Background: Pediatric discharge against medical advice (DAMA) may reflect clinical, financial, familial, and service-related pressures, particularly in migrant and uninsured populations. Objectives: To compare DAMA occurrence and documented reasons for DAMA between discharge episodes involving Iranian and Afghan children and to develop expert-informed recommendations. Methods: At a pediatric hospital in Tehran serving Iranian and Afghan children, we conducted a mixed-methods study in 2024 - 2025. The quantitative analysis included all 4,540 discharge episodes, with the discharge episode as the unit of analysis. Child-clustered modified Poisson generalized estimating equation models estimated DAMA occurrence (adjusted for month) and the prevalence of cost/insurance-related reasons among DAMA episodes (adjusted for sex, length of stay, admission reason, and ward). Five Hospital Information System reason categories were hierarchically mutually exclusive; co-recorded reasons were retained separately. A small purposive sample of six DAMA caregivers and seven DAMA care/management staff completed semi-structured interviews, which were analyzed using inductive qualitative content analysis. Eight experts with ≥ 2 years’ DAMA-related experience prioritized domains, and a nine-member panel developed recommendations. Results: Among 4,540 discharge episodes, 1,088 (24.0%) ended in DAMA. DAMA occurred in 61.9% of episodes involving Afghan children and 20.3% of those involving Iranian children (month-adjusted RR = 3.10, 95% CI 2.81 - 3.42). In the mutually exclusive primary classification, perceived recovery was the predominant reason for DAMA among episodes involving Iranian children (74.9%). Cost/insurance-related reasons were recorded in 127/250 (50.8%) DAMA episodes involving Afghan children versus 10/838 (1.2%) involving Iranian children. This marked disparity was estimated imprecisely (adjusted prevalence ratio = 41.63, 95% CI 22.15 - 78.25) because only 10 such episodes involved Iranian children. Eight experts ranked financial/insurance factors as most important. Conclusions: Nationality-defined differences should not be interpreted causally; rather, they should be considered in the context of financial and structural vulnerability. Expert-informed recommendations emphasized communication about clinical readiness, financial assessment and support, and clearer documentation; prospective evaluation is required.
Context: Perinatal mental health (PMH) disorders are among the most common complications of pregnancy and childbirth; however, a substantial treatment gap persists because of systemic, structural, and interpersonal barriers. This systematic review and meta-synthesis aimed to synthesize global qualitative evidence on strategies to improve PMH care, thereby informing policy, service design, and clinical practice. Evidence Acquisition: Guided by the Sample, Phenomenon of Interest, Design, Evaluation, Research Type (SPIDER) framework, we conducted a systematic search of seven electronic databases (MEDLINE via PubMed, CINAHL, Scopus, Scientific Information Database (SID), PsycINFO, Embase, and Web of Science) to identify qualitative and mixed-methods studies examining PMH care strategies, barriers, and facilitators. No date restrictions were applied. Methodological quality was appraised using the 10-item Critical Appraisal Skills Programme (CASP) checklist, and confidence in the evidence was assessed using GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative Research). Data were analyzed using thematic meta-synthesis following the framework of Thomas and Harden (1). The review protocol was registered with PROSPERO (registration No. CRD420261501502). Results: A total of 41 studies were included. The studies spanned high-, middle-, and low-income countries across 6 continents and involved diverse participants, including perinatal women, partners, midwives, nurses, psychologists, community health workers, and policymakers. Five overarching analytical themes were generated. First, compassionate, person-centered communication was identified as a fundamental therapeutic strategy to facilitate disclosure and mitigate women’s fears of judgment. Second, integrated and coordinated service delivery, particularly the co-location of mental health professionals within obstetric settings, emerged as a structural imperative to reduce referral attrition and care fragmentation. Third, community-based and peer-supported care was highlighted as a vital strategy to reduce stigma, validate women’s experiences, and extend the reach of formal services. Fourth, workforce development and task-sharing were recognized as essential for sustainable care, requiring practical training and embedded specialist supervision to develop the skills of nonspecialist providers. Finally, flexible, tailored, and technology-assisted delivery models were endorsed as equity-oriented strategies to overcome logistical barriers, although human connection remained irreplaceable. Conclusions: Closing the PMH treatment gap requires a paradigm shift from reactive, siloed care to proactive, integrated, and highly relational support systems. Sustainable improvement depends on a coordinated approach that includes structural integration, workforce expansion, community partnerships, and flexible service delivery, all underpinned by trauma-informed communication. These findings, based on stakeholder experiences and perceptions of acceptability and feasibility, suggest that policymakers and service planners should consider mandating integrated care pathways and funding diversified, patient-centered modalities to ensure equitable, accessible, and high-quality PMH care.
Background: Oral health indices reflect untreated dental caries, which can adversely affect the physical and psychological well-being of individuals and their families. Objectives: This study examined oral health-related quality of life (OHRQoL), oral health behaviors (OHBs), family and individual impacts, and the DMFT index, as well as the associations among them. Methods: This descriptive cross-sectional study was conducted among 300 adolescents aged 11 - 14 years in Rafsanjan, Iran. Data were collected using validated Persian versions of the Child Perceptions Questionnaire (CPQ11 - 14), the Family Impact Scale (FIS), and an oral health behavior (OHB) checklist. The DMFT index was assessed clinically by trained dentists according to WHO criteria. Associations were examined using correlation analyses and multiple linear regression models. Results: The mean scores for CPQ, FIS, OHB, and DMFT were 14.05, 3.64, 16.56, and 2.12, respectively. DMFT was significantly correlated with FIS (r = 0.159; 95% CI, 0.05 - 0.26; P = 0.006) and functional limitations (r = 0.163; 95% CI, 0.06 - 0.27; P = 0.005), whereas OHB was negatively correlated with oral symptoms (r = -0.132; 95% CI, -0.23 to -0.02; P = 0.022). FIS was significantly associated with all OHRQoL dimensions. Higher DMFT scores were observed among adolescents whose fathers were employed in government positions (beta = 1.21; 95% CI, 0.18 - 2.24) and those aged ≥ 13 years (beta = 0.66; 95% CI, 0.15 - 1.17). Lower DMFT scores were associated with higher fluoride concentration (beta = -1.37; 95% CI, -1.90 to -0.84), paternal university education (beta = -1.33; 95% CI, -2.48 to -0.18), and four-member households (beta = -1.45; 95% CI, -2.55 to -0.35). Conclusions: Adolescent DMFT is influenced by household size, paternal occupation, and water fluoride concentration. Integrated public health measures, including optimal fluoride exposure and targeted education, are recommended.
Background: Benzene, toluene, ethylbenzene, and xylenes (BTEX) are key volatile organic compounds (VOCs) that pose substantial environmental and public health risks in urban environments. Objectives: This study presents a methodologically transparent assessment of BTEX concentrations, spatial and seasonal variations, emission sources, and associated human health risks across distinct land-use microenvironments in Tehran, Iran. Methods: Ambient BTEX concentrations were monitored biweekly over 12-hour sampling periods (08:00 - 20:00) from January to December 2025 at five strategic stations (traffic, industrial, residential, urban background, and suburban). Active sampling was conducted using charcoal tubes (NIOSH 1501) and analysis was performed by GC-FID. Seasonal variations were evaluated using an independent-samples t-test, whereas spatial differences among the five monitoring sites were assessed using one-way analysis of variance (ANOVA). Source attribution was evaluated using empirical diagnostic ratios (T/B, X/B) and Pearson correlation (n = 120). Carcinogenic and noncarcinogenic inhalation risks were modeled using the updated United States Environmental Protection Agency (USEPA) Human Health Risk Assessment framework. Results: Toluene was the most abundant species (47.3 ± 19.8 μg/m3), followed by xylenes (34.1 ± 15.2 μg/m3), ethylbenzene (17.4 ± 7.4 μg/m3), and benzene (11.6 ± 5.1 μg/m3). All target species exhibited statistically significant winter accumulation (P < 0.001). BTEX concentrations were significantly higher during the cold season than during the warm season for all target compounds (P < 0.001), with benzene and toluene showing the greatest seasonal increases. Uniformly high diagnostic ratios (T/B = 4.12 - 4.29, X/B ≈ 3.0, and T/X = 1.38 - 1.46), together with strong positive correlations among BTEX compounds (r = 0.90 - 0.95), were consistent with the influence of common traffic-related emission sources, including vehicle exhaust and evaporative fuel losses. Although individual noncarcinogenic hazard quotients were below 1.0, the cumulative Hazard Index (HI) reached 0.84 at the traffic site. The deterministic Incremental Lifetime Cancer Risk (ILCR) for benzene ranged from 2.1 × 10-5 to 6.8 × 10-5, exceeding the strict USEPA de minimis benchmark (1.0 × 10-6). Conclusions: BTEX pollution in Tehran is a critical environmental health concern driven by high mobile fleet intensity and winter meteorological stagnation. Given the pronounced cold-season accumulation, emergency seasonal traffic zoning restrictions and stage II vapor recovery systems at fuel stations should be dynamically prioritized during winter months to mitigate inhalation exposure and protect public respiratory health.
Background: Healthcare entrepreneurship is increasingly relevant to the transformation of the Saudi healthcare system, private-sector participation, digital health, and innovation. However, evidence regarding healthcare providers’ entrepreneurial intentions, awareness, and perceived facilitators and barriers in Saudi Arabia remains limited. Objectives: This study assessed entrepreneurial intention, awareness, perceived facilitators, motivators, and barriers among healthcare providers in Saudi Arabia and examined factors associated with entrepreneurial readiness and willingness. Methods: A cross-sectional online survey was conducted in November 2023 among 435 healthcare providers working in Saudi Arabia. Participants were recruited through convenience sampling, and the bilingual questionnaire was distributed electronically via professional networks and social media platforms, including LinkedIn and X/Twitter. Descriptive statistics were used to summarize the findings, and Mann-Whitney U and Kruskal–Wallis tests were used to examine factors associated with entrepreneurial readiness and willingness scores. Results: Among 435 participants, 82.8% reported interest in entrepreneurship, 76.3% believed that healthcare providers could become entrepreneurs, and 72.2% had considered starting a healthcare-related business. However, only 32.9% were familiar with entrepreneurship concepts, 35.6% had completed entrepreneurship courses, and 6.2% had started a healthcare-related business. The mean entrepreneurial readiness and willingness score was 3.94 ± 0.72 out of 5. Entrepreneurial readiness and willingness scores were significantly higher among female participants than among male participants (4.05 ± 0.64 vs. 3.85 ± 0.77; P = 0.004) and differed significantly across professional groups (P < 0.001). Higher scores were also associated with interest in entrepreneurship, prior entrepreneurship education, institutional support, and previous healthcare-related business experience (all P < 0.001). Conclusions: Among surveyed healthcare providers in Saudi Arabia, entrepreneurial interest was high; however, the establishment of healthcare-related businesses remained uncommon. This intention–implementation gap underscores the need for structured entrepreneurship education, institutional support for innovation, mentorship, regulatory guidance, and access to funding or incubation pathways within the Saudi healthcare system.
