Improving oral health and related health behaviours (substance use, smoking, diet) in people with severe and multiple disadvantage: A systematic review of effectiveness and cost-effectiveness of interventions.

BACKGROUND: People experiencing homelessness co-occurring with substance use or offending ('severe and multiple disadvantage' SMD) often have high levels of poor oral health and related health behaviours (particularly, substance use, smoking, poor diet). This systematic review aimed to assess the effectiveness and cost-effectiveness of interventions in adults experiencing SMD to improve oral health and related health behaviours. METHODS AND FINDINGS: From inception to February 2023, five bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus) and grey literature were searched. Two researchers independently screened the search results. Randomized controlled trials (RCTs), comparative studies and economic evaluations were included that reported outcomes on oral health and the related health behaviours. Risk of bias was assessed and results narratively synthesized. Meta-analyses were performed where appropriate. This review was registered with PROSPERO (reg. no: CRD42020202416). Thirty-eight studies were included (published between 1991 and 2023) with 34 studies reporting about effectiveness. Most studies reported on substance use (n = 30). Interventions with a combination of housing support with substance use and mental health support such as contingent work therapy appeared to show some reduction in substance use in SMD groups. However, meta-analyses showed no statistically significant results. Most studies had short periods of follow-up and high attrition rates. Only one study reported on oral health; none reported on diet. Three RCTs reported on smoking, of which one comprising nicotine replacement with contingency management showed improved smoking abstinence at 4 weeks compared to control. Five studies with economic evaluations provided some evidence that interventions such as Housing First and enhanced support could be cost-effective in reducing substance use. CONCLUSION: This review found that services such as housing combined with other healthcare services could be effective in improving health behaviours, particularly substance use, among SMD groups. Gaps in evidence also remain on oral health improvement, smoking, and diet. High quality studies on effectiveness with adequate power and retention are needed to address these significant health challenges in SMD populations.

Is primary trabeculectomy cost-effective for patients with advanced primary open angle glaucoma? Results from the Treatment of Advanced Glaucoma Study economic model.

BACKGROUND/AIMS: Advanced primary open angle glaucoma (POAG) is a lifelong condition. The aim of this study is to compare medical treatment against trabeculectomy for patients presenting with advanced POAG using an economic evaluation decision model. METHODS: A Markov model was used to compare the two treatments, medical treatment versus trabeculectomy for the management of advanced POAG, in terms of costs and quality-adjusted life-years (QALYs). The uncertainty surrounding the model findings was assessed using probabilistic sensitivity analysis and deterministic analysis. Data for the model came from Treatment of Advanced Glaucoma Study supplemented with data from the literature. The main outcomes of the model presented in terms of Incremental costs and QALYs based on responses to the EQ-5D-5L, Health Utilities Index-3 and a Glaucoma Utility Index. RESULTS: In the base-case analysis (lifetime horizon and EQ-5D-5L measure), participants receiving trabeculectomy had on average, an additional cost of £2687, an additional 0.28 QALYs and an incremental cost per QALY of £9679 compared with medical treatment. There was a 73% likelihood of trabeculectomy being considered cost-effective when society was willing to pay £20 000 for a QALY. Over shorter time horizons, the incremental cost per QALY gained from trabeculectomy compared with medical treatment was higher (47 663) for a 2-year time horizon. Our results are robust to changes in the key assumptions and input parameters values. CONCLUSION: In patients presenting with advanced POAG, trabeculectomy has a higher probability of being cost-effective over a patient's lifetime compared with medical treatment.

Evaluating Primary Treatment for People with Advanced Glaucoma: Five-Year Results of the Treatment of Advanced Glaucoma Study.

PURPOSE: To determine whether primary trabeculectomy or medical treatment produces better outcomes in terms of quality of life (QoL), clinical effectiveness, and safety in patients with advanced glaucoma. DESIGN: Multicenter randomized controlled trial. PARTICIPANTS: Between June 3, 2014, and May 31, 2017, 453 adults with newly diagnosed advanced open-angle glaucoma in at least 1 eye (Hodapp classification) were recruited from 27 secondary care glaucoma departments in the United Kingdom. Two hundred twenty-seven were allocated to trabeculectomy, and 226 were allocated medical management. METHODS: Participants were randomized on a 1:1 basis to have either mitomycin C-augmented trabeculectomy or escalating medical management with intraocular pressure (IOP)-reducing drops as the primary intervention and were followed up for 5 years. MAIN OUTCOME MEASURES: The primary outcome was vision-specific QoL measured with the 25-item Visual Function Questionnaire (VFQ-25) at 5 years. Secondary outcomes were general health status, glaucoma-related QoL, clinical effectiveness (IOP, visual field, and visual acuity), and safety. RESULTS: At 5 years, the mean ± standard deviation VFQ-25 scores in the trabeculectomy and medication arms were 83.3 ± 15.5 and 81.3 ± 17.5, respectively, and the mean difference was 1.01 (95% confidence interval [CI], -1.99 to 4.00; P = 0.51). The mean IOPs were 12.07 ± 5.18 mmHg and 14.76 ± 4.14 mmHg, respectively, and the mean difference was -2.56 (95% CI, -3.80 to -1.32; P < 0.001). Glaucoma severity measured with visual field mean deviation were -14.30 ± 7.14 dB and -16.74 ± 6.78 dB, respectively, with a mean difference of 1.87 (95% CI, 0.87-2.87 dB; P < 0.001). Safety events occurred in 115 (52.2%) of patients in the trabeculectomy arm and 124 (57.9%) of patients in the medication arm (relative risk, 0.92; 95% CI, 0.72-1.19; P = 0.54). Serious adverse events were rare. CONCLUSIONS: At 5 years, the Treatment of Advanced Glaucoma Study demonstrated that primary trabeculectomy surgery is more effective in lowering IOP and preventing disease progression than primary medical treatment in patients with advanced disease and has a similar safety profile. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Interventions to improve oral health and related health behaviours of substance use, smoking, and diet in people with severe and multiple disadvantage: a systematic review of effectiveness and cost-effectiveness.

BACKGROUND: Homelessness overlapping with substance use and offending is described as severe and multiple disadvantage (SMD). People experiencing SMD have poor oral health along with high levels of related behaviours such as substance use, smoking, and poor diet. Existing evidence largely describes the prevalence of oral health problems, substance use, and smoking in SMD groups. Little is known about interventions that can address these conditions in SMD groups. We aimed to review the effectiveness and cost-effectiveness of interventions on oral health and related health behaviours in adults experiencing SMD. METHODS: For this systematic review, we searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, EBSCO, Scopus) and grey literature for papers published from inception to February 2023. Two researchers independently reviewed the searches. Randomised controlled trials (RCTs), comparative studies and economic evaluations were included. Risk of bias was assessed. Population included adults experiencing SMD (including homelessness and substance use or repeat offending). Outcomes included oral health, and related behaviours (substance use, smoking, poor diet). Results were narratively synthesised. This review was registered with PROSPERO, CRD42020202416. FINDINGS: The review included 38 studies (published between 1991 and 2023), with 34 reporting effectiveness. These studies comprised of 23 RCTs and 11 quasi-experimental studies conducted in the USA (25 studies), Canada (seven studies), France (one study), and Spain (one study). The interventions involving multiple components, such as housing services with substance use and mental health support, effectively reduced substance use in SMD groups; these were mostly individual-level interventions. However, these studies had short follow-up periods and high attrition rates. Only one study addressed oral health outcomes, none focused on diet, and three RCTs covered smoking, with one intervention showing smoking abstinence at 4 weeks. Some limited evidence suggested cost-effectiveness of substance use interventions. INTERPRETATION: This review found that integrating services such as housing with other health-care services together could be effective in improving health behaviours, especially substance use among SMD groups. More evidence is needed specifically on oral health, smoking, and diet-related interventions. The generalisability of findings of this review is limited to high-income countries and shorter-term outcomes. FUNDING: National Institute for Health and Care Research (NIHR) Policy Research Programme.

Economic evaluations of interventions to prevent and control health-care-associated infections: a systematic review.

Almost 9 million health-care-associated infections have been estimated to occur each year in European hospitals and long-term care facilities, and these lead to an increase in morbidity, mortality, bed occupancy, and duration of hospital stay. The aim of this systematic review was to review the cost-effectiveness of interventions to limit the spread of health-care-associated infections), framed by WHO infection prevention and control core components. The Embase, National Health Service Economic Evaluation Database, Database of Abstracts of Reviews of Effects, Health Technology Assessment, Cinahl, Scopus, Pediatric Economic Database Evaluation, and Global Index Medicus databases, plus grey literature were searched for studies between Jan 1, 2009, and Aug 10, 2022. Studies were included if they reported interventions including hand hygiene, personal protective equipment, national-level or facility-level infection prevention and control programmes, education and training programmes, environmental cleaning, and surveillance. The British Medical Journal checklist was used to assess the quality of economic evaluations. 67 studies were included in the review. 25 studies evaluated methicillin-resistant Staphylococcus aureus outcomes. 31 studies evaluated screening strategies. The assessed studies that met the minimum quality criteria consisted of economic models. There was some evidence that hand hygiene, environmental cleaning, surveillance, and multimodal interventions were cost-effective. There were few or no studies investigating education and training, personal protective equipment or monitoring, and evaluation of interventions. This Review provides a map of cost-effectiveness data, so that policy makers and researchers can identify the relevant data and then assess the quality and generalisability for their setting.

Global prevalence of nosocomial infection: A systematic review and meta-analysis.

OBJECTIVES: Hospital-acquired infections (HAIs) are significant problems as public health issues which need attention. Such infections are significant problems for society and healthcare organizations. This study aimed to carry out a systematic review and a meta-analysis to analyze the prevalence of HAIs globally. METHODS: We conducted a comprehensive search of electronic databases including EMBASE, Scopus, PubMed and Web of Science between 2000 and June 2021. We found 7031 articles. After removing the duplicates, 5430 studies were screened based on the titles/ abstracts. Then, we systematically evaluated the full texts of the 1909 remaining studies and selected 400 records with 29,159,630 participants for meta-analysis. Random-effects model was used for the analysis, and heterogeneity analysis and publication bias test were conducted. RESULTS: The rate of universal HAIs was 0.14 percent. The rate of HAIs is increasing by 0.06 percent annually. The highest rate of HAIs was in the AFR, while the lowest prevalence were in AMR and WPR. Besides, AFR prevalence in central Africa is higher than in other parts of the world by 0.27 (95% CI, 0.22-0.34). Besides, E. coli infected patients more than other micro-organisms such as Coagulase-negative staphylococci, Staphylococcus spp. and Pseudomonas aeruginosa. In hospital wards, Transplant, and Neonatal wards and ICU had the highest rates. The prevalence of HAIs was higher in men than in women. CONCLUSION: We identified several essential details about the rate of HAIs in various parts of the world. The HAIs rate and the most common micro-organism were different in various contexts. However, several essential gaps were also identified. The study findings can help hospital managers and health policy makers identify the reason for HAIs and apply effective control programs to implement different plans to reduce the HAIs rate and the financial costs of such infections and save resources.

Hemodialysis and peritoneal dialysis-health-related quality of life: systematic review plus meta-analysis.

BACKGROUND: Patients with end-stage renal disease undergoing haemodialysis experience a variety of stressors leading to decreased level of quality of life (QoL). Thus, in this study, we aimed to review the current literature and identify factors affecting the health-related QoL (HRQoL) in these patients. METHODS: A total of 147 studies were extracted from databases of Web of Science, PubMed, Scopus, Google Scholar, and Embase published between January 2000 and December 2020. Data were analysed using R software and results were reported with reference to Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. RESULTS: A total of 623 728 patients undergoing dialysis participated in 147 studies in which QoL was assessed by means of two valid questionnaires, including Short-Form 36 (SF-36) and Kidney Disease Quality of Life (KDQOL)-short form V.1.3. Total HRQoL score for patients undergoing dialysis measured by KDQOL was 64.25 (95% CI 55.67 to 72.82). Based on SF-36, the mean score of mental health items was higher than the mean score of physical health condition. Furthermore, meta-regression based on the geographical place of residence revealed that the highest QoL in patients was observed in Japan, 66.96 (95% CI 63.65 to 70.28) and Brazil, 58.03 (95% CI 53.45 to 62.6). CONCLUSION: Studies conducted on HRQoL among patients undergoing dialysis recommend useful strategies to clinicians, letting them assess patients' QoL in terms of a wide range of physical, mental and environmental aspects.

Anxiety during the COVID-19 pandemic in hospital staff: systematic review plus meta-analysis.

BACKGROUND: This study was conducted to systematically review the existing literature examining the prevalence of anxiety among hospital staff and identifying the contributing factors to address the complications of this disorder and develop effective programmes for reducing the complications of this mental health problem. METHODS: We searched the electronic databases including PubMed, EMBASE, Scopus, Web of Science and Google Scholar from January 2020 to February 2021. To perform meta-analysis, the random effects model was used. To assess the statistical heterogeneity of the included studies, the I2 index was used, and 95% CI was estimated. Data analysis was performed by R software. RESULTS: In the final analysis, 46 articles with the total sample size of 61 551 hospital staff members were included. Accordingly, anxiety prevalence among healthcare workers (HCWs) was 26.1% (95% CI 19% to 34.6%). The prevalence rates of anxiety in health technicians and medical students were 39% (95% CI 13% to 73%) and 36% (95% CI 15% to 65%), respectively, indicating a much higher prevalence than other hospital staff members. Furthermore, a positive significant relationship between prevalence of anxiety among HCWs and their age was approved (p<0.001). The prevalence rate of anxiety was higher among women 37.7% (95% CI 25.4% to 51.8%) than men 27.2% (95% CI 18.2% to 38.6%). CONCLUSION: The findings show a moderately high prevalence rate of anxiety in hospital staff. Due to the high prevalence of this mental health problem in health technicians, medical students and frontline health workers, it is highly suggested that healthcare institutions offer mental health programmes for these working groups in order to appropriately manage anxiety during the COVID-19 pandemic.

Cost-effectiveness of primary surgical versus primary medical management in the treatment of patients presenting with advanced glaucoma.

SYNOPSIS: Advanced glaucoma is associated with sight loss. This within-trial economic evaluation compares medical and surgical management strategies. At 2 years, medication appears more cost-effective though longitudinal outcomes are an important subject in future research. BACKGROUND/AIMS: Open angle glaucoma (OAG) is a progressive optic neuropathy. Approximately 25% of newly diagnosed patients with OAG present with advanced disease in at least one eye. The vision loss associated with OAG can lead to significant impacts on vision, quality of life and health care resources. The Treatment of Advanced Glaucoma Study is a randomised controlled trial comparing the effectiveness of primary surgical and medical management for newly diagnosed advanced patients with OAG. An economic evaluation was carried out to understand the costs and benefits of each strategy. METHODS: A cost utility analysis was carried out from a National Health Service perspective over a 2-year time horizon inclusive of patient costs. The primary outcome was patient health-related quality of life measured by the EQ-5D-5L, Health Utilities Index 3 (HUI3) and Glaucoma Utility Index (GUI). Results were expressed as incremental cost per QALY gained. RESULTS: Trabeculectomy was associated with higher costs and greater effect, the EQ-5D-5L results have an incremental cost per QALY of £45,456. The likelihood of surgery being cost-effective at a £20, 000, £30,000 and £50,000 QALY threshold is 0%, 12% and 56%, respectively. The results for the HUI3, GUI and inclusion of patient costs do not change the conclusions of the study. CONCLUSION: This is the first study to evaluate management strategies for those presenting with advanced glaucoma. At a 2-year time horizon, medication is the more cost-effective approach for managing glaucoma. Future research can focus on the costs and benefits of the treatments over a longer time horizon.

Toward good governance for the prosthetics and orthotics sector in Iran: Evidence from a qualitative study.

BACKGROUND: Prosthetics and orthotics (P&O) services are essential health services whose desired provision is considered as prerequisite to achieving universal health coverage. However, the P&O sector is sometimes not audited and governed, leading to groups that receive and offer the services to face challenges for benefits in Iran. OBJECTIVES: To identify common challenges of governance for the P&O sector and provide some potential policy recommendations to strengthen it. STUDY DESIGN: Qualitative study. METHODS: This study was conducted using semistructured in-depth interviews with prosthetists and orthotists (n = 13), P&O academicians (n = 6), and healthcare policy-makers (n = 8). The interview guide was also established based on 10 dimensions of the Framework for Governance of Healthcare System. RESULTS: Challenges identified included no legislation on P&O services, insufficient government support, uninformed policy-makers, and lack of interest by powerful stakeholders. In addition, nontransparent policy-making, inadequate distribution of workforce across the country, and lack of insurance coverage for P&O services were also raised as other challenges. The respondents identified the need for clear legislation to inform policy-makers and to seek advocacy from the government. CONCLUSIONS: The governance of the P&O sector in Iran has faced with a number of challenges that have made it unable to respond to existing demands desirably. Hence, it is important and necessary to adopt effective and comprehensive policies to reduce current challenges and barriers and improve the governance for P&O services.

Global health-related quality of life in schizophrenia: systematic review and meta-analysis.

BACKGROUND AND AIM: Signs and symptoms of schizophrenia may have serious impacts on patients' quality of life leading to concern about different aspects of their lives. This study presents a systematic review and meta-analysis of the studies examining the quality of life among patients with schizophrenia and its relationship with patients' characteristics. MATERIALS AND METHODS: A total of 40 studies were extracted from searching of relevant databases published between 2000 and 2020. Descriptive data and correlation coefficients between patient's characteristics and quality of life were extracted and the results were reported according to Preferred Reporting Items for Systematic Reviews and Meta-analyses standards and meta-analysis of pooled studies. RESULTS: In total, 8363 patients with schizophrenia participated in 40 studies which used Schizophrenia Quality of Life Scale revision 4. The total score of quality of life (QOL) in the study subjects was reported to be 40.66. Weighted effect size analyses revealed a significant relationship between QOL and variables including patients' age and duration of the disease. Furthermore, the highest (the worst) score of QOL in schizophrenia patients was observed in Europe 47.04 (95% CI 41.26 to 52.82) and the Euro region 47.05 (95% CI 41.18 to 52.92). CONCLUSION: Overall, the QOL among patients with schizophrenia was in a good status, which could be improved through considering different life aspects of people living in various contexts. In fact, clarifying the determinants of QOL would be a key step in the provision of future treatment efforts.

Primary trabeculectomy versus primary glaucoma eye drops for newly diagnosed advanced glaucoma: TAGS RCT.

BACKGROUND: Patients diagnosed with advanced primary open-angle glaucoma are at a high risk of lifetime blindness. Uncertainty exists about whether primary medical management (glaucoma eye drops) or primary surgical treatment (augmented trabeculectomy) provide the best and safest patient outcomes. OBJECTIVES: To compare primary medical management with primary surgical treatment (augmented trabeculectomy) in patients with primary open-angle glaucoma presenting with advanced disease in terms of health-related quality of life, clinical effectiveness, safety and cost-effectiveness. DESIGN: This was a two-arm, parallel, multicentre, pragmatic randomised controlled trial. SETTING: Secondary care eye services. PARTICIPANTS: Adult patients presenting with advanced primary open-angle glaucoma in at least one eye, as defined by the Hodapp-Parrish-Anderson classification of severe glaucoma. INTERVENTION: Primary medical treatment - escalating medical management with glaucoma eye drops. Primary trabeculectomy treatment - trabeculectomy augmented with mitomycin C. MAIN OUTCOME MEASURES: The primary outcome was health-related quality of life measured with the Visual Function Questionnaire-25 at 2 years post randomisation. Secondary outcomes were mean intraocular pressure; EQ-5D-5L; Health Utilities Index 3; Glaucoma Utility Index; cost and cost-effectiveness; generic, vision-specific and disease-specific health-related quality of life; clinical effectiveness; and safety. RESULTS: A total of 453 participants were recruited. The mean age of the participants was 67 years (standard deviation 12 years) in the trabeculectomy arm and 68 years (standard deviation 12 years) in the medical management arm. Over 65% of participants were male and more than 80% were white. At 24 months, the mean difference in Visual Function Questionnaire-25 score was 1.06 (95% confidence interval -1.32 to 3.43; p = 0.383). There was no evidence of a difference between arms in the EQ-5D-5L score, the Health Utilities Index or the Glaucoma Utility Index. At 24 months, the mean intraocular pressure was 12.40 mmHg in the trabeculectomy arm and 15.07 mmHg in the medical management arm (mean difference -2.75 mmHg, 95% confidence interval -3.84 to -1.66 mmHg; p < 0.001). Fewer types of glaucoma eye drops were required in the trabeculectomy arm. LogMAR visual acuity was slightly better in the medical management arm (mean difference 0.07, 95% confidence interval 0.02 to 0.11; p = 0.006) than in the trabeculectomy arm. There was no evidence of difference in safety between the two arms. A discrete choice experiment updated the utility values for the Glaucoma Utility Index. The within-trial economic analysis found a small increase in the mean EQ-5D-5L score (0.04) and that trabeculectomy has a higher probability of being cost-effective than medical management. The incremental cost of trabeculectomy per quality-adjusted life-year was £45,456. Therefore, at 2 years, surgery is unlikely to be considered cost-effective at a threshold of £20,000 per quality-adjusted life-year. When extrapolated over a patient's lifetime in a model-based analysis, trabeculectomy, compared with medical treatment, was associated with higher costs (average £2687), a larger number of quality-adjusted life-years (average 0.28) and higher incremental cost per quality-adjusted life-year gained (average £9679). The likelihood of trabeculectomy being cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life year gained was 73%. CONCLUSIONS: Our results suggested that there was no difference between treatment arms in health-related quality of life, as measured with the Visual Function Questionnaire-25 at 24 months. Intraocular pressure was better controlled in the trabeculectomy arm, and this may reduce visual field progression. Modelling over the patient's lifetime suggests that trabeculectomy may be cost-effective over the range of values of society's willingness to pay for a quality-adjusted life-year. FUTURE WORK: Further follow-up of participants will allow us to estimate the long-term differences of disease progression, patient experience and cost-effectiveness. TRIAL REGISTRATION: Current Controlled Trials ISRCTN56878850. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 72. See the NIHR Journals Library website for further project information.

Glaucoma is an eye condition in which the intraocular pressure is too high, causing damage to the optic nerve and loss of vision. Patients with severe vision loss at diagnosis are the most at risk of blindness in their lifetime. Lowering pressure in the eye is the only way to prevent further vision loss. Two treatments to lower pressure are commonly used: using eye drops or having an operation known as a trabeculectomy. In England, Wales and Northern Ireland, the National Institute for Health and Care Excellence recommends surgery as the first treatment. However, we do not know which treatment is best for preventing vision loss or which is safest, has the best patient experience or provides the best value for money for the NHS. Therefore, surgery is not usually carried out in the first instance and patients start with eye drops instead. This study compared whether starting treatment with eye drops affected the quality of life of patients with advanced glaucoma more or less than starting treatment with trabeculectomy. We also investigated if initial treatment with surgery and initial treatment with eye drops were equally good at controlling pressure and were equally safe, and how much each treatment cost the NHS. Every patient had an equal chance of starting treatment with surgery or eye drops and they participated in the study for 2 years. We found that quality of life was similar regardless of treatment. Those starting with surgery had lower pressure and needed far fewer types of eye drops than those starting with eye drops. Thirty-nine patients in the eye drop arm required surgery to control their glaucoma. Initial treatment with eye drops was cheaper over 2 years' follow-up. Our study suggests that, over a 2-year period, having surgery in the first instance lowers intraocular pressure more than eye drops and is equally as safe as eye drops. Although eye drops are a cheaper treatment option for the NHS, if the effects of surgery on intraocular pressure are lasting, then the increased cost may be justified.

The worldwide prevalence of anxiety in acquired immune deficiency syndrome patients: A systematic review and meta-analysis.

Background: Anxiety affects social, economic, and physical aspects of daily life in patients with AIDS. Therefore, it is necessary to take preventive measures and design plans to maintain their general health. The present study was the first comprehensive systematic literature review research that examined the worldwide prevalence rate of anxiety in patients with AIDS. Methods: We searched for papers published in the English language in the major databases including Embase, PubMed, Web of Science, Scopus, Cochrane, and Google Scholar from 2000 to October 2018. There were 40 studies which found to be eligible. These studies were independently evaluated and the collected data were entered in a data extraction form, which was then analyzed by two authors and a third author if necessary. Der Simonian-Laird model was used to estimate the prevalence rate on a Forest plot at the interval confidence of 95%. Results: The total sample size was 24111, and the total number of people with anxiety was 5546. The results based on the random-effects model showed that the rate of anxiety prevalence in the patients was 25% (CI: 95%, 21% -30%) with heterogeneity of 97.9% and a significance level of p<0.001. The South America continent with a prevalence of 38% (95% CI, 34%-42%) had the highest anxiety prevalence rates and Africa with 19% (95% CI, 12% -29%) had the lowest anxiety prevalence rates. Conclusion: Based on findings, the prevalence of anxiety in developed countries was partially higher than in underdeveloped countries and the obtained mean in the present study. It can be a significant point for policymakers. Therefore, WHO and the world community should have special plans for these countries.

Investigating the Effectiveness and Acceptability of Oral Health and Related Health Behaviour Interventions in Adults with Severe and Multiple Disadvantage: Protocol for a Mixed-Methods Systematic Review.

Increasing numbers of people in England experience homelessness, substance use, and repeated offending (known as 'severe and multiple disadvantage'; SMD). Populations experiencing SMD often have extremely poor oral health, which is closely inter-linked with high levels of substance use, smoking, and poor diet. This study aims to undertake an evidence synthesis to identify the effectiveness, resource requirements, and factors influencing the implementation and acceptability of oral health and related health behaviour interventions in adults experiencing SMD. Two systematic reviews will be conducted using mixed-methods. Review 1 will investigate the effectiveness and resource implications of oral health and related health behaviours (substance use, smoking, diet) interventions; Review 2 will investigate factors influencing the implementation of such interventions. The population includes adults (≥18 years) experiencing SMD. Standard review methods in terms of searches, screening, data extraction, and quality appraisal will be conducted. Narrative syntheses will be conducted. If feasible, a meta-analysis will be conducted for Review 1 and a thematic synthesis for Review 2. Evidence from the two reviews will then be synthesised together. Input from people with experience of SMD will be sought throughout to inform the reviews. An initial logic model will be iteratively refined during the review.

Exploring Interventions to Improve the Oral Health and Related Health Behaviours of Adults Experiencing Severe and Multiple Disadvantage: Protocol for a Qualitative Study with Stakeholders.

The number of individuals in England experiencing homelessness, substance use, and involvement with the criminal justice system is increasing. These issues, referred to as severe and multiple disadvantage (SMD), are often interlinked and co-occur. Health inequalities, particularly poor oral health, persist for those facing these inter-related issues and are closely linked with high levels of substance use, smoking, and poor diet. However, evidence for interventions that can improve these health outcomes for those experiencing these issues is limited. This paper outlines the design of a qualitative study which aims to explore the perspectives of stakeholders to understand what interventions can help to support SMD groups with their oral health and related health behaviours (i.e., substance use, smoking, diet). Interviews and focus groups will be undertaken with stakeholders comprising two groups: (1) individuals with experience of SMD, and (2) service providers (staff and volunteers), policy makers, and commissioners who support such individuals. Public involvement and engagement is central to the project. For example, stakeholders and research partners in policy and practice and people with lived experience of SMD will provide input at all stages of this study. Findings from the study will inform an 'evidence for practice' briefing outlining recommendations for policy. Dissemination will occur through presentations to a range of practice, policy and academic beneficiaries, and through peer-reviewed publications.

Primary trabeculectomy for advanced glaucoma: pragmatic multicentre randomised controlled trial (TAGS).

OBJECTIVE: To determine whether primary trabeculectomy or primary medical treatment produces better outcomes in term of quality of life, clinical effectiveness, and safety in patients presenting with advanced glaucoma. DESIGN: Pragmatic multicentre randomised controlled trial. SETTING: 27 secondary care glaucoma departments in the UK. PARTICIPANTS: 453 adults presenting with newly diagnosed advanced open angle glaucoma in at least one eye (Hodapp classification) between 3 June 2014 and 31 May 2017. INTERVENTIONS: Mitomycin C augmented trabeculectomy (n=227) and escalating medical management with intraocular pressure reducing drops (n=226) MAIN OUTCOME MEASURES: Primary outcome: vision specific quality of life measured with Visual Function Questionnaire-25 (VFQ-25) at 24 months. SECONDARY OUTCOMES: general health status, glaucoma related quality of life, clinical effectiveness (intraocular pressure, visual field, visual acuity), and safety. RESULTS: At 24 months, the mean VFQ-25 scores in the trabeculectomy and medical arms were 85.4 (SD 13.8) and 84.5 (16.3), respectively (mean difference 1.06, 95% confidence interval -1.32 to 3.43; P=0.38). Mean intraocular pressure was 12.4 (SD 4.7) mm Hg for trabeculectomy and 15.1 (4.8) mm Hg for medical management (mean difference -2.8 (-3.8 to -1.7) mm Hg; P<0.001). Adverse events occurred in 88 (39%) patients in the trabeculectomy arm and 100 (44%) in the medical management arm (relative risk 0.88, 95% confidence interval 0.66 to 1.17; P=0.37). Serious side effects were rare. CONCLUSION: Primary trabeculectomy had similar quality of life and safety outcomes and achieved a lower intraocular pressure compared with primary medication. TRIAL REGISTRATION: Health Technology Assessment (NIHR-HTA) Programme (project number: 12/35/38). ISRCTN registry: ISRCTN56878850.

Physical rehabilitation financing in Iran: a policy analysis using Kingdon's multiple streams.

BACKGROUND: Adequate financing is a crucial function, securing that physical rehabilitation services (i.e., physiotherapy, occupational therapy, prosthetics and orthotics) are available with no financial hardship. Like many other countries, despite the adoption of various policies and strategies in recent decades, Iran enjoys no desirable physical rehabilitation financing (PRF). Accordingly, this qualitative study aimed to explore the PRF-related strategies and issues as well as their impacts on relevant policies in Iran. METHODS: An analysis of PRF-related policies was conducted in Iran using semi-structured interviews and policy documents review. Purposive and snowball sampling techniques were employed to select key informants, including health-policy makers, civil society, rehabilitation-policy makers, university professors, and practitioners. Thematic analysis was used to analyze the collected data. The analysis was framed within Kingdon's multiple streams. RESULTS: The hindering factors for desirable financing were weak insurance coverage, lack of sustainable financial resources, fragmented financing, lack of split between provider and financer, high-cost of physical rehabilitation services, low engagement of relevant experts in policy-making processes, and corrupt activities. In the policy stream, the following factors were highlighted: involvement of sustainable financial resources, the use of external revenue sources, allocated resources' earmarking, the integration of the current funds to have better pooling, the use of incentive and timely payment mechanisms, the implementation of strategic purchasing principals, and the employment of effective rationing strategies. Moreover, parliament support, changes in administrations, international effects, pressures from interest campaigns and NGOs, and international sanctions were found as factors affecting the politics stream. CONCLUSION: The study findings revealed that a variety of national and international factors affect PRF-related issues in Iran. The recently enacted laws indicate that the PRF policies have already been on the national health political agenda. The study reflected the multifaceted nature of barriers to optimal PRF in Iran.

Global, regional, and national prevalence of depression among cancer patients: A systematic review and meta-analysis.

This systematic review and meta-analysis aimed to provide a summary of the existing evidence on the prevalence of depression among cancer patients worldwide to assist health policymakers in adopting appropriate measures to prevent and control depression in these patients. EMBASE, Google Scholar, Scopus, PubMed, and Web of Science databases were searched for original studies published in English from January 2000 to July 2019. The studies were screened on the basis of quality and relevance criteria. The statistical analyses were conducted in the R software. Out of 182,521 cancer patients examined in 183 studies, 49,280 (~27%) had depression (95% confidence interval [CI] = 24%-30%). The highest prevalence of depression was among patients with colorectal cancer with 32% (95% CI = 20%-47%). Among countries, Pakistan with 43% (95% CI = 26%-64%), and among continents, Africa with 36% (95% CI = 29%-43%) had the highest prevalence of reported depression in cancer patients. Adjusting for sample size, the prevalence of depression among female cancer patients, 31% (95% CI = 26%-36%), was higher than men, 26% (95% CI = 21%-31%). The prevalence of depression among cancer patients is increasing by an average of 0.6% per year. The findings show higher prevalence of depression among cancer patients in underdeveloped and developing countries compared to the developed nations and the global average.

Physical rehabilitation in Iran after international sanctions: explored findings from a qualitative study.

BACKGROUND: Although the main aims of sanctions are the political and economic pressures on governments, literature has demonstrated the harsh effects of sanctions on the general public, especially on the patients, poor and disabled people. Since the international sanctions regime negatively affected almost all dimensions of Iran's health sector, this qualitative study was conducted to investigate the situation of the physical rehabilitation sector after these sanctions. METHODS: This qualitative study was conducted from January 2019 to June 2019 in Iran using Skype, telephone, and face-to-face in-depth semi-structured interviews. Purposive and snowball sampling approaches were used to identify the participants. Also, framework analysis approach was applied to analyze the collected data. RESULTS: In total, 38 individuals including health policy-maker, faculty member, rehabilitation expert, Physiotherapist, Occupational therapist, and Orthotist/Prosthetist, were involved in the study. Based on our findings, a number of challenges facing the Iranian physical rehabilitation sector during the international sanctions period included: 1) socioeconomic challenges (inadequate funding, rising inflation rate, high unemployment rate, catastrophic expenditures, and inappropriate employment status of practitioners); 2) education challenges (decreased international collaboration and shortage of training devices and materials); 3) international challenges (rising issues in accessing services for patients from neighborhood countries); and 4) service delivery challenges (shortage of raw materials for producing the orthoses and prostheses, hardening of the importing the needed equipment, inappropriate infrastructures, and impossibility to use external assistance). CONCLUSION: After international sanctions, the Iranian physical rehabilitation sector has faced considerable multifaceted challenges. Therefore, the international community must be aware of the situation and be concerned about the irreparable consequences.

Financing of physical rehabilitation services in Iran: a stakeholder and social network analysis.

BACKGROUND: Inadequate financing is one of the major barriers in securing equitable access to high-quality physical rehabilitation services, without imposing financial hardship. Despite this, no sufficient attention has been paid to physical rehabilitation services and no specific financial resources have been allocated to such services in many countries including Iran. Owing to the fact that effective decision- and policy-making requires identifying possible stakeholders and actors and their characteristics, in the current study a stakeholder analysis and also a social network analysis (SNA) was conducted to identify the potential stakeholders and also their characteristics involved in physical rehabilitation financing (PRF)-related policies in Iran. METHODS: The present study was performed in two phases. Firstly, semi-structured interviews and relevant document review were conducted to identify the stakeholders. Then, the position, power, interest, and influence of each stakeholder were determined using a web-based questionnaire. Secondly, SNA approach was utilized to map and visualize the interactions among stakeholders. RESULTS: The findings showed that there are different stakeholders in PRF-related decision- and policy-making processes in Iran. In addition, the position, power, interest, and influence level of the identified stakeholders were varied. Moreover, although some stakeholders, like the Ministry of Health and the parliament have the highest level of power and position, they lack sufficient interest to participate in PRF-policies. Furthermore, SNA demonstrated that social network density was low, which indicates the lack of proper collaboration and interaction among the stakeholders. CONCLUSION: As many powerful and influential stakeholders had low interest levels to warrant participate in the FPR-related decision- and policy-making processes in Iran, employing careful and effective strategies, that is ongoing negotiations, receiving advocacy, and making senior managers and policy-makers aware can be helpful.