An Islamic Bioethics Framework to Justify the At-risk Adolescents' Regulations on Access to Key Reproductive Health Services.

Adolescent sexuality is one of the most important reproductive health issues that confronts healthcare professionals with moral dilemmas and legal issues. In this study, we aim to justify the at-risk adolescents' regulations on access to key reproductive health services (KRHSs) based on principles of Islamic biomedical ethics and jurisprudence. Despite the illegitimacy and prohibition of sexuality for both girls and boys in Islamic communities, in this study, using 5 principles or universal rules of purpose; certainty, no-harm; necessity; and custom, we argue that first, applying these principles in the context of the no-harm principle can provide the best interests of at-risk adolescents; second, it is permissible to provide KRHSs to these adolescents with their own assent, as long as necessary, only with the intention of preventing or reducing harm. In this framework, while preventing harm, it tries to provide the best interests of at-risk adolescent. Thus, the principle of no-harm requires that the government, by designating the responsibility to healthcare professionals, protects at-risk adolescents from harm, and obliges these professionals to choose and implement the option that best suits adolescents' interests.

Primary Health Care Model for Non-Communicable Diseases Management during COVID-19 Pandemic in the Islamic Republic of Iran.

Background: Given the importance of appropriate response to prevent and manage Non-Communicable Diseases (NCDs), this study aimed to analyze the state of NCDs services at the level of the PHC system during the COVID-19 pandemic and to determine the main strategies. Methods: In this qualitative study, first, the circulars and guides in Iran's PHC system from the beginning of the pandemic to the end of September 2020 were retrieved manually and by searching the internal websites of the Ministry of Health. All documents about decision-making or governance and coordination mechanisms for the provision of NCDs services were enrolled and analyzed. In the second phase, the status of service delivery for major NCDs was presented in a model, and finally, SWOT analysis was used to analyze the situation and determine the main strategies. Results: 25 out of 199 circulars and guides were eligible and analyzed. In the crisis phase, most risk assessment, screening, and diagnosis services for NCDs have been suspended, and follow-up and care of patients with major NCDs were done by telephone. In the reopening phase, the general strategies and strategies to increase capacity and provide delayed care were adopted, and the PHC model of the provision of essential services for the major NCDs was developed in low-risk, intermediate and high-risk pandemic conditions. Finally, 16 main strategies were determined with the approach of integrating and focusing on essential services, considering vulnerable groups and the use of E-health technologies. Conclusion: The results indicate on interruption of NCDs services in the crisis phase while adopting strategies for responding to the pandemic. Revision of the COVID-19 guides with a particular focus on NCDs is recommended.

The Relationship Between Death and Do Not Resuscitation Attitudes Among Intensive Care Nurses.

This study aimed to determine the relationship between death and DNR attitudes among ICNs. This descriptive-analytical study was performed on 156 ICNs in 2018. All nurses were enrolled in the study; data collection instruments included Death Attitude Profile-Revised (DAP-R) and the DNR attitude questionnaires. The mean scores of DAP-R and DNR items were 150.89/ ± 23.59 and 91.82 ± 11.41, respectively. There was a significant relationship between death attitude and DNR attitude Famong ICNs. All dimensions of DAP-R significantly predicted attitude toward DNR (P < 0.05). Among those, "neutral acceptance" (1.17 [95% CI (0.68--1.65)] was the strongest predictor and "death avoidance" was the weakest predictor (0.36 [95% CI (0.09--0.62)]. There was a significant relationship between the ICNs' work experience and attitude toward DNR (p = 0.03). The findings can be used in formulation of the national guideline for DNR order.

The Effect of the COVID-19 Pandemic on Non-Communicable Disease Prevention and Management Services in the Primary Health Care System of Iran.

Background: The COVID-19 pandemic has caused significant disruptions in the provision of non-communicable disease (NCDs) prevention and control services in many countries, and there is a concern that it would lead to long-term complications of the diseases. The aim of this study is to assess the changes in the provisions of selected NCD services before and after the COVID-19 epidemic in Iran's primary healthcare system. Methods: In this descriptive-analytical retrospective study, the number of eight NCD services provided during the first 10 months of the COVID-19 pandemic from Feb 2020 to Dec 2020 were compared with the same period in the previous year using the data from the Iranian integrated electronic health record system (SIB) and also the association between the number of deaths due to COVID-19 and a sample of NCD services were assessed using cross-correlation analysis. The statistical analysis was performed in Stata Software v.14. Results: The NCD services have decreased by an average of 18.89% compared to the same period in the previous year; this decline was much more severe at the beginning of the epidemic period (up to 75% in some services) and was greater in physician-provided services than in non-physician services. Also, examining the course of the selected services during this period, a gradual compensation was evident after the initial reduction. Conclusion: The general trend of the selected services of prevention and control of NCDs in the PHC system of Iran within 10 months after the onset of COVID-19 showed a sharp decline and subsequent gradual compensation. Although the process of compensation in some services may be considered somewhat reassuring, in the case of some essential services, more effort and attention to the implementation of programs or compensatory policies seem necessary.

Survival of very preterm infants in the Islamic Republic of Iran: A population-based retrospective cohort study.

Background: Estimation of the survival of very preterm infants is necessary to make decisions and design interventions in order to improve their quality of care. This survey aimed to estimate the survival of very preterm infants born at 23 up to 33 weeks of gestational age (GA) in Iran. Methods: This population-based retrospective cohort study included 8536 infants born before 33 weeks of GA, from March 21st to December 22nd 2013 in Iran. The primary data were extracted from the Iranian national maternal and neonatal registration network (IMAN). All infants who have been discharged alive, followed up by telephone contact up to one year after birth. The Kaplan-Meier and Log-rank tests were performed to estimate survival and to compare survivals, respectively, using SPSS version 26 and R 3.5.2 softwares. Results: The overall survival was estimated at 56.70% (95% C.I: 55.60%-57.80%) at the end of the follow-up period. Total death rate was estimated at 43.30% and was significantly decreased with increasing birth weight (p<0.0001). Survival was increased significantly with increasing GA (p<0.0001), from 5.7% at 23 weeks to 79.6% at 32 weeks. The estimated cumulative proportion of death until the end of the neonatal period had a decreasing trend and then had a steady trend until the end of the follow-up period. The hazard ratio of quadruple or more birth and GA were 1.46 (p=0.021) and 0.83 (p<0.001), respectively. Conclusion: The overall estimated survival of very preterm infants was not high. Even with modern perinatal technology and care, early deaths of very preterm infants were still common.

Situation Analysis of Ear and Hearing Care Program in Islamic Republic of Iran: System's Challenges and Proper Interventions.

Background: More than 6.8% of the world's population suffer from disabling hearing impairment. Hearing impairment can cause lifelong or even life-threatening problems and has a significant impact on the health and quality of life. This study aimed to analyze the current situation of the ear and hearing care (EHC) in the frame of Iran health system. Methods: This situation analysis was performed over a 5-year period (2013-2017) using the Strengths, Weaknesses, Opportunities, and Threats analysis method. First, after formation of the steering committee, all relevant published and unpublished articles and reports were reviewed and analyzed. In the next step, focused group discussion sessions (FGDs) were held with the participation of the experts, stakeholders, and Steering Committee members. Through the scissor-and-sort technique, the relevant data were highlighted and main categories evolved. Results: The main challenges included inadequate health literacy, weak intrasectoral and intersectoral cooperation, the inadequacy of policy responses, nonintegration of the EHC in the primary health care system, poor standard processes, and resources of EHC, and lack of EHC surveillance system. The 6 major interventions and strategies extracted as identifying the capacities of both the public and private sectors, reinforcement of intersectoral cooperation and intersectoral collaboration, standardizing the processes and integrating of EHC services in the PHC, reorganizing the referral system, promoting hearing health literacy, and minimizing hearing loss risk factors. Conclusion: Implementing the proposed interventions and strategies is essential to improve the situation of Iran EHC management system during the next 5 years.

Baseline Characteristics and Associated Factors of Mortality in COVID-19 Patients; an Analysis of 16000 Cases in Tehran, Iran.

Introduction. INTRODUCTION: Given the importance of evidence-based decision-making, this study aimed to evaluate epidemiological and clinical characteristics as well as associate factors of mortality among admitted COVID-19 cases. METHODS: This multicenter, cross-sectional study was conducted on confirmed and suspected COVID-19 cases who were hospitalized in 19 public hospitals affiliated to Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran, between February 19 and May 12, 2020. Epidemiological and clinical characteristics of the infected cases were compared between the deceased and survivors after discharge. Case fatality rates (CFRs) were calculated across all study variables. Single and multiple logistic regressions were used to explore the risk factors associated with COIVD-19 mortality. RESULTS: Out of the 16035 cases that referred to the hospitals affiliated to SBMU, 16016 patients (99.93% of Confirmed and 99.83% of suspected cases) were hospitalized. 1612 patients died with median hospitalization days of 5 (interquartile range (IQR): 2-9) and 3 (1-7) for confirmed and suspected COVID-19 cases, respectively. The highest death rate was observed among ages>65 (63.4% of confirmed cases, 62.3% of suspected cases) and intensive care unit (ICU)/critical care unit (CCU) patients (62.7% of confirmed cases, 52.2% of suspected cases). Total case fatality rate (CFR) was 10.05% (13.52% and 6.37% among confirmed and suspected cases, respectively). The highest total CFR was observed in patients with age>65 years (25.32%), underlying comorbidities (25.55%), and ICU/CCU patients (41.7%). The highest CFR was reported for patients who had diabetes and cardiovascular diseases (38.46%) as underlying non-communicable diseases (NCDs), and patients with cancer (35.79%). CONCLUSION: This study showed a high CFR among suspected and confirmed COVID-19 cases, and highlighted the main associated risk factors including age, sex, underlying NCDs, and ICU/CCU admission affecting survival of COVID-19 patients.

Adoption of Iran's code of ethics for blood donation and transfusion as a public health policy.

Blood is a public resource of human origin and its transfusion process is essential to individual and public health. This study aimed to develop a national code of ethics for blood donation and transfusion (BDT). This was a qualitative research with a multi methods approach in which a combination of methods including situational analysis, focus group discussion and expert panels were used. After situational analysis and orientation, the code of ethics for BDT was developed based on the findings of a content analysis within the framework of the four principles of biomedical ethics. The results were categorized into two sections: situational analysis and underpinnings measures, and the clauses of the code. The Iranian Blood Transfusion Organization has carried out three essential supportive measures over the past decades: approval of insurance coverage of blood recipients against communicable diseases; inclusion of 14 blood services in the book of "Relative Value Units of Health Services"; and formation of the National Ethics Committee of Transfusion Medicine. After recognition and orientation, the national code of ethics for BDT was adopted and imparted to blood donation centers. The code consists of two sections: "Blood Transfusion Centers: Donors and Donation" in 19 clauses, and "Hospitals: Patients" in 8 clauses. The national code of ethics for BDT establishes moral norms in order to protect the rights of blood donors and recipients. It could also serve as a basis for addressing the related ethical challenges and right decision-making in the area of BDT.

Ethical Considerations from the Viewpoint of Headquarters Experts on HIV/AIDS Prevention and Control Strategic Program.

BACKGROUND: The HIV control and prevention program is one of the Public Health programs that confronts with many ethical challenges. This study aimed to explore ethical considerations from the viewpoint of headquarters experts on HIV and AIDS prevention and control strategic plan. METHODS: In this qualitative study with content analysis design, focus group discussion method was utilized. After purposeful introduction of the experts and previous coordination about subject and time, two discussion sessions were held with the participation of six ministry and university headquarters experts of HIV control program. After frequent reviews of the data and using deductive content analysis, main themes and subthemes were categorized. In order to transformability of the findings to similar situations, the data were checked by three external reviewers. RESULTS: The participants agreed that HIV/AIDS control requires focusing on prevention, treatment, and support services, and considering the general population and all vulnerable groups. In this study, five main themes were emerged: informing and empowering to make autonomous decisions, observing confidentiality, prohibiting stigma and discrimination, and being accountable. CONCLUSIONS: The viewpoint of participants indicates on the more need to pay attention the mentioned ethical considerations when compiling and finalizing the program. Moreover, in addition to instructing moral norms in PH programs with a special look to HIV/AIDS and how to apply them in the formulation and implementation of program, systematic evaluation of the program by an ethical framework is recommended to ensure the achievement to the goals of program.

Assessing staff-oriented care with developmental support approach in Iranian NICUs.

BACKGROUND: Regarding improvements in preterm infants' survival rates, it is necessary the improvement of Neonatal Intensive Care Unit (NICUs) status in order to provide comprehensive care. The aim of this study was to assess the aspects of staffing-oriented neonatal care in NICUs affiliated to Universities of Medical Sciences in Iran. METHODS: This survey is a cross-sectional study which was conducted in 23 NICUs of nine type-1 Universities of Medical Sciences across country. The study checklist contained 39 items in four domains, including "Composition, Philosophy, Training, and Support", "Management", "Resources", and "Transition Systems". Data were gathered through observation and analyzed using Stata software, version 13. RESULTS: In this study, the mean score of staffing-oriented care was 43.5 of 100. In none of the studied domains, the mean score obtained was not above 50. Among the four domains studied, the highest score was related to "Management", (the mean score of 50 of 100) and the lowest score related to "Resources" (the mean score of 35 of 100). CONCLUSIONS: Considering the importance of the role of health professionals in the neonatal comprehensive care, and also the low mean score of staffing-oriented care (43.51 out of 100) and also its items in NICUs in this study, it is concluded that more attention is needed for staff-oriented care as well as the strengthening of this dimension of developmental care along with other dimensions, through designing of appropriate interventions to improve the health outcomes of preterm infants.

Severity and frequency of moral distress among midwives working in birth centers.

BACKGROUND: When individuals are aware of the appropriate ethical practice, but lack the ability to do it, they will suffer from moral distress. Moral distress is a frequent phenomenon in clinical practice which can have different effects on the performance of physicians, nurses, and midwives, and therefore patients and health care systems. RESEARCH OBJECTIVE: The present study aimed to determine the severity and frequency of moral distress in midwives working in birth centers. RESEARCH DESIGN: This study is a descriptive cross-sectional research. Researcher-made questionnaire was used to gather data. PARTICIPANTS AND RESEARCH CONTEXT: A total of 180 midwives working in the labor ward of the public birth centers affiliated to Shahid Beheshti University of Medical Sciences were included to the study by census. ETHICAL CONSIDERATIONS: Official permission for data collecting was obtained from the directors of the birth centers affiliated to Shahid Beheshti University of Medical Sciences. Then, after explaining the objectives of the study and assuring the confidentially of information, verbal consent of the participants was obtained. FINDINGS: The total mean ± standard deviation of the severity and frequency of moral distress were 3.85 ± 0.75 and 3.03 ± 0.48, respectively. The highest severity and the lowest frequency of moral distress were obtained for the assistance for abortion and the lowest severity of moral distress was related to the organizational domain. However, the highest frequency of moral distress was related to futile care field. The mean of moral distress severity in the midwives with associate degree was significantly lower than other levels of education. Also, there was a significant relationship between age and moral distress frequency (p = 0.010). DISCUSSION: The midwives' moral distress was relatively high as expected. This finding is consistent with the results of similar studies in intensive care unit nurses. CONCLUSION: After identifying the level and most important factors of moral distress among midwives, the next step is empower them to prevent moral distress, in particular efforts to change structures.

Analysis of Iranian Youth Health Policy: Necessity of Action-oriented Interventions.

BACKGROUND: Protecting the youth and adolescents' health is considered to be an indicator of health equity. The current study was conducted to analyze health status of the Iranian youth and adolescents, identify service gaps, and design action-oriented interventions. METHODS: In this study with multimethods design conducted in 2014, first to identify and analyze the current situation, related articles and national and international documents were searched and reviewed. Then, stakeholders' analysis, interviews, group discussion, and analysis of the youth and adolescent health management system were done, and the policy document was drew up in three sections of recognition, orientation, and suggested interventions. RESULTS: The most important focus areas of the youth and adolescents' health were identified to be their behavior and lifestyle, less advantaging of primary health care in cities, and high rates of educational dropouts. Considering a responsive national structure to develop and implement a comprehensive and integrated program for educating healthy lifestyles and reducing risky behaviors and focusing on accident prevention as a first priority at the level of impact and planning on risk factors of noncommunicable and communicable diseases related to sexually transmitted infections and AIDS at the outcome-level indicators is a necessity through intersectoral collaboration and community participation strategies. CONCLUSIONS: Achieving premiere indicators of the Iranian youth health requires political commitment and support of the state, more than ever. To cooperation and utilize the capacity of other sectors to implement the Ministry of Health and Medical Education programs, establishment of the youth health commission is recommended with participation of the main partners.

The evolution of public health ethics frameworks: systematic review of moral values and norms in public health policy.

Given the evolution of the public health (PH) and the changes from the phenomenon of globalization, this area has encountered new ethical challenges. In order to find a coherent approach to address ethical issues in PH policy, this study aimed to identify the evolution of public health ethics (PHE) frameworks and the main moral values and norms in PH practice and policy. According to the research questions, a systematic search of the literature, in English, with no time limit was performed using the main keywords in databases Web of Science (ISI) and PubMed. Finally, the full text of 56 papers was analyzed. Most of the frameworks have common underpinning assumptions and beliefs, and the need to balance PH moral obligation to prevent harm and health promotion with respect for individual autonomy has been specified. As such, a clear shift from liberal values in biomedical ethics is seen toward the community's collective values in PHE. The main moral norms in PH practice and policy included protecting the population against harm and improving PH benefits, utility and evidenced-based effectiveness, distributive justice and fairness, respect for all, privacy and confidentiality, solidarity, social responsibility, community empowerment and participation, transparency, accountability and trust. Systematic review of PHE frameworks indicates utilization of the aforementioned moral norms through an practical framework as an ethical guide for action in the PH policy. The validity of this process requires a systematic approach including procedural conditions.

Assessing infant-oriented care with developmental support approach in Iranian NICUs.

INTRODUCTION: Developmental care program is a comprehensive program to reduce secondary effects of NICU and special care on brain development in premature infants. This study aimed to assess neonatal care situation in Iranian NICUs based on developmental approach to design and provide clinical guidelines for daily care for the caregivers and the infant's family. METHODS: This was a cross-sectional study conducted in NICUS in Iran. A total of 23 NICUs of 9 Universities of Medical Sciences were investigated. The checklist contains 30 items in 6 domains. Data were analyzed using STATA software, version 13. RESULTS: The total mean score obtained from all six domains was 31.29 of 100, and in all domains, the mean scores calculated were not above 50. In "supporting infant," "developmental caregiving activities," "supporting the infants' state organization," "providing neonatal pain management," "developmental care approaches in documentation," and "developmental care approaches in NICU staffing," the total mean scores were 34.76, 21.6, 20, 30.18, 31.30, and 50, respectively. CONCLUSION: The low mean score of infant-centered developmental care implies health staff's focus on neonatal care with at least the quality of care and its impact on development in preterm infants, and inadequate attention to the infant as an active member in care.

Clinical Outcomes of High-Risk Infant Follow-Up Program in a Tertiary Care Centre.

BACKGROUND: High-risk infant follow-up (HRIF) program is necessary for early detection, timely intervention, and promotion of health outcomes in vulnerable infants, ethically. The present study was carried out to assess the clinical outcomes of the HRIF Program in Alzahra hospital as a tertiary care centre, in Iran. MATERIALS AND METHODS: In this cohort study, 5840 neonates were born at Alzahra hospital, from June 1, 2011 to 30th February 2012. Among those who were admitted to neonatal intensive care unit (NICU), 253 infants were recruited by census according to HRIs criteria. After doing necessary measurements and family education, information was recorded in HRI health certificate and then entered in the access database for analysis. RESULTS: From 253 eligible HRIs registered, 241 (95%) infants attended the follow-up clinic after discharge. A total of180 cases were recalled for further visits, 110 of which attended the clinic. Anthropometric indices had an increasing trend in the first 6 months of life. There was no significant relation between ages and stages questionnaire (ASQ) results and infant birth weight, height, and head circumference. The ratios of intraventricular hemorrhage (IVH) and retinopathy of prematurity (ROP) were 8.7% and 3.1%, respectively. The incidence of congenital hypothyroidism was 2:341 in HRIs. CONCLUSIONS: Although some outcomes, such as ROP, improved in our study compared to similar studies, the findings indicate an impairment of the current follow-up processes and highlight the necessity to modify the current HRIF program. Ethically, we insist on integrating HRIF program in child health services to promote early childhood development.

Exploring perceptions of instructors about childbirth preparation training courses: A qualitative study.

BACKGROUND: Childbirth preparation training courses on maternal and neonatal health increase awareness, and capability of pregnant women in overcoming fear and anxiety and managing labor pains. OBJECTIVE: To identify the affecting factors and barriers of these courses from the perspective of their instructors. METHODS: This qualitative study of the content analysis type, has been conducted on 16 certified teachers of the training courses of the Hamadan city in 2015. Data were collected by semi-structured in-depth interviews and were then analyzed by using MAXQDA10 application. RESULTS: Participants' experiences are indicated on three main themes including the objectives of the course, facilitators and barriers. The main objectives of the course were reported as to improve maternal and newborn health, promote natural childbirth and preparedness for parenting and breastfeeding. The main facilitators of the successful implementation include observing educational standards, strengthening the communication and relationship between mothers and staff, mobilization, and the role of instructor. The major barriers are reported as inadequate support from management system, insufficient intra-sector collaboration, poor attitude of obstetricians and physicians, inadequate access, theory-practice gap and not intended to labor naturally. CONCLUSION: The results of our study show that multiple factors are involved in the participation of pregnant women in antenatal classes. Promoting natural childbirth requires intra-sector and inter-sectoral collaboration, as well as the community participation.

Analyzing the politico-moral foundations of the Iran's health system based on theories of justice.

Public health ethics is a field that covers both factual and ethical issues in health policy and science, and has positive obligations to improve the well-being of populations and reduce social inequalities. It is obvious that various philosophies and moral theories can differently shape the framework of public health ethics. For this reason, the present study reviewed theories of justice in order to analyze and criticize Iran's general health policies document, served in 14 Articles in 2014. Furthermore, it explored egalitarianism as the dominant theory in the political philosophy of the country's health care system. According to recent theories of justice, however, health policies must address well-being and its basic dimensions such as health, reasoning, autonomy, and the role of the involved agencies and social institutions in order to achieve social justice beyond distributive justice. Moreover, policy-making in the field of health and biomedical sciences based on Islamic culture necessitates a theory of social justice in the light of theological ethics. Educating people about their rights and duties, increasing their knowledge on individual agency, autonomy, and the role of the government, and empowering them will help achieve social justice. It is recommended to design and implement a strategic plan following each of these policies, based on the above-mentioned values and in collaboration with other sectors, to clarify the procedures in every case.

High Risk Infants Follow-Up: A Case Study in Iran.

Background. A follow-up program for high risk infants was initiated in Alzahra Maternity Hospital in Tabriz city, Iran, in 2013. The aim of this paper is to give a brief report of the program. Material and Methods. Two groups of high risk neonates were studied. The first group comprising 509 infants received services in Alzahra Maternity Hospital implemented by the follow-up program. This included a full package for family to look after high risk infant and periodic clinical evaluation at two and four weeks after birth and then two, three, four, five, and six months later again. The second group including 131 infants in Taleqani Maternity Hospital received routine services after birth with no specific follow-up care. Results. Some anthropometric indices showed a significant improvement in the intervention hospital compared to control group. These included the following: head circumference at first and second months; weight in the first, fourth, fifth, and sixth months; and height in sixth month only. Clinical evaluation of infants showed an improvement for some of the medical conditions. Conclusion. Follow-up care program for a minimum of six months after discharge from maternity hospitals may help to avoid adverse and life threatening consequences in high risk infants.