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IntroductionLow socioeconomic status (SES) is identified as a pivotal risk factor for mental health. Objective socioeconomic status (OSS) is measured by tangible resources, whereas subjective social status (SSS) reflects an individual’s perception of their OSS. A paucity of literature exists that elucidates the specific psychosocial mechanisms or pathways linking OSS with mental illness via SSS. This research aimed to explore the mediating role of SSS in the OSS-mental health association, utilizing data from the Iranian Mental Health Survey (IranMHS).MethodsThis study is a secondary analysis of data from IranMHS, a national survey conducted in 2011 through face-to-face interviews with 7,886 Iranian adults aged 15-64. As part of the original survey, the General Health Questionnaire-28 (GHQ-28) was randomly administered to half of these participants. We focused our analysis on data from 3,759 participants who completed all items of the GHQ-28. OSS was evaluated using education, occupation, wealth, and a combined OSS index, while SSS was measured using the MacArthur Scale. We examined how SSS mediates the associations between OSS factors and GHQ scores, including its four dimensions—somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression— while adjusting for demographic variables and conducting gender-stratified analyses.ResultsAmong the 3759 respondents, 2157 (57.4%) were women, 2110 (56.1%) lived in urban areas, with an average age of 33.1 years (SD=12.1). SSS mediated the associations between wealth and the overall GHQ score (mediation percentage: 92.3%), education (75.4%), OSS index (66.7%), and occupation (34.0%) on the GHQ score. The most significant mediation effects were observed for wealth on the somatic symptoms, social dysfunction, and depression dimensions, with SSS accounting for more than 80% of these associations.ConclusionThe findings indicate a significant mediating role of SSS in the relationship between OSS and mental health. Enhancing our comprehension of the social determinants that moderate the relationship between objective and subjective socioeconomic status may contribute to a more nuanced understanding of the impact of SES on mental health outcomes.

Abstract Background Number of opiate users worldwide has doubled over the past decade, but not all of them are diagnosed with opioid use disorder. We aimed to identify the prevalence and risk factors for OUD after ten years of follow-up. Methods Among 8,500 chronic opiate users at Golestan Cohort Study baseline (2004–2008), we recalled a random sample of 451 subjects in 2017. We used three questionnaires: a questionnaire about current opiate use including type and route of use, the drug use disorder section of the Composite International Diagnostic Interview lifetime version, and the validated Kessler10 questionnaire. We defined opioid use disorder and its severity based on the DSM-5 criteria and used a cutoff of 12 on Kessler10 questionnaire to define psychological distress. Results Mean age was 61.2 ± 6.6 years (84.7% males) and 58% were diagnosed with opioid use disorder. Starting opiate use at an early age and living in underprivileged conditions were risk factors of opioid use disorder. Individuals with opioid use disorder were twice likely to have psychological distress (OR = 2.25; 95%CI: 1.44–3.52) than the users without it. In multivariate regression, former and current opiate dose and oral use of opiates were independently associated with opioid use disorder. Each ten gram per week increase in opiate dose during the study period almost tripled the odds of opioid use disorder (OR = 3.18; 95%CI: 1.79–5.63). Conclusions Chronic opiate use led to clinical opioid use disorder in more than half of the users, and this disorder was associated with psychological distress, increasing its physical and mental burden in high-risk groups.

Addiction medicine is a dynamic field that encompasses clinical practice and research in the context of societal, economic, and cultural factors at the local, national, regional, and global levels. This field has evolved profoundly during the past decades in terms of scopes and activities with the contribution of addiction medicine scientists and professionals globally. The dynamic nature of drug addiction at the global level has resulted in a crucial need for developing an international collaborative network of addiction societies, treatment programs and experts to monitor emerging national, regional, and global concerns. This protocol paper presents methodological details of running longitudinal surveys at national, regional, and global levels through the Global Expert Network of the International Society of Addiction Medicine (ISAM-GEN). The initial formation of the network with a recruitment phase and a round of snowball sampling provided 354 experts from 78 countries across the globe. In addition, 43 national/regional addiction societies/associations are also included in the database. The surveys will be developed by global experts in addiction medicine on treatment services, service coverage, co-occurring disorders, treatment standards and barriers, emerging addictions and/or dynamic changes in treatment needs worldwide. Survey participants in categories of (1) addiction societies/associations, (2) addiction treatment programs, (3) addiction experts/clinicians and (4) related stakeholders will respond to these global longitudinal surveys. The results will be analyzed and cross-examined with available data and peer-reviewed for publication.

Objective:The sleep/wake cycle plays a vital role in mental health and daily life. Therefore, this study aimed to investigate the prevalence of circadian rhythm sleep disorders in the young population and their effect on psychological health and mental disability.Materials and Methods:The present study is part of the first phase of the Ravansar cohort (a branch of the Prospective Epidemiological Research Studies in Iran cohort) and included 2991 participants from Ravansar, Iran. Data were collected using standard questionnaires, including the Kessler Psychological Distress (PD) Scale (K10), Sheehan Disability Scale, and sleep timing.Results:The prevalence of advanced sleep phase disorder (ASPD) was 0.4% in the sample, the prevalence of delayed sleep phase disorder (DSPD) was 4.1%, and the prevalence of the desire to change sleep patterns was 61.3%. The results also showed that the level of PD in people with and without ASPD was not significant, but the level of PD was significantly higher in people with DSPD compared to those without (p

Abstract Background The pattern of substance use in Iran is characterized by a high prevalence of opioid use and opioid use disorder (OUD). Although opioid maintenance therapy (OMT) has been introduced in Iran, approximately 50% of people with opioid use disorder remain unreached. Moreover, psychosocial treatment of OUD and common mental health symptoms during OMT is limited. Digital interventions have been shown to improve psychological distress, depression, anxiety, and post-traumatic stress disorder symptoms. In addition, providing psychoeducation and risk reduction counseling to prevent communicable diseases like HIV and infectious hepatitis is common via the Internet. However, despite these promising advances, no smartphone intervention in OMT has been investigated for the treatment of OUD and common comorbid mental health symptoms. Objective We examine the effectiveness of adding a blended smartphone intervention based on community reinforcement approach, motivational interviewing- and cognitive behavioral therapy compared to OMT as usual that aims to improve OMT outcomes and addresses common mental health symptoms in OMT patients in Iran. Method Adults with opioid dependence entering 8 treatment centers in Tehran, Iran will be randomly assigned to receive either OMT plus a smartphone intervention or OMT as usual. The primary outcomes will be the percentage of negative urine tests for illicit, non-prescribed use of opioids (opium, heroin, tramadol) and treatment retention. Secondary outcomes will include the longest period of abstinence from the illicit, non-prescribed use of opioids (opium, heroin, and tramadol) confirmed by urine samples, changes in communicable disease risk-taking behaviors, changes in stress and common mental health symptoms, and client satisfaction. Data analysis will follow the intention-to-treat principle and employ (generalized) linear mixed models. Discussion This study will provide substantial knowledge for designing effective blended interventions for OUD. Moreover, it will investigate if treatment retention and OMT-related outcomes and common mental health symptoms can be improved by adding a smartphone intervention to OMT. Trial Registration https://en.irct.ir/trial/53578 .

Background: Frequent cannabis use is associated with adverse health-related outcomes. This study followed up individuals who used cannabis to assess their use and adverse event status. Methods: The eligible individuals, recruited in the Iranian Mental Health Survey (IranMHS), were contacted via telephone calls six years after the index interview. The frequency of cannabis use and the occurrence of selected adverse events were recorded. The baseline status was extracted from the index survey. If any individual was inaccessible, his/her vital status was assessed. Findings: Of the 50 eligible individuals (all male), two had died. Moreover, from among 25 reached participants, 19 reported abstinence from cannabis in the past year, and 18 reported at least one adverse event in the past six years. Violence and imprisonment were the most common events reported. Conclusion: Six years after the index interview, most of the participants abstained from cannabis. Besides, adverse events were common, emphasizing the need for further investigations on larger samples of cannabis users.

Abstract Background Self-reported substance use is more likely to be influenced by underreporting bias compared to the biological markers. Underreporting bias or validity of self-reported substance use depends on the study population and cannot be generalized to the entire population. This study aimed to compare the validity of self-reported substance use between research setting and primary health care setting from the same source population. Methods and materials The population in this study included from Rafsanjan Youth Cohort Study (RYCS) and from primary care health centers. The sample from RYCS is made up 607 participants, 113 (18.62%) women and 494 (81.38%) men and sample from PHC centers is made up 522 individuals including 252 (48.28%) women and 270 (51.72%) men. We compared two groups in respect of prevalence estimates based on self-reported substance use and urine test. Then for evaluating validity of self-reported substance use in both group, the results of reference standard, urine tests, were compared with the results of self-reported drug use using measures of concordance. Results The prevalence of substance use based on urine test was significantly higher in both settings compared to self-reported substance use over the past 72 h. The sensitivity of self-report substance use over the past 72 h in research setting was 39.4, 20, 10% and zero for opium, methadone, cannabis and amphetamine, respectively and in primary health care setting was 50, 20.7, 12.5% and zero for opium, methadone, cannabis and amphetamine, respectively. The level of agreement between self-reported substance use over the past 72 h and urine test indicated fair and moderate agreement for opium in both research and primary health care settings, respectively and also slight agreement for methadone and cannabis in both settings were reported. There was no significant difference between the two groups in terms of self-reported substance use. For all substances, the level of agreement increased with longer recall periods. The specificity of self-report for all substances in both groups was more than 99%. Conclusion Individuals in primary health care setting were more likely to self-reported substance use than in research setting, but setting did not have a statistically significant effect in terms of self-reported substance use. Programs that rely on self-reported substance use may not estimate the exact prevalence of substance use in both research and primary health care settings, especially for substances that have a higher social stigma. Therefore, it is recommended that self-report and biological indicators be used for more accurate evaluation in substance use studies. It is also suggested that future epidemiological studies be performed to reduce bias of social desirability and find a method providing the highest level of privacy.

Background: The most common drug, illegally used in Iran is opium. The treatment of people with substance use disorder is one of the most important strategies in reducing its burden. The aim of this study was to investigate the effect of different increasing and decreasing opium treatment coverage on the patterns of abstinence, transition to heroin dependence and mortality, over 30 years. Methods: This study was a dynamic compartmental modeling conducted in three stages: 1) presenting a conceptual model of opium dependence treatment in Iran, 2) estimating model’s parameters value, and 3) modeling of opium dependence treatment and examining the outcomes for different treatment coverage scenarios. The input parameters of the model were extracted from the literature, and secondary data analysis, which were finalized in expert panels. Results: The number of opium dependence will increase from 1180550 to 1522063 [28.93% (95% CI: 28.6 to 29.2)] over 30 years. With a 25% decrease in coverage compared to the status quo, the number of deaths will increase by 459 cases [3.28% (95% CI: 0.91 to 5.7)] in the first year, and this trend will continue to be 2989 cases [15.63% (95% CI: 13.4 to 17.9)] in the 30th year. A 25% increase in treatment coverage causes a cumulative decrease of heroin dependence by 14451 cases [10.1% (95% CI: 9.5 to 10.8)] in the first decade. Conclusion: The modeling showed that the treatment coverage level reduction has a greater impact than the coverage level increase in the country and any amount of reduction in the coverage level, even to a small extent, may have a large negative impact in the long run.

Abstract Opioid use disorder (OUD) is diagnosed using the qualitative criteria defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Diagnostic biomarkers for OUD do not currently exist. Our study focused on developing objective biological markers to differentiate chronic opiate users with OUD from chronic opiate users without OUD. Using biospecimens from the Golestan Cohort Study, we compared the metabolomics profiles of high opium users who were diagnosed as OUD positive with high opium users who were diagnosed as OUD negative. High opium use was defined as maximum weekly opium usage greater than or equal to the median usage (2.4 g per week), and OUD was defined as having 2 or more DSM-5 criteria in any 12-month period. Among the 218 high opium users in this study, 80 were diagnosed as OUD negative, while 138 were diagnosed as OUD positive. Seven hundred and twelve peaks differentiated high opium users diagnosed as OUD positive from high opium users diagnosed as OUD negative. Stepwise logistic regression modeling of subject characteristics data together with the 712 differentiating peaks revealed a signature that is 95% predictive of an OUD positive diagnosis, a significant (p

Abstract Background People who use drugs (PWUD) are considered as one of the main at-risk populations for Hepatitis B virus (HBV) infection. We conducted a systematic review on the prevalence of HBV infection among PWUD in Iran. Methods Consistent with PRISMA guideline, international (Medline, Web of Science, Scopus, and Embase) and national (Scientific Information Database) databases were searched using a comprehensive search strategy up to September 2019. The retrieved records were reviewed, and experts were contacted for unpublished studies. Studies on Iranian PWUD reporting HBV surface Antigen (HBsAg) prevalence among people who inject drugs (PWID) and non-injecting PWUD were included. HBsAg prevalence was pooled for PWID and non-injecting PWUD and for other subgroups using random-effects model meta-analysis. The trend of HBV prevalence over time was investigated using meta-regression analysis. Results Overall, 35 studies reported data on HBV infection among PWID (33 studies) and non-injecting PWUD (11 studies). The pooled prevalence of HBsAg among PWID was 4.8% (95% CI 3.7–6.2). The only risk factor significantly associated with the odds of positive HBsAg in PWID was the previous history of imprisonment (OR 1.72, 95% CI 1.29–2.30, p value = 0.000). The pooled estimate of HBsAg among non-injecting PWUD was 2.9% (95% CI 2.5–3.2). Time trend analyses showed significant decrease in HBV prevalence among PWID reaching from 8.2% (95% CI 3.9–16.5) in 2004–2006 to 3.1% (95% CI 2.3–4.1) in 2016 and later (b = -0.07; p value = 0.05). No significant trend was detected for non-injecting PWUD. Conclusion The prevalence of HBV infection among non-injecting PWUD and even PWID was not considerably higher than the Iranian general population. This might be the result of extensive harm reduction interventions in Iran. However, it seems that there are subgroups of PWID, who do not adequately benefit from existing harm reduction interventions. Future programs should more specifically target these high-risk groups.

Background: This qualitative study was undertaken with the aim to identify the reasons for sharing syringesor needles among people who inject drugs (PWID) in Iran.Methods: We used purposive sampling to recruit 4 groups of participants, male PWID (n = 14), female PWID(n = 6), service providers (n = 8), and human immunodeficiency virus (HIV)/addiction experts (n = 9). Datawere collected through 2 focus group discussions (FGDs) among male PWID, and semi-structured interviewswith female PWID, service providers, and HIV/addiction experts. Using conventional content analysis,themes were extracted for reasons for sharing needles to inject drugs.Findings: We found 13 themes for barriers such as low perceived risk of HIV, high stigma around druginjection and use, low access to harm reduction education and prevention services due to their limitedworking hours as a well as uneven geographical distribution of services, some structural barriers likeincarceration, poverty, and homelessness, and several competing survival needs beyond the injection-relatedsafe behaviors.Conclusion: Our study was able to provide the perspectives of both PWID and health care authorities andproviders towards several barriers to accessing HIV prevention services that lead to needle sharing amongPWID in Iran. These barriers need to be addressed to achieve the target of HIV epidemic control.

Background: The current study aimed at determining the pattern of drug dependence and its related factors in mid-term residential treatment centers (MTRCs). Methods: The current cross-sectional study was conducted on all drug dependent people residing in MTRCs of Tehran, Iran, who were voluntarily seeking treatment from April to August, 2018. Required data were collected through face-to-face interviews. Drug dependence was categorized into four groups: soft opioids, hard opioids, methamphetamine, and combination of hard opioids and methamphetamine. The association of potential risk factors with drug dependence was measured using chi-square test and multinomial logistic regression. Results: Out of 1868 participants in the current study, 97% were male. Mean age (SD) of the participants was 38.1 (9.9). The different types of drug dependence were hard opioids (43.0%),soft opioids (29.5%), methamphetamine (15.4%), and a combination of hard opioids and methamphetamine (12.1%). The prevalence of injecting drug use was 2.7%. In comparison with the reference group (soft opioids), being un-married and unemployment, significantly increased the risk of using the three groups of drugs (odds ratios [ORs]: 1.5-3.34, P values:

Objective: National surveys revealed a high prevalence of psychiatric disorders in Iran. Province-level estimates are needed to manage the resources and focus on preventive efforts more efficiently. The objective of this study was to provide province-level estimates of psychiatric disorders. Method: In this study, Iranian Mental Health Survey (IranMHS) data (n = 7886) was used to produce province-level prevalence estimates of any psychiatric disorders among 15-64 year old males and females. Psychiatric disorders were diagnosed based on structured diagnostic interview of the Persian version of Composite International Diagnostic Interview (CIDI, version, 2.1). The Hierarchical Bayesian (HB) random effect model was used to calculate the estimates. The mental health status of half of the participants was also measured using a 28-item general health questionnaire (GHQ). Results: A wide variation in the prevalence of psychiatric disorders was found among 31 provinces of Iran. The direct estimates ranged from 3.6% to 62.6%, while the HB estimates ranged from 12.6% to 36.5%. The provincial prevalence among men ranged from 11.9% to 34.5%, while it ranged from 18.4% to 38.8% among women. The Pearson correlation coefficient between HB estimates and GHQ scores was 0.73. Conclusion: The Bayesian small area estimation provides estimation with improved precision at local levels. Detecting high-priority communities with small-area approach could lead to a better distribution of limited facilities and more effective mental health interventions.

[This corrects the article DOI: 10.1371/journal.pone.0183017.].

Background and aimsCannabis is the most widely used illicit substance globally. In this systematic review, we examined the prevalence and trends of cannabis use and cannabis use disorder in Iran.MethodsWe searched International and Iranian databases up to March 2021. Pooled prevalence of use among sex subgroups of the general population, university and high school students, combined youth groups, and high-risk groups was estimated through random-effects model. Trends of various use indicators and national seizures were examined.ResultsNinety studies were included. The prevalence estimates of last 12-month cannabis use were 1.3% (95%CI: 0.1-3.6) and 0.2% (95%CI: 0.1-0.3) among the male and female Iranian general population, respectively. The prevalence of cannabis use disorder among general population in national studies rose from 0% in 2001 to 0.5% in 2011. In the 2016-2020 period, the pooled prevalence estimates of last 12-month cannabis use were 4.9% (95% CI: 3.4-6.7) and 0.3% (95% CI: 0.0-1.3) among males and females of "combined youth groups", respectively. The linear trend of last 12-month cannabis use among males of "combined youth groups" and among female university students increased significantly from 2000 to 2020.ConclusionsPrevalence of cannabis use in Iran is low compared to many countries. However, there is strong evidence of an increase in cannabis use among the youth and some evidence for an increase in cannabis use disorder.

Summary: Background: Oral rehydration solution (ORS) is a form of oral rehydration therapy (ORT) for diarrhoea that has the potential to drastically reduce child mortality; yet, according to UNICEF estimates, less than half of children younger than 5 years with diarrhoea in low-income and middle-income countries (LMICs) received ORS in 2016. A variety of recommended home fluids (RHF) exist as alternative forms of ORT; however, it is unclear whether RHF prevent child mortality. Previous studies have shown considerable variation between countries in ORS and RHF use, but subnational variation is unknown. This study aims to produce high-resolution geospatial estimates of relative and absolute coverage of ORS, RHF, and ORT (use of either ORS or RHF) in LMICs. Methods: We used a Bayesian geostatistical model including 15 spatial covariates and data from 385 household surveys across 94 LMICs to estimate annual proportions of children younger than 5 years of age with diarrhoea who received ORS or RHF (or both) on continuous continent-wide surfaces in 2000–17, and aggregated results to policy-relevant administrative units. Additionally, we analysed geographical inequality in coverage across administrative units and estimated the number of diarrhoeal deaths averted by increased coverage over the study period. Uncertainty in the mean coverage estimates was calculated by taking 250 draws from the posterior joint distribution of the model and creating uncertainty intervals (UIs) with the 2·5th and 97·5th percentiles of those 250 draws. Findings: While ORS use among children with diarrhoea increased in some countries from 2000 to 2017, coverage remained below 50% in the majority (62·6%; 12 417 of 19 823) of second administrative-level units and an estimated 6 519 000 children (95% UI 5 254 000–7 733 000) with diarrhoea were not treated with any form of ORT in 2017. Increases in ORS use corresponded with declines in RHF in many locations, resulting in relatively constant overall ORT coverage from 2000 to 2017. Although ORS was uniformly distributed subnationally in some countries, within-country geographical inequalities persisted in others; 11 countries had at least a 50% difference in one of their units compared with the country mean. Increases in ORS use over time were correlated with declines in RHF use and in diarrhoeal mortality in many locations, and an estimated 52 230 diarrhoeal deaths (36 910–68 860) were averted by scaling up of ORS coverage between 2000 and 2017. Finally, we identified key subnational areas in Colombia, Nigeria, and Sudan as examples of where diarrhoeal mortality remains higher than average, while ORS coverage remains lower than average. Interpretation: To our knowledge, this study is the first to produce and map subnational estimates of ORS, RHF, and ORT coverage and attributable child diarrhoeal deaths across LMICs from 2000 to 2017, allowing for tracking progress over time. Our novel results, combined with detailed subnational estimates of diarrhoeal morbidity and mortality, can support subnational needs assessments aimed at furthering policy makers' understanding of within-country disparities. Over 50 years after the discovery that led to this simple, cheap, and life-saving therapy, large gains in reducing mortality could still be made by reducing geographical inequalities in ORS coverage. Funding: Bill & Melinda Gates Foundation.

As a response to the COVID-19 pandemic, many governments have introduced steps such as spatial distancing and “staying at home” to curb its spread and impact. The fear resulting from the disease, the ‘lockdown’ situation, high levels of uncertainty regarding the future, and financial insecurity raise the level of stress, anxiety, and depression experienced by people all around the world. Psychoactive substances and other reinforcing behaviors (e.g., gambling, video gaming, watching pornography) are often used to reduce stress and anxiety and/or to alleviate depressed mood. The tendency to use such substances and engage in such behaviors in an excessive manner as putative coping strategies in crises like the COVID-19 pandemic is considerable. Moreover, the importance of information and communications technology (ICT) is even higher in the present crisis than usual. ICT has been crucial in keeping parts of the economy going, allowing large groups of people to work and study from home, enhancing social connectedness, providing greatly needed entertainment, etc. Although for the vast majority ICT use is adaptive and should not be pathologized, a subgroup of vulnerable individuals are at risk of developing problematic usage patterns. The present consensus guidance discusses these risks and makes some practical recommendations that may help diminish them.

Abstract Background It has been shown in the past two decades that anxiety disorders are the most common mental disorders in general population across the world. This study sought to assess the prevalence of major anxiety disorders, their sociodemographic correlates and mental health service utilization as part of the Iranian Mental Health Survey (IranMHS). Methods A national household face-to-face survey was carried out on a representative sample of Iranian adults from January to June 2011 using Composite International Diagnostic Interview (CIDI 2.1). A total of 7886 subjects between 15 and 64 years who can understand Persian language were included. The 12-month prevalence of anxiety disorders according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), their socio-demographic correlates, health service use and days out of role were measured in this study. Results The 12-month prevalence of anxiety disorders (not including specific phobias) was 15.6%. The prevalence was 12.0% in males and 19.4% in females. The three most prevalent anxiety disorders were generalized anxiety disorder (5.2%), obsessive-compulsive disorder (5.1%) and social phobia (3.2%), respectively. Factors found to be significantly associated with anxiety disorders were: female gender (OR = 1.16, 95% CI: 1.09–1.23), middle (OR = 1.23, 95%CI: 1.01–1.50) or low (OR = 1.66, 95%CI: 1.31–2.10) socioeconomic status, unemployment (OR = 1.98, 95%CI: 1.49–2.62), and urban residence (OR = 1.31, 95%CI: 1.10–1.57). Comorbidity with non-anxiety disorders significantly increased service utilization. In all subgroups, service utilization was higher among females while the number of days out of role was higher among males. Conclusions Anxiety disorders are common conditions with a higher prevalence among the female gender, unemployed individuals, and people with low socioeconomic conditions living in urban areas. Comorbidity of anxiety disorders with other psychological disorders aggravates the disability and significantly increases the number of days out of role.

HIV/AIDS is among the leading causes of morbidity and mortality in world. There are more than 35 million people living with HIV/AIDS in the world. Although the annual incidence of HIV infection is decreasing globally, HIV prevalence is rising due to development of more effective treatment and higher survival. Iran suffers from concentrated HIV epidemics among injecting and non-injecting drug users. There are more than 27 thousand registered cases of HIV infection and it is estimated that there are above seventy eight thousand cases in the country. Regarding the burden of disease, it is projected that HIV/AIDS will have the highest growth during the next 10 years. The outcome of this epidemics will be determined by human behavior. HIV, psychiatric disorders and substance use disorders are closely correlated and are accompanied by similar risk factors. They also share common consequences such as stigma and discrimination. Correlation of psychiatric disorders, as one of the most influential determinants of our behavior, and HIV/AIDS infection is reviewed in this narrative article. Psychiatric disorders are associated with greater risk of HIV acquisition. Substance use disorders, both injecting and non-injecting, as well as severe mental illnesses put the individual at higher risk of acquiring HIV infection. Impaired judgment, diminished inhibition and control over behaviors, lack of insight and poor self-care have been proposed as the underlying mechanisms. On the other hand, HIV infection may put the individual at greater risk of developing a mental illness. Coping with a chronic and life-threatening illness, fear of stigma and discrimination, CNS invasion of the virus as well as the adverse neuropsychiatric side effects of anti-retroviral medications may all contribute to establishment of a psychiatric disorder. Although there exists a bi-directional correlation between mental health problems and HIV/AIDS infection, this reciprocity goes beyond. Psychiatric disorders can affect the patient’s adherence, access to treatment and care and can worsen the course and clinical outcome of the infection. The clinical importance, underlying mechanism and other implications of this correlation are reviewed in this article.

Background: This study was aimed to determine the prevalence, predictors and cost of CAM practitioner use among traumatic patients in Iran. Methods: This cross-sectional household survey of a nationally representative sample of Iranians 15 to 64 yr old was conducted in 2011, using a three-stage cluster sampling. Short Form Injury Questionnaire 7 (SFIQ7) was utilized through face-to-face interviews and data on demographics, history of injuries, mechanism, site and type of injury, type and place of the treatment were attained. Via telephone calls, service use and costs of treatment were also collected. Results: The prevalence of CAM practitioner use in injured people and victims seeking medical care was 0.7% and 4.1%, respectively in 3-month interval in 2011. There were no significant sociodemographic differences between victims who seek unconventional settings and those who seek conventional treatment. The most common injury description treated by CAM providers was as follows: fracture (type of injury), upper limb (site of injury), fall (mechanism of injury) and cast, splint, and physiotherapy (type of treatment). The average medical cost of CAM practitioner was US$14.7 while this amount in the conventional setting was US$195.5. Conclusion: Use of CAM is not very common among injured people in Iran. However, due to lack of formal training, CAM usage has possible side effects.

[This corrects the article DOI: 10.1371/journal.pone.0183017.].

Objective: Drug users, particularly drug injectors, are at elevated risk of blood-borne diseases. This study systematically reviewed the prevalence of hepatitis C virus (HCV) mono-infection and its co-infections with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) in drug users in Iran. Methods: Searches were conducted in international, regional, and Iranian databases. Documents were screened, data extracted, and pooled point prevalence and 95% confidence intervals (CI) were calculated. Results: Overall, 13 821 subjects (87.4% male) with an average age of 32.4 years (95% CI 31–33 years) from 24 original studies were included in the analysis. The pooled HCV prevalence (95% CI) among drug users with and without an injection history was 45% (37–54%) and 8% (4–13%), respectively. The pooled HCV prevalences (95% CI) among individuals with vs. without a history of imprisonment and needle sharing were 58% (39–77%) vs. 44% (20–68%) and 56% (41–71%) vs. 49% (26–71%), respectively. The prevalence of HCV/HIV co-infection among injectors was 11% (95% CI 5–16%). Conclusions: HCV prevalence is high in drug users in Iran, especially among those with a history of injection drug use, needle sharing, and imprisonment. Drug user-focused HCV prevention and treatment programs are urgently needed.

Background: We aimed to evaluate the current status of scientific production in the field of substance use and addiction in Iran, to determine its trend and pattern during a 5 years period (2008-2012). Methods: Using relevant keywords, we searched three international databases (Web of Science, Medline, and Scopus) and two local databases (SID and Iranmedex) to locate the papers published in the field of addiction by Iranian researchers during 2008-2012. Findings: The results indicated a significant increase in the number of studies published in the field during the 5 years study period, with more than half of the papers published in the last 2 years. Results also indicated that over half (53.5%) of the papers were published in Persian-language Iranian Journals, but the rate of increase in the number of papers published in English was slightly higher than that of Persian ones. Opioid substances were found to be the topic of approximately 75% of the papers. Studies on key topics, including national surveys, evaluation of current programs, addiction in women and children, and so forth, were found to be highly lacking. Conclusion: Results suggested a significant growth in the scientific production of Iran in the field of substance use and addiction. However, considering the significance of substance use and dependence in the country, and compared to the scientific production of developed countries, the amount of research conducted in the field of addiction in Iran is still limited.

Several case-control studies have shown associations between the risk of different cancers and self-reported opium use. Inquiring into relatively sensitive issues, such as the history of drug use, is usually prone to information bias. However, in order to justify the findings of these types of studies, we have to quantify the level of such a negative bias. In current study, we aimed to evaluate sensitivity of self-reported opioid use and suggest suitable types of control groups for case-control studies on opioid use and the risk of cancer.In order to compare the validity of the self-reported opioid use, we cross-validated the response of two groups of subjects 1) 178 hospitalized patients and 2) 186 healthy individuals with the results of their tests using urine rapid drug screen (URDS) and thin layer chromatography (TLC). The questioners were asked by trained interviewers to maximize the validity of responses; healthy individuals were selected from the companions of patients in hospitals.Self-reported regular opioid use was 36.5% in hospitalized patients 19.3% in healthy individuals (p-value> 0.001).The reported frequencies of opioid use in the past 72 hours were 21.4% and 11.8% in hospitalized patients and healthy individuals respectively. Comparing their responses with the results of urine tests showed a sensitivity of 77% and 69% among hospitalized patients and healthy individuals for self-reports (p-value = 0.4). Having corrected based on the mentioned sensitivities; the frequency of opioid regular use was 47% and 28% in hospitalized patients and healthy individuals, respectively. Regular opioid use among hospitalized patients was significantly higher than in healthy individuals (p-value> 0.001).Our findings showed that the level of opioid use under-reporting in hospitalized patients and healthy individuals was considerable but comparable. In addition, the frequency of regular opioid use among hospitalized patients was significantly higher than that in the general population. Altogether, it seems that, without corrections for these differences and biases, the results of many studies including case-control studies on opioid use might distort findings substantially.

The marked shift in the patterns of drug use in Iran, from opium smoking to injecting drug use, has led to serious health-related outcomes. This study was designed to explore characteristics of people who inject drugs (PWID) in Tehran, Iran. Nine hundred and four PWID were recruited from treatment and harm reduction facilities, as well as drug user hangouts in public areas in Tehran. Participants were interviewed using the Persian version of the World Health Organization Drug Injecting Study Phase II questionnaire. The median age at the time of the first illegal drug use, at the time of the first injection and current age was 20, 24 and 32, respectively. In more than 80% of the cases, the first drug used was opium. The transition from the first drug use to the first drug injection occurred after an average of 6.6 and 2.7 years for those who had started drug use with opium and heroin, respectively. Two-thirds of the participants shared injecting equipment within the last 6 months. Difficulty in obtaining sterile needles and thehigh cost of syringes were reported as the major reasons for needle/syringe sharing. Approximately 80% of community-recruited PWID reported difficulties in using treatment or harm reduction services. Self-detoxification and forced detoxification were the most common types of drug abuse treatment in alifetime. Despite a dramatic shift in drug policy in Iran during the past few years, wider coverage of harm reduction services, improvement of the quality of services, and education about such services are still necessary.

Background: Injuries and psychiatric disorders, notably both major public health concerns, are associated with a high burden and are believed to be bi-directionally correlated. Those inflicted with injuries face increased risks of mental illnesses. Psychiatric disorders may make the individual prone to injuries. The objective of the study was to assess the correlation of mental disorders with non-fatal injuries. Methods: A total of 7886 participants aged 15 to 64 yr were interviewed in a national household survey in 2011 in Iran. Composite International Diagnostic Interview (CIDI v2.1) was implemented to assess the prevalence of psychiatric disorders in the past twelve months. Injuries were assessed using Short Form Injury Questionnaire (SFIQ-7). Results: Injury was reported in 35.9% and 22.8% of participants in the past twelve and past three months, respectively. Using multivariate logistic regression analysis, mental disorders were significantly associated with injuries in the past three months (OR=1.6, 95% CI:1.36-1.87), recurrent injuries (OR=1.7, 95% CI: 1.21-2.41) and road/traffic accidents (OR=2.4, 95% CI: 1.28-4.49). Conclusion: Psychiatric disorders were found to be associated with an increased risk of injuries. Early detection and treatment of mental illnesses can contribute to injury prevention.

Breaking bad news is one of the most burdensome tasks physicians face in their everyday practice. It becomes even more challenging in the context of HIV+ patients because of stigma and discrimination. The aim of the current study is to evaluate the quality of giving HIV seroconversion news according to SPIKES protocol. Numbers of 154 consecutive HIV+ patients from Imam Khomeini Hospital testing and counseling center were enrolled in this study. Patients were inquired about how they were given the HIV news and whether or not they received pre- and post-test counseling sessions. Around 51% of them were men, 80% had high school education, and 56% were employed. Regarding marital status, 32% were single, and 52% were married at the time of the interview. Among them, 31% had received the HIV news in a counseling center, and only 29% had pre-test counseling. SPIKES criteria were significantly met when the HIV news was given in an HIV counseling and testing center (P.value

Latent class analysis (LCA) is a method of assessing and correcting measurement error in surveys. The local independence assumption in LCA assumes that indicators are independent from each other condition on the latent variable. Violation of this assumption leads to unreliable results. We explored this issue by using LCA to estimate the prevalence of illicit drug use in the Iranian Mental Health Survey. The following three indicators were included in the LCA models: five or more instances of using any illicit drug in the past 12 months (indicator A), any use of any illicit drug in the past 12 months (indicator B), and the self-perceived need of treatment services or having received treatment for a substance use disorder in the past 12 months (indicator C). Gender was also used in all LCA models as a grouping variable. One LCA model using indicators A and B, as well as 10 different LCA models using indicators A, B, and C, were fitted to the data. The three models that had the best fit to the data included the following correlations between indicators: (AC and AB), (AC), and (AC, BC, and AB). The estimated prevalence of illicit drug use based on these three models was 28.9%, 6.2% and 42.2%, respectively. None of these models completely controlled for violation of the local independence assumption. In order to perform unbiased estimations using the LCA approach, the factors violating the local independence assumption (behaviorally correlated error, bivocality, and latent heterogeneity) should be completely taken into account in all models using well-known methods.

Objective: The prevalence of smoking in the adolescence is a valuable indicator for prediction of national burden of smoking in the future. The aim of this systematic review is to determine the prevalence of lifetime smoking among high school students in Iran.Methods: Various search methods have been used including searching Pubmed, ISI, PsycINFO, CINAHL, Embase, IranMedex, IranPsych and database on drug abuse, as well as hand-searching. All original researches, which had described lifetime use of cigarette, hookah, and pipe among high school students were included in the study with no restriction on date of publication, and were qualitatively assessed. Subsequent to data extraction, heterogeneity test was carried out on indicators for which more than two studies were found and meta-analyses were performed.Results: In total, 18 studies were included in this review. The combined prevalence of lifetime cigarette smoking for boys, girls and total high school students were calculated as 30.9% (95% confidence interval (CI): 25-36.8), 14% (95% CI: 7-20.9) and 21% (95% CI: 15.1-26.9), respectively. The combined prevalence of lifetime cigarette smoking for boys was significantly different (P

Objective(s): An urgent project for arresting and mandatory treatment of high risk drug addicts started in May 2007 in Tehran. After triage, those with more severe patterns were sent to a residential center for compulsory methadone maintenance treatment. This paper presents the evaluation of the process of interventions. The two and six-months follow-up outcomes are presented in the second paper.Methods: Seventy nine drug addicts that were arrested within 11 days and sent to Shafagh residential center were followed. Repeated individual interviews with the residents, focus group discussions, morphine test in urine, observations, reviews of the records and reports, interviews with staff and authorities of involved organizations were conducted.Results: The majority of the drug addicts welcome methadone maintenance treatment. During residence, morphine test was positive in 20% and 4% in the first and second time of assessment, respectively. From the 79 individuals entering the residential center, three fourth were kept less than 50 days. There were shortcomings in providing services. During the first months, the strict control of the police, was impairing the supported environment needed for treatment. However, the majority of residents were satisfied with the provided compulsory treatment.Conclusion: Cooperaion of law enforcement and Ministry of Health, preparation of treatment protocol, and evaluation were strengths of the whole project, which differentiated it from previous similar efforts. It is suggested that the project be continued as an experimental field without expansion in order to integrate judiciary supervision, improving the process and utilization of a variety of approaches.|

Objective(s): An urgent project for arresting and mandatory treatment of high risk drug addicts started in May 2007 in Tehran. After triage, those with more severe patterns were sent to a residential center for compulsory methadone maintenance treatment. This paper presents the outcomes in two and six-month follow-up. The results of process evaluation of interventions were presented in the first paper.Methods: A total of 500 addicts that have been arrested within 11 days were followed. Seventy nine were sent to the residential center. Follow-up of these arrestees within the center, and two and six months after discharge were carried out through individual interviews, focus group discussions, morphine test in urine, and review of the records.Results: From the 79 individuals entering the residential center, 51 were discharged after two months. Fifteen (29.4%) was in treatment in two month follow-up and 7 (13.7% from 51) had negative morphine test. In six month follow-up, retention rate was 23.5% (11 of 51) and morphine test was negative in 6 (11.8% from 51).Conclusion: Because of the criminal approach to addiction in the country and provision of various punishments in anti-drug law, this was the first scientific approach to mandatory treatment. Although the positive outcomes are less than the results of other compulsory treatments like Drug Court Treatment, but with improvements in the provided services, utilization of a variety of approaches, and promoting aftercare services, the outcomes can improve, considerably.

Objectives: There are a large number of primary researches on the prevalence of major depressive disorder (MDD) in Iran; however, their findings are varied considerably. A systematic review was performed in order to summarize the findings. Methods: Electronic and manual searches in international and Iranian journals were conducted to find relevant studies reporting MDD prevalence. To maximize the sensitivity of the search, the references of relevant papers were also explored. We explored the potential sources of heterogeneity such as diagnostic tools, gender and other characteristics using meta-regression model. The com-bined mean prevalence rates were calculated for genders, studies using each type of instruments and for each province using meta-analysis method. Results: From 44 articles included in the systematic review, 24 reported current prevalence and 20 reported lifetime prevalence of MDD. The overall estimation of current prevalence of MDD was 4.1% (95% CI: 3.1-5.1). Women were 1.95 (95% CI: 1.55-2.45) times more likely to have MDD. The current prevalence of MDD in urban inhabitants was not significantly different from rural inhabitants. The analysis identified the variations in diagnostic tools as an important source of heterogeneity. Conclusions: Although there is not adequate information on MDD prevalence in some areas of Iran, the overall current preva-lence of MDD in the country is high and females are at the greater risk of disease.

"n Objective: "n "nThe aim of the present study is to perform a systematic review of studies that have investigated the prevalence of sexual disorders in Iran. "nMethod: A broad search was conducted in Pubmed Medline, ISI web of Science, PsychINFO, CINAHL, EMBASE, and three Iranian databases, including IranPsych, IranMedex, and Scientific Information Database (SID). To cover those studies that were not published, we did a hand searching of all theses, reports and congresses abstract booklets which were available in IranPsych and universities' libraries. Then we included original studies which reported the prevalence of sexual disorders and data extraction was performed with two researchers for each document. "nResults: five studies were finally included, one in men and the others in women. There was a great heterogeneity between studies and performing metaanalysis was impossible. "nConclusion: Prevalence rates of mental disorders were reported in a wide range in different studies. More high quality studies with standard instruments are necessary in this field.

"n Objectives: "n "nThe mean age of cigarette smoking has decreased along with an increase in its prevalence, in developing countries. The aim of this systematic review is to determine the prevalence of lifetime, current and daily smoking among middle school students in Iran . "nMethods: Various search methods have been used in this study including searching different international databanks such as Pubmed, ISI web of Science, PsychInfo, CINAHL, Embase, as well as domestic databanks including IranPsych and IranMedex. All original studies and researches in Persian or English, which had described any kind of use including lifetime, current and daily use of cigarette, hookah, and pipe among middle school students, were included in the study with no restriction on date of publication, and were qualitatively assessed. Subsequent to data extraction, heterogeneity test was carried out on indicators for which more than two studies were found, and meta-analysis was done using random effects model . "nResults: The combined prevalence of lifetime, current and daily cigarette smoking were calculated as 14.2% (95% CI: 6.6-21.7), 2.7% (95% CI: 0.5- 5.9) and 1.1% (95% CI: 0.6-2.8), respectively. The combined prevalence of "current tobacco use of all kinds" was 15% (95% CI: 10.4-19.5), as well. "nConclusions: The prevalence of smoking in this age range is lower in Iran compared to other countries. However, a conclusion cannot be made about the changes in the prevalence of smoking in recent years. Moreover, studies carried out to the present have several qualitative limitations, which points to the necessity of high quality repeated surveys

"nObjective: The objective of the present study was to perform a systematic review of studies that investigated the prevalence of anxiety and depression in medical inpatients. "nMethod: A search was conducted in Pubmed Medline, ISI Web of Science, PsychINFO, CINAHL, EMBASE, Irandoc, IranPsych, IranMedex, and dissertations. In the next step, the original studies which reported the prevalence of anxiety and/or depression in medical inpatients were included and then evaluated. These evaluations included two parts. The first part was the qualitative evaluation of the articles, which was carried out using a checklist. The second part was data extraction, performed with two researchers for each document. "nResults: Thirty nine studies (13 articles and 26 dissertations) were finally included. Only in seven studies, diagnostic interview was used to diagnose patients with anxiety and depression. Results of the qualitative evaluation of articles showed that a high percentage of them lacked the appropriate methodology. The maximum and minimum prevalence of depression in the reviewed studies was 91.7% and 17% respectively. The maximum and minimum prevalence of anxiety in the reviewed articles was 78.33% and 6% respectively. The prevalence of depression and anxiety in all studies which had reported prevalence according to sex was higher in females. Meta-analysis with Random effect model indicates the heterogeneity of studies, so we just perform meta- analysis in two groups of patients, chronic renal failure patients and patients with ischemic heart disease. The combined estimation of the prevalence of depression and anxiety in patients with chronic renal failure according to this meta-analysis was 55.91 (confidence interval=37.14-74.69) and 46.72 (confidence interval=20.31-73.13) respectively. The combined estimation of the prevalence of depression and anxiety in patients with ischemic heart disease was 52.54 (confidence interval=42.82-62.26) and 30.92 (confidence interval=1.21-60.64) respectively. "nConclusion: The presence of heterogeneity in prevalence of anxiety and depression can be due to the nature of observational studies, which could result in diverse results from different aspects Some of these differences include the difference in instruments and their cutting points, difference in populations under study, dissimilar and non-standard methods, difference in clinical signs and symptoms, and difference in the times of evaluations. Many of the mentioned factors are also responsible for disparities in prevalence in the present study, with the difference in the somatic illnesses being among the most important reasons. However, in subgroups with similar somatic illnesses such as ischemic heart disease and chronic renal failure this difference is also observed. Considering the low quality of articles with regard to methodology, there is a possibility that this factor could have had a more decisive role in the differences observed in similar subgroups.

Objective: This study aimed to describe the characteristics of Iran’s child and adolescent mental health research published from 1973 to 2002. Method: The articles were drawn from IranPsych, which is a national database of published research in mental health and related fields. This database gathers scientific papers on psychiatry, psychology, and neuroscience published in both national and international journals. Bibliometric data, general scientific areas of research, specific subject topics and research design, were extracted from aticles. Egypt was selected as one of the Middle East countries that has some similarities with Iran. Iranian and Egyptian child and adolescent mental health research articles indexed in ISI 1994 to 2004 also were compared. Results: From a total of 883 articles, 9% appeared in international journals. There was a marked increase in the number of publications over time, especially in the last 5 years. Psychology and clinical research constituted 70%, and 32% of articles, respectively; followed by epidemiology 11%, health service research 2% and neuroscience 0.7%. During the first five years of the mentioned period Iran fell behind Egypt in terms of international child and adolescent mental health research articles; however, in the last five years, Iranian articles numbered 2.75 times the Egyptian’s. Conclusion: This study showed that it is feasible to outline the status of research activity of a country by using databases that cover publications and would yield several remarkable findings that could be used as a basis for policy making and strategy development in child and adolescent mental health research.

Objective: The Sheehan Disability Scale (SDS) assesses disability in four domains of home management, work responsibilities, close relationships and social life. The main objective of this study was to develop the Persian version of the SDS. Method: Two steps of field work followed the Persian translation and cultural adaptation of the tool: First, the internal consistency and convergent validity was examined in 104 clinical cases recruited from inpatient and outpatient psychiatric services, using 36-item Short Form Health Survey (SF-36) and Global Assessment of Functioning (GAF). Then 88 individuals were randomly selected from the adult general population to assess internal consistency, inter-rater reliability and known group validity. Results: In the clinical settings, Cronbach’s α coefficient was 0.88 and item-total correlation ranged from 0.71 to 0.78 in various domains. The correlation between SDS and SF-36 (P

Iranian Mental Health Survey (IranMHS) was conducted to assess the twelve-month prevalence and severity of psychiatric disorders in the Iranian adult population and to determine the pattern of health care utilization and cost of services. IranMHS is a cross-sectional national household survey with face-to-face interviews as the main data collection method. The study was carried out between January and June 2011. A three-stage probability sampling was applied for the selection of a representative sample from the non-institutionalized population aged 15 to 64. The primary instrument utilized for assessing the prevalence of mental disorders was the Persian version of Composite International Diagnosis Interview, version 2.1. The instruments for assessing the service and cost of mental illness were developed by the research team. The response rate was 86.2%, and a total of 7886 individuals participated in the study. Sampling weights were the joint product of inverse probability of unit selection, non-response weights and post-stratification weights. This paper presents an overview of the study design, fieldwork organization and procedures, weightings and analysis. The strengths and limitations of the study are also discussed.

Objective: The aim of the present study is to perform a systematic review of studies that have investigated the prevalence of sexual disorders in Iran. Method: A broad search was conducted in Pubmed Medline, ISI web of Science, PsychINFO, CINAHL, EMBASE, and three Iranian databases, including IranPsych, IranMedex, and Scientific Information Database (SID). To cover those studies that were not published, we did a hand searching of all theses, reports and congresses abstract booklets which were available in IranPsych and universities' libraries. Then we included original studies which reported the prevalence of sexual disorders and data extraction was performed with two researchers for each document. Results: five studies were finally included, one in men and the others in women. There was a great heterogeneity between studies and performing metaanalysis was impossible. Conclusion: Prevalence rates of mental disorders were reported in a wide range in different studies. More high quality studies with standard instruments are necessary in this field.

Objective: Taking the diversity of the methodologies applied in prevalence studies of psychiatric disorders in Iran and their heterogeneous results into consideration, there seems to be need for a systematic review in order to compile the findings and seek appropriate recommendations for future studies. This study aims at systematically identifying studies conducted in Iran describing the prevalence of psychiatric disorders in general population, and to summarize the findings of these studies. Method: To identify the relevant studies, several databases including Pubmed Medline, ISI Web of Science, PsychINFO, CINAHL, EMBASE, Irandoc, IranPsych, IranMedex, Scientific Information Database as well as reference lists of the accessed documents, unpublished reports, conference proceedings and dissertations were searched. In the next step, the original studies which contained an estimation of prevalence of 'any psychiatric disorder' (overall prevalence) among a sample of general population in the country were selected. This was followed by data extraction, presentation of the results, quality assessment and quantitative pooling of estimated rates of prevalence of psychiatric disorders. Results: A total number of 35 studies were included. Estimations provided for prevalence rates in different groups illustrate diversity and heterogeneity; the rates varied in the range of 1.9-58.8%. Most of the studies had assessed the point prevalence of the disorders conducted using screening instruments. The median point prevalence has been reported to be 28.70% in screening studies, and 18.60% in studies using diagnostic interviews. Pooled estimates obtained through meta-analysis for screening and diagnostic studies were 29.1% and 21.9%,respectively. The results of the studies which have used diagnostic interviews as their data collection tool showed less heterogeneity than the ones using screening instruments. In quality assessment of the studies, only one third proved to be of high quality. Conclusion: Even though the pooled rates for prevalence of psychiatric disorders are comparable to the rates in many other countries, the most important finding of this study is the diversity of the prevalence rates among different communities in Iran. This diversity does not seem to be attributed solely to the different time frames and geographical locations of the studies. It might also have resulted from differences in methodologies (e.g., using different tools), study procedures and study quality.