During a survey of endophytic fungi associated with medicinal plants in Iran, three novel species of the genus Xenodidymella including X. euphorbiae, X. hamanae and X. kopetdagensis were isolated from asymptomatic tissues of Euphorbia kopetdaghi Prokh and Thymus transcaspicus Klokov. Species delimitation was conducted using a combination of morphological characterisation and multilocus phylogenetic analyses based on the ITS rDNA, partial beta-tubulin (tub2), and RNA polymerase II second largest subunit (rpb2) gene regions. Both Bayesian inference and Maximum Likelihood phylogenetic analyses revealed that each new species formed distinct, well-supported clades, clearly separated from previously known taxa. In addition, Xenodidymella camporesii is reported for the first time from healthy roots of Salvia sclarea L., representing a novel host record. These findings suggest a potential endophytic lifestyle for Xenodidymella species, contrasting with their traditionally known roles as pathogens or saprobes. This study contributes to the taxonomic expansion of the genus and underscores the rich, yet underexplored fungal diversity of Iran's arid and semi-arid ecosystems.
Implementation of health development programs contributes to economic growth, poverty eradication, educational achievements, reductions in inequalities, and environmental sustainability. However, several obstacles limit the progress of quantitative indicators after the implementation of these programs. This paper aims to conduct a comparative study of health-related sustainable development goals (SDGs) in Iran and selected countries worldwide. This mixedater-method research includes qualitative and quantitative phases. The qualitative phase involves a systematic review using a framework analysis approach, while the quantitative phase employs meta-analysis to compare Iran with selected countries from the European and Eastern Mediterranean regions, utilizing a judgmental sampling method. Data were collected from the WHO website. The countries included in the study are Iran, Cyprus, Greece, the Netherlands, Portugal, Germany, and Italy. Comparative studies of these countries were based on criteria such as health policies, financing, planning, and health indicators. The findings from the comparative study and the experiences of the investigated countries, alongside existing limitations and capacities, informed suggestions for the country's development planning. Iran's life expectancy is 77.3 years, which is relatively low. In terms of maternal mortality ratio, Iran ranks sixth among the selected countries. Additionally, Iran has the highest rates of under-five mortality and infant mortality. The service coverage index stands at 74%, indicating low coverage. Immunization coverage is notably high; however, the density of healthcare professionals-including doctors, nurses, midwives, dentists, and pharmacists-was found to be insufficient. Furthermore, public health expenditures by the Iranian government were higher than those of other countries. Iran has made significant efforts to improve health indicators, but to control and reduce certain metrics, it requires careful planning and effective management of related issues. Prioritizing the indicators where Iran is lagging necessitates the utmost attention from decision-makers.
Sustainable financing is essential for Iran's health system to achieve universal health coverage and improve healthcare quality. It involves gathering and managing financial resources for health services, aiming to enhance access to quality care while keeping costs manageable. These financing needs to address current health system demands without burdening the government and public, while also boosting healthcare quality. The study explores how to prioritize sustainable financing using the Kingdon multiple streams model. This qualitative study looks at how a sustainable financing program is set up in Iran's health system using Kingdon's multiple streams model. It identifies three main areas: issues (problem stream), solutions (policy stream), and political will (political stream). Data were gathered through interviews and analyzed for themes. Sustainable financing in Iran's health system faces major challenges in three areas: problems, policies, and politics. Key issues include a lack of financial resources, high healthcare costs, unequal access to care, low government funding, and poor resource management. Other challenges are high out-of-pocket expenses, limited insurance coverage, and reliance on oil revenue. Proposed solutions are to improve resource tracking, increase public health budgets, encourage community involvement, and use modern technology. The government must recognize these issues to build political commitment for sustainable financing, prioritizing resilience and effectiveness. The collaboration between the World Health Organization, the Islamic Consultative Assembly, and health entities in Iran shows the alignment of problems, policies, and politics. By addressing financial issues and involving stakeholders, they create opportunities for sustainable health financing, improve community health, and strengthen the healthcare system.
Accurate measurement of routine immunization coverage is essential for detecting immunity gaps, guiding programmatic responses, and supporting equitable vaccine delivery. Iran's Expanded Programme on Immunization has achieved high coverage, but administrative estimates can mask some disparities. The aim of this protocol is to evaluate coverage among children under 3 years old and mothers who have given birth within the last 12 months. We will conduct a national, cross-sectional, mixed-methods survey on vaccination coverage across all 31 provinces of Iran. A multistage, stratified cluster design will target about 9200 children aged 0-35 months (1325 clusters) and 2109 mothers who delivered in the past 12 months (211 clusters), with oversampling of smaller strata and an allocated proportion for non-Iranian residents. Vaccination status will be verified preferentially from home-based records and electronic registries, supplemented by caregiver recall. Digital data capture and photographed records will be used alongside supervisory quality checks. Quantitative analyses will apply complex survey weighting to estimate coverage, dropout, timeliness, and missed opportunities. Also, thematic analysis of 30-40 in-depth interviews will show determinants of vaccination. This manuscript describes the protocol for a national mixed-methods study. No empirical results are presented. The findings from this mixed-methods study will deliver high-quality, disaggregated evidence on immunization coverage and its drivers in Iran, enabling policymakers and programme managers to design and implement targeted interventions to close equity gaps and support sustained uptake of both established and newly introduced vaccines.
Cardiovascular diseases (CVD) are a major global health challenge, with rising prevalence, high mortality and disability rates, and significant economic costs. Emerging research suggests that climate change worsens these risks. This study aims to assess the impact of climate change on CVD mortality. This study analyzed validated national CVD mortality data from 2017 to 2019, with annual recorded deaths of 18,146; 21,945; and 24,352, respectively. These figures were aggregated to form the basis for subsequent analysis. We utilized advanced spatial statistical techniques, including Anselin Local Moran's I and Hot Spot Analysis (Getis-Ord Gi*), to assess CVD mortality patterns. Additionally, GIS were employed to identify and analyze climate change impacts at the township level, enabling a comprehensive spatial understanding of environmental and health-related factors. Following temperature, climate, and topographic assessments, an initial national zoning of these parameters was conducted. Analysis of spatial patterns revealed significant heterogeneity in CVD mortality across Iran's diverse climate zones, which range from arid deserts to mountainous regions. Hotspot analysis (Getis-Ord Gi*) identified significant high-risk clusters, particularly in the central arid regions, and low-risk clusters in other areas. The findings demonstrate a clear association between extreme climatic conditions, geographic features, and elevated cardiovascular mortality rates. Climate change and environmental factors significantly influence CVD mortality in Iran. Rising extreme heat events threaten cardiovascular health, especially among vulnerable groups. To combat this, targeted public health strategies and adaptive measures are needed to reduce heat-related risks nationwide.
Iran was heavily affected by COVID-19 and faced a delayed, uneven vaccine rollout. While global vaccine hoarding constrained access, the delay also reflected an immunitarian decision by the Supreme Leader to ban US- and UK-produced vaccines. Using Walt and Gilson's Health Policy Analysis (HPA), I examine Iran's early COVID-19 response, tracing how context, content, process, and actors shaped vaccine governance and outcomes. I compare deaths per 100,000 from the World Health Organization (WHO) with eight peer countries benchmarked by income group and vaccine portfolio. Adjusting for GDP per capita, the share aged 65 and over, and a Health Resources score, I identify excess mortality beyond expectations. Drawing on Esposito's immunity and Agamben's homo sacer, I read Iran alongside Global North policies prioritizing economic continuity and invoking 'natural herd immunity.' In both settings, protection is pursued through selective exposure, edging toward autoimmunity. In the Global North, sacrifice fell along the lines of unequal welfare and labour regimes and unequal vaccine markets; in Iran, martyrdom and purification moralized immunitary sovereignty as resistance to 'Western arrogance,' casting dissent as impurity and tending toward 'disinfestation,' where defence turns against the life it claims to secure.
Tibial shaft fractures are among the most common injuries resulting from trauma and are typically managed surgically via either plate fixation or intramedullary nailing. Given the constraints on healthcare resources and the imperative to control costs, evaluating the cost-effectiveness of these treatment strategies is essential. This study aimed to assess and compare the cost-effectiveness of intramedullary nailing versus plate fixation for tibial shaft fractures. This cross-sectional economic evaluation was conducted from a modified societal perspective, incorporating direct medical costs (from hospital records and patient reports) and direct non-medical costs (from patient reports), alongside treatment effectiveness measured by health-related quality of life (HRQoL) and QALYs. The study included 276 patients with mid-shaft tibial fractures treated surgically with either intramedullary nailing or plate fixation at Shahid Dr. Rahnemoon Hospital, Yazd, Iran. Patients were followed for three months post-discharge. A willingness-to-pay (WTP) threshold of USD 4,771.4 per QALY (based on Iran's 2024 GDP per capita) was applied, and cost-effectiveness analysis was performed using Stata version 16 and TreeAge Pro 2020. The mean total direct cost per patient was lower for intramedullary nailing (USD 602.87) than plate fixation (USD 669.68), with hospital expenses comprising the largest share (USD 448.47 vs. USD 472.84, respectively). Using a linear area-under-the-curve approach, accumulated QALYs over 90 days were higher for nailing (0.0627) than plate fixation (0.0448). Cost-effectiveness analysis identified intramedullary nailing as the undominated strategy, while plate fixation was absolutely dominated due to higher costs and lower effectiveness. Probabilistic sensitivity analysis, cost-effectiveness acceptability curves, and one-way sensitivity analyses consistently supported the cost-effectiveness advantage of intramedullary nailing under uncertainty at a willingness-to-pay threshold of USD 4,771.4 per QALY. This short-term economic evaluation indicates that intramedullary nailing is an undominated and more cost-effective option than plate fixation for the surgical management of tibial shaft fractures over a 90-day follow-up period, providing higher accumulated QALYs at lower direct costs. These findings support the preferential use of intramedullary nailing in similar clinical settings; however, longer-term studies incorporating fracture healing, complications, and indirect costs are needed to confirm cost-effectiveness beyond the early postoperative period.
Rehabilitation is essential in supporting individuals with disabilities to improve their functional abilities and independence, and it is considered a key element of universal health coverage (UHC). This study examines the current considerations within Iran's rehabilitation system and offers policy suggestions aimed at strengthening and improving its performance. This qualitative study utilized a systematic review of relevant documents, 22 in-depth interviews, and two focus group discussions (FGDs) with 24 participants from different levels of the health system. Participants included policymakers from the Ministry of Health and the Social Security Organization, rehabilitation center managers, and academic faculty. Data were thematically analyzed using MAXQDA version 22. Rehabilitation services in Iran have not yet been fully incorporated into health policy and planning, which has resulted in opportunities for further development in areas such as accessibility, service availability, governance structures, stakeholder coordination, and workforce training. The current governance arrangements and intersectoral collaboration mechanisms may benefit from greater coherence to enhance overall system performance. Moving toward a more unified stewardship framework under the Ministry of Health could contribute to aligning policies and strengthening cross-sectoral coordination. Furthermore, integrating rehabilitation services into primary healthcare represents an important step toward providing comprehensive and continuous care. Designing an evidence-based integration model will require a systematic assessment of existing capacities and resources. Enhancing Iran's rehabilitation system can benefit from context-sensitive and evidence-informed policy initiatives. Recognizing rehabilitation as an integral component of universal health coverage may support more equitable access, continuity of services, and improved health outcomes for individuals who require such care.
Artificial intelligence (AI) is rapidly transforming healthcare worldwide, yet the readiness of physicians and medical students to adopt AI-particularly in low- and middle-income settings-remains insufficiently understood. Examining knowledge, attitudes, and practices (KAP) toward AI is essential for informing educational priorities and implementation strategies. This study aimed assessing AI-related knowledge, attitudes, and practices among Iranian physicians and medical students, examine demographic differences, and identify barriers to AI adoption. A cross-sectional survey was conducted using an online convenience sampling approach across medical universities and clinical settings in Iran between June and August 2024. A validated questionnaire was developed based on a comprehensive literature review of existing KAP surveys related to artificial intelligence and digital health which assessed AI-related knowledge (3 items), attitudes (27 items), and practices (5 items). The reliability of the questionnaire was confirmed using Cronbach's alpha and ICC. Descriptive statistics and multivariable logistic regression were used to examine associations between demographic variables and KAP outcomes. Statistical significance was set at p-value < 0.05. A total of 238 participants completed the survey, including 165 physicians (69.7%) and 72 medical students (30.3%). Overall, 61.3% demonstrated good knowledge, 83.2% had positive attitudes, and 58.4% showed good AI-related practice. Medical students had higher mean knowledge scores than physicians (0.62 (SD = 0.32) vs. 0.58 (SD = 0.35); p = 0.025). Younger participants (18-25 years) showed higher mean knowledge than those aged > 65 years (0.70 (SD = 0.29) vs. 0.36 (SD = 0.36); p = 0.036). Although attitudes toward AI were uniformly positive (97.4% considered AI essential in medicine), practice levels were lower, particularly among participants aged 50-65 years (Mean practice score (SD) = 0.52 (0.21); p < 0.01). In adjusted analyses, age 50-65 years was independently associated with lower odds of good practice (AOR = 0.12; 95% CI: 0.04-0.41). Despite strong support for AI integration among Iranian physicians and medical students, gaps remain between positive attitudes and real-world AI use, especially among older clinicians. Structured, practice-oriented AI training and improved institutional infrastructure are needed to facilitate effective and equitable adoption of AI in Iran's healthcare system.
BackgroundWhile numerous studies have explored motivational factors, few have applied a macroergonomic lens to public-sector administrative settings in non-Western contexts like Iran, where hierarchical structures and economic challenges uniquely shape workplace dynamics.ObjectiveThis qualitative study aimed to identify and explore the key macroergonomic factors influencing job motivation among administrative staff in a public health school, using the Work Systems Model (WSM) as a conceptual framework.MethodsA qualitative content analysis approach was employed, using semi-structured interviews with a total of sixteen full-time administrative staff during March to May 2024. Data were collected until saturation and analyzed through the lens of macroergonomics, categorizing findings into five core domains: organizational, environmental, technological, individual, and task-related factors.ResultsFindings revealed that motivational dynamics are shaped by a complex interplay of systemic factors. Key organizational factors identified by 5 major domains, 11 dimensions, and 38 subcategories from 426 codes, containing leadership style and reward systems; environmental influences encompassed office noise and temperature; technological factors involved the quality and availability of digital tools; individual factors addressed personality traits and internal motivation; and task-related aspects emphasized role clarity and task variety.ConclusionWSM provided a robust framework to uncover culturally specific barriers in Iran's public sector, offering actionable insights for systemic interventions like leadership training and technology upgrades to reduce turnover and boost performance. Results suggest that optimizing work environments through macroergonomic strategies can significantly contribute to employee well-being and organizational performance.
Air pollution represents a major environmental challenge in Iran's industrial metropolitan areas, where urban development and climatic conditions interact in complex ways. This study investigates the short-run and long-run dynamics of major air pollutants, including PM2.5, NO2, SO2, and O3, in the metropolitan area of Isfahan using monthly data from 2020 to 2025 and the Autoregressive Distributed Lag (ARDL) approach. Electricity consumption is employed as a proxy for the intensity of urban development and economic activity, alongside climatic variables such as temperature, precipitation, solar radiation, and wind speed. The results of the bounds cointegration test indicate that only PM2.5 and O3 exhibit a stable long-run equilibrium relationship with the explanatory variables, at the same time NO2 and SO2 are primarily driven by short-run dynamics and transitory shocks. Long-run estimates confirm the Environmental Kuznets Curve (EKC) hypothesis for PM2.5, as higher electricity consumption is associated with lower particulate matter concentrations. In contrast, ozone displays a strong positive elasticity with respect to electricity consumption, highlighting the critical role of precursor emissions linked to energy use and industrial activities in ozone formation. Climatic factors further reveal that temperature intensifies PM2.5 concentrations, whereas wind speed significantly contributes to reducing long-run ozone levels through atmospheric dispersion. These findings underscore the importance of targeted energy and emission control policies, particularly focusing on ozone precursors, along with urban climate adaptation strategies to improve air quality in semi-arid industrial cities.
Competency-based medical education (CBME) requires robust alignment between theoretical knowledge assessments and clinical performance evaluations. In resource-constrained settings like Iran, conducting separate high-stakes examinations strains limited faculty, infrastructure, and budgets. This study examined the predictive relationship between pre-internship written examination scores and Objective Structured Clinical Examination (OSCE) performance, with implications for sustainable assessment redesign. Retrospective analytical study of 312 sixth-year medical students (208 female, 104 male) from OSCE sessions 17-20 (2021-2024) at Ahvaz Jundishapur University. Pre-internship scores (200-item MCQ, 0-100 scale) and OSCE scores (12 stations: 6 theoretical, 6 practical) were analyzed using t-tests, Pearson correlations, multiple regression, and quartile analysis (SPSS 26.0). No gender differences emerged (pre-internship: female 66.2±7.9 vs male 64.8±8.7, P=0.18; OSCE: female 69.4±9.8 vs male 67.1±10.9, P=0.07). Strong positive correlation existed between assessments (r=0.55, 95% CI: 0.45-0.63, P<0.001, R2=0.30). Correlations persisted for theoretical stations (r=0.52) and practical stations (r=0.48), consistent across genders. Regression confirmed pre-internship as significant predictor (β=0.55, adjusted R2=0.29). Top pre-internship quartile: 38% achieved top OSCE quartile vs 9% from lowest quartile (χ2=32.1, P<0.001). Theoretical knowledge explains ∼30% of OSCE variance, supporting integrated curricula while highlighting needs for enhanced practical training. In Iran's resource-limited context, consolidated hybrid or programmatic assessment models could optimize efficiency, reduce costs, maintain validity, and advance sustainable CBME implementation.
Iran's long history of climate-related crises, primarily driven by droughts, has been intensified by ongoing climate change, placing forest ecosystems under increasing hydroclimatic stress. In recent decades, prolonged droughts combined with elevated atmospheric moisture deficits have reduced ecosystem resilience and increased vulnerability to degradation. To better understand long-term drought dynamics and their ecological impacts, we developed two 200-year chronologies (1821-2020) of tree-ring width (TRW) and stable oxygen isotope variations (δ1⁸O) from Juniperus polycarpos in the Hezar Masjed Mountains, northeastern Iran. The δ1⁸O record served as a proxy for atmospheric moisture conditions and was used to reconstruct growing-season (March-September) vapor pressure deficit (VPD). When combined with TRW in a multiple regression framework, this dual-parameter approach enabled reconstruction of the Standardized Precipitation-Evapotranspiration Index (SPEI07), representing cumulative growing-season hydroclimatic conditions related to soil moisture availability. This allows the differentiation of atmospheric and soil drought impacts on tree growth over two centuries. By classifying drought years into VPD-only, SPEI-only, and combined drought events, we found that drought conditions associated with reduced soil moisture availability (SPEI) exerted the strongest constraint on radial growth. Tree growth declined most strongly during severe SPEI droughts, followed by severe combined drought (COMB-D) years, whereas atmospheric drought alone (VPD-D) had a weaker and more transient effect. Growth typically recovered within two years following drought events. Analysis of long-term drought classifications (1821-2020) revealed a shift towards more intense droughts in recent decades, particularly in the frequency of severe VPD and combined drought years. Our findings highlight that tree growth in semi-arid mountain ecosystems is primarily limited by soil moisture availability, with atmospheric drought acting as an additional stressor when coinciding with soil moisture deficits. This study demonstrates the value of combining multiple tree-ring proxies to disentangle drought mechanisms and improve understanding of forest responses to climate change.
The effectiveness of training organ donation teams in improving organ donation rates has been well established. However, studies have shown that this impact is often temporary and diminishes without ongoing support and quality control programs. This study aimed to evaluate the effects of initial training and the role of a structured quality control program in sustaining these improvements in Iran's organ procurement units (OPUs). A comprehensive training program, the Iranian OPUs Supporting System (IrOSS), was developed and implemented with the participation of 25 OPUs. Their organ donation (PMP) rates were recorded at baseline and monitored every 3 months for 6 months posttraining. Later, a quality control initiative, the Iranian OPUs Quality Control System (IrOQS), was introduced in 15 of these units. Through periodic assessments, weaknesses were identified and addressed via targeted interventions such as strategy improvements and retraining. The remaining 10 units served as a control group. PMP was reevaluated 3 and 6 months after the initial IrOQS implementation, with a final assessment 3 months after the second round. Longitudinal data were analyzed using advanced statistical techniques, including repeated-measures ANOVA, difference-in-differences (DiD), linear mixed-effects models (LMMs), trajectory analysis, and change point detection. The mean PMP across all 25 OPUs increased from 5.31 before training to 8.05 six months after training. In the intervention group, the mean PMP increased to 13.06 after the first IrOQS phase, decreased to 9.84 over the next 6 months, and increased again to 15.6 after the second IrOQS phase. In contrast, while the control group showed an initial increase after training, their PMP gradually decreased over time. Statistical analyses showed that the initial training had a significant positive effect on performance, but these improvements were not sustained without repeated interventions. Path analyses also showed that units with lower initial performance responded most positively to training but tended to regress if retrained. The findings of this study suggest that initial training programs can lead to significant improvements in PMP. However, to maintain these gains, regular implementation of ongoing training programs is essential. Data science approaches and longitudinal data analysis can play a critical role in identifying performance patterns in the quality management of OPUs.
Iran's ageing population presents distinct social challenges within a culture where belonging has been traditionally based on family relationships. While research suggests ageism may affect a sense of belonging, this association remains unexplored in non-Western contexts with traditionally family-centred values. This cross-sectional study investigated the association between ageism experiences and sense of belonging among older Iranian adults. A sample of 302 community-dwelling older adults (mean age = 67.75 years, SD = 6.59) from Tehran and Qazvin completed the Ageism Survey Scale and Sense of Belonging Instrument. Results showed that older adults who reported a lower sense of belonging also reported more experiences of ageism. Hierarchical regression analysis demonstrated that the full model, including demographic variables and sense of belonging, explained 8% of the variance in ageism experiences, with belonging accounting for 7% of the variance beyond demographic factors. Additionally, higher education levels, higher socio-economic status, and visits from relatives were associated with stronger psychological belonging. These findings contribute to understanding how demographic factors and a sense of belonging relate to ageism experiences in a non-Western, collectivist culture where older adults are traditionally valued.
Rapid and sensitive early childhood development is vital for lifelong health, cognition and socio-emotional well-being. Suboptimal care during these formative years increases the risk of developmental delays affecting motor, cognitive, speech, hearing and visual domains. Early identification and intervention can mitigate these risks but structured, integrated service delivery remains limited in many low- and middle-income countries. Since 2014, comprehensive child development centres (CCDCs) have been established under Iran's Ministry of Health to address these gaps, with Tabriz hosting one of the pioneering centres. This qualitative study protocol aims to systematically document the implementation of the Tabriz CCDC over a decade, identifying key facilitators and barriers essential for shaping a scalable, evidence-based model of comprehensive child development services adaptable to Iran's health system. A qualitative, exploratory study design grounded in phenomenology will be employed to explore the lived experiences of key stakeholders involved in implementing the CCDC in Tabriz over 10 years. Purposeful and snowball sampling will recruit diverse participants, including policymakers, healthcare providers and parents of children under five. Data collection will include semi-structured interviews and focus group discussions conducted until thematic saturation is reached. Audio-recorded data will be transcribed verbatim and analysed using framework-guided content analysis. A triangulated approach will integrate document reviews and stakeholder questionnaires to enrich findings. Methodological rigour will be ensured through member checking, peer debriefing and double coding. Ethical considerations such as informed consent and confidentiality will be strictly maintained. The study's reporting will adhere to the Consolidated Criteria for Reporting Qualitative Research (COREQ) 32-item checklist, guaranteeing transparency, completeness and methodological rigour. This study was approved by the Ethics Committee of Tabriz University of Medical Sciences. Two separate ethical approval codes were issued for the qualitative protocol of this study IR.TBZMED.REC.1404.025 and IR.TBZMED.REC.1404.139. Separate informed consent forms have been developed for all stakeholder groups. Participants will provide oral and written consent before interviews or focus group discussions, and audio recordings will be conducted only with their permission; for those who do not consent to recording, detailed notes will be taken. Participants will be informed of their right to withdraw from the study at any time without consequence. Study results will be disseminated through peer-reviewed journals, scientific conferences and policy meetings to inform future strategies for comprehensive child development services.
Digital health adoption is accelerating in many low- and middle-income countries, yet governance, ethical safeguards, and data stewardship often lag behind technological uptake. This mismatch can undermine user trust, service quality, and the long-term sustainability of digital health innovations. This study aimed to identify and conceptualize key governance gaps influencing the development of Iran’s digital health ecosystem. A qualitative thematic analysis was conducted using 18 semi-structured interviews with policymakers, entrepreneurs, and healthcare professionals, alongside content analysis of 700 user comments extracted from major Iranian digital health platforms. Data were analyzed through the six-phase framework of Braun and Clarke, combining inductive (data-driven) and deductive (theory-informed) coding. Triangulation between interview and user datasets enhanced validity, and the COREQ checklist guided reporting. Six interrelated governance gaps were identified: (1) Regulatory and Oversight Gap – fragmented authorities and lack of unified licensing; (2) Ethical and Trust Gap – weak accountability and declining user confidence; (3) Data Governance Gap – unclear data ownership and poor privacy protection; (4) Quality and Standardization Gap – lack of evaluation indicators and accreditation systems; (5) Institutional Capacity Gap – limited expertise and low readiness for digital transformation; and (6) Economic and Sustainability Gap – insufficient financial incentives and policy support. Findings from user comments confirmed that governance weaknesses directly affect satisfaction, perceived fairness, and trust in digital health services. Digital health in emerging settings requires a multi-level governance approach that aligns national policy, institutional regulation, and operational accountability. We propose an integrated macro–meso–micro governance model with cross-cutting principles (transparency, responsibility and data integrity, participation, trust) to guide policymakers and platform operators. Strengthening a unified regulator, a national ethics charter for digital health, and a health data governance framework are priority actions. The online version contains supplementary material available at 10.1186/s12913-026-14439-9.
Better evaluation of the contribution of the main diseases, injuries, and risk factors for mortality and life expectancy is crucial for more efficient policy making at the national and subnational levels in Iran. The aim of this study is to assess the effect of emerging causes of mortality on health, specifically COVID-19, which can help policy makers implement preventive measures in similar situations. In this systematic analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023, we present estimates of cause-specific mortality at the national and subnational levels in Iran from 1990 to 2023. New to this iteration of GBD, we present a decomposition analysis of the contribution of specific causes of death to net gain or loss in life expectancy across 31 provinces of Iran. We used an array of data sources including censuses, vital registration, and surveys for national and subnational estimates. The two leading causes of death in Iran were ischaemic heart disease and stroke in both 1990 and 2019. However, in 2020 and 2021, the COVID-19 pandemic displaced the leading causes of death, ranking first with age-standardised mortality rates of 286·2 deaths (95% uncertainty interval 267·9-310·5) per 100 000 in 2020 and 250·0 deaths (233·2-272·5) per 100 000 in 2021. COVID-19 ranked second and tenth in 2022 and 2023, respectively. Life expectancy at birth for both sexes combined declined from 78·0 years (77·7-78·1) in 2019 to 74·3 years (74·0-74·4) in 2020. It steadily recovered to 78·8 years (78·5-79·2) in 2023. COVID-19 was the main cause of loss in life expectancy, by 4·19 years, between 2019 and 2020. There was a net gain of 12·4 years in life expectancy in Iran from 1990 to 2023. The net gain at the national level can be mostly attributed to reduced mortality from ischaemic heart disease (2·61 years), stroke (1·63 years), neonatal disorders (1·26 years), transport injuries (0·88 years), and neoplasms (0·64 years). The decline in mortality rates of major causes continued to 2023 despite the pandemic. An exception was Alzheimer's disease, which showed a 4·0% increase in rate between 2019 and 2023 and led to a net loss of 0·04 years in life expectancy since 1990. Diabetes led to a net loss of 0·09 years since 1990. There were variations between provinces in terms of age-standardised rates and the net change in life expectancy before and after the COVID-19 pandemic. The COVID-19 pandemic disrupted the rising trend of life expectancy in Iran, varying across provinces. Findings show that the health-care infrastructure and policies in Iran were not efficient in controlling the pandemic in 2020 and 2021, mainly due to inadequate vaccination coverage and timeliness, specifically for vulnerable subgroups. Sanctions may have aggravated the effect of COVID-19 on loss in life expectancy of Iranians. Despite the pandemic, the declining trend in age-standardised rates for top causes of mortality has continued to 2023, leading to a full recovery of life expectancy and underscoring the ultimate resilience of Iran's health system. Gates Foundation.
Dryland and semiarid ecosystems in Iran are increasingly threatened by climate change and human activities, posing significant risks to endemic avian species such as the Iranian Ground-jay (Podoces pleskei). In this study, we used ecological niche models and GIS analyses to predict the impacts of climate change on the habitat suitability of this bird. Our models showed that the habitat suitability for P. pleskei was primarily concentrated within the deserts and xeric shrublands biomes and identified extensive suitable habitat patches along the Iran-Pakistan border. Podoces pleskei showed a higher probability of presence at low values of mean temperature of the driest quarter, annual precipitation, NDVI, and distance from human settlements. Our findings reveal that although approximately 36% of suitable habitats fall within formally designated protected areas, the majority remain unprotected and suffer from severe fragmentation, compromising long-term conservation prospects. We found that P. pleskei lost a considerable proportion of its suitable habitats due to climate change i.e., 18% and 52% under SSP1-2.6 and SSP5-8.5 scenarios, respectively. Our models showed strong predictive performance as indicated by high Area Under Curve and True Skill Statistic values. Moving beyond traditional protected area designation, conservation efforts must prioritize habitat connectivity and community engagement to ensure the persistence of P. pleskei and other dryland avian species, particularly in light of the significant habitat loss caused by climate change. Our findings contribute valuable insights into avian ecology in Iran's fragile ecosystems and inform evidence-based conservation planning in the country.
Retinopathy of prematurity (ROP) is a leading cause of preventable childhood blindness, particularly in low- and middle-income countries. In Iran, where the prevalence of ROP among premature infants exceeds 20%, limited access to subspecialist ophthalmologists constrains timely screening. This study evaluated the cost-utility of three alternative ROP screening strategies to inform national policy on optimizing resource allocation. A lifetime, societal-perspective cost-utility analysis was conducted using a state-transition Markov model. Three strategies were compared: (1) universal referral of all at-risk infants to tertiary centers; (2) RetCam-based nurse-led imaging with remote ophthalmologist review (telemedicine); and (3) local screening by general ophthalmologists with selective referral. Model inputs were derived from national data, published literature, and expert opinion. Costs (2025 Iranian Tomans) and quality-adjusted life years (QALYs) were discounted at 5.8%. Deterministic and probabilistic sensitivity analyses were performed to assess parameter uncertainty. The Direct Examination scenario (general ophthalmologist screening) had the lowest mean cost (33.52 USD) and effectiveness (16.83 QALYs). RetCam imaging achieved higher effectiveness (17.14 QALYs) at a cost of 122.69 USD, yielding an incremental cost-effectiveness ratio (ICER) of 288.81 USD per QALY gained, well below Iran's willingness-to-pay (WTP) threshold of USD 7,047. The Universal Referral strategy was dominated, being both more costly and less effective. Probabilistic sensitivity analysis confirmed that RetCam imaging was cost-effective in 95.2% of 10,000 Monte Carlo simulations at a WTP of USD 6,000 per QALY. Diagnostic specificity and long-term vision care costs were the key ICER drivers. RetCam-based telemedicine screening for ROP in Iran is highly cost-effective compared to traditional direct examination or universal referral, offering substantial long-term health gains at an acceptable cost. Scaling up telemedicine screening, supported by quality assurance and training programs, could reduce preventable childhood blindness and improve efficiency of neonatal eye care delivery.