Mode of Presentation of Hypertension in a Group of Hypertensive Patients in Erbil.

Background Hypertension is a major public health problem, and it remains the major preventable cause of cardiovascular and all-cause mortality worldwide. Most cases are asymptomatic and discovered incidentally. Objectives The objective of this study is to identify (i) the proportion of hypertensive patients diagnosed incidentally and those diagnosed due to symptoms, (ii) the most common symptoms among patients that present with symptoms, (iii) the presentation of acute elevations of blood pressure in hypertensive patients, and (iv) hypertension-related symptoms affect compliance with medications. Patients and methods A cross-sectional study was carried out on 386 hypertensive patients in two public health care centres and public places in Erbil, the capital of the Kurdistan Region of Iraq, from December 20, 2021, to February 7, 2022. Data was collected through interviews with the patients using a questionnaire designed by the researchers. A p-value ≤ 0.05 was considered to be statistically significant. Results The majority (76.5%) of patients were diagnosed because they got their blood pressure measured due to symptoms. The likelihood of being diagnosed incidentally was not significantly different with age, gender, age at diagnosis, socioeconomic status, or having one or more risk factors. The most common symptoms were headache followed by lightheadedness. Since diagnosis, 87.7% of subjects reported feeling symptoms with elevations in blood pressure, most commonly headaches followed by lightheadedness. Women and individuals belonging to a low socioeconomic status were more likely to report feeling symptoms. Whether or not patients felt symptoms with elevations of blood pressure, it didn't significantly affect compliance with medications. Conclusion The majority of hypertensive patients are diagnosed once they develop symptoms or complications, and a small percentage are diagnosed incidentally. Screening for hypertension in our region may be inadequate. Treatment rates were high. Hypertension-related symptoms didn't seem to affect compliance with medications.

Umbilical vein injection of 400 versus 800 µg misoprostol for the treatment of retained placenta: A multicenter, randomized double-blind controlled trial.

AIMS: This trial was conducted to determine the efficacy of umbilical vein injection of 400 versus 800 µg misoprostol to deliver retained placenta and to compare both regimens regarding the time of placental delivery and amount of vaginal blood loss. METHODS: A double-blind, multicenter randomized clinical trial was undertaken in four teaching hospitals in the North of Iraq and Al-Azhar University Hospital in Egypt, from March 2016 to May 2019. Group I (274 women) received 400 µg misoprostol and group II (249 women) received 800 µg misoprostol. Data regarding the time of placental separation and amount of vaginal blood loss were analyzed and proportions were compared between groups using Chi-squared test. Mean values were compared using the Student's t-test. The Mann-Whitney test was used to determine the median of vaginal blood loss. RESULTS: The proportion of placental separation was 84.3% among women in group I and 86.7% of women in group II. The mean time of placental separation was 18.86 ± 234.2 and 17.86 ± 213.09 min in groups I and II, respectively (P < 0.05).The mean hemoglobin levels on admission and 24 h after placental deliveries were significantly higher in group I than group II. CONCLUSIONS: Intra-umbilical injection of 400 and 800 µg misoprostol were both safe and effective methods for delivery of retained placenta.

Screening for depression during pregnancy using the Kurdish version of the Edinburgh Postnatal Depression Scale in Erbil city.

We aimed to determine any difference in the prevalence rate of depression during the three trimesters of pregnancy and its association with certain obstetric risk factors. In total, 1000 pregnant women attending primary health centers in the city of Erbil, Kurdistan, Iraq were assessed for depression using the Edinburgh Postnatal Depression Scale. Women in the first and second trimesters had a significantly higher probability of depression than those in the third trimester. Screening early in pregnancy and following pregnant women in each trimester may help to identify those who are susceptible to depression and enable appropriate intervention.

Comparison of clinical and hormonal characteristics among four phenotypes of polycystic ovary syndrome based on the Rotterdam criteria.

PURPOSE: Polycystic Ovary Syndrome (PCOS) is the most common endocrine disturbances in women and is divided into different phenotypes. The aim of study is to compare the clinical and hormonal parameters among the four phenotypes of PCOS based on the Rotterdam criteria and with control group. METHODS: Women with PCOS (n = 263) confirmed based on the Rotterdam criteria and 263 women with no evidence of PCOS were recruited as controls using observational case-control study. Evaluation of clinical and hormonal parameters, and differences in anti-Mullerian hormone (AMH) were compared between four phenotypes of PCOS and controls. RESULTS: Women with phenotype A (olig-anovulation (O) + hyperandrogenism (H) + polycystic ovary morphology (P)) had significantly larger waist than phenotype D (O + P) and higher body mass index than phenotype C (H + P). The LH/FSH ratio was significantly higher in phenotype A than phenotype D and controls along with significantly higher serum total testosterone levels in phenotype A compared to the phenotype B (O + H), C, D, and controls. AMH was significantly higher with phenotype A, C, and D than in women phenotype B and controls. CONCLUSIONS: The highest AMH levels were found in phenotype A. Phenotype B similar to controls had significantly low AMH compared to other three PCOS phenotypes. Women in the phenotypes D and controls showed significantly lower levels of LH/FSH ratio, total testosterone, and free androgen index, and higher levels of FSH and SHBG compared with phenotype A (P < 0.001). In logistic regression analysis, AMH and LH were predictors for PCOS.

Bemiparin versus enoxaparin as thromboprophylaxis following vaginal and abdominal deliveries: a prospective clinical trial.

BACKGROUND: Venous thromboembolism (VTE) is a leading cause of maternal mortality and morbidity, with the highest incidence occurring during the postpartum period. This study compared the ability of two types of low-molecular-weight heparin, enoxaparin and bemiparin, to decrease the incidence of VTE following elective caesarean section, emergency caesarean section, and vaginal delivery in women who had risk factors for thromboembolism. METHODS: In this prospective clinical trial using a sequential group allocation method, 7020 haemodynamically stable women delivered vaginally or abdominally at the Maternity Teaching Hospital, Kurdistan region, Erbil, Iraq, between May 1, 2012, and November 1, 2013. These women had risk factors for VTE and were allocated to the following groups: treatment with 3500 IU/day of bemiparin, 4000 IU/day of enoxaparin, or no intervention (control). The first dose was administered 6 hours after vaginal or abdominal delivery, or 8 hours after delivery in women receiving spinal anaesthesia. Subsequent doses were administered daily for up to 6 days. The incidence of VTE was assessed for up to 40 days postpartum. Data were analyzed using the Statistical Package for Social Sciences version 19. Proportions were compared using the chi square test of association or Fisher's exact test. Binary logistic regression analysis was used with VTE as the dependent variable. RESULTS: VTE occurred in 1 (0.042%) woman in the bemiparin group, two (0.085%) women in the enoxaparin group, and nine (0.384%) women in the control group (P = 0.017). Regression analysis showed that women on bemiparin (OR = 0.106; 95% CI = 0.013-0.838) and enoxaparin (OR = 0.226; 95% CI = 0.049-1.049) were at lower risk of developing VTE than control women. Adverse events in the enoxaparin group included wound dehiscence, haematoma, and separation. None of these occurred in the bemiparin group. CONCLUSIONS: Postpartum bemiparin is significantly effective as a prophylaxis for VTE. Wound complications develop after use of enoxaparin, but not after bemiparin. TRIAL REGISTRATION: ClinicalTrials.gov; Identifier: NCT01588171 ; date: April 26, 2012.

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.

A case-control observational study of insulin resistance and metabolic syndrome among the four phenotypes of polycystic ovary syndrome based on Rotterdam criteria.

BACKGROUND: Polycystic ovary syndrome (PCOS) is associated with an increased risk of insulin resistance (IR), metabolic syndrome (MetS), impaired glucose tolerance (IGT) and type 2 diabetes mellitus (T2DM). Metabolic aspects of the four PCOS phenotypes remain to be fully defined. The aim of this study was to compare metabolic parameters and insulin resistance among the four PCOS phenotypes defined according to the Rotterdam criteria and to determine predictors of these complications. METHODS: A total of 526 reproductive-aged women were included in this observational case-control study. Of these, 263 were diagnosed as a PCOS based on Rotterdam criteria and 263 infertile women with no evidence of PCOS were recruited as controls. Biochemical, metabolic and insulin resistance parameters were compared in the two groups and the frequency of MetS and IR were compared among the four phenotypes. Data were analyzed for statistical significance using Student's t-test and one way analysis of variance followed by a post-hoc test (least significant difference). Chi-square tests were used to compare proportions. Univariate and multivariate logistic regression analyses were also applied. RESULTS: IR was identified in 112 (42.6%) of the PCOS women and 45 (17.1%) of the control (P <0.001). There were no significant differences in the frequency of IR and MetS between the four PCOS phenotypes. Homeostatic model assessment for IR (HOMA-IR) ≥3.8 was the most common IR parameter in PCOS and control groups. Women with oligo-anovulation (O) and PCO morphology (P) had a significantly lower level of 2-h postprandial insulin compared to women with O, P and hyperandrogenism (H) phenotypes. Logistic regression analysis showed that body mass index, waist circumference, triglyceride/high-density lipoprotein ratio (cardiovascular risk), HOMA-IR and glucose abnormalities (T2DM) were associated with increased risk of having MetS (P < 0.05). CONCLUSIONS: PCOS women with (O + P) show milder endocrine and metabolic abnormalities. Although, there were no significant differences in IR, MetS and glucose intolerance between the four PCOS phenotypes, women with PCOS are at higher risk of impaired glucose tolerance and undiagnosed diabetes.

Ovarian reserve markers and assisted reproductive technique (ART) outcomes in women with advanced endometriosis.

BACKGROUND: The role of ovarian reserve markers as predictors of the controlled ovarian stimulation (COS) response in intracytoplasmic sperm injection (ICSI) cycles in women with endometriosis has been much debated. The aim of the present study is to assess the predictability of ovarian reserve markers for the number of mature oocytes (MII) retrieved and to assess the pregnancy rate and live birth rate in women with advanced endometriosis. METHODS: Two hundred eighty-five infertile women who had laparoscopy followed by a first ICSI cycle were recruited in this prospective study. One hundred ten patients were diagnosed with endometriosis stage III-IV (group 1), and 175 patients had no endometriosis (group II). Sixty-three patients in group 1 had no history of previous endometrioma surgery (group Ia), and 47 patients had a history of previous endometrioma surgery (group Ib). RESULTS: The number of mature oocytes retrieved was significantly lower in women with advanced endometriosis than in women with no endometriosis. The number of mature oocytes retrieved in women with and without endometriosis was best predicted by antral follicle count (AFC) and age, whereas only AFC was a predictor in women with previous endometrioma surgery (odds ratio: 0.49; 95% confidence interval: 0.13-0.60). Women with endometriosis had a lower rate of live births than the control group, but this difference was not statistically significant; the number of live births was significantly lower in those with previous endometrioma surgery. CONCLUSIONS: The best predictor of the COS response in ICSI was AFC, followed by age. Women receiving ICSI following surgery for ovarian endometrioma had a poorer clinical outcome and lower rate of live births compared with those with endometriosis but no previous surgery and the control group.

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.

Prevalence of urinary incontinence and probable risk factors in a sample of kurdish women.

OBJECTIVES: The most common manifestation of pelvic floor dysfunction is urinary incontinence (UI) which affects 15-50% of adult women depending on the age and risk factors of the population studied. The aim of this study was to determine the probable risk factors associated with UI; the characteristics of women with UI; describe the types of UI, and determine its prevalence. METHODS: A cross-sectional study was conducted between February and August 2011, in the Maternity Teaching Hospital of the Erbil Governorate, Kurdistan Region, northern Iraq. It included 1,107 women who were accompanying patients admitted to the hospital. A questionnaire designed by the researchers was used for data collection. A chi-square test was used to test the significance of the association between UI and different risk factors. Binary logistic regression was used, considering UI as the dependent variable. RESULTS: The overall prevalence of UI was 51.7%. The prevalence of stress, urgency, and mixed UI was 5.4%, 13.3% and 33%, respectively. There was a significant positive association between UI and menopause, multiparity, diabetes mellitus (DM), chronic cough, constipation, and a history of gynaecological surgery, while a significant negative association was detected between UI and a history of delivery by both vaginal delivery and Caesarean section. CONCLUSION: A high prevalence of UI was detected in the studied sample, and the most probable risk factors were multiparity, menopausal status, constipation, chronic cough, and DM.

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.

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.

Prevalence of silent stroke in Kurdistan, Iraq.

OBJECTIVES: To measure the prevalence of silent strokes in the Iraqi Kurdish population, and to identify silent stroke risk factors. METHODS: This cross-sectional study was carried out in Rizgary Teaching Hospital, Erbil, Iraq from January to June 2009. A sample of 200 patients attending the outpatient clinic was taken. The results of CT and MRI were analyzed, and the proportion of silent infarcts was measured. Patients were interviewed for presence of hypertension, diabetes, ischemic heart disease, alcohol drinking, and smoking. Body mass index and serum lipid levels were calculated. RESULTS: Out of 200 subjects, 19% showed silent infarct(s). Logistic regression analysis showed significant association between hypertension and old age with presence of silent infarcts. The age of affected individuals was significantly higher than the age of the non-affected individuals. CONCLUSIONS: The percentage of silent infarcts among apparently normal individuals in the Kurdish population is around 19%, and physicians must always keep this diagnosis in mind, especially among hypertensive and older aged patients.

Pattern of migraine headache in a group of Kurdish Iraqi patients.

OBJECTIVE: To study the pattern of migraine, and to show the effect of age and duration of illness on the evolution of migraine symptoms. METHODS: A review of 200 migraine cases (attending the outpatient neurology clinic at Rezgary Teaching Hospital, and Kurdistan Private Neurology Clinic) was carried out during the period between October 2007 to May 2008. Case definition of migraine was according to the International Headache Society (IHS) criteria. RESULTS: The majority (77%) of the studied sample was female. The mean age (+/- SD) at onset was 22.33+/-9.52 years. The most common type of migraine observed was migraine without aura (72%). Different symptoms like phonophobia (92%), nausea (86.5%), photophobia (84%), vertigo (78%), scalp tenderness (75%), attacks of facial pallor (64%), sweating (57%), vomiting (50%), pain in the arms (39%), and pain in the chest (6%) was studied in relation to age at presentation and duration of illness in years. No significant association was found between the duration of illness and age at presentation and evolution of migraine symptoms. No significant association was found between the duration of illness and frequency of the attacks. CONCLUSION: Many migraine symptoms remain the same in each attack no matter the duration of illness and age at presentation, except for bouts of vomiting, which may be less common in younger patients.