Iranian Journal of

---

Background & Objectives: Over the last few years, the province of Golestan has ranked second among all Iranian provinces in terms of TB prevalence after Sistan and Balochestan. The present study was done with the aim of evaluating the incidence of TB among different ethnic groups residing in Golestan.
Methods: In a descriptive study, all TB patients including sputum smear-positive and negative, extra-pulmonary, and milliary cases were evaluated from 1999 to 2003. The incidence of all types of TB was compared among different ethnicities in the province.
Results: Forty-seven percent of the 2773 cases registered for Golestan Province in the Communicable Disease Control Center from1999 to 2003 were male. As regards the type of disease, 62.7% of the cases were sputum smear-positive, 16.4% were smear-negative, 20.7% had extra-pulmonary disease, and 0.1% were milliary TB cases. The incidence rate of all types of TB was 36 per 100000 population and the rate did not show any significant changes over the study period. As for the ethnic distribution of the cases, more than 50% of all TB cases were observed among Sistanis and Baluches, who together account for only 20% of all Golestan residents. The incidence in Sistanis was ten times that in Turks and Kurds, six times that in Persians, 4 times the rate in Torkamans, and 2.5 times that in Afghans living in the same region.
Conclusions: The incidence rate of tuberculosis was significantly different among various ethnicities of Golestan province, being highest in Sistanis.

---

Background & Objectives: Children are highly vulnerable to TB and childhood tuberculosis is a sign of TB transmission in community. This study aimed to determine the epidemiologic trend of this disease in Iranian children.
Method: A Trend Study was conducted to evaluate all Iranian patients aged below 14 who had been diagnosed with pulmonary or extrapulmonary TB from 1992 to 2005. Statistical relationships were tested using chi square tests (c²) and the software package SPSS (version 11.5).
Results: Out of the 6168 cases studied, 2528 (40.1%) were boys. Patients were assigned to three groups based on disease type: there were 1812 (29.4%) sputum- positive, 1920 (31.1%) sputum-negative, and 2449(39.7%) extrapulmonary cases.The incidence of sputum-positive TB declined from 0.8 per 100000 in 1992 to 0.2 per 100000 in 2005. A similar declining trend was observed for the overall TB incidence and in the incidence of sputum-negative and extrapulmonary cases. There was significant difference in TB incidence between girls and boys in the 10-14 year age group (P<0.001), but no sex difference was observed in 0-4y and 5-9y age groups.
Discussion: The incidence of sputum-positive TB decreased by 75 percent over the study period. This could be partly due to improvements in health status, better disease knowledge and the effects of Iran's National TB Control Program.
Conclusions: In children aged below 10 years, there was no significant difference in the incidence of tuberculosis between girls and boys. At puberty, the incidence of all types of TB was higher in girls. Based on these findings, further studies are needed to elucidate the gender distribution of childhood tuberculosis in Iran.

---

Background & Objectives: Despite an increased risk of obesity and CHD in people with spinal cord injury (SCI), there is little known about the dietary intake in this group, therefore the aim of this study was to examine nutrient intake and body mass index (BMI) in the spinal cord injury (SCI) population according to level of injury and related variables.
Methods: In this cross-sectional study, 162 patients with spinal cord injury participated from Brain and Spinal Injury Repair research Center, Tehran, Iran. Dietary intakes were assessed by means of a semi quantitative food frequency questionnaire.
Results: The mean age of study population was 34.1±0.6 years. Total energy and carbohydrate intake were higher in men than women (P<0.001). Incomplete injured consumed more MUFA (P=0.03). The elderly were consumed less total calorie, saturated fat, MUFA, cholesterol (P<0.01) and PUFA (P<0.05). Injured patients with longer times had lower total calorie, carbohydrate (P<0.01), total fat and MUFA intake (P<0.05). Based on new classification 60.5% were at the risk of obesity or obese. Central obesity was seen in 33.1%of man and 48.4% of women. BMI of the paraplegia group was greater than that of the tetraplegia group (P= 0.009).
Conclusion: Macronutrients balance is moved towards higher saturated fat intake and less complex carbohydrates and protein intake in SCI patient’s .The elderly and patients who had lived with SCI longer time tended to maintain healthier diets.

---

Background & Objectives: Non-Communicable disease (NCD) is a main group of diseases which are responsible for a large proportion of the Global Burden of Disease around the world. Although disparities in the NCDs' risk factors can affect the goals of health for all, less attention has been paid so far on this topic. In this study, we investigated socio-economic inequality in the NCDs’ risk factors and evaluated the causes affecting on this inequality in Shahroud, Iran.
Methods: Conducting this survey, we used surveillance data for NCD of 1000 individuals who lived in Shahroud district during 2005. We determine a socio-economic variable which explained social and economic status of the people using Principal Component Analysis. We then evaluated each NCD risk factors at different levels of the socio-economic variable and calculated concentration index for the risk factors. The causes of the inequality were described by decomposition analysis of the concentration indices.
Results: Concentration indices for hypertension, smoking, insufficient physical activity, and unhealthy diet were -0.141, -0.191, -0.046 and -0.091, respectively. Differences of concentration curves of the risk factors from the line of equality were significant but not for diabetes, obesity and high blood cholestrol. Age, being a government employee, being unmarried, living in rural area and low economic status were the most important factors which influence on these inequalities.
Conclusion: Inequality in some NCD risk factors was significant in Shahroud district. More investigations with larger sample size and more appropriate variables to measure socioeconomic status are recommended.

---

Background & Objectives: The economic costs of cancer care are a burden to people diagnosed with cancer, their families, and society as a whole. Despite several studies about cancer in Iran, there is paucity of cost analysis in this area. The aim of this study was to estimate the cost of cancer subgroups in Kerman, Iran.
Methods: A retrospective analysis of administrative 223 diagnosed patients with different cancers was undertaken.
Results: Monthly average cost of cancer was 3.32 thousand US dollars (average exchange rate in 2010: 10308 Iranian rials= 1 US dollar). Breast cancer, with an average 4.30 thousand US dollars per month was the most expensive and cancer of male reproductive organs with average2.16 thousand US dollars were the cheapest cancer.
The hidden monthly cost of all types of cancer was 2 thousand US dollars, breast cancer, lung, blood and female reproductive organs were costly and brain and peripheral nerves cancer, gastrointestinal tract and prostate were medium and male reproductive organs cancer was less costly.
Conclusion: Economically impact and burden of cancer should be an important consideration in the health policy making in Iranian health service system.

Normal 0

---

Background & Objectives: Urinary calculi are a common problem worldwide. The pattern of fluid consumption in healthy people and patients with renal calculi is not totally clear. The aim of this study was to determine the association between the amount of fluids intake and urinary calculi.

Methods: In this case-control study, cases were the patients with urinary calculi admitted to Emam-Hossein Hospital, Shahroud, Iran. The controls were selected among the patients admitted to other wards of the hospital except for dialysis and ICU wards. The association between independent variables and urinary calculi was investigated using logistic regression analysis.

Results: A total of 127 people (60 cases and 67 controls) participated in this study. The mean age of the participants was 44.6 years (SD = 1.7). The mean intake of tea, natural juice, alcohol free beer, and total fluid intake were higher in cases compare to controls. In participants with a negative history of urinary calculi, the total intake of fluid (P=0.021) and natural juice (P=0.006) was higher in cases. The male gender (OR=3.2), higher BMI (OR=1.2), and a positive family history of urinary calculi (OR=3.5) were associated with renal calculi in a multivariate logistic regression model, while the milk intake (OR=0.995) was a protective factor in this model.

Conclusion: Milk intake is a protective factor and the male gender, higher BMI and a positive family history are the risk factors for urinary calculi.

---

Background and Objectives: Universities of medical sciences play a vital role in promoting population health and without a doubt, their performance should be measured and evaluated.

Methods: The study was a mixed method study (consecutive combination) and the universities were examined by census. In the qualitative phase of the study, by examining the documents and focused group discussions, the basic framework of the performance evaluation model and its associated challenges were elicited. Then, the policies, objectives, and strategies related to each dimension were extracted and finally, key indicators were selected. Finally, by running Analytic Hierarchy Process method, the weight of dimensions and their key aspects were calculated and the model was implemented.

Results: BSC was designed in accordance with the universities. In this model, four main aspects including population health, services, finance, and development were identified. Then, by reviewing the documents, key policies and strategies, key policies and criteria, primary and secondary strategies were extracted. 13 key indicators were chosen as the final indexes. Moreover, 3 main challenges and 11 secondary challenges were identified. The results of the AHP-BSC model indicated that categorizing (ranking) universities had an impact on their functional status.

Conclusion: The main challenge for evaluating the performance of universities was the presence of a logical connection between policies, strategies, and criteria to have comprehensive and concise indexes for evaluation and ranking.

---

Background and Objectives: Timely access to required health services without any financial hardship is necessary to achieve public health. Therefore, the aim of present study was to review the policies and plans adopted in the health financing system.

Methods: The qualitative study with a policy research approach reviewed upstream laws, policies, and plans in Iranian health financing. Then, by holding seven focused group discussions with 28 participants who represented various stakeholders, financing policies and programs were identified. Using framework analysis, the data were coded and categorized.

Results: In response to health financial protection indexes improvement, policies and plans in this field were defined in 10 themes and 4 categories: resources collection, resources management and pooling, resources allocation, and strategic purchasing of health services. The most important policies and plans were integration of insurance funds, increasing sustainable financial resources and targeted allocation of subsidies, services priority setting, establishment and improvement of a performance-based payment system with emphasis on integration of the professional element in the public and private sectors.

Conclusion: There is no gap for documented laws and policies in the Iranian health financing system. The main barriers are the method of implementation and adequate commitment to laws that have created major difficulties in relation to financial protection. Resolving these barrierrs requires sufficient political support and a common understanding between stakeholders at different levels of policymaking and implementation and designing programs based on the infrastructures.

---

Good governance promotion in the health sector needs effective policies and evidence-based decision making. Using efficient and effective information is an important issue so that planners will not be confused amid many figures and numbers and also the main problem will not be marginalized. Hence, having a common language and consensus between policy makers and decision makers about the cycle (collecting and processing information, analysis, and judgment) and decision-making tools (criterion, indicator, index, and variable) is an initial and crucial step in evidence-based decision making. The main challenge for creating such an information system is the lack of a common language among scientific and executive experts; so the aim of this study was to provide a perspective of the concept of decision-making and the main components of its cycle and tools and to review these concepts in health care financing system.

---

Governance and leadership are seen as the most important function in the realization and promotion of community health. This two components through legislation must identify present situation, determine the desirable situation, provide infrastructures and implementation mechanisms and in accordance with stated policies and planning, they should apply necessary monitoring and control. In this regard, the most important challenge is a comprehensive and evidence-based identification and analysis, which can consider all functions in relation to the objectives at a general and coherent glance and assess the functions of the health system.

---

Background and Objectives: Promoting health indicators is a key issue in most societies. In this regard, health deputies, through stewardship, monitoring, and coordination, take meassures to promote these indicators. The aim of the present study was to design a model for ranking the performance of the deputies.
 
Methods: This applied qualitative study was conducted in 2012. The research team included 12 health experts who were selected according to management records and long experience in the health deputy. In this study, a review of the literature and documents was done and then, with the focus group discussions and expert opinions, key indicators were defined.
 
Results: a model consisting of 9 process criteria (13 general indicators and 15 specific indicators) was identified for ranking of health deputies. The general processes included leadership and management, programs and strategies, resources and partnerships, manpower, and comprehensive information and statistics system And specific processes included primary health care (PHC), family physician (FP), social determinants of health (SDH) and pilot national plans. The range of indicators scores was between 1-8, which were compared with the zero indicator.
 
Conclusion: The findings showed that the process components and indicators were more effective in determining the status of the health deputies’ performance, and the proposed model is based on the matter. So, it is recommended that the Ministry of Health ranks health deputies every two years to improve process components and criteria of the model based on practical results.

---

The human approach to health and identification of the factors affecting it over time has changed. Understanding these approaches is helpful in promoting policymaking and good governance can be helpful in the health sector. Biomedical, psychological, health promotion, health determinants, health in all policies and one health are the most important health approaches that have emerged in different years in order. Each of these approaches has many challenges and strengths. Documents and studies show that although these health approaches have been inconsistently addressed in Iran, no specific doctrine has been define to guide the health policies. Therefore, in practice, what seems to be that a biomedical approach to health is the dominant approach in Iran's health system.

---

Concurrent with globalization, some changes have been created in the performance of the universities in developed countries that have turned them into a power source for economic development. In this study, generation changes of Iranian universities in the health sector were analyzed by the layer analysis (CLA) framework. The results showed that the status of universities in Iran is moving from the first and second university generations (i.e. education and research oriented) to the third generation (wealth creation). Too much concentration on indexes such as expert human resources training and number of papers and citations in the Iranian universities has led to stagnation in litany and structural layers. Obtaining scientific authority and technology development requires fundamental evolutions of sciences in deeper layers such as Islamic world view, governance of valuable contexts and evolution in the relationship among higher education and the research and technology system with other sectors.     

---

Background and Objectives: Researchers and health specialists are increasingly using self-reports to obtain information on chronic illnesses. This study was conducted to assess the validity of self-reports of diabetes based on a recent field survey in Mashhad.
 
Methods: In this cross-sectional study, we used the results of 2015 census in Mashhad, a population based survey of people over the age of 30 (n =307103), to determine the proportion of self-reported diabetes. The patient records of Sina Electronic Health Record system (SinaEHR®) coded as E11 and E12 approved by doctors were used as a reference. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated with 95% confidence intervals.
 
Results: The sensitivity, specificity, PLR, NLR, PPV, and NPV of self-reported diabetes was 24.59% (95% CI: 23.97-25.21), 98.04% (95% CI: 97.99-98.09), 12.56% (95% CI: 12.11-13.02), 0.77% (95% CI: 0.76-0.78), 44.77% (95% CI: 43.89-45.67), and 95.27% (95% CI: 95.23-95.31), respectively. The sensitivity of self-reported diabetes was higher in men, Iranian individuals, single subjects, people aged 60 and over, individuals with a BMI of 18.5-25, and those with university education.
 
Conclusion: Although the sensitivity of self-reported diabetes was poor in this study, its specificity and positive and negative predictive values were good. Furthermore, the sensitivity of self-reported diabetes was higher in men, Iranian individuals, single subjects, people aged 60 and over, individuals with a BMI of 18.5-25, and those with university education. It seems that caution should be exercised in using self-reported data in epidemiological studies.

---