Motivating non-physician health workers to reduce the behavioral risk factors of non-communicable diseases in the community: a field trial study.

BACKGROUND: Non-communicable diseases behavioral risk factors can be improved if effective interventions are designed considering the health system's capabilities and local resources. This study evaluated the effectiveness of interventions that aimed at increasing non-physician community health workers' motivation in reducing non-communicable diseases behavioral risk factors in the community. METHODS: A randomized field trial study was conducted in 32 community health centers in 4 Iranian districts after a baseline population survey on the status of NCDs of 30-70-year-old individuals (n = 1225). The interventions were performed to improve insufficient physical activity, insufficient fruit consumption, insufficient vegetable consumption, high salt intake, and tobacco use. Four intervention packages were implemented in 24 community health centers; the other 8 centers were used as control groups. The non-physician community health workers performed the interventions. The packages additively included goal-setting, evidence-based education, operational planning, and incentive payments. A second survey was conducted 1 year after the start of the interventions to identify the effects on an independent random sample of 30-70-year-old individuals (n = 1221). Difference-in-difference method was used to quantify the interventions' effects. RESULTS: The average age of participants in both surveys was about 49 years. Also, about half of the participants were female, and about 43% were illiterate or had a primary school education. The interventions had statistically significant effects only on decreasing the prevalence of insufficient physical activity. The package with all the intervention components decreased the odds of insufficient physical activity to 0.24 (95% CI, 0.08, 0.72). The package with operational planning but no performance-based financing did not change the odds of insufficient physical activity. CONCLUSIONS: This study highlighted the importance of components, design, and implementation details of interventions intended to reduce NCDs behavioral risk factors. Some risk factors, such as insufficient physical activity, seem more easily modifiable with limited low-cost interventions in a one-year horizon. However, risk factors related to healthy food consumption and tobacco use need more extensive interventions. TRIAL REGISTRATION: This trial was registered on the Iranian Registry of Clinical Trials (IRCT20081205001488N2) on 3 June 2018 ( https://en.irct.ir/trial/774 ).

Early-life exposure to Saharan dust storms and adolescence functional disability: Evidence from Cameroon.

The direct link between early-life dust storm exposure and later-in-life outcomes is not fully understood. This study examines the association of functional disability in a large sample of adolescent Cameroonians (N = 112,855) with in-utero and early childhood exposure to Saharan dust storms. Adjusting all estimations for temperature, precipitation, time and location fixed-effects, and person and family sociodemographic characteristics, we documented adverse effects on functional disability in female adolescents due to exposure to dense dust storms during the third gestation trimester and the second postnatal trimester. We also found suggestive evidence that an effect exists for the first as well as the third through fifth postnatal trimesters. In the third trimester of gestation and the second postnatal trimester, exposure to an average length dust storm with PM10 levels beyond 190 µg/m3 increased the likelihood of disability among female adolescents by approximately 229 (95 % CI: 10-464) in 100,000. The size of the adverse effects for the other periods followed similar patterns. These results show the value of creating infrastructures to mitigate or adapt to the effects of dust storms. These endeavors should focus on communities and populations in and around the Sahara where international organizations can play a role. In addition, establishing health data infrastructures not only improves public health but also advances our understanding of the long-term effects of dust storms. This study demonstrates the importance of research on the long-term effects of early-life exposure to dust storms and the need for additional work on this topic.

Evaluating the impact of results-based motivating system on noncommunicable diseases risk factors in Iran: Study protocol for a field trial.

Background: Risk factors of noncommunicable diseases (NCD) are increasingly contributing to morbidity and mortality in Iran. Health care providers' competencies and motivation are essential factors for the success and efficiency of primary health care. This field trial aims to evaluate the impact of a results-based motivating system on population level of the NCD risk factors field trial (IRPONT) in Iran. Methods: Population groups of 24 rural or urban catchment areas from 3 provinces were randomized to 1 of the 4 types of study groups. The groups were defined based on a set of 4 intervention packages. Extra 8 rural or urban catchment areas in a separate city were considered as independent nonintervention (control) group. Population levels of major NCD risk factors in all 32 population groups were measured at the beginning of the trial, at the end of the first year, and will be measured in the second year through standardized population surveys. As the outcome measure, the difference in population levels of the risk factors will be compared among the study groups. Study group IV will be compared with combined control groups (study groups I, II, and III). Also, we will conduct subgroup analysis to determine the effects of interventions 2, 3, and 4. Ethics: This trial has received ethical approval from National Institute for Medical Research Development in Iran (IR.NIMAD.REC.1396.084) in 2017. Trial Registration Number: This trial has been registered on the Iranian Registry of Clinical Trials (identifier: IRCT20081205001488N2). Registered on 3 June 2018 and updated on 12 April 2020.

Prevalence of unmasked and improperly masked behavior in indoor public areas during the COVID-19 pandemic: Analysis of a stratified random sample from Louisville, Kentucky.

Wearing a facial mask can limit COVID-19 transmission. Measurements of communities' mask use behavior have mostly relied on self-report. This study's objective was to devise a method to measure the prevalence of improper mask use and no mask use in indoor public areas without relying on self-report. A stratified random sample of retail trade stores (public areas) in Louisville, Kentucky, USA, was selected and targeted for observation by trained surveyors during December 14-20, 2020. The stratification allowed for investigating mask use behavior by city district, retail trade group, and public area size. The total number of visited public areas was 382 where mask use behavior of 2,080 visitors and 1,510 staff were observed. The average prevalence of mask use among observed visitors was 96%, while the average prevalence of proper use was 86%. In 48% of the public areas, at least one improperly masked visitor was observed and in 17% at least one unmasked visitor was observed. The average prevalence of proper mask use among staff was 87%, similar to the average among visitors. However, the percentage of public areas where at least one improperly masked staff was observed was 33. Significant disparities in mask use and its proper use were observed among both visitors and staff by public area size, retail trade type, and geographical area. Observing unmasked and improperly masked visitors was more common in small (less than 1500 square feet) public areas than larger ones, specifically in food and grocery stores as compared to other retail stores. Also, the majority of the observed unmasked persons were male and middle-aged.

U.S. Health Care Expenditure Across Income Groups by Age and Type of Care.

Health care expenditure (HCE) does not significantly vary by income in the U.S. However, health outcomes vary significantly by income. To understand the disconnection, we used the Medical Expenditure Panel Survey (MEPS) data and adjusted HCE for utilization and stratified it by income and age. We showed that the adjusted HCE is significantly higher among lower-income Americans, especially at older ages. At age 45-64, for example, the adjusted HCE for the poor, low-income, and high-income were $10,552; $7,118; and $5,300 in 2015 prices, respectively. We also found that children from lower-income families receive less nonurgent, preventive care than those from higher-income families. However, adults from lower-income families use much more urgent care than those from higher-income families. Our results, alongside the evidence of continuously widening gaps in mortality and morbidity rates among income groups, raise policy-relevant questions about the optimal age profile of health care provision, particularly among lower-income groups.

Weather and COVID-19 Deaths During the Stay-at-Home Order in the United States.

OBJECTIVE: To estimate the association between weather and COVID-19 fatality rates during US stay-at-home orders. METHODS: With a county-level longitudinal design, this study analyzed COVID-19 deaths from public health departments' daily reports and considered exposure as the 18 to 22 day-period before death. Models included state-level social distancing measures, Census Bureau demographics, daily weather information, and daily air pollution. The primary measures included minimum and maximum daily temperature, precipitation, ozone concentration, PM2.5 concentrations, and U.V. light index. RESULTS: A 1 °F increase in the minimum temperature was associated with 1.9% (95% CI, 0.2% to 3.6%) increase in deaths 20 days later. An ozone concentration increase of 1 ppb (part per billion) decreased daily deaths by 2.0% (95% CI, 0.1% to 3.6%); ozone levels below 38 ppb negatively correlated with deaths. CONCLUSIONS: Increased mobility may drive the observed association of minimum daily temperature on COVID-19 deaths.

Short-term fetal nutritional stress and long-term health: Child height.

OBJECTIVE: This study examined the impact of in utero exposure to Ramadan, the Islamic fasting month, by trimester on height at ages 0 to 18 for a sample of children from Tehran, Iran. If exposure to Ramadan is associated with significant nutritional stress to the fetus, the fetus's adaptive responses to nutritional insufficiency could manifest as changes in height during childhood, long before any effects on aging or disease risk at older ages. METHODS: Children who were exposed and not exposed to Ramadan in utero were compared to identify any systematic difference between their parents' and households' characteristics (including height, age, education, and indicators of wealth). Also, the seasonal pattern of food consumption in Tehran was analyzed. Finally, the association of child height with prenatal exposure to Ramadan was measured, controlling for seasonality and parent and household. RESULTS: Ramadan associated fasting in the second trimester of gestation was associated with 0.091 age-adjusted SDs (ie, 0.60-0.67 cm) decrease in children's height at age 10 years or older. The negative association was largest in male children and was approximately 1 cm at age 12 years or older among male children. CONCLUSION: Maternal Ramadan fasting in the second trimester, the critical period for long bone development, was associated with decreased height. Exposure to ritual fasting is important because approximately 75% of all Muslim children are exposed to Ramadan in utero.

Saharan sand and dust storms and neonatal mortality: Evidence from Burkina Faso.

West African populations are exposed to the longest and harshest dust storms on the planet, the Saharan sand and dust storms (SDS). Nonetheless, little is known about the effects of the severe storms on early-life health in West Africa. This study investigated the association of the risk of neonatal mortality, an indicator of the population's early-life health, with potential prenatal and neonatal exposure to the Saharan SDS. Data on 30,552 under-five children from Burkina Faso's 1993, 2003, and 2010 demographic and health surveys were matched to the particulate matters (PM) and terrestrial air temperature and precipitation forecasts. Exposure to dust events was measured by the number of days with average PM10 and PM2.5 concentrations above a series of threshold. Intensity-dependent patterns of associations between neonatal mortality and both prenatal and birth month exposure to dust events were identified. There was no association if average daily PM10 and PM2.5 levels were <60 and 30 µg/m3, respectively. However, strong associations, which increase almost linearly with the intensity of exposure, were identified when daily PM10 and PM2.5 levels ranged from 70 to 150 and from 40 to 70 µg/m3, respectively. At the higher PM levels, the association for the gestation period decreased, but that for the birth month remained mostly unresponsive to changes in the PM levels. Larger associations were identified when siblings were compared.

Continuous exposure to ambient air pollution and chronic diseases: prevalence, burden, and economic costs.

Studies that assess the connection between the prevalence of chronic diseases and continuous exposure to air pollution are scarce in developing countries, mainly due to data limitations. Largely overcoming data limitations, this study aimed to investigate the association between the likelihood of reporting a set of chronic diseases (diabetes, cancer, stroke and myocardial infarction, asthma, and hypertension) and continuous exposure to carbon monoxide (CO), nitrogen dioxide (NO2), ozone (O3), and coarse particulate matter (PM10). Using the estimated associations, the disease burden and economic costs of continuous exposure to air pollutants were also approximated. A 2011 Health Equity Assessment and Response Tool survey from Tehran, Iran, was used in the main analyses. A sample of 67,049 individuals who had not changed their place of residence for at least 2 years before the survey and reported all relevant socioeconomic information was selected. The individuals were assigned with the average monthly air pollutant levels of the nearest of 16 air quality monitors during the 2 years leading to the survey. Both single- and multi-pollutant analyses were conducted. The country's annual household surveys from 2002 to 2011 were used to calculate the associated economic losses. The single-pollutant analysis showed that a one-unit increase in monthly CO (ppm), NO2 (ppb), O3 (ppb), and PM10 (µg/m3) during the 2 years was associated with 751 [confidence interval (CI): 512-990], 18 (CI: 12-24), 46 (CI: -27-120), and 24 (CI: 13-35) more reported chronic diseases in 100,000, respectively. The disease-specific analyses showed that a unit change in average monthly CO was associated with 329, 321, 232, and 129 more reported cases of diabetes, hypertension, stroke and myocardial infarction, and asthma in 100,000, respectively. The measured associations were greater in samples with older individuals. Also, a unit change in average monthly O3 was associated with 21 (in 100,000) more reported cases of asthma. The multi-pollutant analyses confirmed the results from single-pollutant analyses. The supplementary analyses showed that a one-unit decrease in monthly CO level could have been associated with about 208 (CI: 147-275) years of life gained or 15.195 (CI: 10.296-20.094) thousand US dollars (USD) in life-time labor market income gained per 100,000 30-plus-year-old Tehranis.

The effect of prenatal exposure to Ramadan on children's height.

We examine the effect of prenatal exposure to Ramadan on children's height by sex, age, region, and the degree of religiosity. Since Ramadan rotates on solar calendars, we pool demographic and health survey data from numerous developing countries to increase the number of birth years and fairly control for potential seasonal effects. Our results suggest that Ramadan-induced nutritional stress during early- and mid-gestation may negatively affect the height of 3 and 4 years old Muslim male children. The effect tends to be stronger in West Africa and Central Asia. It also tends to be stronger in more religious countries. We do not detect consistent negative effects on height in female children.

Prevalence and Years Lived with Disability of 310 Diseases and Injuries in Iran and its Neighboring Countries, 1990-2015: Findings from Global Burden of Disease Study 2015.

BACKGROUND: Due to significant achievements in reducing mortality and increasing life expectancy, the issue of disability from diseases and injuries, and their related interventions, has become one of the most important concerns of health-related research. METHODS: Using data obtained from the GBD 2015 study, the present report provides prevalence and years lived with disability (YLDs) of 310 diseases and injuries by sex and age in Iran and neighboring countries over the period 1990-2015. Age-standardized rates of all causes of YLDs are presented for both males and females in 16 countries for 1990 and 2015. We present the percentage of total YLDs for 21 categories of diseases and injuries, the percentage of YLDs for age groups, as well as the ranking of the most prevalent causes and YLDs from the top 50 diseases and injuries in Iran. RESULTS: In 2015, the burden of 310 diseases and injuries among the Iranian population was responsible for 8,357,878 loss of all-age total years, which is equal to 10.58% of total years lived per year. This differs from the neighboring countries, as it ranges from 9.05% in Turkmenistan to 13.36% in Russia. During the past 25 years, a remarkable decrease was observed in all-cause YLD rates in all 16 countries. Meanwhile, in all countries, the age-standardized rate of all causes of YLDs was higher in females than males. CONCLUSION: Based on our findings, one of the remarkable changes in NCDs observed among the studied age groups was increased rate of YLDs from mental disorders, which was replaced by musculoskeletal disorders in older age groups in 2015.

Disability-Adjusted Life-Years (DALYs) for 315 Diseases and Injuries and Healthy Life Expectancy (HALE) in Iran and its Neighboring Countries, 1990-2015: Findings from Global Burden of Disease Study 2015.

BACKGROUND: Summary measures of health are essential in making estimates of health status that are comparable across time and place. They can be used for assessing the performance of health systems, informing effective policy making, and monitoring the progress of nations toward achievement of sustainable development goals. The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) provides disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) as main summary measures of health. We assessed the trends of health status in Iran and 15 neighboring countries using these summary measures. METHODS: We used the results of GBD 2015 to present the levels and trends of DALYs, life expectancy (LE), and HALE in Iran and its 15 neighboring countries from 1990 to 2015. For each country, we assessed the ratio of observed levels of DALYs and HALE to those expected based on socio-demographic index (SDI), an indicator composed of measures of total fertility rate, income per capita, and average years of schooling. RESULTS: All-age numbers of DALYs reached over 19 million years in Iran in 2015. The all-age number of DALYs has remained stable during the past two decades in Iran, despite the decreasing trends in all-age and age-standardized rates. The all-cause DALY rates decreased from 47,200 in 1990 to 28,400 per 100,000 in 2015. The share of non-communicable diseases in DALYs increased in Iran (from 42% to 74%) and all of its neighbors between 1990 and 2015; the pattern of change is similar in almost all 16 countries. The DALY rates for NCDs and injuries in Iran were higher than global rates and the average rate in High Middle SDI countries, while those for communicable, maternal, neonatal, and nutritional disorders were much lower in Iran. Among men, cardiovascular diseases ranked first in all countries of the region except for Bahrain. Among women, they ranked first in 13 countries. Life expectancy and HALE show a consistent increase in all countries. Still, there are dissimilarities indicating a generally low LE and HALE in Afghanistan and Pakistan and high expectancy in Qatar, Kuwait, and Saudi Arabia. Iran ranked 11th in terms of LE at birth and 12th in terms of HALE at birth in 1990 which improved to 9th for both metrics in 2015. Turkey and Iran had the highest increase in LE and HALE from 1990 to 2015 while the lowest increase was observed in Armenia, Pakistan, Kuwait, Kazakhstan, Russia, and Iraq. CONCLUSIONS: The levels and trends in causes of DALYs, life expectancy, and HALE generally show similarities between the 16 countries, although differences exist. The differences observed between countries can be attributed to a myriad of determinants, including social, cultural, ethnic, religious, political, economic, and environmental factors as well as the performance of the health system. Investigating the differences between countries can inform more effective health policy and resource allocation. Concerted efforts at national and regional levels are required to tackle the emerging burden of non-communicable diseases and injuries in Iran and its neighbors.

Trend of Socio-Demographic Index and Mortality Estimates in Iran and its Neighbors, 1990-2015; Findings of the Global Burden of Diseases 2015 Study.

BACKGROUND: The Global burden of disease and injuries study (GBD 2015) reports expected measures for years of life lost (YLL) based on socio-demographic index (SDI) of countries, as well as the observed measures. In this extended GBD 2015 report, we reviewed total and cause-specific deaths and YLL for Iran and all its neighboring countries between 1990 and 2015. METHODS: We extracted data from the GBD 2015 database. Observed YLL measures were calculated by multiplying the number of deaths by standard life expectancy at each age. SDI was a composite index, calculated based on income per capita, average years of schooling, and total fertility rate. The GBD world population was used for age standardization. RESULTS: All-ages crude death rate in Iran reduced from 665.6 per 100,000 population (95% uncertainty interval: 599.3-731.6) in 1990 to 487.2 (414.9-566.1) in 2015. The ratio of observed to expected YLL (O/E ratio) for all-causes ranged between 0.54 (Turkey) and 1.95 (Russia) in 2015. For Iran, the all-causes O/E ratio was less than 1 in all years (1990-2015), except 2003. However, cause-specific O/E ratio was more than 1 for some causes, including the top leading causes of YLL (ischemic heart disease, road injuries, and cerebrovascular disorders). Ischemic heart disease was the first or second cause of YLL in all comparator countries except Afghanistan. CONCLUSION: The leading YLL causes with high O/E ratios should be prioritized in public health efforts. In addition to research evidence, countries with low O/E ratios should be scrutinized to find feasible innovative interventions.

Burden of Skin and Subcutaneous Diseases in Iran and Neighboring Countries: Results from the Global Burden of Disease Study 2015.

BACKGROUND: Iran and its neighboring countries represent four world regions with unique cultures and geography. Skin diseases span a wide diversity of etiologies including infectious, inflammatory, autoimmune, vascular, neurogenic, and oncologic. The Global Burden of Disease Study (GBD) 2015 measures the burden from skin diseases in 195 countries. METHODS: Epidemiologic data were collected from literature review, survey data, and hospital inpatient/outpatient claims data. These raw data entered modeling using a Bayesian meta-regression tool, DisMod MR-2.1, which yielded prevalence estimates by age/sex/location/year. Prevalence estimates were combined with disability weights to yield years lived with disability (YLDs). YLDs are combined with years of life lost (YLLs), from mortality estimates, to yield disability-adjusted life years (DALYs). DALYs were obtained for 16 skin conditions and both sexes in Iran and 15 surrounding countries. The sociodemographic index (SDI) for each country was also correlated with skin disease DALY rate using the Pearson coefficient (r) with two-tailed P-value. RESULTS: There was no significant correlation between individual skin diseases and SDI. Acne and dermatitis caused the greatest burden and BCC the lowest burden of skin diseases in Iran and the other 15 countries. SCC and BCC were responsible for the largest discrepancy by sex, with higher burden in males compared to females. CONCLUSION: Skin diseases, particularly dermatitis and acne, cause considerable burden in Iran and surrounding regions. Objective and transparent epidemiologic data such as GBD has the potential to inform and impact many facets of healthcare, research prioritization, public policy, and international partnerships.