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Abstract Background Network analysis, commonly used to describe the patterns of multimorbidity, uses the strength of association between conditions as weight to classify conditions into communities and calculate centrality statistics. Our aim was to examine the robustness of the results to the choice of weight. Methods Data used on 27 chronic conditions listed on Australian death certificates for women aged 85+. Five statistics were calculated to measure the association between 351 possible pairs: odds ratio (OR), lift, phi correlation, Salton cosine index (SCI), and normalised-joint frequency of pairs (NF). Network analysis was performed on the 10% of pairs with the highest weight according to each definition, the ‘top pairs’. Results Out of 56 ‘top pairs’ identified, 13 ones were consistent across all statistics. In networks of OR and lift, three of the conditions which did not join communities were among the top five most prevalent conditions. Networks based on phi and NF had one or two conditions not part of any community. For the SCI statistics, all three conditions which did not join communities had prevalence below 3%. Low prevalence conditions were more likely to have high degree in networks of OR and lift but not SCI. Conclusion Use of different statistics to estimate weights leads to different networks. For exploratory purposes, one may apply alternative weights to identify a large list of pairs for further assessment in independent studies. However, when the aim is to visualise the data in a robust and parsimonious network, only pairs which are selected by multiple statistics should be visualised.

Background Estimating the number of people using illicit drugs and alcohol is necessary for informing health policy and programming. However, it is often challenging to reliably estimate the size of these marginalized populations through direct methods. In this study, we estimated the population size of these groups using the indirect Network Scale-Up (NSU) method in Iran from 2015 to 2016.Methods Using a self-administered questionnaire, we asked 15 124 individuals (54% men) about the number of people they know who used different types of drugs at least once in the past 12 months. Prevalence estimates were reported per 100 000 population. The uncertainty level (UL) was calculated using the bootstrap method.Results The average age of the respondents was 33 years old, and 35.1% of them were unmarried. The most common drugs and their prevalence were as follows: opium (2534 [95% UL: 2467-2598]), hashish (849 [95% UL: 811-886]), stimulants (methamphetamine, ecstasy pills, cocaine, and Ritalin) (842 [95% UL: 802-879]), heroin/crack (578 [95% UL: 550-607]), and drug injection (459 [95% UL: 438-484]). Additionally, we estimated the prevalence of alcohol use as 2797 (95% UL: 2731-2861). On average, substance use was 5.23 times more prevalent among men than women. Opium use was more prevalent among individuals aged >50 years old. Moreover, alcohol use was more prevalent among participants between 18 and 30 years old (5164 per 100 000 population).Conclusion Although opium continues to be the most prevalent illicit drug in Iran, the patterns of illicit drug use are heterogeneous among different age groups, genders, and provinces. Age-gender specific and culturally appropriate interventions are warranted to meet the needs of people in different subgroups.

Cystic Echinococcosis (CE) as a prevalent tapeworm infection of human and herbivorous animals worldwide, is caused by accidental ingestion of Echinococcus granulosus eggs excreted from infected dogs. CE is endemic in the Middle East and North Africa, and is considered as an important parasitic zoonosis in Iran. It is transmitted between dogs as the primary definitive host and different livestock species as the intermediate hosts. One of the most important measures for CE control is dog deworming with praziquantel. Due to the frequent reinfection of dogs, intensive deworming campaigns are critical for breaking CE transmission. Dog reinfection rate could be used as an indicator of the intensity of local CE transmission in endemic areas. However, our knowledge on the extent of reinfection in the endemic regions is poor. The purpose of the present study was to determine E. granulosus reinfection rate after praziquantel administration in a population of owned dogs in Kerman, Iran. A cohort of 150 owned dogs was recruited, with stool samples collected before praziquantel administration as a single oral dose of 5 mg/kg. The re-samplings of the owned dogs were performed at 2, 5 and 12 months following initial praziquantel administration. Stool samples were examined microscopically using Willis flotation method. Genomic DNA was extracted, and E. granulosus sensu lato-specific primers were used to PCR-amplify a 133-bp fragment of a repeat unit of the parasite genome. Survival analysis was performed using Kaplan-Meier method to calculate cumulative survival rates, which is used here to capture reinfection dynamics, and monthly incidence of infection, capturing also the spatial distribution of disease risk. Results of survival analysis showed 8, 12 and 17% total reinfection rates in 2, 5 and 12 months following initial praziquantel administration, respectively, indicating that 92, 88 and 83% of the dogs had no detectable infection in that same time periods. The monthly incidence of reinfection in total owned dog population was estimated at 1.5% (95% CI 1.0-2.1). The results showed that the prevalence of echinococcosis in owned dogs, using copro-PCR assay was 42.6%. However, using conventional microscopy, 8% of fecal samples were positive for taeniid eggs. Our results suggest that regular treatment of the dog population with praziquantel every 60 days is ideal, however the frequency of dog dosing faces major logistics and cost challenges, threatening the sustainability of control programs. Understanding the nature and extent of dog reinfection in the endemic areas is essential for successful implementation of control programs and understanding patterns of CE transmission.

Abstract Background National mortality statistics are based on a single underlying cause of death. This practice does not adequately represent the impact of the range of conditions experienced in an ageing population in which multimorbidity is common. Methods We propose a new method for weighting the percentages of deaths attributed to different causes that takes account of the patterns of associations among underlying and contributing causes of death. It is driven by the data and unlike previously proposed methods does not rely on arbitrary choices of weights which can over-emphasise the contribution of some causes of death. The method is illustrated using Australian mortality data for people aged 60 years or more. Results Compared to the usual method based only on the underlying cause of death the new method attributes higher percentages of deaths to conditions like diabetes and dementia that are frequently mentioned as contributing causes of death, rather than underlying causes, and lower percentages to conditions to which they are closely related such as ischaemic heart disease and cerebrovascular disease. For some causes, notably cancers, which are usually recorded as underlying causes with few if any contributing causes the new method produces similar percentages to the usual method. These different patterns among groups of related conditions are not apparent if arbitrary weights are used. Conclusion The new method could be used by national statistical agencies to produce additional mortality tables to complement the current tables based only on underlying causes of death.

Background: The prevalence of infections among general population can affect the prevalence among blood donors. Due to to the importance of blood safety, this study was conducted to estimate the prevalence of HIV, HBV, and HCV in donated bloods in Iran in 2018.Methods: Using information of 1,308,284 blood donors, we designed this cross-sectional study to estimate the prevalence of transfusion-transmitted infections (TTIs) in Iranian blood donors. All the prevalence was reported per 100,000 population.Results: HIV prevalence in blood donors was about 2 per 100,000 (95% CI: 1.999, 2.001) population. Prevalence of HBV and HCV was 53(95% CI: 52.999-53.00) and 26 (95% CI: 25.999-26.001), respectively.Conclusion: It seems that the screening of volunteers would defer many people who may have been infected with TTIs; as a result, people with the least risk of being infected are selected to donate blood. Notice: All of these infected bloods were detected and discarded from the blood donation chain.

Background: There are many mental health challenges associated with immigration. Culture has a notable impact on the mental health of immigrants. The inability to adapt to the new culture is effective in developing mental health problems. Acculturation is a dynamic process that involves multiple aspects of adjustment to a new environment. Various acculturation levels and processes are associated with mental health problems. However, this association is complex and can vary for different groups of migrants. The primary goal of the present study was to study the relationship between acculturation and mental health among Afghan immigrant women compared to Iranian women.Methods: The study included about 400 immigrant Iranian and Afghan women. Participants answered questions regarding age, marital status, education, occupation, religion, length of stay in Iran (in the Afghan participants), study in Iranian schools (in the Afghan participants) and the neighborhood characteristics where you live (with a majority of Iranian neighbors, a majority of Afghan neighbors and an equal population of both) and economic status. Information about mental health status and acculturation was also obtained through a self-administered questionnaire.Results: The severity of mental illness among the three groups of Iranians, Afghans with low acculturation, and Afghans with high acculturation was significantly different (0 < 0.001). While mental disorders among Afghan women with high and low acculturation differed, this difference was not statistically significant. Some of the demographic features, such as widowhood, neighborhood features, socioeconomic status, and religion, had affected mental disorders in the two acculturated groups.Conclusion: In societies with strong cultural similarities, individual factors and ethnic solidarity seem to be more crucial to the mental health of immigrants.

Abstract The present study investigates different scenarios to project the chance of achieving SDG 3.4 in Iran. In this study, the Iranian Death Registry System data was employed to estimate the Unconditional Probability of Dying (UPoD) for the four major categories of NCDs; then, the Bayesian model averaging was used to project the UPoD at the national and sub-national levels. Also, the prevalence of the risk factors was projected by 2030 based on STEPs as well as some other study data. Plus, UPoD and the possibility of achieving the target were estimated once again based on the assumption that the global reduction in risk factors proposed by WHO would be adopted in Iran. The UPoDs for the four NCDs in Iran were 17.5% (95% UI: 16.3–19.2) and 14.7% (13.3–16.2) in 2010 and 2015 respectively and if the current trend continues, 2030 will mark the UPoD of 10.8% (7.9–14.3). However, If the risk factors are reduced to the WHO target level by 2030, the UPoDs will be reduced to 5.44% (3.51–7.39) and 6.55% (5.00–8.13) of the 2010 and 2015 baseline scenarios, respectively, to enable some provinces to meet SDG 3.4. If the current trend continues, Iran will and will not achieve the SDG 3.4 in 2010 and 2015 baseline scenarios, respectively. However, if the global target set for reducing risk factors is achieved, Iran will meet all expectations in SDG 3.4 except in Asthma and COPD. Therefore, effective interventions are recommended to be designed and followed to reduce Asthma and COPD.

Abstract Understanding dynamics of free-roaming dog (FRD) population is critical for planning and implementation of dog population management programs. FRD population size estimation as well as dynamic modeling of dog population under different female dog neutering interventions were investigated in order to determine the most appropriate animal birth control approach. We performed population size estimate of dogs using sight-resight surveys by photography in a randomly selected 25 blocks of the city and all the suburbs of greater Kerman area. Main demographic features were characterized and the dog density distribution was mapped. A dynamic model was developed to predict free-roaming dog population variations after 5 and 10 years. Different scenarios based on 10, 30, 50, 60 and 70% female dog sterilization were considered to predict the effects of animal birth control measures. Free roaming dog population was estimated at 6781 dogs (65.3% males) in Kerman and suburbs with several major population hotspots. Analysis of the dog locations within the city showed that the largest proportion of the dogs were observed in the vacant lots (46.2%). Modeling predictions indicated that, in the absence of management, the free-roaming dog population could increase from a baseline of 6781 to 13,665 dogs (2.02 fold increase) in 5 years and to 19,376 dogs in 10 years (2.86 fold increase). Using a population dynamics model, we simulated five neutering coverages to explore the impact of female neutering on free-roaming dog population size. The 5-year projections of the model have shown that 50% annual female dog sterilization significantly reduced free-roaming dog population by 0.44 comparing to the baseline population. Findings of the present study improve our knowledge on the nature and extent of dog population dynamics in Iran. Effective population control and selection of the most appropriate neutering interventions require a comprehensive knowledge of the characteristics and dynamics of FRD population.

Background: Bayesian mixture cure rate frailty model is a model used in survival analysis by controlling frailty when the fraction of cured individuals exists. The present study was performed as the first systematic review in survival analysis with cure fraction. The aim of this systematic review was to study and evaluate the related studies on Bayesian mixture cure rate frailty model. Also, this model was used to demonstrate its importance and applicability in determining the variables affecting the survival of patients with gastric cancer.Methods: This systematic review was done based on the PRISMA guideline by considering related searching keywords in PubMed, Scopus, Science Direct, Web of Science, and Google Scholar. Also, Bayesian mixture cure rate frailty model was used to analyze gastric cancer data.Results: In the beginning, 882 studies related to survival analysis of cure rate model were found. Finally, by reading the full-text, only 4 related studies were found based on the inclusion and exclusion criteria. In these studies, semi-parametric models and parametric model with Weibull distribution were used for time-to-event data. Also, based on the results of the model, significant and affective variables on the survival of patients with gastric cancer were found.Conclusion: According to the results of this study, in the cure model, choice of proper distribution for the frailty variable and baseline distribution can influence the results. It was also found that place of residence, chemotherapy, morphology, and metastasis are effective variables on survival of patients with gastric cancer.

Background: We examined and estimated the trend of breast cancer incidence in Kerman, the largest province in Iran. Method: Having compiling the data of new cases from three sources (cancer registry, pathology, radiotherapy) in this longitudinal study, the number of untouched cases was estimated using log-linear model. We estimated the annual age-standardized rate (ASR) per 100,000 women in 2001-2015. We utilized joint point regression method to estimate the trend of breast cancer incidence during the examined years. Results: The ASR of breast cancer increased from 25 in 2001-2005 to 37 in 2011- 2015, showing that the annual average percentage increased by 5.9% (95% Confidence Interval: 3.5, 8.4, p

Background and purpose: Parkinson's disease (PD) is a chronic neurological disorder. Prevalence estimates of the disease are pivotal for planning and appropriate allocation of health care. The present study was conducted to investigate the prevalence of PD and its geographic variations in Iran. Materials and methods: In this cross-sectional study, the prevalence of PD in different provinces was estimated using the frequency of specialized drugs prescribed per 100,000 people. Then, geographical distribution of the disease was determined in Iran. Results: In this study, the prevalence of Parkinson’s disease in general population and >50 years old were 50.4 and 261.1 in 100,000 people, respectively. In general population, the lowest and highest PD prevalence were seen in Hormozgan province (15.7/100,000) and Isfahan province (96.9/100,000). Also, in those >50 years old the lowest PD prevalence was found in Hormozgan province (114.2/100,000) and the highest was observed in Isfahan province (449.5/100,000). Conclusion: PD prevalence in >50 years old was lower in Iran than that in western countries, but it is somewhat comparable with PD prevalence reported in developing countries in Asia. In Iran, the prevalence of PD is considerably different in various regions.

Background: Previous studies have shown that breast cancer (BC) risk perception could be a motivation for screening behaviors. This study was conducted to compare the level of BC risk perception of women aged between 30-40 and 41-60 years, and to determine the factors affecting screening behaviors and examine the association between BC risk perception and BC screening behaviors. Methods: This cross-sectional study was performed using a Rutherford instrument for BC risk perception on 754 women aged 30 to 60 years with no history of BC in 2018. The questionnaire included demographic information, risk factors of BC, screening practice, and risk perception of BC. The association between screening behaviors with women’s BC risk perception and some other variables were assessed utilizing pathway analysis method with the Structural equation modeling (SEM), which summarized the results by odds ratio index. Results:The mean score of BC risk perception was 28.9±24.3, which was 31.2±24.4 in women aged 30 to 40 and 25.9±23.9 in women aged 41 to 60 years (P value = 0.003). The association between mammography with risk perception was (OR:1 [95%CI: 0.9, 1]). According to this study, the most important variables affecting mammography were increased clinical examination (OR: 34.6 [95%CI: 16.3, 73.7]), age (OR: 8.8 [95%CI: 4.9,16]), family history of breast cancer (OR: 4 [95%CI: 1.3, 12.9]), and higher education level ([OR: 1.4[95%CI: 1.1,1.9]). Conclusions: The results of our study indicated that younger women had higher BC risk perception. BC risk perception was not found to have any direct effects on mammography. This survey revealed that physicians had an important role in encouraging women to perform mammography.

Background In Sudan, where studies on HIV dynamics are few, model projections provide an additional source of information for policy-makers to identify data collection priorities and develop prevention programs. In this study, we aimed to estimate the distribution of new HIV infections by mode of exposure and to identify populations who are disproportionately contributing to the total number of new infections in Sudan. Methods We applied the modes of transmission (MoT) mathematical model in Sudan to estimate the distribution of new HIV infections among the 15-49 age group for 2014, based on the main routes of exposure to HIV. Data for the MoT model were collected through a systematic review of peer-reviewed articles, grey literature, interviews with key participants and focus groups. We used the MoT uncertainty module to represent uncertainty in model projections and created one general model for the whole nation and 5 sub-models for each region (Northern, Central, Eastern, Kurdufan, and Khartoum regions). We also examined how different service coverages could change HIV incidence rates and distributions in Sudan. Results The model estimated that about 6000 new HIV infections occurred in Sudan in 2014 (95% CI: 4651-7432). Men who had sex with men (MSM) (30.52%), female sex workers (FSW) (16.37%), and FSW’s clients accounted (19.43%) for most of the new HIV cases. FSW accounted for the highest incidence rate in the Central, Kurdufan, and Khartoum regions; and FSW’s clients had the highest incidence rate in the Eastern and Northern regions. The annual incidence rate of HIV in the total adult population was estimated at 330 per 1 000 000 populations. The incidence rate was at its highest in the Eastern region (980 annual infections per 1 000 000 populations). Conclusion Although the national HIV incidence rate estimate was relatively low compared to that observed in some sub-Saharan African countries with generalized epidemics, a more severe epidemic existed within certain regions and key populations. HIV burden was mostly concentrated among MSM, FSW, and FSW’s clients both nationally and regionally. Thus, the authorities should pay more attention to key populations and Eastern and Northern regions when developing prevention programs. The findings of this study can improve HIV prevention programs in Sudan.

Abstract Background This study was conducted to provide evidence on the current status of breast cancer and its incidence trend in Eastern Mediterranean Region during 1998–2019. Also, this study aimed to investigate the association between the incidence of breast cancer and Human Development Index and some factors related to this index, including total fertility rate, and obesity, using a meta-analysis. Method Data on incidence of breast cancer were collected from various sources, including PubMed, Embase, Web of Science, and WHO, from 1998 to 2019 using systematic review and meta-analysis. Pooled age standardized rate was calculated based on study duration and quality of data using a subgroup analysis and random effect meta-analysis. Results A total of 80 studies (545 data points) were analyzed. Pooled age standardized rate of breast cancer for Eastern Mediterranean Region was 37.1 per 100,000 person-year (95% confidence interval [CI], 34.5, 39.8) during 2011–2019. age standardized rate of breast cancer had an upward trend in Eastern Mediterranean Region from 2005 to 2019. However, the increasing trend was found to be slightly different in various regions based on quality of data. Moreover, pooled age standardized rate had a significant association with Human Development Index [− 89.2 (95% CI, − 119.8, − 58.7)] and obesity [1.2 (95% CI, 0.9, 1.5)]. Conclusion Pooled age standardized rate of breast cancer in Eastern Mediterranean Region was lower than the global average. Also, the age standardized rate value and its incremental trend have been higher in countries with high-quality data than in other countries of this region in recent years. Data quality or physiological factors, such as increase in obesity rates, could be the reasons for this incremental trend.

Phenylketonuria is a disease caused by congenital defects in phenylalanine metabolism that leads to irreversible nerve cell damage. However, its detection in the early days of life can reduce its severity. Thus, many countries have started disease screening programs for neonates. The present study aimed to determine the worldwide prevalence of classic phenylketonuria using the data of neonatal screening studies. The PubMed, Web of Sciences, Sciences Direct, ProQuest, and Scopus databases were searched for related articles. Article quality was evaluated using the Joanna Briggs Institute Critical Appraisal Evaluation Checklist. A random effect was used to calculate the pooled prevalence, and a phenylketonuria prevalence per 100,000 neonates was reported. A total of 53 studies with 119,152,905 participants conducted in 1964–2017 were included in this systematic review. The highest prevalence (38.13) was reported in Turkey, while the lowest (0.3) in Thailand. A total of 46 studies were entered into the meta-analysis for pooled prevalence estimation. The overall worldwide prevalence of the disease is 6.002 per 100,000 neonates (95% confidence interval, 5.07–6.93). The metaregression test showed high heterogeneity in the worldwide disease prevalence (I2=99%). Heterogeneity in the worldwide prevalence of phenylketonuria is high, possibly due to differences in factors affecting the disease, such as consanguineous marriages and genetic reserves in different countries, study performance, diagnostic tests, cutoff points, and sample size.

Background: Network Scale Up (NSU) is applied in many settings to estimate the size of hidden populations.The visibility of alcohol consumption - as a hidden behavior - in Iran has not been yet set. Our aim is to estimatethe visibility factor (VF) of alcohol consumption in Iran which is an Islamic country in the Middle East.Methods: Ninety persons who had a history of alcohol consumption were recruited. Relationships in networkwere aligned in three main subgroups: immediate family, extended family, and non-family. According to thegame of contact methodology, participants answered questions about total and aware number of personsthey know in each relationship category. VF was calculated by dividing total number of people aware aboutthe respondent’s alcohol consumption by total number of respondent’s social network. The 95% confidenceintervals (CIs) were computed through bootstrapping.Findings: The mean and standard deviation (SD) of participants’ age was 32.9 ± 10.2, the sex ratio was 3.Overall VF (95% CI) was 40% (33% to 47%). VF was estimated at 44% and 23% among men and women’snetwork, respectively. The immediate family was the highest informed group, followed by non-family andextended family members.Conclusion: The visibility of alcohol consumption in Iran was not high. This is due to religious and legalprohibitions around it

Background: Alcohol use and drug injection are prevalent among homeless youths. The aim of this study wasto identify the associated factors of alcohol consumption and drug injection among homeless youths aged18-29 years.Methods: Data on 202 homeless youths (111 males and 91 females) were collected using a standardizedquestionnaire and face-to-face interview. Lasso logistic regression was applied to determine the impact ofassociated factors on alcohol consumption and drug injection.Findings: The mean age of the participants was 26.30 ± 3.19 years. Also, the prevalence of alcoholconsumption and drug injection was 33.0% [95% confidence interval (CI): 30-36] and 4.0% (95% CI: 0-8),respectively; 6 people (3.0%) consumed alcohol and injected drugs at the same time. Correlates of alcoholconsumption and drug injection were male sex [odds ratio (OR)Alc = 5.7], age (ORAlc = 0.96 and ORDI = 0.98),bachelor or higher education level (ORAlc = 1.34), non-Iranian nationality (ORAlc = 0.05 and ORDI = 0.18),food score (ORDI = 0.92), smoking (ORAlc = 2.05), substance use (ORAlc = 1.12), opposite sex relationship(ORAlc = 1.6), homosexual relationship (ORAlc = 3.56 and ORDI = 2.69), and mental disorder (ORAlc = 0.99).Conclusion: Based on our findings, it seems that the homeless youth are more desired to use alcohol and druginjection, whereas the prevalence of alcohol consumption and drug injection in homeless youth was higherthan general youth population in Iran. Therefore, some suitable solutions are needed to prevent thehomelessness. Also, the effective variables that were identified in this study for alcohol use and drug injectioncan help design and implement beneficial interventions.

Background: Heavy vehicle drivers spend a great deal of time away from their families. This issue and other difficulties around their job may increase risky behaviors among them. The current study aims to investigate the prevalence of opium drugs, stimulants, cannabis, and alcohol use 12 hours before driving among heavy vehicle drivers. Methods: We selected two sites that were in charge of medical examination of drivers and recruited 363 drivers of heavy vehicles (trucks, trailers, and buses). We asked drivers about total number of drivers they knew and number of drivers who experienced use of different types of drugs. The data were analyzed using Network Scale Up Method (NSUM). Findings: Mean of age and job experience was 43.28 ± 10.04 years and 16.07 ± 9.67 years, respectively. The highest and lowest prevalence of drug use related to opium-based drugs at 12.8% to 14.0% and simulants at 1.97% to 2.84%, respectively. The prevalence of alcohol use 12 hours before driving was 4%. Conclusion: 12-hour before driving prevalence of opium-based drugs among drivers was high. This might put them in higher risk of road accidents. There is a need to design appropriate educational programs for them.

Background:Dialysis is a process for eliminating extra uremic fluids of patients with chronic renal failure. The present study aimed to determine the variables that influence the survival of dialysis patients using random survival forest model (RSFM) in low-dimensional data with low events per variable (EPV). Methods:In this historical cohort study, information was collected from 252 dialysis patients in Bandar Abbas hospitals, Iran. The survival time of the patients was calculated in years from the onset of dialysis to death or until the end of the study in 2016. RSFM was used as the number of events per variable (EPV) was low. The data collected from 252 patients were randomly divided into training and testing sets, and this process was repeated 100 times. C-index and Brier Score (BS) were used to assess the performance of the model in the test set. Results: In this study, 35 (13.9%) mortality cases were observed. Based on the findings, the mean C-index value in training and testing sets was 0.640 and 0.687, and the mean BS value in training and testing sets was 0.017 and 0.023, respectively. The results of the RSFM revealed that BMI, education, occupation, dialysis duration, number of dialysis sessions and age at dialysis onset were the most important factors. Conclusion: RSFM can be used to determine the survival of dialysis patients and manage low-dimensional data with few-events if the researcher desires to select a nonparametric model.

Background Abortion is a sensitive issue surrounded by social, cultural and religious stigmata. Therefore, estimation of its prevalence involves methodological challenges. The aim of this manuscript is to estimate the abortion prevalence, stratified by type, using a direct and two indirect methods. Materials and Methods This cross-sectional study was done in 2016, we recruited 1020 women aging 18-49 years. Three methods were applied to estimate the abortion prevalence: direct question, network scale-up (NSU), and single sample count (SSC). In the direct method, to guarantee anonymity, data were collected by means of a self-administered questionnaire. In other methods, data were collected through gender-matched street-based inter- views. Results The annual rate of abortion estimated by direct and NSU methods were respectively 29 (10 intentional, 4 therapeutic and 15 spontaneous) and 23 (9 intentional, 3 therapeutic, and 11 spontaneous) per 1000 women aging 18-49 years. The annual rate of intentional abortion estimated based on SSC method was higher (15 per 1000 women) than other methods. Conclusion The present estimates are higher than previously reported ones. The results of three methods more or less supported each other confirming the internal validity of our estimates.

Objective: To estimate (under reporting) UR of SDS (Suicide deaths) and SAS (suicide attempts) in Kermanshah Province which is among provinces with high suicide rate in Iran.Methods: For estimating the size of UR suicide death registers, all cases of SAS and suicide deaths were retrieved from forensic medicine and health centers. Then, using network scale up method, a sample of 500 cases, aged 18 to 65 years, were randomly selected from the general population on the basis of age - sex proportion. To find the 95% confidence interval, bootstrap technique was used.Results: The average coverage of SDS was 58.4%, the lowest and highest coverage rate of SDS were attributed to self-immolation (34.2%) and hanging (80.7%), respectively. The coverage rate of SAS for self-immolation and deliberate self-poisoning were 82.4% and 77.2%, respectively. Size estimation of SAS by NSU method revealed that deliberate self-poisoning with medication (61.7%), poisoning with toxins and chemicals (20.6%), and self-immolation (7.7%) were the most frequent methods of SAS.Conclusion: Given the low coverage of suicide registers, all causes of death, especially deaths classified as accident or deaths with undetermined category, are required to be accurately registered. Investigations of causes of death, correction of wrong codes, as well as interviews with survivors to give them assurance can reduce the rate of suicide denial and result in increased accuracy of death register coverage.

Background Providing population-based data on awareness, attitude and practice of drug and stimulant use has policy implications. A national study was conducted among Iranian general population to explore life time prevalence, awareness and attitudes toward opioids and stimulant use. Methods We recruited subjects from 5 provinces with heterogenic pattern of drug use. Participants were selected using stratified multistage cluster sampling. Data were collected using a validated self-administered questionnaire. Logistic regression model was applied to identify the variables that are associated with drug and stimulant use. Results In total 2065 respondents including 1155 men (33.96 ± 10.40 years old) and 910 women (35.45 ± 12.21 years old) were recruited. Two-third of respondents had good awareness about adverse effects of opioid use. Corresponding figure in terms of stimulants was 81.4%. Almost 95% of participants reported a negative attitude towards either opioid or stimulant use. The lifetime prevalence of opioid use and stimulant use were 12.9% (men: 21.5%, women: 4.0%) and 7.3% (men: 9.6%, women: 4.9%), respectively. Gender (adjusted odds ratio [AOR]M/W = 6.92; 95% CI: 2.92, 16.42), education (AORundergraduate/diploma or less = 0.49; 95% CI: 0.26, 0.90), and marital status (AORothers/single = 2.13; 95% CI: 1.36, 3.33) were significantly related with opioid use. With respect to stimulant use, age was negatively associated with the outcome (AOR60+/20-29 years = 0.08: 95% CI; 0.01, 0.98) and men were 2 times more likely than women to use stimulants (ORM/W=2.15: 95% CI: 0.83, 5.56). In addition, marital status (AOROthers/singles = 3.45; 95% CI: 1.09, 10.93), and awareness (AORWeak and moderate/good = 0.40; 95% CI: 0.25, 0.61) were independently correlated with stimulants use. Conclusion While the attitude of Iranian adults toward opioid and stimulant use was negative, their awareness was not that adequate to prevent the drug use. Men and those with lower socio-economic status (SES) should be the focus of health promotion programs regarding opioid use. However, regarding stimulants use, promotion programs should target younger age groups and those with higher SES status.

Introduction: Trichloroethylene (TCE) is an industrial solvent which is often used as a degreaser for metal parts. Due to adverse health effects and carcinogenic properties of this solvent, knowing its concentration in the workplace atmosphere is really crucial. Nowadays, carbon nanotubes with high efficiency are being used for sampling of this chemical. Method: Three types of static standard atmosphere with the concentrations of 18, 35, and 53 ppm were produced. Then, sampling tubes which contained 10 mg of functionalized multi-walled carbon nanotubes were prepared. Subsequently, air standard atmosphere was made inside sampling bags. The mean adsorption efficiency was examined in three sampling flows (0.1, 0.15, and 0.2 L/minute). Finally, desorption was performed by carbon disulfide and analysis was conducted using gas chromatography coupled to mass spectrometry) GC/MS (according to the instructions of NIOSH 1022 and OSHA 1001. Results: The highest amount of adsorption occurred in the flow of 0.1 L/minute (81.51±3.72). Furthermore, considering the three studied concentrations of trichloroethylene (18, 35, and 53 ppm); the highest efficiency was recorded at 18 ppm concentration (83.18±11.67). The highest adsorption efficiency with the lowest standard deviation (80.55±3.85) was observed in samples that were immediately injected into the GC/MS machine. Conclusion:Given that time-lapse had no significant effect on adsorption efficiency, it is argued that the pollutant had suitable stability on the surface of the adsorbent. The results of this study show that multi-walled carbon nanotubes have better performance at lower concentrations of trichloroethylene.

Drug abuse and addiction exist around the world. People addicted to drugs such as opium or heroin often encounter dehumanizing discriminatory behaviors and health-care systems that are reluctant to provide services. Experiencing discrimination often serves as a barrier to receiving help or finding a home or work. Therefore, it is important to better understand the mechanisms that lead to the stigmatization of drug addiction and who is more prone to stigmatizing behaviors. There is also a dearth of research on whether different patterns of stigma exist in men and women. Therefore, this study investigated factors affecting gender-specific stigmatization in the context of drug addiction. In our vignette study (NMensample = 320 and NWomensample = 320) in Iran, we experimentally varied signals and signaling events regarding a person with drug addiction (i.e., NVignettes = 32 per sample), based on Attribution Theory, before assessing stigmatizing cognitions (e.g., blameworthiness), affective responses (e.g., anger), and discriminatory inclinations (e.g., segregation) with the Attribution Questionnaire. We also tested assumptions from the Familiarity Hypothesis by assessing indicators of respondents' familiarity with drug addiction (e.g., knowledge about addiction). Results, for example, show higher stigma if the person used “harder” drugs, displayed aggressive behavior, or had a less controllable drug urge. Self-attributed knowledge about addiction or prior drug use increased some forms of stigma, but diminished others. These findings only partially converged between men and women. We suggest that anti-stigma initiatives should consider information about the stigmatized person, conditions of the addiction, and characteristics of stigmatizers.

Multiple imputation by chained equations (MICE) is the most common method for imputing missing data. In the MICE algorithm, imputation can be performed using a variety of parametric and nonparametric methods. The default setting in the implementation of MICE is for imputation models to include variables as linear terms only with no interactions, but omission of interaction terms may lead to biased results. It is investigated, using simulated and real datasets, whether recursive partitioning creates appropriate variability between imputations and unbiased parameter estimates with appropriate confidence intervals. We compared four multiple imputation (MI) methods on a real and a simulated dataset. MI methods included using predictive mean matching with an interaction term in the imputation model in MICE (MICE-interaction), classification and regression tree (CART) for specifying the imputation model in MICE (MICE-CART), the implementation of random forest (RF) in MICE (MICE-RF), and MICE-Stratified method. We first selected secondary data and devised an experimental design that consisted of 40 scenarios (2 × 5 × 4), which differed by the rate of simulated missing data (10%, 20%, 30%, 40%, and 50%), the missing mechanism (MAR and MCAR), and imputation method (MICE-Interaction, MICE-CART, MICE-RF, and MICE-Stratified). First, we randomly drew 700 observations with replacement 300 times, and then the missing data were created. The evaluation was based on raw bias (RB) as well as five other measurements that were averaged over the repetitions. Next, in a simulation study, we generated data 1000 times with a sample size of 700. Then, we created missing data for each dataset once. For all scenarios, the same criteria were used as for real data to evaluate the performance of methods in the simulation study. It is concluded that, when there is an interaction effect between a dummy and a continuous predictor, substantial gains are possible by using recursive partitioning for imputation compared to parametric methods, and also, the MICE-Interaction method is always more efficient and convenient to preserve interaction effects than the other methods.

Background: The prevalence of alcohol consumption in Iran cannot be estimated because large variations have been observed in the reported prevalences of alcohol consumption. The main aim of this study was to assess the methodological challenges in estimation of the life time prevalence of alcohol consumed in Iran. By the same token we provided a standard approach for future researches in this regard. Methods: Published articles were reviewed systematically. Using the risk of bias tool, 49 out of 600 articles met the eligibility criteria. Based on the population of alcohol consumers, the included studies were categorized into 5 groups: general populations, patients, school students, university students, and specific population (first relatives of opium addicts and women who were faced with epistemic violence). Results: There was a paucity of reliable information in about 40% of provinces. Almost all studies applied the direct size estimation methods, but 11 studies used face to face interview and 38 studies used self-administered questionnaires. The non-response bias seemed prominent in entire studies except those on school students. It is important to mention that 97% of papers in general population did not represent any information about the non-response rate. The reported prevalence ranged from 1.37% in university students to 88.8% in patient population. Even among university students, the prevalence varied considerably (1.37% to 34.7%). Conclusion: The observed huge variations in the reported prevalence of alcohol consumption, due to the methodological consideration, appear largely in Iran. Therefore, it is necessary to develop a standard protocol for data collection and sampling to harmonize the findings in future studies. In addition, it is recommended to assess the frequency of alcohol use by indirect methods such as the Network Scale Up method.

Statement of the Problem: In dentistry, incorrect working posture is the most important cause of musculoskeletal disorders. Purpose: The aim of this research was to evaluate the work postures of general dentists and specialists using rapid entire body assessment (REBA) method. Materials and Method: In this cross-sectional study, work postures were assessed in 90 dentists by employing REBA method. Stratified sampling method was used. Data were analyzed by analysis of variance (ANOVA), Independent t-test and Pearson’s correlation test in SPSS 19. Results: The results showed that work postures of 90% of dentists were at moderate- to high-risk levels. Among the specialists, periodontists, pedodontists and oral and maxillofacial surgeons had the worst body postures. Conclusion: In general, dentists’ working postures need improvement and consequently, a more comprehensive ergonomic training and promotion is required in dentistry curriculum at Universities.

Introduction: Injury is recognized as a major health problem in most high and low-income countries. Rafsanjan is considered as one of the accident-prone areas in Kerman province. Objective: To study the epidemiology of traffic accidents in the Rafsanjan city. Methods: This cross-sectional study was conducted, by using the data from the Emergency Department (ED) of Aliebn Abitaleb Hospital in Rafsanjan city. The population included all people who had had a traffic accident in the city of Rafsanjan from March 21, 2014 through February 18, 2015. The sample included those who had been injured and transferred to the ED of Aliebn Abitaleb Hospital. Data were analyzed using Chi-square, independent-samples t-test, and logistic regression. SPSS software version 19 was used for data analysis. P< 0.05 was considered statistically significant. Results: Age, gender and location of accident, had significant association with the number of mortalities (p=0.02), and other results of this study suggest that there was a significant relationship between the status of the injured and the gender (p

ABSTRACT Introduction: Animal bites are one of the serious threats to human health, leading numerous consequences such as fatal disease of rabies. Given the importance of animal bite throughout the country, the purpose of the present study was to investigate the geographical distribution, time trend and epidemiological characteristics of animal-bite cases in Bardsir County, Iran. Methods: This cross-sectional study was conducted on the records of people suffering from animal bite between April 2010 and March 2014 in Bardsir County. Data were analyzed in SPSS v.20 software using descriptive statistics including frequency and percentage, log-linear model and time series model. Arc GIS software was employed to plot the geographical distribution of animal-bite cases. Results: The findings of this study indicated that totally 1,500 cases of animal bite had occurred during the study period. Mashiz district (with 695 cases of bite) had the most animal bites. In terms of time, animal-bite cases had no particular trend. The results showed that the incidence rate of bite in men was 2.12 times more than in women (p

Background: Alcohol consumption is a potential risk factor with acute and chronic health consequences and social impacts, which is more prominent among men. There is no precise statistics on the scope of alcohol consumption in Iran; however, there is some evidences showing an increasing trend, particularly among young generation. In order to evaluate the scope of this issue in Kerman, a large city in the south-east of Iran, this exploratory study was designed to approach a group of people having an experience of alcohol use.Methods: Samples were recruited to the study using a snowball sampling. 200 eligible subjects were questioned about the type of alcohol consumed, frequency of use, and other factors associated with alcohol consumption. In order to maximize the validity of responses, data were collected through self-administered questionnaires.Findings: The main alcoholic drinks consumed by individuals were the homemade distillates (46%), wine (22%), beer (14%), distilled spirits (11%), and medical alcohol (7%), respectively. The majority of individuals participating in the study (73%) used mostly homemade drinks; moreover, 63%, 26%, 9%, and 2% of subjects took monthly or less, two to four times a month, two to three times a week, and at least four times a week, respectively. Only 2% of the subjects were heavy consumers of alcoholic beverages.Conclusion: Due to the lack of control over homemade alcoholic beverages, its high levels can be a huge potential risk. Furthermore, it seems that both factors of access and price to be very effective in the amount of alcoholics taken by individuals. Therefore, further studies in this area will help to reduce the harm caused by alcohol consumption.

Background: Total fertility rate in Iran has declined unprecedentedly over the past thirty years. However, debating on proper strategies to increase fertility is still a matter of discussion among experts. Objective: To explain the main strategies to increase fertility from the viewpoints of the policy makers. Methods: This is a qualitative study using content analysis. Purposeful sampling approach was used to gather data. The data were collected via semi-structured interviews. Eight experts participated in the study and the main criteria were executive experience related to public health, scientific publication in these areas and availability as well as their own interest. Content analysis was used to extract the codes. Results: The main theme extracted was improving the infrastructures. Almost all participants agreed on interventions around removing marriage obstacles, improving working conditions for women, improving the quality of the educational system, training and consultation, research, and improving services to increase fertility rate. Conclusions: The government should formulate long-term instead of short-term policies, and note that improving the economic conditions along with the promotion of social welfare, and enabling women in balancing work and family, are highly influential in childbearing decision-making, as they ensure a better future for the next generation. In addition, people should touch on the potential risk of future fertility reduction, so it is suggested to inform the public through free discussions.

Background In Islamic countries alcohol consumption is considered as against religious values. Therefore, estimation of frequency of alcohol consumptions using direct methods is prone to different biases. In this study, we indirectly estimated the frequency of alcohol use in Iran, in network of a representative sample using network scale up (NSU) method. Methods In a national survey, about 400 participants aged above 18 at each province, around 12 000 in total, were recruited. In a gender-match face to face interview, respondents were asked about the number of those who used alcohol (even one episode) in previous year in their active social network, classified by age and gender. The results were corrected for the level of visibility of alcohol consumption. Results The relative frequency of alcohol use at least once in previous year, among general population aged above 15, was estimated at 2.31% (95% CI: 2.12%, 2.53%). The relative frequency among males was about 8 times higher than females (4.13% versus 0.56%). The relative frequency among those aged 18 to 30 was 3 times higher than those aged above 30 (3.97% versus 1.36%). The relative frequency among male aged 18 to 30 was about 7%. Conclusion It seems that the NSU is a feasible method to monitor the relative frequency of alcohol use in Iran, and possibly in countries with similar culture. Alcohol use was lower than non-Muslim countries, however, its relative frequency, in particular in young males, was noticeable.

BACKGROUND Irritable bowel syndrome (IBS) is a digestive system disorder with an unknown etiology. Serotonin has a key role in the secretion and motility of the intestine. Polymorphism in serotonin reuptake transporter (SERT or SLC6A4) gene may have a functional role in the gut of patients with IBS. The aims of the present study were to investigate the association between SLC6A4 gene polymorphism and IBS and to detect the correlation between rectal serotonin levels and IBS sub-types. METHODS SLC6A4 gene polymorphism in 131 patients with IBS and 211 healthy controls were analysed using the quantitative polymerase chain reaction high-resolution melting (qPCR-HRM) curve technique. Serotonin was measured in rectal biopsies of patients with IBS using the enzyme-linked immunosorbent assay (ELISA) method. RESULTS The patients were categorized into three groups: IBS with diarrhoea (IBS-D): 70 patients, IBS with constipation (IBS-C): 18 patients, and IBS with mixed symptoms (IBS-M): 43 patients. The frequency of SLC6A4 s/s and l/s genotypes was significantly higher in IBS-C than IBS-D, IBS-M, and controls (p=0.036). Serotonin levels were similar in IBS sub-types. CONCLUSION SLC6A4 polymorphism is a possible candidate gene associated with the pathogenesis of IBS-C. Although serotonin levels did not differ in rectal biopsies of IBS sub-types, further investigation is recommended.

Background: Network Scale-up (NSU) method is an indirect method for the estimation of hidden behaviors. In NSU, respondents are asked about the number of members they know from a subpopulation of interest (e.g., injecting drug user) and assume that the prevalence of risky behavior in the networks of a random sample of respondents is similar to that of the population. However, first, we need to identify the total number of people each respondent knows [the social network size (C)]; Moreover, certain risky behaviors happen in particular age and gender groups. Our aim was to determine the size and age-gender distribution of female networks.Methods: This cross-sectional study was conducted in the city of Kerman, Iran. A total sample of 1275 women was recruited using multistage sampling. In this study, 25 first names were selected as reference groups. Participants were asked how many people they know with the selected names. The respondent’s answers were categorized into eight separate age-gender subgroups and C was estimated for each subgroup.Findings: The results of this study showed that, on average, each Kermanian woman knows about 234 people and about two-thirds of them are female (82 males and 152 females); moreover, participants were more likely to communicate with their peers. The majority of males (88%) known by Kermanian women were in young and middle age groups; in contrast the female young and middle age groups, who are at reproductive age, form only 45% of the female part of their networks.Conclusion: We have seen that the age-gender distribution of the networks is not the same as that of the general population. Our figures can be applied in NSU studies focusing on risky behaviors of particular age and gender groups.

BACKGROUND AND AIM: Poor oral health among children with impaired hearing has been reported frequently due to lack of communication skills and effective health educations. In this study, we assessed the effect of two training methods on short-term oral health outcomes among children with impaired hearing. METHODS: In this experimental study, 80 hearing impairment (HI) student aged 7-19 years old were randomized into two groups, one group watched a guided training video and the other group was educated by a dental model. The training sessions were weekly and continued for 1 month. A trained dentist examined all participants using O’Leary plaque index (PI) at baseline, 1-month, and 3-month visits. RESULTS: At baseline, the difference between the mean O’Leary PI in the video training and dental model training groups was not significant (34.3% vs. 35.6%). In the video training group, sharp decrease was seen at the 1-month visit (reinforcement periods), i.e., 18.7% (P = 0.001), followed by a slight increase at the 3-month visit (non-reinforcement periods), i.e., 19.1% (P = 0.100), respectively. On the other hand, in the dental model, a decreasing trend was seen 24.7% at 1-month (reinforcement periods) and 19.9% (P = 0.001) at 3-month visits (non-reinforcement periods). Overall, there were no significant differences between the two methods of training (P = 0.300). CONCLUSION: Both video and dental model effectively improve the oral health of children with HI in short term. Continuous school-based oral health education programs, particularly for HI children, need to be considered.

Background: Adherence to medical recommendations is very important to control gestational diabetes mellitus (GDM), as one of the most important disorders during pregnancy. In this study, we explored the impact of socio-economic status (SES) on the adherence of a cohort of GDM in Iran. Methods: In this prospective study, 230 pregnant women with confirmed GDM were followed from Feb to Jun 2013 in a referral diabetic care center in Iran. The SES of subjects were quantified using a combined score generated by principal component analysis (PSA). Medical adherence score of subjects was measured in three follow up visits in a range of 0 to 10 and were linked to SES using linear regression model. Results: The adherence scores women in the first, second, and third follow up visits were 5.06±2.12, 5.46±2.06, and 5.08±1, respectively. Women fourth quartile of SES (the highest level of SES) has a least compliance to medical orders in comparison to first quartile of SES (the lowest level of SES) with the OR -2.75 (95% Cl: -3.17, -2.23). Conclusion: The medical adherence of pregnant women with GDM is significantly poorer in high SES groups. Therefore, as an important determinant, we may target high SES pregnant women to control the adverse effects of the disorder more efficiently.

BackgroundNetwork Scale Up (NSU) is a promising tool for size estimation of sensitive issues. In this study we investigated the important methodological considerations to employ this method for estimating behaviors, such as abortion, which happens in a particular age-gender group.MethodsWe recruited 1250 males and 1250 females aged 18 to 50. Abortion rate was calculated through direct question and NSU methodology. The NSU was applied on three sub-samples (male, female and aggregate). Integrating replies to 25 reference groups, we estimated the network size (C) of respondents and its age-gender structure. To calculate the part of network that is subject to abortion, we compared two approaches: proportional and data based. The Visibility Factor (VF) was calculated through 222 females who had abortion. Direct estimate was considered as gold standard.ResultsUsing C's derived from proportional method, the Relative Bias (RB) in the male and female samples was 33% and 84%. Applying the data-based C's, the RB in the gender-specific and aggregate samples was 5% and 2%.ConclusionThe proportional method overestimates the prevalence. The data-based method to calculate the C is superior. The determination of the age-sex distribution of the network and the specific VF is essential.

Background: Dyslipidemia (DL) is an important risk factor of coronary artery disease (CAD). We evaluated DL prevalence and its 5-year incidence rate in southeastern Iran, to assess the severity and growth rate of this CAD risk factor in the region. Materials and Methods: This study was a part of the Kerman CAD Risk Factors Study Phase 2 (2014–2018) among 9996 individuals aged 15–80 years, from whom 2820 individuals had also participated in Phase 1 (2009–2011). In mg/dl, cholesterol ≥240 and/or low-density lipoprotein cholesterol ≥160 and/or high-density lipoprotein cholesterol 200 were defined as DL. Results: The lipid profile of 9911 persons was analyzed. Overall 19.6% had borderline cholesterol and 6.4% suffered from hypercholesterolemia. 56.6% of the population (62.5% of females vs. 48.5% of males) suffer from DL, from whom 73.4% were undiagnosed. Female gender, advanced age, obesity, hypertension, diabetes, anxiety, and depression predicted DL in the study population. The prevalence of DL was significantly lower in Phase 2 (56.6%) compared to Phase 1 (81.4%). The prevalence of undiagnosed DL (UDL) and diagnosed DL (DDL) was 40.7% and 16.2%, respectively. The 5-year incidence rate of DL was 2.58 persons/100 person-years (3.24 in females vs. 2.20 in males). Conclusion: Although there were promising signs of a reduction in DL and increase in DDL in the last 5 years, a high percentage of the population have DL yet, from whom mostly are undiagnosed. DL was significantly associated with other CAD risk factors. Therefore, the health-care management system should improve its strategies to reduce the health burden of DL.

Background: Chronic renal failure disease is considered as a health problem . Because of their high prevalence and economic burden on the society, health system managers consider to the disease as a public health concern. This study aimed at comparing the cost-effectiveness of long-term dialysis treatments and kidney transplant using DALY index. Materials and Methods:This cross-sectional study was designed to compare the cost-effectiveness of two methods such as long-term hemodialysis and kidney transplant using Disability Adjusted Life Years (DALY) in Afzalipour Hospital of Kerman in 2012. The decision tree model and TreeAge software were used for data analysis. In this research, costs and effects were studied from the patient perspective. Results: The cost of a kidney transplant was 165 million Rials, effectiveness of a kidney transplant was 4.40 DALY, chronic dialysis cost was 1.283 billion Rials and its effectiveness was 6.52 DALY. Cost-effectiveness ratio for dialysis was 196 million Rials per DALY and this ratio is 37 million Rials per DALY for a kidney transplant respectively. According to the findings, kidney transplant is more cost effective than dialysis. Conclusion: This study suggests kidney transplant over dialysis due to its better quality of life and more life expectancy. The results can help out the government to decide about the more resource allocation to kidney transplant programs. The method in this research can be applied to measure the cost-effectiveness of other organs transplantation.

Background Understanding the prevalence of symptoms associated with sexually transmitted infections (STIs) and how care is sought for those symptoms are important components of STIs control and prevention. People’s preference between public and private service providers is another important part of developing a well-functioning STIs surveillance system. Methods This cross-sectional survey was carried out in spring 2011, using a nonrandom quota sample of 1190 participants (52% female) in 4 densely-populated cities of Tehran, Kerman, Shiraz, and Babol. Two predictive logistic regression models were constructed to assess the association between the socio-demographic determinants (independent variables) and the dependent variables of history of STIs-associated symptom and seeking care. Results Around 57% (677 out of 1190; men: 29.70% and women: 81.80%) had experienced at least one STIsassociated symptom during the previous year. History of experiencing STIs-associated symptoms among men, was negatively significantly associated with older age (adjusted odds ratio [AOR] = 0.34, CI 95%: 0.17-0.67). Women who were married, in older ages, and had higher educations were more likely to report a recent (past year) STIs symptom, however all were statistically insignificant in both bivariate and multivariable models. Among those who have had STIs-associated symptoms in the last year, 31.15% did nothing to improve their symptoms, 8.03% attempted self-treatment by over-the-counter (OTC) medications or traditional remedies, and 60.93% sought care in health facilities. In both bivariate and multivariable analyses, care seeking among men was insignificantly associated with any of the collected demographic variables. Care seeking among women was positively significantly associated with being married (AOR = 2.48, 95% CI: 1.60-3.84). Conclusion The reported prevalence of STIs-associated symptoms among our participants is concerning. A considerable number of participants had delayed seeking care and treatment or self-medicated. People should be informed about their sexual health and the consequences of delaying or avoiding seeking care for STIs. Participants preferred seeking care at private sectors which calls for engaging both public and private health sectors for reporting and following up STIs cases.

Background & Aims: Maternal mortality is a tragedy which threatens human life. It is an indicator of womenʼs health and development of society as well. Therefore, prevention of maternal deaths is one of the main goals in many countries, including Iran. The aim of this study was to review and analyze the recorded data on maternal mortality in the country, in order to improve the management of maternal mortality. Methods: In this ecological study, the data related to the maternal mortality during the years 2007-2010 were obtained from the Health unit at the Iranian Ministry of Health and Medical Education. Data were analyzed according to the number of births during the studied period and the country indices using univariate and multivariate analysis methodologies. Results: The maternal mortality ratio (MMR) in the studied years was calculated by 22.3 per 100,000 of live births which showed the average reduction of 0.41 in every 100,000 births annually in the whole country. The highest value was reported in Sistan and Baluchistan province (48.6) and the lowest in Cheharmehal and Bakhtyari province (9.6). In Iran, the maternal mortality was relatively high in the age groups under the 15 (50.2 in every 100,000 child births) and over the 35 years (61.3 in every 100000 child births). The analysis related to the different provinces indicated that there was a significant reverse relationship between the maternal mortality ratio and variables of net attendance of girls in secondary schools, men and women literacy, access to improved water and sanitation, as well as antenatal and delivery care. Likewise, there was a significant positive relationship between the maternal mortality ratio and births in the house assisted by unskilled health personnel. Conclusion: This study showed the association between the health and social variables with maternal mortality ratio in Iran at an ecologic level. In order to reduce maternal mortality, more efforts seem to be essential to develop the various provinces, particularly poor areas.

Network scale-up is an indirect size estimation method, in which participants are questioned on sensitive behaviors of their social network members. Therefore, the visibility of the behavior affects the replies and estimates. Many attempts to estimate visibility have been made. The aims of this study were to review the main methods used to address visibility and to provide a summary of reported visibility factors (VFs) across populations. We systematically searched relevant databases and Google. In total, 15 studies and reports that calculated VFs were found. VF calculation studies have been applied in 9 countries, mostly in East Asia and Eastern Europe. The methods applied were expert opinion, comparison of NSU with another method, the game of contacts, social respect, and the coming-out rate. The VF has been calculated for heavy drug users, people who inject drugs (PWID), female sex workers (FSWs) and their clients, male who have sex with male (MSM), alcohol and methamphetamine users, and those who have experienced extra-/pre-marital sex and abortion. The VF varied from 1.4% in Japan to 52.0% in China for MSM; from 34.0% in Ukraine to 111.0% in China for FSWs; and from 12.0% among Iranian students to 57.0% in Ukraine for PWID. Our review revealed that VF estimates were heterogeneous, and were not available for most settings, in particular the Middle East and North Africa region, except Iran. More concrete methodologies to estimate the VF are required.

Introduction: Chronic kidney disease (CKD) is an important health problem that gradually leads to end-stage renal disease (ESRD). In ESRD patients, death due to other diseases or some events, such as renal transplantation (known as competing risks), would change the probability of observing the event of interest. The aim of this study was to estimate the survival of ESRD patients using competing risk analyses. Methods: In this retrospective longitudinal study, 307 ESRD patients who were older than 20 were recruited from the dialysis and kidney transplant Centers in Kerman City, Iran, from2007 to 2011. To assess the impacts of the investigated factors on the outcome, a cause-specific hazard model and competing risk models were fitted. Also, the cumulative incidence (CI) approach and sensitivity analysis were implemented. All of the analyses were performed using Stata software, V.12. Results: The results of competing risk models showed that age and type of dialysis were associated with death (hazard ratio (HR)=1.03, p

Background: The predictors of missing data when parents fill out questionnaire about their children′s diet are not defined. The aim of this study was to evaluate predictors which affect unresponsiveness to diet questions based on " Oral Health Situation of Iranian Children" Survey carried out in 1998. Materials and Methods: A dummy variable was created as dependent variable according to responding eight questions relating to diet. Then predictors of missing data were defined using multivariable logistic regression and classification tree method. To evaluate goodness of fit of logistic regression model, sensitivity and specificity were assessed. Classification tree analysis was done by Quest growing method. Significance level was set at 0.05 in logistic regression analysis. Observations and Results: "Missing data" variable was marked as missing in 616 (7.2%) of questionnaires. In logistic regression model revealed that, gender, mother′s education level and father′s education level didn′t affect "missing data" variable (P > 0.05). But, dmf index (OR = 0.94), Area of living (OR = 0.49), number of children in the family (OR = 1.19), sibling order (OR = 0.85), brushing (OR = 0.84) and visiting dentist (OR = 0.59) had statistically significant association with dependent variable (P < 0.05). Classification tree analysis showed that questionnaires related to children in urban area whose dmf index is under 5 and haven′t visited dentist are predicted to have missing data more than other groups. Conclusions: Area of living, dmf index, number of children in the family, sibling order, brushing and visiting dentist are significant variables for predicting the risk of missing data when asking parents about their children′s diet.

Background & Aim: Nowadays, we have some data in different sciences which number of zeros is more than expected, such data are called zero-inflated which can be modeled by regressions for count data. Many researches have been conducted in the field of classical method on count data. Most of Bayesian analysis which is conducted for these data used zero-inflated Poisson regression. Therefore, the main purpose of this research is comparison of Bayesian and classic approaches in regression of zero-inflated negative binomial (NB) on data for determining the size estimation of people who have used alcohol more than once in last year. Methods & Materials: This research had been in two provinces of Fars and Kerman in 2011, a sample size of each province was formed proportional to people of that province, and totally the calculated sample size was 700. Zero-inflated NB regression was fitted to the data in two Bayesian and classical methods, and then two methods have been compared. Results of Bayesian method were extracted in OpenBUGS software and through related codes in R and results of classical method were extracted in R software too. Results: After fitting classical method, variables of province, gender, age groups, and education had been effective on identifying number of alcoholics, but in Bayesian method, three variables of gender, age groups, and education have become significant. In this research, it was specified that obtained probability intervals from Bayesian method are much Widder than classical method. Conclusion: Results of this research indicate that Bayesian method has better function than the classic

Abstract: Despite the importance of body satisfaction on one’s self image and well-being, little has been written about body image or how it affects people in Iran. The aim of this study is to assess body dissatisfaction and its risk factors in the general Iranian population. The sample size for this cross-sectional study included approximately 1,200 participants (both male and female) and was conducted in 2011. Body dissatisfaction (based on the Figure Rating Scale), demographic characteristics, socioeconomic status, body mass index (BMI) and use of the media were recorded. Nearly two thirds of the participants were included in the middle age group and roughly half of them had a university education. Approximately two thirds of the participants were satisfied with their body. The mean score of body dissatisfaction in women was greater than men (p < 0.0001). Age, gender, marital status and BMI had a significant relationship with body dissatisfaction. The finding of this study demonstrates that in Iran, body dissatisfaction and it consequences must be addressed. While the prevalence and pattern of body dissatisfaction in Iran is as high as other Asian countries, considering cultural variation within Asian countries is also important.

OBJECTIVES Rates of attempted deliberate self-poisoning (DSP) are subject to undercounting, underreporting, and denial of the suicide attempt. In this study, we estimated the rate of underreported DSP, which is the most common method of attempted suicide in Iran. METHODS We estimated the rate and number of unaccounted individuals who attempted DSP in western Iran in 2015 using a truncated count model. In this method, the number of people who attempted DSP but were not referred to any health care centers, n0, was calculated through integrating hospital and forensic data. The crude and age-adjusted rates of attempted DSP were estimated directly using the average population size of the city of Kermanshah and the World Health Organization (WHO) world standard population with and without accounting for underreporting. The Monte Carlo method was used to determine the confidence level. RESULTS The recorded number of people who attempted DSP was estimated by different methods to be in the range of 46.6 to 53.2% of the actual number of individuals who attempted DSP. The rate of underreported cases was higher among women than men and decreased as age increased. The rate of underreported cases decreased as the potency and intensity of toxic factors increased. The highest underreporting rates of 69.9, 51.2, and 21.5% were observed when oil and detergents (International Classification of Diseases, 10th revision [ICD-10] code: X66), medications (ICD-10 code: X60-X64), and agricultural toxins (ICD-10 codes: X68, X69) were used for poisoning, respectively. Crude rates, with and without accounting for underreporting, were estimated by the mixture method as 167.5 per 100,000 persons and 331.7 per 100,000 persons, respectively, which decreased to 129.8 per 100,000 persons and 253.1 per 100,000 persons after adjusting for age on the basis of the WHO world standard population. CONCLUSIONS Nearly half of individuals who attempted DSP were not referred to a hospital for treatment or denied the suicide attempt for political or sociocultural reasons. Individuals with no access to counseling services are at a higher risk for repeated suicide attempts and fatal suicides.

Estimating the number of key populations at risk of HIV is essential for planning, monitoring, and evaluating prevention, care, and treatment programmes. We conducted this study to estimate the number of female sex workers (FSW) in major cities of Iran.We used three population size estimation methods (i.e., wisdom of the crowds, multiplier method, and network scale-up) to calculate the number of FSW in 13 cities in Iran. The wisdom of the crowds and multiplier methods were integrated into a nationwide bio-behavioural surveillance survey in 2015, and the network scale-up method was included in a national survey of the general population in 2014. The median of the three methods was used to calculate the proportion of the adult female population who practice sex work in the 13 cities. These figures were then extrapolated to provide a national population size estimation of FSW across urban areas.The population size of FSW was 91,500 (95% Uncertainty Intervals [UIs] 61,400-117,700), corresponding to 1.43% (95% UIs 0.96-1.84) of the adult (i.e., 15-49 year-old) female population living in these 13 cities. The projected numbers of FSW for all 31 provincial capital cities were 130,800 (95% UIs 87,800-168,200) and 228,700 (95% UIs 153,500-294,300) for all urban settings in Iran.Using methods of comparable rigor, our study provided a data-driven national estimate of the population size of FSW in urban areas of Iran. Our findings provide vital information for enhancing HIV programme planning and lay a foundation for assessing the impact of harm reduction efforts within this marginalized population.

Background & Objective: The main purpose of medical researches is to answer a research question or to solve a problem to promote the health of a society The first objective is to answer the research question correctly with minimal errors The second objective is the publication of the results in order to generalize them to a population and use in a wider dimension To achieve these objectives using biostatistics is necessary Despite the importance of biostatistics in medical research researchers have limited understanding of it or due to its complications they refrain from its use Statistics help the researcher in different levels of research including writing a proposal and interpretation of other papers Moreover biostatisticians and epidemiologists also play a very important role in the preparation of manuscripts for publication The present article has eloquently described the most important statistical tests in medical research with applied examples

Background The aim of this study was to examine the impacts of multiple indicators of Socio-economic Status (SES) on Congestive Heart Failure (CHF) related readmission. Methods A prospective study consisting of 315 patients without the history of admission due to CHF was carried out in Tehran during 2010 and 2011. They were classified into quartiles based on their SES applying Principal Component Analysis (PCA), and followed up for one year. Using stratified Cox regression analysis, Hazard Ratios (HRs) were computed to assess the impact of SES on the readmission due to CHF. Results During the 12 months follow-up, 122 (40%) were readmitted at least once. HR of lowest SES patients vs. the highest SES patients (the fourth versus first quartile) was 2.66 (95% CI= 1.51–4.66). Variables including abnormal ejection fraction (