Barriers to healthy eating practices among school-aged children in Armenia: A qualitative study.

The aim of this study was to use diverse perspectives of stakeholders to explore barriers to healthy eating, and attitudes, norms, and practices contributing to unhealthy food choices among school-aged children in Armenia. A qualitative study was carried out through focus group discussions and in-depth interviews, using the Theory of Planned Behavior. The study was conducted in 21 public schools located in three provinces (marzes) of Armenia: Shirak, Lori, and Tavush, and the capital city Yerevan. These study areas were chosen purposefully to target more vulnerable regions and have a geographically diverse sample. Purposive sampling techniques were used to choose the study participants. Five groups were targeted: high school students, school principals, teachers, school cafeteria staff members, and mothers of school children. Overall, 10 focus group discussions, and 51 in-depth interviews were conducted with a total of 94 participants. The study explored two main themes underlying unhealthy eating behaviors among school-aged children in Armenia - suboptimal preferences and restricted opportunities. Three subthemes were identified within the theme of suboptimal preferences: preferences/tastes, attitudes, and role models/normative referent, and another three subthemes within the theme of restricted opportunities: choice restrictions, time constraints, and financial barriers. The study found that most of the constructs of theory of planned behavior, such as general attitudes, preferences, perceived norms and perceived behavioral control, impacted unhealthy eating behaviors of school-aged children in Armenia. The recommendations for practice included enhancing the appeal of healthy foods, highlighting the significance of breakfast and healthy eating in educational activities utilizing role models, expanding and empowering school canteens, including higher grade students in school feeding programs, and extending school breaks to provide sufficient time for healthy eating.

Risk factors of childhood cancer in Armenia: a case-control study.

INTRODUCTION: Childhood cancer (CC) is a leading cause of death among children aged 0-19 years worldwide. Each year, 400,000 new cases of CC are diagnosed globally. Given the between-country differences in CC incidence rates, types and trends, this study aimed to identify possible risk factors for CC in Armenia. METHODS: We used a case-control study design and enrolled participants from the only specialized pediatric hematology and oncology center in Armenia. Cases included patients ≤ 14 years old diagnosed and treated with a malignant disease between 2017 and 2020 in the centre. Controls included patients diagnosed and treated in the center during the same period for a non-malignant disease. We conducted telephone interviews with mothers of cases and controls. Independent risk factors of cancer were identified using multivariable logistic regression analysis. RESULTS: Overall, 234 participants (117 cases, 117 controls) were included in the study. Based on the fitted model, maternal usage of folic acid during pregnancy was protective against CC, almost twice decreasing its odds (OR = 0.54; 95% CI: 0.31-0.94). On the contrary, experiencing horrifying/terrifying event(s) during pregnancy (OR = 2.19; 95% CI: 1.18-4.07) and having induced abortions before getting pregnant with the given child (OR = 2.94; 95% CI: 1.45-5.96) were associated with higher odds for a child to develop cancer. CONCLUSION: Despite the limited sample size of the study, significant modifiable risk factors for CC in Armenia were identified, all of which were linked to the period of pregnancy. The data from this study adds to the limited information available from etiological CC research throughout the world, and it will increase understanding of CC risk factors in settings with small populations and low resources. Although these findings may be helpful for future research, they should be taken with caution unless validated from further larger-scale studies.

Qualitative study of barriers and facilitators of health entrepreneurship in rural and semirural communities of Armenia.

INTRODUCTION: Low- and middle-income countries often face the issue of unequal distribution of healthcare services and human resources between rural and urban areas. Globally, there are many factors negatively affecting the willingness of physicians to work in remote and rural areas, such as low wages, poor living conditions, poorer and sicker patients, suboptimal equipment and supplies, and a lack of quality infrastructure and transportation. METHODS: This study explored the perceptions of barriers and facilitators of medical entrepreneurship and the impact of medical entrepreneurship on the served communities among the owners of private medical practices in rural and semirural areas of Armenia. The researchers conducted qualitative in-depth interviews with the 13 owners of 12 private practices. The interviews were transcribed in the original language (Armenian). Only the quotes were translated into English. The direct content analysis approach was used for analyzing textual data. RESULTS: The findings of the study suggest that high investment cost, intense competition with state facilities, unfavorable laws and regulations, and a lack of entrepreneurship and healthcare quality assurance skills were perceived as barriers to establishing and running private healthcare practices. The dissatisfaction of healthcare providers with their work conditions in state facilities, the instability of the job market in Armenia, and the development of clear marketing strategies by the entrepreneurs facilitated opening and operating private practices. All of the interviewees felt that their practices had a positive impact on the communities they served, in terms of creating new jobs and introducing up-to-date and in-demand services into these communities. CONCLUSION: The study recommended providing potential entrepreneurs with training in entrepreneurship and healthcare quality assurance and mentorship opportunities, as well as with tools to support financing their enterprises.

Posttraumatic Stress Disorder 23 Years After the 1988 Spitak Earthquake in Armenia.

This population-based longitudinal study examined the rates and predictors of posttraumatic stress disorder (PTSD) among 725 differentially exposed survivors of the 1988 Spitak earthquake in Armenia, 23 years after the event. Participants had been previously evaluated in 1991. Evaluations included assessment of current PTSD (based on DSM-5 criteria), and a variety of potential risk and protective factors. For the whole sample, the rate of PTSD attributed to the earthquake decreased from 48.7% in 1991 to 11.6% in 2012 (p < .001). A "dose of exposure" pattern persisted, and 15.7% of participants who were in Spitak (high exposure) and 6.6% of participants who were in Kirovagan (low exposure) during the earthquake met the criteria for PTSD (p = .003). Additionally, in 2012, another 9.9% of participants met PTSD criteria due to post-earthquake traumas, which is a 5-fold increase from pre- to postearthquake (p < . 001). Factors positively associated with PTSD included earthquake-related job loss, exposure to post-earthquake traumas, depression at baseline, and chronic illness since the earthquake. Factors inversely associated with PTSD included housing assistance within two years after the earthquake, support of family and/or friends, and to a lesser degree, higher education and high living standard. These variables accounted for 23.1% of the variance in current PTSD severity scores. These findings indicate that PTSD rates subside significantly after a catastrophic disaster, although earthquake-related PTSD persists among a subgroup of exposed individuals. Predictors of PTSD identified in this study provide guidance for planning acute and longer-term postdisaster public mental health recovery programs.

Predictors of Stunting Among Children Ages 0 to 59 Months in a Rural Region of Armenia.

OBJECTIVES: The prevalence of stunting in Armenia more than doubled since the 1990 s. This study aimed to investigate the prevalence and the predictors of stunting among children younger than 5 years in a rural region of Armenia, Talin, targeted by the World Vision (WV) nutrition interventions. METHODS: Anthropometric measurements were conducted among a large representative sample of children 0 to 59 months old to identify the prevalence of stunting. Children identified as stunted were included in a case-control study as cases and compared with normally growing controls randomly selected from the same pool of children. The mothers of cases and controls were interviewed. Logistic regression analysis was applied to identify the predictors of stunting. RESULTS: Of 739 measured children, 101 (13.7%) were undernourished, including 94 (12.7%) who were stunted. The fitted logistic regression model identified 7 independent predictors of stunting, of which 4 were protective: mother's height, child's birth length, number of child's hand washings per day, and the full set of WV interventions carried out in the community; whereas 3 were risk factors, that is, never/rarely using soap during hand washing, being the fourth or later child in the family, and family size. CONCLUSIONS: The study findings suggest that although WV nutrition interventions have shown impact, there is also a nonnutritional pathway of child stunting in rural Armenia. Thus, antistunting interventions should include sanitation and hygienic measures along with adequate perinatal care and maternal and child nutrition to further reduce childhood stunting, ensuring long-term health benefits for children not only in rural Armenia but also in rural communities in other low/middle-income countries.

Prevalence and determinants of anaemia among children aged 0-59 months in a rural region of Armenia: a case-control study.

OBJECTIVE: Despite the trend of increasing prevalence of childhood anaemia in Armenia, no studies exploring its risk factors have been conducted in the country. The present study aimed to investigate the prevalence and determinants of childhood anaemia in rural Armenia. DESIGN: Blood Hb level was measured among a representative sample of children using the HemoCue Hb201+ analyser. The revealed cases with anaemia were compared with randomly selected non-anaemic controls. Mothers of cases and controls were interviewed. Logistic and linear regression models were fitted to identify the risk factors of anaemia and low Hb level, respectively. SETTING: Talin communities, Aragatsotn Province, Armenia. SUBJECTS: Children under 5 years of age in Talin region. RESULTS: Of the 729 studied children, 32·4% were anaemic with 14·7% having moderate/severe anaemia. Infants were the most affected group with 51·1% being anaemic before 6 months and 67·9% at 6-12 months of age. Fitted regression models identified the following predictors of anaemia: younger age, male gender, shorter birth length, anaemia during pregnancy, lower meal frequency per day, lack of meat in the diet, using dung cakes for heating and living in a community that received an incomplete set of nutrition interventions. CONCLUSIONS: The study identified several modifiable risk factors that could be targeted to reduce childhood anaemia in rural Armenia and, possibly, in rural areas in other low-/middle-income countries. The suggested interventions include prevention and treatment of anaemia during pregnancy, provision of adequate complementary feeding to children with inclusion of meat in their daily diet and reduction of their exposure to biomass fuel smoke.

A post-earthquake psychopathological investigation in Armenia: methodology, summary of findings, and follow-up.

The post-earthquake psychopathological investigation (PEPSI) was designed to probe the short-and long-term effects of the earthquake in northern Armenia on 7 December 1988 on survivors' mental and physical health. Four phases of this study have been conducted to date, and, overall, more than 80 per cent of a sub-sample of 1,773 drawn from an initial cohort of 32,743 was successfully followed during 2012. This paper describes the methodology employed in the evaluation, summarises previous findings, details the current objectives, and examines the general characteristics of the sample based on the most recent follow-up phase outcomes. Despite a significant decrease in psychopathology rates between 1990 and 2012, prevalence rates of post-traumatic stress disorder and depression among study participants in 2012 were greater than 15 and 26 per cent, respectively. The paper also notes the strengths and limitations of the study vis-à-vis future research and highlights the importance and potential practical implications of similar assessments and their outcomes.

Loss and psychosocial factors as determinants of quality of life in a cohort of earthquake survivors.

BACKGROUND: Despite the existing evidence of a long lasting effect of disaster related experiences on physical and psychological health, few studies have evaluated long-term quality of life (QOL) outcomes of disaster survivors and the factors associated with such outcomes. METHODS: 23 years after the 1988 Spitak earthquake in Armenia, the associations of demographic characteristics, trauma exposure and psychosocial variables on QOL were explored among a cohort of 725 exposed individuals. The EQ-5D-5 L instrument was applied to measure QOL of participants. Multivariate linear and ordinal logistic regressions were applied to evaluate the determinants of QOL and its underlying five domains (mobility, self-care, usual activity, pain/discomfort, and anxiety/depression). RESULTS: Older age, current depression, post-traumatic stress disorder and anxiety symptoms were negatively associated with QOL. Additionally, those with severe losses (who did not receive any financial/material aid) had significantly poorer QOL outcomes, with higher odds of mobility difficulties (OR = 1.86, p < 0.05), self-care difficulties (OR = 2.85, p < 0.05), and mood problems (OR = 2.69, p < 0.05). However, those with severe earthquake related losses who received financial/material aid reported less self-care difficulties (OR = 0.21, p < 0.05) usual activity difficulties (OR = 0.40, p < 0.05), and mood problems (OR = 0.44, p < 0.05). Finally, each unit increase in current social support score was found to be significantly associated with a better QOL outcome and better self-reported outcomes across all underlying domains of QOL. CONCLUSIONS: These findings suggest that earthquake related loss and concurrent psychopathology symptoms can have adverse impact on the QOL of survivors. They also indicate that well-targeted post-disaster financial/material aid and social support should be considered as means for improving the long-term QOL outcomes of disaster survivors.

Estimated prevalence and predictors of undernutrition among children aged 5-17 months in Yerevan, Armenia.

OBJECTIVE: Child undernutrition is a serious public health problem in many low- and middle-income countries. Data on child undernutrition prevalence and its risk factors in Armenia are limited. The present study aimed to estimate the prevalence and explore the predictors of undernutrition among children aged 5-17 months in Yerevan. DESIGN: The study was cross-sectional and employed a review of the ambulatory charts of children selected through a multistage cluster sampling. This phase was followed by a case-control study. The cases were undernourished children identified during the record review and randomly matched with normally growing controls of the same age and gender from the same pool of records. Mothers of cases and controls participated in a telephone interview. The study used conditional logistic regression analysis. SETTING: Yerevan, Armenia. SUBJECTS: Children aged 5-17 months residing in Yerevan, Armenia. RESULTS: Review of 570 ambulatory charts suggested the prevalence of stunting, underweight and wasting among 5-17-month-old children in Yerevan to be 17·9 %, 7·3 % and 3·1 %, respectively. The case-control study of eighty-nine matched pairs identified four significant predictors of child undernutrition: family's socio-economic status score (P = 0·030), child's length at birth (P = 0·027), duration of predominant breast-feeding (P = 0·046) and food diversity score (P = 0·039). CONCLUSIONS: The factors determining growth patterns of children in Yerevan are mostly behavioral and environmental, hence modifiable. Reducing poverty and inequalities in food availability, promoting breast-feeding and adequate complementary feeding, and ensuring optimal care before, during and after pregnancy are likely to help reduce child undernutrition in Yerevan, Armenia and societies with similar public health concerns.

Rate and predictors of postpartum depression in a 22-year follow-up of a cohort of earthquake survivors in Armenia.

Disasters have serious long-term impact on mental health for those exposed. The aim of this study was to identify predictors of postpartum depression among survivors of the 1988 devastating earthquake in Armenia. A nested case-control design was applied to investigate postpartum depression in a large-scale cohort of survivors followed between 1990 and 2012. From an original group of 725 adults who were assessed for psychopathology in 1990, 146 women reported having a delivery after the earthquake and were included in this study. Women with postpartum depression were identified using Edinburgh Postnatal Depression Scale. A logistic regression model was fitted to identify the predictors of postpartum depression. Of the 146 women, 19 (13.0%) had postpartum depression. Five independent predictors of postpartum depression were identified: number of woman's stressful life events (odds ratio (OR)=2.06), her prior history of postpartum depression (OR=16.98), delivering sick/dead neonate (OR=13.65), poor living standards during the post-earthquake decade (OR=5.77), and perceiving oneself reliable in 1990 (OR=0.24). Anxiety in 1990 was marginally significantly related to the outcome (OR=3.75). The rate of postpartum depression in this 22-year cohort was similar to that among the Armenian general population. Earthquake exposure was not related to postpartum depression, indicating that the impact of disaster-related trauma diminishes over time. The identified predictors provided evidence to develop interventions targeting groups of women most prone to postpartum depression under such circumstances.

Seroprevalence of Hepatitis C Virus and Factors Associated with It in Armenia, 2021.

Hepatitis C virus (HCV) infection is among the leading causes of cirrhosis and hepatocellular carcinoma. Knowledge of its prevalence and risk factors can help to effectively fight the virus. This study was the first to investigate the seroprevalence of HCV, its genotypes, and factors associated with it among the general adult population of Armenia selected countrywide via cluster sampling. Anti-HCV antibodies were detected using third-generation immunoassay. Polymerase chain reaction and genotyping was performed among anti-HCV-positive individuals. Shortly after testing, the participants underwent a telephone survey. Logistic regression models were fitted to identify factors associated with anti-HCV antibody positivity and chronic HCV infection. The prevalence of anti-HCV antibodies among 3831 tested individuals was 2% (99% CI 1.4, 2.5), and chronic HCV infection was 0.7% (99% CI 0.4, 1.0), with genotypes 3 and 2 being the most common. The risk factors for chronic HCV infection included self-reported chronic liver disease (95% CI 1.47, 15.28), having tattoos (95% CI 1.34, 10.94), ever smoking (95% CI 1.16, 9.18), and testing positive for hepatitis B virus core antibody (95% CI 1.02, 7.17). These risk factors demonstrate that there could be room for strengthening infection control measures to prevent the transmission of HCV in Armenia.

Prevalence of hepatitis B virus infection among general population of Armenia in 2021 and factors associated with it: a cross-sectional study.

OBJECTIVES: This study sought to determine the prevalence and associated factors of hepatitis B virus (HBV) infection ever in life and chronic HBV infection in Armenia. DESIGN: A population-based cross-sectional seroprevalence study combined with a phone survey of tested individuals. SETTING: All administrative units of Armenia including 10 provinces and capital city Yerevan. PARTICIPANTS: The study frame was the general adult population of Armenia aged ≥18 years. PRIMARY AND SECONDARY OUTCOME MEASURES: The participants were tested for anti-HBV core antibodies (anti-HBc) and HBV surface antigen (HBsAg) using third-generation enzyme immunoassays. In case of HBsAg positivity, HBV DNA and hepatitis D virus (HDV) RNA PCR tests were performed. Risk factors of HBV infection ever in life (anti-HBc positivity) and chronic HBV infection (HBsAg positivity) were identified through fitting logistic regression models. RESULTS: The seroprevalence study included 3838 individuals 18 years and older. Of them, 90.7% (3476 individuals) responded to the phone survey. The prevalence of anti-HBc positivity was 14.1% (95% CI 13.1% to 15.2%) and HBsAg positivity 0.8% (95% CI 0.5% to 1.1%). The viral load was over 10 000 IU/mL for 7.9% of HBsAg-positive individuals. None of the participants was positive for HDV. Risk factors for HBsAg positivity included less than secondary education (aOR=6.44; 95% CI 2.2 to 19.1), current smoking (aOR=2.56; 95% CI 1.2 to 5.6), and chronic liver disease (aOR=8.44; 95% CI 3.0 to 23.7). In addition to these, risk factors for anti-HBc positivity included age (aOR=1.04; 95% CI 1.04 to 1.05), imprisonment ever in life (aOR=2.53; 95% CI 1.41 to 4.56), and poor knowledge on infectious diseases (aOR=1.32; 95% CI 1.05 to 1.67), while living in Yerevan (vs provinces) was protective (aOR=0.74; 95% CI 0.59 to 0.93). CONCLUSION: This study provided robust estimates of HBV markers among general population of Armenia. Its findings delineated the need to revise HBV testing and treatment strategies considering higher risk population groups, and improve population knowledge on HBV prevention.

Short and long term determinants of incident multimorbidity in a cohort of 1988 earthquake survivors in Armenia.

BACKGROUND: Multimorbidity, presence of two or more health conditions, is a widespread phenomenon affecting populations' health all over the world. It becomes a serious public health concern due to its negative consequences on quality of life, mortality, and cost of healthcare services utilization. Studies exploring determinants of multimorbidity are limited, particularly those looking at vulnerable populations prospectively over time. This study aimed at identifying short and long term socioeconomic, psychosocial, and health behavioral determinants of incident multimorbidity among a cohort of the 1988 Armenian earthquake survivors. METHODS: The study included a representative subsample of 725 from a larger initial cohort of the earthquake survivors. Data on this subsample were collected via four phases of this cohort study during the period 1990-2012. The final logistic regression analysis eliminated all those cases with baseline multimorbidity to investigate short and long term determinants of incident multimorbidity; this subsample included 600 participants. RESULTS: More than 75% of the studied sample had multimorbidity. Perceived low affordability of healthcare services, poor living standards during the post-earthquake decade, and lower education were independent predictors of incident multimorbidity developed during the period 1990-2012. Stressful life events and poor social support were among psychosocial determinants of incident multimorbidity. Participants' baseline BMI reported in 1990 was independently associated with incident multimorbidity. CONCLUSIONS: Most of the identified determinants of incident multimorbidity in our study population were markers of social inequities, indicating that inequities pose a serious threat to both individual and public health-related outcomes. Strategies targeting to decrease such inequities along with promotion of healthy lifestyle and strengthening of social networks may considerably reduce multimorbidity among population groups with similar socioeconomic and cultural profiles.

Gender differences in predictors of self-rated health in Armenia: a population-based study of an economy in transition.

INTRODUCTION: Self-rated health is a widely used health outcome measure that strongly correlates with physical and mental health status and predicts mortality. This study identified the set of predictors of fair/poor self-rated health in adult female and male populations of Armenia during a period of long-lasting socio-economic transition to a market economy. METHODS: Differences in self-rated health were analyzed along three dimensions: socioeconomic, behavioral/attitudinal, and psychosocial. The study utilized data from a 2006 nationwide household health survey that used a multi-stage probability proportional to size cluster sampling with a combination of interviewer-administered and self-administered surveys. Both female and male representatives of a household aged 18 and over completed the self-administered survey. Multivariate odds ratios (OR) for fair/poor self-rated health were calculated for different sets of variables and logistic regression models fitted separately for women and men to identify the determinants of fair/poor self-rated health. RESULTS: Overall, 2310 women and 462 men participated in the survey. The rate of fair/poor self-rated health was 61.8% among women and 59.7% among men. For women, the set of independent predictors of fair/poor self-rated health included age, unemployment, poverty, low affordability of healthcare, depression, and weak social support. For men, the set included age, lower education, depression, weak social support, and drinking alcohol less than once a week. For both genders, depression and weak social support demonstrated the strongest independent association with fair/poor self-rated health. CONCLUSIONS: The prevalence of fair/poor self-rated health was similar among men and women in this study, but the sets of independent predictors of perceived health differed somewhat, possibly, reflecting lifestyle differences between men and women in Armenia. Nevertheless, psychosocial variables were the strongest predictors of fair/poor self-rated health for both genders, indicating the importance of improving the country's psychosocial environment through social reforms and poverty reduction.

The course, trajectories and predictors of depression 23 years after the 1988 Spitak earthquake in Armenia: A prospective cohort study.

There is a scarcity of long-term studies of depression after natural disasters. This prospective epidemiologic study evaluated the course of depression and factors associated with it among survivors 23-years post-earthquake. A geographically stratified subsample of 725 adults exposed to the Spitak earthquake was assessed for depression using DSM-III-R criteria in 1991 and 2012. Additionally, an adapted CES-D-16 scale was used to assess depressive symptoms in 2012. A fitted multi-nominal logistic regression model identified predictors of different trajectories of depression. For the whole group, the rate of clinical depression dropped from 51.5% in 1991 to 31.7% in 2012. Earthquake intensity and experiencing strong fear at baseline were strongly associated with chronic (depressed at both assessments, 18.1%) and recovered (depressed only in 1991, 33.5%) depression trajectories compared with the healthy group, with odds ratios (OR) over 4.0 and 3.0, respectively. Predictors distinguishing chronic depression included earthquake-related nuclear-family deaths (OR=3.79), chronic illnesses at baseline (OR=1.24), and social support (OR=0.91). Predictors of the late-onset trajectory (depressed only in 2012, 13.5% of the cohort) included post-earthquake trauma (OR=1.42), socioeconomic status (OR=0.45), and social support (OR=0.86). The factors associated with the different trajectories of depression provide guidance for planning more effective mental health interventions after disasters.

Main Barriers to Optimal Breastfeeding Practices in Armenia: A Qualitative Study.

BACKGROUND: In 2015, the median duration of exclusive breastfeeding was 2.2 months in Armenia, and only 15% of 4-5-month-old children were exclusively breastfed, indicating an issue with breastfeeding knowledge and practices. RESEARCH AIM: To identify the main barriers to optimal breastfeeding practices in Armenia. METHODS: We used qualitative research methods via focus group discussions and in-depth interviews with four groups of providers from different levels of care, and mothers of young children, from Yerevan city and two provinces, Lori and Shirak. Overall, eight in-depth interviews and 13 focus group discussions were conducted with a total of 99 participants. Qualitative content analysis was applied, with elements of both inductive and deductive approaches. RESULTS: We identified two main categories of barriers to optimal breastfeeding-systemic barriers and knowledge deficiencies. The main themes within systemic barriers were lack of skilled breastfeeding support services and low motivation of providers-mainly related to inadequate recognition of their role in breastfeeding counseling and low remuneration. The main knowledge-related barriers were insufficient counseling of mothers, lack of reliable information sources about infant feeding, and misconceptions among both mothers and providers. CONCLUSION: Optimal breastfeeding is crucial for the best start to an infant's life; however, there were a number of barriers to optimal breastfeeding practices in Armenia. Our findings and recommendations could help policymakers apply effective strategies for improving breastfeeding rates in Armenia. Considering the similar historical backgrounds of the post-Soviet countries, our findings could also be applicable to other Commonwealth of Independent States countries.

How Effective Is Iron Supplementation During Pregnancy and Childhood in Reducing Anemia Among 6-59 Months Old Children in India?

Objectives: The study sought to identify whether iron and folic acid supplementation of pregnant women and preschool children is associated with child's anemia status and the predictors of anemia among children in India. Design: Secondary data analysis was performed using the National Family Health Survey 4 data. Multivariable logistic regression was used to identify the adjusted associations between child's anemia status and iron supplementation, both during pregnancy and childhood. Also, a model of significant predictors of anemia among children was fitted. Setting: India. Participants: Youngest children (6-59 months) in families. Results: The adjusted association between supplementation during pregnancy and child's anemia status was significant (p = 0.010), whereas the adjusted association between supplementation during childhood and child's anemia status was insignificant (p = 0.16). The variables independently associated with anemia status of the child included younger age (95% CI 2.67-2.86), child's recent diarrhea (95% CI 1.02-1.14), low birth weight (95% CI 1.17-1.27), current underweight (95% CI 1.14-1.28), diet diversity score (95% CI 0.96-0.98), higher birth order (95% CI 1.01-1.05), mother's current anemia (95% CI 1.68-1.81), months of breastfeeding (95% CI 0.99-1.00), no/primary education (95% CI 1.23-1.35), family's low wealth index (95% CI 1.11-1.23), and backward caste (95% CI 1.04-1.14). Conclusions: The National Iron Plus Initiative strategy of child's iron supplementation should be evaluated to identify the reasons of its ineffectiveness in anemia reduction. In addition, vulnerable groups of children, i.e., children from poor and less educated families and those with low birth weight, higher birth order, and poor nutritional status, should be targeted first with anemia reduction interventions.

Determinants of self-rated health in women: a population-based study in Armavir Marz, Armenia, 2001 & 2004.

BACKGROUND: The former soviet Republic of Armenia entered a turbulent and long-lasting economic transition when it declared its independence in 1991. This analysis sought to identify the determinants of poor self-rated health as an indirect measure of health status and mortality prognosis in an adult female population during a period of socio-economic transition in Armenia. METHODS: Differences in self-rated health in women respondents were analyzed along three main dimensions: social, behavioral/attitudinal, and psychological. The data used were generated from cross-sectional household health surveys conducted in Armavir marz in 2001 and 2004. The surveys utilized the same instruments and study design (probability proportional to size, multistage cluster sampling with a combination of interviewer-administered and self-administered surveys) and generated two independent samples of households representative of Armavir marz. Binary logistic regression models with self-rated health as the outcome were fitted to the 2001 and 2004 datasets and a combined 2001/2004 dataset. RESULTS: Overall, 2 038 women aged 18 and over participated in the two surveys (1 019 in each). The rate of perceived "poor" health was relatively high in both surveys: 38.1% in 2001 and 27.0% in 2004. The sets of independent predictors of poor self-rated health were similar in all three models and included severe and moderate material deprivation, probable and possible depression, low level of education, and having ever smoked. These predictors mediated the effect of women's economic activity (including unemployment), ethnicity, low access to/utilization of healthcare services, and living alone on self-rated health. CONCLUSION: Material deprivation was the most influential predictor of self-rated health. Thus, social reforms to decrease the gap between the rich and poor are recommended as a powerful tool for reducing health inequalities and improving the health status of the population.

Factor Structure and Psychometric Properties of the Posttraumatic Stress Disorder (PTSD) Checklist and DSM-5 PTSD Symptom Set in a Long-Term Postearthquake Cohort in Armenia.

Psychometric properties of the Armenian-language posttraumatic stress disorder (PTSD) Checklist-Civilian version (PCL-C) and the DSM-5 PTSD symptom set were examined in a long-term cohort of earthquake survivors. In 2012, 725 survivors completed the instruments. Item-/scale-level analysis and confirmatory factor analysis (CFA) were performed for both scales. In addition, exploratory factor analysis (EFA) was conducted for DSM-5 symptoms. Also, the differential internal versus external specificity of PTSD symptom clusters taken from the most supported PTSD structural models was examined. Both scales had Cronbach's alpha greater than .9. CFA of PCL-C structure demonstrated an excellent fit by a four-factor (reexperiencing, avoidance, numbing, and hyperarousal) model known as numbing model; however, a superior fit was achieved by a five-factor model (Elhai et al.). EFA yielded a five-factor structure for DSM-5 symptoms with the aforementioned four domains plus a negative state domain. This model achieved an acceptable fit during CFA, whereas the DSM-5 criteria-based model did not. The Armenian-language PCL-C was recommended as a valid PTSD screening tool. The study findings provided support to the proposed new classification of common mental disorders, where PTSD, depression, and generalized anxiety are grouped together as a subclass of distress disorders. Recommendations were made to further improve the PTSD diagnostic criteria.

Prospective study of predictors of poor self-rated health in a 23-year cohort of earthquake survivors in Armenia.

Long-term prospective studies exploring general health outcomes among disaster survivors are rare. Self-rated health (SRH) - a proven correlate of morbidity and mortality prognosis - was used to investigate predictors of perceived health status among a 23-year cohort of survivors of 1988 Spitak earthquake in Armenia. A geographically-stratified subsample of 725 adults from a larger initial cohort was followed during the period of 1990-2012. A logistic regression model identified predictors of SRH. Adjusted relative risks for the long-term predictors of SRH were calculated. The rate of poor SRH among the survivors was 18.8%, fair 56.5%, and good/excellent 24.7%. In the fitted model, long-term risk factors of poor SRH included baseline body mass index, baseline multi-morbidity, number of experienced stressful life events, and perceived poor living standards during the post-earthquake decade, while participation in sports in the early 1990s was a protective factor. Short-term protective factors included socio-economic status score, social support, employment and dignity, while current household size was a risk factor for poor SRH. No association was found between earthquake exposure severity and SRH after 23 years. However, the identified predictors included a number of modifiable lifestyle, material and psychological factors. Thus, interventions targeting these factors could have a long-lasting impact on disaster victims' health status.