An An outbreak of cutaneous leishmaniasis in Erbil governorate of Iraqi Kurdistan Region in 2015.

INTRODUCTION: This study aimed to identify the sociodemographic factors associated with the occurrence of an outbreak of cutaneous leishmaniasis in Erbil governorate and to determine the geographical distribution and clinical pattern of the disease during this outbreak. METHODOLOGY: This cross-sectional study involved 234 cutaneous leishmaniasis cases from Erbil governorate. A questionnaire completed in an interview provided data on sociodemographic and clinical characteristics, risk factors, and preventive measures. RESULTS: About 60% of participants were younger than 35 years; 59.4% were living in urban areas. Most cases (40.2%) were from Maxmur district, while 20.9% were internally displaced persons and 7.7% were refugees. Nearly 70% of the cases had a low socioeconomic status. Cases with multiple lesions constituted 65.5%. Upper limb lesions constituted 44.7%. Most lesions were 1-5 cm in size (64.7%) and were wet (63.6%). Nearly three-quarters of the cases had a history of traveling to endemic areas; most (49.7%) to Maxmur district. Around 80% reported fogging around the houses and 44.4% in the working area. The peak incidence of the cutaneous leishmaniasis cases was in December, with a total of 115 cases. CONCLUSIONS: Cutaneous leishmaniasis was not endemic in Erbil governorate, but it became a public health challenge in 2015. Most of the cases were reported in Maxmur district and among internally displaced people and military personnel deployed there. Control and prevention activities, including fogging and spraying, face important challenges and need strengthening, especially in Maxmur district.

Experimental Trial with a Heat-Shocked Protoscolex Extract as a Vaccine Candidate for Protection Against Hydatid Disease.

OBJECTIVE: Cystic echinococcosis is distributed worldwide and is an important public health challenge in many countries. The present study was an experimental trial to use hydatid antigens derived from viable protoscoleces cultivated at 37 and 45°C for 4 h as a vaccine candidate for protection against hydatid infection. METHODS: Balb/c mice were immunized with hydatid antigens extracted from protoscoleces exposed to 37 and 45°C as well as partially purified hydatid antigens containing 30, 60, and 90 µg of heat shock protein 70 administered with or without an adjuvant. RESULTS: Crude antigens from protoscoleces exposed to 37°C conferred non-significant immunity with protection and reduction rates that ranged from 0% to 25% and 77.69% to 98.38%, respectively. In mice receiving crude antigens from protoscoleces exposed to 45°C, the protection and reduction rates ranged from 0% to 66.66% and 94.62% to 98.92%, respectively. The purified antigen from protoscoleces exposed to 45°C conferred significant immunity with absolute protection observed in mice immunized with 60 and 90 µg of the antigen combined with the adjuvant. Immunological parameters (anti-hydatid antibody titer and lymphocyte transformation %) showed a negative correlation with the number of cysts. The assessment of renal and liver functions showed non-significant differences (p>0.05) in comparison with the liver and renal functions of non-immunized mice of the negative control group. CONCLUSION: Purified hydatid antigens containing heat shock protein 70 confer high levels of protection against hydatid infection in mice.

Risky Driving Behaviours among Medical Students in Erbil, Iraq.

OBJECTIVES: This study aimed to assess risky driving behaviours among medical students in Erbil, Iraq, and to explore the relationship between risky driving behaviours and perceptions of risky driving. METHODS: This self-administered questionnaire-based survey was conducted from January to May 2014 among a random sample of 400 medical students at Hawler Medical University in Erbil. The questionnaire was designed to assess the frequency of engagement in 21 risky driving behaviours, the perceived risk of each behaviour and the preference for each behaviour as ranked on a 5-point scale. RESULTS: A total of 386 students responded to the survey (response rate: 96.5%). Of these, 211 reported that they currently drove a vehicle (54.7%). Drivers most frequently engaged in the following behaviours: playing loud music (35.9%), speeding (30.4%), allowing front seat passengers to not wear seat belts (27.9%) and using mobile phones (27.7%). Least frequent driving behaviours included not stopping at a red light (3.9%), driving while sleepy (4.4%), driving after a mild to moderate intake of alcohol (4.5%) and drunk driving (6.4%). Mean risky driving behaviour scores were significantly higher among males (P <0.001) and those who owned a car (P = 0.002). The mean risk perception score was higher among >20-year-olds (P = 0.028). There was a significant positive relationship between the preference for risky behaviours and risky driving behaviours (beta = 0.44; P <0.001). CONCLUSION: Medical students in Erbil reported high frequencies of several serious risky driving behaviours. The preference for risky behaviours was found to be an important predictor of risky driving behaviours among medical students in Erbil.

A qualitative assessment of faculty perspectives of small group teaching experience in Iraq.

BACKGROUND: Although medical colleges in Iraq started recently to increasingly use small group teaching approach, there is limited research on the challenges, opportunities and needs of small group teaching in Iraq particularly in Kurdistan Region. Therefore, this study was aimed to assess the small group teaching experience in the 4(th) and 5(th) year of study in Hawler College of Medicine with a focus on characterizing the impressions of faculty members about how small group teaching is proceeding in the college. METHODS: A qualitative study based on semi-structured interviews with 20 purposively selected faculty members was conducted. An interview guide was used for data collection that was around different issues related to small group teaching in medical education including planning, preparation, positive aspects, problems facing its implementation, factors related to it and recommendations for improvement. Qualitative data analysis comprised identifying themes that emerged from the review of transcribed interviews. RESULTS: Participants reported some positive experience and a number of positive outcomes related to this experience including better controlling the class, enhancing students' understanding of the subject, increasing interaction in the class, increasing the students' confidence, enhancing more contact between teachers and students, improving the presentation skills of the students and improving the teacher performance. The participants emphasized poor preparation and planning for application of this system and highlighted a number of problems and challenges facing this experience particularly in terms of poor infrastructure and teaching facilities, poor orientation of students and teachers, inadequate course time for some subjects and shortage of faculty members in a number of departments. The main suggestions to improve this experience included improving the infrastructure and teaching facilities, using more interactive teaching methods and better organization and management of the system. CONCLUSIONS: Despite what the faculty perceived as the college's failure to provide physical settings or training for small group learning to the faculty and the students, the faculty members were able to articulate positive experiences and outcomes associated with their college's efforts to introduce teaching in smaller group sessions.

Distribution of Chronotypes among a Sample of Iraqi Kurdish Medical Students.

OBJECTIVES: The aim of this study was to assess the distribution of chronotypes in a sample of Iraqi Kurdish medical students. METHODS: A descriptive cross-sectional study was conducted at the Hawler Medical University College of Medicine in Erbil City, Iraq, between 1(st) January and 31(st) March 2013. A total of 580 students were given the reduced version of the Horne and Ostberg Morningness-Eveningness Questionnaire (MEQr), a close-ended self-administered questionnaire. RESULTS: Of the 580 students, 130 (22.4%) were male and 450 (77.6%) were female. The mean age ± standard deviation was 20.3 ± 1.45 years, with a range of 17-24 years. Most of the students (52.6%) were in the intermediate class, followed by morning type (24.1%) and evening type (23.3%). Significant gender differences were detected in the proportion of morning, intermediate and evening types (P <0.001). The mean scores for the female students were 14.8 ± 2.2 and the mean scores for the male students were 14.6 ± 7.3, with no statistically significant differences (P = 0.45). CONCLUSION: Students in the College of Medicine were mostly classified as intermediate types. The morning type was more common among this student population, particularly male students, than has been reported in similar age groups in some Western countries. There was a significant gender difference in the proportion of MEQr types.

Using Q-methodology to explore people's health seeking behavior and perception of the quality of primary care services.

BACKGROUND: Information on health seeking behavior and beneficiaries' perception of the quality of primary care can help policy makers to set strategies to improve health system. With scarcity of research on this particular field in Iraqi Kurdistan region, we sought to explore the patterns of health seeking behavior and perception of the quality of primary care services of a sample of population. METHODS: This explorative study was carried out in Erbil governorate, Iraq. Data were collected using the novel approach of Q-methodology for eliciting subjective viewpoints and identifying shared patterns among individuals. Forty persons representing different demographic and socioeconomic groups and living in different areas of Erbil governorate sorted 50 statements reflecting different aspects of health-seeking behavior and primary care services into a distribution on a scale of nine from "disagree most" to "agree most". By-person factor analysis through centroid factor extraction and varimax rotation of factors were used to derive latent viewpoints. RESULTS: Four distinct patterns of health seeking behavior and viewpoints toward the primary care services were identified. People in factor 1 are extremely critical of the services at primary health care centers and are regular users of the private health sector. People in factor 2 positively recognize the services at primary health care centers but mainly turn to inappropriate health seeking behavior. People in factor 3 have satisfaction with the services at primary health care centers with minimal use of these services, but mainly turn to the private sector. People in factor 4 are slightly satisfied with the services at primary health care centers but mainly rely on these services. CONCLUSIONS: This study highlighted the typical characterizations that were associated with each uncovered factor. Informing on the beneficiaries' concerns about the primary care services can help to improve the system through further exploring the issues raised by the respondents and directing particular action on these issues. The characterizing and distinguishing statements can be used as a set of questions to conduct community-based survey on this important aspect of health services.

Intimate partner violence against women in the Erbil city of the Kurdistan region, Iraq.

BACKGROUND: Violence against women is a worldwide problem and serious human rights abuse that occurs among all social, cultural, economic and religious groups. There is a paucity of research on intimate partner violence against women in Iraq, particularly in the Kurdistan region. This study assessed the prevalence of emotional, physical and sexual intimate partner violence against women and the impact of physical violence in Erbil, the main city of the Iraqi Kurdistan region. METHODS: A cross-sectional study was carried out on a convenience sample of 800 Kurdish ever married women. Women (aged 16 to 65 years) attending two public hospitals in Erbil city for reproductive health problems were included in the study. The study was conducted between 1st of October 2009 and 30th of March 2011. Each woman was seen only once. Intimate partner violence was assessed by administering a modified version of the World Health Organization's domestic violence questionnaire through direct interview by a female doctor. Prevalence of intimate partner violence was assessed by timing (lifetime or past year), frequency (once, 2-5 times, > 5 times), and type (emotional, physical, and sexual violence). Descriptive statistical analysis was conducted with calculation of frequencies and percentages of women who reported different types, severities and impact of intimate partner violence. RESULTS: The prevalence of the overall lifetime and the overall past year intimate partner violence against women was 58.6% and 45.3%, respectively. The proportions of women experienced at least one form of lifetime intimate partner violence were: 52.6% for emotional abuse; 38.9% for physical violence; and 21.1% for sexual violence, while 43.3%, 15.1%, and 12.1% of women experienced at least one form of past year emotional, physical and sexual violence, respectively. Among those with lifetime physical violence, 11.6% were subjected to more serious injuries like stab wound, broken teeth or broken bones. CONCLUSIONS: There is a high prevalence of intimate partner violence, in particular emotional abuse behavior, against the women attending hospitals in Erbil. Physical violence is also a significant problem particularly in terms of its consequences.

Female genital mutilation among Iraqi Kurdish women: a cross-sectional study from Erbil city.

BACKGROUND: Iraqi Kurdistan region is one of the areas where female genital mutilation is reportedly widely practiced but inadequately studied. The aim of this study was to determine (i) the prevalence of female genital mutilation among Muslim Kurdish women in Erbil city, (ii) the patterns and types of female genital mutilation, (iii) the factors associated with this practice and (iv) women's knowledge and attitudes towards this practice. METHODS: A cross-sectional study was conducted in the primary health care centers and the Maternity Teaching Hospital in Erbil city, involving 1987 women aged 15-49 years. Data were obtained about female genital mutilation status and knowledge and perception towards this practice. The participants were clinically examined to verify the self-reported female genital mutilation status. RESULTS: The self-reported prevalence of female genital mutilation was 70.3%, while it was 58.6% according to clinical examination of the women's genitalia. The most common type of female genital mutilation was type I (99.6%) and the most common age at which mutilation was performed was 4-7 years (60.2%). This practice was mostly performed by traditional birth attendants (72.5%). Only 6.4% of mutilated women reported having complications after mutilation, most commonly bleeding (3.6%). The practice was more reported among housewives (OR = 3.3), those women whose mothers were mutilated (OR = 15.1) or with unknown mutilation status (OR = 7.3) and those women whose fathers were illiterate (OR = 1.4) or could only read and write (OR = 1.6). The common reasons for practicing female genital mutilation were cultural tradition (46.7%) and dictate of religion (38.9%). Only 30% of the participants were aware about the health consequences of female genital mutilation. More than one third (36.6%) of the women support the practice and 34.5% have intention to mutilate their daughters. CONCLUSIONS: Prevalence of female genital mutilation among Muslim Kurdish women in Erbil city is very high; although, most cases are of type I. There is clear lack of knowledge about the health consequences of female genital mutilation and a relatively important segment of women support this practice. Custom or tradition and dictate of religion are the main reasons for this practice that need further in-depth exploration.

A qualitative assessment of the small group teaching at hawler college of medicine.

CONTEXT: Although the medical schools in Iraq recently started to increasingly use the small group teaching approach, only little is known about the students' perceptions toward this approach. Therefore, the aim of this study was to assess small group teaching as a method of teaching at Hawler College of Medicine, from the students' perspectives. SETTING: This study was a qualitative study which was based on six focus group discussions which involved a sample of students from the three last years at the Hawler College of Medicine. A topic guide was used to lead the discussions and it covered questions on the positive aspects and the problems of small group teaching in the college, in addition to recommendations for its improvement. The qualitative data analysis involved a content analysis, followed by a thematic analysis. RESULTS: The participants were generally happy with the application of the small group teaching approach and they recognized many positive aspects which were related to this experience, which included, increasing the focus on the study subjects, enhancing the student-teacher interaction, building a better student-teacher relationship, encouraging the students' attendance, providing a better opportunity to apply a student-centered learning, enhancing a more efficient use of time and assisting in a better understanding of the subjects. The main problems which were faced, included a poor infrastructure and teaching facilities, problems which were related to examinations and the mark distribution, an improper syllabus preparation and problems which were related to the teachers' commitments and performances. The main suggestions which were put forth to improve this system, included, changing the assessment system with the focus more on the end of the course assessment, the students' involvement in the curriculum design, improving the infrastructure and teaching facilities and a better organization and management of the system. CONCLUSIONS: The concept of the small group teaching approach was well received by the students and many positive aspects of this approach have been highlighted. However, this experience witnessed many problems and faced different challenges that need better preparation, organization of the resources and the orientation of students and teachers, for insuring its success.

Post-conflict health reconstruction: where is the evidence?

In the context of the CARA Iraq Research Fellowship Programme, staff from Hawler Medical University in Erbil, Iraq and the London School of Hygiene and Tropical Medicine in the UK collaboratively conducted a multimodal research project analysing challenges and opportunities for reform of the primary care system in Iraq. Through a mix of quantitative and qualitative methods a range of challenges were identified, both in terms of services offered and the utilisation of those services. The collaborative study proved positive in terms of direct research outcomes, in boosting academia with skill development and use of new methodologies, and in reengaging displaced Iraqi academics.

The range and diversity of providers' viewpoints towards the Iraqi primary health care system: an exploration using Q-methodology.

BACKGROUND: The increasingly recognized need for reorganizing the primary health care services in Iraq calls for a comprehensive assessment of the system to better understand its problems and needs for development. As part of such comprehensive assessment and due to the important role of primary health care providers in adopting any change, we ought to explore the range and diversity of viewpoints of primary health care providers towards the Iraqi primary health care system. METHODS: This explorative study was carried out in Erbil governorate, Iraq from May to July 2011. Data were collected from primary health care providers using Q-methodology to elicit subjective viewpoints and identify shared patterns among individuals. Forty primary health care providers representing eight primary health care centers sorted 41 statements reflecting different aspects of the Iraqi primary health care system into a distribution on a scale of nine from "disagree most" to "agree most". By-person factor analysis was used to derive latent viewpoints through centroid factor extraction and varimax rotation of factors. RESULTS: Analysis of the participants' Q-sorts resulted in four distinct viewpoints among primary health care providers toward the current primary health care system. One factor emphasized positive aspects of the current primary health care system that is content with the current primary health care system. The other three factors highlighted the negative aspects and they included (i) professionally-centered viewpoint, (ii) comprehensive perception and problem-based solutions and (iii) critical to leadership/governance aspects of the system. CONCLUSIONS: This study revealed diverse viewpoints of primary health care providers toward the current Iraqi primary health care system and recognized the particular issues related to each viewpoint. The findings can contribute to a better understanding of health policy makers and primary health care managers concerning the problems facing the primary health care system that might contribute to change in the management of this system.

Iraqi primary care system in Kurdistan region: providers' perspectives on problems and opportunities for improvement.

BACKGROUND: As part of a comprehensive study on the primary health care system in Iraq, we sought to explore primary care providers' perspectives about the main problems influencing the provision of primary care services and opportunities to improve the system. METHODS: A qualitative study based on four focus groups involving 40 primary care providers from 12 primary health care centres was conducted in Erbil governorate in the Iraqi Kurdistan region between July and October 2010. A topic guide was used to lead discussions and covered questions on positive aspects of and current problems with the primary care system in addition to the priority needs for its improvement. The discussions were fully transcribed and the qualitative data was analyzed by content analysis, followed by a thematic analysis. RESULTS: Problems facing the primary care system included inappropriate health service delivery (irrational use of health services, irrational treatment, poor referral system, poor infrastructure and poor hygiene), health workforce challenges (high number of specialists, uneven distribution of the health workforce, rapid turnover, lack of training and educational opportunities and discrepancies in the salary system), shortage in resources (shortage and low quality of medical supplies and shortage in financing), poor information technology and poor leadership/governance. The greatest emphasis was placed on poor organization of health services delivery, particularly the irrational use of health services and the related overcrowding and overload on primary care providers and health facilities. Suggestions for improving the system included application of a family medicine approach and ensuring effective planning and monitoring. CONCLUSIONS: This study has provided a comprehensive understanding of the factors that negatively affect the primary care system in Iraq's Kurdistan region from the perspective of primary care providers. From their experience, primary care providers have a role in informing the community and policy makers about the main problems affecting this system, though improvements to the health care system must be taken up at the national level and involve other key stakeholders.

Birth defects in Iraq and the plausibility of environmental exposure: A review.

An increased prevalence of birth defects was allegedly reported in Iraq in the post 1991 Gulf War period, which was largely attributed to exposure to depleted uranium used in the war. This has encouraged further research on this particular topic. This paper reviews the published literature and provided evidence concerning birth defects in Iraq to elucidate possible environmental exposure. In addition to published research, this review used some direct observation of birth defects data from Al-Ramadi Maternity and Paediatric Hospital in Al-Anbar Governorate in Iraq from1st July 2000 through 30th June 2002. In addition to depleted uranium other war-related environmental factors have been studied and linked directly or indirectly with the increasing prevalence of birth defects. However, the reviewed studies and the available research evidence do not provide a clear increase in birth defects and a clear indication of a possible environmental exposure including depleted uranium although the country has been facing several environmental challenges since 1980.

Teaching methods in Hawler College of Medicine in Iraq: a qualitative assessment from teachers' perspectives.

BACKGROUND: Medical education in Iraq is poorly assessed and there is a general lack of documented knowledge about the challenges facing this field and the needs for its development. This study aimed to assess the existing teaching methods in the Hawler College of Medicine, Iraq from teaching staff perspectives and assess the knowledge of the teaching staff about student-centred learning. METHODS: A qualitative study based on a self-administered questionnaire survey of a purposive sample of 83 teaching staff in Hawler Medical University was conducted. The questionnaire addressed the participants' view on the positive aspects and problems of the current teaching methods and priorities to change it. The qualitative data analysis comprised thematic analysis. RESULTS: The study revealed significant problems facing the existing teaching methods including having large number of students in the lecture hall (45.0 %), having focus on teacher-centred teaching (45.0 %) and lack of infrastructures and facilities suitable for proper teaching (26.7 %). The priorities for improving the quality of teaching methods included adoption of small group teaching strategy in all study years (34.6 %), improving the infrastructure and facilities for teaching in the college (34.6 %) and provision of continuous academic development programs for the teaching staff (24.3 %). CONCLUSIONS: The existing medical education system face significant problems and it needs important and comprehensive improvements in different areas. There is a need for further research in this field to explore the identified problems in a more in-depth manner in order to better understand of the problems and needs of this important area of education.

A qualitative assessment of the Iraqi primary healthcare system.

With the limited availability of empirical and documented knowledge about the Iraqi primary healthcare (PHC) system, this study aimed to identify the main problems facing the Iraqi PHC system and the priorities for change. A qualitative study based on a self-administered questionnaire survey involving 46 primary care managers, public health professionals and academics was conducted in Erbil, Iraq. The questionnaire addressed participants' views on positive aspects, problems, priorities and barriers to change of the PHC system through seven open questions. The qualitative data analysis comprised thematic analysis. The survey revealed significant impediments to delivering PHC services, including problems in organization and management of the system, shortage of and poor quality of medications, and inadequate or uneven distribution of manpower and expertise. Priorities for improving the primary healthcare system included reorganization of the services and leadership involving adoption of family practice and regulation of public-private practice, placing emphasis on prevention and health education, and provision of continuing professional training and development. The enormous problems facing the system might signal the need for important and comprehensive improvements based on more in-depth assessment.

Iraqi health system in kurdistan region: medical professionals' perspectives on challenges and priorities for improvement.

BACKGROUND: The views of medical professionals on efficiency of health system and needs for any changes are very critical and constitute a cornerstone for any health system improvement. This is particularly relevant to Iraqi Kurdistan case as the events of the last few decades have significantly devastated the national Iraqi health system while the necessity for adopting a new health care system is increasingly recognized since 2004. This study aims to examine the regional health system in Iraqi Kurdistan from medical professionals' perspectives and try to define its problems and priorities for improvement. METHODS: A survey questionnaire was developed and administered to a convenience sample of 250 medical professionals in Erbil governorate. The questionnaire included four items; rating of the quality of services and availability of resources in the health institutions, view on different aspects of the health system, the perceived priority needs for health system improvement and gender and professional characteristics of the respondents. RESULTS: The response rate to the survey was 83.6%. A high proportion of respondents rated the different aspects of services and resources in the health institutions as weak or very weak including the availability of the required quantity and quality of medicines (68.7%), the availability of sufficient medical equipment and investigation tools (68.7%), and the quality of offered services (65.3%). Around 72% of respondents had a rather negative view on the overall health system. The weak role of medical research, the weak role of professional associations in controlling the system and the inefficient health education were identified as important problems in the current health system (87.9%, 87.1% and 84.9%, respectively). The priority needs of health system improvement included adoption of social insurance for medical care of the poor (82%), enhancing the role of family medicine (77.2%), adopting health insurance system (76.1%) and periodic scientific evaluation of physicians and other health staff (69.8%). CONCLUSION: Medical professionals were generally unsatisfied with the different aspects of the health system in Iraqi Kurdistan region. A number of problems and different priority needs for health system improvement have been recognized that require to be studied in more details.

Landmine injuries at the Emergency Management Center in Erbil, Iraq.

BACKGROUND: Landmines can cause death, injury and disability in addition to many indirect public health consequences. This study aimed at understanding the trends, demography and other epidemiological characteristics of hospitalized landmine injured patients in Erbil governorate. METHODS: The case records of landmine injured patients who had been admitted to the Emergency Management Centre in Erbil city from July 1998 to July 2007 were reviewed and descriptively analyzed. RESULTS: Two hundred eighty five landmine injured patients were admitted to the center, their mean +/- SD age was 26.5 +/- 13.2 years (range 6-71 years), 95.1% were males, nearly 50% were between 19 to 35 years of age and 96.8% were civilians. Around 72% of victims sustained limb amputations; 58.6% lower limb and 13.3% upper limb out of the total. The hospital mortality rate was 2.1%. The number of admissions for landmine injury was steadily decreasing between July 1998 and July 2001, followed by prominent increase between July 2002 and July 2003. The highest proportion of admissions occurred in summer (35.4%) and majority of incidents occurred along the borders with Iran and Turkey (61.8%). CONCLUSION: Civilian male adolescents and young adults constituted the majority of hospitalized landmine victims in Erbil governorate. While a high proportion of victims sustained lower limb amputations, upper limb amputations particularly among children and injury to head and face were relatively common which might be attributed to handling explosives. This emphasizes the need to examine the reasons behind handling explosives.