Health Workforce Planning: Designing a Specialty and Subspecialty Supply Model for Iran.

Background: One of the approaches to health workforce planning is supply-based. It has been emphasized that countries should model health workforce based on evidence and their context. The objective of this study is to "design a supply health workforce planning model for specialty and subspecialty in Iran." Methods: This is a study using Walker and Avant's (2018) theory synthesis framework to construct the model. This method has three steps. According to the viewpoint of the research team and the needs of the country, the focal concept is determined. Then, a literature review was done to determine related factors and their relationships. In the third step, according to the review, the viewpoint of the research team, the rationale of the connection between components, and the graphic model were presented. Results: "Supply" was selected as the focal concept. In the literature review, 42 components were obtained from the systematic review, 43 components obtained from the study of other texts were combined with the opinion of the research team about the field of Iran, and the connections between them were determined. In the third step, the supply model was designed using the Stock and Flow method. Finally, by applying the "functional full-time coefficient", the number of full-time equivalent physicians was calculated. Conclusion: The presented model is an evidence-based model that follows stock and flow design. Stock is the number of specialties or subspecialties that exist in the labor market. Flow includes inflow and outflow according to the educational pathway in the context of Iran.

Relationship between Health Literacy and Proper Antibiotic Use Awareness in Tehran 2019-2020.

Background: Improper use of antibiotics is one of health care problems that can lead to side effects or antibiotic resistance without benefit. This study aimed to evaluate the association between health literacy and knowledge on appropriate use of antibiotics in a population sample from Tehran. Methods: This was a cross-sectional, descriptive-analytic study on adults aged between 18 and 65 years. Health literacy was measured by the Health literacy for Iranian Adults (HELIA: Health Literacy for Iranian Adults) questionnaire, and awareness about proper antibiotic use was evaluated by a checklist designed based on a literature review and expert's opinion in domains of knowledge and attitude. Both an online Google Forms questionnaire and a paper questionnaire completed by outpatients from particular clinics in Tehran's north, west, or center were used to collect the data. SPSS Version 22 was used to analyze the data. Results: Out of 359 participants, 59.6% were women, and 66.8% had a university education level. Internet and health care workers were the main sources of health information. The mean score of health literacy was 71.4 out of 100, and 67.4% of the respondents had excellent or sufficient health literacy. The mean antibiotic awareness score was 10.5 out of 13, and the score in the domain of attitude was higher than knowledge. There was a significant relationship between health literacy and awareness about proper antibiotic use (P < 0.001). Health literacy was significantly higher in women (P = 0.001), people with higher education levels (P = 0.001), and financial sufficiency (P = 0.0038). Also, there was a significant relationship between awareness about proper antibiotic usage and age (P = 0.007) and financial sufficiency (P < 0.001) of the respondents. The online questionnaire users were not different in terms of their health literacy, but they were more educated and aware of antibiotics. Conclusion: The level of health literacy and awareness about the proper use of antibiotics in this study was good. level of health literacy was closely related to knowledge about the proper use of antibiotics, thus, it seems that promoting health literacy may increase awareness about proper antibiotic use.

Risk Communication in Early Containment of COVID-19 Pandemic in Iran: Implementation of the World Health Organization Strategic Preparedness and Response Plan (WHO-SPRP).

Background: Health systems must have functional and efficient preparedness and response plans to manage pandemics. Moreover, it is essential to adjust to changing circumstances and the dynamic character of pandemics. The World Health Organization (WHO) introduced the Strategic Preparedness and Response Plan (SPRP), emphasizing 144 measures across 10 pillars, helping governments prepare and respond to the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to determine how the Iranian health system, based on the WHO-SPRP, addresses strategic preparedness and response plan in the COVID-19 pandemic at the national level. Methods: The WHO-SPRP was adopted and translated into Persian by 2 bilingual natives. The chief of the health office requested that authorized officers complete the SPRP. Then, a meeting was held by officers of related units involved in COVID-19 management to address the SPRP at regional and national levels. Results: Our findings suggest that up to August 2020, effective risk communication and community engagement were not fully established. Our response plan lacked evidence-based information and educational messaging to consistently shape public opinion and impression of a respiratory pandemic. Conclusion: The Iranian health care system and services were almost able to address the SPRP and perform the major indicators that the WHO had proposed. However, special attention should be paid to risk communication and community engagement to empower informed decision-making by individuals and communities.

Best Practices in Achieving Universal Health Coverage: A Scoping Review.

Background: The Universal Health Coverage (UHC) is a very important and effective policy in the health system of countries worldwide. Using the experiences and learning from the best practices of successful countries in the UHC can be very helpful. Therefore, the aim of the present study is to provide a scoping review of successful global interventions and practices in achieving UHC. Methods: This is a scoping review study that has been conducted using the Arkesy and O'Malley framework. To gather information, Embase, PubMed, The Cochrane Library, Scopus, Scientific Information Database, and MagIran were searched using relevant keywords from 2000 to 2019. Studies about different reforms in health systems and case studies, which have examined successful interventions and reforms on the path to UHC, were included. Articles and abstracts presented at conferences and congresses were excluded. Framework Analysis was also used to analyze the data. Results: Out of 4257 articles, 57 finally included in the study. The results showed that of the 40 countries that had successful interventions, most were Asian. The interventions were financial protection (40 interventions that were categorized into 14 items), service coverage (31 interventions categorized into 7 items), population coverage (36 interventions categorized into 9 items), and quality (18 interventions categorized into 7 items), respectively. Also, the positive results of interventions on the way to achieving UHC were financial protection (14 interventions), service coverage (7 interventions), population coverage (9 interventions), and quality (7 interventions), respectively. Conclusion: This study provides a comprehensive and clear view of successful interventions in achieving the UHC. Therefore, with consideration to lessons learned from successful interventions, policymakers can design appropriate interventions for their country.

The attainment of physician's professional identity through meaningful practice: A qualitative study.

Background: Medical professional identity is how an individual perceives him/herself as a doctor. Formation of professional identity includes development, advancement, and socialization through social learning of specific knowledge, skills obtained while performing professional roles, practicing, and new attitudes and values. A qualitative study was performed to examine live experience of undergraduate medical science students with regards to obtaining professional identity. Methods: This qualitative study was performed using a conventional content analysis method. Participants were students who were studying medicine at Iran University of Medical Sciences. Sampling was done based on a purposeful sampling method. A total of 23 students took part in semi-structured interviews until data saturation was reached. The interviews were transcribed verbatim. Also, to develop themes, data were analyzed using conventional content analysis. Moreover, data management was done using MAXQDA software. Results: Based on data analysis, 2 main themes were as follow: meaningful medical practice" and "professional medical practice". The first theme had 3 categories: (i) self-insight; (ii) manner; and (iii) values and beliefs. The second theme had 2 categories: (i) professionalism; and (ii) holistic view of medicine. Conclusion: Certain individual characteristics and personality type were factors that affected participants' choice of their field of study. The participants' understanding of their profession was formed, not only by studying in the university through learning relevant knowledge, skills, and practice, but also by perceived attitude, views, and values in their profession.

Ethical considerations and interdisciplinary approach to research on COVID-19 pandemic: The response of Iran University of Medical Sciences.

Background: Research ethics committees are comprised of policymakers, supervisors, and decision-makers and aim at increasing adherence to professional ethics standards in conducting health-related research. The existential philosophy of these committees is to preserve the patients' health, maintain and promote public trust in health care providers, protect the rights of both patients and health care providers, and promote organizational ethics. However, this task can be complex and challenging during a public health emergency. Research ethics committees set the standard of research in the emergency situations through defining which research has the potential to promote the quality of response to a public health emergency. Methods: This study aims at collecting and classifying the valuable experiences of the research ethics committee members and reviewers during the early days of the COVID-19 epidemic in Iran University of Medical Sciences, one of the major universities in Tehran. It provides a basic understanding of the key concepts and challenges in reviewing and approving research by research ethics committees and the recommendations to overcome these challenging issues. Results: To accelerate the review process of COVID-19 research proposals, the scientific, methodological and ethical review panel was integrated as a large committee called 'IUMS Corona Research Team'. The first meeting was held on March 7, two weeks after the official announcement of the first case of the disease and is continued once a week. A total of 130 projects have been discussed and evaluated in this committee, among which 83 proposals were approved after modification. Conclusion: An interdisciplinary approach supports a flexible and effective scientific and ethical review of research leading to more protection of research subjects as well as promotion in the treatment and management of the pandemic ahead.

Psychometric properties of the Persian version of the Anesthetic Trainee Theatre Educational Environment Measure (ATEEM).

Background: The quality improvement of medical education programs and the ongoing reform of the curriculum should be done in the light of clinical training fields and identifying the strengths and improving the weaknesses. Therefore, this study was conducted to evaluate the validity and reliability of ATEEM (Anesthetic Trainee Theatre Educational Environment Measure) questionnaire for assessing learning environment of anesthesiology residents in educational centers affiliated to 3 main medical schools in Tehran, Iran. Methods: This study was conducted on first to fourth year anesthesiology residents using a questionnaire. Validity (face, content, construct) and reliability of ATEEM questionnaire was investigated. Construct validity was measured by confirmatory factor analysis, stability of reliability by test-retest, and internal consistency by Cronbach's alpha. Results: A total of 156 questionnaires out of 190 were fully answered, returned by residents of anesthesiology, and analysis were performed (82% response rate; 44.5% male (n=69); 55.5% female (n=86)). The age range of respondents was 26 to 48 years. The mean total ATEEM score was 114.03 out of 160. Face and content validity of the questionnaire was approved. Content validity ratio (CVR) and content validity index (CVI) were 0.63 and 0.88, respectively. Fitness indices in confirmatory factor analysis were greater than 0.9, and RMSEA (root mean square error of approximation) index was less than 0.08 (0.07). This indicator measures the acceptability of fitness and it is an appropriate measurement model. The average reliability coefficient was 0.73 and the overall Cronbach's alpha coefficient was 0.959. Conclusion: The results of this study showed that the Persian version of the ATEEM questionnaire, with appropriate psychometric properties, can be used to evaluate the anesthetic trainee theatre learning environment used in hospitals.

Prevalence of high blood pressure in Iranian adults based on the 2017 ACC/AHA guideline.

Background: : In 2017, American College of Cardiology (ACC) and the American Heart Association (AHA) presented a new guideline for assessing blood pressure in adults. This study aimed to assess the prevalence of hypertension in Iranian adults based on ACC/AHA 2017 guideline. Methods: Data from 9801 Iranian adults (59.2% women) aged between 20-69 years were obtained from the sixth round of National Surveillance of Risk Factors of Non-Communicable Diseases (SuRFNCD) performed in 2011. Blood pressure was classified as normal, elevated blood pressure, and stage 1 and 2 hypertension using a weighted analysis and 2017 ACC/AHA guidelines. Data were presented as prevalence and 95% confidence interval (95% CI). All analyses were performed in Stata/SE 14.0. Results: Overall prevalence of hypertension in Iranian men was 52.0%. Also, 32.9% (95% CI: 29.9-36.0) and 19.1% (95% CI: 16.9-21.6) of men had stage 1 and 2 hypertension, respectively. In addition, 44.3% of women had hypertension, of whom 26.3% (95% CI: 24.5 - 28.2) had stage 1 and 18.0% (95% CI: 16.1-20.1) stage 2 hypertension. Furthermore, 16.5% (95% CI: 14.4-18.9) and 9.6% (95% CI: 7.86-11.7) of men and women had elevated blood pressure, respectively. Conclusion: The findings of this study indicated that adopting the 2017 ACC/AHA guidelines showed a higher prevalence of adult hypertension (48.2%) in Iran. In this study, the prevalence of hypertension in men was higher than in women, which was steadily increased by age in older adults in both sexes.

The effects of amantadine on traumatic brain injury outcome: a double-blind, randomized, controlled, clinical trial.

INTRODUCTION: Amantadine, as a dopamine receptor agonist, may stimulate and help the recovery of the nervous system after traumatic brain injury (TBI). METHODS: We performed this study as a double-blind, randomized, controlled clinical trial with target population including all patients with TBI who scored nine or lower on the Glasgow Coma Scale (GCS), admitted to our hospital between January 2013 and April 2014. The protocol included administration of the drug (placebo or amantadine) for 6 weeks and patient evaluation using the GCS and FOUR score on the first, third and seventh days after the drug was started. After 6 months from starting study drug, the patients were evaluated on the Mini-Mental State Examination, Glasgow Outcome Study, Disability Rating Scale and Karnofsky Performance Scale. RESULTS: We included 40 patients in the study. The mean age of the patients was 36.77 ± 18.21. As an only important finding, the amantadine group registered an important rise between the first and the seventh day of study drug (∆GCS7-GCS1) with p-value = 0.044. CONCLUSION: Based on our findings during the first week and the 6 months (since starting drug) follow-ups, prescribing amantadine did not lead to reportable effects on the patients' level of consciousness, memory, disability, cognition, mortality and performance.

Delivering clinical preventive services in the Islamic Republic of Iran: A model for screening and behavior consultation practices.

Background: Screening and behavior consultation are considered to be limited, dispersed and expensive services across the country. To deliver efficient and equitable services current disordered practices need to be consolidated. Methods: An analysis of current situation, learned lessons and future scopes of country's preventive care delivery, along with a review of international experience and generous participation of various stakeholders, led to proposing a model for screening and behavior consultation practices in IR. Iran. Results: Upon the results of the previous steps, the desired model was based on the network system and family physician. Comprehensive health centers and other centers affiliated to the network are the most appropriate service positions. However, private and academic preventive centers are playing their rules. Conclusion: The proposed model matches the overall pattern of service delivery in the health system (network system with the private sector and the educational sector).

The effect of foot hyperpronation on spine alignment in standing position.

Background: According to clinical observations, foot hyperpronation is very prevalent and may cause malalignment of the lower extremity, leading to structural and functional deficits in standing and walking. This study aimed at investigating the effect of foot hyperpronation on spine alignment in the standing position. Methods: Thirty-five healthy males with an age range of 18-30 years participated in this cross-sectional study. Evaluation was performed with two examiners in four standing positions (on the floor, and on the wedges angled at 10, 15, and 20 degrees) using a motion analysis system (Zebris). Moreover, each of the measurement methods was repeated for three short times. Paired t- test and repeated measures ANOVA test were used for statistical analysis. Results: Significant differences were observed between all modes in the sacral angle, pelvic inclination, lumbar lordosis, and thoracic kyphosis variables (except between the first and second mode). Finally, a positive correlation was obtained for the examiners and all the variables with an increasing slope of the angle of wedge. Conclusion: The results of the present study revealed sacral angle, pelvic inclination, lumbar lordosis, and thoracic kyphosis were increased with an increase in bilateral foot pronation. In fact, each one of them is a compensatory phenomenon.

Ergonomic risk factors and musculoskeletal symptoms in surgeons with three types of surgery: Open, laparoscopic, and microsurgery.

Background: Musculoskeletal symptoms are the main cause of loss of working time, and increase in labor costs. Poor posture is the most important risk factor for work-related musculoskeletal symptoms. This study aimed at evaluating the role of ergonomic risk factors in different surgical (open surgery, laparoscopy, and microsurgery) in the frequency or resonance frequency of musculoskeletal symptoms. Methods: This descriptive-analytic study was conducted on 81 surgeons in a hospital in Tehran. In this study, the prevalence of musculoskeletal symptoms was evaluated using the Nordic Questionnaire. Moreover, Workplace ergonomic risk assessment method (WERA) was used to evaluate ergonomic risk factors in 3 types of open surgery, laparoscopy, and microsurgery. Results: The results revealed that the prevalence of musculoskeletal symptoms of the neck, back, shoulder, and arm is high in surgeons (over 75%). The mean final score of WERA was 40.11, representing the high risk of the 3 types of surgery for the prevalence of musculoskeletal symptoms. Results revealed that the prevalence of musculoskeletal symptoms in the neck, waist and wrists had a significant relationship with the body posture in the 3 types of open surgery, laparoscopy, and microsurgery (p<0.05). Conclusion: In the present study, the prevalence of musculoskeletal symptoms was high in the neck, waist, and hands surgeries. Depending on the type of surgery, teaching correct working methods, using proper seats and ergonomic equipment are the best strategies to reduce musculoskeletal symptoms in the surgical profession.

The role of work- related physical and psychological factors on prevalence of neck/shoulder complaints among nurses: A multicentric study.

Background: Identifying the predisposing factors of neck and shoulder complaints and finding solutions to avoid them could improve the occupational health condition of the nurses. In this study, we aimed at determining the role of psychological and physical occupational factors in developing neck and shoulder complaints among the participants. Methods: This analytic cross-sectional study was conducted on the nurses of main hospitals of Tehran. To study the prevalence of neck and shoulder pain, the Nordic questionnaire was used, and job content questionnaire was used to assess the psychological and physical occupational factors. Data were analyzed using SPSS and statistical methods. Independent sample t-test was used to compare the qualitative variables, and chi-square test was utilized for the statistical analysis of the qualitative variables. Results: Prevalence of neck and shoulder complaints among the nurses with high physical workload was significantly higher than in those nurses with low physical workload. Unlike physical workload, the prevalence of neck and shoulder complaints was not significantly different between the nurses with low or high psychological workload. Prevalence of neck and shoulder complaints among the female nurses was significantly higher than in the male nurses. In our study, only female nurses with high physical workload had been known as independent predictors of neck and shoulder complaints. Conclusion: Those nurses who had more workload, especially physical workload, had a higher prevalence of neck and shoulder complaints, and this fact could affect their work tasks.

Psychometric analysis of the ambulatory care learning education environment measure (ACLEEM) in Iran.

BACKGROUND: Examining educational environment (academic and clinical) by means of a valid, reliable and comprehensive questionnaire is a major key in achieving a highly qualified student - oriented curricula. The Persian translation of Ambulatory Care Learning Education Environment Measure-ACLEEM questionnaire has been developed to support this goal, and its psychometrics has been explored in this administration in teaching hospitals affiliated to Tehran University of Medical Sciences. METHODS: This descriptive - analytical study involved medical residents in four major clinics. In this study, the ACLEEM Questionnaire was conducted after translating and retranslating the questionnaire and examine the face and content validity, construct validity, test retest reliability and internal consistency coefficient. RESULTS: In this study, 157 out of 192 residents completed the questionnaire (response rate 82%). The mean age of the residents was 31.81 years .The final mean of the questionnaire was calculated as 110.91 out of 200 (with 95% confidence interval). Test - retest stability of the questionnaire was between 0.322 and 0.968. The face validity of the questionnaire was confirmed. The content validity ratio was 0.64; and content validity Index was 0.78. In Exploratory factor analysis, eight factors were confirmatory that changed the orientation of some questions. The Cronbach's alpha coefficient of the whole questionnaire was 0.936. CONCLUSION: According to the data, the Persian version of the ACLEEM questionnaire has sufficient psychometric reliability and validity to be used for conducting research, teaching and practicing the educational learning environment in ambulatory care in Iran.

Validity and reliability of activities coaching context questionnaire.

BACKGROUND: Learning in a clinical environment is an inseparable part of a training program in medical education. To evaluate the quality of training in a clinical environment, a comprehensive questionnaire which is adjusted for local purposes is essential. This study was conducted to determine the validity and reliability of Activities Coaching Context (ACC)-questionnaire from the perspective of residents and students in a clinical learning environment. METHODS: This was a cross-sectional study conducted with 65 residents and students of Semnan University of Medical Sciences. The Content Validity of the questionnaire was confirmed by the judgment of a panel of ten experts in medical education. The construct validity of the questionnaire was determined by factor analysis. Data were collected and analyzed by SPSS16. RESULTS: The ratio and index of content validity calculated by experts' view were quite acceptable (0.31 and 0.7, respectively). Construct validity was examined by factor analysis which confirmed seven first order factors. Cronbach's Alfa coefficient revealed a high degree of internal consistency (0.932). The reliability of the questionnaire was measured by test - retest (0.9). CONCLUSIONS: The ACC questionnaire appeared to be a valid, reliable and also appropriate tool to evaluate the educational quality of a clinical learning environment.

Assessing validity and reliability of Dundee ready educational environment measure (DREEM) in Iran.

BACKGROUND: If an institute is looking for improvement of its learning environment, a reliable and valid assessment tool is needed for measurement of the educational environment .The Dundee Ready Educational Environment Measure (DREEM) has been used in various studies to evaluate the educational environment. However, psychometric evaluations of the instrument seem necessary, for all known versions of the instrument. The aim of this study was to investigate the reliability and validity of Persian version of the DREEM in the major clinical wards in teaching hospitals affiliated to Iran University of Medical Sciences. METHODS: This descriptive - analytical study, involved medical students (clinical stagers and interns) in 4 major clinical wards. In this study, DREEM questionnaire was reviewed in content, face validity and construct validity through confirmatory factor analysis. The reliability was calculated according to test - retest and the internal consistency was measured using Cronbach's alpha coefficient. RESULTS: A total number of 267 questionnaires were completed by medical stagers (60%) and interns (40%) including 181 females and 82 males. The mean age of stagers and interns were 23.60 ± 1.27 and 25.45 ± 1.22 years, respectively. The total mean of the questionnaire was calculated as 96.15 (93.5375, 98.7547) out of 176, with 95% confidence interval. The face validity of the questionnaire was confirmed. The mean of content validity ratio (CVR) was calculated as 0.35, and 6 questions were omitted in this step. The content validity index (CVI) was 0.39. The reliability coefficient mean was 0.71. In confirmatory factor analysis five factors were confirmed that changed the orientation of some questions. The Cronbach's alpha coefficient of the whole questionnaire was obtained as 0.914. CONCLUSION: The modified and validates DREEM questionnaire in Persian language with 44 items and appropriate psychometric attributes is capable of being used in assessment of clinical education environments in Iran.

Age, Period and Cohort Analysis of Smoking Prevalence in Iranian Population over a 25-Year Period.

BACKGROUND: Current and daily smoking prevalence rates have been have investigated in several cross-sectional studies. However, analyses in terms of age-period-cohort (APC) have not been carried out. We assessed daily smoking dynamics over a 25-year period using the APC model. METHODS: In our analyses, we used data from 214,652 people aged 15 to 64 years, collected by national health surveys conducted in 1990-1991, 1999, 2005, 2007, 2011 and 2016. The Intrinsic Estimator model was used to analyze the impact of APC on daily smoking prevalence. RESULTS: Males were found to exhibit a higher prevalence of smoking compared to females (26.0% against 2.7%). Prevalence of smoking increased by age, peaking at the age groups of 40-44 in men and 45-49 in women, followed by a decreasing trend. The 1990 period had the highest prevalence in both genders, and the 2016 period had the lowest. The coefficients of birth cohort effects showed different patter19s of fluctuations in the two genders with the maximum and minimum coefficients for men calculated in the 1966-1970 and 1991-95 birth cohorts, and for females the 1931-1935 and 1971-1975 birth cohorts, respectively. CONCLUSION: We showed the impact of APC on daily tobacco smoking prevalence, and these factors should be considered when dealing with smoking.

Men's willingness to pay for prostate cancer screening: a systematic review.

BACKGROUND: This study aimed to review studies on willingness to pay (WTP) for prostate cancer screening. METHODS: This systematic-review was conducted based on the Preferred Reporting Items for Systematic Reviews guidelines. By searching six-health-database, WTP studies on prostate cancer screening using contingent valuation method published in English until March 2020 were included and those with unavailable full-text and inadequate quality-assessment scores were excluded. Smith checklist was used for the quality assessment. Extracted WTPs were converted to US dollar in 2018 using exchange rate parity and net present value formula to make comparison. Factors' effect was assessed by vote counting. RESULTS: Six final studies published after 2006 reported above 70% Smith checklist items needed to be considered in contingent valuation study reports. Seven factors have positive effects on WTP. The reported WTP value varied from 11$ to 588$ in Japan and Germany, respectively. CONCLUSION: WTP for prostate cancer screening was positive among all studied men. The results of factors' effect assessment showed that better understanding prostate cancer risks or screening tests and factors such as age, income, family history of cancer, hospitalization history, and educational level have positive effects. Moreover, prostate-specific antigen history, health insurance, employment, and subject's health assessment received less attention. The results' generalization to all countries is not applicable because there are no studies for low- and middle-income countries. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2020 CRD42020172789.

Medicinal plants in the adjunctive treatment of patients with type-1 diabetes: a systematic review of randomized clinical trials.

PROPOSE: This study aims to systematically review the randomized controlled trials that address the effectiveness and safety of herbal medicine in patients with type 1 diabetes. METHODS: The Cochrane Library (latest issue); MEDLINE (until recent); EMBASE (until recent); AMED (Allied and Complementary Medicine Database) (until recent); and CINHAL (until recent) were searched electronically for the identification of trials until October 2019. Articles were initially screened based on title and abstract and then by full text by two independent authors. References of retrieved studies were hand-searched for further studies. Risk of bias was assessed according to the Cochrane handbook of systematic reviews of interventions. The results were summarized into GRADE (grading of recommendations, assessment, development and evaluation) tables. No meta-analysis was applicable as only one study was found for each intervention. RESULTS: Four RCTs were finally included in the systematic review with an overall moderate quality of conduct and low quality of reporting. The sample sizes were very small. The results of these RCTs show that cinnamon pills and Berberine/Silymarine compound capsules may decrease blood glucose indices from baseline, while fenugreek seeds and fig leaf decoction do not show any statistically significant effect. CONCLUSIONS: The evidence is scarce and no recommendations can be made based on current evidence. Further trials with more rigorous methodology and stronger quality of reporting are needed to make conclusions.