Measuring Iran's success in achieving Millennium Development Goal 4: a systematic analysis of under-5 mortality at national and subnational levels from 1990 to 2015

Association between short-term ozone exposure and allergic conjunctivitis in China: A multi-city case-crossover study

Short-term exposure to ozone has been linked to multiple allergic diseases, but the relationship between ozone exposure and allergic conjunctivitis (AC) remains unclear. This study aimed to investigate the association between short-term exposure to ozone and the risk of AC. We conducted a time-stratified case-crossover study across five Chinese cities from 2014 to 2022. Daily outpatient visit records for AC were identified in five hospitals using either the diagnosis name or ICD-10 code H10.1. Data on air pollution and meteorological conditions were also collected. We first examined the city-specific association between short-term ozone exposure and AC using conditional logistic regression. A random-effects meta-analysis was then conducted to obtain overall estimates. During the study period, 130,093 outpatient visits for AC occurred, with 58.8% (76,482) being male and 41.2% (53,611) female. A one-standard-deviation (SD) increase in ozone was associated with an 8.3% increase (95% CI: 3.8%, 13.0%) in AC outpatient visits. Similar positive associations were observed when adjusting for other pollutants (PM2.5, CO, SO2 and NO2) in two-pollutant and multi-pollutant models. Furthermore, the positive association remained consistent when using mixed-effects regression models or further adjusting for meteorological conditions. In addition, no effect modification of the AC-ozone association by sex, age and season was apparent. This study provides evidence supporting a positive association between short-term ozone exposure and AC risk in China. This highlights the potential value of mitigating ozone pollution to reduce the risk of ocular surface disorders.

Lessons from Peru to reduce under-5 mortality: understanding program implementation and context

BACKGROUND

Health policymakers aiming to reduce under-5 mortality (U5M) often lack data regarding how successful interventions in other countries were implemented. The Exemplars in U5M Study identified countries that achieved significant reductions in amenable U5M. This case study in Peru used implementation research to explore the contextual factors and strategies that contributed to the successful implementation of key evidence-based interventions (EBIs).

METHODS

This research utilized a hybrid implementation research framework and a mixed-methods approach to understand the factors associated with EBI implementation and the successful reduction of U5M between 2000-2015. A desk review of existing literature on EBIs and U5M in Peru was completed, and in-depth interviews were performed with key Peruvian informants to understand the implementation strategies employed and the contextual factors that facilitated or were barriers to success. For the purposes of this analysis, three EBIs were selected and evaluated: antenatal care visits (ANC), facility-based deliveries, and infant vaccination.

RESULTS

Between 2000-2015, the percent of mothers attending at least four antenatal care visits rose from 69% to 96.9%, and the percent of facility-based deliveries increased from 56 to 91%. Three doses of the tetanus/diphtheria/pertussis vaccine, widely acknowledged as a key global health indicator, reached 90% by 2015. Key informants noted that economic growth, financial reforms, strong national commitment to reduce poverty in Peru, and national prioritization of maternal and child health, were important contextual factors that contributed to the successful reduction of U5M. They noted key strategies that helped achieve success during the implementation of EBIs, including utilization of data for decision-making, adaptation driven by cultural sensitivity to address gaps in coverage, and a focus on equity and anti-poverty initiatives with the participation of government, civil society, and political parties to assure continuity of policies.

CONCLUSION

Several EBIs contributed to the successful reduction of U5M in Peru between 2000-2015. Strategies such as the focus on equity throughout the study period contributed to an increase in coverage of EBIs like ANC visits, facility-based deliveries and infant vaccination which worked to reduce U5M. Understanding how Peru successfully implemented programs that reduced preventable infant and child deaths could be useful to replicating this substantial public health success in other low- and middle-income countries.

Child mortality inequalities and socioeconomic determinants of health in Iran, 2016-2018

Measuring health inequalities is essential to inform policy making and for monitoring implementation to reduce avoidable and unfair differences in health status. We conducted a geospatial analysis of child mortality in Iran using death records from the Ministry of Health and Medical Education from 2016 to 2018 stratified by sex, age, province, and district, and household expenditure and income survey data from the Statistical Center of Iran collected in 2017. We applied multilevel mixed-effect models and detected significant inequality in child mortality and the impact of socioeconomic factors, especially household income. We advocate for using mortality rate for young children (< 5 years old) as an indicator for assessing the impact of interventions to reduce inequalities among various socioeconomic groups. We also recommend to design and implement comprehensive and longitudinal data collection systems for accurate, regular, and specific monitoring of health inequalities.

Trends, influencing factors and prediction analysis of under-five and maternal mortality rates in China from 1991 to 2020

Introduction

Under-five mortality rate (U5MR) and maternal mortality rate (MMR) are important indicators for evaluating the quality of perinatal health and child health services in a country or region, and are research priorities for promoting maternal and infant safety and maternal and child health. This paper aimed to analysis and predict the trends of U5MR and MMR in China, to explore the impact of social health services and economic factors on U5MR and MMR, and to provide a basis for relevant departments to formulate relevant policies and measures.

Methods

The JoinPoint regression model was established to conduct time trend analysis and describe the trend of neonatal mortality rate (NMR), infant mortality rate (IMR), U5MR and MMR in China from 1991 to 2020. The linear mixed effect model was used to assess the fixed effects of maternal health care services and socioeconomic factors on U5MR and MMR were explored, with year as a random effect to minimize the effect of collinearity. Auto regressive integrated moving average models (ARIMA) were built to predict U5MR and MMR from 2021 to 2025.

Results

The NMR, IMR, U5MR and MMR from 1991 to 2020 in China among national, urban and rural areas showed continuous downward trends. The NMR, IMR, U5MR and MMR were significantly negatively correlated with gross domestic product (GDP), the proportion of the total health expenditure (THE) to GDP, system management rate, prenatal care rate, post-natal visit rate and hospital delivery rate. The predicted values of national U5MR from 2021 to 2025 were 7.3 ‰, 7.2 ‰, 7.1 ‰, 7.1 ‰ and 7.2 ‰ and the predicted values of national MMR were 13.8/100000, 12.1/100000, 10.6/100000, 9.6/100000 and 8.3/100000.

Conclusion

China has made great achievements in reducing the U5MR and MMR. It is necessary for achieving the goals of Healthy China 2030 by promoting the equalization of basic public health services and further optimizing the allocation of government health resources. China's experience in reducing U5MR and MMR can be used as a reference for developing countries to realize the SDGs.

Social determinants of health inequity in Iran: a narrative review

Objective

COVID-19 burden the health system by influencing several aspects of social determinants of health (SDH). We review SDH inequity in Iran with notice on COVID-19 pandemic and sanctions.

Method

The Databases such as MEDLINE, Scopus, and Google Scholar were searched. The SDH components were extracted regarding the effect of COVID-19 and sanctions. Global burden of disease was used to evaluate the impact of sanctions on mortality in Iran.

Result

The literacy rate improved over the last decades but, there is still inequality between provinces. Age and regional inequity exists, regarding NCD mortality. Food insecurity varies in different regions between 20% and 60%.Providing care for a growing aging population, with a large burden of NCDs and disabilities will be the major issue in the next decade. The decrease slop of mortality rate due to NCDs, have become smoother since impose of sanctions, while, cancer mortality have changed upwards. COVID-19, and sanctions negatively impacts lower socioeconomically vulnerable groups due to preexisting conditions which wider the existing inequity in SDH are adding a heavy burden of inequity in Iran.

Conclusion

Iran, similar to large numbers of countries, face inequity at regional level in different SDH related issues. The COVID-19 pandemic showed that economic status and health are aligned. Sanctions superimposed on the COVID-19 pandemic cause harm to millions of innocent people. One of the main goals of health authorities is to reduce SDH inequity in order to achieve the goal of "health for all". To tackle these inequities, prompt action is needed.

A bibliometric analysis of sustainable development goals (SDGs): a review of progress, challenges, and opportunities

The Sustainable Development Goals (SDGs) are a global appeal to protect the environment, combat climate change, eradicate poverty, and ensure access to a high quality of life and prosperity for all. The next decade is crucial for determining the planet's direction in ensuring that populations can adapt to climate change. This study aims to investigate the progress, challenges, opportunities, trends, and prospects of the SDGs through a bibliometric analysis from 2015 to 2022, providing insight into the evolution and maturity of scientific research in the field. The Web of Science core collection citation database was used for the bibliometric analysis, which was conducted using VOSviewer and RStudio. We analyzed 12,176 articles written in English to evaluate the present state of progress, as well as the challenges and opportunities surrounding the SDGs. This study utilized a variety of methods to identify research hotspots, including analysis of keywords, productive researchers, and journals. In addition, we conducted a comprehensive literature review by utilizing the Web of Science database. The results show that 31% of SDG-related research productivity originates from the USA, China, and the UK, with an average citation per article of 15.06. A total of 45,345 authors around the world have contributed to the field of SDGs, and collaboration among authors is also quite high. The core research topics include SDGs, climate change, Agenda 2030, the circular economy, poverty, global health, governance, food security, sub-Saharan Africa, the Millennium Development Goals, universal health coverage, indicators, gender, and inequality. The insights gained from this analysis will be valuable for young researchers, practitioners, policymakers, and public officials as they seek to identify patterns and high-quality articles related to SDGs. By advancing our understanding of the subject, this research has the potential to inform and guide future efforts to promote sustainable development. The findings indicate a concentration of research and development on SDGs in developed countries rather than in developing and underdeveloped countries.

Graphical abstract

Size-specific particulate matter and outpatient visits for allergic conjunctivitis in children: a time-stratified case-crossover study in Guangzhou, China

This time-stratified case-crossover study aims to quantify the risk of allergic conjunctivitis (AC) associated with short-term exposure to PMs (i.e., PM₁, PM_2.5, PM_c, and PM₁₀) among children in Guangzhou, China. We collected data on children's daily AC outpatient visits from the Guangzhou Women and Children Medical Center during February 20, 2016 to December 31, 2018, and also extracted air pollution and meteorological data in the same time frame. We used conditional logistic regression model to estimate the associations between PMs and AC outpatient visits, and conducted subgroup analyses stratified by sex, age, and season. During the study period, we recorded 39,330 children's outpatient visits for AC, including 27,638 boys and 11,692 girls. The associations between PMs and AC were general linear with no clear threshold, which were largest at the current days but remained positive for lag 1 to 3 days. For every 10 μg/m³ increase in daily PM₁, PM_2.5, PM_c, and PM₁₀ concentrations, the estimated risks of AC outpatient visits at the current days increased by 2.5% (OR = 1.025, 95% CI: 1.011-1.039), 1.8% (OR = 1.018, 95% CI: 1.009-1.027), 2.1% (OR = 1.021, 95% CI: 1.004-1.039), and 1.3% (OR = 1.013, 95% CI: 1.007-1.020), respectively. In addition, our stratified analyses revealed that girls and children aged 1 to 6 years were more sensitive to PM exposure, and the PM-associated risks for AC were more apparent in autumn and winter. Our study suggests that short-term exposure to PMs may induce AC in children.

Factors associated with patients' mobility rates within the provinces of Iran

BACKGROUND

The absence of a referral system and patients' freedom to choose among service providers in Iran have led to increased patient mobility, which continues to concern health policymakers in the country. This study aimed to determine factors associated with patient mobility rates within the provinces of Iran.

METHODS

This cross-sectional study was conducted in Iran. Data on the place of residence of patients admitted to Iranian public hospitals were collected during August 2017 to determine the status of patient mobility within each province. The sample size were 537,786 patients were hospitalized in public hospitals in Iran during August 2017. The patient mobility ratio was calculated for each of Iran's provinces by producing a patient mobility matrix. Then, a model of factors affecting patient mobility was identified by regression analysis. All the analyses were performed using STATA14 software.

RESULTS

In the study period, 585,681 patients were admitted to public hospitals in Iran, of which 69,692 patients were referred to the hospital from another city and 51,789 of them were admitted to public hospitals in the capital of the province. The highest levels of intra-provincial patient mobility were attributed to southern and eastern provinces, and the lowest levels were observed in the north and west of Iran. Implementation of negative binomial regression indicated that, among the examined parameters, the distribution of specialist physicians and the human development index had the highest impact on intra-provincial patient mobility.

CONCLUSION

The distribution of specialists throughout different country areas plays a determining role in patient mobility. In many cases, redistributing hospital beds is impossible, but adopting different human resource policies could prevent unnecessary patient mobility through equitable redistribution of specialists among different cities.

Retrospective study of postoperative mortality at a tertiary children's hospital in Iran: A cross sectional study

INTRODUCTION

Although mortality rates among children after surgery in developing countries are higher than in developed nations, little is known about the causes of post-operative pediatric death. Further insight into post-operative mortality rates and causes of death may help improve postoperative care. The present study investigates in-hospital mortality rates and causes of death at a major pediatric tertiary referral hospital in Iran.

METHODS

Patients younger than 18 years of age who underwent surgery with anesthesia between January 1, 2015 and Jan 1, 2018 at Dr. Sheikh Children's Hospital in Mashhad, Iran, were included in this retrospective study. Factors connected to the surgery and mortality rate were analyzed, including patient demographics and comorbidities, surgery type and emergency level, length of operation, and the mortality rate at different time intervals after surgery, were analyzed.

RESULTS

A total of 55,027 surgeries were performed between 2015 and 2018, resulting in 214 deaths. Pediatric mortality within 30 days was 78.6 deaths per 10,000 procedures. The highest mortality rate was observed in children under three years of age (67.2 per 10,000), and females were more likely than males to die after an operation (52.8%). The most common comorbidity associated with postoperative death was cardiac disease(18.9%). There was a significant relationship between age and time interval between surgery and death showed (p < 0.0001), and type of surgery (p = 0.013) with the time interval between surgery and death.

CONCLUSION

This study demonstrated that patient age and type of surgery were the main predictors of post-operative mortality.

STUDY TYPE

Prognosis study.

LEVEL OF EVIDENCE

Level II.

Level and trend of total plasma cholesterol in national and subnational of Iran: a systematic review and age-spatio-temporal analysis from 1990 to 2016

Purpose

We aimed to estimate the level and trend of plasma cholesterol and raised total cholesterol (TC > 200 mg/dl) prevalence at national and subnational level of Iran.

Methods

Nine national surveys and 27 studies, encompassing 3,505 unique points on over 500,000 adults, aged > 25 years with a report of laboratory measurement of TC were found. Age-spatio-temporal model and Gaussian Process Regression were used to estimate mean TC for each sex, 5-year age groups, and 31 provinces from 1990 to 2016.

Results

At national level, age-standardized prevalence of TC > 200 mg/dL has decreased from 57·2%(53·3-61·1) to 22·4%(20·5-24·3) in women and 53·2%(49·1-57·3) to 18·0%(16·4-19·6) in men. TC distribution presented a condensation between 170-200 mg/dL. At subnational level, decreasing and converging patterns of raised TC prevalence were detected.

Conclusion

The decrease in raised TC is likely the result of statin widespread use, food industry improvements, and the expanded primary health care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01052-w.

The age and cause decomposition of inequality in life expectancy between Iranian provinces: application of Arriaga method

BACKGROUND

This study aimed to decompose the age and cause inequality in life expectancy between two Iranian provinces with the highest and the lowest life expectancy using the Arriaga method.

METHODS

The required data was extracted from the death registration system (DRS) and statistical center of Iran. First, we calculated life expectancy at birth for 31 provinces of Iran using life tables, and subsequently, two provinces with the highest and the lowest life expectancy were determined. To decompose the age and cause share in the life expectancy gap between the two provinces, we used Arriaga's method.

RESULTS

Tehran with 80.09 years and Sistan and Baluchistan with 72.9 years had the highest and the lowest life expectancy among Iranian Provinces respectively. As a result, the life expectancy gap between Tehran and Sistan and Baluchistan was 7.19 years. Results of age decomposition showed that the highest share in the life expectancy gap attributed to the age group under one year (1.25 years). In terms of the cause of death, the highest percentage belonged to hypertensive diseases with a share of 1.77 years.

CONCLUSIONS

There is a wide gap between two provinces with the highest and the lowest life expectancy. Age less than one year and hypertensive diseases were major factors in this inequality. Therefore, policy-makers should concentrate on improvement of survival in children and the reduction of hypertensive diseases to promote life expectancy in Sistan and Baluchistan.

Epidemiologic View and Spatial Analysis of the Mortality of Children under 5 Years of Age in Isfahan Province in 2011-2016

Background

Children's mortality rate reflects the health level of the community. Therefore, accurate mapping of child mortality is one of the most important ways to reduce this rate. The purpose of this study was to investigate the mortality rate of children under 5 in Isfahan province in 2011-2016.

Methods

In this analytical cross-sectional study, all mortalities of children under 5 of Isfahan province related to Child Death Care System Program during 2011-2016 were studied. Mortality rate of children was calculated. Relationship between variables [demographic characteristics, place of death (urban/rural), and underlying cause of death] and child mortality was analyzed using Chi-square test. Mortality rate in the cities of Isfahan province was plotted on a geographical map.

Results

Whole number of mortalities of children under 5 was 5247 cases. Most of the mortalities (60.1%) were occurred in neonatal. Mortality rate was higher in boys than girls (12.6 vs. 11.1 per 1000 live births) (P < 0.001); "mortality rate in non-Iranians who live in Iran was more than that of Iranians (21.4 vs. 11.5 per 1000 live birth) (P < 0.001) and rural areas more than urban areas (15.2 vs. 11.4 per thousand live births) (P < 0.001)." Certain conditions originating in the perinatal period were reported as the greatest causes of death (45.9%). Congenital malformations (27.4%) and external causes of morbidity and mortality (6.7%) were the second and third causes of death. Fereidun Shahr had the highest U5MR and Khansar had the lowest U5MR.

Conclusions

Considering the major contribution of neonatal to the death of children under 5 and also the most important causes of death, interventions such as preventing early delivery, genetic counseling in high-risk couples, and parent training for accident prevention can play an effective role in reducing child mortality.

The Trend of Interpersonal Violence Mortality at National and Provincial Levels in Iran From 1990 to 2015

Interpersonal violence (IPV) is a major public health concern with a significant impact on physical and mental health. This study was designed to evaluate age-sex-specific IPV mortality trends and the assault mechanisms (firearm, sharp objects, and other means), at national and provincial levels, in Iran. We used the Iranian Death Registration System (DRS) and the population and housing censuses in this analysis. Spatio-temporal and Gaussian Process Regression methods were used to adjust for inconsistencies at the provincial level and to integrate data from various sources. After assessing their validity, all records were reclassified according to the International Classification of Diseases, 10th Revision (ICD-10). All ICD-10 codes were then mapped to Global Burden of Disease (GBD) 2013 coding. More than 700 individuals died due to IPV in 1990 and more than twice this number in 2015. The IPV mortality age-standardized rate, per 100,000, increased from 1.62 (95% Uncertainty Interval [UI] = [0.96, 2.75]) in 1990 to 1.81 [1.15, 2.89] in 2015. Among females, the age-standardized mortality rate at national level per 100,000 due to IPV was 1.27 [0.66, 2.43] in 1990 and decreased to 1.08 [0.60, 1.96] in 2015. Among males, the age-standardized mortality rate was 1.96 [1.25, 3.09] in 1990 rising to 2.54 [1.70, 3.82] in 2015. Data from provinces revealed that during the period of our study, Hormozgan province had the largest increase of IPV among females, and Fars province had the largest increase of IPV among males. Conversely, the largest decrease was detected in West Azarbaijan and Qom provinces in females and males, respectively. This study showed a wide variation in the incidence and trends of IPV in Iran by age, sex, and location. The study has provided valuable information to reduce the burden of IPV in Iran and a means to monitor future progress through repeated analyses of the trends.

The Economic Burden of Smoking-Attribution and Years of Life Lost due to Chronic Diseases in Mashhad, 2015-2016

Background:

Tobacco smoking is one of the most preventable causes of mortality related to noncommunicable diseases (NCDs). This study aimed to estimate the direct economic burden and years of life lost (YLL) attributable to smoking in NCDs in Mashhad, 2015–2016.

Methods:

Hospital-based data were utilized to calculate the economic burden of four selected diseases related to smoking. An epidemiological population-attributable risk method was used to determine the smoking-attributable fraction (SAF). Moreover, the study was conducted by data related to disease-specific expenditures and patients' information on cost and the number of mortality for estimating the YLL for each disease, population and life expectancy data, the prevalence of smoking, and the relative risk of smoking. Data analysis was performed with STATA software, version 12.

Results:

The total costs attributable to smoking for stroke, myocardial infarction, chronic obstructive pulmonary disease (COPD), and lung cancer were 94148, 151272, 1191396, and 574784 US Dollars, respectively (per 100000). In 2015, the YLL per deaths due to COPD were 4217 and 3522 among males and females, respectively. Furthermore, in 2016, the YLL per deaths due to the stroke in males and females were 8317 and 7563, respectively. In the same year, the highest proportion of years of potential life lost per 100000 smoking-attributable deaths belonged to COPD.

Conclusions:

The results of this study can be used to inform policy-makers about smoking-attributable diseases in Iran. To decrease the smoking-attributable costs, which have resulted in the spread of NCDs, policy-makers should adopt and implement effective policies regarding smoking prevention and control.

Spatio-temporal analysis of misaligned burden of disease data using a geo-statistical approach

Data used to estimate the burden of diseases (BOD) are usually sparse, noisy, and heterogeneous. These data are collected from surveys, registries, and systematic reviews that have different areal units, are conducted at different times, and are reported for different age groups. In this study, we developed a Bayesian geo-statistical model to combine aggregated sparse, noisy BOD data from different sources with misaligned areal units. Our model incorporates the correlation of space, time, and age to estimate health indicators for areas with no data or a small number of observations. The model also considers the heterogeneity of data sources and the measurement errors of input data in the final estimates and uncertainty intervals. We applied the model to combine data from nine different sources of body mass index in a national and sub-national BOD study. The cross-validation results confirmed a high out-of-sample predictive ability in sparse and noisy data. The proposed model can be used by other BOD studies especially at the sub-national level when the areal units are subject to misalignment.

Differentiating the effects of ambient fine and coarse particles on mortality from cardiopulmonary diseases: A nationwide multicity study

BACKGROUND

Both inhalable particles (PM₁₀) and fine particles (PM_2.5) are regulated in various countries mainly due to their adverse health effects. However, there is increasing evidence that PM_2.5 might be responsible for these effects and coarse particles (PM_c) plays little role in adverse health effects, if so, it might be not necessary to monitor PM₁₀.

METHODS

In this study, we conducted a time-series analysis using a generalized additive model to explore the effects of PM_2.5, PM_c, and PM₁₀ on mortality from ischemic heart disease (IHD) and chronic obstructive pulmonary disease (COPD) in 96 Chinese cities during 2013-2016. The mortality number and attributable fraction were further estimated using the national air quality standard and WHO's guideline as the reference.

RESULTS

We observed significant effects of PM_2.5 on IHD and COPD mortality; each 10 ug/m³ increase in lag₀₁ PM_2.5 was associated with a 0.26% (95% CI: 0.17%, 0.34%) increase in IHD mortality and a 0.19% (95% CI: 0.09%, 0.29%) increase in COPD mortality. We also found significant effects of PM_c and PM₁₀ on mortality from IHD and COPD, but the magnitudes of effects were weaker than those of PM_2.5. The results were robust when adjusting for co-pollutants and altering model parameters. We further estimated that about 1.27% (95% CI: 0.29%, 2.30%) of IHD mortality and 1.25% (95% CI: 0.08%, 2.46%) of COPD mortality could be attributable to PM_2.5 exposure using WHO's guideline (25 ug/m³) as a reference, corresponding to 15,337 (95% CI: 3,375, 27,842) mortalities from IHD and 5,653 (95% CI: 379, 11,152) COPD mortalities in the 96 cities. Across all of China, almost fifty thousand cases of IHD mortality and twenty thousand cases of COPD mortality might be avoidable if the PM_2.5 concentration declined to the WHO guideline.

CONCLUSIONS

Our study indicates that short-term exposure to PM_2.5 could be an important risk factor of mortality from IHD and COPD, and substantial cardiopulmonary mortality could be avoidable by reducing daily PM_2.5 concentrations. It is nonnegligible to consider the role of PM_c in triggering in cardiopulmonary mortality. And it could be necessary to continue monitoring PM₁₀ in the study regions due to the adverse effects of PM_c.

Associations between acute exposure to ambient air pollution and length of stay for inpatients with ischemic heart disease: a multi-city analysis in central China

Ambient air pollution (AAP) has been widely associated with increased morbidity of ischemic heart disease (IHD). However, no prior studies have investigated the effects of AAP exposure on the length of stay (LOS) due to IHD. Hospital data during 2015-2017 were obtained from hospital information system in five cities of Hubei province, China. We collected daily mean concentrations of air pollutants, including PM_2.5, PM₁₀, SO₂, NO₂, O₃, and CO, and meteorological data during the same time period. Poisson regression was applied to estimate the acute impacts of AAP on the LOS of IHD inpatients. A total of 42,114 inpatients with primary diagnosis of IHD were included, 50.63% of which were chronic IHD inpatients. Annual average concentrations of PM_2.5, PM₁₀, SO₂, NO₂, O₃, and CO were 61.93 μg/m³, 95.47 μg/m³, 18.59 μg/m³, 35.87 μg/m³, 100.30 μg/m³, and 1.117 mg/m³, respectively. After adjusting for temperature, relative humidity, gender, age group, payment method, number of hospital beds, location of hospital, and surgery or not, exposures to PM_2.5, PM₁₀, SO₂, O₃, and CO were associated with increased LOS for all IHD patients in both single- and multi-pollutant models, and stronger associations were observed among chronic IHD patients. In addition, subgroup analyses demonstrated that males and the group aged 65+ years were more vulnerable to air pollution, and the adverse effects were also promoted by low temperature in cold season. This study provides the first investigation of the adverse effects of AAP on the LOS for IHD patients. In order to shorten the LOS of IHD, measures should be taken to strengthen the AAP management and protect the high-risk population.

The trend of fall-related mortality at national and provincial levels in Iran from 1990 to 2015

Falls are one of the major causes of unintentional injuries. Understanding the epidemiology of fall-related mortality helps to identify the root causes of this event and planning preventive strategies to inhibit falls. The aim of this study was to assess the trend of fall-related mortality rate and its epidemiological patterns based on sex and age-groups at national and subnational levels in Iran during the years 1990 to 2015. All data were gathered from Death Registration Systems, cemetery databases of Tehran and Isfahan, the Demographic and Health Survey of 2000 and three rounds of national population and housing censuses. The age-standardized death rate (ASDR) due to falls per 100,000 people decreased from 2.61 (95% Uncertainty Interval (UI): 1.94-3.51) in 1990 to 2.13 (1.62-2.80) in 2015 at national level. Males were at higher risk of death due to falls than females. Our data showed that the elderly population was at higher risk of death due to falls and individuals less than 4-year old had the highest fall-related mortality rate among children and adolescents. Our data should be used to accelerate interventions to reduce fall-related mortality.

Trend of Appendicitis Mortality at National and Provincial Levels in Iran from 1990 to 2015

BACKGROUND

Appendicitis is one of the most preventable causes of death worldwide. We aimed to determine the trend of mortality due to appendicitis by sex and age at national and provincial levels in Iran during 26 years.

METHODS

Data were collected from Iran Death Registration System (DRS), cemetery databanks in Tehran and Esfahan, and the national population and housing censuses of Iran. The estimated population was determined for each group from 1990 to 2015 using a growth model. Incompleteness, misalignment, and misclassification in the DRS were addressed and multiple imputation methods were used for dealing with missing data. ICD-10 codes were converted to Global Burden of Disease (GBD) codes to allow comparison of the results with the GBD study. A Spatio-Temporal model and Gaussian Process Regression were used to predict the levels and trends in child and adult mortality rates, as well as cause fractions.

RESULTS

From 1990 to 2015, 6,982 deaths due to appendicitis were estimated in Iran. The age-standardized mortality rate per 100000 decreased from 0.72 (95% UI: 0.46-1.12) in 1990 to 0.11 (0.07-0.16) in 2015, a reduction of 84.72% over the course of 26 years. The male: female ratio was 1.13 during the 26 years of the study with an average annual percent change of -2.31% for women and -2.63% for men. Among men and women, appendicitis mortality rate had the highest magnitude of decline in the province of Zanjan and the lowest in the province of Hormozgan. In 1990, the lowest age-standardized appendicitis-related mortality was observed in both women and men in the province of Alborz and the highest mortality rate among men were observed in the province of Lorestan. In 2015, the lowest mortality rates in women and men were in the province of Tehran. The highest mortality rates in women were in Hormozgan, and in men were in Golestan province.

CONCLUSION

The mortality rate due to appendicitis has declined at national and provincial levels in Iran. Understanding the causes of differences across provinces and the trend over years can be useful in priority setting for policy makers to inform preventive actions to further decrease mortality from appendicitis.

Trends of National and Subnational Incidence of Childhood Cancer Groups in Iran: 1990-2016

Background: Childhood cancer is a double-edged sword, considering its high rate of response to treatment despite a high vulnerability to develop future malignancies in survivors. Thus, multidisciplinary preventive, curative, and supportive strategies must be incorporated in childhood cancer care that require understanding the distribution and trend of cancer in the target population. In this article, we aimed to report the national and subnational trends of childhood cancer incidence in Iran from 1990 to 2016, and mortality/incidence ratio (MIR), which, to our knowledge, have not been reported in previous literature.

Method: Data on the incidence and mortality rates were collected from the National and Subnational Burden of Diseases project. We employed a two-stage spatiotemporal model to estimate cancer incidences by sex, age, province, and year based on the primary dataset of national death registration system. National and subnational age and gender-specific trends as well as MIR were calculated.

Result: The age-standardized incidence rate had a steady increasing trend for cancers in both female [annual percent change (APC), 1.6%] and male (APC, 2.1%) patients. Not only there was an increasing trend in most provinces but also there was a 40% divergence in age-standardized incidence rate at subnational levels. Leukemia, lymphoma, neoplasms of the central nervous system (CNS), digestive tract, endocrine gland, and urinary tract were the leading causes of cancer comprising more than half of all cancers. There was a remarkable general decrease in MIR by 75% as a proxy of care quality.

Conclusion: Regarding the increased trend of childhood cancer incidence, there is an essential need to address the etiologic factors and establish preventive plans for childhood cancers. Despite the favorable outcomes observed in cancer care, commensurate health resource allocation must be applied to diminish the subnational disparities.

National and sub-national HIV/AIDS-related mortality in Iran, 1990-2015: a population-based modeling study

Surveillance of HIV/AIDS mortality is crucial to evaluate a country’s response to the disease. With a modified estimation approach, this study aimed to provide more accurate estimates on deaths due to HIV/AIDS in Iran from 1990 to 2015 at national and sub-national levels. Using a comprehensive data set, death registration incompleteness and misclassification were addressed by demographical and statistical methods. Trends of mortality due to HIV/AIDS at national and sub-national levels were estimated by applying a set of models. A total of 474 men (95% uncertainty interval [UI]: 175–1332) and 256 women (95% UI: 36–1871) died due to HIV/AIDS in 2015 in Iran. Peaked in 1995, HIV/AIDS-related mortality has steadily declined among both genders. Mortality rates were remarkably higher among men than women during the period studied. At the sub-national level, the highest and the lowest annual percent change were found at 10.97 and −1.36% for women, and 4.04 and −3.47% for men, respectively. The findings of our study (731 deaths) were remarkably lower than the Joint United Nations Programme on HIV and AIDS (4000) but higher than Global Burden of Disease (339) estimates in 2015. The overall decrease in mortality due to HIV/AIDS may be attributed to the increasing burden of noncommunicable diseases; however, the role of the national and international organizations to fight HIV/AIDS should not be overlooked. To decrease HIV/AIDS mortality and to achieve international goals, evidence-based action is required. To fast-track targets, the priority must be to prevent infection, promote early diagnosis, provide access to treatment, and to ensure treatment adherence among patients.

Finding the reasons of decrease in the rate of population growth in Iran using causal layered analysis (CLA) method

Background: According to census 2011, general fertility rate in Iran was 1.6 children. The United Nations published a low population growth scenario for Iran in 2010, and if Iran continues to experience population replacement and does not have a plan to balance it, it will experience a population of 31 million, with a high percentage of elderly people in the next 80 years. This study was conducted to identify the causes of a decrease in population growth rate. Methods: This was a secondary study conducted by reviewing the scientific texts, papers, and upstream documents. The upstream documents contain all national documents related to population decline in Iran. Causal layered analysis (CLA) was used for data analysis. Results: The 9 most important identified causes for a decrease in population were litany (child mortality, maternal mortality, diseases burden, fertility rate, marriage squeeze, abortion, marriage age, high-risk behaviors, and badly supervised and neglected children. Also, 5 causes in structural layer were urbanization, education rate, economic participation rate and unemployment rate, new structures, a change in family structure, and intergenerational gap. Moreover, three causes in discourse layer included welfare, materialism, individualism, and 2 causes in metaphor layer were changing the perception of life and family formation, and women as workforce. Conclusion: It seems that the decrease in population growth in Iranian society is less the result of social planning and population control and more the result of the value and structural changes that have been occurred due to modernization in the society. It is recommended that policymakers primarily address the discourse and metaphor layers to solve the problems.

Evaluating maternal and child health indicators for the Sustainable Development Goals in 2018: what is Iran's position?

OBJECTIVES

Since many Millennium Development Goals (MDGs) were not achieved, countries including Iran—despite achieving some of the MDGs—need regular planning to achieve the Sustainable Development Goals (SDGs) by 2030. This article examines maternal and child health indicators in the early years of the SDGs in Iran relative to several other countries.

METHODS

This study was carried out through a secondary analysis of maternal and child health indicators in Iran. The results were compared with data from other countries divided into three groups: countries with upper-middle income levels, countries in the Eastern Mediterranean region, and the countries covered by the Outlook Document 1,404 (a regional classification). Then, the relationship between these indicators and the Human Development Index was investigated.

RESULTS

Iran has attained better results than other countries with respect to maternal mortality, family planning, skilled birth attendance, under-5 deaths, incidence of hepatitis B, diphtheria-tetanus-pertussis vaccination coverage, and antenatal care. In contrast, Iran performed worse than other countries with respect to under-5 wasting, under-5 stunting, and care-seeking behavior for children.

CONCLUSIONS

Overall, among the 11 indicators surveyed, Iran has attained better-than-average results and seems to be improving. We recommend that Iran continue interventions in the field of maternal and child health.

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.

Iran in transition

Being the second-largest country in the Middle East, Iran has a long history of civilisation during which several dynasties have been overthrown and established and health-related structures have been reorganised. Iran has had the replacement of traditional practices with modern medical treatments, emergence of multiple pioneer scientists and physicians with great contributions to the advancement of science, environmental and ecological changes in addition to large-scale natural disasters, epidemics of multiple communicable diseases, and the shift towards non-communicable diseases in recent decades. Given the lessons learnt from political instabilities in the past centuries and the approaches undertaken to overcome health challenges at the time, Iran has emerged as it is today. Iran is now a country with a population exceeding 80 million, mainly inhabiting urban regions, and has an increasing burden of non-communicable diseases, including cardiovascular diseases, hypertension, diabetes, malignancies, mental disorders, substance abuse, and road injuries.

Trend of fatal poisoning at national and provincial levels in Iran from 1990 to 2015

OBJECTIVES

Comprehensive and up-to-date data on fatal injury trends are critical to identify challenges and plan priority setting. This study provides a comprehensive assessment of poisoning mortality trends across Iran.

STUDY DESIGN

The data were gathered from various resources, including death registration systems, cemetery databases of Tehran and Esfahan, the Demographic and Health Survey of 2000, and three rounds of national population and housing censuses.

METHODS

After addressing incompleteness for child and adult death data separately and using a spatio-temporal model and Gaussian process regression, the level and trend of child and adult mortality were estimated. For estimating cause-specific mortality, the cause fraction was calculated and applied to the level and trend of death.

RESULTS

From 1990 to 2015, 40,586 deaths due to poisoning were estimated across the country. The poisoning-related age-standardized death rate per 100,000 was estimated to have changed from 3.08 (95% uncertainty interval [UI]: 2.32-4.11) in 1990 to 0.96 (95% UI: 0.73-1.25) in 2015, and the male/female ratio was 1.35 during 25 years of study with an annual percentage change of -5.4% and -4.0% for women and men, respectively. The annual mortality rate was higher among children younger than 5 years and the elderly population (≥70 years) in the study period.

CONCLUSIONS

This study showed that mortality from poisoning declined in Iran over the period from 1990 to 2015 and varied by province. Understanding the reasons for the differences of poisoning mortality by province will help in developing and implementing measures to reduce this burden in Iran.

Self-reported health problems, health care seeking behaviour and cost coping mechanism of older people: Implication for primary health care delivery in rural Bangladesh

BACKGROUND

Optimum utilization of primary health care system by older people is a challenge for every low and middle income country. Little is known about self reported health problems, health care seeking behaviour and cost coping mechanism of older people in developing countries.

OBJECTIVES

This study aimed to measure self-reported health problems, health care seeking behaviour and expenditure coping mechanism of older people, and to describe its implication for primary health care delivery in rural Bangladesh.

METHODOLOGY

It was a cross sectional study. In total, 362 older people were enrolled who sought health care preceding the last month of the interview. Descriptive and bivariate data analysis along with proportion test (z test) was carried out.

RESULTS

The most frequent self-reported health problems were fever (43.8%) followed by physical pain (15.2%). More than half of the respondents (57.5%) had a second health problem. Only one third (33.8%) visited qualified health providers having minimum western health or medical training from government approved authority. More than half (54%) of the older people spent for health care out of pocket from their own. Only 2% older people sold their assets or took loans to meet their health care. 36% older people thought that they could afford to pay for health care in future.

CONCLUSIONS

The findings of this study will help in developing primary health care policy for older people in rural Bangladesh and similar settings in South Asia.

Liver cirrhosis mortality at national and provincial levels in Iran between 1990 and 2015: A meta regression analysis

BACKGROUND

Liver cirrhosis mortality number has increased over the last decades. We aimed to estimate the liver cirrhosis mortality rate and its trends for the first time by sex, age, geographical distribution, and cause in Iran.

METHOD

Iranian Death Registration System, along with demographic (Complete and Summary Birth History, Maternal Age Cohort and Period methods) and statistical methods (Spatio-temporal and Gaussian process regression models) were used to address the incompleteness and misclassification and uncertainty of death registration system to estimate annual cirrhosis mortality rate. Percentages of deaths were proportionally redistributed into cirrhosis due to hepatitis B, C and alcohol use based on the data from the Global Burden of Disease (GBD) 2010 study.

RESULTS

Liver cirrhosis mortality in elder patients was 12 times higher than that in younger patients at national level in 2015. Over the 26 years, liver cirrhosis mortality in males has increased more than that in females. Plus, the percentage of change in age adjusted mortality rate at provincial levels varied between decreases of 64.53% to nearly 17% increase. Mortality rate has increased until 2002 and then decreased until 2015.The province with highest mortality rate in 2015 has nearly two times greater rate compare to the lowest. More than 60% of liver cirrhosis mortality cases at national level are caused by hepatitis B and C infection. The rate of hepatitis B mortality is four times more than that from hepatitis C.

CONCLUSION

This study demonstrated an increasing and then decreasing pattern in cirrhosis mortality that could be due to national vaccination of hepatitis B program. However monitoring, early detection and treatment of risk factors of cirrhosis, mainly in high risk age groups and regions are essential. Cirrhosis mortality could be diminished by using new non-invasive methods of cirrhosis screening, hepatitis B vaccination, definite treatment of hepatitis C.

Temporal and spatial distribution of under-five mortality and factors associated with multiple cases of under-five deaths within a family in the rural area of Khuzestan, Southern Iran

Under-five mortality (U5M) is an important indicator of the overall health and development of society. There is a wide gap in U5M among different countries and also within the countries. This study was carried out to assess the prevalence, as well as the socio-demographic, and health-related causes of U5M in the region of study. A cross-sectional study was conducted among all registered cases of U5M in rural areas of Khuzestan province, Iran, during the years 2011 to 2015. To assess the socio-demographic determinants of U5M, the sample surveyed consists of 320 families with at least one under-five death using a multistage random sampling method. Also, this study evaluated the number of variables, which may increase the chance of families to have more than one U5M. U5M was 26 per 1000 live births in 2011, but decreased to 22 per 1000 live births in 2015. With the highest cumulative incidence of 43 in Masjed Soleyman and the lowest of 15 in Dehdez, infant mortality constitutes 76% of all U5M. Prematurity and congenital anomalies were responsible for 46% of all causes of mortality (that is, U5). Maternal age at delivery <18 years or >35 years (OR = 3.5; 95% CI, 1.29–6.22), marriage duration >9 years (1.85, 1.06–3.21), spouse age gap >5 years (2.32, 1.20–4.50), cesarean section (3.85, 1.19–5.74), delivery interval <3 years (2.83, 1.22–5.58), non-Arab ethnicity (2.58, 1.50–4.44), and mother working in agriculture or animal husbandry (3.93, 1.41–6.94) were the most important determinants associated with more than one child death per family. Spatially, there was a great disparity in U5M with different reduction rate during the 5 years of the study. Marriage age, cesarean delivery, delivery interval, and mother field activity were associated with U5M. This may have implications for the preventive health program.

Mortality burden attributable to PM1 in Zhejiang province, China

BACKGROUND

Limited evidence is available on the health effects of particulate matter with an aerodynamic diameter of <1 μm (PM₁), mainly due to the lack of its ground measurement worldwide.

OBJECTIVES

To identify and examine the mortality risks and mortality burdens associated with PM₁, PM_2.5, and PM₁₀ in Zhejiang province, China.

METHODS

We collected daily data regarding all-cause (stratified by age and gender), cardiovascular, stroke, respiratory, and chronic obstructive pulmonary disease (COPD) mortality, and PM₁, PM_2.5, and PM₁₀, from 11 cities in Zhejiang province, China during 2013 and 2017. We used a quasi-Poisson regression model to estimate city-specific associations between mortality and PM concentrations. Then we used a random-effect meta-analysis to pool the provincial estimates. To show the mortality burdens of PM₁, PM_2.5, and PM₁₀, we calculated the mortality fractions and deaths attributable to these PMs.

RESULTS

Daily concentrations of PM₁, PM_2.5, and PM₁₀ ranged between 0-199 μg/m³, 0-218 μg/m³, and 0-254 μg/m³, respectively; Mortality effects were significant in lag 0-2 days. The relative risks for all-cause mortality were 1.0064 (95% CI: 1.0034, 1.0094), 1.0061 (95% CI: 1.0034, 1.0089), and 1.0060 (95% CI: 1.0038, 1.0083) associated with a 10 μg/m³ increase in PM₁, PM_2.5, and PM₁₀, respectively. Age- and gender-stratified analysis shows that elderly people (aged 65+) and females are more sensitive to PMs. The mortality fractions of all-cause mortality were estimated to be 2.39% (95% CI: 1.28, 3.48) attributable to PM₁, 2.53% (95% CI: 1.42, 3.63) attributable to PM_2.5, and 3.08% (95% CI: 1.95, 4.19) attributable to PM₁₀. The ratios of attributable cause-specific deaths for PM₁/PM_2.5, PM₁/PM₁₀, and PM_2.5/PM₁₀ were higher than the ratios of their respective concentrations.

CONCLUSIONS

PM₁, PM_2.5 and PM₁₀ are risk factors of all-cause, cardiovascular, stroke, respiratory, and COPD mortality. PM₁ accounts for the vast majority of short-term PM_2.5- and PM₁₀-induced mortality. Our analyses support the notion that smaller size fractions of PM have a more toxic mortality impacts, which suggests to develop strategies to prevent and control PM₁ in China, such as to foster strict regulations for automobile and industrial emissions.

What has Iran achieved in under-five mortality in terms of equity and efficiency in the past decades?

OBJECTIVE

Iran has made remarkable progress in reducing child mortality over the past few decades. However, this promising profile is mainly average driven, and inequalities are not counted in judgments about the progress. In the present study, we used an achievement index approach to combine average and inequalities to provide a better picture of Iran's achievement in under-five mortality over the last two decades.

STUDY DESIGN

The study had a cross-sectional design.

METHODS

Data gathered in the two recent national demographic health surveys (DHSs) in 2000 and 2010 were used to conduct the analyses. Accordingly, 45,646 live births covered by DHS 2000 and 10,604 live births covered by DHS 2010 were investigated. An achievement index was constructed by incorporating some extensions to the concentration index, namely by incorporation of the average into the index.

RESULTS

The standard concentration index showed that under-five mortality was unequally distributed, hurting the poor, across all provinces and Iran overall in 2000 (concentration index = -0.1311 [standard error {SE} = 0.0139]) and 2010 (-0.1367 [SE = 0.0381]). The achievement index revealed that Iran has had achievements in under-five mortality (relative change in the mean has decreased from 29.5% to 25.8%), but the achievement was mostly due to reductions in the average mortality and not in its unequal distribution. The same result applied to a considerable number of provinces, and only a few have made achievements in both inequality and average.

CONCLUSIONS

Considering the lack of progress in the reduction of inequalities in under-five mortality over the past decades, equity-oriented policies should be of prime importance for Iran's healthcare system.

Life expectancy of HIV-positive patients after diagnosis in Iran from 1986 to 2016: A retrospective cohort study at national and sub-national levels

OBJECTIVES

Little is known about the life expectancy of individuals with human immunodeficiency virus (HIV) in Iran. This study therefore aimed to estimate the life expectancy of HIV-positive patients in Iran.

METHODS

In this retrospective cohort study, we extracted data from the Center for Disease Control and Prevention of the Ministry of Health and Medical Education and the Death Registration System. We included patients aged 20 years and older who had a specified date of diagnosis. We estimated life expectancy and its 95% confidence intervals (CIs) using Chiang's methodology.

RESULTS

The overall life expectancy at the national level was 23.1 years (95% CI, 22.6 to 23.5). Life expectancy was 21.6 years (95% CI, 21.1 to 22.0) for men and 32.7 years (95% CI, 31.4 to 34.0) for women. The life expectancy of patients who did or did not receive antiretroviral therapy (ART) was 37.0 years (95% CI, 36.2 to 37.8) and 15.5 years (95% CI, 15.1 to 15.9), respectively. The life expectancy of patients with or without tuberculosis (TB) was 21.6 years (95% CI, 20.4 to 22.9) and 36.5 years (95% CI, 35.7 to 37.4), respectively.

CONCLUSIONS

The life expectancy of Iranian HIV-positive patients was found to be very low. To improve their longevity, improvements in ART coverage and the control and treatment of TB are advised.

The trend of burn mortality in Iran - A study of fire, heat and hot substance-related fatal injuries from 1990 to 2015

INTRODUCTION

Burn injuries are a major cause of preventable mortality worldwide. To implement preventive strategies, a detailed understanding of the rate and trend of fatal burn injuries is needed. The aim of this study was to determine the rate and trend of burn mortality at national and province level in Iran from 1990 to 2015.

MATERIALS AND METHODS

The data were retrieved from various sources: the Death Registration System, cemetery databases, the Demographic and Health Survey and three national population and housing censuses. ICD-10 codes were converted to Global Burden of Disease (GBD) codes for comparability. After addressing the incompleteness of death data, statistical methods such as spatio-temporal modelling and Gaussian Process Regression (GPR) were applied to estimate the levels and trend of death and cause specific mortality.

RESULTS

The number of deaths due to burning across Iran was 80,625, with a male to female ratio of 0.88, 0.94 and 1.14 in 1990, 1995 and 2015, respectively. The annual percentage change of age-standardized death rate from 1990 to 2015 was -5.42% and -4.22% in women and men, respectively. The burn-related age-standardized mortality rate decreased considerably from 5.97 in 1990 to 1.74 per 100,000 in 2015. The mortality rate due to burns was highest among those aged more than 85 years, especially in Ilam province.

CONCLUSION

This study showed a decline in burn mortality in Iran from 1990 to 2015. Continued efforts to reduce the burden of burns are needed to accelerate this progress and prevent injuries.