Assessment of eye health programme reach by comparison with rapid assessment of avoidable blindness (RAAB) survey data, Talagang, Pakistan.

BACKGROUND: The purpose of this study was to quantify how much of the burden of visual impairment (VI) and unmet need in Talagang, identified by Rapid Assessment of Avoidable Blindness (RAAB) survey data, has been addressed by Community Eye Health (CEH) programme efforts. METHODS: A RAAB survey was carried out in November 2018, with 2,824 participants in Talagang Tehsil, Punjab, Pakistan, aged 50 and over. Census data were used to extrapolate survey data to the population. Alongside this, a CEH programme was launched, consisting of community eye screening, and onward referral to rural health centres, secondary or tertiary ophthalmological services, as required. This health intervention aimed to address the eye care needs surfaced by the initial survey. From 2018 to 2022, 30,383 people aged 50 or over were screened; 14,054 needed referral to further steps of the treatment pathway and more detailed data collection. Programme data were compared to estimates of population unmet needs. Main outcome measures were prevalence of VI, and proportion of need met by CEH Programme, by cause and level of VI. RESULTS: Among those aged 50 and over, 51.0% had VI in at least one eye. The leading causes were cataract (46.2%) and uncorrected refractive error (URE) (25.0%). In its first four years, the programme reached an estimated 18.3% of the unmet need from cataract, and 21.1% of URE, equally in both men and women. CONCLUSIONS: Robustly collected survey and programme data can improve eye health planning, monitoring and evaluation, address inequities, and quantify the resources required for improving eye health. This study quantifies the time required to reach eye health needs at the community level.

How to create a successful mobile learning strategy for medical education during lockdowns?

BACKGROUND: Mobile learning has played an important role during the COVID-19 pandemic and medical schools now consider it as an effective educational method in current and future crises. In this qualitative study, an attempt was made to demonstrate the principles of designing a mobile learning strategy in medical education from the perspective of experts. MATERIALS AND METHODS: The study was conducted by the qualitative content analysis method. The data were collected from July 2022 to Feb 2023. Twelve participants were included in this study from Iran's medical universities, consisting of two members of the Higher Council of Virtual Education, three educational directors, three clinical faculty members, two faculty members specializing in e-learning and medical education, an educational vice, and a dean. Data were collected using semi-structured interviews and analyzed by Granheim and Lundman's (2004) method. RESULTS: Out of twelve participants in the study, eight (66%) were males and four (44%) females. Data were classified into eight categories and one theme. Based on the participants' experiences, the main theme, that is, "the principles of medical education design in mobile learning," included pedagogical component, interactive design, effective and comprehensive analysis, achieving objectives with the mobile learning platform, generating micro- and interactive e-content, teaching-learning interactive methods, course implementation and interactive evaluation at both micro- and macro-levels. CONCLUSION: Data analysis revealed that in addition to the eight principles in the medical education design in mobile learning, the participants prioritized the two principles of pedagogical component and interactive design over other principles in educational design. Using a successful mobile learning strategy in situations of restrictions limiting physical presence may improve the quality of medical education.

Near vision data and near correction requirements from community eye health programmes in nine countries.

BACKGROUND: Recent estimates of global prevalence of uncorrected presbyopia range from 510 to 826 million. There is a shortage of primary data regarding Near Visual Impairment (NVI) magnitude. METHODS: Near visual acuity (NVA) and NVI data was collected from over 388,000 people aged 35 or over across 9 countries, within Community Eye Health programmes between January 2022 and June 2023. In Kenya (n = 34,328), dioptric power of required near correction was also recorded, and any association with age, gender or level of NVA was assessed via linear regression model. RESULTS: 146,801 of 388,939 people failed initial near vision screening (37.74%, 95% CI 37.59-37.89%), with significantly higher prevalence of NVI in Sub-Saharan Africa than South Asia. Of those with distance acuity 6/12 or better, 27.97% failed (95% CI 27.81-28.13%) with evidence of difference between genders (p < 0.001): 30.77% of women vs. 24.47% of men. The most commonly required dioptric powers of correction were +2.00D, +2.50D and +3.00D, and required power correlated with age and NVA. CONCLUSIONS: NVI remains common among Community Eye Health programme participants aged 35 and over. Data from large scale programmes such as these provide an opportunity to contribute to more accurate epidemiological estimates, and to guide future research, resource planning and intervention, ideally with improved standardisation of testing in the future.

Prevalence of refractive errors in population aged 50 years and over: The Gilan eye study.

PURPOSE: To describe the prevalence of refractive error (RE) and its association with other environmental and health factors among population aged ≥50 years who lived in Gilan, Iran in 2014. METHODS: In this population-based cross-sectional study, 3281 individuals aged ≥50 years living in Gilan for at least 6 months were enrolled. The prevalence of different types of REs including myopia (spherical equivalent (SE)≤-0.50D), high myopia (SE ≤ -6.00D), hyperopia (SE≥ + 0.50D), high hyperopia (SE≥ + 3.00D), astigmatism (cylinder < -0.50D) and high astigmatism (cylinder < -2.25D) were determined. Anisometropia was defined as the SE difference of ≥1.00D between the two eyes. Associated factors including age, body mass index (BMI) and education were also studied. RESULTS: 2587 eligible individuals (58% female subjects) with the mean age of 62.6 ± 8.8 years participated (87.6% response rate). The prevalence of myopia, hyperopia and astigmatism was 19.2%, 48.6% and 57.4%, respectively. 3.6% high hyperopia, 0.5% high myopia and 4.5% high astigmatism were identified. The positive simultaneous effects3 of older age (Odds Ratio (OR) = 3.14), nuclear (OR = 1.71) and posterior subcapsular (OR = 1.61) cataracts as well as the negative effects of higher levels of education (OR = 0.28) were obtained on myopia. Higher BMI was found as a risk factor for hyperopia (OR = 1.67), while older patients were less likely to be hyperopic (OR = 0.31). CONCLUSION: Higher incidence of myopia and astigmatism was found in patients aged over 70 years. It was also found that patients at older ages who suffered with cataracts were at a higher risk of myopia, while elderly people with greater BMI were at a higher risk of hyperopia.

Prevalence of cataract and its contributing factors in Iranian elderly population: the Gilan eye study.

PURPOSE: To report the prevalence and the associated factors leading to cataract among the Iranian population living in Gilan Province, Iran. METHODS: This population-based cross-sectional study was performed from June to November 2014 on 2,975 residents aged ≥ 50 years old living in urban and rural regions of the Gilan Province in Iran. A representative sample of residents in the province was recruited into the study through door-to-door visiting, and baseline data were collected by questionnaire. All participants were referred to the medical center for comprehensive ophthalmic examination, laboratory tests, and blood pressure measurement. RESULTS: Among the population, 2,588 (86.99%) subjects were eligible to be included in this study, categorized either into the cataract or the non-cataract group. The mean age of participants was 62.59 ± 8.92 years, and 57.5% were female. Higher prevalence of cataract was found in individuals of older ages (odds ratio (OR) = 1.13; 95% confidence interval (CI) = 1.10 to 1.16; P < 0.001) and a history of previous ocular surgery (OR = 5.78; 95% CI = 2.28 to 14.63; P < 0.001). At the same time, a lower prevalence of cataract was seen in patients exposed to sunlight for more than 4 h per day (OR = 0.49; 95% CI = 0.32 to 0.73; P = 0.001). CONCLUSION: Cataract affects 50.50% of the study population, especially those over 80. The mildest form of cataract, grade zero, is the most common. Surgery for cataract has good outcomes. The risk of cataract is higher for those older or who have had eye surgeries. People not affected by cataract tend to be exposed to more sunlight.

Development and Validation of a Digital (Peek) Near Visual Acuity Test for Clinical Practice, Community-Based Survey, and Research.

Purpose: Unaddressed near vision impairment (NVI) affects more than 500 million people. Testing near vision is necessary to identify those in need of services. To make such testing readily accessible, we have developed and validated a new smartphone-based near visual acuity (NVA) test: Peek Near Vision (PeekNV). Methods: Two forms of the PeekNV test were developed: (1) quantitative measurement of NVA, and (2) binary screening test for presence or absence of NVI. The validity study was carried out with 483 participants in Sagarmatha Choudhary Eye Hospital, Lahan, Nepal, using a conventional Tumbling "E" Near Point Vision Chart as the reference standard. Bland-Altman limits of agreement (LoA) were used to evaluate test agreement and test-retest repeatability. NVI screening was assessed using Cohen's kappa coefficient, sensitivity, and specificity. Results: The mean difference between PeekNV and chart NVA results was 0.008 logMAR units (95% confidence interval [CI], -0.005 to 0.021) in right eye data, and the 95% LoA between PeekNV and chart testing were within 0.235 and -0.218 logMAR. As a NVI screening tool, the overall agreement between tests was 92.9% (κ = 0.85). The positive predictive value of PeekNV was 93.2% (95% CI, 89.6% to 96.9%), and the negative predictive value 92.7% (95% CI, 88.9% to 96.4%). PeekNV had a faster NVI screening time (11.6 seconds; 95% CI, 10.5 to 12.6) than the chart (14.9 seconds; 95% CI, 13.5 to 16.2; P < 0.001). Conclusions: The PeekNV smartphone-based test produces rapid NVA test results, comparable to those of an accepted NV test. Translational Relevance: PeekNV is a validated, reliable option for NV testing for use with smartphones or digital devices.

Improving equity, efficiency and adherence to referral in Pakistan's eye health programmes: Pre- and post-pandemic onset.

Background: Over one billion people worldwide live with avoidable blindness or vision impairment. Eye Health Programmes tackle this by providing screening, primary eye care, refractive correction, and referral to hospital eye services. One point where patients can be lost in the treatment journey is adherence to hospital referral. Context: Peek Vision's software solutions have been used in Pakistan with the goal of increasing eye health programme coverage and effectiveness. This involved collaboration between health system stakeholders, international partners, local community leaders, social organizers and "Lady Health Workers". Results: From the beginning of the programmes in November 2018, to the end of December 2021, 393,759 people have been screened, 26% of whom (n = 101,236) needed refractive services or secondary eye care, and so were referred onwards to the triage centers or hospital services. Except for a short period affected heavily by COVID-19 pandemic, the programmes reached an increasing number of people over time: screening coverage improved from 774 people per month to over 28,300 people per month. Gathering and discussing data regularly with stakeholders and implementers has enabled continuous improvement to service delivery. The quality of screening and adherence to hospital visits, gender balance differences and waiting time to hospital visits were also improved. Overall attendance to hospital appointments improved in 2020 compared to 2019 from 45% (95% CI: 42-48%) to 78% (95% CI: 76-80%) in women, and from 48% (95% CI: 45-52%) to 70% (95% CI: 68-73%) in men. These patients also accessed treatment more quickly: 30-day hospital referral adherence improved from 12% in 2019 to 66% in 2020. This approach helped to utilize refractive services more efficiently, reducing false positive referrals to triage from 10.6 to 5.9%. Hospital-based services were also utilized more efficiently, as primary eye care services and refractive services were mainly delivered at the primary healthcare level. Discussion: Despite various challenges, we demonstrate how data-driven decisions can lead to health programme systems changes, including patient counseling and appointment reminders, which can effectively improve adherence to referral, allowing programmes to better meet their community's needs.

Introducing a mobile learning model in medical education during COVID-19; a critical review.

Introduction: Mobile learning is one of the innovative teaching techniques that help medical students gain knowledge and skills. One of the factors that expanded the use of this strategy was the COVID-19 pandemic. However, the educational pedagogy of such technology has been neglected. This article aimed to critically review available mobile learning models in medical education to suggest a comprehensive model in the field of mobile learning. Methods: We conducted this critical review based on the five steps of the Carnwell and Daly method. For a comprehensive systematic search from 2000 to April 2021, the following keywords were used: Personal Digital Assistant, m learning, Mobile learning, Ubiquitous learning, U learning, medical students, and medical education. 3176 studies in PubMed, Scopus, ERIC, Magiran, and Web of Science were identified. In total, 8 articles entered the study. Results: Eight models of mobile learning in medical education were identified. The key features of each model were extracted and integrated into the new model for the successful design and implementation of mobile learning. This model includes three main elements of mobile learning: 1-stakeholders, 2-interaction, and 3-technology, which are influenced by external factors including Mobiquette, legitimacy, and awareness. Conclusion: The results of this study are an important contribution to the knowledge collection in mobile learning in medical education. We introduced a comprehensive model of mobile learning including specific characteristics of strategies in the context of medical education.

Distance learning strategies in medical education during COVID-19: A systematic review.

The current outbreak of coronavirus disease 2019 (COVID-19) across the world forced universities to suspend learning to limit the spread of the virus. Many medical schools have shifted to online education as an information delivery mechanism where the educator and learner are separated in space and potentially also in time. This systematic review aims to explore and understand the variety of distance learning strategies in medical students in the contexts of COVID-19. A systematic review was conducted in Web of Sciences, PubMed, Educational Resources and Information Center, and Scopus from December 2019 to July 2020. Eight sets of terminology were used, combining "Distance learning" AND "Medical education" AND "Pandemic." Studies were reviewed independently by two reviewers. Data were extracted and quality appraised using QualSyst tools, and synthesized by performing thematic analysis. A total of 473 articles were identified after removing duplicates and 314 records were screened, of which 125 were included in this study. The primary articles were 52 primarily qualitative articles. Five learning strategies consisted of technology-enhanced learning (TEL), simulation-based learning, technology-based clinical education, mobile learning, and blended learning. Tools, methods, and learning resources associated with these five learning strategies were extracted from the articles. Our review highlights that TEL and simulation-based learning were more commonly used than others in distance learning in medical education during the COVID-19 pandemic. These strategies have the potential to improve learners' level of knowledge and performance through making online learning resources such as Massive Open Online Courses, virtual clinical cases, and blended sources accessible.

Eye Care Utilization in A Community-oriented Mobile Screening Programme for Improving Eye Health in Iran: A Cluster Randomized Trial.

PURPOSE: To evaluate the effect of a mobile-based screening programme on eye care utilization in Iran. METHOD: In this cluster randomized community trial, a representative sample of residents aged≥50 years from urban and rural areas in four districts in Tehran province were enrolled. The clusters were randomly assigned to one of the three parallel arms; the mHealth arm with digital data collection, vision screening test and retina evaluation using an integrated mobile application, the conventional arm with manual data collection and screening tests using Snellen chart and Fundus photography at the local primary healthcare facility, and the control arm with manual data collection without screening tests. The main outcome measure was eye care utilization which was defined as at least one visit to an optometrist or ophthalmologist. RESULTS: Of 3312 eligible individuals, 2520 (76.1%) participated. In the first 3 months after the screening programme, eye care utilization was higher among those who were referred by the mHealth method (35.6% 95%CI: 31.1-40.4%) compared to those referred by the conventional method (32.7%, 95%CI: 27.5-38.2%) and to those observed in the control arm (4.5%, 95%CI: 3.2-6.0). Eye care utilization improved (OR = 1.5, 95%CI: 1.2-1.9) among the referred people after the screening programme compared to the utilization before this programme; however, this improvement was significantly higher in the mHealth method (OR: 1.7, 95%CI: 1.2-2.4) compared to the conventional method (OR: 1.2, 95%CI: 0.8-1.8). CONCLUSION AND RELEVANCE: The mobile-based screening programme can significantly improve eye care utilization at the community level.

Hypertension and associated factors in the Islamic Republic of Iran: a population-based study.

BACKGROUND: Hypertension is a major risk factor for cardiovascular diseases and has a high prevalence in the Eastern Mediterranean Region. AIMS: To estimate the prevalence and awareness of hypertension and its associated factors in a central province of the Islamic Republic of Iran. METHODS: This cross-sectional study was conducted among 2320 adults aged 40-80 years in Yazd, Islamic Republic of Iran, in 2010-2011. Multivariable logistic regression analysis was performed to calculate the odds ratios (ORs) for exploring the association between hypertension and associated risk factors. Of eligible subjects, 2098 participated in clinical examinations (response rate: 90.4%). RESULTS: The sex- and age-standardized prevalence of hypertension was 52.8% [95% confidence interval (CI): 49.6-56.1%]. Of 1170 participants with hypertension, 421 were diagnosed for the first time in this survey; therefore, the unawareness proportion was 36.0% (95% CI: 33.2-38.8%). Among known cases (749 of 1170), 68.5% (95% CI: 65.0-71.8%) had uncontrolled blood pressure. Age (OR 70-80 vs. 40-50 years=7.01, 95% CI: 4.01-12.24), obesity (OR=2.78, 95% CI: 2.06-3.75), diabetes (OR=1.46, 95% CI: 1.12-1.89), hyperlipidaemia (OR=1.60, 95% CI: 1.26-2.03) and living in a rural area (OR=1.57, 95% CI: 1.0- 2.45) were significantly associated with hypertension. CONCLUSIONS: Although age is an inevitable risk factor for hypertension, the high unawareness proportion, uncontrolled hypertension and modifiable risk factors such as obesity, hyperlipidaemia and diabetes demand effective preventive and curative strategies.

A Population-based Study on the Prevalence and Associated Factors of Age-related Macular Degeneration in Northern Iran the Gilan Eye Study.

Purpose: To estimate the prevalence and associated factors of AMD in an Iranian population in 2014.Methods: In this population-based cross-sectional study, a total of 2975 Iranian residents (age: ≥50 years) from the urban and rural areas of Gilan province were included. The prevalence of different grades of AMD was determined using the International Age-Related Maculopathy Epidemiological Study Group grading system.Results: Of 2975 eligible individuals, 2587 (87.0%) subjects participated and 2275 (76.5%) subjects (62.6 ± 8.8 years old) had gradable fundus photographs. Age- and sex-standardized prevalence of early and late AMD based on the 2016 Iran census were 13.2% (95% confidence interval [CI], 10.6-16.2) and 0.7% (95% CI, 0.4-1.3), respectively. In multivariate analysis, each decade increase in age was associated with the adjusted odds of any (adjusted odds ratio [AOR] = 1.31, 95% CI, 1.09-1.56; P = .0031), early (AOR = 1.27, 95% CI, 1.06-1.53; P = .012) and late AMD (AOR = 2.39, 95% CI, 1.08-5.28; P = .031). Hyperopia was identified to be less frequent in late AMD (AOR = 0.20, 95% CI, 0.04-0.80; P = .024). No significant association was found between AMD and sex, smoking, outdoor working, diabetes, hypertension, pseudophakia, hyperlipidemia and myopia.Conclusion: Gilan Eye Study demonstrated the first estimate of age-specific AMD prevalence in Iran being compatible with other WHO regions. With the expected increase in the life expectancy and aging of Iranians, the number of people affected by AMD will be increasing in future. Healthcare policy makers should be advised to provide more efficient eye care services and preventive strategies in this regard.

Rapid Assessment of Avoidable Blindness in Kurdistan, Iran.

PURPOSE: To determine the magnitude and causes of blindness and visual impairment (VI) in Kurdistan, using the Rapid Assessment of Avoidable Blindness methodology. METHODS: In this population-based cross sectional study, 99 clusters were selected through probability proportional to size sampling. Visual acuity (VA) was measured using a standard tumbling "E" chart. Ophthalmologists examined participants with VA < 6/18 in both eyes. The cause of VI in the better eye or the most treatable cause was considered as the primary cause of VI. RESULTS: A total of 3203 (response rate: 92.4%) individuals aged 50 years and older participated, of whom 1657 (51.7%) were female. The standardized prevalence of blindness, severe visual impairment (SVI), and moderate visual impairment (MVI) based on available correction (presenting VA) were 2.1% (1.5-2.6), 1.7% (1.2-2.2), and 9.6%(8.4-10.8), respectively. The proportion of avoidable causes of blindness, SVI, and MVI were 58.1%, 78.4%, and 83.4%, respectively. The most common cause of blindness and SVI was cataract (27.4% and 60.8% respectively), followed by age-related macular degeneration (25.8% and 13.7%, respectively). The leading causes of MVI were uncorrected refractive errors (RE) (37.2%) and cataract (33.6%). CONCLUSION: The prevalence of blindness in the study population seems comparable to the region. According to our results, blindness, SVI, and MVI were mostly due to avoidable causes. Cataract and refractive errors are the principal causes of blindness and VI in Kurdistan.

Modeling a Telemedicine Screening Program for Diabetic Retinopathy in Iran and Implementing a Pilot Project in Tehran Suburb.

PURPOSE: To model a community-based telescreening program for diabetic retinopathy (DR) in Iran and to implement a pilot project at the Iranian Diabetes Society (IDS) branch in a Tehran suburb. METHODS: In this mixed model study, a web application called the "Iranian Retinopathy Teleophthalmology Screening (IRTOS)" was launched. The educational course for DR screening was established for general practitioners (GPs). Registered patients in IDS branch were recalled for fundus photography; images were transferred to the reading center via IRTOS to be graded by GPs, and patients were informed about the results via mobile messaging. All images were independently reviewed by a retina specialist as the gold standard. Patients who required further assessment were referred to an eye hospital. RESULTS: Overall, 604 subjects with diabetes were screened; of these, 50% required referral. The sensitivity and specificity for diagnosis of any stage of DR by trained GPs were 82.8% and 86.2%, respectively, in comparison to the gold standard. The corresponding values for detecting any stage of diabetic macular edema (DME) were 63.5% and 96.6%, respectively. CONCLUSIONS: Telescreening was an effective method for detecting DR in a Tehran suburb. This screening model demonstrated its capacity for promoting diabetic eye care services at the national level. However, the sensitivity for detecting DME needs to be improved by modifying the referral pathway and promoting the skill of GPs.

Designing a Screening Program for Prevention of Avoidable Blindness in Iran through a Participatory Action Approach.

PURPOSE: To design a screening program for prevention of blindness at the community level in Iran. METHODS: In this qualitative study, the components and properties of the screening program were identified using a participatory action research method with focus group meetings (FGMs) with relevant health care providers and authorities. A content analysis approach was used for data analysis. RESULTS: In total, 18 stakeholders including six ophthalmologists with different sub-specialties participated in the five FGMs. The screening program aims to discover vision-threatening eye conditions in people aged 50 years and over. Primary health care workers deliver the program including vision tests and fundus imaging with the support of an ophthalmic technician. Retina specialists perform decision-making. Referral plans are interacted through an automated digital program. The screening environment, feedback, ethics and medical legal issues are other main components of the program. CONCLUSION: This study presents the initial concepts and components of a screening program for prevention of blindness in the adult population in Iran. The program has the potential to improve eye health at the community level and may potentially be replicated as a model for similar settings elsewhere.

Awareness of the Necessity of Regular Eye Examinations among Diabetics: The Yazd Eye Study.

BACKGROUND: Diabetic retinopathy and its consequence, diabetic macular edema, are leading causes of vision loss in diabetics and can develop even in the first years after onset of diabetes. Being asymptomatic in primary phase and having compensatory effect of bilateral vision delay the necessity of eye care utilization. We conducted this study to determine diabetic individuals' level of awareness about the importance of regular eye examinations. METHODS: As part of the cross-sectional, population-based, Yazd Eye Study on people aged 40-80 years, diabetic participants were identified for enrollment in this research. Participants underwent thorough ophthalmic examinations as well as detailed interview. Well-trained interviewers asked participants about their awareness of screening eye examinations and their necessity. Fasting blood sugar, glycated hemoglobin, and complete lipid profile were assessed. All descriptive and analytic tests were done in survey mode. Logistic regression was applied to assess related risk factors. RESULTS: Among 497 diabetic persons out of 2098 participants, 364 respondents (73.4%; 95% confidence interval: 68.6-78.2) were not aware of the necessity of regular eye examinations. Among 133 aware respondents, 21 (16%) respondents had no eye examination over the past year. Educational level significantly correlated with awareness (P = 0.004), and physicians were the most frequent source of awareness (79.7%). CONCLUSIONS: This study showed that a significant proportion of Yazd diabetic population (about 73%) needs to be informed about the necessity of regular eye examinations. The remaining respondents, who had this information, mainly had undergone regular ophthalmologist visits, which imply that educational interventions could improve the situation.

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.

A Stakeholder Perspective on Diabetes Mellitus and Diabetic Retinopathy Care in Iran; A Qualitative Study.

OBJECTIVE: To assess the national health system for management of diabetes mellitus (DM) in Iran, with particular focus on diabetic retinopathy (DR). MATERIALS AND METHODS: In this qualitative study, the national stakeholders related to DR and DM management system were invited to participate. Two researchers performed interview using a semi-structured questionnaire recommended by the World Health Organization titled "Tool for Assessment of Diabetic Retinopathy and DM Management Systems". The questionnaire contains seven different sections, each consisting of closed and open-ended questions, and a final Likert-type score, ranging from 1 indicating the worst to 4 indicating the best status. Inconsistencies were resolved through a collective decision of the research team, followed by a focus group discussion with stakeholders at the Ministry of Health. RESULTS: Fourteen stakeholders out of 15 total invitees were interviewed (response rate: 93.3%). There were national priorities, defined policies, and running programs (score = 3), but the care system should be strengthened in terms of implementation of clinical guidelines, with specific reference to the availability of regular screenings for DR (score = 2). The network of care providers, health information systems, and promotional programs were insufficient (score = 2). The health workforce and technology for DR and DM were acceptable (scores 4 and 3, respectively); however, there were concerns about the appropriate distribution and utilization of resources and out-of-pocket costs paid by patients. CONCLUSION: The existence of national policies, programs, a qualified workforce, and modern technology is promising. Nevertheless, other aspects of the health system need to be improved to ensure access to health and eye care for people with DM and achieve universal health coverage.