Health workers worldwide report being exposed to workplace violence, but those in conflict settings (or post-conflict settings) are especially targeted, as political conflict shifts societal norms. Iraq has suffered war and conflict for decades. A 2013 study of 567 Iraqi-trained physicians found nearly 2/3 had emigrated to mostly English-speaking countries; further, half of those remaining wished to leave Iraq. While prior studies have examined the phenomenon of violence against health workers in Iraq, no qualitative study has characterized Iraqi front line junior doctors’ experiences of workplace violence within a workplace violence causal framework, to inform an educational and policy response. We consented and interviewed 73 junior physicians at six teaching hospitals across Central Iraq between December 2021, and January 2022. We analyzed 22 of the 73 conversations, after rejecting 29 because they were terminated prematurely when doctors were called away for patient care, and 22 others where doctors indicated they had no experience with workplace violence. (Our goal was to understand these interactions, not to quantify them). The physicians we interviewed had been practicing an average 3 years since graduating from medical school (ranging from 6 months to 7 years). Interviewees represented eight hospital departments, with most coming from internal medicine and surgery. Within a socio-ecological framework, we identified two primary individual-level factors prompting patient-associated violence: patients and their families don’t understand triage (and resent being pushed to the side when doctors focus on more serious cases), and junior doctors (by definition) are young and inexperienced. At the family level, doctors reported patient relatives often demonstrate their devotion to the patient by acting out. At the hospital level, institutions are operating in an environment of scarcity, which generates high emotions as patients compete for attention, supplies and space. At a societal level, doctors reported family attacks persist because perpetrators face no real legal consequences. In addition to causes of violence, there are consequences. Doctors who are targets of violence reported experiencing mental health problems, including depression and loss of self-esteem, and reported thoughts of leaving their positions and even their country. Doctors also expressed regret for choosing a career in medicine. Young, inexperienced junior doctors in Iraq are bearing the brunt of patient frustrations with the scarcity of resources in the health system. Hospitals would likely improve the job satisfaction of junior physicians, and their longevity in the health system, by attending to this problem.

Background: Workplace violence represents a severe problem facing health systems in almost all countries globally. Communication failure is thought to be the major issue that initiates violence. Objective: This study aimed to test the effectiveness of a short training course for junior doctors on how to deal with patients’ aggressive attitudes in a trial to de-escalate violence against them. Materials and Methods: This interventional randomized trial was conducted in a sample of hospitals in Baghdad and Karbala governorates, Iraq, from August 2021 through July 2022. A pre-training survey was conducted to collect data from a sample of junior doctors (1079) to explore their exposure to violent attacks. The one-arm randomized trial measured the difference in exposure of 190 doctors to violent attacks during a comparable period, six months before and six months after the training. Results: Three-quarters (74.8%) of the sample reported exposure to lifetime violence. The prevalence of exposure to violence in the six months before the intervention was 66.8%, while six months after the training, it dropped to 53.2%, with a statistically significant difference. Conclusion: A two-day training proved effective in reducing violent incidents. This result indicates the necessity of starting a nationwide, wide-scale, regular, periodic training program for junior doctors to de-escalate violence. The findings of this study represent a message to policymakers to make more efforts to lessen violence against healthcare workers.

Background: Violence toward health-care workers is a global health problem, usually associated with decreased job satisfaction, and poor patient care outcomes, with serious consequences for the patients. Its extent is difficult to measure due to under-reporting. Objective: The objective of this study was to explore the opinion of some influential community members about violence against health workers with respect to its types, reasons, mechanisms in place, and suggestions to de-escalate it. Methods: A qualitative in-depth study was conducted with 10 key informants (including people working in judicial premises, police and military services, teachers, municipality members, and religious leaders). The discussion was conducted through a direct face-to-face interview, using a semi-structured interview guide that included open-ended questions. Results: Almost all the interviewees agreed that the main reasons for violence were the general security instability in the whole country, the poor quality of health services, weakness of laws and regulations for the punishment of the perpetrators, irresponsible behaviors of some doctors, in addition to the unexplained negative role of media toward doctors. Conclusion: workplace violence is a common, frequently happening practice in most health-care facilities in Iraq, probably attributed to the long-suffering of wars and conflicts. Shortage of staff and equipment is the base for this malpractice.

Objectives: To assess the structure as well as availability of essential equipment and medicine at emergency departments. Method: The descriptive, cross-sectional study was conducted from March to June 2021 after approval from the ethics review committee pf the College of Medicine, Mustansiriyah University, Baghdad, Iraq, and comprised emergency departments of general and teaching hospitals in the city. Evaluations were done using the World Health Organisation checklist and the guidelines of the Australasian College for Emergency Medicine related to Emergency Department Design. Results: Of the 26 secondary care hospitals in Baghdad, 13(50%) were evaluated. Triage was not available in 8(62%) hospitals, resuscitation room in 10(77%) and waiting room in all the 13(100%). An obvious shortage of medicines and vaccines was noted in 11(85%) hospitals. Coronary care unit and intensive care unit were not close to the emergency department in 7(54%) hospitals, and liaison psychiatry and social work links were not available in all 13(100%) hospitals. Conclusion: There is a need to improve service delivery at emergency departments functioning at hospitals in Baghdad. Key Words: Coronary Care, Emergency, World Health Organization, Social Work, Psychiatry, Vaccines

Objective: To estimate the prevalence of workplace violence and its impact on doctors in hospitals. Method: The cross-sectional study was conducted from August 2021 to January 2022 in Baghdad and Karbala governorates of Iraq, and comprised resident doctors at a number of hospitals. Data was collected using a self-administered questionnaire that focussed on the frequency of exposure to violence, type, source, most common time, and other details about violence as well as its impact on doctors and their careers. Data was analysed using SPSS 23. Results: Of the 1,079 subjects working at 18 participating hospitals and having a mean age 30.0±5.72 years, 567(52.5%) were females and 512(47.5%) were males, while 570(52.8%) were aged <30 years and 509(47.2%) were aged >30 years. Overall, violence exposure was reported by 811(75.2%) subjects; 427(52.6%) females and 384(47.4%) males. Gender was not significantly associated with exposure to violence (p>0.05). Due to missing data, further analysis was limited to 792(97.6%) subjects who faced exposure to workplace violence. In 671(85%) cases, the assaults were nonphysical. However, 110(14%) doctors reported physical attacks and severe consequences. There were 673(85%) of doctors with exposure to violence who expressed their intention to change their job, workplace, or leave the country because of violence. Conclusion: The problem of violence against Iraqi doctors was found to be highly prevalent with a seriously negative impact on the medical professionals. Key Words: Violence, Prevalence, Intention, Malpractice.

Objective: To explore the psychological impact of coronavirus disease-2019 on frontline healthcare workers in Iraq. Method: The cross-sectional study was conducted from November 2020 to September 2021 after approval from the ethics review committee of the College of Medicine, Mustansiriyah University, Baghdad, Iraq, and comprised doctors and nurses from 4 teaching hospitals and 8 primary healthcare centres in Baghdad. Psychological sequels, like anxiety, depression, fear and insomnia, were assessed along with exposure to coronavirus disease-2019. The study questionnaire was based on the Patient Health Questionnaire Anxiety and Depression Scale. Data was analysed using SPSS 26. Results: Of the 400 participants, 288(72%) were doctors and 112(28%) were nurses. Overall, 215(53.7%) subjects had had a coronavirus disease-2019 infection, 192(48%) reported having anxiety, 148(37%) fear, 100(25%) depressive symptoms, and 51(12.8%) complained of insomnia. Doctors were more likely to have anxiety than nurses (p<0.05), but the difference in terms of depression was not significant (p>0.05). Conclusions: The mental health of the frontline healthcare workers was found to have been affected by the coronavirus disease-2019 pandemic, with anxiety and fear being the main symptoms. Key Words: Depression, Mental Health, Pandemics, Sleep Initiation, Disorders, Anxiety, Fear, Coronavirus

Objective: To assess the prevalence of cosmetic interventions, and the factors that instigate women to undergosuch procedures.Method: The cross-sectional study was conducted from January to June 2021 in Baghdad, Iraq, and comprisedwomen aged 18 years or above from 4 general hospitals, 4 health centres and 8 schools. The sample was dividedinto group A having subjects with experience of cosmetic interventions, and group B having those with no suchexposure. Data was collected using a a questionnaire. Data was analysed using SPSS (version 25).Results: Of 1113 women, 997(90%) were aged 20-40 years. There were 375(34%) women in group A and 738(66%)in group B. Within group A, Botox was the most common intervention 89(23%). Besides, 215(57%) women had theintervention in clinics, and 75(20%) had it in beauty centres. Dermatologist did the intervention in 146(39%) cases,while side effects were noted in 142(38%). Within group A, 248(66%) subjects said they would not advise theirdaughters or sisters to have cosmetic interventions. Age and marital status were significantly different between thestudy groups (p<0.05).Conclusion: Cosmetic interventions among the women studied were found to be relatively high, and Botox was themost common intervention.Key Words: Botulinum Toxins, Dermatologists, Nuclear,

Background: There is a relation between sleep quality, mental health, and academic performance among medical students. Students who experience better sleep quality and have good mental health will exhibit higher academic performance compared to those who have reduced sleep quality and poor psychological health. Objective: To assess the relation between mental health problems, sleep quality, and academic performance among medical students in the stage of clinical training at the University of Fallujah, Iraq. Methods: In this cross-sectional study, a self-administered questionnaire was adopted that gathered three validated and previously used screening tools: The Pittsburgh Sleep Quality Index (PSQI), Depression Anxiety Stress Scale (DASS-21), and the AHELO Self-Assessment Questionnaire. Results: The findings revealed a high prevalence of anxiety, 40% of the students reported experiencing mild to moderate anxiety, while 24.1% showed severe anxiety, 20.0% experienced mild depression, and 10.8% had moderate depression. There was a significant negative correlation between stress and academic performance (Pearson’s r = −.333, p < .001), between depression and academic performance (Pearson’s r = −.437, p < .001), and between anxiety and academic performance (Pearson’s r = −.417, p < .001). Conclusion: Mental health problems are prevalent among medical students represented by the study sample, and are significantly correlated to the students’ academic performance.

Background: War represents a major human crisis; it destroys communities and results in ingrained consequences for public health and well-being Objective: We set this study to shed light on the public health status in Iraq after the successive wars, sanctions, sectarian conflicts, and terrorism, in light of certain health indicators. Design: The primary source of data for this analysis comes from the Iraqi Ministry of Health, and The World Health Organization disease surveillance. Results: Most of the morbidity indicators are high, even those that are relatively declining recently, are still higher than those reported in the region. Common communicable diseases such as schistosomiasis, mumps, and measles continue to be a problem. Mumps showed two recent epidemics; in 2015, and in 2020. The same with respect to Measles. More than 40·% of the surveyed population showed both systolic and diastolic hypertension. Fasting glucose of 10·4% of the participants showed hyperglycaemia, only 6·5% of whom reported being diagnosed and treated as diabetic. The leading cancer in males is Bronchus and Lung cancer, followed by Colorectal, Urinary bladder, and Prostatic cancers while in females; Breast cancer is in the top of the list, followed by Thyroid, Colorectal, Brain, and Bronchogenic cancers. Rates for childhood cancers are obviously higher even than those in high-income countries. Conclusions: The struggling public health services in Iraq have been severely impacted by humanitarian and political crises and brutal armed conflict that resulted in restricted population access to food, clean water and basic services including healthcare and medicines.

Suicide is the third-leading cause of death globally, predominantly among youth. We aimed at reviewing the available published literature and some reports about suicide, in an attempt to unveil aspects of this mental health problem in Iraq. Articles about suicide in Arab/Middle Eastern countries were also included to compare those populations of a similar race and religion. The estimated suicide rate in Iraq is 1.7/100000 population (mostly among youth), which is still lower than in western countries. However, underreporting is the reason actual numbers are not known and many who attempt suicide do not report it and so hide their intent to die. The most common method of suicide is self-hanging, followed by firearms, self-burning, and self-poisoning. Suicide and suicidality in Iraq are on the increase even though it is believed to be underreported. Many socio-demographic, psychological and environmental factors predispose to ideation, attempts, and completed suicides despite the religious and social taboos. Young females are more represented in suicide attempts and ideation using potentially lethal methods like self-burning as a consequence of higher rates of depression, community and domestic violence. A key component in suicide prevention is improving the accessibility and quality of mental and social health care services.

Review of: "Cross-national associations of IQ and infectious diseases: Is the prevalence of Corona an exceptional case?" Riyadh LaftaPotential competing interests: No potential competing interests to declare.This is a very interesting article, with very rich information, and a promising scope for future designs, however, certain points should be considered and mentioned in the text to highlight the real value and the limitations of this study: First; this is actually a correlational (ecologic) study, that is done cross-nations depending on rough estimates of independent and dependent variables.Such a design usually has some weaknesses, the main of which is the difficulty in linking exposure-disease relationship at the individual level, and the inability to control for confounding factors.Furthermore, the results (including the correlational association) were built on the estimated numbers that are declared by the governments of the sampled countries, however, we know that -due to the population panic that COVID-19 createdsome countries have manipulated the real numbers of morbidity, mortality, and other variables towards under or overestimation attributed to different reasons, so, there is a sort on uncertainty in the outcome (findings).On the other hand, have the authors tried to see if there is any association between the independent variables they chose to test, with the morbidity statistics of some other infectious diseases in the studied countries in order to check the consistency of their results, as IQ level would affect other infectious diseases and not solely COVID-19.Nevertheless, the manuscript is a huge and valid work that should not be under-valued, and my decision is to accept, probably with a minor revision.

Violence against health care workers is a serious problem that is experienced all over the world with a high (and increasing) global prevalence. Two samples (170 patients/or their relatives and 140 health care workers) were collected from the emergency departments of the general hospitals in Kar-bala governorate during the period from 1st June through August 2022. A semi-structured questionnaire was used to collect data through a face to face interview. Significant differences were found in the per-spectives of health care providers and the attendants of the health care facilities. A significantly lower proportion of the patients (than health care workers) believe that workplace violence is common, while a high proportion of them admitted that they have themselves committed violence against health care workers. Health care workers attributed violence against them to: low education, recklessness, igno-rance, dissatisfaction, and bad manners of the people. On the other hand, some patients blamed the health workers or the health system (dereliction, carelessness, inexperienced doctors, and poor services) for the escalated violence.

Background Violence against health care workers (HCWs) is a multifaceted issue entwined with broader social, cultural, and economic contexts. While it is a global phenomenon, in crisis settings, HCWs are exposed to exceptionally high rates of violence. We hypothesize that the implementation of a training on de-escalation of violence and of a code of conduct informed through participatory citizen science research would reduce the incidence and severity of episodes of violence in primary healthcare settings of rural Democratic Republic of Congo (DRC) and large hospitals in Baghdad, Iraq. Methods In an initial formative research phase, the study will use a transdisciplinary citizen science approach to inform the re-adaptation of a violence de-escalation training for HCWs and the content of a code of conduct for both HCWs and clients. Qualitative and citizen science methods will explore motivations, causes, and contributing factors that lead to violence against HCWs. Preliminary findings will inform participatory meetings aimed at co-developing local rules of conduct through in-depth discussion and input from various stakeholders, followed by a validation and legitimization process. The effectiveness of the two interventions will be evaluated through a stepped-wedge randomized-cluster trial (SW-RCT) design with 11 arms, measuring the frequency and severity of violence, as well as secondary outcomes such as post-traumatic stress disorder (PTSD), job burnout, empathy, or HCWs’ quality of life at various points in time, alongside a cost-effectiveness study comparing the two strategies. Discussion Violence against HCWs is a global issue, and it can be particularly severe in humanitarian contexts. However, there is limited evidence on effective and affordable approaches to address this problem. Understanding the context of community distrust and motivation for violence against HCWs will be critical for developing effective, tailored, and culturally appropriate responses, including a training on violence de-escalation and a community behavioral change approach to increase public trust in HCWs. This study aims therefore to compare the effectiveness and cost-effectiveness of different interventions to reduce violence against HCWs in two post-crisis settings, providing valuable evidence for future efforts to address this issue. Trial registration ClinicalTrial.gov Identifier NCT05419687. Prospectively registered on June 15, 2022.

Background: COVID-19 pandemic has affected all crucial aspects of daily life, including; food security, education, gender relation, mental health, and environmental air pollution, in addition to the impact of the lockdown that had far-reaching effects in different strata of life. Aims: To study the impact of COVID-19 on people with respect to their mental and social suffering and consequences. Methods: This cross sectional study was conducted during the period from November 2020 through August 2021. A sample of 1,000 attendants to four teaching hospitals and eight PHCCs, was collected. The mental and social sequels of COVID-19 were assessed for all participants whether previously infected or not. Results: Out of the total sample (1,000), 389 had a history of infection with COVID-19. The main mental symptoms reported were depression (67.8%), and anxiety (46.9%), males and females equally reported symptoms of anxiety, while depressive symptoms were reported more among females (59.9%), Fear and worries of the participants about their health and their families’ was the main reason for mental symptoms (94.7%). Conclusions: Symptoms of depression and anxiety in time of COVID-19 are prevalent. Suspending educational activities was the most social burden that affect people while increase the price of food and cessation of work were the main causes of economic burden.

PurposeThe objective of this study was to assess the impact of COVID-19 infection on households in Baghdad, Iraq.MethodsA cross-sectional household survey was conducted in early 2022; 41 clusters were selected proportional to population size from the districts of the Baghdad governorate. Households were randomly selected for inclusion. The head of household or senior female member present was interviewed to obtain a listing of COVID-19 infections, deaths, and vaccinations among members of the household and to understand if social and economic changes occurred during the pandemic. All analyses incorporated the complex survey design and sample weights for clustering.FindingsThe findings revealed that there were 1,464 cases of COVID-19 (37.1%) and 34 reported fatalities among the 927 households enrolled in this study. One or more COVID-19 immunizations were received by 50.9% of household members. Preventive measures against COVID-19 were widely reported to be being practiced but were not more commonly reported in households having reported a clinical case of infection. While some households where infections had occurred stated that their household expenses were increased, overall, infections were not associated with significantly increased household costs. In households where COVID-19 had occurred, senior members reported a substantial increase in emotional and psychological problems compared with uninfected households.ImplicationsCOVID-19 deaths were rare, though infections were common, suggesting an effect of vaccination and other efforts. The household economic implications were minimal in houses with and without COVID-19-infected members. COVID-19 had mental health consequences on affected and unaffected populations alike. It is conceivable that the fear and uncertainty generated by the pandemic had an effect on senior household members which was out of keeping with the other effects in the households sampled. This suggests that there may be a persisting need for mental health services for a protracted period to manage the consequences of mental health needs arising from the pandemic.

Thalassemia is a common hereditary hemoglobinopathy that occurs all over the world, mostly in the middle and low-income countries. We set this study to study the demographic and clinical profile of thalassemia patients, and to highlight the burden of this disorder on the health system, in Iraq. This cross sectional survey was carried out during the period from January through June 2022 in the two major centers of thalassemia in Baghdad. All thalassemia patients that were attending those centers during a six-month period, were included. The direct and indirect annual cost of medicines and health services were computed. The prevalence of thalassemia is slopping up, with the estimated annual cost of health care regarding diagnosis, treatment, blood transfusions and other services for each thalassemia patients is $6815. The indirect health care services were $3995, making the total annual cost for each thalassemia patient $10810. It is proven that consanguineous marriages increase the prevalence of Thalassemia. Public policies aimed at clarifying this for the population would be relevant. The annual cost for thalassemia patients in Iraq is relatively high, most of which is covered by the Ministry of Health and its institutions. This causes a burden on the health system. Also, adopting new policies to reduce the costs especially through finding substitutes (or less costly therapy) for blood chelating agents, is crucial on the long term strategy

ObjectiveThis analysis examines governorate-level disease incidence as well as the relationship between incidence and the number of persons of concern for three vaccine-preventable diseases-measles, mumps, and rubella-between 2001 and 2016. MethodsUsing Iraqi Ministry of Health and United Nations High Commissioner for Refugees (UNHCR) data, we performed descriptive analyses of disease incidence and conducted a pooled statistical analysis with a linear mixed effects regression model to examine the role of vaccine coverage and migration of persons of concern on subnational disease incidence. ResultsWe found large variability in governorate-level incidence, particularly for measles (on the order of 100x). We identified decreases in incident measles cases per 100,000 persons for each additional percent vaccinated (0.82, 95% CI: [0.64, 1.00], p-value < 0.001) and for every additional 10,000 persons of concern when incorporating displacement into our model (0.26, 95% CI: [0.22, 0.30], p-value < 0.001). These relationships were insignificant for mumps and rubella. ConclusionsNational level summary statistics do not adequately capture the high geospatial disparity in disease incidence between 2001 and 2016. This variability is complicated by MMR vaccine coverage and the migration of "persons of concern" (refugees) during conflict. We found that even when vaccine coverage was constant, measles incidence was higher in locations with more displaced persons, suggesting conflict fueled the epidemic in ways that vaccine coverage could not control.

OBJECTIVE:Our objective was to compare care-seeking patterns in Mosul, Iraq, in 2018, 1 y after Islamic State of Iraq and Syria (ISIS) control, with findings from neighborhoods that had been sampled in 2017.METHODS:For this multi-stage randomized cluster household survey, we created one cluster in each of 20 neighborhoods randomly selected from the 40 neighborhoods in the 2016/17 survey; 12 in east Mosul, 8 in west Mosul. In each, 30 households were interviewed beginning at a randomly selected start house. Questions were derived from the 2016/2017 post-ISIS survey.RESULTS:We interviewed the head of household or senior female in 600 households containing 3375 persons. One year after ISIS, some household demographic shifts had occurred. Diarrhea in children during the past 2 wk decreased from 50.1% to 7.5% (P < 0.001); however, cough/difficulty breathing increased from 15.5% to 33.6% (P < 0.01). Among adults, care-seeking for noncommunicable diseases increased from 22.3% to 43.5% (P < 0.001). Emotional and psychological complaints common in the previous survey were now nearly absent. Pregnancy complications diminished from 65.2% to 15.4% (P < 0.001).CONCLUSIONS:Communicable diseases predominated among children and noncommunicable diseases among adults. Access to health care substantially improved, although barriers remained. Satisfaction with services was mixed, with dissatisfaction expressed about testing, medicine access, and costs, but the work of health providers was rated highly.