performed aiming at triangulation. The thematic framework approach was used for the analysis.
Twelve interviews were conducted with three health system policy makers and decision makers, four experienced in the production or adaptation of clinical practices, and five experts in evidence-based medicine development and education. In addition, 11 policy makers, managers, and decision makers of the health system took part in FGD. The proposed interventions were classified in the following themes: Health professionals-oriented, Financial, Organizational, Regulatory, and Multifaceted interventions.
Along with adaptation and development process of CPGs, their utilization should also be planned; otherwise spent time and money would be in vain. Certainly, imposing above-mentioned interventions with the ultimate goal of sustainable behavior change in health system service providers is beyond the capacity of specific groups or few academic centers. It requires the participation of all practitioners under the monitoring and support of the Ministry of Health and Medical Education. Deployment of the family physician plan and referral system is an opportunity which must be considered a trophy.
PMCID: PMC3971789  PMID: 24719697
Practice Guidelines; Health Plan Implementation; Early Intervention
23.  The perspectives of iranian physicians and patients towards patient decision aids: a qualitative study 
BMC Research Notes  2013;6:379.
Patient preference is one of the main components of clinical decision making, therefore leading to the development of patient decision aids. The goal of this study was to describe physicians’ and patients’ viewpoints on the barriers and limitations of using patient decision aids in Iran, their proposed solutions, and, the benefits of using these tools.
This qualitative study was conducted in 2011 in Iran by holding in-depth interviews with 14 physicians and 8 arthritis patient. Interviewees were selected through purposeful and maximum variation sampling. As an example, a patient decision aid on the treatment of knee arthritis was developed upon literature reviews and gathering expert opinion, and was presented at the time of interview. Thematic analysis was conducted to analyze the data by using the OpenCode software.
The results were summarized into three categories and ten codes. The extracted categories were the perceived benefits of using the tools, as well as the patient-related and physician-related barriers in using decision aids. The following barriers in using patient decision aids were identified in this study: lack of patients and physicians’ trainings in shared decision making, lack of specialist per capita, low treatment tariffs and lack of an exact evaluation system for patient participation in decision making.
No doubt these barriers demand the health authorities’ special attention. Hence, despite patients and physicians’ inclination toward using patient decision aids, these problems have hindered the practical usage of these tools in Iran - as a developing country.
PMCID: PMC3849268  PMID: 24066792
Patient decision aid tool; Qualitative study; Iran
24.  A social network analysis on clinical education of diabetic foot 
Identification of Educational Influentials (EIs) in clinical settings helps considerably to knowledge transfer among health and medical practice providers. The aim of this study was identifying EIs in diabetic foot ulcers (DFU) by medical students (clerks, interns and residents) and providing their relational pattern in this subject.
Subjects were medical students at clerk, intern and resident levels in a local educational hospital. A standard questionnaire with four domains (knowledge, communication, participation and professional ethics) was used for identifying EIs. Students introduced those people with these characteristics who referred them for DFU. Respective communication networks were drawn as intra-group (such as resident-resident) and inter-group (such as intern-resident) networks and quantitative criteria of density, in-degree and out-degree centrality and reciprocity were measured.
The network density of clerks-residents (0.024) and interns-residents (0.038) were higher than clerks-attends (0.015) and interns-attends (0.05); indicating that there were more consulting interactions in former networks than the latter. Degree centrality in residents-related networks (clerks-residents = 2.3; interns-residents = 2.6) were higher than attends-related ones (clerks-attends = 1.1; interns-attends = 1.7), while they were not statistically significant. However, In-degree centralization, which indicating a degree of variance of the whole network of ingoing relationships, in attends-related networks was greater than resident-related networks.
Resident were consulted with almost as same as attends on DFU. It showed that residents were playing a remarkable role in knowledge transfer and they can be considered as EIs in this clinical setting. It seemed that the availability was the main reason for this key role.
PMCID: PMC3879216  PMID: 24330538
25.  Disease Surveillance and Private Sector in the Metropolitans: A Troublesome Collaboration 
An effective response to health problems is completely dependent upon the capacities of the health system in providing timely and valid information to take action. This study was designed to identify various reasons from various perspectives for underreporting disease by physicians in the private sector in big cities in developing countries setting.
In this qualitative study, we used focus group discussions (16 manager), and in-depth semi-structured interviews
Themes were classified in 6 categories: Infrastructure and legal issues, the priority of disease reporting, workflow processes, motivation and attitude, human resources and knowledge and awareness. As the main reasons of under reporting, most physicians pointed out complicacy in reporting process and inadequate attention by the public sector. Managers emphasized instituting legal incentives and penalties. Experts focused on physicians’ knowledge and expressed a need for continuing medical education programs.
Independent interventions will have little chance of success and sustainability. Different intervention programs should consider legal issues, attitude and knowledge of physicians in the private sector, and building a simple reporting process for physicians. Intervention programs in which the reporting process offers incentives for all stakeholders can help improving and sustaining the disease reporting system.
PMCID: PMC3793485  PMID: 24130945
Iran; notification; public health practice; reporting

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