Health burden and attributable economic damage of conflict and terrorism in the Eastern Mediterranean Region.

This study aimed to vividly describe the direct and severe health impacts of conflict in the Eastern Mediterranean Region (EMR) using data from the Global Burden of Disease (GBD). It also sought to quantify the staggering portion of economic damage attributable to the health burden of conflict and terrorism. From 1990 to 2019, the region endured the devastating effects of conflict and terrorism. These circumstances led to 64%, 50%, and 35% of all causes of Disability-Adjusted Life Years (DALYs) in Libya, Syria, and Palestine, respectively, in 2011, 2016, and 2008. These figures represent not just statistics but the profound human cost of these conflicts. The health-related economic burden (HEB) due to conflict was estimated at $4.6 billion in Iraq, $3.7 billion in Afghanistan, and $1.7 billion in Libya in current international dollars. However, due to missing data, the HEB could not be calculated for Yemen and Syria despite significant conflict-related DALYs. In 2019, the HEB to Current Health Expenditure (CHE) ratio, which indicates the proportion of the health-related economic burden compared to health expenditure, was 30% in Afghanistan and 25% in Iraq. This high ratio underscores the significant strain that conflict places on the health systems.

Exploring the inequalities experienced by health and care workforce and their bases - A scoping review protocol.

Planning for investment in human resources for health (HRH) is critical to achieve Universal Health Coverage (UHC) and establish a sustainable health system. Informed planning warrants a better understanding of the health labour market (HLM) to tackle a variety of health and care workforce challenges: from addressing critical supply shortage, to ensuring optimal skills mix and distribution, and addressing motivation and performance challenges. Scant evidence around the overall role of socioeconomic and cultural factors like gender, race, marital status, citizenship (migrant) status, workplace hierarchy etc. in determining workforce composition, deployment, distribution, retention, un- and underemployment, sub-optimal work environments and other factors in the 'HRH crisis' warrants further exploration. This scoping review protocol aims to map and present the available evidence on inequalities experienced by health and care workforce, the socio-economic, cultural and other bases of these inequalities, and their outcomes/ consequences. PubMed, Web of Science, CINAHL and SCOPUS will be used to identify relevant literature. All types of published study designs in English language will be included if they discuss any inequality experienced by any category of health and care workers. Elaborate keyword categories for health and care workers and inequalities context have been developed, tested and reduced to the near-final search string. Eligible articles will be charted using the Joanna Briggs Institute checklist. The sample data extraction chart in JBI manual will be used as a basic skeleton with fields added to it to serve the needs of the scoping review. Descriptive analysis will be performed, depicting basic frequencies. While no further analysis has been advised in the JBI and PRISMA protocol, thematic analysis will be undertaken; following the Braun and Clarke's method with some modification and open coding as suggested by Maquire and Delahunt.

Peer interventions to improve HIV testing uptake among immigrants: A realist review.

Background: As a vulnerable group in HIV control programs, immigrants face various obstacles to HIV testing. Despite the effectiveness of peer interventions on health promotion in HIV testing, relatively little is known about how these interventions work. This realist review aims to understand why, how, and under what conditions peer interventions can improve immigrants' HIV testing uptake. Methods: We followed the steps suggested by Pawson and colleagues for conducting the realist review. To test a initial program theory, we first systematically searched databases of PubMed, Web of Science, Scopus, Embase, and Cochrane, as well as the websites of UNAIDS, World Bank, Global Fund, WHO, and IOM. After data extraction and quality appraisal, data synthesis was conducted to explain the intervention pathways corresponding to context-mechanism-outcome configurations. Results: Seventeen studies were included in the review. Peer interventions for improving immigrants' HIV testing uptake worked through four pathways: Following the improvement of communications (as a proximal mechanism): 1) increasing awareness, 2) reduced stigma, 3) improved support, and 4) increased access to services could lead to improved HIV testing uptake among immigrants. The identified mechanisms were influenced by three groups of individual/ interpersonal, service delivery, and structural factors. Conclusion: Peer interventions with multiple strategies to be designed and implemented considering the barriers to HIV testing and also moving beyond one-size-fits-all approaches can successfully improve the immigrants' HIV testing uptake. The refined program theory in this study can help the healthcare providers and policy-makers promote the immigrants' HIV testing uptake and reduce the risk of disease transmission.

The experiences and perceptions of people with chronic and rare diseases during political-economic sanctions in Iran: a qualitative study.

BACKGROUND: Economic sanctions aim to exert pressure on political and economic foundations. Hypothesizing that sanctions might affect various aspects of population health, this study, as a component of a broader investigation to ascertain the trend effects of sanctions on selected health outcomes in Iran, seeks to explore the experiences of Iranian citizens associated with the imposed sanctions. METHODS: This is a qualitative study. We conducted 31 semi-structured interviews with randomly selected patients diagnosed with at least one chronic and rare disease from diverse backgrounds across four provinces in Iran. We analyzed data using an inductive content analysis approach, facilitated by the MAXQDA10 software. RESULTS: We identified three primary themes: direct effects, side effects, and coping strategies. The immediate effects were perceived to be manifested through the restriction of healthcare service availability and affordability for citizens. The side effects included the economic hardships experienced in individuals' lives and the perceived devastation caused by these difficulties. Some coping mechanisms adopted by patients or their families/relatives included prioritizing comorbidities, prioritizing health needs within families with multiple ill members, and readjusting health/illness requirements in light of daily living needs. CONCLUSION: In addition to the inherent burden of their illness, patients faced substantial healthcare costs as a result of sanctions, restricted access to medications, and availability of low-quality medications. We advocate considering these challenges within the healthcare system resilience framework as a crucial first step for policymakers, aiming to determine actionable measures and mitigate the adverse effects of sanctions on citizens, particularly the most vulnerable groups.

Establishing research impact assessment in Iran: The first report from a non-high-income country.

Background: This study presents the first report on research impact assessment (RIA) in non-high-income countries, undertaken as a pilot initiative in 2021. Within it, we aimed to explore the feasibility of employing the 'payback' model for evaluating the impact of health research and enhancing the accountability of universities. We focussed on three key impact domains: 'production of decision support documents and knowledge-based products,' 'implementation of research results,' and 'health and economic impact.' Methods: We adopted a case study approach to assess the impact of 5334 health research projects conducted by researchers from 18 universities from 2018 to 2020. Researchers were required to submit evidence related to at least one of the specified impact domains; six scientific committees verified and scored claimed impacts at the national level. Results: Only 25% of the assessed projects achieved impact in at least one domain, with the production of decision support documents and knowledge products being the most reported impact. Notably, economic impact was verified in only three projects, indicating room for improvement in this area. Technology research exhibited the highest acceptance rate of claimed impact, suggesting a positive correlation between technology-focused projects and impactful outcomes. Conclusions: This study demonstrates the feasibility of employing a case study approach and the 'payback' model to evaluate the impact of health research, even within the constraints of a moderately equipped research infrastructure. These findings underscore the potential of integrating RIA into the governance of health research in Iran and other non-high-income countries, as well as the importance of using RIA to assess the accountability of health research systems, guide the allocation of research funding, and advocate for the advancement of health research. The study sets a precedent for future assessments in similar contexts and contributes to the ongoing global dialogue on the societal impact of health research.

Sustainable political commitment is necessary for institutionalizing community participation in health policy-making: Insights from Iran.

BACKGROUND: Community participation is currently utilized as a national strategy to promote public health and mitigate health inequalities across the world. While community participation is acknowledged as a civic right in the Constitution of Iran and other related upstream documents, the government has typically failed in translating, integrating and implementing community participation in health system policy. The present study was conducted to determine the level of public voice consideration within the health policy in Iran and address fundamental interventions required to promote the public voice in the context of Islamic Republic of Iran (IRI). This study has originality because there is no study that addresses the requirements of institutionalizing community participation especially in low-middle-income countries, so Iran's experience can be useful for other countries. METHODS: Methodologically, this study utilized a multi-method and multi-strand sequential research design, including qualitative, comparative and documentary studies. In the first phase, the current level of community participation in the health policy cycle of Iran was identified using the International Association for Public Participation (IAP2) spectrum. In the second phase, a comparative study was designed to identify relevant interventions to promote the community participation level in the selected countries under study. In the third phase, a qualitative study was conducted to address the barriers, facilitators and strategies for improving the level of public participation. Accordingly, appropriate interventions and policy options were recommended. Interventions were reviewed in a policy dialogue with policy-makers and community representatives, and their effectiveness, applicability and practical feasibility were evaluated. RESULTS: Based on the IAP2 spectrum, the level of community participation in the health policy-making process is non-participation, while empowerment is set at the highest level in the upstream documents. Moreover, capacity-building, demand, mobilization of the local population, provision of resources and setting a specific structure were found to be among the key interventions to improve the level of community participation in Iran's health sector. More importantly, "political will for action" was identified as the driving force for implementing the necessary health interventions. CONCLUSIONS: To sum up, a paradigm shift in the governing social, economic and political philosophy; establishing a real-world and moral dialogue and communication between the government and the society; identifying and managing the conflicts of interest in the leading stockholders of the healthcare system; and, more importantly, maintaining a stable political will for action are integral to promote and institutionalize participatory governance in the health sector of Iran. All of the above will lead us to scheme, implement and institutionalize suitable interventions for participatory governance in health and medicine.

Exploring nationwide policy interventions to control COVID-19 from the perspective of the rapid learning health system approach.

Introduction: The health systems needed to improve their learning capacities during the COVID-19 pandemic. Iran is one of the countries massively struck by the pandemic. This study aimed to explore whether and how the policy interventions made by Iran's policymakers at the national level to control COVID-19, could improve the rapid learning characteristics of the health system. Methods: A guide to clarify rapid learning health system (RLHS) characteristics was developed. The guide was used by two independent authors to select the policy interventions that could improve RLHS characteristics, then, to analyze the content of the selected policy interventions. In each stage, results were compared and discussed by all three authors. Final results were presented based on different RLHS characteristics and the potential mechanisms of contribution. Results: Five hundred policy interventions were developed during the first 7 months of the outbreak. Thirty-one policy interventions could potentially improve RLHS characteristics (6.2%). Two characteristics, such as the timely production of research evidence and the appropriate decision support were addressed by selected policy interventions. Policies, that could improve learning capacities, focused on decision-maker groups more than user groups or researcher groups. Conclusions: Most of the developed policy interventions during the first months of the epidemic did not address the learning capacities of the health system. To improve health system functions, improving RLHS characteristics of the health system, especially in patient-centered and data linkage characteristics, is recommended.

Investigating the Rate of the Use of Persian Traditional Medicine Services in Tehran.

Background: Despite all the advancements and publicity made in regard to classical medicine, every day more and more people are interested in complementary medicine. This study was designed and conducted to determine the relative frequency of the use of Persian traditional medicine services by the people of Tehran. Methods: This cross-sectional study was conducted using the telephone survey method in Tehran. A total of 1824 samples were included in the study based on Cochran's formula. At first, by searching databases, including Google Scholar, PubMed, Embase, and internal sources, including the Iran Medex database, numerous medical texts and articles were reviewed in the field of using traditional medicine services. Then, interview guide questions were designed and asked over the phone. Finally, the data were extracted and subjected to quantitative analysis. Frequency and percentage of relative frequency were used to describe the study data. Results: In the study, 62% (n = 1131) of the participants were women, and 60.5% (n = 1103) of the participants have turned to modern medicine for treatment and have also used traditional medical treatments. Also, 43.5% (n = 864) of the participants have used herbal medicines and their products; 43% (n = 616) of the participants have used Persian traditional medicine treatments as self-treatment based on their personal information; and only 46.5% (n = 666) have evaluated the therapeutic effect of Persian traditional medicine methods as "good." Conclusion: The results of the study indicate the need for more emphasis on Persian traditional medicine alongside modern medicine, more organization and supervision of traditional medicine service providers in the country, and the creation of coherent and integrated management in this field.

Revising the essential package of health services through stakeholder alignment, Somalia.

Problem: The fragmented health sector in Somalia, burdened by financial challenges and an inadequate regulatory system, struggles to provide equitable essential health services to the entire population. Approach: To revise an essential package of health services that stakeholders could support and that aligned with stakeholders' financial and technical resources, the federal health ministry invited all key stakeholders in 2020 to participate in the revision process of the essential package. The ministry distributed a concept note to invited stakeholders, describing the scope and purpose of the revision process of the essential package. The note also contained a timeline and the expected contribution of each stakeholder. Stakeholders nominated representatives based on their technical expertise and knowledge of the health sector in Somalia. Local setting: The health sector in Somalia involves multiple stakeholders, including the health ministry and many development partners. The private sector plays a substantial role in health-care provision. Public spending is an estimated 17% of the total health expenditure. Relevant changes: After an 18-month revision process, the health ministry and development partners agreed to prioritize high-impact, cost-effective services and use a progressive realization of the package to improve access and coverage. The implementation strategy considers the health system and operational capacity of service providers, particularly in security-compromised areas. Lessons learnt: The approach showed that inclusivity, collaboration and transparency were of importance for a successful revision of the package. These achievements in consensus-building and priority alignment advance the government's pursuit of equitable and comprehensive health care for all.

Impact of Targeted Subsidies Reform on Household Nutrition: Lessons Learned from Iran.

Background: In 2010, Iran became the first major oil-exporting country to reduce substantially implicit energy subsidies by increasing domestic energy and agricultural prices by up to 20 times. The current research aims to evaluate the profound impact of the countywide implementation of this targeted subsidy reform (TSR) on the consumption patterns of households in Iran, specifically in relation to the consumption of healthy food commodities. Methods: This study employed a robust approach to examine the impact of the TSR on household food consumption, as a natural experiment, using pooled cross-section data from the Household Income and Expenditure Survey (HIES) spanning the years 1992 to 2019. The analysis was based on a comprehensive interpretation of survey data, which served as the primary source for analysis. The estimation procedure utilized an interrupted time series (ITS) model to capture the parameters associated with food consumption. Results: The findings revealed a substantial increase in household expenditures on food immediately following the policy intervention, with an impressive rise of 823 thousand Rials (equivalent to approximately $6.36 based on the floating exchange rate in 2019). Furthermore, the results strongly indicate a significant annual upward trend in total monthly food expenditures per adult person, surpassing the pre-intervention trend by 441 thousand Rials (approximately $3.40) (P=0.044, CI=[12.86, 1016.81]). Moreover, the implementation of the policy led to an annual per capita increase in fruit consumption by 1.02 grams per day (P=0.225, CI=[-0.68; 2.72]). Conclusion: This study shows that the initial positive effects of the TSR have gradually been eroded by inflation in subsequent years. This experience can serve as a lesson for all countries that TSR should be accompanied by other measures, such as poverty alleviation interventions, in order to achieve desired long-term results.

Institutionalisation Is a Vital Element for Fairness of Priority Setting in the Package Design if the Target is Universal Health Coverage Comment on "Evidence-Informed Deliberative Processes for Health Benefits Package Design - Part II: A Practical Guide".

The evidence-informed deliberative processes (EDPs) guide provides a practical framework for fair priority setting of the health benefits package (HBP) that countries can reasonably use. The steps presented in the EDPs are applicable for prioritising health services in designing HBP and are consistent with practical experience in countries. However, institutionalisation must be considered an element of fairness in the priority-setting process if the aim is to reach broader goals of a health system, such as universal health coverage (UHC). Otherwise, the EDPs for priority setting might not be integrated into the formal health system or impactful, resulting in a waste of time and resources, which is unfair. Institutionalisation means formalising the desired change as an embedded and integrated system so that the change lasts over time. For the institutionalisation of EPDs, four stages are suggested, which are (1) establishing a supportive legal framework, (2) designating governance and institutional structure, (3) stipulating the EDPs processes and (4) individual and institutional capacity building.

Barriers and Facilitators to Participatory Governance in Iran Health Policymaking: A Qualitative Study.

Background: Community participation has been accepted as a promising approach to promoting health and health equality. Based on Iran's constitution and the general health policies, community participation in health is addressed as a right, and during recent decades, some measures have been put in place. However, it is critical to improve public participation in Iran's health system and institutionalize community participation in health policymaking. This study aimed to identify barriers and facilities affecting public participation in Iran's health policymaking. Methods: Semi-structured qualitative interviews with health policymakers, health managers and planners, and other stakeholders were conducted to collect data. The conventional content analysis approach was used to analyze the data. Results: Two themes-including community level and government level-and 10 categories were identified through the qualitative analysis. Cultural and motivational factors, lack of awareness of the right to participate, and lack of sufficient knowledge and skills are among the identified barriers in the process of establishing effective interaction. From the health governance perspective, a lack of political will is identified as one of the obstacles. Conclusion: A culture of community involvement and political will are pivotal in the sustainability of community participation in health policymaking. The provision of a suitable context for participatory processes and capacity building on the community and government levels can be useful in institutionalizing community participation in the health system.

The human cost of economic sanctions and strategies for building health system resilience: A scoping review of studies in Iran.

OBJECTIVES: This review aimed to analyse the impacts of international economic sanctions on the overall health status of Iranians and the health system performance of Iran, in addition to identifying effective strategies for making the health system resilient to sanctions. STUDY DESIGN: A scoping review. METHODS: Three databases and grey literature were reviewed, and additional papers were identified in the lists of references. Two authors reviewed papers to check duplications and screen through inclusion/exclusion criteria. Furthermore, a narrative approach was employed to synthesise the findings. RESULTS: Given overall health impacts, economic sanctions are believed to have adverse effects on Iranian's health and cause significant financial hardships in accessing healthcare services. These hardships mostly affect those in marginalised and vulnerable groups. Economic sanctions degrade Iran's health system by negatively impacting health services' availability. The detrimental effects of sanctions on economic and social circumstances were also documented. Economic sanctions could also adversely affect health research and education. Most strategies identified for health system resilience to sanctions are related to the health system governance. CONCLUSIONS: Even if essential medicines and supplies are exempted from the sanction regime, the impact of economic sanctions on public health is unavoidable. The quantification of the effect economic sanctions on different health-related areas needs by further research. The measures identified for dealing with sanction can be considered in other countries but more work is needed to explore how health of people can be resilient against negative consequences of sanctions.

Relationship between anthropometric indices and Mizaj (temperament) in Persian medicine.

Background: The process of diagnosis and treatment in Persian medicine (PM) are based on the concept of Mizaj (temperament). Among the indices of Mizaj determination, anthropometric indices are less influenceable regarding age change and other environmental factors. The purpose of this study was to investigate the relationship between anthropometric indices and Mizaj. Methods: Four PM experts determined the Mizaj of 121 participants. Those who had ≥70% agreement in their Mizaj determination by the experts were selected and their anthropometric indices were measured. The best cutoff point of each index and its relationship with the defined Mizaj were extracted using Receiver Operative Characteristic Curve and Binary Logistic Regression. Results: 52 out of 121 participants entered the main study. The warm-Mizaj people had larger dimensions in height, shoulder, chest, palm and sole width, and head height. Cold-Mizaj people had smaller dimensions in weight, height, shoulder, chest and head. High levels of BMI, chest depth and head dimensions had the highest correlation with the wet Mizaj and lower dimensions of these indices had the highest correlation with the dry Mizaj. Conclusion: Among the anthropometric indices, chest, palm, sole dimensions, head height and weight had the highest correlation with warmness/coldness and BMI, head width and chest dimensions had the highest correlation with wetness/dryness. The BMI which is more closely related to the soft tissue, only correlates with the wetness/dryness, while, bone dimensions are associated with warmness/coldness. Further studies are needed to metricize the anthropometric indices for Mizaj determination.

Participatory evaluation of municipal obesity prevention clubs in Tehran city: Strengths, challenges, and future direction.

Background and aim: Community-based initiatives are important for obesity prevention. This study aimed to evaluate the activities of municipal obesity prevention clubs (OBCs) in Tehran, Iran, using a participatory approach. Methods: The evaluation team was formed, and the members identified the OBC's strengths, and challenges and provided suggestions for change through a participatory workshop, observation, focus group discussions, reviewing relevant documents (n = 97), and 35 interviews with involved stakeholders. The MAXQDA software was used for data analysis. Results: An empowerment training program for volunteers was identified as one of the strengths of OBCs. Despite the obesity prevention efforts of OBCs through public exercise sessions, healthy food festivals, and educational sessions, several challenges were identified that hinder participation in OBCs. These challenges included poor marketing strategies, poor training approaches in participatory planning, insufficient motivational support for volunteers, low perceived recognition of volunteers by the community, volunteers' low food and nutrition literacy, poor educational services in the communities, and limited funding for health promotion activities. Conclusion: Weaknesses in all stages of community participation, including information, consultation, collaboration, and empowerment, in OBCs were detected. Facilitating a more enabling environment for informing and involving citizens, expanding neighborhood social capital, and involving health volunteers, academia, and all potential governmental sectors to collaborate for obesity prevention is recommended.