Is the surge in cesarean section rates during the COVID-19 pandemic truly substantiated?

BACKGROUND: Cesarean section (C-section) rates, deemed a critical health indicator, have experienced a historical increase. The advent of the COVID-19 pandemic significantly impacted healthcare patterns including delays or lack of follow-up in treatment and an increased number of patients with acute problems in hospitals. This study aimed to explore whether the observed surge is a genuine consequence of pandemic-related factors. METHODS: This study employs an Interrupted Time Series (ITS) design to analyze monthly C-section rates from March 2018 to January 2023 in Kurdistan province, Iran. Segmented regression modeling is utilized for robust data analysis. RESULTS: The C-section rate did not show a significant change immediately after the onset of COVID-19. However, the monthly trend increased significantly during the post-pandemic period (p < 0.05). Among primigravid women, a significant monthly increase was observed before February 2020 (p < 0.05). No significant change was observed in the level or trend of C-section rates among primigravid women after the onset of COVID-19. CONCLUSION: This study underscores the significant and enduring impact of the COVID-19 pandemic in further increasing the C-section rates over the long term, the observed variations in C-section rates among primigravid women indicate that the COVID-19 pandemic had no statistically significant impact.

Socioeconomic inequality in unmet outpatient healthcare needs among people living in urban informal settlements in Sanandaj city, Iran.

BACKGROUND: The growing trend of informal settlements is a serious humanitarian crisis. Unmet need for health care services is an indicator to measure the state of equality and access to healthcare services. This study, for the first time in Iran, examined the prevalence of unmet needs for outpatient healthcare services and related socioeconomic inequalities among residents of informal settlements in Sanandaj city. METHODS: This cross-sectional study was conducted on informal settlements of Sanandaj city with a sample size of 1345 people. Data were collected using a questionnaire. Multivariate logistic regression was used to determine significant predictors of unmet needs for healthcare services. Concentration index (C) and concentration curve (CC) were calculated to measure inequality in the prevalence of unmet needs for healthcare services. RESULTS: The prevalence of unmet needs for outpatient healthcare services was 31.7%. Financial and physical barriers were the most common reasons for not using the needed services. The highest unmet need was related to dental (80.6%) and rehabilitation services (78.8%). Being elderly with about 2.3 times (OR: 2.37, 95% CI: 1.19-4.75), not having a job with about 1.7 times (OR: 1.70, 95% CI: 1.13-2.57) and having a low economic status with about 4 times (OR: 4.46, 95% CI: 2.39-9.70) increased the odds of experiencing unmet need for outpatient healthcare services. The value of concentration index showed that unmet need for outpatient healthcare services was significantly concentrated among people with lower economic status (C= -0.330, 95% CI: -0.432 to -0.227). CONCLUSION: The unmet need is high among people living in informal settlements of Sanandaj city and a significant part of the residents of these settlements does not have access to required healthcare services. Regardless of the needs of people living in these settlements, who constitute a large population of Iran, access to universal health coverage is not possible in such areas. Removing the identified obstacles and causes behind the unmet needs requires the interdisciplinary participation of all actors, including the government, the nation, and civil society.

The association between nutrient patterns and metabolic syndrome among Iranian adults: cross-sectional analysis of Shahedieh cohort study.

OBJECTIVE: To assess the association between patterns of nutrient intake and metabolic syndrome (MetS) in a large sample of Iranian adults. DESIGN: Baseline data from the Shahedieh cohort study were used in the current cross-sectional study. Dietary intakes were assessed through the use of a validated semi-quantitative FFQ. Nutrient patterns (NP) were derived using factor analysis. The MetS was defined according to criteria introduced from the National Cholesterol Education Program Adult Treatment Panel III, modified for Iranian adults. SETTING: Yazd, Iran. PARTICIPANTS: A total of 7325 Iranian adults aged between 30 and 75 years. RESULTS: Three NP were identified. A significant positive association was found between adherence to semi-plant NP (characterised by the high intakes of P; vitamins B1, B3, B6 and B5; Se; Mg; Fe; protein; Cr; Cu; fibre; biotin; Mn; Zn and Na) and odds of MetS (OR 1·68, 95 % CI 1·43, 1·98). However, after adjusting for potential confounders, this association became non-significant. In addition, after taking potential confounders into account, individuals in the highest quintile of the semi-animal NP, rich in Ca; K; vitamins B2, B12, A, D, K and C; SFA; dietary cholesterol and trans-fatty acid, were 26 % more likely to have MetS compared with those in the lowest quintile (OR 1·26, 95 % CI 1·05, 1·51). No significant association was seen between adherence to the high-carbohydrate/low-fat NP and odds of MetS. CONCLUSIONS: We found that adherence to a semi-animal NP was associated with increased odds of MetS.

Effects of saffron (Crocus sativus L.) supplementation on inflammatory biomarkers: A systematic review and meta-analysis.

The effect of saffron supplementation on subclinical inflammation remains inconclusive. We performed a systematic review and meta-analysis to summarize available findings on the effect of saffron supplementation on inflammatory biomarkers (C-reactive protein [CRP], tumor necrosis factor-α [TNF-α], and interleukin-6 [IL-6]) in adults. We searched PubMed/Medline, Scopus, Web of Science, and Google Scholar databases up to November 2019 using relevant keywords to identify eligible trials. All randomized controlled trials (RCTs) that examined the effect of oral saffron supplementation on plasma concentrations of CRP, TNF-α, and IL-6 were included. For each outcome, mean differences and SDs were pooled using a random-effects model. Overall, eight RCTs were included in this meta-analysis. The pooled results showed that saffron supplementation did not result in significant changes in serum CRP (weighted mean difference [WMD]: -0.43 mg/L; 95% confidence interval [CI]: -1.04 to 0.17; p = .16), serum TNF-α (WMD: -1.29 pg/mL; 95% CI: -4.13 to 1.55; p = .37), and IL-6 concentrations (WMD: 0.11 pg/mL; 95% CI: -0.79 to 1.00; p = .81). Subgroup analysis indicated a significant reduction in serum CRP levels in studies with baseline CRP of ≥3 mg/L, saffron dosage of ≤30 mg/day, and intervention duration of <12 weeks, as well as trials that used crocin. Similarly, saffron was found to decrease TNF-α in studies that recruited non-diabetic subjects, subjects with baseline levels of ≥15 pg/mL, and participants with <50 years old, as well as trials that administered saffron at the dosage of ≤30 mg/day. We also found a significant non-linear effect of saffron dosage on serum CRP concentrations (pnon-linearity = .03). The overall results indicated that saffron supplementation did not affect inflammatory cytokines. Further high-quality studies are needed to firmly establish the clinical efficacy of supplemental saffron on inflammatory biomarkers.

Fruit and vegetable consumption in relation to primary headaches: the MEPHASOUS study.

BACKGROUND: Fruit and vegetable consumption may beneficially affect the odds of primary headaches due to their antioxidant contents. However, no study has examined the association between fruit and vegetable consumption and primary headaches among university students. AIM: To assess the relation between fruit and vegetable intakes and primary headaches among Iranian university students. METHODS: Overall, 83,214 university students with an age range of ≥ 18 years participated in the present study. Dietary intakes and also data on confounding variables were collected using validated questionnaires. Data on dietary intakes were collected using a validated dietary habits questionnaire. We used the International Classification of Headache Disorders-3 (ICHD-3) criteria to define primary headaches. RESULTS: Fruit consumption was negatively associated with primary headaches; such that after controlling for potential confounders, greater intake of fruits was associated with 30% lower odds of primary headaches (OR: 0.70, 95% CI 0.58-0.84). Such an inverse association was also found for vegetable consumption. In the fully adjusted model, students in the top category of vegetable consumption were 16% less likely to have primary headaches compared with those in the bottom category (OR: 0.84, 95% CI 0.74-0.95). Subgroup analysis revealed that fruit consumption was inversely associated with primary headaches in females, unlike males, and vegetable consumption was inversely associated with these headaches in males, as opposed to females. Moreover, fruit and vegetable consumption was related to lower odds of primary headaches in normal-weight students. CONCLUSION: Fruit and vegetable intakes were associated with reduced odds of primary headaches. LEVEL OF EVIDENCE: Level III, cross-sectional analytic studies.

The effect of vitamin d-calcium co-supplementation on inflammatory biomarkers: A systematic review and meta-analysis of randomized controlled trials.

Data on the effect of vitamin d-calcium co-supplementation on inflammatory biomarkers, compared to placebo or intake of calcium and vitamin D supplements alone, are conflicting. The current systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to summarize available findings on the effect of vitamin d-calcium co-supplementation on inflammatory biomarkers in adults. Online databases including PubMed, Scopus, ISI Web of Science and Google Scholar were searched using relevant keywords up to June 2019. We included RCTs investigating the effect of vitamin d-calcium co-supplementation, compared to placebo or intake of calcium and vitamin D supplements alone, on inflammatory biomarkers. In total, 8 RCTs that enrolled 706 participants, aged ≥18 years, were included. Pooling 9 effect sizes from 8 RCTs on C-reactive protein (CRP) levels revealed a significant reducing effect of vitamin d-calcium co-supplementation on serum CRP concentrations compared to placebo intake (WMD: -0.82, 95% CI: -1.56, -0.07 mg/L, P = 0.03). However, this beneficial effect became non-significant when compared to the intake of calcium and vitamin D supplements alone. Also, we found that the associations of vitamin d-calcium dosages and duration of intervention with the reduction in CRP concentrations were in a non-linear fashion. Combining 5 effect sizes for IL-6 and 3 effect sizes for TNF-α, we found no significant effect of joint calcium and vitamin D supplementation on serum concentrations of IL-6 (WMD: -1.45, 95% CI: -5.31, 2.41 pg/mL, P = 0.46) and TNF-α (WMD: -0.79, 95% CI: -2.19, 0.61 pg/mL, P = 0.26). We found a beneficial effect of vitamin d-calcium co-supplementation on serum CRP concentrations. However, such a beneficial effect was not seen for IL-6 and TNF-α concentrations.

Effects of zinc supplementation on lipid profile in patients with type 2 diabetes mellitus: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND AIM: Findings on the effects of zinc supplementation on the lipid profile in patients with type 2 diabetes mellitus (T2DM) are conflicting. The current comprehensive systematic review and meta-analysis aimed to summarize available evidence in this regard. METHODS AND RESULTS: After a systematic search in the online databases, we included the randomized controlled trials (RCTs) investigating the effect of zinc supplementation on lipid profile [total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglyceride (TG)] in patients with T2DM. Altogether, 9 studies with a total sample size of 424 patients with T2DM were included in the analysis. Combining 9 effect sizes from 9 RCTs, we found a significant lowering effect of zinc supplementation on serum levels of TG (weighted mean difference (WMD): -17.08, 95% CI: -30.59, -3.58 mg/dL, P = 0.01) and TC (WMD: -26.16, 95% CI: -49.69, -2.62 mg/dL, P = 0.02). Although the overall effect of zinc supplementation on LDL-C levels was not significant, a beneficial effect was seen in studies that administered <100 mg/d zinc. Based on the non-linear dose-response analysis, a greater reduction in serum levels of TC and LDL-C following zinc supplementation was seen at <12 weeks' duration of intervention. Unlike the overall effect size, we found a significant increasing effect of zinc supplementation on serum HDL-C concentrations in most subgroups of RCTs according to the subgroup analyses. CONCLUSION: We found that zinc supplementation may beneficially influence lipid profile in patients with T2DM.

The effects of green coffee extract supplementation on glycemic indices and lipid profile in adults: a systematic review and dose-response meta-analysis of clinical trials.

BACKGROUND: The role of coffee consumption in the risk of cardiovascular diseases has been debated for many years. The current study aimed to summarize earlier evidence on the effects of green coffee extract (GCE) supplementation on glycemic indices and lipid profile. METHODS: We searched available online databases for relevant clinical trials published up to October 2019. All clinical trials investigating the effect of GCE supplementation, compared with a control group, on fasting blood glucose (FBG), serum insulin, total cholesterol (TC), triglyceride (TG), low-density lipoprotein (LDL), and high-density lipoprotein (HDL) were included. Overall, 14 clinical trials with a total sample size of 766 participants were included in the current meta-analysis. RESULTS: We found a significant reducing effect of GCE supplementation on FBG (weighted mean difference (WMD): -2.35, 95% CI: - 3.78, - 0.92 mg/dL, P = 0.001) and serum insulin (WMD: -0.63, 95% CI: - 1.11, - 0.15 µU/L, P = 0.01). With regard to lipid profile, we observed a significant reduction only in serum levels of TC following GCE supplementation in the overall meta-analysis (WMD: -4.51, 95% CI: - 8.39, - 0.64, P = 0.02). However, subgroup analysis showed a significant reduction in serum TG in studies enrolled both genders. Also, such a significant reduction was seen in serum levels of LDL and HDL when the analyses confined to studies with intervention duration of ≥8 weeks and those included female subjects. In the non-linear dose-response analyses, we found that the effects of chlorogenic acid (CGA) dosage, the main polyphenol in GCE, on FBG, TG and HDL were in the non-linear fashions. CONCLUSION: In conclusion, we found that GCE supplementation improved FBG and serum levels of insulin and TC. Also, there was a significant improvement in other markers of lipid profile in some subgroups of clinical trials.

Can judgments according to case fatality rate be correct all the time during epidemics? Estimated cases based on CFR in different scenarios and some lessons from early case fatality rate of coronavirus disease 2019 in Iran.

Background: The new Coronavirus disease (COVID-19) was first identified in China in 2019. Case fatality rate (CFR) indicator of the disease is one of the most important indices noticed by experts, policymakers, and managers, based on which daily evaluations and many judgments are made. CFR can change during epidemics. This study aimed to estimate the actual number of COVID-19 cases in Iran and to calculate the early CFR for the disease based on official statistics. Methods: This was a descriptive study whose data were obtained from the website of the Ministry of Health and Medical Education of Iran from February 20, 2020 until March 26, 2020. CFR has been obtained by dividing the total number of deaths by the total number of confirmed cases at one point in time. In this study, the actual number of COVID-19 cases in Iran was estimated based on the mortality model in 4 scenarios. Excel 2013 software was used to analyze the data. Results: According to the findings of this study, In Iran, until March 26, 2020, a total of 27 017 people have been infected by COVID-19 and 2077 died of it. However, CFR indicator had a descending trend in Iran: 100%, 18.6%, 8.8%, 3.3%, 6.9%, and 7.7% on days 1, 5, 10, 20, 30, and 35, respectively. The actual number of COVID-19 cases in Iran was estimated to be 4 789 454, 2 873 673, 1 436 836, and 718418 as of March 26, 2020 according to the 4 scenarios, respectively. Conclusion: In emerging epidemics, CFR indicator must not be used as a basis to judge the performance of a health system unless that epidemic condition has been clarified. Moreover, it is suggested that in the outbreak of an epidemic, specifically emerging diseases, CFR must not be the base of judgment. Making judgments, specifically in the outbreak of emerging epidemics, based on fatality rate can lead to information bias. It is also possible to estimate the total number of patients based on the CFR in circumstances where little information is available on the disease.

Extent and nature of dual practice engagement among Iran medical specialists.

BACKGROUND: Dual practice (DP) by medical specialists is a widespread issue across health systems. This study aims to determine the level of DP engagement among Iran's specialists. METHODS: A pre-structured form was developed to collect the data about medical specialists worked in all 925 Iran hospitals in 2016. The forms were sent to the hospitals via medical universities in each province. The data were merged at the national level and matched using medical council ID codes, national ID codes, and eventually a combination of the first name, surname, and father's name. RESULTS: A total of 48 345 records were collected for 30 273 specialists from 858 (93%) hospitals out of total 925 hospitals. Sixteen thousand eight hundred forty-nine (69% of) specialists were non-faculty members and 6317 (26% of) specialists were employed on a contract basis. Eleven thousand six hundred and thirty-eight (47.7% of) specialists were engaged in DP on total. Female specialists had 0.78 times less DP chance; faculties compared to non-faculties had 0.65 times more DP chance and full-time geographic specialists compared to non-full-time specialists had 0.15 times more DP chance. DP was more frequent in specialists with higher age and more job experience and in provinces with more population, deprivation, and higher number of specialists per facility (P < 0.05). CONCLUSIONS: The level of DP is relatively high among Iran medical specialists, especially in geographic full-time specialists. However, they are totally banned and they receive extra payment for being full-time; restrictive regulations and financial incentives without considering other factors might not eliminate DP in specialists and it should be addressed based on conditions of each country and regions inside the country.

Human resources for health strategies: the way to achieve universal health coverage in the Islamic Republic of Iran.

BACKGROUND: It is impossible to achieve universal health coverage (UHC) without an adequate, competent and motivated workforce. AIMS: The study aimed to describe how the Iranian health sector has formulated its human resources strategies to achieve UHC. METHODS: This was a qualitative study using a conceptual framework approach to content analysis. Primary data were gathered through expert focused group discussions and document analyses. Both transcribed discussions and the selected documents were analysed using in-depth thematic analysis. A conceptual framework from the Global Health Workforce Alliance was used for content analysis and to draft and develop the strategies. The framework suggested five human resources for health (HRH) pathways to achieve UHC aspects structured according to availability, accessibility, acceptability and quality. RESULTS: Thirty strategies were formulated for Iranian HRH. Eleven of the developed strategies were related to the field of education and training, such as development of new required academic disciplines; balancing university admissions based on workforce requirements; and enrolling local students from deprived and underserved areas. Ten of the developed strategies were structured under the workforce accessibility dimension. CONCLUSIONS: Strategies for HRH were formulated by adopting a comprehensive, scientific and collaborative approach to ensure alignment with the country's health system priorities and Global Strategy on Human Resources for Health to overcome health workforce challenges.

Factors influencing medical specialists' dual practice in the Islamic Republic of Iran.

BACKGROUND: Dual practice (DP) is performing several different jobs at the same time and has effects on healthcare services delivery. AIMS: To identify the causes of medical specialists' tendency towards DP in the Islamic Republic of Iran. METHODS: We used a qualitative approach to identify the factors affecting DP in medical specialists in 2016. We used a purposive and outlier sampling method to conduct semistructured deep interviews with 14 key informants. The data analysis was performed simultaneously with data collection using thematic content analysis by MAXQDA (version 10.0). Interviews continued up to data saturation. The quality of the study was ensured by addressing the criteria of Guba and Lincoln. RESULTS: The results of the interviews showed six themes and 16 subthemes for specialists' propensity to DP. Major themes included financial incentives, cultural attitudes about professional identity of physicians, experience and academic level of specialists, controlling approaches in the public sector, available infrastructure for responding to the population needs in the public sector, and regional characteristics of health service locations. CONCLUSIONS: Medical specialists' DP is a multidimensional issue, influenced by different factors such as financial incentives, cultural attitudes and available infrastructure. Considering the capacities and conditions of each country, control and management of this phenomenon require regulatory and incentive mechanisms, which in the long term can modify private and public sector differences and increase the willingness of doctors to work in the public sector.

Effect of dual practice on service delivery time by surgeons in the Islamic Republic of Iran: multi-level analysis of a national survey, 2016.

BACKGROUND: One of the work patterns which affects the supply of specialists is the phenomenon of dual practice (DP), i.e., working simultaneously in the public and private sectors. Uncontrolled DP in the surgery health workforce can have adverse effects on access to surgeons, efficiency, effectiveness and quality of surgery services. AIMS: The aim of this article is to examine the impact of DP on service delivery time by surgeons. METHODS: We used a prestructured form to collect data on surgery specialists in all 925 Iranian hospitals. National medical ID codes, council ID codes, first name, surname and father's name were used for data matching. Multilevel linear regression was used to assess the association between DP and study variables, which were recruitment type, faculty status, experience, sex and age. RESULTS: The 4642 surgery specialists in this study, representing 31.08% of the total number of surgeons identified, spent mean 1.09 (standard deviation 0.33) hours full-time equivalent (FTE) on health care service delivery. Specialists with DP had long service delivery time (ß = 0.427). Female specialists (ß = -0.049) and full-time specialists (ß = -0.082) spent less time on health care service delivery. Permanent specialists had higher FTE (P < 0.001) and as the population increases, FTE increases (P < 0.05). CONCLUSIONS: Although DP had a direct impact on surgeons' working hours, it seems that a greater share of the difference in working time was used in the private sector services, leading to poor access to surgery services in the public sector. Therefore, it is necessary to develop a systems approach to regulate DP.

Situational analysis of general practitioners using a forecasting approach until 2025 and a multi-state Markov model: A retrospective longitudinal study.

Introduction: Undesirable working conditions, insufficient professional development and other labour market pressures have significantly impacted the status of general practitioners (GPs). This study aimed to conduct a situational analysis of GPs in Iran using a forecasting approach until 2025. Methods: Data were collected concurrently through direct contact, data matching among databases and tracking among graduates from four clusters of medical science universities over the past decade. This retrospective longitudinal study determined the status of GPs over consecutive years. Multi-state Markov and binary logistic regression analyses were performed using R and Stata 14. Results: Of 430 graduates over the past decade, 94% were successfully identified. Only 20% of the graduates remained active as GPs. The greatest fluctuations in transfer occurred in the third year after graduation, with the remaining proportion of GPs dropping to less than 50%. The probability of remaining as GPs was 0.76 per year, while the highest transition was observed towards specialisation (0.12). Additionally, 2% of the GPs chose not to work, and less than 1% transitioned to a different specialty. Based on the transfer matrix for 2025, only 19% of the GPs were projected to remain, with the majority (59%) transitioning to specialisation. Conclusion: The transfer probability varies across different years, indicating higher flow rates among GPs. However, only a limited number of GPs are projected to remain until 2025. A comprehensive set of interventions should be considered, spanning the pre-medical stage, during education and after graduation, to mitigate the factors contributing to GPs leaving their profession.

Has Iran achieved the goal of reducing the prevalence of households faced with catastrophic health expenditure to 1%?: A national survey.

Background and Aims: One of the goals of the Islamic Republic of Iran is to reduce the prevalence of catastrophic health expenditures among Iranian households to 1% by the end of the sixth 5-year development plan (2016-2021). This study was conducted to evaluate the level of access to this goal in the final year of this program. Methods: A national cross-sectional study was conducted on 2000 Iranian households in five provinces of Iran in 2021. Data were collected through interviews using the World Health Survey questionnaire. Data from households whose health care costs were more than 40% of their capacity to pay were included in the group of households with catastrophic health expanditure (CHE). Determinants of CHE were identified using univariate and multivariate regression analysis. Results: 8.3% of households had experienced CHE. The variables of being a female head of household (odd ratio [OR] = 2.7), use of inpatient (OR = 1.82), dental (OR = 3.09), and rehabilitation services (OR = 6.12), families with disabled members (OR = 2.03) and low economic status of the households (OR = 10.73) were significantly associated with increased odds of facing CHE (p < 0.05). Conclusion: In the final year of the sixth 5-year development plan, Iran has not yet achieved its goal of "reducing the percentage of households exposed to CHE to 1%." Policymakers should pay attention to factors increasing the odds of facing CHE in designing interventions.

Prevalence of metabolic syndrome and its association with oral health: First results from the Kurdish cohort study.

Aims: Investigate the association between oral and dental health (ODH) and metabolic syndrome (MetS) in adults aged 35-70 years. Methods: The study utilized data from the enrollment phase of Dehgolan prospective cohort study in the west of Iran. A cross-sectional assessment was conducted on a total of 3996 participants, involving a comprehensive oral examination and the assessment of their oral hygiene behavior (ODH). MetS was defined according to the updated National Cholesterol Education Program Adult Treatment Panel III. Logistic regression used to calculate odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for sociodemographic characteristics. Results: MetS was more prevalent among those who not daily brushing and flossing. Participants with missing teeth (MT) show higher prevalent of MetS. Being female, lower age, illiteracy, family history of diabetes, low physical activity, and salt at table were independently associated with increase odds of MetS (p < 0.05). Odds of MetS were significantly decreased with use flossing (OR = 0.75; CI = 0.60-0.93), decayed (OR = 0.83; CI = 0.72-0.97), filled (OR = 0.84; CI = 0.71-0.99), and increased with MT (OR = 1.45; CI = 1.16-1.81) as long as adjusted for ODH factors. When other potential confounder such as sociodemographic, personal and nutritional habits were adjusted, daily flossing was the only factor that still statistically decreased (OR = 0.79; CI = 0.62-0.99) the odds of MetS. Conclusion: Daily flossing was the only factor that independently associated with MetS. Relationship of other ODH factors with Mets were confounded by sociodemographic characteristics of the participants.

An assessment of the relationship between national rates of Covid-19 incidence and mortality as reported to an international comparison database: An ecological study.

Background and Aims: Making a judgment only based on formal national reports can be misleading. We aimed to assess the relationship between countries' development indicators and reported coronavirus disease 2019 (Covid-19)-related incidences and death. Methods: Covid-19 related incidence and death cases were extracted from the updated Humanitarian Data Exchange Website on October 8, 2021. Univariable and multivariable negative binomial regression were utilized to investigate the relationship between development indicator and incidence and mortality from Covid-19 by calculating the Incidence rate ratio (IRR), mortality rate ratio (MRR), and fatality risk ratio (FRR). Results: Very high human development index (HDI) compared with low HDI (IRR:3.56; MRR:9.04), the proportion of physicians (IRR:1.20; MRR:1.16), besides extreme poverty (IRR:1.01; MRR:1.01) were independently correlated with the mortality and incidence rate of Covid-19. Very high HDI and population density were inversely correlated with the fatality risk (FRRs of 0.54 and 0.99). The cross-continental comparison shows Europe and the North Americas, had significantly higher incidence and mortality rates with IRR of 3.56 and 1.84 as well as MRRs of 6.65 and 3.62, respectively. Also, they inversely correlated with the fatality (FRR:0.84 and 0.91, respectively). Conclusion: A positive correlation between the fatality rate ratio based on countries' development indicators and the reverse for the incidence and mortality rate was found. Developed countries with sensitive healthcare systems can diagnose infected cases as soon as possible. Also, the mortality rate of Covid-19 will be accurately registered and reported. Due to more access to diagnostic tests, patients are diagnosed at the initial stages and will have a better opportunity to receive treatment. This leads to higher reports of incidence/and/or mortality rates and lower fatality of COVID-19. In conclusion, more Covid-19 incidence and mortality cases in developed countries can result from a more comprehensive care system and a more accurate recording procedure.

Barriers to community participation in primary health care of district health: a qualitative study.

INTRODUCTION: Community participation is one of the principles of primary health care (PHC). However, it has not been adequately institutionalized due to numerous barriers. Therefore, the present study is conducted to identify barriers to community participation in primary health care in the district health network from the perspectives of stakeholders. METHODS: This qualitative case study was conducted in 2021 in Divandareh city, Iran. A total of 23 specialists and experts experienced in community participation, including nine health experts, six community health workers, four community members, and four health directors in primary health care programs, were selected using the purposive sampling method until complete saturation. Data was collected using semi-structured interviews and analyzed simultaneously using qualitative content analysis. RESULTS: After data analysis, 44 codes, 14 sub-themes, and five themes were identified as barriers to community participation in primary health care in the district health network. The themes included community trust in the healthcare system, the status of community participation programs, the community and system's perception of participation programs, health system management approaches, and cultural barriers and institutional obstacles. CONCLUSION: Based on the results of this study most important barriers to community participation relate to community trust, the organizational structure, community and the health profession's perception regarding the participatory programs. It seems necessary to take measures to remove barriers in order to realize community participation in primary healthcare system.