Predicting the natural history of metabolic syndrome with a Markov-system dynamic model: a novel approach.

BACKGROUND: Markov system dynamic (MSD) model has rarely been used in medical studies. The aim of this study was to evaluate the performance of MSD model in prediction of metabolic syndrome (MetS) natural history. METHODS: Data gathered by Tehran Lipid & Glucose Study (TLGS) over a 16-year period from a cohort of 12,882 people was used to conduct the analyses. First, transition probabilities (TPs) between 12 components of MetS by Markov as well as control and failure rates of relevant interventions were calculated. Then, the risk of developing each component by 2036 was predicted once by a Markov model and then by a MSD model. Finally, the two models were validated and compared to assess their performance and advantages by using mean differences, mean SE of matrices, fit of the graphs, and Kolmogorov-Smirnov two-sample test as well as R2 index as model fitting index. RESULTS: Both Markov and MSD models were shown to be adequate for prediction of MetS trends. But the MSD model predictions were closer to the real trends when comparing the output graphs. The MSD model was also, comparatively speaking, more successful in the assessment of mean differences (less overestimation) and SE of the general matrix. Moreover, the Kolmogorov-Smirnov two-sample showed that the MSD model produced equal distributions of real and predicted samples (p = 0.808 for MSD model and p = 0.023 for Markov model). Finally, R2 for the MSD model was higher than Markov model (73% for the Markov model and 85% for the MSD model). CONCLUSION: The MSD model showed a more realistic natural history than the Markov model which highlights the importance of paying attention to this method in therapeutic and preventive procedures.

Social prescribing for people with mental health needs living in disadvantaged communities: the Life Rooms model.

BACKGROUND: People live socially complex lives and have different health care needs influenced by socio-economic factors such as deprivation, unemployment, and poor housing. Lack of access to community based social care results in people seeking social support from health care services. This study explores the Life Rooms as a social prescribing model addressing the social determinants of mental health by providing support and access to resources in a local community setting. With an aim to identify key elements that contribute toward enhancing the effectiveness of the Life Rooms social prescribing approach. METHODS: Data were obtained through six semi-structured focus groups with mental health service users from two locations in the North West of the UK. Postcode data was collected to generate an Index for Multiple Deprivation (IMD) score, to understand their socio-economic background. Data were analysed using thematic analysis. RESULTS: A total of 18 participants took part in the study. The majority of participants came from disadvantaged backgrounds; 14 participants measuring 3 and below in terms of overall IMD scores and 9 participants belonged to the poorest decile (IMD score = 1). Participants reported on different elements of the Life Rooms which they found as an effective approach to care. Four main themes emerged from the data: 1) social belonging: being able to just 'be' 2) resourceful and accessible; 3) social inclusion and connectedness; and 4) moving forward: self-development and independence. CONCLUSION: Findings support the need and benefit social prescribing to improve mental health wellbeing and reduce the burden of mental illness.

Differential achievements in childhood immunization across geographical regions of Pakistan: analysis of wealth-related inequality.

BACKGROUND: Childhood immunization is one of the most cost-effective interventions for child health. Still, many children are not able to receive completed immunization status. Wealth - related inequality in immunization is considered a major reason for equitable coverage of immunization in Pakistan. Therefore, we examine wealth-related inequality in completed childhood immunization and to assess achievement indices across geographical regions in Pakistan. METHODS: The analysis was based on a nationally representative demographic and health survey (DHS) of Pakistan, conducted in 2012-13. We examined completed childhood (12-23 months) immunization in the various regions of the country and we used concentration, extended concentration and achievement indices to demonstrate inequality across geographical regions in Pakistan. RESULTS: Inequality in completed childhood immunization was seen in Pakistan with concentration index (CI) of 0.181 (95% CI: 0.164-0.209). Regions with high average of complete immunization showed lower inequality except for Sindh. Despite having better average immunization coverage in Kyber Pakhtunkhwa, the relative change of 128% in concentration index (CI) from C2 (standard CI) to C5 (when poorer quantile received highest weights) shows this to be also the most inequitable regions. Four parameters of inequality aversion (v = 2, 3, 4 & 5) demonstrated that 'dis - achievement' in completed immunization is densely concentrated among the poorer regions. Balochistan, Sindh and Gilgit Baltistan exhibited broader inequality gaps (93.75%, 83.35%, and 54.93%, respectively) at higher aversion parameter. CONCLUSIONS: As hypothesized, achievement index uncovers 'penalized' immunization coverage amongst the poorest population. Thus any policy that stringently focuses on improving average immunization rate without any strategy to deal with inequality will only improve immunization rate within wealthier groups. Based on these results, it is advisable to public health policy makers to use both aspect of information: average and degree of inequality in immunization coverage.

Assessment of women's empowerment: An exploratory study to develop a valid and reliable Persian-version tool.

Lack of a valid and reliable women's empowerment tool was reported by previous studies in Iran. The authors of this paper, accordingly, intended to fill this gap by developing a valid questionnaire. 600 women in Dezful city, southeast of Iran, took part in the study in 2014-2015. Multistage sampling method was used to recruit the participants. Our exploratory factor analysis revealed that 18 items of the model loaded on 4 factors. Internal consistency of the questionnaire was suitable as Cronbach's alpha coefficient was 0.77. Considering high validity and shortness of the questionnaire, it can be used as a trustful and comprehensive tool to measure women's empowerment in future studies.

Understanding determinants of socioeconomic inequality in mental health in Iran's capital, Tehran: a concentration index decomposition approach.

BACKGROUND: Mental health is of special importance regarding socioeconomic inequalities in health. On the one hand, mental health status mediates the relationship between economic inequality and health; on the other hand, mental health as an "end state" is affected by social factors and socioeconomic inequality. In spite of this, in examining socioeconomic inequalities in health, mental health has attracted less attention than physical health. As a first attempt in Iran, the objectives of this paper were to measure socioeconomic inequality in mental health, and then to untangle and quantify the contributions of potential determinants of mental health to the measured socioeconomic inequality. METHODS: In a cross-sectional observational study, mental health data were taken from an Urban Health Equity Assessment and Response Tool (Urban HEART) survey, conducted on 22 300 Tehran households in 2007 and covering people aged 15 and above. Principal component analysis was used to measure the economic status of households. As a measure of socioeconomic inequality, a concentration index of mental health was applied and decomposed into its determinants. RESULTS: The overall concentration index of mental health in Tehran was -0.0673 (95% CI = -0.070 - -0.057). Decomposition of the concentration index revealed that economic status made the largest contribution (44.7%) to socioeconomic inequality in mental health. Educational status (13.4%), age group (13.1%), district of residence (12.5%) and employment status (6.5%) also proved further important contributors to the inequality. CONCLUSIONS: Socioeconomic inequalities exist in mental health status in Iran's capital, Tehran. Since the root of this avoidable inequality is in sectors outside the health system, a holistic mental health policy approach which includes social and economic determinants should be adopted to redress the inequitable distribution of mental health.

The dynamics of metabolic syndrome development from its isolated components among Iranian adults: findings from 17 years of the Tehran lipid and glucose study (TLGS).

BACKGROUND: Evaluating the process of changes in the Metabolic Syndrome (MetS) components over time is one of the ways to study of the MetS natural history. This study aimed to determine the trend of changes in the progression of MetS from its isolated components. METHODS: This longitudinal study was performed on four follow-up periods of the Tehran Lipid and Glucose Study (TLGS) between 1999 and 2015. The research population consisted of 3905 adults over the age of 18 years. MetS was diagnosed based on the Joint Interim Statement (JIS). The considered components were abdominal obesity, hypertension, hyperglycemia, and dyslipidemia. RESULTS: The highest incidence of MetS from its components was related to hypertension in the short term (3.6-year intervals). In the long run, however, the highest increase in the MetS incidence occurred due to abdominal obesity. Overall, the incidence of MetS increased due to obesity and dyslipidemia, but decreased due to the other factors. Nonetheless, the trend of MetS incidence from all components increased in total. The most common components were dyslipidemia with a decreasing trend and obesity with an increasing trend during the study. CONCLUSION: The results indicated that obesity and hypertension components played a more important role in the further development of MetS compared to other components in the Iranian adult population. This necessitates careful and serious attention in preventive and control planning.

The value of involving patients and public in health services research and evaluation: a qualitative study.

BACKGROUND: Public and Patient Involvement, Engagement and Participation research encompasses working with patients/service users (people with a medical condition receiving health service treatment), public members, caregivers and communities (who use services or care for patients). The Partner Priority Programme (PPP) was developed by the National Health Service [NHS] and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care [NIHR CLAHRC] NWC to share information and experience on evaluating new services being offered to patients that were seeking to reduce health inequalities, improve people's health and wellbeing and reduce emergency hospital admissions. This paper seeks to explore an approach developed for involving the public as equal partners within the evaluation and decision-making processes of health and social care services research. The aim of this study was to identify how public advisors were included, the impact of their involvement, and how change occurred within the organisations following their involvement. METHODS: A qualitative approach using focus group discussions was adopted to explore the experiences of two cohorts of participants involved in PPP project teams. Focus groups were held with public advisors (n = 9), interns (n = 9; staff or public who received a funded internship for a PPP project), NHS and Local Authority initiative leads (n = 10), and academic facilitators (n = 14). These were transcribed verbatim and analysed using a thematic approach. RESULTS: Thirty-two public advisors were recruited to support 25 PPP projects across the Collaboration for Leadership in Applied Health Research and CLAHRC North West Coast [NWC] partner organisations. Three inter-related themes were conceptualised: 1)"Where it all started - involving public advisors" identified the varying journeys to recruitment and experiences of becoming a public advisor; 2)"Steps toward active involvement and engagement" related to public advisors becoming core team members; and 3) "Collaborative working to enhance public and patient involvement" relayed how projects identified the benefits of working jointly with the public advisors, particularly for those who had not experienced this style of working before. CONCLUSIONS: The findings indicate that the PPP model is effective for embedding Public and Patient Involvement [PPI] within health services research, and recommends that PPI is integrated at the earliest opportunity within research projects and service evaluations through the use of support-led and facilitative programmes.

The purpose of involving the public and patients in research is to help them have a say in decisions about healthcare and enable patients or other people with relevant experience to contribute to how research is planned, carried out, and shared with a wider audience. The Partner Priority Programme (PPP) was developed by the National Health Service [NHS] and Local Authority partners to share information and experience on evaluating new services being offered to patients that were seeking to reduce health inequalities, improve people's health and wellbeing and reduce emergency hospital admissions. In this paper, we explore an approach we developed for involving public advisors (service users/patients, and caregivers) as equal partners within the evaluation and decision-making processes of health and social care services research. The aim of this study was to identify how public advisors were included, the impact of their involvement, and identify the changes organisations made as a result of public advisor involvement. Most projects had not included public advisors in their teams before and initially did not understand how to involve them. By attending scheduled meetings, they had time to learn how to engage with public advisors (and what methods to use to recruit them to be part of their teams). Participants also learned the benefits of including public advisors within their teams. With the help and support provided as part of the programme, public advisors seemed to grow in confidence and take part in teams as equal partners.

Decomposing Socioeconomic Inequality in Health Literacy in Iran: A Concentration Index Approach.

BACKGROUND: Health literacy is a major factor for health promotion and well-being. In spite of several researches on health literacy, information on the subject of the status of health literacy in Asian countries such as Iran is inadequate. Therefore, this study aimed to assess the inequality of health literacy in an Iranian population and its influencing factors. METHODS: In this cross-sectional study, 736 families were selected by cluster random sampling. A validated questionnaire was used to measure the health literacy of participants. Socioeconomic status (SES) was calculated by asset-based approach, and principal component analysis (PCA) was performed to estimate the families' SES. Concentration index and curve were used to measure SES inequality in health literacy, and after that decomposed into its determinants. The data were analyzed by Stata software. RESULTS: The mean age of the participants was 34.81 years (standard deviation = 5.98 years). The value of concentration index for health literacy equals 0.2292 (95% confidence interval = 0.168-0.283), and this value indicates that there is inequality in distribution of health literacy in Iran and the inequality disfavors the poor. CONCLUSIONS: The results of this study revealed that there is inequality in distribution of health literacy in Iran, and people of higher economic status in Iran enjoy from better health literacy levels.

Reading skills in Persian deaf children with cochlear implants and hearing aids.

OBJECTIVES: Reading skills are necessary for educational development in children. Many studies have shown that children with hearing loss often experience delays in reading. This study aimed to examine reading skills of Persian deaf children with cochlear implant and hearing aid and compare them with normal hearing counterparts. METHOD: The sample consisted of 72 s and third grade Persian-speaking children aged 8-12 years. They were divided into three equal groups including 24 children with cochlear implant (CI), 24 children with hearing aid (HA), and 24 children with normal hearing (NH). Reading performance of participants was evaluated by the "Nama" reading test. "Nama" provides normative data for hearing and deaf children and consists of 10 subtests and the sum of the scores is regarded as reading performance score. RESULTS: Results of ANOVA on reading test showed that NH children had significantly better reading performance than deaf children with CI and HA in both grades (P < 0.001). Post-hoc analysis, using Tukey test, indicated that there was no significant difference between HA and CI groups in terms of non-word reading, word reading, and word comprehension skills (respectively, P = 0.976, P = 0.988, P = 0.998). CONCLUSION: Considering the findings, cochlear implantation is not significantly more effective than hearing aid for improvement of reading abilities. It is clear that even with considerable advances in hearing aid technology, many deaf children continue to find literacy a challenging struggle.

Ethical Considerations of Community-based Participatory Research: Contextual Underpinnings for Developing Countries.

BACKGROUND: The nature of community-based participatory research (CBPR) poses distinctive ethical challenges. In the absence of organized guidelines, a remarkable amount of researchers' time and energy will be spent tackling these ethical challenges. The study aimed to explore ethical issues and principles potentially arising when conducting CBPR. METHODS: This qualitative study conducted in CBPR Center of Tehran University of Medical Sciences. Required data were gathered through systematic literature review and semi-structured interviews. Representatives of community, academia, and nongovernmental organizations (NGOs) participated in our study. Ten interviews with representatives of partner organizations, four group interviews with academic staff, and four with representatives of community were conducted. Repeated thematic analysis was used to elicit ethics-related overarching themes from transcribed interviews. As recommendations, these themes were then organized into a set of CBPR-related ethical issues and principles. RESULTS: Four CBPR ethical guidelines (including 173 articles) were selected from a systematic review. Overarching themes relating to ethical principles which emerged from interviews were as follows: Trust, transparency and accountability, equity and inclusion, power imbalance, tolerance and conflict management, and attention to cultural sensitivity. Practical principles that emerged included: Consensus rather than informed consent, ownership of data and research achievements, and sustainability and maintenance of relationships. According to findings and in comparison to international guidelines, the present study put more emphasis on cultural sensitivity and sustainability as CBPR ethical tangles. CONCLUSIONS: Community-based participatory research ethical challenges are of the same kind in most parts of the world. However, some discrepancies exist that calls for local scrutiny. Future use and critic of current explored ethical issues and principles are highly encouraged.

Revealing mental health status in Iran's capital: putting equity and efficiency together.

Information about urban health is often based on averages, while to better understand health status in urban areas, inequality should also be included. In this paper, we applied an achievement index approach in order to surmount this defect and to examine mental health status in Iran's capital, Tehran. The data we required for this study were taken from the Urban Health Equity Assessment and Response Tool (Urban HEART) survey which was conducted in Tehran in 2007, covering people aged 15 and above. The concentration index, which is a commonly used measure of socioeconomic inequalities in health, was extended to enable the combination of inequality and averages and the formation of a mental health achievement index. Values from the standard concentration indices showed that mental disorders are concentrated disproportionately among the poor in Tehran. An extension of the standard concentration indices revealed that, in most of Tehran's districts, the mental health of populations in the poorest quintile is much worse than that of other groups. In addition, when we computed the achievement index and ranked districts according to this index, the ranking was different from the ranking by averages. These findings imply that mental health varies significantly across the economic groups of the population in Tehran and that efficiency-oriented strategies which target average level of mental health alone are not sufficient to improve mental health of all people especially mental health of the poor. Equity-oriented strategies which target the mental health inequalities should be considered as well.