Wars and armed conflicts are inherently destructive, and their impacts extend far beyond military resources and intended targets. Generally speaking, the damage caused by wars and conflict extend even beyond civilian populations and facilities, this spillover often referred to as collateral damage, there are numerous additional victims of wars and conflicts, which includes animals, plants, natural resources, biodiversity, and climate systems and ecosystems. Wars and conflicts, which may represent both drivers and consequences of shortcomings in Sustainable development goals (SDG), specifically SDG16, which has to do with (Peace, Justice and Strong Institutions Wars and other conflicts also negatively affect the progress across of almost all other Sustainable Development Goals (SDGs), including poverty reduction, health and well-being, food security, economic development, education, equity as well as goals related to natural resources and the environment. Consequently, wars and other conflicts constitute major barriers to achieving sustainable development. The consequences of wars and armed conflicts on global sustainability, natural resources, biodiversity, and climate systems are widespread, long-lasting, and potentially intergenerational. Although these impacts have received increasing attention in international documents and protocols, they continue to be inadequately addressed by military powers that often fail to safeguard even civilian populations. The most effective mitigation strategy for the sustainability impacts of wars and armed conflicts is prevention; however, such efforts frequently fail. Regarding the environmental consequences of wars and armed conflicts, we argue that the current limited initiatives for documenting these impacts should be expanded into an independent global surveillance system to systematically identify, monitor, analyse, and inform policies and interventions. We also call for sustainability-related taxation of military industries to partially and pre-emptively compensate for their destructive contributions to planetary sustainability.

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease with limited diagnostic and prognostic biomarkers. The neutrophil-to-lymphocyte ratio (NLR), a marker of systemic inflammation, has been proposed as a potential indicator. This systematic review and meta-analysis assesses the diagnostic and prognostic value of NLR in ALS. We searched PubMed, Scopus, Embase and Web of Science through June 2025 for peer-reviewed studies evaluating NLR in adults with ALS diagnosed by established criteria. Eligible studies reported validated measurements of NLR and diagnostic or prognostic outcomes. Two reviewers independently extracted data and assessed quality. Random-effects meta-analyses were performed, with heterogeneity, publication bias, evidence certainty and sources of heterogeneity evaluated using meta-regression. Sixteen studies from 12 countries including 357 044 participants met inclusion criteria, comprising 8710 ALS patients (mean age 60.3 years; 59.1% male) and 348 334 controls (mean age 57.8 years; 47.6% male). Meta-analysis of 11 studies showed a pooled mean NLR of 2.74 in ALS patients [95% CI (2.42, 3.10); I 2 = 95.4%], while three control studies yielded a pooled mean NLR of 1.94 [95% CI (1.55, 2.43); I 2 = 94.7%]. Comparison of three studies demonstrated a 35% higher NLR in ALS patients than controls [95% CI (1.03, 1.76); I 2 = 88.3%], with low certainty according to GRADE due to observational design and substantial heterogeneity. Elevated NLR was consistently associated with worse clinical outcomes, including faster disease progression, lower ALSFRS-r scores, reduced forced vital capacity, shorter survival and increased mortality. Pooled univariate analyses from four studies showed that higher NLR predicted mortality [HR = 1.16; 95% CI (1.04, 1.29); I 2 = 93.8%]. Multivariable-adjusted analyses from six studies confirmed NLR as an independent predictor of poorer survival (HR = 1.13; 95% CI (1.06, 1.21); I 2 = 86.5%), with heterogeneity modestly reduced after adjustment for age and sample size. Certainty of evidence for prognostic outcomes was rated low to moderate. Associations between higher NLR and age at onset, sex and classical ALS phenotype were inconsistent. NLR correlated with inflammatory markers and gut microbiota features, supporting a potential mechanistic link between systemic inflammation and ALS disease progression. Elevated NLR is associated with ALS diagnosis and poorer prognosis, including faster disease progression and reduced survival. Despite heterogeneity and potential bias, NLR appears to be a readily accessible biomarker for disease monitoring and risk stratification in ALS, warranting validation in large, longitudinal studies.

The present study was conducted to evaluate the external validity of various cardiovascular disease (CVD) risk assessment tools in predicting CVD events among individuals with metabolic dysfunction-associated steatotic liver disease (MASLD). The Amol prospective cohort study spanned a follow-up period of seven years, from 2009 to 2010 to 2016-2017. A total of 1,431 individuals aged 40-75 years were included. The 10-year cardiovascular risk was estimated for each participant using four risk assessment tools: the Pooled Cohort Equations of the American College of Cardiology/American Heart Association (ACC/AHA), the Systematic Coronary Risk Evaluation (SCORE) equations, the Framingham General Cardiovascular Risk Profile, and the SCORE2 equations. Receiver Operating Characteristic (ROC) curves were used to assess the discrimination ability of these tools. The ACC/AHA tool demonstrated the highest predictive ability for both fatal CVD events (AUC: 0.92, 95% CI: 0.88-0.97 for men; AUC: 0.87, 95% CI: 0.79-0.96 for women) and composite CVD events (AUC: 0.68, 95% CI: 0.62-0.75 for men; AUC: 0.79, 95% CI: 0.72-0.85 for women). Based on these findings, cardiovascular risk assessment tools, particularly the ACC/AHA tool, can be applied in clinical settings to evaluate the future risk of CVD events in women with MASLD. However, the SCORE equations also exhibited excellent predictive ability for fatal cardiac events, requiring fewer variables.

Background: Despite the global decline in neonatal mortality rates since 1990, reaching the Sustainable Development Goals (SDGs) targets by 2030 remains a considerable challenge. Three-quarters of infant deaths happen during the early infancy stage, influenced by fetal and maternal factors as well as health service readiness. Consequently, this period is crucial for mitigating the burden of infant mortality. Therefore, this critical period holds vital importance in alleviating the burden of infant mortality. Hence, the current study aimed to assess the factors contributing to early neonatal mortality, focusing on Afghan immigrant neonates and utilizing hospital information systems and medical records to identify potential determinants. Methods: Throughout a 21-month study period from 2017 to 2018, data was collected from 576 neonates, comprising 441 neonatal near-miss (NNM) cases and 135 neonates who died and were admitted to the neonatal intensive care unit across six selected hospitals. Data collection methods included thorough reviews of hospital systems and medical records and conducting telephone or face-to-face interviews using checklists and questionnaires. Statistical analysis was performed using SPSS version 20 for Windows, with a significance level set at P<0.05 and confidence intervals at 95%. A logistic regression model was employed for analysis, enabling control for confounding variables. Results about risk factors were presented as both unadjusted (crude odds ratio) and adjusted odds ratios (ORs) alongside corresponding 95% confidence intervals (CIs). Statistical significance was established at a p-value of <= 0.05. Results: Our data demonstrated that age of 20-35 (AOR = 1.394, 95% CI 1.209, 3.743; p = 0.005), mother's illiteracy [AOR 2.544, (95% CI, 1.316-6.498; p = 0.03)], newborn insurance [AOR 2.544, (95% CI, 2.387-10.656; p = 0.03)], risk factors of pregnancy [AOR 1.351, (95% CI, 1.833-5.978; p = 0.003)], number of pregnancies >= 5 [AOR 3.273, (95% CI, 2.083-10.84; p = 0.002)], 2-4 pregnancies [AOR 2.539, (95% CI,2.342-6.848; p = 0.007)], antenatal care [AOR 5.103, (95% CI,3.17-056.901; p = 0.001)], gestational age [AOR 2.385, (95% CI, 2.322-9.652; p = 0.004)] and delay [AOR 3.178, (95% CI, 3.084-9.376; p = 0.001)] were linked to an increased risk of neonatal mortality. According to our findings, the first delay (delay in decision-making for care) was the most important delay factor involved in neonatal death, followed by the third delay (delay in receiving services) and the second delay (access to services). Conclusion: The elevated neonatal mortality rate (NMR) observed among Afghan neonates in Iran underscores their heightened vulnerability when compared to their Iranian counterparts. Our study revealed significant associations between neonatal mortality risk and factors such as maternal age, maternal illiteracy, insurance coverage, pregnancy-related risk factors, high parity (>= 5 pregnancies), moderate parity (2-4 pregnancies), antenatal care, gestational age, and delays in care-seeking behaviors. These findings emphasize the imperative of implementing targeted interventions to support Afghan mothers and their neonates by enhancing access to comprehensive antenatal care, promoting health literacy, addressing maternal health complexities, and raising awareness about neonatal morbidity risk factors.

In this study, we reviewed previous information regarding the effect of fossil fuel pricing intervention on the consumption of fossil fuels, air quality, and population health. In a rapid review, we searched and reviewed reports about the effect of fossil fuel pricing interventions on each or some of the following outcomes: fossil fuel consumption, concentrations of air pollutants, and mortalities or morbidities attributable to exposure to air pollutants. As part of our investigation, we also present the findings of an unpublished, original study that specifically estimated the effects of an elevated gasoline price in Iran's ten most populous cities. Pricing interventions were effective in reducing the consumption of fossil fuels, both in developing and developed countries. Price elasticity for transport gasoline was reported to be -0.227 and -0.715 for short- and long-term, respectively. Reductions in concentrations of air pollutants, especially NOx and particulate matter, were reported in several studies. This review study demonstrates the effects of escalating fossil fuel prices on reducing consumption, air pollution, and mortalities and morbidities attributable to air pollution. Considering the external costs of fossil fuels through environmental, climate, traffic congestions and accidents, and population health, the real costs of fossil fuels are much higher than their retail price. Pro-rich policies of subsidizing fossil fuels should be replaced by alternative policies that support clean public transport, which is suitable for population health, environment, and equity.

Background. The burden of diseases is generally higher in low- and middle-income compared to high-income countries. Mental disorders are among the rare categories that have the highest disability-adjusted life year (DALY) rates in high-income countries. This is a paradox when we consider the higher percentage of socioeconomic stressors, such as poverty, violence, and political instability in many of the low- and middle-income countries. This study aims to review potential reasons for the higher burden of mental disorders in countries with higher incomes, focusing on adolescents and young adults. Methods. Utilizing the data from the Global Burden of Diseases, Injuries and Risk Factors (GBD) 2019 study, this study explores the distribution of population-level prevalence, mortality, and DALY rates of mental disorders classified by income levels of the countries. Results. In 2019, the DALY rate for mental disorders was 2,118 per 100,000 adolescents/young adults in high-income countries compared to 1,558 in low-income, 1,363 in lower-middle-income, and 1,516 in upper-middle-income countries. The DALY rate for “substance use disorders” is also higher in high-income, compared to other countries. self-harm did not follow the same pattern and was highest in lower-middle-income countries. Conclusions. Our assessment supports the fact that the burden of mental disorders is a real issue in high-income countries, but the difference could be at least partially related to higher stigma and limited access to high-quality data in middle- and low-income countries. Mental disorders and substance use disorders in high-income countries both need comprehensive policies addressing mental health and its social determinants; our study also underscores the need for low- and middle-income countries to prioritize the collection of high-quality data and the reduction of the stigma of mental disorders to ensure more accurate assessments.

PurposeDespite significant progress in Iran's immunization programs, vaccine policymaking in the country still faces various challenges and shortcomings. To address these issues and ensure sustained progress toward achieving comprehensive vaccination policies, it is essential to identify the critical factors influencing vaccine policies in Iran. Our study aims to provide evidence-based insights that can inform the development of effective and equitable vaccine strategies, leading to a more sustainable and efficient approach to vaccination in the country.Design/methodology/approachThis mixed-method study aimed to analyze the factors influencing the future of human vaccine policy using Cross Impact Analysis. Firstly, a scoping review was conducted to identify the factors affecting the future of human vaccine development. Secondly, a semi-structured interview was conducted with experts in this field to add more factors and confirm the identified factors within the Iranian context. Finally, a Cross-Impact Analysis (CIA) approach was applied to comprehend the complex relationships between the identified factors. Thematic analysis was used for the qualitative data, and MICMAC analysis was applied to characterize the relationships between the factors.FindingsSeventeen key driving force factors were identified through comprehensive review and interviews. These factors were assigned weighted values ranging from zero to three and subsequently analyzed using MICMAC software. Employing the Cross-Impact Analysis (CIA) technique, the study characterized the impact of each factor on vaccine policy and elucidated the intricate interactions between them. The findings underscored that robust leadership and governance, an innovative ecosystem, and well-established immunization information systems emerged as pivotal driving forces shaping vaccine policy in Iran.Research limitations/implicationsWhile this study contributes valuable insights into the driving factors influencing vaccine policy in Iran, it is important to acknowledge several limitations. The results rely on the subjective perceptions of a diverse group of specialists, and future research could delve into additional factors in other countries to identify common themes and differences.Practical implicationsThis study provides evidence to assist policymakers in making informed decisions regarding vaccines in Iran. The findings suggest that enhancing access to vaccines, fostering trust in the healthcare system, and prioritizing equity in distribution can contribute to increased vaccination rates and a reduction in vaccine-preventable diseases.Originality/valueThis study provides a unique contribution to the field of vaccine policy by utilizing the cross-impact analysis to examine the complex interactions among various factors. The results of this analysis demonstrate that these interactions can significantly impact the overall system, highlighting the need for policymakers to consider multiple factors when formulating effective strategies. By revealing the significance of these interactions, this research offers valuable insights into the development of successful policies that can shape a desirable future for vaccine policy in Iran. Future studies could ratify the findings from this research by applying other methodological approaches.

Background Severe mental illness (SMI) imposes a substantial worldwide burden of disability, highlighting the need for comprehensive and adaptable mental health services. This study aims to assess the efficacy and cost-effectiveness of community-based mental health services (CBMHS) in reducing relapse and rehospitalization rates among individuals with SMI in Iran.Method A systematic review and meta-analysis were conducted. Medline, EMBASE, ISI, SCOPUS, and ProQuest were searched until December 2022. We focused on randomized controlled trials, quasi-experimental studies, or economic studies related to individuals with SMI. Out of 127 articles, 17 were selected for a full-text review. The primary outcomes were the severity of psychopathology, rehospitalization rates, and the mental health of caregivers. We also examined community-based interventions and their impact on various outcomes. Data extraction and risk of bias assessment were performed, and critical appraisal was conducted using JBI checklists. Meta-analysis was carried out using STATA software. (PROSPERO registration. CRD42022332660).Result Rehospitalization rates among patients who received CBMHS were significantly lower, with an odds ratio of 2.14 (95% CI: 1.44 to 3.19), indicating a 2.14 times lower likelihood than those who received treatment as usual. A reduction in psychopathology accompanied this, SMD: -0.31, 95% CI: -0.49 to -0.13, I2 = 40.23%). Moreover, there was a notable improvement in social skills (SMD: -0.7, 95% CI: -0.98 to -0.44, I2 = 0.00%). The burden on caregivers also decreased (SMD: -0.55, 95% CI: -0.99 to -0.1, I2 = 63.2). The Incremental Cost-Effectiveness Ratio (ICER) for QUALY was acceptable, albeit with a wide range of 613 to 8400 Dollars.Conclusion CBMHS has demonstrated effectiveness and efficiency in Iran as a developing country. Additionally, it shows promise in mitigating the shortage of acute psychiatry beds. Using multiple data collection tools poses a limitation regarding data consolidation and conducting a meta-analysis.

BackgroundIran is facing an epidemiological transition with the increasing burden of non-communicable diseases, such as obesity-related disorders and cardiovascular diseases (CVDs). We conducted a population-based prospective study to assess the prevalence and incidence rates of CVDs and obesity-related metabolic disorders and to evaluate the predictive ability of various CVD risk assessment tools in an Iranian population.MethodWe enrolled 5,799 participants in Amol, a city in northern Iran, in 2009–2010 and carried out the first repeated measurement (RM) after seven years (2016–2017). For all participants, demographic, anthropometric, laboratory, hepatobiliary imaging, and electrocardiography data have been collected in the enrollment and the RM. After enrollment, all participants have been and will be followed up annually for 20 years, both actively and passively.ResultsWe adopted a multidisciplinary approach to overcome barriers to participation and achieved a 7-year follow-up success rate of 93.0% with an active follow-up of 5,394 participants aged 18–90 years. In the RM, about 64.0% of men and 81.2% of women were obese or overweight. In 2017, about 16.2% and 5.2% of men had moderate or severe non-alcoholic fatty liver disease, while women had a significantly higher prevalence of metabolic syndrome (35.9%), and type 2 diabetes mellitus (20.9%) than men. Of 160 deceased participants, 69 cases (43.1%) died due to CVDs over seven years.ConclusionThe most prevalent obesity-related chronic disease in the study was metabolic syndrome. Across the enrollment and RM phases, women exhibited a higher prevalence of obesity-related metabolic disorders. Focusing on obesity-related metabolic disorders in a population not represented previously and a multidisciplinary approach for enrolling and following up were the strengths of this study. The study outcomes offer an evidence base for future research and inform policies regarding non-communicable diseases in northern Iran.

BackgroundInteractive dashboards are a powerful tool for dynamic visualization and monitoring of patient performance and serve as a useful to for optimal decision-making. The National Spinal Column and Cord Injury Registry of Iran (NSCIR-IR) was designed to efficiently display and broadcast important patient care data. This has been achieved through an electronic dashboard display (graph and visual displays), rather than traditional static paper reports (text).ObjectivesThe objective of this study was to design and develop an electronic visual dashboard as a display system to monitor the quality of care in the NSCIR-IR collaborating centers.MethodsThe indicators chosen were 20 pre-hospital and in-hospital quality of care (QoC) assessment tool indicators. A structured query was created from the NSCIR-IR system database to create the dashboard database. The Microsoft Power BI software was used. After data cleaning, filtering of erroneous records, and modeling, visual displays were designed and evaluated.ResultsThe dashboard reported on quality of care (QoC) for 2,745 patients registered in NSCIR-IR. 17% of registered cases had at least one data error in the quality of care indicators. These errors were automatically filtered by the system. The two most prominent weaknesses in (QoC indicators were delay in patient transfer by EMS (Mean and SD were 9.54 ± 13.8 hours) and timing of surgical spinal cord decompression (114.5 ± 45.3 hours).ConclusionsElectronic dashboards provide efficient and concise data summaries “at a glance”. However, their value and accuracy are dependent on the entered data quality. Identifying data source errors and correcting them continuously led to improved quality of data.

Background Non-communicable diseases can be controlled and managed by reducing their associated metabolic risk factors. In this study, a set of intervention packages were designed to reduce the prevalence of three common metabolic risk factors (hypertension, hyperlipidemia, and obesity and overweight) in the community by motivating non-physician health workers. Methods A field trial study was conducted in 4 districts of Iran. Thirty-two community health centers were randomly selected. A survey of 30 to 70-year-old was conducted to measure baseline metabolic risk factors. The intervention packages focused on improving hypertension, hyperlipidemia, obesity and overweight. The interventions included goal-setting, evidence-based education, operational planning, and incentive payments for non-physician health workers. A second survey to measure the final metabolic risk factors was performed after one year. The difference-in-difference method was used to evaluate the effectiveness of the intervention packages. Results The average age of participants in both surveys was 49 years. The interventions had statistically significant effects only on decreasing the prevalence of overweight and obesity. The package with all the interventions except pay-for-performance decreased the odds of overweight and obesity to 0.57 (95% CI: 0.34, 0.95). Conclusions Involving non-physician health workers and having action plans based on the health needs of the covered population can decrease obesity and overweight in the community. However, longer trials are needed to observe the effects on hypertension and hyperlipidemia.

Nonalcoholic fatty liver disease (NAFLD) or metabolic dysfunction–associated steatotic liver disease (MASLD) is a significant global public health dilemma with wide-ranging social and economic implications. Diet and lifestyle modifications remain essential components of NAFLD management. The current study investigated the association between diet-related inflammation and NAFLD among 3110 Iranian adults participating in the Amol Cohort Study (AmolCS), employing the Structural Equation Modeling (SEM) approach.The inflammatory potential of the diet was quantified using an energy-adjusted dietary index (E-DII) score. Findings showed that in the total sample and separately in males, the E-DII score had a significant effect on NAFLD, with mediation through hypertension (βstandardized = 0.16, and 0.13, p < 0.001, respectively) and c-reactive protein (CRP) (βstandardized = 0.07, and 0.07, p < 0.001, respectively). In the total sample and separately in females, the E-DII score significantly affected NAFLD, with mediation through diabetes (βstandardized = 0.06, p < 0.001, and 0.07, p = 0.006, respectively). In full and both gender-specific models, dyslipidemia was a risk factor for NAFLD and partially mediated the effect of hypertension on NAFLD. The current study concluded a mediated association between dietary inflammation and NAFLD through hypertension, CRP, diabetes, and dyslipidemia, suggesting further longitudinal studies, especially in high-risk populations. These findings underscore the complex interplay between diet, inflammation, and NAFLD in Iranian adults.

This study aimed to vividly describe the direct and severe health impacts of conflict in the Eastern Mediterranean Region (EMR) using data from the Global Burden of Disease (GBD). It also sought to quantify the staggering portion of economic damage attributable to the health burden of conflict and terrorism. From 1990 to 2019, the region endured the devastating effects of conflict and terrorism. These circumstances led to 64%, 50%, and 35% of all causes of Disability-Adjusted Life Years (DALYs) in Libya, Syria, and Palestine, respectively, in 2011, 2016, and 2008. These figures represent not just statistics but the profound human cost of these conflicts. The health-related economic burden (HEB) due to conflict was estimated at $4.6 billion in Iraq, $3.7 billion in Afghanistan, and $1.7 billion in Libya in current international dollars. However, due to missing data, the HEB could not be calculated for Yemen and Syria despite significant conflict-related DALYs. In 2019, the HEB to Current Health Expenditure (CHE) ratio, which indicates the proportion of the health-related economic burden compared to health expenditure, was 30% in Afghanistan and 25% in Iraq. This high ratio underscores the significant strain that conflict places on the health systems.

Abstract: Objective: Determine the related causes of stillbirth and reduce the unexplained cases Design: Observational cohort study Setting: 14 selected hospital from 12 provinces (14 cities) of Iran Population: A total of 105,562 births and 762 registered stillbirths at 22 completed weeks of gestation or more Methods: Iranian Maternal and Neonatal Network (IMaN) registers information about almost all births (live & dead) around the country, but this network does not collect data about stillbirth causes. In this study, we developed the stillbirth evaluation protocol with experts’ cooperation, and we designed forms for the stillbirth registration system electronically. Then we trained related individuals in 14 selected hospitals around the country. After a year, we extracted, analyzed, and, based on the Relevant Condition of Death Classification (ReCoDe), interpreted the collected data. Main outcome measures: Related causes of stillbirth Results: In 742 registered stillbirth cases in 14 selected hospitals, the relevant causes were identified in 65.4% of cases, while 34.6% of cases remained unclassified. The most frequent relevant conditions were fetal (33.2%), maternal (9.1%), amniotic fluid (8.8%), placenta (7.7%), and umbilical cord (6.2%). Conclusions: Our registration decreased the percentage of stillbirth with an unexplained cause from about 70% to 34.6%. Funding: Iran University of Medical Sciences Key words: stillbirth, cause of stillbirth, Iran Tweetable abstract: The most frequent relevant causes of stillbirth in Iran were fetal, maternal, and amniotic fluid conditions.

Scientometrics and bibliometrics, the subfields of library and information science, deal with the quantity and quality of research outputs. Currently, various scientometric indices are being used to quantify and compare research outputs. The most widely known is the h-index. However, this index and its derivatives suffer from dependence on the mere count of a scholar's highly cited publications. To remedy this deficiency, we developed a novel index, the Universal Research Index (UR-Index) (https://usern2021.github.io/UR-Index/) by which every single publication has its own impact on the total score. We developed this index by surveying international top 1 % cited scientists in various disciplines and included additional component variables such as publication type, leading role of a scholar, co-author count, and source metrics to this scientometric index. We acknowledge that unconscious biases built into the component variables included in the UR-Index might put research from specific groups at a disadvantage, thus continued efforts to improve equitable scholarly impact in science and academia are encouraged.

Background Non-communicable diseases behavioral risk factors can be improved if effective interventions are designed considering the health system’s capabilities and local resources. This study evaluated the effectiveness of interventions that aimed at increasing non-physician community health workers’ motivation in reducing non-communicable diseases behavioral risk factors in the community. Methods A randomized field trial study was conducted in 32 community health centers in 4 Iranian districts after a baseline population survey on the status of NCDs of 30–70-year-old individuals ( n = 1225). The interventions were performed to improve insufficient physical activity, insufficient fruit consumption, insufficient vegetable consumption, high salt intake, and tobacco use. Four intervention packages were implemented in 24 community health centers; the other 8 centers were used as control groups. The non-physician community health workers performed the interventions. The packages additively included goal-setting, evidence-based education, operational planning, and incentive payments. A second survey was conducted 1 year after the start of the interventions to identify the effects on an independent random sample of 30–70-year-old individuals ( n = 1221). Difference-in-difference method was used to quantify the interventions’ effects. Results The average age of participants in both surveys was about 49 years. Also, about half of the participants were female, and about 43% were illiterate or had a primary school education. The interventions had statistically significant effects only on decreasing the prevalence of insufficient physical activity. The package with all the intervention components decreased the odds of insufficient physical activity to 0.24 (95% CI, 0.08, 0.72). The package with operational planning but no performance-based financing did not change the odds of insufficient physical activity. Conclusions This study highlighted the importance of components, design, and implementation details of interventions intended to reduce NCDs behavioral risk factors. Some risk factors, such as insufficient physical activity, seem more easily modifiable with limited low-cost interventions in a one-year horizon. However, risk factors related to healthy food consumption and tobacco use need more extensive interventions. Trial registration This trial was registered on the Iranian Registry of Clinical Trials (IRCT20081205001488N2) on 3 June 2018 ( https://en.irct.ir/trial/774 ).

INTRODUCTION:Autism spectrum disorders (ASD) encompass a range of neurodevelopmental disorders that affect the patient's communication and behavior. There are some reports about the increasing prevalence of ASD in recent decades, mostly due to the improvement in diagnosis and screening status. Few studies suggested a lower prevalence of ASD in North Africa and Middle East compared to more developed regions. The aim of this study is to provide a comprehensive outlook of ASD in the region.METHODS:We used Global Burden of Disease (GBD) data from 1990 to 2019 in North Africa and Middle East, which is one of the seven super regions of the GBD categorization. In this study, we reported the epidemiologic indices, including prevalence, incidence, and years lived with disability (YLDs) for ASD in the 21 countries of the super region. We also compared these indices between the countries based on their sociodemographic index (SDI) which was calculated according to income per capita, mean education, and fertility rate.RESULTS:Age-standardized prevalence rate (ASPR) of ASD in the region is 304.4 (95% uncertainty interval 251.2-366.1) per 100,000 in 2019 with less than one percentage change since 1990. Age-standardized YLDs and incidence rates were 46.4 (30.4-67.5) and 7.7 (6.3-9.3) per 100,000 in 2019. The ASPR was 2.9 times greater in males compared to females in 2019. The highest age-standardized prevalence, incidence, and YLD rates among the countries were seen in Iran in 2019 (370.3, 9.3, and 56.4 per 100,000, respectively). High SDI countries had higher age-standardized YLDs rates compared to the other countries of the region.CONCLUSION:In conclusion, the trends of age-standardized epidemiologic indices remained approximately steady through the years 1990-2019 in the region. Though, there was a wide discrepancy between the countries of the region. The difference of YLDs among the countries of this region is related to the SDI of the countries. Monetary and public awareness status are the SDI factors that may affect the quality of life of ASD patients in the region. This study provides valuable information for governments and health systems to implement policies for maintaining the improving trend, achieving more timely diagnosis, and bettering the supportive actions in this region.