Iranian Journal of

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Background and Objectives: One of the applications of population attributable risk percent (PAR%) is to estimate the disease burden in a population exposed to several risk factors. Therefore, this study was conducted to estimates the PAR% of the space-time clusters of pulmonary tuberculosis.

Methods: In this study, the data of pulmonary TB cases were obtained from the health department of Hamadan University of Medical Sciences. After detecting significant clusters using the spatiotemporal scan statistic, PAR% was used to analyze the clusters and to detect the location of clusters more accurately.

Results: Four primary space-time clusters and three secondary spatiotemporal clusters were detected for patients with pulmonary tuberculosis and 92% of the patients who did not have a clear state in term of HIV infection. Despite differences in the location of clusters and PAR%  attributed to them, the second primary cluster of pulmonary tuberculosis cases (consisting of the cities of Razan, Famenain and Kabudrahang) had the highest amount of PAR% that needs more attention.

Conclusion: The presence of significance spatiotemporal clusters in Hamadan highlights the necessity of the use of PAR% to distinguish cluster areas and to implement prevention and control policy. However, more analytical studies are needed to detect the on the determinants of the occurrence of pulmonary TB.

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Background and Objectives: Evaluation is one of the main components of communicable diseases surveillance. Despite the World Health Organization’s emphasis for preparation of evaluation tools, there is no suitable tool in Iran. This study aimed to prepare a tool for evaluation of communicable diseases surveillance in hospitals and to pilot it.

Methods: Items were prepared in the first step and the first version of questionnaire was developed. Face validity and content validity were checked. Piloting of the questionnaire was done in Tabriz hospitals. Data were entered into SPSS 18. For evaluation of reliability, internal consistency was measured using Cronbach's α and Kuder-Richardson.

Results: According to the results, we developed a questionnaire containing 29 questions in 5 domains with 20 indexes. Fifteen hospitals (78.9%) had a communicable diseases reporting system. The goals of reporting system were not described in these hospitals and only 2 (13.3%) hospitals had supporting laws. None of the hospitals had complete access to the surveillance system and reporting tools.

Conclusion: The developed questionnaire can be a useful tool to evaluate the communicable diseases surveillance system in hospitals. The reporting systems in the hospitals are not complete.

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Background and Objectives: The Millennium Development Goals (MDGs) are common goals that were established by the United Nations in 2000. The aim of this study was to compare some of these indicators in Iran, the Eastern Mediterranean Region (EMR), and the world.

Methods: The existing data from the World Health Status in 2014 and some other available sources in Iran, EMR, and across the world were addressed. The most relevant health indicators included decreased childhood mortality, maternal well-being, prevention of AIDS, tuberculosis and other diseases, and environment quality assurance.

Results: The proportion of neonatal mortality to total mortality among those less than 5 years increased from 37 to 44 in the world compared to 39 to 46 in EMRO and 46 to 61 in Iran. About 14.5% (71000 out of 490000) of the AIDS/HIV cases reported in the EMRO belonged to Iran in 2002. The maternal mortality rate (MMR) showed a decline of 72.2%, 50% and 44% in Iran, EMRO and the World respectively. The proportion of delivery by skilled persons and the proportion of pre-delivery care had a positive trend in Iran and were higher as compared to EMRO and the world average.

Conclusion: Iran achieved many MDGs, however, despite a decline in the AIDS/HIV incidence rate, its prevalence rate has increased in Iran, EMRO and the world from 2001 to 2013. The proportion of neonatal mortality rate to under 5-year mortality rate has had an increasing trend. Decision-makers should give priority to indicators that have not achieved MDGs.

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Background and Objectives: Using the anthropometric indicators of children is one of the ways of monitoring their growth. Because of the racial divisions and levels of health and welfare, comparing these indicators with the global reference is not reasonable; therefore, designing a local reference seems necessary. This study aimed to evaluate the growth indices for boys and girls aged 5 to 18 years old living in Isfahan and to compare the indices with standard values.
Methods: In this cross-sectional study, 53,839 subjects were included. Percentiles of body mass index, height, and weight were calculated using the LMS method in the LMS Light software. After normalization of the growth indices, their mean and standard deviation were calculated for each age group and anthropometric indices curves were plotted versus the 5th, 50th and 95th percentiles of the NCHS reference.
Results: In all age categories, the mean SDS scores of BMI in boys and girls was -0.004 ± 0.029 and 0.014 ± 0.062, respectively, indicating no difference with reference values. However, the 95th percentile of the body mass index for the reference population was consistent with the 90th percentile for the population studied. Also, weight in boys below 13 years of age was higher than the reference line while in girls, weight was always higher than the reference value.
Conclusion: Due to differences in the pattern of growth and also lower anthropometric values, particularly among boys, it seems that a national growth curve can be a better guide for future decisions.

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Background and Objectives: Satisfaction of health care recipients is always considered by policy makers and implementers as an indicator of measuring the quality and determining the effectiveness of services. This study aimed to determine the satisfaction of mothers from first level of Iranian network system.
Methods: This cross-sectional study was conducted to assess the incidence of maternal mortality in six provinces of Iran in 2015. Twenty-four public health centers were randomly stratified and selected. In each center, 15 to 20 mothers who were covered by prenatal care were examined. The data were collected through a researcher-made questionnaire whose validity and reliability were confirmed, interviews with mothers, and their medical records. SPSS version 17 was used for analysis. P values less than 0.05 were considered significant.
Results: Of 2722 mothers participating in the study, 2187 (80.3%) were satisfied with the condition and facilities of health units and service providers and 535 (19.7%) were dissatisfied. The highest level of satisfaction in mothers was observed in the areas of behavior, complete services, training of health professionals, and adequacy of pharmaceutical products while the lowest level of satisfaction was related to the adequacy of the medical education and the distance between the health unit and home. There was a significant relationship between 16 demographic variables and maternal satisfaction (P<0.05).
Conclusion: This study showed that about one fifth of pregnant mothers are still not satisfied with the first level of network systems in Iran and many factors have an impact on their satisfaction. It is recommended to design and implement interventional programs to increase their satisfaction.

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Background and Objectives: Improving the efficiency and productivity of the higher education, especially in the field of research on health sciences, is one of the characteristics of sustainable development in today's societies. This study aimed to measure the efficiency and productivity of Iran's Medical Sciences Universities (MSU) in the research function.
Methods: In a descriptive study, the research function of fourty five MSUs in Iran was evaluated using data envelopment analysis (DEA) method and Malmquist index in 2010, 2013, and 2016 years. Measurement of both efficiency and Malmquist index was developed and modeled based on the assumption of variable returns to scale (VRS) and output-oriented. Also, the ranking of efficient units was done using Anderson-Patterson's model.
Results: The mean research efficiency was estimated to be 0.86. Findings of Malmquist index showed that between 2010 and 2013, there was a 6% growth in the productivity; while the performance of universities had a 12% drop in research function from 2013 to 2016. Also, the average total productivity during two periods is 0.96, indicating 4% reduction in research efficiency which technology efficiency growth has dropped by 8% and other components of total productivity had a positive growth.
Conclusion: The results of the study showed that universities do not work efficiently and average productivity has been decreasing which was mainly due to a decline in the efficiency of technology, which despite the development of technology in recent years could be the result of the lack of effective use of it.
 

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Background and Objectives: Research plays an important role in solving health problems in the community. One main mission of higher education institutions is developing research tailored to the needs of the community by providing equal and fair opportunities for research sectors. The present study aimed to measure inequality in the rea of research in Iranian medical sciences universities.
Methods: In this descriptive study, the Gini Coefficient (GC) was used to measure inequality from 2010 to 2016. The indexes included the number of published papers, citations, citation per paper, self-citation, Scimago Journal Rank (SJR), Source Normalized Impact per Paper (SNIP), Citescore, Hirsch
(h-index), number of faculty members, number of students, and educational and research budget. Stata 14 software was used for data analysis.
Results: During the study years, the GC of SJR, SNIP, and Citescore varied from 0.65 to 0.73, 0.62 to 0.73, and 0.61 to 0.72, respectively. In addition, The GC of international papers, total articles, self-citation, citation per article, Hirsch index, and total citations varied from 0.62 to 0.70, 0.56 to 0.66, 0.22 to 0.27, 0.12 to 0.28, 0.33 to 0.39, and 0.57 to 0.72, respectively. The GC of the number of faculty members and budget ranged from 0.26-0.40 and 0.34-0.67, respectively.
Conclusion: Inequality in self-citation and citation per article was relatively fair, while Hirsh and the number of faculty members had intermediate inequality. Other indicators had a high and very high inequality. To reduce inequality, developing of the balanced research infrastructures in medical universities is recommended.

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Background and Objectives: Human resources is a key factor in achieving the Millennium Development Goals. Lack of indicators and standard tools for monitoring and evaluating human resources may cause limitations in achieving these goals. This study was done to develop evaluation indicators of human resources in the health sector.
Methods: The present study was carried out using the Delphi technique to extract the indicators of human resources evaluation in 2017. To conduct this study, three independent stages including a review of theoretical concepts, preparation of initial indicators of human resources evaluation, and consensus building were undertaken. The data were collected by a panel of 12 experts and representatives of related organizations in three rounds, with a scorecard designed to score from 1 to 10. In each round, the indexes that attained at least 8 out of 10 by two thirds of the experts were confirmed in the final model.
Results: In the first stage, 220 indicators were identified. The final model of human resources evaluation had 45 indicators in 11 main criteria. Four criteria were accepted at the stage of entrance to job market, (qualified applicants for health education, accreditation, capacity and outsourcing of health education institutions, approval and licensing). Five criteria were confirmed during the work (main indicators of availability and distribution, activity, productivity of labor force, waste and renewal, desirable governance on the information system of labor). Two criteria were accepted at the exit stage (transfer and withdrawal).
Conclusion: Despite the complexity of the human resources assessment, three different stages of the life cycle of the workforce (input, active labor force and output) should be considered for evaluation and monitoring. The indicators presented in this study make it possible to assess and monitor the health workforce.
 

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Background and Objectives: The higher education system plays an important role in the socio-economic development of the country due to its mission in training the required human resources. Therefore, performance evaluation of different sectors of higher education is of great importance. The present study was conducted to evaluate the educational efficiency and productivity changes of Iranian medical sciences universities.
Methods: This descriptive study was conducted in 2011, 2014, and 2017 to evaluating the performance of 43 Iranian medical universities using Data Envelopment Analysis and output oriented approach. In addition, productivity changes were measured using the Malmquist index. For this purpose, Deap 2.1 software was used. The Anderson Patterson Model and EMS software were also used to rate the units accurately.
Results: The average educational efficiency of medical universities was 0.97 in the study years. The average total productivity based on the Malmquist Index was 1.05, and educational productivity of the universities showed an average growth of 5% over the study years. This growth was 1% from 2011 to 2014 and 10% from 2011 to 2017.
Conclusion: The results of the study showed the acceptable efficiency of the education sector of Iranian medical sciences universities. Moreover, a positive increasing trend was observed in the productivity of the education sector during the study years. Further research using quality and quantity measures are necessary to assess the educational performance of medical universities more accurately.

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Background and Objectives: Quantitative and qualitative improvement of human resources inequality have a significant effect on achievement to health system goals. The purpose of this study was to investigate the trend of geographic, supply, and gender distribution inequality of human resources of the Ministry of Health and Medical Education (MOHME) in Iran.
Methods: In this descriptive study, the trend of human resources of the Ministry of Health during the years 2009-2015 was investigated based on gender, level of education, and type of employment. In order to study the inequality, Lorenz curve and Gini coefficient index were used. Data were collected from the Human Resources Office of the Deputy of Management Development and Resources of the MOHME and analyzed by Excel 2013 and Stata-14 software.
Results: In the present study, women had the highest portion with a growth rate of 6.66% in 2015 and a Gini coefficient of 0.29 except in 2011. The highest and lowest growth rate compared to the base year in 2010 was related to specialist doctors (83.12) and general practitioners (-19.61), respectively. The lowest and highest Gini coefficient was related to the associate degree (0.26) and subspecialty (0.45), respectively.
Conclusion: The present study was the first study to investigate the trend of changes in the human resources characteristics of the MOHME at a national level. Since this study only considered the quantity of the trend of human resources changes, it is recommended that the quality of human resources be investigated in the future studies.              

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Background and Objectives: A significant portion of the total health expenditure is related to medicines. Evaluation of medication system indicators forms a basis for modifying the consumption pattern and cost containment. Therefore, the present study was conducted to investigate the trend of medication consumption indicators in Iran.
Methods: In this descriptive-cross-sectional study, medicine consumption per capita was calculated based on the medicine type, medicine form, and treatment category. The data were extracted from the Pharmacological Statistics of the Food and Drug Administration and the Statistics Center of Iran between 2012 and 2015. Catzung categorization was used for treatment categories. Data were analyzed using descriptive statistics and annual growth index by Excel 2013 software.
Results: During the study years, the highest medicine consumption per capita was related to metformin 500 (18.52), ranitidine 150 (15.45), and adult cold (15.29). The highest average consumption per capita in different treatment categories was related cardiac medications (97.65). The lowest and highest growth rates were related to glibenclamide 80 with -12% in 2014 and metformin 500 with 16.9% in 2013, respectively. Tablets were the most widely used form of medicine.
Conclusion: According to the results, medicine consumption per capita in Iran is higher than developed countries. Cardiac and diabetes medications have a high consumption per capita in Iran compared to other medications. Therefore, in order to rationalize drug prescription, strengthening the clinical evaluation system is recommended by developing and implementing clinical guidelines for common and high-cost diseases.

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Background and Objectives: Access to equal educational opportunities is one of the fundamental rights in each country, and elimination of inequalities, especially in the higher education system, is one of the most important priorities. This study aimed to measure educational inequality in the medical sciences sector in Iranian provinces.
Methods: In this study, educational inequality in medical sciences was measured using the Gini coefficient. The study indexes included the number of students, faculty members, staff, majors and educational budget. Data were analyzed using Stata 14 software.
Results: During the study years, the Gini coefficient of the number of female students, male students, and faculty members showed a more or less decreasing trend from 0.51 to 0.46, from 0.53 to 0.46, and from 0.59 to 0.53, respectively. However, the values of inequality in the number of personnel working in educational sector and educational budget showed a slight increasing trend from 0.49 to 0.50 and from 0.53 to 0.54, respectively. According to the academic majors, the lowest Gini coefficient was related to non-continuous bachelor’s degree that varied from 0.13 to 0.17, and the highest value was related to fellowship degree ranging from 0.66 to 0.69 in the study years.    
Conclusion: Despite reduced inequality in some educational indicators, there is a high inequality in the number of academic majors of some postgraduate degrees, number of students by gender, and educational budget, which requires policy makers to focus more on balanced distribution of educational infrastructures among provinces to provide equal educational opportunities.

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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.     

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Background and Objectives: Drug abuse is one of the medical, social, economic and cultural problems in the present era that increases the morbidity, mortality, and disability among addicts. Iran, due to its adjacency to major centers of opiate drugs production, has a severe and critical condition. Therefore, epidemiological studies are essential for comprehensive management of drug abuse disorders.   
   
Methods: In this descriptive cross-sectional study, demographic and epidemiological data of all people whose cause of death was drug abuse in 2013-14 (1392 Hijri) were extracted by two checklists. Data were then analyzed with SPSS software.

Results: A total of 2957 deaths occurred during the study period. Most deaths occurred in unmarried young males with a low income and education level. The mean age of the subjects was 36.6  12.81 years. The mortality rate from opiate and psychoactive abuse in the whole country was 53.28 in 1000000 population. The most commonly used drugs in the study population were opium, crystal, and heroin in a descending order. Hamedan, Lorestan, and Zanjan provinces with a mortality rate of 150, 101, and 80.06 per 1,000,000 people had the highest mortality due to drug abuse.

Conclusion: Training programs and harm reduction approaches such as methadone treatment and naloxone distribution programs should be designed in high-risk groups to reduce mortality associated with drug abuse.

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Background and Objectives: One of the most common problems during pregnancy is sleep disorders, which is the result of physiological, hormonal and physical changes in pregnancy and can be the basis for many disorders before, during, and after delivery. The aim of this study was to determine the psychometric properties of the persion version of  Sleep Condition Indicator in a sample of Iranian pregnant women.
 
Methods: In present study, 300 pregnant women reffered to health center of Kowsar (affiliated to Qazvin University of Medical Sciences) that were gathered via accesible sampling method, completed the Sleep Condition Indicator in 2017. Face, content, and construct validity (convergent and divergent validity) and reliability of selected questionnaire were calculated.
 
Results: The results of exploratory and confirmatory factor analysis showed two sustained and distinct factors, including quantity in sleep quality and the consequences of low sleep quality. The two-factor fit of Sleep Condition Indicator was approved based on standard indicators. Convergent and divergent validity were acceptable for all factors. Moreover, the internal consistency and reliability of the construct were also acceptable.
 
Conclusion: The results of this study showed that the Sleep Condition Indicator is valid and reliable among pregnant women, so it seems that this tool can be used to screen sleep disorders in women during pregnancy.

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Background and Objectives: The purpose of this study was to predict the mortality rate of colorectal cancer in Iranian patients and determine the effective factors  on the mortality of patients with colorectal cancer using random forest and logistic regression methods.
 
Methods: Data from 304 patients with colorectal cancer registry from the Gastroenterology and Liver Research Center of Shahid Beheshti University of Medical Sciences during the years 2009 to 2014 were used as a retrospective study. Data analysis was performed using random forest and logistic regression methods. To analyze the data, R software version 3.4.3 was considered.
 
Results: Ten important variables related to colorectal cancer deaths were selected by random forest method. Several criteria such as the area under the characteristic curve (AUC) were used to compare the random forest method with logistic regression. According to both criteria, five important variables ranked by random forest were Cancer stage, age of diagnosis, patient's age, HLA, and degree of differentiation (tumor differentiation). In terms of different criteria, the random forest method had better performance than logistic regression (Area under the ROC curve for random forest and logistic regression methods was: 98%; 80% respectively).
 
Conclusion: Variables such as Cancer stage, age of diagnosis, patient's age, HLA, and degree of differentiation are considered as the most important factors affecting mortality in colorectal cancer, that the patients' longevity can be increased with the early diagnosis of cancer and screening programs.
 

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Background and Objectives: Suicide is one of the psychosocial problems in Lorestan Province due to its socio-cultural and economic structure. The aim of this study was to investigate the effect of age group, time period, and birth cohort on the suicide incidence in Lorestan Province during the 2006-2015.
 
Methods: In this study, to overcome the identifiability problem, the Carstensen approach and natural cubic smoothing character were used in age-period-cohort models (APC). Cohort effect was calculated as the relative rate from the 1984 reference cohort for men and 1987 cohort for women. The period effect in both sexes constrained to be relative to 1390 and to be 0 on average with 0 slope. The best APC model for both sexes was the models with "AC-P" parameter, 7 knots, and natural splines for men and B splines for women. All analyses were performed using the R software with Epi package.
 
Results: The age effect showed that the highest suicide incidence rate was seen in the elderly. Two strong birth cohort effects were observed, one increasing one in the 1980 cohort and one decreasing one in 1991 cohort. The most significant period effect was seen in men in 2011.
 
Conclusion: The effects of 1991 and 1980 birth cohorts could be due to the consequences of imposed war in Iran. The three economic phenomena, oil price change, increased divorce rate, and increased unemployment rate can be effective in the emergence of the period effect in year 2011.

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Background and Objectives: This research was conducted to investigate the socioeconomic and geographical inequality in mortality from road traffic accidents in Iran in 2016.
 
Methods: In this descriptive cross-sectional study, the data of 16,584 people that died from road traffic accidents in 2016 were received from the Legal Medicine Organization. Theil entropy index was used to determine inequality in geographic areas. Moreover, relative and absolute concentration indices were used to measure inequality in mortality from RTAs across educational levels.
 
Results: The mortality rate from road traffic accident was 21.5 per 100,000 people. Theil index was 0.66 for traffic-related deaths among the provinces, indicating an unequal distribution of traffic injuries caused by traffic accidents among the provinces. When inequality was measured at smaller geographical levels, i.e., among cities in each province, the results indicated a fair distribution across smaller geographic levels. The focus index also indicated a fair distribution of traffic accidents among the deceased sub-classes (concentration index & 95% CI: -0.13 (-0.41; 0.16).
 
Conclusion: Our findings showed that the distribution of mortality from road traffic accidents was unequal at provincial positions. According to our findings, mortality from traffic accidents was distributed equally among the socioeconomic and urban levels. Therefore, health managers can use the findings of this study to develop interventions to reduce inequalities. In addition to targeting factors contributing to known social inequalities in the health and social status, other factors should be considered and applied to evaluate their interventions in the future.

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Background and Objectives: Anthropometric indices, especially weight, provide useful information for the care and treatment of newborn infants and can be used to identify infants at risk. Therefore, this study was conducted to examine the mean weight, height and head circumference measurements of infants and some related factors.
 
Methods: This cross-sectional study was performed to investigate the anthropometric indices (weight, height and head circumference), demographic characteristics, and delivery data of 1484 newborns in 2016 using multi-stage sampling. Moreover, the predictors of these indices were analyzed using a linear regression model.
 
Results: The mean weight, height and head circumference of the newborn infants was 3185 ± 465 g, 49.92 ± 2.92 cm, and 34.58 ± 2.29 cm respectively, and 7% of newborns were low birth weight. The male newborns weighed 57.29 g more than females on average at birth (p <0.05). Besides, the height and head circumference of the male newborns were 0.15 and 0.10 cm larger than the female newborns respectively but the difference was not statistically significant. In addition to gender, gestational age at birth (week) and type of delivery correlated with all three anthropometric indices in multivariate analysis.
 
Conclusion: Identifying and controlling largely adjustable risk factors can make it possible to prevent low anthropometric parameters, particularly low birth weight.

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Background and Objectives: Congenital anomalies are also known as birth defects and congenital disorders. Congenital anomalies occur in about 3-7% of the newborn babies worldwide. The purpose of this study was to determine the incidence of congenital anomalies and their determinants in hospitals affiliated with Isfahan University of Medical Sciences in 1395.

Methods: This cross-sectional study was conducted in all infants born in 1395. The data were analyzed with the SPSS software version 20 using Binary logistic regression.

Results: Of 5455 births in Isfahan hospitals, 121 neonates were diagnosed with major congenital anomalies. The total incidence of major congenital anomalies was 2.2 per 100 births. The results showed a statistically significant relationship between maternal blood group, consanguinity, sex and height of infant with congenital anomalies in newborns (P <0.05). Moreover, 26.7% of all abnormalities were related to limbs and the lowest percentage was related to genetic abnormalities, digestive system, anus, and spine with an incidence of 0.7% for each.

Conclusion: More attention should be paid to premarital genetic counseling in order to identify the consanguinity factor as a risk factor for genetic abnormalities. Moreover, pregnant women should be educated about the timely intake of micronutrients to control abnormalities.