مجله تحقیقات نظام سلامت حکیم
سال نهم شماره 3 (پیاپی 34، پاییز 1385)

Abstract: Health sector reform is an absolute necessity to make the health system more responsive to community needs. In Iran, activities on health sector reform have been carried out since about six years ago. This article uses expert opinion and the global experience to define the main principles and goals of health sector reform, compare the situation in Islamic Republic of Iran with that in other countries, show areas of strength and weakness and find the way ahead. So far, health sector reform in Iran has answered some critical questions, carried out many vital studies and published several effectual books and reports. More importantly, it has created a common language among policy-makers, legislative bodies, managers and experts. Yet, it hasn’t found the chance to translate these ideas into action, never enjoyed full political commitment, and has relied entirely upon financial and technical support from WHO/EMRO plus a small part of the second World Bank loan. This article concludes with some recommendations to pave the way for the future: notably to continue with applied research projects using local resources and foreign assistance, especially by implementing newly developed models in multiple pilot areas.

General fertility rate (GFR) can be used to predict population growth. The aim of the present ecological study is to determine the effects of some social and health factors on Iranian women's GFR. This study uses data based on the Iranian nation-wide Demographic Health Survey (DHS), which took place in the year 2000. Stepwise multiple linear regression models were applied to estimate the value of the seven independent variables on prediction of GFR as dependent variable. In the urban population, three of the independent variables including the proportions of illiteracy, use of the modern methods and use of the traditional methods could predict up to 65% variations of the GFR and in the rural population only two of the independent variables including the proportions of illiteracy and use of the modern methods could predict up to 70% variations of the GFR. The very high GFR in Sistan and Balochestan province has a substantial effect on the findings. After removing Sistan and Balochestan province from the analyses, it seems that in Iran, efforts aiming at men ' s marriage in appropriate ages in urban areas, and increasing the use of the modern methods of prevention among married women in rural areas will reduce the GFR.

Widespread medical usage of botulinum toxins has increased the need for the precise analysis of its biological activity. The aim of this study was production and crystallization of the botulinum type A toxins. In this study, Clostridium botulinum was grown and inoculated into the Tripticase Soya Broth culture media, under anaerobic condition and toxin production was monitored. The maximum yield of toxin was obtained after 96 hours, then toxin was harvested by acidifying the whole culture and centrifugation. The period of bacterial growth was extensively checked for toxin activity by mouse assay and crystallization was done at the same time. The results of this study showed that Clostridium botulinum grew in the above condition and produced toxin after 96 hours. The toxin produced in the low pH range of 4– 5.8 was stored as cube- shaped crystals. The crystallized toxin preparation was stable over time and maintained its biological activity after 4 years of storage in a temperature of 4-6 ° C. Clostridium botulinum type A toxin rapidly becomes inactive in the laboratory environment. Therefore, it is important to find a way to keep its biological activity. According to the results of this study, biological activity of the crystallized toxin remained stable for a long period of time. Thus, this method is useful for both preventive and research applications of botulinum toxin.

In recent years, researchers have become interested in evaluating mediator as well as family variables. The purpose of this study was to assess relationship between family variables (parents mental disorder, child rearing patterns and marital satisfaction), adolescent self understanding and conduct disorders. The relationship among family variables (mental problems, child rearing pattern, marital satifaction), self- understanding and conduct disorders in youth were assessed in 57 young subjects and their parents (29 normal and 28 with conduct disorders). The parents compeleted MMPI short form, child rearing patterns qustionniare and Enrich marital satisfaction qustionniare. Twenty- nine normal and 28 conduct disorder yougsters were interviewed using self- understanding interview (SUI). Stepwise regression suggested that there were significant relations among conduct disorders, parents’ mental problems, child rearing pattern and youth self- understanding. The variables which entered the model were father’s schizophrenia, continue dimension, social dimension, father’s depression, father’s paranoia, father’s despot, mother’s despot and father’s authoritative pattern. Path analysis suggeseted that self- understanding plays the role of a mediator among marital satisfacion, child rearing patterns, parents’ mental disorders with conduct disorders. Self- understanding is a mediator between parental mental disorders and children ’s conduct disorders. Parent s’ mental disorders and despot child rearing affect self- understanding and predispose to conduct disorders. Father ’s mental disorder and despot child rearing more than mother ’s can product conduct disorders.

Dental caries in childhood is important for two reasons: 1. Childhood is the best years to form correct hygienic habits 2. There is a close relationship between the decay of deciduous teeth and permanent teeth. One of the WHO goals by the year 2010 is a caries-free index of 90% in 5 year- old children. Thus, the proportion of preschool caries- free children (DMF=0) of Hamedan was assessed in terms of socioeconomic, hygienic and nutritional factors and treatment needs. This was a descriptive- analytic and cross- sectional study. In this study 240 children in 12 kindergartens were evaluated. Visual and tactile sensation method (mirror & e x plorer) was selected for determining the DMF. The information obtained was analyzed with Pearson chi square and Fisher's exact tests. The percentage of caries- free children was 14.7%. High percentage of caries- free teeth was observed in children who used tooth brush and dental floss indicating a significant relationship between hygienic behaviors and caries- free index. Snack feeding and duration of breast- feeding period had important influence on caries rate. Unmet restorative treatment need index (UTNI) was 98% for all these children There is no significant relationship between socioeconomic status (parents education and occupation) and caries- free teeth. Caries- free index is considerably lower then the goal determined by WHO for the year 2010 (90%). A program of dental health education should be organized as a PHC activity in kindergartens.

Systemic lupus erythematosus (SLE) is an immunological disease with unknown etiology that may affect many organs. Therapy in this disease is not curative and decreased physical abilities are obvious in patients with SLE. The aim of this study was to determine physical disability ranges in patients with SLE. This is a cross sectional study focusing on determination of physical disabilities in relation to different demographic including sex, age, duration of disease and the number of diagnostic criteria of American Rheumatiological Association (ARA). The mean age of patients was 16.32 ± 10.35 years and the female to male ratio was 8.33 to 1. The mean score of physical disability was 3.42±3.17 according to Health Assessment Questionnaire (HAQ). Females were more affected than males, and disability was more severe in females (3.5±4) than males (3.00±3, p<0.05).

To determine whether neurological outcome is improved in traumatic spinal cord-injury patients who had time-related surgery. A retrospective evaluation of a nonconsecutive cohort of patients with a spinal cord injury (SCI) from C1 to L1 were reviewed. Data evaluated included patient ’s age, level of injury, neurologic exam according to the Frankel Grading System, the performance of surgery, mechanism of the time-related SCI decompression, and motor index score (MIS). The analysis included a total of 50 eligible patients. The neurologic and functional outcomes were recorded from hospital admission to the most recent follow- up. In the cases of SCI, no significant correlation between time-related spinal cord decompression and motor movement was found. A greater improvement in motor function, regardless of the timing of surgery was seen in cases of incomplete spinal cord injury (p=0.02). Complications related to the presence of SCI were similar in both operated and non- operated groups. The results of this study revealed no significant difference in neurologic outcomes between observation and early (within 24 hours after injury- mean: 15.2 hours) or late (more than 24 hours- mean: 11 days) surgery in patients with a traumatic SCI.

This study investigates the conditions under which neonatal hearing screening is useful in Iran. The objectives of the study were to identify prevalence of significant bilateral SNHL and then to demonstrate whether newborn mass screening is feasible and cost effective and would result in early detection and treatment of significant hearing impairment. Babies born at Akbarabadi and Mirzakouch-Khan university maternity hospitals from June 2003 to October 2004 were screened at birth in three stages by using transient evoked otoacoustic emissions (TEOAEs) and ABR. All newborns were tested under standard conditions before discharge from the hospital. According to the screening results, full audiological evaluations were performed when necessary. The screening method used was the TEOAEs-acoustic method. There were three stages in this study: initial screening, re-screening and diagnostic tests with ABR/OAEs. High risk neonates, especially those hospitalized in NICU, were scheduled for follow-up even if they were normal in the initial screening. The result from 8490 live newborns indicated that 89.7% of newborns proved normal in the primary screening in the maternity ward, and 10.3% were abnormal. Out of 873 infants scheduled for follow-up study only 571 neonates returned. Using follow- up letters and phone calls, we managed to improve the response rate to 56% of bilateral failures. Using Poison's distribution for frequency rate of hearing impairment and normal estimate for this distribution and 95% confidence intervals, significant bilateral sensorineural hearing loss was present in ~1 to 4 per 1000 live births in the well baby nursery population (12 neonates), and in ~2.5 to 4.6 per 100 infants in the intensive care unit. The outcome of this program has stimulated the development of a nationwide (universal) newborn screening program which will be started in near future. Mass newborn screening for hearing impairment in our population was found to be feasible, beneficial, cost beneficial and justified.