https://doi.org/10.47108/jidhealth.vol5.iss3.233 mohammad fk., journal of ideas in health 2022;5(3):725-726 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access calculation of 95% confidence interval of the median lethal dose determined by the up-and-down procedure: a letter to editor fouad kasim mohammad 1* dear editor; acute toxicity of chemicals can be detected by the widely advocated up-and-down procedure (udp) used to measure the median lethal dose (ld50) in laboratory animals [1,2]. a recent article by zhang et al. [3] reliably introduced an improved upd (iudp) to measure the ld50 values of substances in animals. in an innovative way, the iudp procedure was presented in a suitable manner to include the 95% confidence intervals (ci) for the ld50 values using the equation: 95% confidence interval = ld50 + the standard error (se) se = sd x √2/n sd is the standard deviation of all dosages in n trials in animals. however, not all the reports using the udp report 95% ci; some studies use elaborate software programming to calculate the ci [1,3,4]. others have tried calculating the ci with the arithmetic means (as an ld50) + standard error of the doses used in the udp [5]. to further benefit from the iudp and its simple way of calculating the ci [3], here we suggest an additional input for researchers in toxicology by using the above-mentioned equations to calculate the 95% ci for udp using the table of the maximum likelihood estimation of ld50-the section with a standard error of 0.61 of dixon [2]. this is because this version of udp is still being used, and reports are still being published without mentioning the ci. in this context and for demonstration purposes, we recalculated selected ld50 examples from published literature [6-9] and included their 95% ci (table 1) according to zhang et al. [3]. table 1: acute (24 h) median lethal doses (ld50) and their 95% confidence intervals (c.i.) of drugs or toxicants administered in laboratory animals reference animal drug/ toxicant doses dose interval response x: dead o: alive ld50 mean + sd c.i. = ld50 + se naser and mohammad [6] chicks propofol 100, 80, 60, 80, 60, 40, i.p. 20 xxoxxo 57.22 70.0 + 20.98 45.11, 69.33 mohammad et al. [7] chicks diazinon 15, 10, 5, 10, 5, 10, orally 5 xxoxox 6.32 9.17 + 3.76 4.15, 8.49 al-baggou and mohammad [8] mice cadmium chloride 10, 8, 10, 8, 10, i.p. 2 xoxox 8.6 9.2 + 1.1 7.9, 9.3 mohammad et al. [9] mice tetramisole 50, 60, 50, 60, 50, s.c. 10 oxoxo 57.0 54.0 + 5.48 53.5, 60.5 all doses are in mg/kg of body weight; i.p.: intraperitoneal injection; s.c.: subcutaneous injection; sd: standard deviation; se: standard error (= sd x √2/number of animals) calculated for the 95% c.i. (= ld50 + se) [3]. ld50 was determined by the upand-down procedure, and the table of the maximum likelihood estimation of ld50-the section with a standard error of 0.61 of dixon [2] was used for this purpose. abbreviations udp: up-and-down procedure; ld50: median lethal dose; iudp: improved upd; ci: confidence intervals ___________________________________________________ fouadmohammad@yahoo.com 1department of physiology, biochemistry and pharmacology, college of veterinary medicine, university of mosul, mosul, iraq. keywords: confidence interval, ld50, median lethal dose, up-anddown procedure https://doi.org/10.47108/jidhealth.vol5.iss3.233 http://www.jidhealth.com/ mohammad fk., journal of ideas in health 2022;5(3):725-726 726 declarations this is a correspondence, and no experimental work has been done for this letter. acknowledgment none funding the author received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing fouadmohammad@yahoo.com. authors’ contributions fouad kasim mohammad (fkm) is the principal investigator of this manuscript (letter to editor). fkm is responsible for the study concept, design, writing, reviewing, editing, and approving the manuscript in its final form. fkm read and approved the final manuscript. ethics approval and consent to participate the corresponding author conducted the research following the declaration of helsinki; however, letter to editor article needs no ethics committee approval. consent for publication not applicable competing interest the author declares that he has no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of physiology, biochemistry and pharmacology, college of veterinary medicine, university of mosul, mosul, iraq. article info received: 19 june 2022 accepted: 27 july 2020 published: 20 august 2022 references 1. rispin a, farrar d, margosches e, gupta k, stitzel k, carr g, greene m, meyer w, mccall d. alternative methods for the median lethal dose (ld (50)) test: the up-and-down procedure for acute oral toxicity. ilar j. 2002;43(4):23343. doi: 10.1093/ilar.43.4.233. 2. dixon wj. efficient analysis of experimental observations. annu rev pharmacol toxicol. 1980; 20:441-62. doi: 10.1146/annurev.pa.20.040180.002301. 3. zhang yy, huang yf, liang j, zhou h. improved up-anddown procedure for acute toxicity measurement with reliable ld50 verified by typical toxic alkaloids and modified karber method. bmc pharmacol toxicol. 2022 jan 4;23(1):3. doi: 10.1186/s40360-021-00541-7. pmid: 34983670; pmcid: pmc8725450. 4. manage a, petrikovics i. confidence limit calculation for antidotal potency ratio derived from lethal dose 50. world j methodol. 2013 mar 26;3(1):7-10. doi: 10.5662/wjm.v3.i1.7. pmid: 25237618; pmcid: pmc4145567. 5. ahur vm, anika sm, onyeyili pa. age-sex dimorphisms in the estimation of median lethal dose (ld50) of lead diacetate in rabbits using up-and-down procedure (arithmetic method). sokoto j vet sci.2018; 16(4):64-72. https://www.ajol.info/index.php/sokjvs/article/view/18303 3 6. naser as, mohammad fk. central depressant effects and toxicity of propofol in chicks. toxicol rep. 2014 aug 13; 1:562-568. doi: 10.1016/j.toxrep.2014.08.003. 7. mohammad fk, al-badrany ym, al-jobory mm. acute toxicity and cholinesterase inhibition in chicks dosed orally with organophosphate insecticides. arh hig rada toksikol. 2008 sep;59(3):145-51. doi: 10.2478/10004-1254-592008-1873. 8. al-baggou bk, mohammad fk. effects of cadmium on the acute toxicity of cholinesterase inhibiting insecticides in mice. arabian j sci res. 2022. (in press). 9. mohammad fk, faris ga, rhayma ms, ahmed k. neurobehavioral effects of tetramisole in mice. neurotoxicology. 2006 mar;27(2):153-7. doi: 10.1016/j.neuro.2005.08.003. https://doi.org/10.47108/jidhealth.vol5.iss3.236 wang j., journal of ideas in health 2022;5(3):727-729 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access barriers to telepsychiatry in the geriatric asian american population during covid-19 jami wang1,2*, brian kato1,2, davin a. agustines 2 abstract: due to the increase in anti-asian discrimination during covid-19, there has been a decline in mental health in the asian community, particularly in the geriatric population. although the current literature tends to focus on the underutilization of telemedicine in the asian american population due to cultural barriers, our research found that the barrier to access heavily contributed to this inequity. in this study, we discuss the limited language options for the geriatric asian american population on a few large telepsychiatry platforms, including “teladoc and betterhelp”, during covid-19. keywords: covid-19, geriatric, telepsychiatry, asian american population, language, health services, accessibility, barriers, usa background during covid-19, the geriatric asian american population faced the greatest discrimination among all ethnic groups [1-4]. several literature reports describe the negative impact that discrimination, on both a macro and micro scale, can have on a patient's physical health, including increased risk for cardiovascular disease, infections, chronic pain, and so on [1-5]. chronic racism can also have a large impact on both emotional and psychological wellbeing [6]. telemedicine has been presented as a potential solution to help patients gain additional access to care, with telepsychiatry being particularly promising. compared to other medical specialties, psychiatry was the second most utilized telehealth specialty during covid 19, with general medicine being the first [7]. however, in the nationally representative survey of "health, ethnicity, and pandemic study," zhang et al. report that asian americans had the lowest utilization of telemedicine [8]. in addressing the reason behind the underutilization of telemedicine, the current literature focuses on the asian cultural barriers that stigmatize mental health [1,9]. however, in this study, we like to address the lack of accessibility as a contributing factor to the disparity, specifically with the languages available in telemedicine companies. the inequity in the utilization of telemedicine can be seen in the languages used in the visits. in one study by lott et al., the authors found that 92.0% of the telemedicine visits documented english as their primary language. this is not reflective of the particular patient population studied, as only 61.0% of the patients reported english as their primary language [7]. the significant difference between the visits further emphasizes how critical language is in gaining access to medical care, as the lack of a particular language creates an additional barrier. to further understand this gap, we created accounts in the top telepsychiatry companies currently available, including “teladoc and betterhelp”. in the teladoc mental health sector, they had four available languages: english, spanish, french, and danish, with 0/14 (0%) in an asian language. in comparison, the top competitor in telepsychiatry, “betterhelp”, listed a total of 3/21 (14.3%) asian languages, including mandarin, japanese, and malaysian. limited mental health resources cater to their likely cultural needs, further exacerbating the structural racism and institutional barriers to appropriate care. the shortage of available languages for translation is especially concerning, as there is great potential for the use of telemedicine in the asian american community. for large telehealth companies like teladoc, it is important to note that the company does provide a "notice of nondiscrimination and language assistance" on their general policy page, which includes information that ___________________________________________________ jami.wang@westernu.edu 1psychiatry, western university of health sciences, pomona, usa. 2 psychiatry, olive view university of california los angeles medical center, los angeles, usa. full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol5.iss3.236 http://www.jidhealth.com/ wang j., journal of ideas in health (2022); 5(3):727-729 728 they are legally bound to provide free language interpreters to prevent discrimination based on national origin and age. despite the good intentions behind the policy, it still leaves two important issues. first, the policy specifies that a language interpreter, not a physician, speaks the additional language. interactions with an interpreter are not only more timeconsuming but also less personal than talking directly with a physician. in a field like psychiatry, the interpersonal relationship between the physician and the patient is particularly important in understanding and treating the patient's clinical presentation. second, accessing an interpreter requires the patient to call a different number that is not part of the online appointment questionnaire. it is more difficult to navigate to these additional languages because it is buried under the company's compliance information rather than on the initial page. several literature studies indicate that older adults have more difficulties acquiring the appropriate equipment and internet access to engage in telehealth compared to their younger peers, which leaves the geriatric population particularly vulnerable to being unable to use the site [10,11]. the telemedicine industry was fast-tracked during covid19. during a time of social unrest, telehealth provides the geriatric asian american population access to psychiatric care by eliminating the fear of going out and minimizing the social stigma of mental health. in addition, the patient has more flexibility in keeping their medical appointments private if they depend on family members for transportation. it is critical to assess the growing geriatric asian american population. according to the pew research center analysis of the u.s. census bureau population estimates, asian americans had the highest population growth rate among all racial and ethnic groups in the united states between 2000 and 2019. by the year 2060, the asian american population is predicted to be 35.8 million, while 7.9 million will be part of the geriatric population. despite these growing numbers, asian americans remain the most understudied ethnic group, as only 0.17% of the national institutes of health goes towards asian american health research [5, 9, 12]. not only has covid-19 highlighted the active discrimination the asian american population faces, but it also demonstrated the vulnerabilities due to the lack of research data, political support, and medical infrastructure for this particular population. large telehealth companies, including teladoc and “betterhelp”, need to consider adding more providers who speak additional asian languages in order to support this population in a more accessible manner. in addition, investing in programs that promote educational awareness of telehealth options in the local community is a potential solution to reducing this disparity. rebranding psychiatric services in a culturally mindful manner, such as removing the words "mental health," could be beneficial in increasing usage. although telehealth cannot replace in-person medical visits, it is a viable first step toward decreasing mental healthcare access amongst the geriatric asian american population. the lack of education on available telehealth services and the continuous shortage of bilingual and bicultural healthcare providers further exacerbates the disparity. the healthcare community and telehealth companies need to recognize that the geriatric asian american population is one of the fastest growing yet severely underserved populations, with the most to gain from telepsychiatry. conclusion given the current disparities surrounding access to telemedicine, there is a need to make the various platforms more accessible to the population that would benefit from it the most. abbreviation covid-19: coronavirus declaration acknowledgment none. funding the author received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing jami.wang@westernu.edu authors’ contributions jw participated in data collection and interpretation of results; jw, bk, and da contributed to drafting and study design. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, viewpoint articles need no ethics committee approval. all authors have read and approved the final manuscript. consent for publication not applicable competing interest the author declares that he has no competing interests author details 1psychiatry, western university of health sciences, pomona, usa. 2psychiatry, olive view university of california los angeles medical center, los angeles, usa. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. article info received: 04 july 2022 accepted: 01 august 2022 published: 24 august 2022 wang j., journal of ideas in health (2022); 5(3):727-729 729 references 1. chen ja, zhang e, liu ch. potential impact of covid19–related racial discrimination on the health of asian americans. am j public health. 2020;110(11):1624-1627. doi:10.2105/ajph.2020.305858. 2. hwang wc, goto s. the impact of perceived racial discrimination on the mental health of asian american and latino college students. cultural diversity and ethnic minority psychology. 2008;14(4):326-335. doi:10.1037/1099-9809.14.4.326. 3. nadal kl, wong y, sriken j, griffin k, fujii-doe w. racial microaggressions and asian americans: an exploratory study on within-group differences and mental health. asian american journal of psychology. 2015;6(2):136-144. doi:10.1037/a0038058. 4. sue dw, bucceri j, lin ai, nadal kl, torino gc. racial microaggressions and the asian american experience. asian american journal of psychology. 2009; s (1):88101. doi:10.1037/1948-1985. s.1.88. 5. williams dr, mohammed sa. discrimination and racial disparities in health: evidence and needed research. j behav med. 2009;32(1):20-47. doi:10.1007/s10865-0089185-0. 6. carter rt. racism and psychological and emotional injury: recognizing and assessing race-based traumatic stress. the counseling psychologist. 2007;35(1):13-105. doi:10.1177/0011000006292033. 7. lott a, campbell ka, hutzler l, lajam cm. telemedicine utilization at an academic medical center during covid-19 pandemic: are some patients being left behind? telemedicine and e-health. 2022;28(1):4450. doi:10.1089/tmj.2020.0561. 8. zhang d, shi l, han x, et al. disparities in telehealth utilization during the covid-19 pandemic: findings from a nationally representative survey in the united states. j telemed telecare. published online october 11, 2021:1357633x2110516. doi:10.1177/1357633x211051677. 9. yi ss. taking action to improve asian american health. am j public health. 2020;110(4):435-437. doi:10.2105/ajph.2020.305596 10. narasimha s, madathil kc, agnisarman s, et al. designing telemedicine systems for geriatric patients: a review of the usability studies. telemedicine and ehealth. 2017;23(6):459-472. doi:10.1089/tmj.2016.0178 11. dang s, ruiz di, klepac l, et al. key characteristics for successful adoption and implementation of home telehealth technology in veterans affairs home-based primary care: an exploratory study. telemedicine and ehealth. 2019;25(4):309-318. doi:10.1089/tmj.2018.0009 12. shah ns, kandula nr. addressing asian american misrepresentation and underrepresentation in research. ethn dis. 2020;30(3):513-516. doi:10.18865/ed.30.3.513. https://doi.org/10.47108/jidhealth.vol6.iss2.282 bouhmidi m, et al., journal of ideas in health 2023;6(2):861-863 © the author(s). 2023 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access omenn syndrome: the drama of a family, congenital ichthyosis is not always mundane! massilia bouhmidi1*, boudarbala hajar1, ayad ghannam1, el ouali aziza1, abdeladim babakhouya1, maria rkain1, noufissa benajiba1 abstract background: the case we are reporting is about one of the rare manifestations of severe combined immunodeficiency, omenn syndrome (os). case presentation: a 43-days-old female presented with thick diffuse erythrodermic scaly ichthyosiform lesions on the scalp, face, and trunk since birth. lymphadenopathy, splenomegaly, and growth retardation as well as eosinophilia and increased serum ige levels. a pregnancy was planned for an allograft of bone marrow, but the procedure was not carried out due to a persistent post-covid pneumopathy with bilateral parenchymal condensation that resulted in death. conclusion: this case report intends to incite clinicians to be alert to this possible diagnosis and not to underrate an immune deficiency in the case of neonatal erythroderma. keywords: omenn syndrome, ichthyosis, severe combined immunodeficiency, congenital, morocco background omenn syndrome is a rare expression of serious combined immune deficits. the presence of a self-reactive clone requires the use of intense conditioning, a major source of morbidity, and mortality, and the management of which still needs to be improved [1]. omen's disorder is one of a few shapes of severe combined immunodeficiency deficiency (scid). individuals with scid are inclined to repeat diseases that can be exceptionally genuine or life-threatening. infants with omenn syndrome are often presenting with pneumonia and constant diarrhea because of opportunistic microorganisms [2]. children with omenn syndrome suffer from alopecia, pachydermy, polyadenopathy, hepatosplenomegaly, fever, and possibly digestive signs. the main biological abnormalities are spinal and blood eosinophilia, hypergammaglobulinemia e, an increase in circulating hla lymphocytes dr + and cd 25 +, and hypogammaglobulinemia related to a deficiency in b lymphocytes. the treatment consists of a marrow transplant [2,3]. omenn syndrome can be caused by a mutation of the rag1 and rag2 genes on chromosome 11p and the artemis gene on chromosome 10p [3]. case presentation we report here the case of a 43-day-old infant who was hospitalized in april 2022 at the university hospital center of oujda, morocco. the only daughter of her parents, with 1stdegree parental consanguinity, resulting from an unremarkable pregnancy carried to term with a notion of gestational diabetes in the mother put on insulin therapy in the 7th month. of pregnancy, delivered by high route on a scarred uterus, eutrophic at 3300g, without delay in cord fall, with the notion of congenital ichthyosis, the notion of vomiting and chronic diarrhea, and history of two deaths in the siblings in a similar picture of neonatal ichthyosis, the first of which is a female infant who died at 4 months of life in an array of meningitis with recurrent bronchiolitis and dermatitis, and the second is a boy who died at d18 of life in an array of congenital ichthyosis. clinical examination revealed ichthyosiform erythroderma with erosive and dry skin surmounted by fine desquamation of the entire skin covering, and hyperkeratosis of the folds and neck. on examination of the integuments, the scalp is covered with a scaly whitish coating, the eyebrows absent, and the nails of normal appearance. on examination of the mucous membranes, the presence of mouth ulcers was noted. in addition, splenomegaly was objectified 2 fingerbreadths on abdominal palpation, failure to thrive with a weight of 3kg700 (-2sd) and a height of 52cm (-2sd). on examination of the lymph nodes, the presence of left inguinal adenopathy measuring 2cm, ___________________________________________________ boumidi@gmail.com 1mother and child department, university hospital mohamed vi, faculty of medicine and pharmacy of oujda, morocco. a full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol4.iss4.190 http://www.jidhealth.com/ bouhmidi m, et al., journal of ideas in health (2023); 6(2):861-863 862 bilateral cervical poly adenopathy, the largest of which on the left measuring 1.5cm on the long axis with bilateral subcentimetric, inguinal, and axillary adenopathy. in addition, the patient was febrile at 39°c with symptoms of a respiratory infection. the biological assessment revealed hyperleukocytosis at 45,480/mm3 with lymphocyte predominance at 30,017/mm3 and eosinophilia at 18,870/mm3. the immune assessment first ruled out an acquired cause, the hiv serology was negative, then showed severe hypogammaglobulinemia at 0 .6g/l, hyper ige at 9843ng/ml with a normal level of the other weight assays of igg, igm, and iga, deep b lymphopenia affecting cd 19 at 0% with a level of normal t lymphocyte subpopulations. regarding the infectious assessment, the cytomegalovirus (cmv) detection by realtime reverse transcriptase polymerase chain reaction (rt pcr) came back negative <35ui/ml, covid pcr positive with a c-reactive protein (crp) at 27mg/l. a thoracic ct scan was performed showing covid-19 pneumopathy classified by the covid-19 reporting and data system (co-rads) with a degree of involvement of 25.0% to 50.0% associated with bilateral parenchymal condensation. preventive measures based on cotrimoxazole and infusion of immunoglobulins 0.5g/kg were taken with topical emollients. thus, she was put under the therapeutic protocol of covid 19, and ganciclovir intravenously and which was stopped once the result of the cmv pcr came back negative. the evolution led to the death of the girl in the context of persistent pneumopathy post-sars-cov2 with bilateral parenchymal condensation despite adequate management. figure 1: 43-days -old girl presented with generalized exfoliative dermatitis. discussion omenn syndrome originally reported as familial reticuloendotheliosis with eosinophilia, is an autosomal recessive form of severe combined immunodeficiency (scid) characterized by erythroderma, desquamation, alopecia, chronic diarrhea, growth retardation, lymphadenopathy, hepatosplenomegaly, eosinophilia, and elevated serum ige levels [4,5]. patients are very susceptible to infection and develop fungal, bacterial, and viral infections typical of scid. in this syndrome, scid is associated with low levels of igg, iga, and igm and a near absence of b cells with a high number of t cells with impaired function [4]. omenn syndrome is caused by mutations in the rag1 or rag2 genes [6]. normally, the enzymes rag1 and rag2, which are restricted to immature lymphocytes, initiate v(d)j (variable, diversity, joining) recombination which leads to the development of t and b cells. lack of v(d)j recombination results in scid, such as os. in os, the v(d)j recombination defect is partial and characterized by the presence of only a small number of clones of t cells, which infiltrate the skin, intestines, liver, and spleen leading to clinical manifestations. indeed, in a study of nine patients with clinical and immunological features of sg, seven had no detectable mutations in the rag or artemis genes, suggesting that mutations in as yet undiscovered genes may cause immunodeficiency syndrome immunologically and phenotypically similar to os [6]. low to absent numbers of cd19þ b cells are characteristic of os associated with mutations in rag1, rag2, artemis, or dna ligase. pruszkowski et al. [7] conducted a retrospective review of 51 cases of neonatal erythroderma. on average, the etiological diagnosis was established 11 months after the onset of erythroderma. the underlying causes observed were immunodeficiency (30%), simple or complex ichthyosis (24%), netherton syndrome (ns) (18%), and eczematous or papulosquamous dermatitis (20%), atopic dermatitis and seborrheic dermatitis were less common in neonatal erythroderma. other causes of erythroderma include fungal infections, graft versus host disease (gvhd), and drug rashes. the cause remains unknown in 10% of cases. the differential diagnosis of erythroderma with immunodeficiency and growth retardation in neonates is mainly based on os, gvhd, and ns [7]. the clinical presentation of these neonates can be very bouhmidi m, et al., journal of ideas in health (2023); 6(2):861-863 863 similar; therefore, blood work, skin biopsy, immunocytochemical analysis, and molecular genetic analysis are required to establish the diagnosis. early recognition of this condition is important for genetic counseling and early treatment. if left untreated, omenn syndrome is fatal. prognosis may be improved with early diagnosis and treatment with compatible bone marrow or cord blood stem cell transplantation [1,2]. conclusion neonatal ichthyosis and erythroderma are rare but can be rapidly fatal. they remain a diagnostic challenge for pediatricians, dermatologists, immunologists, and geneticists. family history, pattern of onset, associated clinical signs, existence of recurrent infections, and statutory retardation, should be sought not to miss an immune deficiency that must be excluded even in the absence of systemic manifestation, and make think of performing an immune check. abbreviation os: omenn syndrome; sd: standard deviation; scid: severe combined immunodeficiency; ns: netherton syndrome; gvhd: graft versus host disease; who: world health organization; covid-19: novel coronavirus disease; cmv; cytomegalovirus; rt-pcr: real-time reverse transcriptase polymerase chain reaction; sars-cov-2: severe acute respiratory syndrome coronavirus-2; crp: c-reactive protein; co-rads: the covid-19 reporting and data system declaration acknowledgment none. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing boumidi@gmail.com. authors’ contributions all authors contributed equally to the concept, design, literature search, writing, editing, and review of the manuscript. massilia bouhmidi (mb) is responsible for the accuracy of all information related to the case report. all authors read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. ethical permission was granted by [university hospital center of oujda, morocco, 2022]. the parents’ consent form was secured. all omenn syndrome-related images (in figure 1) presented in the current study belong to the university hospital center of oujda, morocco. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1mother and child department university hospital mohamed vi, faculty of medicine and pharmacy of oujda, morocco. article info received: 11 april 2023 accepted: 17 may 2023 published: 27 may 2023 references 1fournier b, hogan j, neven b. syndrome d’omenn: caractéristiques cliniques et thérapeutiques d’une série de 30 patients. revue d'oncologie hématologie pédiatrique 2015; 3(4): 228. https://doi.org/10.1016/j.oncohp.2015.10.015. 2omenn syndrome, national library of medicine. medline plus, medical encyclopedia.available at: https://medlineplus.gov/genetics/condition/omennsyndrome/#description [accessed on 15th may 2023]. 3taghian m, thierry p, girardin p, coupé b, haghiri n, baumann f, l. theuriet l, puzenat e. p419 le syndrome d’omenn, à propos d’une observation révélée par une érythrodermie néonatale, intérêt d’un diagnostic précoce.2010 ;17(6-supp-s1), 1. doi :10.1016/s0929-693x (10)70813-7. 4elnour, ib, halim k, nirmala v.omenn's syndrome: a rare primary immunodeficiency disorder. sultan qaboos university medical journal vol. 7,2 (2007): 133-8. 5aleman k, noordzij jg, de groot r, van dongen jj, hartwig ng. reviewing omenn syndrome. eur j pediatr. 2001 dec;160(12):718-25. doi 10.1007/s004310100816. 6zhang zy, zhao xd, jiang lp, liu em, cui yx, wang m, wei h, yu j, an yf, yang xq. clinical characteristics and molecular analysis of three chinese children with omenn syndrome. pediatr allergy immunol. 2011 aug;22(5):482-7. doi: 10.1111/j.1399-3038.2010.01126. x. 7pruszkowski a, bodemer c, fraitag s, teillac-hamel d, amoric jc, de prost y. neonatal and infantile erythrodermas: a retrospective study of 51 patients. arch dermatol. 2000 jul;136(7):875-80. doi: 10.1001/archderm. https://doi.org/10.47108/jidhealth.vol6.iss2.286 sakhiya jj, et al., journal of ideas in health (2023); 6(2):874-877 © the author(s). 2023 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access a case report on generalized pemphigus vulgaris treated with rituximaba jagdish jadavbhai sakhiya1*, dhruv jagdish sakhiya1, jashmine mukeshbhai gandhi1, feral ravi daruwala2 abstract background: pemphigus vulgaris has an obscure etiology; the presence of autoantibodies is coherent with an autoimmune disease. rituximab a monoclonal antibody that specifically targets the cd20 antigen of b lymphocytes, has arisen as a novel treatment approach for pemphigus vulgaris. case presentation: a 39-year-old male patient presented with a three-month history of mouth ulcers, poor oral hygiene accompanied with heavy tobacco smoking and alcohol consumption. he was diagnosed with pemphigus vulgaris. the disease gradually progressed to involve other body parts. the patient had shown partial improvement after conventional therapy (oral cefuroxime, oral prednisolone with azathioprine) and was later on successfully treated with rituximab. after 90 days of follow-up, no future recurrence was observed. conclusion: with this case, the authors would like to aware other clinicians of the potential use of rituximab in treating pemphigus vulgaris, especially when the conventional therapy fails. keywords: autoantibodies; pemphigus, rituximab, oral hygiene, ulceration, tobacco smoking, alcohol consumption, india background the term pemphigus implies a group of autoimmune, mucocutaneous blistering diseases, in which the keratinocyte antigens are the target of the autoantibodies, prompting acantholysis and the formation of blisters. main variants of pemphigus include pemphigus vulgaris (pv) and pemphigus foliaceus (pf). pv is the most common subtype and represents well over 80% of cases. as being a serious and potentially lifethreatening condition, early treatment is of utmost importance [1]. the advent of corticosteroids in the amelioration of pemphigus has dramatically changed the outlook of this perpetually disastrous disease; thus, corticosteroids have become the cornerstone of pemphigus therapy. one case reported favorable outcomes with combined therapy of highdose corticosteroids and other immunosuppressants. however, such a high dose of corticosteroids can cause serious adverse events such as several metabolic problems, global reduction of immune system efficacy, antecedent risk of serious infections, and mortality [2]. to overcome these long-term events, pasricha and gupta introduced dexamethasone cyclophosphamide pulse (dcp) therapy in 1984 [3]. later on, dcp and oral corticosteroids with or without adjuvant immunosuppressants (azathioprine, cyclophosphamide, mycophenolate mofetil, and cyclosporine) have emerged as the backbone of pemphigus treatment, however, they are associated with the high death rate in pemphigus [4]. with these conventional treatments, some patients fail to improve or some have contraindications for their usage, or some encounter relapse. hence, advanced research has continuously been going on for finding newer molecules in pemphigus. in 2001, heizmann et al. [5] first used rituximab for the therapy of autoimmune bullous diseases. he reported a case of paraneoplastic pemphigus favorably managed with rituximab, since then there was a drastic development in the pemphigus treatment era. rituximab chimeric monoclonal antibody selectively acts on the cd20 expressing b cells, which are known to secrete auto-antibodies targeting the epidermal desmogleins (dsg). it has been used nearly in one million patients for treating lymphoma worldwide. recently, rituximab has been approved for rheumatoid arthritis that is unresponsive ___________________________________________________ sakhiya.acedemic@rediffmail.com 1department of dermatology, sakhiya skin clinic, surat, gujarat, india. a full list of author information is available at the end of the article 10.47108/jidhealth.vol6.iss2.286 http://www.jidhealth.com/ sakhiya jj, et al., journal of ideas in health (2023); 6(2):874-877 875 to tumor necrosis factor alpha (tnf-α) inhibitors. rituximab is off-label and used for various autoimmune disorders including, pv due to potential therapeutic effects in the modulation of pathogenic b cells [5]. we report a case of generalized pv, treated with rituximab. case presentation a 39-year-old male patient who lives in surat, gujarat, was referred with a 3-month history of painful ulcerated lesions in the oral cavity. on enquiring about the patient's history, we came to know that initially, the patient had difficulty chewing food and the severity increased gradually. the ulcerations caused considerable discomfort, affecting his normal oral functions. subsequently, fluid-filled lesions developed involving the scalp, trunk, limbs, and axilla. lesions were increasing in size and number and had little tendency to heal. blisters were flaccid and burst on their own to form erosions within 2-3 days. medical and family history was noncontributory. no history of fever, joint pain, malaise, and photosensitivity. he had weak oral hygiene due to the bad habit of taking betel quid with tobacco five times a day and smoking seven bidis per day for the past 12 years. further, he consumes two-quarters of alcohol on an alternative day for the last 12 years. history of any drug intake before the appearance of lesions was also absent. intraoral examination revealed that approximately 1.0 × 1.5 dimensions ulceration lesions were present on the buccal mucosa. dermatological examination revealed multiple vesicular lesions ranging from 0.3 × 0.3 to 1.5 × 1.5 involving the face, trunk, upper limbs, and dorsum of the penis (figure 1a-i). figure 1: showing (a) ulcerative lesions present on the buccal mucosa (b) multiple vesicular lesions present on the face (c) multiple vesicular lesions with erosion present on the lower neck (d) multiple vesicular lesions present on the umbilicus (e) multiple vesicular lesions with erosion present on the upper limb (f) multiple vesicular lesions with erosion present on the back (g) multiple vesicular lesions with erosion on the axilla (h) flaccid blister lesions on the scalp (i) multiple vesicular lesions present on the dorsum of the penis. there was a positive nikolsky sign and a bulla spread sign. the clinical manifestations of oral ulcers, flaccid bullae, and positive nikolsky sign hinted at the provisional diagnosis of pv. mucous membrane pemphigoid, bullous lichen planus, paraneoplastic pemphigus, chronic ulcerative stomatitis, recurrent herpes lesions in immunocompromised patients, and erythema multiforme were the potential differential diagnosis of this condition. regarding this, a biopsy was performed from a new vesicle to confirm the diagnosis. histopathological examination revealed an intraepidermal suprabasal acantholytic blister. several acantholytic cells and neutrophils could be seen in the blister. the floor of the blister showed a tombstone pattern with occasional acantholytic cells. a moderately dense superficial perivascular mixed infiltrate was present in the dermis. mild spongiosis with neutrophils was present at the periphery of the blister (figure 2). figure 2: photomicrograph showing acantholysis of the keratinocytes, tombstone appearance, epithelium exhibiting spongiosis, and superficial perivascular mixed infiltrate (h & e stain, ×5). the hematological test had all findings within standard limits and, routine urine examination was unremarkable. in accordance with these findings, the definite diagnosis of pv was made and the treatment with oral cefuroxime (500mg twice a day) and oral prednisolone (20mg twice a day) with azathioprine (50mg twice a day) was started. topical antibiotics and triamcinolone gel are advised for local application in the oral cavity. the dose of oral prednisolone was gradually tapered to 20mg, 10mg, 5mg, and 2.5mg (twice a day) every 30 days. the patient was maintained on the same dose of azathioprine (50mg twice a day) for one year. with the given therapy, complete remission was not achieved. also, azathioprine was discontinued due to an elevated level of liver enzymes. hence, the patient was shifted to rituximab therapy. the patient was initially given three doses of rituximab 1 gm each on days 1, 15, and 45. as premedication, ceftriaxone 1gm intravenously, hydrocortisone 100mg intravenously, paracetamol 650mg stat orally, and pheniramine maleate 2cc stat intravenously were given, sequentially on the day of infusion. after 30 minutes of these premedications rituximab (1gm) intravenously in 500ml of normal saline was given slowly over six to eight hours. the last dosage of rituximab was given after 3 months. administration of rituximab lead to decrease dsg 3 antibody levels which in turn resulted in the complete remission of the skin lesions within the next year (figure 3ag). sakhiya jj, et al., journal of ideas in health (2023); 6(2):874-877 876 figure 3: after rituximab therapy, almost complete healing of (a) ulcerative lesions in the mouth (b) vesicular lesions on the face (c) lesions on the lower neck, umbilicus, and upper limb (d) lesions on the back (e) multiple vesicular lesions with erosion on the axilla (f) blister lesions on the scalp (g) vesicular lesions of the dorsum of penis. the level of dsg 1 and dsg 3 was detected by the commercial enzyme-linked immunosorbent assays mesacup dsg test ‘dsg 1’ and mesacup dsg test ‘dsg 3’. the level of dsg 3 and dsg 1 was found to be 252.6µ /ml and 178.8µ /ml, respectively, before treatment, however, it was reduced to 45.89 µ /ml and 1.76 µ /ml, respectively, after treatment. lesions healed with post-inflammatory hyperpigmentation without any scarring and milia formation. the patient was followed up 90 days after the last injection and no future reoccurrence of lesions was observed. all the patient's pictures are belonging to the authors. discussion the introduction of rituximab in pemphigus has been the first major progression in the treatment of the disease over 60 years. many authors have used rituximab in the treatment of multiple immunobullous diseases including pv and pf [5, 6-15]. based on the literature review; we have noted that the use of rituximab in the treatment of pemphigus has exponentially increased in the globe. rituximab binds particularly to the transmembrane antigen cd20, which is present on b lymphocytes from the preb-cell stage to the pre-plasma-cell stage. cd20 is neither expressed on hematopoietic stem cells nor plasma cells. the binding of rituximab to cd20 triggers b-cell depletion by diverse mechanisms: antibody-dependent cellular cytotoxicity, complement-mediated lysis, direct disruption of signaling pathways, and triggering of apoptosis [4]. this may be the presumable mechanism of action for treating pv in our case. at present, a proper treatment algorithm pertaining to optimal dosage and schedule is not established for the use of for rituximab to treat pemphigus. multiple treatment protocols are available, from which lymphoma and rheumatoid arthritis protocols have been extensively used in literature. in lymphoma protocol, patients received a total of four infusions of rituximab at the dose of 375 mg/m2 on a weekly basis. as per rheumatoid arthritis protocol, the patient received two infusions of 1,000 mg each 15 days apart [6]. apart from these, various modified treatment protocols that show promising results were also used [6 -15]. in the present case, the patient was not completely improved with conventional treatment of oral cefuroxime, and oral prednisolone with azathioprine; therefore, based on the empirical experience, we treated a patient with our own modified protocol in order to get relief as well as the more beneficial effect. rituximab is contraindicated in various conditions such as hypersensitivity to rituximab or other murine proteins, active severe infections, the human immunodeficiency viruses (hiv) infection with cd4 cell count <250/΅l and severe heart failure, children, pregnancy, and lactation. rituximab may also be associated with severe adverse effects that can cause mortality, including infusion reactions, serious skin and mouth reactions, hepatitis b virus reactivation, and the developing multifocal leukoencephalopathy. moreover, tumor lysis syndrome, serious infection, heart problems, kidney problems, stomach, and serious bowel problems might be possible side effects [6-15]. due to such detrimental side effects, rituximab should always be received under a physician’s guidance. recently, u.s. food and drug administration (usfda) has approved rituxan® (rituximab) in treatment-resistant rheumatoid arthritis (with another prescription medicine-methotrexate), wegener's granulomatosis and microscopic polyangiitis (with glucocorticoids) and pv [16]. in the past, it has been off-label used for these indications. currently, no randomized control studies are available comparing the efficacy of rituximab to conventional treatment modalities. most of the data was obtained from a large case series and prospective open-labeled trials. in a new era, future studies will pave the way in providing patient care with this molecule. abbreviation pv: pemphigus vulgaris; pf: pemphigus foliaceus; dcp: dexamethasone cyclophosphamide pulse; dsg 3: desmoglein 3; usfda: u.s. food and drug administration; dsg: desmogleins; tnf-α: tumor necrosis factor alpha; hiv: human immunodeficiency viruses. declaration acknowledgment we would like to thank the patient for sharing details and contributing to scientific work. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing sakhiya.acedemic@rediffmail.com authors’ contributions jagdish jadavbhai sakhiya (jjs) was the principal investigator of this manuscript and approved the final manuscript. dhruv jagdish sakhiya (djs), jashmine mukeshbhai gandhi (jmg), and feral ravi daruwala (frd) were responsible for the study concept, design, writing, reviewing, and editing of the manuscript in its final form. sakhiya jj, et al., journal of ideas in health (2023); 6(2):874-877 877 ethics approval and consent to participate the study was conducted in accordance with the ethical principles of the declaration of helsinki (2013). ethical approval was obtained from sakhiya skin clinic, surat, gujarat, india. (approval no: 2023/06). consent forms were signed by patient. he was informed that he had the right to withdraw from the study at any time without any consequences. all pictures reported in this case-report study belong to sakhiya skin clinic, surat-395003, gujarat, india. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of dermatology, sakhiya skin clinic, surat, gujarat, india. 2department of medical writing, sakhiya skin clinic, surat, gujarat, india article info received: 21 april 2023 accepted: 03 june 2023 published: 07 june 2023 references 1. grando sa. pemphigus autoimmunity: hypotheses and realities. autoimmunity. 2012 feb;45(1):7-35. doi 10.3109/08916934.2011.606444. 2. lever wf, schaumburg-lever g. immunosuppressants and prednisone in pemphigus vulgaris: therapeutic results obtained in 63 patients between 1961 and 1975. arch dermatol. 1977 sep;113(9):1236-41. doi: 10.1001/archderm.1977.01640090084013. 3. pasricha js, gupta r. pulse therapy with dexamethasonecyclophosphamide in pemphigus. indian j dermatol venereol leprol. 1984; 50:199-203. 4. bystryn jc, steinman nm. the adjuvant therapy of pemphigus. an update. arch dermatol. 1996 sep;132(2):203-12. 5. heizmann m, itin p, wernli m, borradori l, bargetzi mj. successful treatment of paraneoplastic pemphigus in follicular nhl with rituximab: report of a case and review of treatment for paraneoplastic pemphigus in nhl and cll. am j hematol. feb 2001;66(2):142-4. doi: 10.1002/1096-8652(200102)66:2<142::aidajh1032>3.0.co;2-0. 6. food and drug administration. rituxan label; 2012 [cited feb 2, 2021]. available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2012 /103705s5373lbl.pdf. 7. belgi as, azeez m, hoyle c, williams rea. response of pemphigus vulgaris to anti-cd20 antibody therapy (rituximab) may be delayed. clin exp dermatol. 2006 jan;31(1):143. doi: 10.1111/j.1365-2230.2005.01941.x. 8. schmidt e, seitz cs, benoit s, bröcker eb, goebeler m. rituximab in autoimmune bullous diseases: mixed responses and adverse effects. br j dermatol. 2007 feb;156(2):352-6. doi: 10.1111/j.1365-2133.2006.07646.x. 9. barrera mv, mendiola mv, bosch rj, herrera e. prolonged treatment with rituximab in patients with refractory pemphigus vulgaris. j dermatolog treat. 2007 jan;18(5):312-4. doi 10.1080/09546630701323988. 10. faurschou a, gniadecki r. two courses of rituximab (anti-cd20 monoclonal antibody) for recalcitrant pemphigus vulgaris. int j dermatol. 2008 mar;47(3):2924. doi: 10.1111/j.1365-4632.2008.03423.x. 11. craythorne ee, mufti g, duvivier aw. rituximab used as a first-line single agent in the treatment of pemphigus vulgaris. j am acad dermatol. 2011 nov;65(5):1064-5. doi: 10.1016/j.jaad.2010.06.033. 12. horváth b, huizinga j, pas hh, mulder ab, jonkman mf. low-dose rituximab is effective in pemphigus. br j dermatol. 2012 feb;166(2):405-12. doi: 10.1111/j.13652133.2011.10663. x. 13. craythorne e, du viver a, mufti gj, warnakulasuriya s. rituximab for the treatment of corticosteroid—refractory pemphigus vulgaris with oral and skin manifestations. j oral pathol med. 2011 sep;40(8):616-20. doi: 10.1111/j.1600-0714.2011. 01017.x 14. kim jh, kim yh, kim mr, kim sc. clinical efficacy of different doses of rituximab in the treatment of pemphigus: a retrospective study of 27 patients. br j dermatol. 2011sep;165(3):646-51. doi: 10.1111/j.1365-2133.2011. 10411.x 15. kasperkiewicz m, shimanovich i, ludwig rj, rose c, zillikens d, schmidt e. rituximab for treatment-refractory pemphigus and pemphigoid: a case series of 17 patients. j am acad dermatol. 2011 sep;65(3):552-8. doi 10.1016/j.jaad.2010.07.032 16. investor update. basel; june 12, 2019. [cited feb 5, 2021]. available from: https://www.roche.com/investors/updates/inv-update2019-06-12.htm. https://doi.org/10.47108/jidhealth.vol4.issspecial3.154 andrabi sw, et al., journal of ideas in health 2021;4(special 3):438-442 © the author(s). 2021 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access ivf laboratory management in covid-19 pandemic syed waseem andrabi1*, puneet rana arora2, mir jaffar3 abstract background: since the first report of severe acute respiratory syndrome coronavirus-2 (sars-cov-2), widely known as covid-19, in late december 2019, it has spread worldwide. the eventual return of new normal has started to happen in most countries where the covid-19 curve has flattened, and assisted reproduction technology (art) services are eventually resuming. well-organized art (embryology/andrology) laboratories safeguard the wellbeing of all staff, patients, and their gametes/embryos. main body: a well-organized pandemic management plan must be implemented in anticipation of possible subsequent covid-19 waves. apart from local and national guidelines, some mandatory changes need to be taken into considerations that will allow us to overcome the fear of this deadly pandemic, work smoothly and stop any possible transmission without comprising the quality control for successful treatment. these mandatory changes include conserving different supplies, reducing manpower needs, and various protective measures for non-clinical and clinical staff, patients, and gametes/embryos. conclusion: the current pandemic of covid-19 suggests a well-organized action-oriented emergency plan to assure the wellbeing of all stakeholders. keywords: covid-19, infertility, response plan, ivf laboratory, embryology, and andrology laboratories, india background within the last two decades, severe acute respiratory syndrome (sars) and the middle east respiratory syndrome (mers) emerged as highly pathogenic and were responsible for major respiratory disease outbreaks. the recent deadly human coronavirus (sars-cov-2) in cells is mediated by using angiotensin-converting enzyme 2 (ace2) receptors by binding with a 1273 amino acid, long spike (s) viral protein protruding a 'corona' like appearance [1]. ace2 receptors have been reported in leydig, sertoli, theca, granulosa cells of the human ovary, and spermatogonia of the human testis [2]. globally, the health care system has been under an unprecedented strain introduced by the covid-19 pandemic, and to stop the spreading of sars-cov-2, all non-essential care treatments were discontinued in numerous countries. although assisted reproductive technology (art) also comes under the "nonessential" healthcare system, various international groups, and bodies such as the american society for reproductive medicine (asrm), european society of human reproduction and embryology (eshre), and british fertility society (bfs), raised the concern regarding discontinuing fertility treatments resulting in generating a difference of opinion to what to be considered as essential or non-essential. after the world health organization (who) announced covid-19 as a pandemic, fertility treatments were suspended, as recommended by various fertility societies, including asrm, eshre bfs, raising anxieties in patients with fertility issues [3]. although, from june 2020 onwards, there has been some resumption in the art treatment, however, there are still discrepancies regarding the manner and the extent of art treatment to be offered. although the covid-19 pandemic has affected both public and private centers, all fertility societies have gradually recommended the resumption of art treatment, highlighting the early identification of patients requiring immediate treatment [4]. positive hope the viral presence in the reproductive tract in males affects fertility and highly increases the risks of sexually transmitted infections [5]. up to date, the extent of existence and replication of viruses in the male reproductive system is not clear [6]; however, the zika virus has been reported to stay up to one year in males after recovering from infection [7]. salam and horby [8] reported the transmission of 27 viruses in male semen [8]. moreover, structural stability plays a vital role in this shedding ___________________________________________________ wasiandrabi@gmail.com 1department of embryology, cloudnine hospitals, gurugram, haryana, india. full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol4.issspecial3.154 http://www.jidhealth.com/ andrabi sw, et al., journal of ideas in health (2021); 4(special 2):438-442 439 process. li d et al. [9] reported the transmission of covid-19 into semen [9]; however, biases like low sample size, the stage of infection, and the time of the study (covid-19 pandemic) altered the result. furthermore, there was no crosscontamination of cryopreserved semen samples has been reported yet. mandatory changes per the centers for disease control and prevention (cdc) safety standards, it was mandatory for all front-line staff to use personal protective equipment (ppe), including face masks, disposable laboratory coats, eye protectors, and shoe covers. at least two alternate mini-teams should be made available to limit the spread of the virus if any staff is infected. in case of any staff being infected, at least two alternate mini-teams should be available to limit the spread of the virus. proper safety measures should be followed, and all staff should be appropriately educated. proper face masks and distance should be maintained and contact with patients should be avoided. non-laboratory (clinicians and nurses) and non-medical (security, technicians) persons should be trained for liquid nitrogen tank filling under video conference call with embryologists for cryopreserved samples if lab staff is quarantined. proper sanitization of equipment, devices, and workspace with detergents, uv irradiation, and disinfectants with proven efficiency should be performed after every procedure. in times of peak spread, the use of telehealth technologies in video conferencing and phone consultation should be given preference over the in-person faceto-face interactions. honest counseling about the cycle cancellation in case of covid-19 positive test before the stimulation, in-between stimulation, and before trigger should be done in advance. apart from this, as the effect of covid-19 infection on sperm, oocytes, embryos, implantation, and miscarriages is still unknown, it should also be discussed with the patient. all the persons (both staff and patients) entering any fertility clinic should fill the art triage questionnaire to understand any potential source of infection [10]. any potential infectious case should be referred to covid-19 testing according to local and national guidelines. some basic recommendations as an early-level response plan in pre-pandemic management for art laboratories are listed below in table 1. andrology laboratory recommendations as some studies have reported the possible viral transmission in either semen or testicular sample, proper necessary measures should be taken. some possible recommendations needed to be made summarized in table 2. embryology laboratory recommendations for smooth working of embryology laboratories in covid-19 pandemic, certain recommended precautions that need to be taken are summarized in table 3. non-laboratory recommendations all the possible transmission ways should be blocked starting from by proper 6-step hand-washing at entry before entering the laboratory, use of ppe kits by all staff, well-organized miniteams of staff, cutting down in-person interactions within laboratory staff and with patients, a proper social distancing between patients and staff, introduction of alarm sensors system in liquid nitrogen tanks, proper backup of all essential commodities, and removing outer packing of all media. moreover, consumables should be adequately monitored and removed before taking inside the laboratory, avoiding unnecessary movement, extra mobile air filters, shearing of pens and papers should be discouraged, and door handle should be cleaned frequently. table 1: early-level recommendations for art laboratories to stop covid-19 transmission. recommendation basis of evidence a spare cryogenic storage tank should be available to store sufficient liquid nitrogen in case of possible lockdown. practice committees of the american society for reproductive medicine, society for reproductive biologists and technologists, and society for assisted reproductive technology [11]. maintaining records online. practice committee of society for assisted reproductive technology; practice committee of american society for reproductive medicine [12]. wearing proper masks and ppe kits to stop cross-contamination. recommendation based on expert opinion. vaccinating all staff on a priority basis. world health organization [13]. preparing emergency contact list for all clinical and non-clinical staff. eshre guideline group on good practice in ivf labs et al., 2016 [14]. educating the possible disease transmission and mitigation methods to all staff. kuhar et al., 2019 [15]. summary and conclusion covid-19 pandemic has a severe risk for all healthcare workers and patients, including ivf laboratory workers. any accidental exposure of contaminated fluids or materials poses a direct concern for ivf healthcare workers. most of the standard operating procedures (sop) are inadequate to face the aerosolmediated transmission of viruses. all sops should be revised following the national and local guidelines, with strict implementations to withstand future infections. good collaboration between different units and team members is mandatory for smooth functioning when running ivf laboratories in times of crisis, such as the current covid-19 pandemic. andrabi sw, et al., journal of ideas in health (2021); 4(special 2):438-442 440 table 2: andrology laboratory recommendations during covid-19 recommendation basis of evidence as a precautionary measure, all males starting their fertility treatments should be tested for covid-19. practice committee of society for assisted reproductive technology; practice committee of american society for reproductive medicine [12]. fertility preservation should be considered invulnerable males, including males undergoing therapy and autoimmune and inflammatory treatments. esteves et al [16]. where planned, a proper dedicated area of semen collection and separate semen cryopreservation tank should be assigned. andrabi et al [17]. a proper semen collection written instruction in local and national language should always be available in the collection room before sample collection to avoid in-person contact. andrabi et al [17]. all andrology technicians/embryologists should strictly follow the standard operating protocols in handling the semen samples. onigbinde et al [18]. proper filtration systems should be installed in the form of mobile towers to increase air quality inside the andrology laboratory. recommendation based on expert opinion all the materials used in performing andrological procedures should be disposed of immediately after the procedure, followed by thorough cleaning. recommendation based on expert opinion in covid-19 positive patients, home collection and proper care can be an ideal way. recommendation based on expert opinion table 3: embryology laboratory recommendations during covid-19 recommendation basis of evidence avoiding in-person counseling and use of tele phone or email calling. adequate time should be given between procedures when performing a thorough cleaning in ovum pickup areas. andrabi et al [17]. minimal embryology teams should be made available for worstcase scenarios. andrabi et al [17]. extra care should be taken in follicular fluid handling during screening procedures, especially in covid-19 infection recovered patients. recommendation based on expert opinion after the proper follicular fluid screening, care should be taken in the form of non-spillage of fluid, proper closing of the lid, and immediate disposal should be taken care of. recommendation based on expert opinion pipette holders should be disinfected after every oocyte retrieval procedure. recommendation based on expert opinion although no cross-contamination of gametes or embryos has been reported yet; however, it is better to use a closed type vitrification system that avoids direct contact of embryos with liquid nitrogen. porcu et al [19] a separate liquid nitrogen tank should store cryopreserved embryos and oocytes of patients having symptoms or tested positive for covid-19. recommendation based on expert opinion after every procedure, proper disinfection of the workstation and other equipment should be done with disinfectant, which is alcohol-free, non-voc releasing, non-fragranced, and effective against bacteria, yeasts, viruses, and mycobactericidal. alaluf et al [20] although the chances of cross-contamination are very low in art laboratories due to antibiotics in media and continuous washing of gametes repeatedly, every laboratory should properly follow its standard operating protocols. onigbinde et al [18] some other suggestions during this covid-19 pandemic period include, following routine good laboratory practice, proper protection of staff, proper cleaning of safety cabinets with tested quaternary ammonium compounds lab disinfectants, proper pre and post sanitization of all equipment, bed, trolley, and theatre (general suggestions). recommendation based on expert opinion andrabi sw, et al., journal of ideas in health (2021); 4(special 2):438-442 441 abbreviation covid-19: coronavirus disease 19; who: world health organization; art: assisted reproductive techniques; ivf: in-vitro fertilization; sars-cov-2: severe acute respiratory coronavirus 2; asrm: american society for reproductive medicine; eshre: european society of human reproduction and embryology; bfs: british fertility society; ace2: angiotensin-converting enzyme 2; cdc: centers for disease control and prevention; ppe: personal protective equipment declaration acknowledgment we express our gratitude to all scientific communities for their relentless work to produce the covid-19 vaccine. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing wasiandrabi@gmail.com. authors’ contributions syed waseem andrabi (swa) and puneet rana arora (pra) are the principal investigators of this manuscript (viewpoint). swa is the responsible author for the study concept, design, and writing. pra is responsible for reviewing and editing the manuscript in its final form. jaffar mir (mj) approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, “viewpoint article” need no ethics committee approval. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of embryology, cloudnine hospitals, gurugram, haryana, india. 2centre for infertility and assisted reproduction, gurugram, haryana, india. 3valley fertility center, srinagar kashmir, india article info received: 05 august 2021 accepted: 07 september 2021 published: 19 september 2021 references 1. hoffmann m, kleine-weber h, schroeder s, et al. sars-cov-2 cell entry depends on ace2 and tmprss2 and is blocked by a clinically proven protease inhibitor. cell. 2020;181(2):271280.e8. doi:10.1016/j.cell.2020.02.052 2. zhou p, yang xl, wang xg, hu b, zhang l, zhang w, si hr, zhu y, li b, huang cl, chen hd, chen j, luo y, guo h, jiang rd, liu mq, chen y, shen xr, wang x, zheng xs, zhao k, chen qj, deng f, liu ll, yan b, zhan fx, wang yy, xiao gf, shi zl. a pneumonia outbreak associated with a new coronavirus of probable bat origin. nature. 2020;579(7798):270-273. doi: 10.1038/s41586-020-2012-7. 3. anifandis g, messini ci, daponte a, messinis ie. covid-19 and fertility: a virtual reality. reprod biomed online. 2020;41(2):157159. doi:10.1016/j.rbmo.2020.05.001. 4. alviggi c, esteves sc, orvieto r, conforti a, la marca a, fischer r, andersen cy, bühler k, sunkara sk, polyzos np, strina i, carbone l, bento fc, galliano d, yarali h, vuong ln, grynberg m, drakopoulos p, xavier p, llacer j, neuspiller f, horton m, roque m, papanikolaou e, banker m, dahan mh, foong s, tournaye h, blockeel c, vaiarelli a, humaidan p, ubaldi fm; poseidon (patient-oriented strategies encompassing individualized oocyte number) group. covid-19 and assisted reproductive technology services: repercussions for patients and proposal for individualized clinical management. reprod biol endocrinol. 2020;18(1):45. doi: 10.1186/s12958-02000605-z. 5. liu w, han r, wu h, han d. viral threat to male fertility. andrologia. 2018;50(11):e13140. doi: 10.1111/and.13140. 6. mansuy jm, suberbielle e, chapuy-regaud s, mengelle c, bujan l, marchou b, delobel p, gonzalez-dunia d, malnou ce, izopet j, martin-blondel g. zika virus in semen and spermatozoa. lancet infect dis. 2016;16(10):1106-1107. doi: 10.1016/s14733099(16)30336-x. 7. kurscheidt fa, mesquita css, damke gmzf, damke e, de a carvalho arb, suehiro tt, teixeira jjv, da silva vrs, souza rp, consolaro mel. persistence and clinical relevance of zika virus in the male genital tract. nature review urology 2019;16(4):211-230. https://doi.org/10.1038/s41585-019-0149-7. 8. salam ap, and horby pw. the breadth of viruses in human semen. emer inf diseases. 2017;23(11):1922-1924. https://doi.org/10.3201/eid2311.171049. 9. li d, jin m, bao p, zhao w, zhang s. clinical characteristics and results of semen tests among men with coronavirus disease 2019. jama network open. 2020;3(5):e208292. doi:10.1001/jamanetworkopen.2020.8292. 10. eshre guidance on recommencing art treatments. eshre covid-19 working group. published on the eshre website. 23/04/2020. 11. practice committees of the american society for reproductive medicine, society for reproductive biologists and technologists, and society for assisted reproductive technology. electronic address: asrm@asrm.org. cryostorage of reproductive tissues in the in vitro fertilization laboratory: a committee opinion. fertility sterility. 2020;114(3):486-491. doi: 10.1016/j.fertnstert.2020.06.019. 12. practice committee of society for assisted reproductive technology; practice committee of american society for reproductive medicine. guidelines for development of an emergency plan for in vitro fertilization programs. fertility sterility. 2008; 90(5):s131-33. doi: 10.1016/j.fertnstert.2008.08.063. 13. world health organization. (2020). guiding principles for immunization activities during the covid-19 pandemic: interim guidance, 26 march 2020. world health organization. https://apps.who.int/iris/handle/10665/331590. license: cc bync-sa 3.0 igo. 14. eshre guideline group on good practice in ivf labs, de los santos mj, apter s, coticchio g, debrock s, lundin k, plancha ce, prados f, rienzi l, verheyen g, woodward b, vermeulen n. andrabi sw, et al., journal of ideas in health (2021); 4(special 2):438-442 442 revised guidelines for good practice in ivf laboratories (2015). human reproduction. 2016;31(4):685-686. doi: 10.1093/humrep/dew016. 15. kuhar dt, carrico rm, cox k, de perio ma, irwin kl, lundstrom t, overholt ad, roberts kt, russi m, steed c (2019) infection control in healthcare personnel: infrastructure and routine practices for occupational infection prevention and control services. accessible version: https://www.cdc.gov/infectioncontrol/guidelines/healthcarepersonnel/index.html. 16. esteves sc, lombardo f, garrido n, alvarez j, zini a, colpi gm, kirkman-brown j, lewis sem, björndahl l, majzoub a, cho cl, vendeira p, hallak j, amar e, cocuzza m, bento fc, figueira rc, sciorio r, laursen rj, metwalley am, jindal sk, parekattil s, ramasamy r, alviggi c, humaidan p, yovich jl, agarwal a. sars-cov-2 pandemic and repercussions for male infertility patients: a proposal for the individualized provision of andrological services. andrology. 2021;9(1):10-18. doi: 10.1111/andr.12809. 17. andrabi sw, jaffar m, arora pr. covid-19: new adaptation for ivf laboratory protocols. jbra assisted reproduction. 2020;24(3):358-361. doi:10.5935/1518-0557.20200054. 18. onigbinde oa, ajagbe ao, oyeniran oi, chia t. post-covid19 pandemic: standard operating procedures for gross anatomy laboratory in the new standard. morphologie. 2020. issn 12860115. https://doi.org/10.1016/j.morpho.2020.10.004. 19. porcu e, tranquillo ml, notarangelo l, ciotti pm, calza n, zuffa s, mori l, nardi e, dirodi m, cipriani l, labriola fs, damiano g. high-security closed devices are efficient and safe to protect human oocytes from potential risk of viral contamination during vitrification and storage especially in the covid-19 pandemic. j assist reprod genet. 2021; 38(3):681-688. doi: 10.1007/s10815-021-02062-y. 20. alaluf mg, pasqualini a, fiszbajn g, botti g, estofan g, ruhlmann c, solari l, bisioli c, pene a, branzini c, quintero retamar a, checkherdemian v, pesce r, serpa i, lorenzo f, avendaño c, alvarez sedo c, lancuba s. covid-19 risk assessment and safety management operational guidelines for ivf center reopening. j assist reprod genet. 2020 nov; 37(11):26692686. doi: 10.1007/s10815-020-01958-5. yaseen et al, journal of ideas in health 2019;2(1):60-64 © the author(s). 2019 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access predictive factors of successful extracorporeal shockwave lithotripsy (eswl) for renal stones: evidence of retrospective study shukur mahmood yaseen1, saad ahmed ali jadoo2*, ayad aziz abdullah3, anmar shukur mahmood4, wassan nasrat abd al-wahaab1 abstract background: extracorporeal shockwave lithotripsy (eswl) has proved to be effective in treating ureterolithiasis. this study aimed to investigate the predictive factors related to success eswl among patient presented with renal stone. methods: a retrospective study was conducted among 40 patients who underwent eswl at the urology department, baquba teaching hospital, diyala university, iraq. data was collected between 1st october 2018 and 31st january 2019 for renal stones diagnosed by non-enhanced spiral computed tomography (ncct). the success rate defined as no stone or the remnant stones < 4 mm. we analyzed predictive factors by using multiple linear regression. results: the success rates ranged from 50-90%. in the univariate analysis, body mass index (bmi), skin-to-stone distance (ssd) and the renal stone-attenuation value (in hounsfield units, hu) were found to be significantly correlated with the outcome of eswl (p<0.05). however, in the multiple linear regression, only the hu (b = -0.619, p < 0.0001; 95% confidence interval [ci]: 0.03 to 0.07) was the independent predictive factor. conclusion: hounsfield unit is an independent predictive factor influencing the success of eswl for treating renal stones. keywords: eswl, renal stone, ncct, hounsfield unit, baquba, diyala, iraq background some facts and figures cannot overcome when discussing the issue of renal calculi and ureteral calculi (ureterolithiasis). first, the incidence rate is increasing at the global level regardless of region, race, gender, and age [1]. second, diagnosis often delayed when the stone is large enough to affect the function of the urinary tract system [2]. third, the significant change in lifestyle and bad dietary habits have emerged as other complicating factors in the way of treatment [3]. fourth, the lack of awareness about the causes and the risk of urinary tract stones among most people [4]. fifth, there is a misconception that when removing stone by any way of treatment means full recovery. unfortunately, the recurrence rate is high [5]. sixth, the magnitude of ureterolithiasis goes beyond the health and psychological impact on serious economic and social repercussions [6]. seventh, the technological advances in diagnosis and treatment of ureterolithiasis, especially the introduction of non‐contrast computed tomography (ncct) and extracorporeal shockwave lithotripsy (eswl) in the early 1980s, increased the chances of early diagnosis and the safe treatment with fewer side effects [7]. eighths, ncct is superior to intravenous urogram (ivu) in the sensitivity and specificity regarding the diagnosis of the renal and ureteral calculi. however, ncct’s safety is not guaranteed due to the high radiation dose [8]. ninth, the success and failure rate of eswl have been extensively discussed in previous research and most of them revolved around the age of patient, gender, body mass index (bmi), stone size, location, the skin-to-stone distance (ssd), the renal stone-attenuation value (in hounsfield units, hu), and presence or absence of complications and so on. in this current study, we are also trying to find out the most important predicting factors for the success of the eswl procedure among sample of iraqi patients presented with renal stone. ___________________________________________________ drsaadalezzi@gmail.com department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey full list of author information is available at the end of the article http://www.jidhealth.com/ yaseen et al, journal of ideas in health 2019;2(1):60-64 61 methods a retrospective analysis was performed among 40 patients who underwent eswl between 1st october 2018 and 31st january 2019 for renal stones at the urological department of baquba teaching hospital. a non-enhanced spiral computed tomography (nesct) was used to diagnose the included cases. table 1 inclusion and exclusion criteria no. the main criteria inclusion & exclusion 1. stone size >4 mm + 2. solitary stones + 3. radiopaque stones on the pretreatment plain radiography + 4. stone < 20mm + 5. ongoing urinary tract infections 6. blood coagulation disorders 7. ureteral stricture 8. neurogenic bladder 9. polycystic kidney 10. multiple stones 11. obstructed stones with severe grades of hydronephrosis 12. renal failure 13. pregnancy (+) inclusion criteria, (-) exclusion criteria patient age, gender, body mass index (bmi), stone size, location, skin-to-stone distance (ssd), hounsfield unit (hu) were the main variables recruited to predict the successful procedure of eswl (table 2). for each patient, height in meters and weight in kilogram were measured to calculate the bmi following the formula: “bmi = kg/m2 where kg is a patient’s weight in kilograms and m2 is their height in meters squared". an average of three different measures (0°, 45°, and 90°) from the skin to renal stone has been taken on nesct to determine the ssd for each stone. the stone attenuation values (hounsfield units [hu]) were measured following the steps described by choi et al. [9]. the first step was to obtain images using the non-enhanced helical technique by considering the 5-mm collimation breadth from the tip of the kidneys to the level of the pubic symphysis. the second step was to analyze the stones in largest dimension, where three regions of interest (roi) with similar-size roi (2.0±0.5 mm2) were considered. in the third step, the average measure of three rois was considered as the hu for that stone. all patients were planned for second ncct 30 days after the eswl to assess the success rate and to check for the possible complications. in this study, the success rate of eswl was considered when the targeted stone disappeared completely (stone free) or with remaining of residual stone fragments of less than 4 mm size as clinically insignificant remaining fragments (cirf). however, residuals fragments of ≥4 mm considered the sign for the failure of eswl. eswl procedure performed under pethidine sedation and the supervision of a urologist by using an electroconductive lithotriptor (sonolith praktis, edap tms, vaulx-en-velin, france). the stones fragmented under fluoroscopic guidance. when there was a large fragment with a long diameter >4 mm, eswl was tried repeatedly until each fragment became smaller than 4 mm. the failure of eswl was defined as remnant stones larger than 4 mm at three months after the first session. statistical analysis descriptive data presented as the mean (sd). univariate analysis was used to assess the association between the various factors and outcomes. an independent sample t‐test was used to compare means between the categorical variable, e.g., gender and stone location with stone free rate. pearson correlation coefficient was used to test the relation between the continuous variables, e.g., age, bmi, stone size, skin to stone distance and the values of the hounsfield unit and the outcome stone free rate. after that, the significantly associated variables were tested with multiple linear regression analysis to identify the independent predictors of successful treatment. statistical analysis performed by using spss ver. 16.0 (spss inc., chicago, il, usa). values of p<0.05 were considered statistically significant. results descriptive analyses (univariate analysis) table 1 presents the descriptive characteristics of the sociodemographic variables. the patient means age (±sd) was 44.36 years (±1.80) (range, 11 to 78 years). more than half of respondent (23, 57.5%) were females and an average bmi 25.23(±3.42). most of the patients presented with left side (22, 55.0%) renal stone with a mean stone size of 11.48 (±2.23) and average skin-to-stone distance of 80.23(±1.76) mm. the density of stones was in average hounsfield unit of 7.1(±1.44) and average stone free rate of 65.75(±11.74). an independent sample t-test was used to compare the mean of stone free rate scores across demographic and other variables. there were no significant differences between the gender, stone location and the stone free rate (table 3). table 4 presents the results of the pearson correlation coefficient with stone free rate. two variables; ssd, and the hu found to be correlated significantly with stone free rate. multivariate analysis predictors of fragmentation table 5 shows the results of multiple linear regression analysis to identify the associated variables with the stone-free rate. in backward elimination (or backward deletion) the multivariate linear regression analysis (after excluding of non-contributing variables) was statistically significant, and overall, explained 38.3% of the variance in the stone-free rate, f (38, 23.591) = 2059.753, p < 0.0005. the “hounsfield unit” appeared to be the only factors predicting the stone-free rate (table 5). the high numbers of hounsfield unit were more likely to have a low stone-free rate (b = -0.619, p < 0.001). yaseen et al, journal of ideas in health 2019;2(1):60-64 62 table 2 descriptive statistic of socio-demographic and other variables (n=40) no. variables category mean (±sd) range n% 1 age 44.36 (sd 1.80) (11-78) 2 gender male 17 (42.5) female 23 (57.5) 3 body mass index (bmi) 25.23 (sd 3.42) (16.96-34.96) 4 stone location right side 18 (45.0) left side 22 (55.0) 5 stone size 11.48(sd 2.23) (7-20) 6 skintostone distance (ssd) 80.23 (sd1.76) (50-124) 7 hounsfield unit (hu) 7.1 (sd1.44) (500-990) 8 stone free rate 65.75 (sd 11.74) (50-90) table 3 an-independent sample t-test on stone free rate (n=40) no. variables category n% mean + sd t-test p-value 95% upperlower 1 gender male 17 (42.5) 62.9 (10.5) 1.347 0.186 2.5-12.2 female 23 (57.5) 67.8 (12.4) 2 stone site right 18 (45.0) 65.6 (12.9) 0.092 0.927 7.5-8.2 left 22 (55.0) 65.9 (11.0) table 4 pearson correlation coefficient on stone free rate (n=40) no. variables r value sig (2-tailed) 1 age (years) 0.126 0.437 2 body mass index (bmi) 0.251 0.118 3 stone size (mm) 0.107 0.511 4 skin-to-stone distance (mm) 0.402* 0.010 5 hounsfield unit (hu) 0.619* 0.000 table 5 results of multiple linear regression on stone free rate (n=40) variables b s.e. beta t-test sig. 95% ci lower-upper tolerance vif constant 101.563 7.520 13.506 0.000 86.3-116.8 hounsfield unit -0.050 0.010 -0.619 -4.875 0.000 0.03-0.07 0.662 1.511 discussion there is an agreement among urologists that eswl contributed significantly to reducing the patient suffering and accelerating the treatment. high success rates of eswl reported around the world associated with promising outcomes in terms of low cost, less length of patient stay (los) and minimal side effects [10]. in the current study, the success rate of eswl was on average of 65.75 (sd 11.74) which in line to findings reported by assimos et al [11]. in this study, a high correlation (r =0.619) between the hu and sfr and in multiple linear regression only hu (p<0.001) was significantly predicting the rate of sf. similarly, berber-deseusa et al [12] found that there was a statistically significant relationship between the hu and the success of eswl (p = 0.01) (or 6; 95% ci: 1.4-26.2). massoud et al [7] concluded that the failure rate of eswl would be more than half when treating the patients presented with the stone of 1000 hu or more. the author argued that in such case eswl should not be considered as a first line in the treatment. in our sample, the renal stone-attenuation value was within the acceptable range of (500 to 990) for eswl procedure [7]. part of our study analysis showed weak correlation (r =0.308) between the weight of patients and sfr. many studies discussed obesity and its relationship to the success of the eswl procedure; the higher the obesity, the lower the success rate [13,14]. obesity is associated with increased absorption of radiation and difficulty in locating the calculi [13]. pareek et al [15] found that both bmi and hu are independent predictors for successful sewl. however, in respect to our findings, dede et al [13], bulent et al [14] and pompeo et al [16] reported in different studies that bmi does not affect sfr. moreover, bulent et al [14] and pareek et al [15] found a significant relationship between the ssd and the success of eswl. similarly, in our study, moderate correlation (r=0.402) was reported between the ssd and sfr. however, jacobs et al [17] found that ssd did not have a statistically significant effect on the success of eswl treatment. although the results of our study found that the size of stone has no relation to the success of the eswl procedure, however this finding conflict with previous results confirmed that the size of renal stone has a direct impact on the sfr [9,18]. whenever the size of the stone was larger the possibility of eswl failure is high. joshi et al yaseen et al, journal of ideas in health 2019;2(1):60-64 63 [19] concluded that for the stone size of less than 15 mm the likelihood of sfr is high. location of stone within the different parts of the kidney may alter the skin to stone distance especially when associated with high. two studies carried out in egypt [7], and oman [20] indicated that the success rate of eswl decreased significantly when the stone location was in lower calyceal. dede et al [13] reported that the position of stone (right or lift kidney) was not related to the rate of sf which is in line to our findings. concerning the sociodemographic factors, age appeared to have no impact on the outcome of eswl. similar results were reported in oman [20]. previous studies conducted by lee et al [21] found that there were no significant differences between men and women patients concerning the success of eswl, which is in line with our current findings. however, shinde et al [20] found a significant gender difference, and the success rate was higher among men. the author also found that women patients were less tolerated for treatment than men [20]. the retrospective design and the inclusion of a small number of patients (only the successfully treated cases) led to a selection bias as the main limitation for this research. conclusion in conclusion, the results of this study added another event that the renal stone-attenuation value (in hounsfield units, hu) is the most potent predictor for successful eswl. moreover, there is a significant, but in reverse, the relationship between the value of hu and the stone-free rate. abbreviations eswl: extracorporeal shockwave lithotripsy ncct: non-enhanced spiral computed tomography bmi: body mass index ssd: skin-tostone distance hu: hounsfield units ivu: intravenous urogram sd: standard deviation roi: regions of interest cirf: clinically insignificant remaining fragments sfr: stone free rate los: length of stay declarations acknowledgement we render our special thanks to all patients for their patience and help during the study. special thanks to all directors of baquba teaching hospital including the doctors and paramedical staff at the department of urology for their unlimited support and full cooperation during the data collection. funding the author (s) received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing drsaadalezzi@gmail.com authors’ contributions saaj is the principal investigator of the study who designed the study and coordinated all aspects of the research including all steps of the manuscript preparation. he is responsible for the study concept, design, writing, reviewing, editing and approving the manuscript in its final form. smy, aa, asm, and la contributed in the study design, analysis and interpretation of data, drafting the work, writing the manuscript and reviewed and approved the manuscript. all authors read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki, and the protocol was approved by the ethic committee of faculty of medicine, university of diyala, iraq (ref: 1714 at 24-june-2018). moreover, written informed consent was obtained from each included patient who were willing to participate after explanation of the study objectives and guarantee of secrecy. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated author details 1department of anatomy, molecular genetics, faculty of medicine, university of diyala, diyala, iraq. 2department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey.3department of urology, baquba teaching hospital, diyala, iraq. 4faculty of computer engineering, altinbas university, istanbul, turkey article info received: 24 march 2019 accepted: 23 april 2019 published: 17 may 2019 references 1. pawar as, thongprayoon c, cheungpasitporn w, sakhuja a, mao ma, erickson sb. incidence and characteristics of kidney stones in patients with horseshoe kidney: a systematic review and meta-analysis. urol. ann.2018; 10(1):87-93. http://dx.doi.org/10.4103/ua.ua_76_17. 2. türk c, knoll t, petrik a, sarica k, seitz c, straub m. eau guidelines on urolithiasis. uroweb 2012. available from: http://www.uroweb.org/gls/pdf/20_urolithiasis_lr%20march%2013% 202012.pdf. [accessed 22 mart 2019]. 3. dai m, zhao a, liu a, you l, wang p: dietary factors and risk of kidney stone: a case-control study in southern china. j ren nutr 2013;23: e21-e28. http://dx.doi.org/10.1053/j.jrn.2012.04.003. 4. alghamdi sy, alamri am, alzahrani ra, alghamdi ah, alghamdi aa, alghamdi aa, et al. awareness about symptoms and role of diet in renal stones among the general population of albaha city. the egyptian journal of hospital medicine 2018;70: 50-59. http://dx.doi.org/10.12816/0042983. 5. d'costa mr, pais vm, rule ad. leave no stone unturned: defining recurrence in kidney stone formers. curr opin nephrol hypertens 2019; 28:148-153. http://dx.doi.org/10.1097/mnh.0000000000000478. 6. hyams es, matlaga br. economic impact of urinary stones. transl. androl urol. 2014; 3:278–283. http://dx.doi.org/10.3978/j.issn.22234683.2014.07.02. 7. massoud am, abdelbary am, al-dessoukey aa, moussa as, zayed as, mahmmoud o. the success of extracorporeal shock-wave lithotripsy based on the stone-attenuation value from non-contrast computed tomography. arab j urol. 2014; 12:155-161. http://dx.doi.org/10.1016/j.aju.2014.01.002. 8. alrwaili a. a non-contrast computed tomography and intravenous urography interrogation in patients with renal colic at hospitals. sm j clin med. 2018; 4(1): 1036. 9. choi jw, song ph, kim ht. predictive factors of the outcome of extracorporeal shockwave lithotripsy for ureteral stones. korean j urol 53, 424–430 (2012). http://dx.doi.org/10.4111/kju.2012.53.6.424. yaseen et al, journal of ideas in health 2019;2(1):60-64 64 10. kroczak t, scotland kb, chew b, pace kt. shockwave lithotripsy: techniques for improving outcomes. world j urol 2017; 35:1341-1346. http://dx.doi.org/10.1007/s00345-017-2056-y. 11. assimos d, krambeck a, miller nl, monga m, murad mh, nelson cp, et al. surgical management of stones: american urological association/endourological society guideline, part ii. j urol 2016; 196:1161e9. http://dx.doi.org/10.1016/j.juro.2016.05.090. 12. berber-deseusa a, maldonado-ávila m, garduño-arteaga ml, jaspersengastelum j, virgen-gutiérrez f, rodríguez-nava p. predictive success factors in extracorporeal shock wave lithotripsy (eswl). rev mex urol 2017; 77 (4): 251-257. 13. dede o, şener nc, baş o, dede g, bağbancı mş. does morbid obesity influence the success and complication rates of extracorporeal shock wave lithotripsy for upper ureteral stones? turk j urol 2015; 41(1): 20-23. http://dx.doi.org/10.5152/tud.2015.94824. 14. bulent k, eyyup sp, ismail y, suleyman s. effects of the distance between renal calculi and skin and the body mass index on the success of eswl among renal calculi patients. joj uro & nephron. 2017; 3(3): 555614. http://dx.doi.org/10.19080/jojun.ms.id.555614. 15. pareek g, armenakas na, panagopoulos g, bruno jj, fracchia ja. extracorporeal shock wave lithotripsy success based on body mass index and hounsfield units. urology 2005; 65:33–36. http://dx.doi.org/10.1016/j.urology.2004.08.004. 16. pompeo a, molina wr, juliano c, sehrt d, kim fj. outcomes of intracorporeal lithotripsy of upper tract stones are not affected by bmi and skin-to-stone distance (ssd) in obese and morbid patients. int braz j urol. 2013; 39:702–709. http://dx.doi.org/10.1590/s16775538.ibju.2013.05.13. 17. jacobs bl, smaldone mc, smaldone am, ricchiuti dj, averch td. effect of skin-to-stone distance on shockwave lithotripsy success. j endourol2008;22(8):1623-1627. http://dx.doi.org/10.1089/end.2008.0169. 18. al-ansari a, as-sadiq k, al-said s, younis n, jaleel oa, shokeir aa. prognostic factors of success of extracorporeal shock wave lithotripsy (eswl) in the treatment of renal stones. int urol nephrol 2006;38(1):63-67. http://dx.doi.org/10.1007/s11255-005-3155-z. 19. joshi hn, karmacharya rm, shrestha r, shrestha b, de jong ij, shrestha rkm. outcomes of extracorporeal shock wave lithotripsy in renal and ureteral calculi. kathmandu univ med j 2014; 12 :51-54. 20. shinde s, al balushi y, hossny m, jose s, al busaidy s. factors affecting the outcome of extracorporeal shockwave lithotripsy in urinary stone treatment. oman med j. 2018; 33(3): 209–217. http://dx.doi.org/10.5001/omj.2018.39. 21. lee hy, yang yh, lee yl, shen jt, jang my, shih pm, et al. noncontrast computed tomography factors that predict the renal stone outcome after shock wave lithotripsy. clin imaging 2015; 39(5):845850. http://dx.doi.org/10.1016/j.clinimag.2015.04.010. https://doi.org/10.47108/jidhealth.vol6.iss1.268 alberifkani nm and naser as, journal of ideas in health (2023); 6(1):814-819 © the author(s). 2023 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access assessment of anxiolytic-like effects of acute and chronic treatment of flurbiprofen in murine naktal mamish alberifkani1, ahmed salah naser2* abstract background: non-steroidal anti-inflammatory drugs are commonly used medications with atypical pharmacological effects. this aims to evaluate the anxiolytic-like effects of flurbiprofen in rodent models. methods: in vivo experimental trial was conducted from october 2022 to january 2023 at the college of veterinary medicine, university of mosul, iraq. the effect of flurbiprofen was assessed in mice exposed to the elevated plus maze (epm), light-dark box test (ldt), and open-field test (oft). fifty male mice were divided into two groups of twenty-five, weighing 30–35 g, for acute and chronic treatment. each group was subdivided into five subgroups: distilled water was administered to the control group; the positive control was injected with 10 mg/kg diazepam; and the flurbiprofen groups were administered orally at 10, 20, and 40 mg/kg. each subgroup was subjected to epm, ldt, and oft one hour after administration. the second group was also subdivided like the first group. it was treated for 15 days constantly and subjected to anxiety tests on the 16th day. results: acute treatment with 20 mg/kg flurbiprofen revealed an anxiolytic effect, with increased time spent in the open arm of the epm test, increased time spent in the ldb test, and increased time spent in the central area in the oft compared to the control group. chronic administration of flurbiprofen was ineffective in producing an anxiolytic effect. conclusion: the low doses of flurbiprofen may eliminate the anxiety effect in experimental mice; however, the antianxiety effect does not appear significantly after repeated or chronic administration of flurbiprofen. keywords: flurbiprofen, anxiety, elevated plus maze open field test, mice, iraq background anxiety and depression are recognized as psychiatric diseases worldwide [1]. these two mental disorders are linked to physiological, cognitive, behavioral, and psychological alterations in individuals classified as having negative emotional experiences [2]. depression and anxiety have detrimental impacts on human and animal life, causing significant functional loss, and depression and anxiety disorders are frequently detected together [3-4]. the etiopathogenesis of both diseases has not yet been clarified, and antidepressant drugs from the selective serotonin reuptake inhibitor (ssri) group are the first-choice treatment [5]. alprazolam and diazepam appeared beneficial in lowering both the frequency and intensity of panic attacks. the use of benzodiazepines for treating panic disorders has been supported by previous research [6]. a low dose of a nonselective beta blocker, propranolol, administered on the morning of day-case surgery, significantly treated patients' worry [7-8]. in latest years, substantial attention has been paid to neuroimmune processes associated with depression. numerous preclinical and clinical experiments have been shown to investigate the possible antidepressant and anxiolytic benefits of various antiinflammatory medications [9]. flurbiprofen produces antiinflammatory properties by inhibiting pro-inflammatory cytokines by inhibiting cyclooxygenase 1 and cyclooxygenase 2 [10]. we aimed to assess the anxiolytic properties of acute and chronic flurbiprofen treatment in murine models. methods study design an experimental study was designed to assess the effect of flurbiprofen in mice exposed to the elevated plus maze (epm), light-dark box test (ldt), and open-field tests (oft). the ___________________________________________________ ahmadphd0@gmail.com 2department of physiology, biochemistry, and pharmacology, faculty of veterinary medicine, university of mosul, mosul, iraq full list of author information is available at the end of the article 10.47108/jidhealth.vol6.iss1.268 http://www.jidhealth.com/ alberifkani nm and naser as, journal of ideas in health (2023); 6(1):814-819 815 study was conducted in an isolated room in the college of veterinary medicine, university of mosul, iraq, from october 2022 to january 2023. animals male swiss albino mice weighing 25–32g were purchased from the laboratory animal house of the faculty of veterinary medicine of the university of mosul in iraq. mice were housed at a temperature of 20 ± 2°c with a 12/12 hours light, dark cycle and given water and food ad libitum. the procedures used were in accordance with european legislation on the use and care of laboratory animals (eu directive 2010/63/eu) and authorized by the department of physiology, biochemistry, and pharmacology (ref: 2022-08-15/1470). every effort was made to reduce the number of animals used and their suffering. dosage preparation different flurbiprofen doses (10, 20, and 40 mg/kg) were chosen. flurbiprofen was dissolved in distilled water and given orally at a 10 ml/kg dose by a gavage needle. diazepam (10mg/kg) was dissolved in normal saline and given intraperitoneally in a dose volume of 10ml/kg. trials design at the start of the trials, the mice were randomly separated into two experimental groups, each involving five subgroups of five mice: 1-first group: for acute treatment, which was subjected to anxiety tests after one hour of administration, which was classified into: group 1 was treated with distilled water as a negative control. group 2 was treated intraperitoneally with diazepam (10 mg/kg). group 3 was orally administered flurbiprofen at a dose of 10 mg/kg. group 4 was orally administered flurbiprofen (20 mg/kg). group 5 was orally administered flurbiprofen (40 mg/kg). 2-second group: chronic treatment, which was subjected to anxiety tests after 15 days of continuous administration, was classified as follows: group 1 was treated with distilled water as a negative control. group 2 was treated intraperitoneally with diazepam (10 mg/kg). group 3 was orally administered flurbiprofen at a dose of 10 mg/kg. group 4 was orally administered flurbiprofen (20 mg/kg). group 5 was orally administered flurbiprofen (40 mg/kg). anxiety tests anxiety in mice was assessed using the elevated plus maze (epm) test. it had two open arms (35×5 cm2), two opposite closed arms (35×5 cm2), and a small middle square (5×5 cm2) between arms. the maze was placed 50 cm above the ground in a dim area. each mouse was placed in the center of the elevated plus maze with its head facing the open arm. a video camera was used to record the mice's free exploration for 5 min [11-12]. the following were recorded within 5 minutes: 1-time spent in open arms. 2time spent in the closed arm. also, anxiety behavior in mice was assessed using dark and lightbox tests. the trial used two compartments for video recordings: a light side (42 × 30 × 20 cm3; white walls and highly lit with a 100 w bulb) and a dark side (42 × 30 × 20 cm3; opaque black walls and dark), with an opening (6 × 6 cm2) between the two sections and a mobile phone stand situated 50 cm overhead the box [13-14]. the mouse was located on the dark side with its head to the light side and allowed to discover for 5 minutes and record the following: 1. period of stay on the dark side. 2-periods of staying on the bright side. then, an open-field test was conducted, which can be used to detect anxiety in mice. the floor of the transparent acrylic box (72×72×36 cm3) was divided into 16 equal-sized squares (18×18 cm2) [15]. the center was four squares, whereas the periphery was 12 squares along the walls. a video camera was used to record the following. 1period of stay in the middle of the field. 2period of stay in the vicinity of the field. the devices were rinsed after each mouse to remove the odor of the previous mice. statistical analysis the elevated plus maze, light-dark box test, and open-field test parameters were analyzed by one-way analysis of variance. statistical significance was set at p≤ 0.05. data are expressed as mean ± standard error of the mean (sem). data were analyzed using spss for windows version 16. results time spent on the closed arm flurbiprofen, one hour after administration of 20 mg/kg, caused an anxiolytic effect, represented by a significant increase in the time spent in the open arm and a significant decrease in the time spent in the closed arm compared to the control group in the elevated maze test (figure 1a and figure 1b). fig. 1a. effects of acute oral administration of flurbiprofen (10,20, and 40 mg/kg) and diazepam(standard) (10 mg/kg) on time spent in the closed arms for 5 minutes in the elevated plus maze. data are expressed as mean ±sem (5 mice/group) * significantly different from control data (p ≤ 0.05). the light/dark box test revealed anti-anxiety effects as a significant increase in the time spent by mice dosed with flurbiprofen at a dose of 20 mg/kg body weight on the bright side and a significant decrease in the time spent on the dark side compared to the control group (figure 1c and figure 1d). alberifkani nm and naser as, journal of ideas in health (2023); 6(1):814-819 816 fig. 1b. effects of acute oral administration of flurbiprofen (10,20, and 40 mg/kg) and diazepam (10 mg/kg) on time spent in the open arms for 5 minutes in the elevated plus maze. data are expressed as mean ±sem (5 mice/group) * significantly different from control data (p ≤ 0.05). fig. 1c. effects of acute oral administration of flurbiprofen (10,20, and 40 mg/kg) and diazepam (10 mg/kg) on time spent on the dark side for 5 minutes in the light/dark box. data are expressed as mean ±sem (5 mice/group) * significantly different from control data (p ≤ 0.05). the open field test revealed a significant increase in the time spent in the center and a significant decrease in the time spent in the periphery compared with the control group (figure 1e and figure 1f). flurbiprofen at 10 and 40 mg/kg showed no anxiolytic effects. fig. 1d. effects of acute oral administration of flurbiprofen (10,20, and 40 mg/kg) and diazepam (10 mg/kg) on time spent on the light side for 5 minutes in the light/dark box. data are expressed as mean ±sem (5 mice/group) * significantly different from control data (p ≤ 0.05). the results of chronic treatment with flurbiprofen varied. in contrast to acute treatment in the elevated plus maze test, the time spent in the open arms was significantly shorter in flurbiprofen at 10, 20, and 40mg/kg than in the control group, while the time spent in the open arm was longer in the standard group than in control group. the time spent in the closed arms showed no statistically significant difference between the groups (figure 2a and figure 2b). fig. 1e. effects of acute oral administration of flurbiprofen (10,20, and 40 mg/kg) and diazepam (10 mg/kg) on time spent in the central area for 5 minutes in the open field. data are expressed as mean ±sem (5 mice/group) * significantly different from control data (p ≤ 0.05). fig. 1f. effects of acute oral administration of flurbiprofen (10,20, and 40 mg/kg) and diazepam (10 mg/kg) on time spent in the central area for 5 minutes in the open field. data are expressed as mean ±sem (5 mice/group) * significantly different from control data (p ≤ 0.05). in the light-dark test, the time spent on the light side was significantly longer in the standard and flurbiprofen at 20mg/kg than in the control group. the time spent on the dark side was significantly shorter in the standard than in the control group (figure 2c and figure 2d). fig. 2a. effects of chronic oral administration of flurbiprofen (10,20, and 40 mg/kg) and diazepam(standard) (10 mg/kg) on time spent in the closed arms for 5 minutes in the elevated plus maze. data are expressed as mean ±sem (5 mice/group) * significantly different from control data (p ≤ 0.05). in the open field test, the time spent in the centre area was significantly longer in the standard group and flurbiprofen 20mg/kg than in the control group. the time spent in the centre area was significantly shorter in flurbiprofen at 10 and 40 mg/kg than in the standard group. on the other hand, the time spent on the outer edges was significantly shorter in the standard group than that in the control group (figure 2e and figure 2f). alberifkani nm and naser as, journal of ideas in health (2023); 6(1):814-819 817 fig. 2b. effects of chronic oral administration of flurbiprofen (10,20, and 40 mg/kg) and diazepam (10 mg/kg) on time spent in the open arms for 5 minutes in the elevated plus maze. data are expressed as mean ±sem (5 mice/group). * significantly different from control data (p ≤ 0.05). fig. 2c. effects of chronic oral administration of flurbiprofen (10,20, and 40 mg/kg) and diazepam (10 mg/kg) on time dark side for 5 minutes in the light/dark box. data are expressed as mean ±sem (5 mice/group) * significantly different from control data (p ≤ 0.05). fig. 2d. effects of chronic oral administration of flurbiprofen (10,20, and 40 mg/kg) and diazepam (10 mg/kg) on time light side for 5 minutes in the light/dark box. data are expressed as mean ±sem (5 mice/group) * significantly different from control data (p ≤ 0.05). fig. 2e. effects of chronic oral administration of flurbiprofen (10,20, and 40 mg/kg) and diazepam (10 mg/kg) on time spent in the central area for 5 minutes in the open field. data are expressed as mean ±sem (5 mice/group) * significantly different from control data (p ≤ 0.05). fig. 2f. effects of chronic oral administration of flurbiprofen (10,20, and 40 mg/kg) and diazepam (10 mg/kg) on time spent in the central area for 5 minutes in the open field. data are expressed as mean ±sem (5 mice/group) * significantly different from control data (p ≤ 0.05). discussion the present study showed that flurbiprofen has an anxiolyticlike effect, likely because of its anti-inflammatory properties [16]. flurbiprofen at 20 mg/kg has an anxiolytic effect in acute treatment and, to a lesser extent, in chronic treatment. the inflammatory process, free radicals, and the level of inflammatory mediators are among the main etiology of depression and anxieties [16-17]. there are multiple studies on anxiety and depression in propionic acids from nsaids. one study revealed that ibuprofen failed to prevent brain disease in a lupus neuropsychiatric mouse model, in which chronic ibuprofen administration could not regularize the status of immunity, cognitive and behavioral actions, and brain mass in lupus-prone murine [18]. another study revealed that ibuprofen could not counteract interferon-induced depression in a rat model, and locomotor activity was only impaired with a high dose of ibuprofen (75 mg/kg); thus, it was not evaluated further. after treatment with interferon, anxiety manifestations, and substantial alterations were observed throughout the splash test, and ibuprofen significantly reduced immobility time in the forced swim test. in contrast, grooming time increased when compared to the single doses of celecoxib and indomethacin, ibuprofen exhibited superior antidepressant properties when given with interferon [19]. another study found that pretreatment with meloxicam or ketoprofen-treated nociception increased pge2 levels in the spinal cord and increased escape behavior time during forced swimming by 95% compared to the control group. furthermore, it was found that plasma corticosterone levels were elevated by 97% in rats exposed to stress. in comparison, cox-inhibiting drugs reduced the plasma corticosterone level to 84% compared to the control group, which indicates the possibility of anxiolytic effects of nonsteroidal anti-inflammatory drugs, and supports the use of (nsaids) for chronic pain caused by chronic depression and anxiety [20]. another study revealed that the co-treatment of aspirin with fluoxetine could reverse the stress-induced escape deficit later a week of treatment and that the frequency of the antidepressant-like influence of aspirin was dose-dependent [21]. our findings agree with a study in which mice were administered aluminum chloride to induce anxiety and tested in an open field. blanchard et al. [22] initially discussed, an animal's hesitancy to move from one location to another or into the central region of the test reflects elevated anxiety levels in rodents to examine the effects of ibuprofen on anxiety, locomotion, and exploratory behavior in treated mice. in alberifkani nm and naser as, journal of ideas in health (2023); 6(1):814-819 818 ibuprofen-treated mice, the effects of aluminum chloride treatment were reversed, and there was a reduction in state anxiety. according to the findings of this study, ibuprofen may have a possible treatment effect in the treatment of anxiety associated with neurodegenerative disorders [23]. this study had some limitations. first, we did not use all of the trials for anxiety assessment. second, this was an in vivo study. we did not do in vitro experiments that pinpoint the exact mechanism of action against anxiety, which merits further research. conclusion in conclusion, the administration of 20 mg of flurbiprofen reversed the anxiety-induced condition in three anxiety tests after 1 h of treatment and after 15 days of treatment. the other doses of flurbiprofen were not effective as a treatment for anxiety. therefore, neither all treatment regimens nor all doses of flurbiprofen are effective in producing the anxiolytic-like effect in a murine model. abbreviation epm: elevated plus maze; ldt: light-dark box test; oft: open-field test; ssri: selective serotonin reuptake inhibitor; nsaids: non-steroidal anti-inflammatory drugs declaration acknowledgment the authors thank the deanship of the college of veterinary medicine at the university of mosul and the presidency of physiology, biochemistry, and pharmacology department for their support in providing materials and special supplies for this study. funding the university of duhok, duhok, krg, north of iraq, supported the study. availability of data and materials data will be available by emailing ahmadphd0@gmail.com authors’ contributions ahmed salah naser and naktal albrefkanie contributed equally in the study concept, design, writing, evaluating, proofreading. approval of the final manuscript are shared by all authors. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the procedures used were in accordance with european legislation on the use and care of laboratory animals (eu directive 2010/63/eu) and authorized by the department of physiology, biochemistry, and pharmacology, university of mosul (2022-08-15/1470). every effort was made to reduce the number of animals used and their suffering. consent for publication not applicable competing interest the authors declare that they have no competing interest. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of physiology, biochemistry, and pharmacology, college of veterinary medicine, university of mosul, mosul, iraq. drnaktal.alberifki@gmail.com https://orcid.org/00000002-3491-5351 2department of physiology, biochemistry, and pharmacology, college of veterinary medicine, university of mosul, mosul, iraq. ahmadphd0@gmail.com https://orcid.org/0000-00031618-0678 article info received: 20 december 2022 accepted: 22 february 2023 published: 22 march 2023 references 1. li w, zhao n, yan x, et al. the prevalence of depressive and anxiety symptoms and their associations with quality of life among clinically stable older patients with psychiatric disorders during the covid-19 pandemic. transl psychiatry. 2021;11(1):1-8. doi: 10.1038/s41398021-01196-y 2. steimer t. the biology of fear-and anxiety-related behaviors. dialogues clin neurosci. 2002 sep;4(3):23149. doi: 10.31887/dcns.2002.4.3/tsteimer. 3. hussein rm, mohamed wr, omar ha. a neuroprotective role of kaempferol against chlorpyrifos-induced oxidative stress and memory deficits in rats via gsk3β-nrf2 signaling pathway. pestic biochem physiol. 2018; 152:2937. doi: 10.1016/j.pestbp.2018.08.008 4. russo e, leo a, crupi r, et al. everolimus improves memory and learning while worsening depressive and anxiety-like behavior in an animal model of depression. j psychiatr res. 2016; 78:1-10. doi: 10.1016/j.jpsychires.2016.03.008 5. montgomery sa, judge r. treatment of depression with associated anxiety: comparisons of tricyclic antidepressants and selective serotonin reuptake inhibitors. acta psychiatr scand. 2000;101:9-16. doi: 10.1111/j.1600-0447.2000.tb10943.x 6. dunner dl, ishiki d, avery dh, wilson lg, hyde ts. effect of alprazolam and diazepam on anxiety and panic attacks in panic disorder: a controlled study. j clin psychiatry. 1986 sep;47(9):458-60. pmid: 2875064 7. hayes pe, schulz sc. beta-blockers in anxiety disorders. j affect disord. 1987;13(2):119-130. doi: 10.1016/01650327(87)90017-6 8. mealy k, ngeh n, gillen p, fitzpatrick g, keane fb, tanner a. propranolol reduces the anxiety associated with day case surgery. eur j surgery= acta chir. 1996;162(1):11-14. pmid: 8679756 alberifkani nm and naser as, journal of ideas in health (2023); 6(1):814-819 819 9. bay-richter c, wegener g. antidepressant effects of nsaids in rodent models of depression—a systematic review. front pharmacol. 2022;13. doi: 10.3389/fphar.2022.909981 10. governa p, cusi mg, borgonetti v, et al. beyond the biological effect of a chemically characterized poplar propolis: antibacterial and antiviral activity and comparison with flurbiprofen in cytokines release by lpsstimulated human mononuclear cells. biomedicines. 2019;7(4):73. doi: 10.3390/biomedicines7040073 11. miyakawa t, leiter lm, gerber dj, et al. conditional calcineurin knockout mice exhibit multiple abnormal behaviors related to schizophrenia. proc natl acad sci. 2003;100(15):8987-8992. doi: 10.1073/pnas.1432926100 12. hogg s. a review of the validity and variability of the elevated plus-maze as an animal model of anxiety. pharmacol biochem behav. 1996;54(1):21-30. doi: 10.1016/0091-3057(95)02126-4 13. bourin m, hascoët m. the mouse light/dark box test. eur j pharmacol. 2003;463(1-3):55-65. doi: 10.1016/s00142999(03)01274-3 14. takao k, miyakawa t. light/dark transition test for mice. jove. 1. 2006 nov 13;(1):104. doi: 10.3791/104. 15. prut l, belzung c. the open field as a paradigm to measure the effects of drugs on anxiety-like behaviors: a review. eur j pharmacol. 2003;463(1-3):3-33. doi: 10.1016/s0014-2999(03)01272-x 16. salim s, chugh g, asghar m. inflammation in anxiety. adv protein chem struct biol. 2012; 88:1-25. doi: 10.1016/b978-0-12-398314-5.00001-5 17. sulakhiya k, keshavlal gp, bezbaruah bb, et al. lipopolysaccharide induced anxiety-and depressive-like behaviour in mice are prevented by chronic pre-treatment of esculetin. neurosci lett. 2016;611:106-111. doi: 10.1016/j.neulet.2015.11.031 18. ballok da, ma x, denburg ja, arsenault l, sakic b. ibuprofen fails to prevent brain pathology in a model of neuropsychiatric lupus. j rheumatol. 2006;33(11):21992213. pmcid: pmc1635783 19. mesripour a, shahnooshi s, hajhashemi v. celecoxib, ibuprofen, and indomethacin alleviate depression-like behavior induced by interferon-alfa in mice. j complement integr med. 2020;17(1). doi: 10.1515/jcim-2019-0016 20. guevara c, fernandez ac, cardenas r, suarez-roca h. reduction of spinal pge2 concentrations prevents swim stress-induced thermal hyperalgesia. neurosci lett. 2015; 591:110-114. doi: 10.1016/j.neulet.2015.02.035 21. alboni s, benatti c, capone g, tascedda f, brunello n. neither all anti-inflammatory drugs nor all doses are effective in accelerating the antidepressant-like effect of fluoxetine in an animal model of depression. j affect disord. 2018; 235:124-128. doi: 10.1016/j.jad.2018.04.063 22. blanchard dc, griebel g, blanchard rj. mouse defensive behaviors: pharmacological and behavioral assays for anxiety and panic. neurosci biobehav rev. 2001;25(3):205-218. doi: 10.1016/s0149-7634(01)000094 23. jamil a, mahboob a, ahmed t. ibuprofen targets neuronal pentraxins expresion and improves cognitive function in mouse model of alcl3‑induced neurotoxicity. exp ther med. 2016;11(2):601-606. doi: 10.3892/etm.2015.2928 https://doi.org/10.47108/jidhealth.vol5.iss4.257 karam rs and mohammad fk, journal of ideas in health (2022); 5(4):755-759 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access the use of anesthetics for cesarean section delivery in women in duhok, kurdistan region, iraq rozheen shukry karam1, fouad k. mohammad2* abstract background: limited information is available on anesthetics that are preferred or used by anesthesiologists for cesarean section (cs) delivery in kurdistan region, iraq. this study aims to document general or regional anesthesia use in elective cs deliveries in four major hospitals in duhok province, northern iraq. methods: a retrospective cross-sectional study was conducted from february 2019 to february 2020. the general and regional anesthetics types were recorded for each cs delivery case within the selected hospitals. any adjuvants and medications used with the anesthetics were also recorded. univariate and bivariate analyses were undertaken. the statistically significant was considered at less than 0.05. results: a total of 3420 elective cs deliveries were reported. the mean age ± sd of the pregnant women was 29.6 ± 5.8 years. the anesthetics used in the four hospitals were propofol as a general anesthetic (53.0%) and bupivacaine as a spinal anesthetic (47.0%). the combination of propofol and bupivacaine was used only in 0.3%. the three most frequently and concurrently used adjuvants and medications with propofol or bupivacaine were metoclopramide (90.0%), dexamethasone (80.0%), and ephedrine (73.0%). conclusion: propofol and bupivacaine were the general and spinal anesthesia of choice, respectively, for elective cs delivery in duhok province, northern iraq. some adjuvants and medications were supplemented to improve the quality of anesthesia and the outcome of cs delivery. keywords: bupivacaine, propofol, pregnancy, general anesthesia, spinal anesthesia, iraq background there is a global trend of increasing preference for women to give birth by cesarean section (cs) delivery compared to natural vaginal birth [1-6]. the rate of cs delivery was reported to vary between 1-30% globally [1,4,5]. however, most cs deliveries are elective based on maternal request [4-6]. examples of general anesthetics (ga) used for cs deliveries are isoflurane, sevoflurane, or desflurane with or without nitrous oxide, propofol, thiopental, or ketamine as inducing agents [2,3,7,8]. local anesthetics (la) such as bupivacaine, lidocaine, ropivacaine, 2-chloroprocaine, and tetracaine are used for spinal or epidural anesthesia [2,7,8]. a combination of spinal-epidural anesthetics can be used as well [2,7]. the choice of either ga or la in cs delivery depends on several factors including, but not limited to, the evaluation of the case by the anesthesiologist and the surgeon, the plan of the anesthetic technique, maternal choice, the level of urgency, presence of contraindications for a particular agent or anesthetic technique and the skill of the anesthesiologist [2,6]. an overview of the use of anesthetics for cs delivery indicated that la, when no contraindications exist, is preferred over ga in elective cases in developing countries [8]. a study conducted in zimbabwe showed that spinal anesthesia use for cs delivery constituted 81.0% vs. 19.0% for ga [9]. similarly, the preferred anesthetic technique in turkey was regional anesthesia over the ga [7,10]. however, in an opinion-based survey among anesthesiologists working in the kurdistan regionnorthern iraq, propofol was the drug of choice (79.0%) to induce ga. moreover, their daily preference for regional anesthesia was only 34.0% compared to 48.9% for ga [11]. furthermore, the latter study did not include the use of ga or la in cases of cs delivery. in light of this apparent controversy regarding the nationally preferred anesthetics used in cs delivery and those of other countries, the present study was undertaken to examine ___________________________________________________ fouadmohammad@yahoo.com 1department of physiology, biochemistry and pharmacology, college of veterinary medicine, university of mosul, mosul, iraq full list of author information is available at the end of the article 10.47108/jidhealth.vol5.iss4.257 http://www.jidhealth.com/ karam rs and mohammad fk, journal of ideas in health (2022); 5(4):755-759 756 the records of using ga or la in elective cs delivery in four major hospitals in duhok, northern iraq. methods study design a retrogressive cross-sectional descriptive study was conducted between february 2019 to february 2020 at the college of pharmacy, university of duhok, northern iraq. the record of elective cs delivery was reviewed in three private hospitals (sheelan hospital, vazheen hospital, and wan global hospital) and one public hospital (gynecology and obstetrics governmental hospital) located in duhok city, north of iraq. inclusion and exclusion criteria only elective cs deliveries performed under ga or la individually or in combination were included in the study. any adjuvants and medications used with the anesthetics were also recorded. cases of cs delivery that have been done because of emergency conditions or those of multiple pregnancies were excluded. the procedure of data collection a universal sampling technique was recruited to collect the data from conveniently selected four hospitals. a cs delivery was considered an elective when the cs operation was previously scheduled for hospital admission and surgery on the mother's request and approval of the hospital's surgeon and anesthesiologist. the subjects' demographic data (age) were obtained from the hospital records. the names of the hospitals were coded as a, b, c, and d, not in consecutive order, to protect the hospital's anonymity as the data source. the hospital records were also examined for any complications during cs delivery or anesthesia. statistical analysis all the data were collected and statistically analyzed using the statistical software program “past 4.09” (https://www.downloadcrew.com/article/34304/past). the categorical variables were expressed as frequencies and percentages. any age differences among the women in the hospitals were statistically analyzed by one-way analysis of variance (anova) followed by the post hoc tukey’s test. whenever applicable, the chi-squared test was applied using past 4.09 software on the frequencies using propofol, bupivacaine, or both. the z score calculator “https://www.socscistatistics.com/tests/ztest/default.aspx” was used to calculate the z score for two population proportions (percentages of anesthetics used). the level of statistical significance was p < 0.05. results sociodemographic characteristics a total of 3420 elective cs delivery were performed in oneyear (range 155 to 1437). the mean age ± sd of the pregnant women from the three hospitals was 29.6 ± 5.8 years. the anova with post hoc tukey’s test revealed no statistical differences among the included hospitals. the number of elective cs deliveries recorded in each hospital individually under the use of propofol, bupivacaine, or both varied significantly (chi-squared test, p < 0.05). moreover, the anesthetics used in the four hospitals, propofol, and bupivacaine, were significantly different (z test, p < 0.05). propofol is used as a general anesthetic in about 52.8% compared to bupivacaine, used in 47.0% as a spinal anesthesia, respectively. a combination of two anesthetics was reported only in 0.3% of the cs deliveries (table 1). table 1. frequency of the using propofol or bupivacaine for elective cesarean section (cs) delivery in women within four hospitals in duhok, krg, northern iraq, during february 2019-february 2020 (n=3420) hospital code mean age + sd (years) cs frequency* propofol bupivacaine propofol + bupivacaine n % n % no. % a 30.3 + 5.3 969 5 0.5 964 99.5 0 0 b 29.2 + 6.0 1437 1296 90.2 139 9.7 2 0.1 c 29.3 + 6.1 155 109 70.3 46 29.3 0 0 d na 859 397 46.2 454 52.9 8 0.9 total 29.6 + 5.8 3420 1807 52.8** 1603 46.9** 10 0.3** na: age records were not complete or consistent. * the frequencies of cs delivery after propofol and bupivacaine anesthesia or both were significantly different among the hospitals, chi-squared test, p < 0.05. ** the percentages differed significantly from each other, z test, p < 0.05. there were no significant age differences among the women in the hospitals, anova followed by tukey’s test, p > 0.05. adjuvants and medications concurrently used with propofol or bupivacaine are listed in table 2. they were used according to the individual needs of every cs delivery case. the three most frequently used adjuvants and medications were metoclopramide (90.0%), dexamethasone (80.0%), and ephedrine (73.0%) (figure 1). the hospital records did not include any cs delivery complications or anesthesia complications. discussion the findings of this study showed that the use of ga with propofol was the most common procedure applied for elective cs deliveries. for maintenance anesthesia, isoflurane and halothane were reported because of their availability in local hospitals. abdulkader et al. [11] reported similar practices among surgeons and anesthesiologists surveyed in duhok city, north of iraq. karam rs and mohammad fk, journal of ideas in health (2022); 5(4):755-759 757 the choice of anesthetic usually depends on the preference of the patient and the decision of the surgeon/anesthesiologist. furthermore, several other factors might determine the type of anesthetics, such as the demographic characteristics of the patients, anesthetic availability, professional skills, level of training, the clinical experience of the anesthesiologists, and whether the cs delivery is elective or not [2,7,8,12,13]. table 2: adjuvants and medications used with general and spinal anesthesia for elective cesarean section delivery in women within four hospitals in duhok, krg, northern iraq during february 2019-february 2020 adjuvants and other medications used with general anesthesia amoxicillin, amikacin, atracurium, atropine, calcium gluconate, ceftriaxone, cefotaxime, chlorpheniramine maleate, dexamethasone, diclofenac sodium, ephedrine, ergotamine, fentanyl, fluids (ringer lactate and/or normal saline), gentamicin, halothane, hydrocortisone, ketamine, magnesium, metoclopramide, metronidazole, midazolam, neostigmine, oxytocin, paracetamol, pentothal, prostaglandin, ranitidine, rivastigmine, rocuronium, tranexamic acid, tramadol. adjuvants and other medications used with spinal anesthesia adrenaline, amoxicillin, ampicillin, aminophylline, ceftriaxone, cefotaxime, dexamethasone, diclofenac sodium, ephedrine, ergotamine, fentanyl, fluids (ringer lactate and/or normal saline), furosemide, gentamicin, hydrocortisone, ketamine, lidocaine, metronidazole, metoclopramide, midazolam, oxytocin, paracetamol, pentothal, penicillin, propofol, ranitidine, tramadol, tranexamic acid a unique finding that appeared from the present study, which might impact the decision for future cs delivery in local hospitals, was the fact that all the hospitals under study have broadly used propofol for the induction of ga but maintained by isoflurane or sevoflurane and the la bupivacaine was used for spinal anesthesia; however, the combination of ga and la was minimal (0.3%). other than the clinical experience in the procedures [2,6,11], the anesthesiologists and surgeons involved in cs delivery prefer propofol because of its safety records, fast recovery, and antiemetic effects with no complications reported during the cs operation [14-17]. moreover, maintaining patent airways, ease of ventilation, and reduced cardiovascular complications are advantages reported with the use of propofol as ga for cs delivery in many other countries [2,7,15-17]. the same is equally true for the use of bupivacaine in cs delivery which showed excellent safety records [18,19]. however, in this context, it was cautioned that in the absence of a medical indication, elective cs delivery might be associated with higher risks of asthma and allergic rhinitis in children [20]. anesthesia for cs delivery could be either ga, regional anesthesia (spinal or epidural), or a combination of spinal-epidural anesthesia [2,7,8,13]. however, international studies indicated that la was preferred over ga in cs delivery [7-10]. previous studies commented that ga is beneficial when la is subjected to maternal rejection or when blood clot problems exist. moreover, when there are contraindications for la, such as previous spinal injuries or deformities, ga maintains patent airways with controlled ventilation [1-4,12-15]. on the other hand, la is safe for the baby, easy to perform when proper training is available, avoids airways with lesser risks of gastric content aspiration, and patients are less likely to need a blood transfusion during cs delivery [1-4,14-16]. in the present study, there was no recorded case of using epidural anesthesia for elective cs delivery because the procedure has a prolonged onset of action, and it was considered a timeconsuming technique that was not preferred by the surgeons [2]. adjuvant drugs or therapy are used during surgical operations along with anesthesia in order to produce synergistic action and enhance the safety and quality of anesthesia. adjuvant drugs shorten the onset of action of anesthetics, enhance the duration of analgesic effect, improve the quality of analgesia, and reduce potential adverse effects of anesthesia [4,20,21]. the most frequently used drug intraoperatively in the surveyed hospitals of duhok was metoclopramide 1069 (90.0%), an antiemetic drug [23]. the use of other medications usually depends on the individual needs of each elective cs delivery case [2,4,20-23]. unlike our study, abdulkader et al. [11] surveyed the preferences of the anesthesiologist and their opinions (no patients were involved). hence, the results of our study might further add and support the findings of abdulkader et al. [11]. the descriptive cross-section design does not allow the causeeffect relationship; a lack of patient information in some hospital records; the study was conducted in one governorate, which affected the generalizability of its findings; however, future studies should consider this option. conclusion propofol and bupivacaine were the ga and spinal anesthesia of choice for the elective cs delivery in duhok, krg, northern iraq. the propofol and bupivacaine were supplemented with some adjuvants and medications to improve the quality of anesthesia and the outcome of cs delivery. abbreviation cs: cesarean section; ga: general anesthesia; la: local anesthesia; sd: standard deviation; anova: analysis of variance; sd: standard deviation declaration acknowledgment the authors greatly acknowledge the help of the hospitals in providing access to their cs delivery records. the authors thank the college of pharmacy for supporting and providing research facilities. this report represents a portion of a thesis to be submitted by the first author to the university of duhok, krg, north of iraq, in partial fulfillment of the requirements for an msc degree in clinical pharmacology. funding the university of duhok, duhok, krg, north of iraq, supported the study. availability of data and materials data will be available by emailing rozheen.karam@gmail.com karam rs and mohammad fk, journal of ideas in health (2022); 5(4):755-759 758 authors’ contributions rozheen shukry karam (rsk) contributed to the concept, design, literature search, data analysis, data acquisition, manuscript writing, editing, and reviewing. fouad k. mohammad (fkm) conceptualized and supervised the study, shared in literature search and statistical analyses, and drafted the manuscript all authors have read and approved the final manuscript. figure 1: frequency (expressed as %) of the use of medications (adjuvants and other therapeutic agents) during cesarean section delivery in women within four hospitals in duhok, krg, iraq during february 2019-february 2020 ethics approval and consent to participate we conducted the research following the declaration of helsinki. the protocol was part of the master (msc) research work of the first author and approved by committee of postgraduate studies in the college of pharmacy, university of duhok, krg, iraq (no. 470, october 6, 2021) and from the local research ethics committee at the duhok directorate general of health, duhok, krg, iraq (no. 10112021-11-17, november 10, 2021). the hospitals' administrations have also approved conducting the study and having access to their records regarding the use of types of anesthetics and other medications for elective cs delivery. consent for publication not applicable competing interest the authors declare that they have no competing interest. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of pharmacology, college of pharmacy, university of duhok, krg, iraq. 2department of physiology, biochemistry and pharmacology, college of veterinary medicine, university of mosul, mosul, iraq. article info received: 05 october 2022 accepted: 08 november 2022 published: 30 november 2022 references 1. al-husban n, elmuhtaseb ms, al-husban h, nabhan m, abuhalaweh h, alkhatib ym, yousef m, aloran b, elyyan y, alghazo a. anesthesia for cesarean section: retrospective comparative study. int j womens health. 2021 feb 2; 13:141-152. doi: 10.2147/ijwh.s292434. 2. iddrisu m, khan zh. anesthesia for cesarean delivery: general or regional anesthesia—a systematic review. ainshams j anesthesiol. 2021; 13:1. https://doi.org/10.1186/s42077-020-00121-7 3. kim wh, hur m, park sk, yoo s, lim t, yoon hk, kim jt, bahk jh. comparison between general, spinal, epidural, and combined spinal-epidural anesthesia for cesarean delivery: a network meta-analysis. int j obstet anesth. 2019 feb; 37:5-15. doi: 10.1016/j.ijoa.2018.09.012. 4. ghaffari s, dehghanpisheh l, tavakkoli f, mahmoudi h. the effect of spinal versus general anesthesia on quality of life in women undergoing cesarean delivery on maternal request. cureus. 2018 dec 11;10(12): e3715. doi: 10.7759/cureus.3715. 5. betran ap, ye j, moller ab, souza jp, zhang j. trends and projections of caesarean section rates: global and 0.1% 0.1% 0.1% 0.1% 0.1% 0.2% 0.2% 0.2% 0.3% 0.4% 0.4% 1% 1% 1% 1% 3% 6% 6% 6% 6% 6% 6% 7% 7% 7% 9% 9% 10% 10% 11% 13% 14% 15% 23% 25% 30% 73% 80% 90% 0.0% 20.0% 40.0% 60.0% 80.0%100.0% calcium gluconate chlorpheniramine… prostaglandin amikacin furosemide propofol ranitidine pentothal atropine neostigmine gentamycin tranexamic acid midazolam cefotaxime fentanyl ergotamine metronidazole oxytocin dexamethasone frequency karam rs and mohammad fk, journal of ideas in health (2022); 5(4):755-759 759 regional estimates. bmj glob health. 2021 jun;6(6): e005671. doi: 10.1136/bmjgh-2021-005671. 6. the scottish government. the best start: review of caesarean section rates in scotland, 2021. https://www.gov.scot/publications/best-start-reviewcaesarean-section-rates-scotland/pages/3/ 7. aksoy m, aksoy an, dostbil a, çelik mg, ahıskalıoğlu a. anaesthesia techniques for caesarean operations: retrospective analysis of last decade. turk j anaesthesiol reanim. 2014 jun;42(3):128-32. doi: 10.5152/tjar.2014.80774. 8. rollins m, lucero j. overview of anesthetic considerations for cesarean delivery. br med bull. 2012; 101:105-25. doi: 10.1093/bmb/ldr050. 9. lonnée ha, madzimbamuto f, erlandsen orm, vassenden a, chikumba e, dimba r, myhre ak, ray s. anesthesia for cesarean delivery: a cross-sectional survey of provincial, district, and mission hospitals in zimbabwe. anesth analg. 2018 jun;126(6):2056-2064. doi: 10.1213/ane.0000000000002733. 10. kepekçi ab. choice of anesthesia method in cesarean delivery: communication between anesthesiologist and obstetrician. j contemp med. 2019;9(1):27-31. doi: 10.16899/gopctd.512719. 11. abdulkader ma, mohammed hn, salih hm. anesthetic for cesarean section: the current practice in kurdistan region-iraq. med j bab. 2017;14(1):8-19. https://www.iasj.net/iasj/download/716763e3f76f21a9 12. devroe s, van de velde m, rex s. general anesthesia for caesarean section. curr opin anaesthesiol. 2015 jun;28(3):240-6. doi: 10.1097/aco.0000000000000185. 13. choi su. general anesthesia for cesarean section: are we doing it well? anesth pain med (seoul). 2022 jul;17(3):256-261. doi: 10.17085/apm.22196. epub 2022 jul 26. 14. murdoch h, scrutton m, laxton ch. choice of anaesthetic agents for caesarean section: a uk survey of current practice. int j obstet anesth. 2013 jan;22(1):31-5. doi: 10.1016/j.ijoa.2012.09.001. 15. tafish r, el aish kia, madi w. general versus spinal anaesthesia for caesarean section: a quasi-controlled trial. lancet. 2018 feb 21;391 suppl 2: s33. doi: 10.1016/s0140-6736(18)30399-4. 16. hu l, pan j, zhang s, yu j, he k, shu s, wang r. propofol in combination with remifentanil for cesarean section: placental transfer and effect on mothers and newborns at different induction to delivery intervals. taiwan j obstet gynecol. 2017 aug;56(4):521-526. doi: 10.1016/j.tjog.2016.09.010. 17. odor pm, bampoe s, moonesinghe sr, andrade j, pandit jj, lucas dn; pan-london perioperative audit and research network (plan), for the dreamy investigators group. general anaesthetic and airway management practice for obstetric surgery in england: a prospective, multicentre observational study. anaesthesia. 2021 apr;76(4):460-471. doi: 10.1111/anae.15250. 18. atef h, el-kasaby a, omera m, badr m. optimal dose of hyperbaric bupivacaine 0.5% for unilateral spinal anesthesia during diagnostic knee arthroscopy. local reg anesth. 2010; 3:85-91. doi: 10.2147/lra.s11815. 19. ferrarezi wpp, braga afa, ferreira vb, mendes sq, brandão mjn, braga fsds, carvalho vh. spinal anesthesia for elective cesarean section. bupivacaine associated with different doses of fentanyl: randomized clinical trial. braz j anesthesiol. 2021 nov-dec;71(6):642648. doi: 10.1016/j.bjane.2021.03.030. 20. chu s, zhang y, jiang y, sun w, zhu q, wang b, jiang f, zhang j. cesarean section without medical indication and risks of childhood allergic disorder, attenuated by breastfeeding. sci rep. 2017 aug 29;7(1):9762. doi: 10.1038/s41598-017-10206-3. 21. prabhakar a, lambert t, kaye rj, gaignard sm, ragusa j, wheat s, moll v, cornett em, urman rd, kaye ad. adjuvants in clinical regional anesthesia practice: a comprehensive review. best pract res clin anaesthesiol. 2019 dec;33(4):415-423. doi: 10.1016/j.bpa.2019.06.001. 22. hung ty, huang ys, lin yc. maternal and neonatal outcomes with the addition of intrathecal midazolam as an adjuvant to spinal anesthesia in cesarean delivery: a systematic review and meta-analysis of randomized controlled trials. j clin anesth. 2022 sep; 80:110786. doi: 10.1016/j.jclinane.2022. 35461171. 23. mokini z, genocchio v, forget p, petrini f. metoclopramide and propofol to prevent nausea and vomiting during cesarean section under spinal anesthesia: a randomized, placebo-controlled, doubleblind trial. j clin med. 2021 dec 26;11(1):110. doi: 10.3390/jcm11010110. https://doi.org/10.47108/jidhealth.vol4.iss4.168 saha s, saha s, journal of ideas in health 2021;4(4):573-580 © the author(s). 2021 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access underreporting of treatment outcomes in hospitalized covid-19 infected diabetes patients: a systematic review, meta-analysis, and meta-regression sumanta saha*1, sujata saha2 abstract background: prolonged inpatient care requirements and time constraints of research and researchers lead to the non-reporting of the treatment outcome of certain covid-19 infected diabetes patients in published manuscripts. this study aims to quantify its global burden. methods: a search for citations addressing the above outcome ensued chiefly in the pubmed, embase, and scopus databases, irrespective of the publication date and geographical region. recruited studies were critically appraised with the national heart, lung, and blood institute's tool. using the random-effects meta-analysis with an exact binomial method and freeman-tukey double arcsine transformation, the overall and subgroup-wise weighted pooled prevalence of the missing treatment outcome data was determined. the heterogeneity and publication bias assessment utilized i2 and chi2 statistics, and funnel plot, and egger's test, respectively. results: ten publications (primarily case series; 70.0%) included in this review sourced data from 6687 covid-19 infected inpatient diabetes patients from asia, australia, europe, and north america. the global pooled prevalence of missing treatment outcome data among these patients was 33.0% (95% ci: 15.0-53.0%; i2: 99.53%; p of chi2: <0.001). it was highest in europe (63%; 95% ci: 61.0-66.0%). publication bias assessment was not suggestive of any small study effect. conclusion: a considerable proportion of crucial prognosis information of hospitalized covid-19 patients with diabetes goes underreported. it increases the risk of biasing the contemporary covid-19-diabetes literature. the reporting of these data in the post-publication era or postponing the primary publication until the availability of all patients' treatment outcome data, when feasible, is recommended to address this enigma. keywords: coronavirus infection, diabetes mellitus, type 1, type 2, systematic review, meta analysis, india background the ongoing coronavirus disease (covid-19) pandemic started in december 2019 in wuhan, china [1–3]. as of april 08, 2021, almost 132 million confirmed cases of covid-19 cases got reported globally, including about 2.8 million deaths [4]. one of the most commonly reported comorbidities determining the morbidity and mortality risk in covid-19 patients is diabetes. deaths among hospitalized covid-19 patients with diabetes are substantial (almost 20% globally) and about two times higher than covid-19 patients without diabetes [5]. among hospitalized severe covid-19 patients, deaths are commoner in those with diabetes than those without diabetes [5]. in the past, during the 2009-h1n1 pandemic influenza and the middle east respiratory syndrome, diabetes was also a crucial determinant of death [6, 7]. the poor disease outcome in covid-19 patients with diabetes is plausibly attributable to the damage of pancreatic islet cells caused by sars-cov-2 entry into the host cell via the angiotensin-converting enzyme-2 receptor [8–10]. presently, little is known about the clinical outcomes and treatments of inpatient covid-19 infected diabetes patients, and we must depend heavily on first-hand observational and case series studies for it. the entire covid19 infected inpatient diabetes patient population's treatment outcome data (e.g., morbidity, mortality, recovery, and discharge) remain unavailable in some of these studies since some of these patients remain hospitalized when these studies' manuscripts are prepared or published. such non-reporting may be due to the time constraints imposed by the study funder, the end of the pre-defined follow-up period of the study, and referral of severe covid-19 cases to different health facilities ___________________________________________________ sumanta.saha@uq.net.au 1department of community medicine, r. g. kar medical college, kolkata, india. full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol4.iss4.168 http://www.jidhealth.com/ saha s, saha s, journal of ideas in health (2021); 4(4):573-580 574 making their tracking difficult or impossible for the primary investigators. quantifying the burden of such patients whose prognostic data go missing from the contemporary covid-19 literature is crucial to ensure the comprehensiveness and rigor of this literature. this systematic review and meta-analysis aim to quantify this burden by estimating its pooled prevalence. methods registration this systematic review is pre-registered in the prospero (crd42020197319) [11] and reported here according to the preferred reporting items for systematic review and metaanalysis (prisma)2020 statement (supplementary table s1) [12]. a pre-published protocol does not exist. inclusion criteria we included studies that fulfilled the following inclusion criteria: 1. study population: hospitalized covid-19 infected diabetes patients of any age or gender. 2. study design: observational studies, including case series conducted in any country. 3. outcome: the outcome of interest is the number of patients whose post-hospitalization treatment outcome (i.e., discharge from hospital or death) was not reported in the published manuscript. exclusion criteria 1. studies conducted on pregnant patients. 2. experimental study designs, case reports, letters, and editorials. 3. studies that were reporting of treatment outcomes of its entire sample population. data source: we searched the title and abstract of eligible citations published in the english language in three electronic databases (pubmed, embase, and scopus) irrespective of the publication date or geographical boundary. subsequent search terms were used to search the pubmed database: "diabetes mellitus, type 2"(mesh major topic) or "diabetes mellitus, type 1"(mesh major topic) or "diabetes mellitus"(mesh major topic) and "coronavirus infections"(mesh major topic) and diabetes and sars-cov-2 or coronavirus or covid-19 not "middle east respiratory syndrome" not mers. table s2 provides the detailed search strategy used to search different databases. additional searches ensued in the bibliography of the articles included in this review and the 'google' search engine. study selection and data abstraction after uploading the retrieved citations from the database search and additional searches to a reference management software, the review authors independently skimmed through it to identify dubious and seemingly eligible articles for full-text reading and subsequently finalized the list of articles to be reviewed. data abstraction from the studies included in this review happened for the following components the nation and continent of the conduct of the study, follow-up duration of the study, the total number of inpatient covid-19 infected diabetes patients, the total number of these patients whose prognosis data did not get reported in the article, type of diabetes detected in the study population, diagnostic guideline or criteria used to diagnose diabetes, diagnostic techniques used to ascertain covid-19 infection, the average age of the study population, and the study design. these details are presented in. a tabular form. pre-piloted data abstraction sheets were used to abstract the data. risk of bias evaluation the reviewed studies' risk of bias assessment transpired via the national heart, lung, and blood institute's tool.[13] the 'yes' or 'no' categorization followed for each study's respective risk of bias components, based on if a study did or did not address this, respectively. if such judgment was not possible, 'cannot determine' or 'not applicable' labeling ensued based on whichever was the best applicable categorization. review authors’ role the review authors conducted the study selection, data abstraction, and critical appraisal independently, and resolved any conflict in an opinion by discussion, and did not require a third-party consultation. meta-analysis from published manuscripts, estimation of the pooled weighted prevalence of missing treatment outcome data of hospitalized covid-19 infected diabetes patients ensued by random effect (dersimonian and laird) meta-analysis. the 95% confidence interval (ci) and variance stabilization transpired using the exact binomial method and freeman-tukey double arcsine transformation, respectively. heterogeneity estimation happened by i2 statistics (at values 25, 50, and 75% heterogeneity were categorized as low, moderate, and high, respectively) [14] and p-value of chi2 statistics (statistically significant at p<0.1). the meta-analysis findings are presented using a forest plot and table. subgroup analysis the subgroup-wise weighted prevalence estimation of missing prognosis data transpired for continents, countries, diabetes types, and sample size (≤100 versus >100). publication bias small study effects got evaluated using visually and statistically by funnel plots and egger’s test, respectively. heterogeneity assessment a univariate meta-regression analysis (random-effect) ensued for each of the above-stated subgrouping variables to explain heterogeneity, and its statistical significance was determined at p<0.1. as none of these models produced a statistically significant outcome, we did not include these variables in an adjusted meta-regression model. sensitivity analysis we repeated the overall pooled prevalence meta-analysis by dropping a study each time to see how each study contributed to the meta-analysis model. stata statistical software (version 16) of statacorp, college station, texas, usa, and metaprop [15] package was used for the analysis. saha s, saha s, journal of ideas in health (2021); 4(4):573-580 575 results scope of this review the database search and additional searches retrieved altogether 996 citations, of which 779 records got skimmed following the elimination of duplicates. out of the 54 articles requiring fulltext reading, ten publications published in 2020 got included in this review (figure 1) [16–25]. the primary reason for excluding papers read in full-text was non-reporting the outcome data of interest (61.0%; n=27). the last date of the search was 19-nov-2020. majority of the recruited studies were case series (70.0%) [16–22], followed by cross-sectional studies (20.0%) [23, 24] and retrospective cohort study (10.0%) [25]. the data of the recruited studies came from 6687 covid-19 infected inpatient diabetes patients from four continents (asia, australia, europe, and north america). most of these patients belonged to the us (76.8%; n=5137). about 20.7% (n=1386) of the hospitalized covid-19 patients with diabetes had either type 1 or 2 diabetes, another 1.3% (n=87) had type 2 diabetes, and for the remaining study participants, the exact diabetes type remains unknown. the salient features of the reviewed studies got presented in table 1. figure 1. the prisma 2020 flow diagram [12] risk of bias evaluation upon critical appraisal, the case series were of fair quality [16– 22], whereas the remaining study types were of good quality [23–25]. table 2 depicts the study design-specific risk of bias assessment for the respective studies. meta-analysis findings the overall pooled weighted prevalence of inpatient covid-19 infected diabetes patients whose outcome data did not get reported in covid-19 literature was 33.0% (95% ci: 15.0 53.0%; i2: 99.53%; p of chi2: <0.001) (figure 2). subgroupwise, among the four continents, it was highest in studies conducted in europe (63%; 95% ci: 61.0-66.0%). the latter was about three times higher than north america (24%; 95% ci: 3.0-55.0%; i2: 99.75%; p of chi2 <0.001). the proportion of missing treatment outcome data reporting among hospitalized covid-19 infected diabetes patients was marginally higher (5%) in studies with a larger sample size (i.e., n >100) (table 2). records identified from: databases (n = 994) (pubmed: 411; embase: 165; scopus: 418) records removed before the screening: duplicate records removed (n = 215) records screened (n = 779) records excluded (n = 725) reports sought for retrieval (n = 54) reports not retrieved (n = 0) reports assessed for eligibility. (n = 54) reports excluded: (n=44) reasons of exclusion 1. all participants' final outcomes reported (n=3) 2. unclear outcome data (n=27) 3. missing prognosis data not reported (n=8) 4. participant data from the same hospital over an overlapping period (n=5) 5. wrong study population (n=1) records identified from: websites (n = 2) reports assessed for eligibility (n = 2) reports excluded (n=0) studies included in the review. (n = 10) reports of included studies (n = 10) identification of studies via databases and registers identification of studies via other methods id e n ti fi c a ti o n s c r e e n in g in c lu d e d reports sought for retrieval (n = 2) reports not retrieved (n = 0) saha s, saha s, journal of ideas in health (2021); 4(4):573-580 576 publication bias and heterogeneity assessment on visual inspection, the funnel plots appeared somewhat symmetrical (figure 3). the statistical evaluation of the small study effect did not suggest any publication bias (p = 0.617). the univariate meta-regression analysis was not statistically significant for any of the predictors (table 3). sensitivity analysis on iterating the meta-analysis while dropping a study each time, the prevalence varied between 29-37%. discussion altogether, this review included ten articles published in 2020 reporting of 6687 covid-19 infected diabetes patients sourcing from asia, australia, europe, and north america. meta-analysis suggested a considerable underreporting of the treatment outcome data of hospitalized covid-19 infected diabetes patients. this non-reporting was highest in europe. juxtaposing this review's findings with other review articles on covid-19 was beyond the scope due to conceptual novelty and the non-availability of identical review articles. implications while the number of covid-19-diabetes-related publications soars at an unprecedented rate during the ongoing sars-cov-2 pandemic, it is vital to evaluate the completeness and rigor of this novel evidence. in this regard, the findings of this paper may serve as an identifier and reminder of the bulk of crucial prognosis data lost from the contemporary covid-19-diabetes literature due to underreporting and may encourage researchers to take initiatives to ensure completeness of prognosis data reporting among covid-19 infected hospitalized diabetes patients. it emphasizes the plausible constraints of covid-19 research in the context, like limitations in funding or available time to ensure complete reporting of studies. given the substantial burden of underreported prognostic data, policymakers may consider fetching regular updates from the researchers to calibrate the existing policies accordingly. strengths and weaknesses the key strength of this study is its uniqueness in exploring an unexplored area of covid-19-diabetes literature. besides, this review is likely to be comprehensive as its literature search did not get restricted to any date range or geographic boundary. despite these strengths, our systematic review has a few weaknesses. this review could not include potential studies published in the non-english language since the authors are not adept in any other language. besides, our estimates are based on observational study designs, considered to be a weaker source of evidence than randomized clinical trials. conclusion globally, the under-reporting of hospitalized covid-19 infected diabetes patients’ treatment outcomes is substantial. it increases the threat of biasing the expanding covid-19 literature. the researchers may consider releasing such initially non-published prognostic data as adjunct reports in the postpublication period to decrease the risk of such bias. journals might also take the initiatives to permanently identify such updated supplementary reports by providing digital object identifiers and electronically linking these to the parent publication. alternatively, when feasible, the researchers may defer their manuscript drafting until the treatment outcomes of all admitted patients are known. abbreviation ci: confidence interval; covid-19: coronavirus disease; prisma: the preferred reporting items for systematic review and meta-analysis declaration acknowledgment the authors would like to express gratitude to participants who helped in filling the google form. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing sumanta.saha@uq.net.au on receiving a legitimate request authors’ contributions sumanta saha designed and conceptualized this study analyzed and drafted this manuscript's first and final draft. both authors participated in study selection, data abstraction, and critical appraisal. all authors have read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, review articles need no ethics committee approval. consent for publication not applicable competing interest the authors declare that they have no competing interest. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of community medicine, r. g. kar medical college, kolkata, india. 2department of mathematics, mankar college, mankar, india. article info received: 27 august 2021 accepted: 28 october 2021 published: 23 november 2021 saha s, saha s, journal of ideas in health (2021); 4(4):573-580 577 table 1. salient findings of the reviewed studies author, year country continent dates total diabetes admissions missing prognosis data diabetes type diabetes diagnosis method covid-19 diagnosis method mean age of the study population* study design agarwal, 2020[23] us north america march 11 to may 07, 2020 1279 87 unclear clinical modification code or hba1c ≥6.5% rt-pcr mean±sd:18 6 20 (n=1,279) cross-sectional cariou, 2020[16] france europe march 10 to april 10, 2020 1317 877 type 1 and 2 diabetes personal history or hba1c ≥6.5% rt-pcr mean±sd:169.8 ± 13.0 (n=1,317) case series ciceri, 2020[17] italy europe february 25 to march 24, 2020 69 5 type 1 and 2 diabetes unclear rt-pcr median (iqr): 65 (56– 75) (n= 410) case series croft, 2020[18] us north america unclear 5 1 type 2 diabetes unclear rt-pcr mean: 49 years; (n=5) case series liu, 2020[24] china asia january 16, 2020, to march 16, 2020 19 13 unclear guidelines for the prevention and treatment of type 2 diabetes in china (2017 edition) seventh trial version of the novel coronavirus pneumonia diagnosis and treatment guidance dm patients (mean ±sd): non-critical (61.57 ± 12.01), critical (59.36 ± 12.31) cross-sectional marcello, 2020[19] us north america march 05 to april 16 2045 420 unclear unclear rt-pcr median (iqr): 50.2 (36.6-61.9); (n=22176) case series richardson, 2020[20] us north america march 01 to april 04 1808 1051 unclear unclear rt-pcr median (iqr): 63 (5275) (n=5700) case series wu, 2020[21] australia australia march 20 and may 01, 2020 8 2 type 2 diabetes unclear unclear mean±sd: 55±11.9 years (n=8) case series zhang, 2020a[22] china asia january 03 to april 14, 2020 74 10 type 2 diabetes unclear chinese national health committee (version 5). median (iqr): 62(56– 72) (n=74) case series zhang, 2020b[25] china asia january 29 to february 12 63 40 unclear medical history and guidelines for the prevention and control of t2dm in china world health organization interim guidance median (iqr): 65 (57– 71) (n of diabetes patients=63) retrospective cohort study *n is the total sample size for which demographic data are presented in the respective studies abbreviations: iqr: interquartile range; rt-pcr: reverse transcription-polymerase chain reaction; sd: standard deviation saha s, saha s, journal of ideas in health (2021); 4(4):573-580 578 table 2. overall and subgroup weighted prevalence of missing prognosis data among inpatient covid-19 patients with diabetes subgroup category number of studies number of admitted covid19 patients with diabetes number of admitted covid-19 patients with diabetes with missing prognosis data mean prevalence of missing prognosis data in covid-19 infected patients with diabetes heterogeneity measures % 95% ci i2 (%) chi2 (p-value) continent asia 3 156 63 46 11.0-84.0 australia 1 8 2 25 3.0-65.0 europe 2 1386 882 63 61.0-66.0 north america 4 5137 1559 24 3.0-55.0 99.75 <0.001 country australia 1 8 2 25 3.0-65.0 china 3 156 63 46 11.0, 84.0 france 1 1317 877 67 64.0-69.0 italy 1 69 5 7 2.0-16.0 us 4 5137 1559 24 3.0-55.0 99.75 <0.001 diabetes type both type 1 and 2 2 1386 882 63 61.0-66.0 type 2 3 87 13 12 5.0-21.0 unclear 5 5214 1611 40 16.0, 67.0 99.68 <0.001 sample size ≤100 6 238 71 31 8.0-59.0 93.43 <0.001 >100 4 6449 2435 36 11.0-66.0 99.84 <0.001 overall 10 6687 2506 33 15.0-53.0 99.53 <0.001 abbreviation: ci: confidence interval table 3. univariate meta-regression analysis for the prevalence studies on missing prognosis data of covid-19 patients with diabetes. subgroup category univariate model or p-value 95% ci continent north america 1 asia 2.95 0.389 0.17, 50.72 australia 1.17 0.929 0.02, 75.60 europe 1.386 0.812 0.06, 34.95 country us 1 australia 1.17 0.919 0.03, 51.58 china 2.95 0.332 0.22, 39.06 france 7.00 0.243 0.16, 307.79 italy 0.27 0.420 0.01, 12.06 diabetes type unclear 1 both type 1 and 2 0.63 0.707 0.04, 10.47 type 2 0.37 0.376 0.03, 4.37 sample size ≤100 1 >100 1.21 0.841 0.15, 9.86 abbreviations: ci: confidence interval; or: odds ratio saha s, saha s, journal of ideas in health (2021); 4(4):573-580 579 figure 2. forest plot depicting the overall pooled prevalence of missing prognosis data of covid-19 infected diabetes patients; zhang, 2020a[22], zhang, 2020b[25] the diamonds are centered on the summary of the overall and subgroup-wise prevalence estimates, and their widths indicate the corresponding 95% ci. figure 3. funnel plot assessing small study effect on pooled prevalence among hospitalized covid-19 patients with diabetes. saha s, saha s, journal of ideas in health (2021); 4(4):573-580 580 references 1. huang c, wang y, li x, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet 2020; 395: 497–506. 2. zou l, ruan f, huang m, et al. sars-cov-2 viral load in upper respiratory specimens of infected patients. n engl j med 2020; 382: 1177–1179. 3. liu y, yan l-m, wan l, et al. viral dynamics in mild and severe cases of covid-19. lancet infect dis 2020; 20: 656–657. 4. world health organization. who coronavirus (covid-19) dashboard, https://covid19.who.int/ (2021). 5. saha s, al-rifai rh, saha s. diabetes prevalence and mortality in covid-19 patients: a systematic review, meta‐analysis, and meta‐ regression. j diabetes metab disord. epub ahead of print march 31 2021. doi: 10.1007/s40200-021-00779-2. 6. yang jk, feng y, yuan my, et al. plasma glucose levels and diabetes are independent predictors for mortality and morbidity in patients with sars. diabet med 2006; 23: 623–628. 7. alqahtani fy, aleanizy fs, ali el hadi mohamed r, et al. prevalence of comorbidities in cases of middle east respiratory syndrome coronavirus: a retrospective study. epidemiol infect 2019; 147: e35. 8. letko m, marzi a, munster v. functional assessment of cell entry and receptor usage for sars-cov-2 and other lineage b betacoronaviruses. nat microbiol 2020; 5: 562–569. 9. song z, xu y, bao l, et al. from sars to mers, thrusting coronaviruses into the spotlight. viruses; 11. epub ahead of print 2019. doi: 10.3390/v11010059. 10. yang j-k, lin s-s, ji x-j, et al. binding of sars coronavirus to its receptor damages islets and causes acute diabetes. acta diabetol 2010; 47: 193–199. 11. saha s, saha s. a systematic review and meta-analysis of observational studies and case series to determine the prevalence of missing prognosis data in hospitalized covid-19 patients with diabetes mellitus. prospero 2020 crd42020197319, https://www.crd.york.ac.uk/prospero/display_record.php?id=cr d42020197319 (accessed 27 november 2020). 12. page mj, mckenzie je, bossuyt pm, et al. the prisma 2020 statement: an updated guideline for reporting systematic reviews. bmj 2021; n71. 13. study quality assessment tools | national heart, lung, and blood institute (nhlbi), https://www.nhlbi.nih.gov/healthtopics/study-quality-assessment-tools (accessed june 14, 2020). 14. higgins jpt, thompson sg, deeks jj, et al. measuring inconsistency in meta-analyses. bmj 2003; 327: 557–60. 15. nyaga vn, arbyn m, aerts m. metaprop: a stata command to perform meta-analysis of binomial data. arch public heal 2014; 72: 39. 16. cariou b, hadjadj s, wargny m, et al. phenotypic characteristics and prognosis of inpatients with covid-19 and diabetes: the coronado study. diabetologia 2020; 63: 1500–1515. 17. ciceri f, castagna a, rovere-querini p, et al. early predictors of clinical outcomes of covid-19 outbreak in milan, italy. clin immunol 2020; 217: 108509. 18. croft a, bucca a, jansen jh, et al. first-time diabetic ketoacidosis in type 2 diabetics with covid-19 infection: a novel case series. j emerg med. epub ahead of print july 2020. doi: 10.1016/j.jemermed.2020.07.017. 19. marcello rk, dolle j, grami s, et al. characteristics and outcomes of covid-19 patients in new york city’s public hospital system. medrxiv 2020; 2020.05.29.20086645. 20. richardson s, hirsch js, narasimhan m, et al. presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with covid-19 in the new york city area. jama 2020; 323: 2052. 21. wu l, girgis cm, cheung nw. covid‐19 and diabetes: insulin requirements parallel illness severity in critically unwell patients. clin endocrinol (oxf) 2020; 93: 390–393. 22. zhang q, wei y, chen m, et al. clinical analysis of risk factors for severe covid-19 patients with type 2 diabetes. j diabetes complications 2020; 34: 107666. 23. agarwal s, schechter c, southern w, et al. preadmission diabetes-specific risk factors for mortality in hospitalized patients with diabetes and coronavirus disease 2019. diabetes care 2020; 43: 2339–2344. 24. liu d, lan l, luo d, et al. lymphocyte subsets with the lowest decline at baseline and the slow lowest rise during recovery in covid-19 critical illness patients with diabetes mellitus. diabetes res clin pract 2020; 167: 108341. 25. zhang y, cui y, shen m, et al. association of diabetes mellitus with disease severity and prognosis in covid-19: a retrospective cohort study. diabetes res clin pract 2020; 165: 108227. https://doi.org/10.47108/jidhealth.vol6.iss1.265 yılmaz m, arıka i̇, journal of ideas in health 2023;6(1):800-805 © the author(s). 2023 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access zoonoses awareness and health perception in livestock farmers: example of a city in western türkiye muammer yılmaz1*, i̇nci arıkan2 abstract background: zoonotic diseases are on the increase globally. relevant disease awareness practices regarding public knowledge are useful for disease control. this study aimed to evaluate the relationship between individuals' perception of health and awareness of zoonotic diseases. methods: a cross-sectional study was conducted among farmers in the villages of kutahya province, located in the west of türkiye, between february and march 2022. a questionnaire involving questions about the sociodemographic characteristics of the participants in the first part and information about the transmission route of zoonotic diseases and the health perception scale (hps) in the second part was used in this study. mann whitney u and kruskal wallis-h test was performed to compare group medians. p<0.05 was considered statistically significant. results: the mean age of the participants was 44.10±10.73. the mean score of the individuals obtained from the hps was 46.62±4.58. the health perception of the participants was found to be moderate. there was a negative correlation between the control center and precision sub-dimensions and age (respectively r: -0.260, p<0.001; r: 0.320, p<0.001). a positive correlation was found between the importance of health and self-awareness and age (respectively r:0.248, p<0.001; r:0.279, p<0.001). those who knew that zoonoses could be transmitted from sheep, cattle, and humans had higher hps scores than those who did not know (respectively p:0.003; p:0.001; p:0.007). conclusion: increasing health perception in livestock farmers may effectively prevent zoonotic diseases. keywords: zoonotic diseases, zoonosis, awareness, level of knowledge, health perception, türkiye background infections that can be transmitted from animals to humans or from humans to animals under natural conditions are defined as zoonoses. since zoonoses can cause disease in humans and animals, these diseases' effects and management policies interest both areas [1]. it is reported that approximately 60% of human diseases and 75% of infectious diseases are due to zoonotic pathogens [2]. zoonoses can be transmitted directly through the intestinal tract, by biting, inhaled route, skin contact, or indirectly by contact with contaminated clothing, animal barns, and other environmental surfaces [3]. zoonotic diseases are on the increase globally. countries must identify zoonotic diseases according to their geographical locations and economic development levels to develop prevention and control strategies [4,5]. close contact with animals is crucial for transmission. livestock farmers, especially in low-middleincome countries, are at high risk because they are often in environments contaminated with animal feces or by-products [4]. the intensity and type of contact patterns between farm animals and humans affect disease transmission. therefore, it is a priority to identify risk factors, evaluate livestock farmers' behaviors and understand their health perceptions. because the level of knowledge and awareness about the concepts of illness is one factor that determines the perception of health in the person, farmers must know about the transmission, prevention, and control measures of zoonotic diseases [6-8]. after all, health perception can be a factor that directs the individual to receive health care services. zoonoses are a large group of diseases. in the research, awareness, and knowledge levels were discussed separately according to the diseases. in these studies, it was found that the knowledge and awareness levels were not sufficient [9-13]. relevant disease awareness practices regarding public knowledge can help control the disease. increasing awareness will help prevent and control zoonotic diseases as occupational hazards and reduce the incidence of zoonotic diseases in human and animal populations [6]. people need to have a high perception of health to increase and ___________________________________________________ zerkesa@gmail.com 1department of public health, faculty of medicine, kutahya health sciences university, kütahya, türkiye. a full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol6.iss1.265 http://www.jidhealth.com/ yılmaz m, arıka i̇, journal of ideas in health (2023); 6(1):800-805 801 maintain awareness. after all, it is known that people's positive perception of their health status positively affects their beliefs about controlling their future health status and their lifestyle behaviors [14-16]. this study aimed to evaluate livestock farmers' awareness and health perceptions about zoonoses transmitted from animals to humans. methods study design and area this cross-sectional study was conducted with farmers in the villages of kutahya province, located in the west of türkiye, between february and march 2022. agricultural activities are carried out in 34.0% of the forest land covering 47.7% of the area of kutahya province, which has a population of 578640 in general, and 121908 (21.0%) of this population live in villages/towns. the province has 13 districts and 546 villages, with 23287 registered farmers dealing with agriculture and animal husbandry [17]. study population and sample size the sample size was calculated as at least 221considering that the confidence level (90.0%), response rate (50.0%), the margin of error (5.5%), and the design effect (1). a random sample was drawn using a two-stage stratified sampling methodology. in the first stage, the rural area of kutahya was divided into 13 district strata. a total of 16 villages were selected by random sampling method. four villages from the central district and one village from the other thirteen districts were selected. in the second stage, the interviewers made a list of the farmers in the selected villages, and 17 individuals were taken from each cluster. inclusion and exclusion criteria participation in the study was voluntary, so those who did not want to answer the questionnaire were excluded. those over the age of 18 and those who had the mental ability to answer the questionnaire were included in the study. interviews were conducted on face-to-face basis. data collection forms the first part of the questionnaire involved questions about the participants' sociodemographic characteristics. in contrast, the second part involved questions about information about the transmission route of zoonotic diseases and the health perception scale. the demographic information form included questions such as age, gender, number of people living in the house, education level, monthly income, and animal species. in the second part of the questionnaire, participants were asked whether they were ovine -to-human transmission, bovine -tohuman transmission, human-to-human transmission, the barn environment -to-human transmission, livestock milk -to-human transmission, livestock meat -to-human transmission. the questions were answered either “yes” or “no". ovine were taken as sheep and goats. the bovine was taken as cattle, water buffalo, horse, donkey, and mule. health perception scale (hps) the likert-type scale developed by diamond et al. [18], the scale had 15 items and four sub-factors titled "control center", "self-awareness", "precision," and "importance of health". each item in the scale was answered as "strongly agree (5)", "agree (4)", "undecided (3)", "disagree (2)", and "strongly disagree (1)" [18]. negative statements in the scale were scored reversely, with a minimum score of 15 and the maximum score of 75. the turkish validity and reliability of the scale were performed by kadıoğlu and yıldız [19]. the cronbach's alpha value of the scale was 0.70, with the following values for the subgroups: control center 0.90; self-awareness 0.91; precision 0.91; importance of health 0.82 [19]. statistical analysis data were evaluated with spss 21 program (spss inc., chicago, il, usa). mean, standard deviation (sd), median, minimum, and maximum values were provided for measurement data. since data were not normally distributed, mann whitney u and kruskal wallis-h test was performed to compare group medians. spearman's correlation analysis evaluated the relationship between age and hps score. p<0.05 was considered statistically significant. results sociodemographic characteristics and hps score most of the participants (198 (87.2%) of whom were male, and the mean age was 44.10±10.73 (min:25-max:70). while 68.7% of the farmers were bovine breeders, 87.7% reported that the animal farm belonged to them. in comparing the participants' hps scores according to some sociodemographic characteristics, it was determined that the hps score was higher and statistically significant in the group under 40, those with high school or higher education, and those with a higher income than their expenses. the sociodemographic characteristics and hps score evaluation of the participants are presented in table 1. hps score and age the mean score of the individuals obtained from the hps was 46.62±4.58 (min:36-max:70). spearman's correlation analysis results observed between hps and sub-factor score distributions and age are presented in table 2. accordingly, a negative correlation was determined between the control center and precision sub-dimensions and age. as age increased, control center and precision sub-dimension scores decreased. a positive correlation was found between the importance of health and self-awareness sub-dimensions and age. as the age increased, the importance of health and self-awareness sub-dimension scores also increased. hps scores and transmission routes of zoonotic diseases from animals to humans about 61.7% (n:140) of the participants reported that the disease could be transmitted ovine -to-human transmission. 64.8% (n:147) of the participants reported that the disease could be transmitted from the bovine -to-human transmission. while 74.1% (n:168) of the participants reported that diseases could be transmitted to humans by consuming the milk of sick animals, 61.2% (n:139) attributed it to consuming meat. while 57.8% (n:131) of the farmers reported that transmission could be between people, 38.3% (n:87) said that it could be from the barn environment and its surroundings (table 3). yılmaz m, arıka i̇, journal of ideas in health (2023); 6(1):800-805 802 table 1. evaluation of the participants' sociodemographic characteristics and health perception scale (hps) scores (n=227) variables category scores of hps p-value n (%) mean ± sd median (min-max) age ≤ 40 87 (38.3) 47.21±4.61 47 (39-70) 0.036* >40 140 (61.7) 46.26±4.53 45(36-63) gender female 29 (12.8) 46.45±4.95 46(36-61) 0.785* male 198 (87.2) 46.65±4.53 46(39-70) educational level primary school 79 (34.8) 45.57±4.50 45(36-61) 0.001** secondary school 52 (22.9) 45.98±3.52 46(39-59) high school 96 (42.3) 47.83±4.89 47(39-70) income income less than expenses 84 (37.0) 45.20±4.46 44(36-63) 0.001** income equals expense 121 (53.3) 46.98±3.95 47(39-70) income more than the expenses 22 (9.7) 50.05±6.04 50.5(39-61) marital status single / widow/ divorced 36 (15.9) 46.44±5.64 46(36-61) 0.605* married 191 (84.1) 46.65±4.36 46(39-70) family type alone 28 (12.3) 47.68±5.83 48(36-61) 0.295** nuclear family 187 (82.4) 46.49±4.36 46(39-70) extended family 12 (5.3) 46.17±4.74 46(39-59) animal type bovine 156 (68.7) 46.38±4.45 46(39-70) 0.285* ovine 71 (31.3) 47.15±4.84 46(36-61) working status on the farm own working place 199 (87.7) 46.35±4.26 46(36-63) 0.050* employee 28 (12.3) 48.37±5.16 47.5(41-70) *mann whitney u test; **kruskal wallis-h test in comparing the participant's knowledge of the transmission routes of zoonotic diseases from animals to humans and their hps scores, it was determined that the hps score was higher and statistically significant in the group that said it could be transmitted from ovine-bovine/humans to humans. the results are presented in table 3. discussion to the researchers' knowledge, this is the first study to examine the relationship between zoonosis awareness and health perception among livestock farmers in türkiye. in our study, the hps score was higher in the group under 40 years of age, in those with a higher education level, and in those with a higher income is in line with the literature [16]. however, as the age increased, the perception of "control center" and "precision" decreased, while the sub-dimension scores of "self-awareness" and "the importance of health" increased in our study. accordingly, as age increased, the control of determining one's self-confidence in being healthy and able to change health decreased; he could not concentrate his control center on himself and attributed being healthy to factors other than himself [18,19]. similarly, in our study, the "precision" subdimension score for determining whether an individual knows what to do to be healthier decreased with increasing age [18,19]. table 2. the correlation values observed between the score distributions of health perception scale (hps) sub-dimensions and age (n=227) sub-factors of phs scores of hps age mean ± sd median (min-max) r p control centre 14.48±4.16 14(8-23) -0.260 <0.001 precision 12.47±2.92 12(4-20) -0.320 <0.001 importance of health 10.26±3.11 11(4-15) 0.248 <0.001 self-awareness 9.42±2.38 9(5-15) 0.279 <0.001 total 46.62±4.58 46(36-70) -0.199 0.003 factors such as sociodemographic characteristics, economic status, environmental factors, educational status, and occupation may affect the perception of health [14,16,20]. of these, age, income status, and education are particularly seen as crucial variables. as age increases, the perception of health worsens [20]. in our study, the hps score was higher in the group under 40 years of age, in those with a higher education level, and in those with a higher income is in line with the literature [20]. in our study, as the age increased, the perception of "control center" and "precision" decreased. accordingly, as age increased, the control of determining one's self-confidence in being healthy and able to change his health decreased; he could not concentrate his control center on himself and attributed being healthy to factors other than himself. in addition, an individual's knowledge about what to do to be healthier decreases with increasing age [18,19]. therefore, focusing on the "control center" and "precision" sub-dimensions of health perception may effectively prevent diseases in older breeders. also, considering the 46.62-point average of the participants and that 15.75 points can be obtained from the original hps, it can be said that the perception of health is at a moderate level [18,19]. in previous studies conducted by şen et al. [20], and kolaç et al. [21] in türkiye, the mean hps score was found to be 39.84 and 50.18, respectively (20,21). it is thought that this difference is due to the difference in the populations in which the research was conducted. since the livestock sector contains processes within itself and as a result of these processes, its primary production material is living things, processes involve risks, among which diseases animals are exposed to are the most important, as they can cause high depreciation in production values. therefore, farmers' perceptions of risk and health are expected to be high [4,6,22]. yılmaz m, arıka i̇, journal of ideas in health (2023); 6(1):800-805 803 table 3. evaluation of health perception scale (hps) scores with knowledge of the participants about the transmission routes of zoonotic diseases from animals to humans (n=227) transmission ways categories n (%) scores of hps mean ± sd median (min-max) p-value* ovine-to-human transmission no 87(38.3) 45.74±5.31 45(36-70) 0.003 yes 140(61.7) 47.11±4.05 47(40-63) bovine-to-human transmission no 80(35.2) 45.41±4.99 46(36-63) 0.001 yes 147(64.8) 47.28±4.21 47(39-70) human-to-human transmission no 96(42.2) 45.86±4.61 45(36-63) 0.007 yes 131(57.8) 47.18±4.48 47(39-70) the barn environment -to-human transmission no 140(61.7) 45.95±4.83 45(36-63) 0.084 yes 87(38.3) 46.04±4.23 47(39-70) livestock milk-to-human transmission no 59(25.9) 46.00±4.91 45(36-63) 0.062 yes 168(74.1) 46.91±4.40 46(39-70) livestock meat-to-human transmission no 88(38.8) 46.26±4.72 46(36-63) 0.183 yes 139(61.2) 46.84±4.49 47(39-70) *mann whitney u test in their studies, chand et al. [23] and garforth et al. [22] found animal diseases to be one of the essential risks that farmers complained about and reported that their health perceptions about transmission routes were at a moderate level. it should be noted that the results of health perception assessment vary in different studies, which can be attributed to using different scales in different regions and studying with a small sample group. while 4.0% of the farmers in our study had experienced zoonosis, mostly brucella, 15% had received training from health personnel about the disease. in addition, the zoonosis they had the most idea about was brucella. it has been reported in studies conducted in uganda and italy that breeders have moderate knowledge of brucellosis [24,25]. chikerema et al. [26] found farmers' rabies, anthrax, and brucellosis awareness levels to be 9.0%, 72.0%, and 21.0%, respectively. in our study, more than 80.0% of the participants said that zoonotic diseases could be transmitted between animals. in addition, 90.0% of the farmers reported that they had vaccinated their animals and had been checked by a veterinarian. in the study of hundal et al. [27] in punjab, india, it was reported that more than 50.0% of breeders were aware of the transmission routes of zoonotic diseases to humans [27]. a study conducted among cattle farmers in erzurum, türkiye, reported that the farmers' knowledge levels of zoonotic diseases were high [28]. in the study of singh et al., it was reported that 80.0% of livestock farmers in india had heard the term zoonosis and did not consume raw milk. besides, 10.0% of this group had brucella and tuberculosis tests due to symptoms [3]. in the study of rajkumar et al. [4] in puducherry, india, 16.4% of the farmers knew that animal diseases could be transmitted to humans, and 43.2% reported foot and mouth disease (fmd) outbreaks in their cattle. in taştan et al.’s study [29] in kocaeli-türkiye among nurses, 73.0% of the participants stated that the infection was transmitted from animals to humans, 68.0% from humans to animals, and 16.0% stated that they were not transmitted at all. in addition, there are studies in the literature reporting low level of knowledge in those with a low level of education, advanced age, large families, and a high number of animals, and those living in low-income countries [3,4,6,8,28,30]. in our study, six out of ten farmers reported that diseases could be transmitted from animals to humans and between humans and that people can become infected due to consuming the milk and meat of sick animals. informative education programs on common zoonoses are routinely implemented in türkiye. in this respect, farmers' awareness of zoonoses is expected to be higher. our study determined that the health perception of these three groups was higher than the group without transmission information. the least known way of transmission (38.0%) is the barn environment and its surroundings. and there is no difference between the health perception scores of the groups who know this transmission route and those who do not. these findings suggest that; the health perception score is partially effective in knowing the transmission routes of zoonotic diseases, but other factors affect it. since the self-assessment scale and questionnaire were used in the research, the results are subjective. the results of this study have limitations regarding the generalization of all people at livestock breeders. the study sample consists of livestock breeders living in one province of türkiye. it is thought that future studies in larger samples and geographically different regions may provide more effective results. conclusion the awareness and knowledge level of the livestock farmers, who are the subject of our research, about zoonoses is the key point in preventing zoonoses. a good understanding of endemic zoonotic diseases by farmers will enable human and animal health professionals to control emerging disease threats. in türkiye, awareness-raising activities on the risks to farmers, health workers, and the public are carried out in policies related to animal husbandry. however, this study revealed that awareness of zoonotic diseases is not at the desired level. according to the result of our study, it affects the general health perception of the breeders, as well as their awareness of zoonoses. in order to reduce the risk of zoonotic transmission, it is necessary to increase the perception of health and awareness of zoonosis among farmers. veterinarians and physicians should work together on the perception of health and awareness of zoonosis. moreover, it can be recommended to carry out indepth studies with farmers, veterinarians, doctors, and butchers focusing on knowledge, perception, and awareness about zoonoses to increase their knowledge and awareness about zoonoses. abbreviation hps: health perception scale; sd: standard deviation; fmd: foot and mouth disease yılmaz m, arıka i̇, journal of ideas in health (2023); 6(1):800-805 804 declaration acknowledgment the authors are grateful to veterinarian ahmet hilmi demirel and the kutahya provincial directorate of agriculture and forestry. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing zerkesa@gmail.com. authors’ contributions my and i̇a participated in conceiving, designing, collecting data, drafting, and writing the manuscript. my participated in collecting data. all authors have read and approved the final manuscript. ethics approval and consent to participate the research was performed in accordance with the principles of the declaration of helsinki. this study was approved by the kutahya health sciences university ethics committee (date: 2022, number: 2022/02-19). moreover, informed consent was obtained from each participant after explaining the study objectives and the guarantee of secrecy. consent for publication not applicable competing interest open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of public health, faculty of medicine, kutahya health sciences university, kütahya, turkiye, orcid: 0000-0002-8728-7635 2department of public health, faculty of medicine, kutahya health sciences university, kütahya, turkiye, orcid: 0000-0001-5060-7722. article info received: 25 november 2022 accepted: 30 january 2023 published: 13 march 2023 references 1. grace d, gilbert j, randolph t, kang'ethe e. the multiple burdens of zoonotic disease and an ecohealth approach to their assessment. trop anim health prod. 2012;44(suppl1): s67-s73. doi:10.1007/s11250012-0209-y 2. arı ho, i̇şlek e, bilir uslu mk, özatkan y, karakaş f, yıldırım hh, et al. the monetary impact of zoonotic diseases on society: the turkish case. ankara univ vet fak derg. 2022;69(1):9-15. doi: 10.33988/auvfd.789598 3. singh bb, kaur r, gill gs, gill jps, soni rk, aulakh rs. knowledge, attitude and practices relating to zoonotic diseases among livestock farmers in punjab, india. acta trop. 2019; 189:15-21. doi: 10.1016/j.actatropica.2018.09.021 4. rajkumar k, bhattacharya a, david s, balaji sh, hariharan r, jayakumar m, et al. sociodemographic study on extent of knowledge, awareness, attitude, and risks of zoonotic diseases among livestock owners in puducherry region. vet world. 2016;9(9):1018-1024. doi:10.14202/vetworld.2016.1018-1024 5. stärk kd, morgan d. emerging zoonoses: tackling the challenges. epidemiol infect. 2015;143(10):2015-2017. doi:10.1017/s0950268815000680 6. ayim-akonor m, krumkamp r, may j, mertens e. understanding attitude, practices and knowledge of zoonotic infectious disease risks among poultry farmers in ghana. vet med sci. 2020;6(3):631-638. doi:10.1002/vms3.257 7. cleaveland s, sharp j, abela-ridder b, allan kj, buza j, crump ja, et al. one health contributions towards more effective and equitable approaches to health in lowand middle-income countries. philos trans r soc lond b biol sci. 2017;372(1725):20160168. doi:10.1098/rstb.2016.0168 8. kelly tr, bunn da, joshi np, grooms d, devkota d, devkota nr, et al. awareness and practices relating to zoonotic diseases among smallholder farmers in nepal. ecohealth. 2018;15(3):656-669. doi:10.1007/s10393-018-1343-4 9. alkan s, dindar demiray ek, sıddıkoğlu d, öntürk akyüz h. kırsal kesimde yaşayan kişilerin brusella infeksiyonu bulaş yolları hakkındaki bilgi düzeylerinin değerlendirilmesi. international anatolia academic online journal health sciences. 2022);8(1):98-113. available from: https://dergipark.org.tr/tr/pub/iaaojh/issue/69648/1034477 [accessed on 01 february 2023] 10. çetinkaya d, yelken b, aykanat y.d, dere g, dikkat şarbon çıkabilir! eskişehir’de şarbon farkındalığı anketi. türk tıp öğrencileri araştırma dergisi. 2020;2(1):5-8. 11. dindar demiray ek, öntürk akyüz h, demirci h. doğu anadolu bölgesi’nin tularemi açısından değerlendirilmesi. dental and medical journal review. 2021;3(3):39-44. 12. beyazgül b, koruk i̇, kuzan r, allahverdi ş. şark çıbanı vakalarında bilgi ve farkındalık düzeyini artırmaya yönelik müdahale çalışması: şanlıurfa örneği. mersin univ saglık bilim derg. 2022; 15(2):188-195. doi:10.26559/mersinsbd.985019 13. dell bm, souza mj, willcox as. attitudes, practices, and zoonoses awareness of community members involved in the bushmeat trade near murchison falls national park, northern uganda. plos one. 2020;15(9): e0239599. doi: 10.1371/journal.pone.0239599 14. deniz sş, özer ö, sonğur c. effect of health literacy on health perception: an application in individuals at age 65 and older. social work in public health. 2018:37(2);85–95. doi:10.1080/19371918.2017.1409680 15. ozdelikara a, agacdiken-alkan s, mumcu n. determination of health perception, health anxiety and effecting factors among nursing students. med j bakirkoy. 2018; 14:275-82. doi:10.5350/btdmjb.20170310015347 16. yiğitalp g, bayram değer v, çifçi s. health literacy, health perception and related factors among different ethnic groups: a cross-sectional study in southeastern turkey. bmc public health. 2021;21(1):1109. doi:10.1186/s12889-021-11119-7 yılmaz m, arıka i̇, journal of ideas in health (2023); 6(1):800-805 805 17. kutahya dırectorate of provıncıal agrıculture and forestry. kütahya hakkında. available from: https://kutahya.tarimorman.gov.tr/menu/24/kutahya-hakkinda [accessed on 20 february 2022] 18. diamond jj, becker ja, arenson ca, chambers cv, rosenthal mp. development of a scale to measure adults' perceptions of health: preliminary findings. j community psychol. 2007;35(5);557-61. doi:10.1002/jcop.20164 19. kadıoğlu h, yıldız a. validity and reliability of turkish version of perception of health scale. turkiye klinikleri j med sci. 2012;32(1):47-53. doi: 10.5336/medsci.2010-21761 20. karakoyunlu şen s, kılıç öztürk y. the relationship between health perception and cancer screening awareness. türk aile hek derg 2020; 24 (4):175-183. doi: 10.15511/tahd.20.00475 21. kolac n, balci as, sisman fn, atacer be, dincer s. health perception and healthy lifestyle behaviors in factory workers. bakırköy tıp dergisi. 2018; 14:267-74. doi:10.5350/btdmjb.20170328092601 22. garforth cj, bailey ap, tranter rb. farmers' attitudes to disease risk management in england: a comparative analysis of sheep and pig farmers. prev vet med. 2013;110(3-4):456-466. doi: 10.1016/j.prevetmed.2013.02.018 23. chand s, narayan p, chaudhary kr. sources of risks in livestock production and their management strategies in northern india. indian journal of animal sciences. 2018;88(5):612–619. doi: 10.13140/rg.2.2.24906.88009 24. angelillo if, foresta mr, scozzafava c, pavia m. consumers and foodborne diseases: knowledge, attitudes and reported behavior in one region of italy. int j food microbiol. 2001;64(1-2):161-166. doi:10.1016/s0168-1605(00)00451-7 25. kansiime c, mugisha a, makumbi f, mugisha s, rwego ib, sempa j, et al. knowledge and perceptions of brucellosis in the pastoral communities adjacent to lake mburo national park, uganda. bmc public health. 2014; 14:242. doi:10.1186/1471-2458-14-242 26. chikerema sm, matope g, pfukenyi dm. awareness and attitude toward zoonoses with particular reference to anthrax among cattle owners in selected rural communities of zimbabwe. vector borne zoonotic dis. 2013;13(4):243-249. doi:10.1089/vbz.2011.0916 27. hundal js, sodhi ss, gupta a, singh j, chahal us. awareness, knowledge, and risks of zoonotic diseases among livestock farmers in punjab. vet world. 2016;9(2):186-191. doi:10.14202/vetworld.2015.186-191 28. ozlu h, atasever m, atasever ma. knowledge, attitude, and practices of cattle farmers regarding zoonotic diseases in erzurum, turkey. austral j vet sci. 2020;52(2):79-85. doi: 10.4067/s071981322020000300079 29. taştan r, altıntş l, cevizci s. kocaeli il merkezinde bulunan hastanelerde çalışan hemşirelerin zoonotik hastalıklar hakkındaki bilgi düzeylerinin belirlenmesi. turk hij den biyol derg. 2016; 73(4):365378. doi: 10.5505/turkhijyen.2016.62134 30. yasobant s, bruchhausen w, saxena d, memon fz, falkenberg t. health system contact and awareness of zoonotic diseases: can it serve as one health entry point in the urban community of ahmedabad, india? yale j biol med. 2021;94(2):259-269. pmid: 34211346 pmcid: pmc8223553. https://doi.org/10.47108/jidhealth.vol5.iss4.253 reddy m, et al., journal of ideas in health 2022;5(4):760-765 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access predicting mortality using prognostic scores and electrocardiographic parameters in st-elevation myocardial infarction patients undergoing thrombolysis mamatha reddy*1, vaasanthi chintala2, bairam balaji3 abstract background: the shortand long-term outcomes of thrombolysis has been predicted by various scores and models based on the electrocardiogram. this study aimed to compare various mortality predictors in st-elevation myocardial infarction (stemi) patients undergoing thrombolysis. methods: a prospective, case-control, single-center study was performed at mgm hospital, warangal, india, between november 2019 and november 2021. a total of 100 stemi patients were enrolled, out of which 50 were controls (patients who survived after seven days of thrombolysis) and 50 were cases (patients who died after seven days of thrombolysis). aldrich score, timi risk index (tri), sclarovsky-birnbaum ischemia grading (sb-ig) algorithm, presence of q waves, total st-segment deviation, and the number of leads with st-segment elevation (ste) in anterior wall mi (awmi) were calculated. results: the mean age of the case group was 55.3 ± 11.6 years, and that of the control group was 55.5 ± 10.1 years. males comprised 46.0% and 66.0% of the case and control groups. the c-statistic of tri was found to be the highest (c = 0.68; p = 0.001), followed by the sb-ig algorithm (c = 0.58; p = 0.021), the sum of r waves in awmi (c = 0.5; p = 0.019), the number of leads with ste in awmi (c = 0.47; p = 0.778), total st-segment deviation (c = 0.47; p = 0.552), aldrich score for awmi (c = 0.43; p = 0.590), presence of q waves (c = 0.40; p = 0.676), and aldrich score for inferior wall mi (c = 0.32; p = 0.071). conclusion: tri and sb-ig algorithms had moderate accuracy in predicting seven-day mortality in stemi patients undergoing thrombolysis. other scores and parameters viz. aldrich score, presence of q waves, total st-segment deviation, and the number of leads with ste in awmi had very poor accuracy in predicting in-hospital outcomes. more extensive studies with longer durations are required to validate our findings. keywords: stemi, ecg, prognosis, mortality, thrombolysis, myocardial infarction, india background cardiovascular diseases (cvd) account for the highest number of deaths globally, taking the lives of ~17.9 million people annually [1]. coronary artery disease (cad) is the most common cvd presentation, representing approximately half of all cvd [2]. one of the acute manifestations of cad, stelevation myocardial infarction (stemi), results in transmural ischemia leading to myocardial necrosis [3]. timely myocardial reperfusion is the goal of treatment for stemi, which attempts to preserve the myocardium, lower the size of the eventual infarct, and reduce subsequent mortality rates. one way to achieve this goal is by administering thrombolytics. coronary patency is achieved in 50-75% of patients undergoing thrombolytic therapy [4]. although the outcomes seem inferior to primary percutaneous coronary intervention, thrombolysis is still the preferred treatment strategy when the time from medical contact to the device is more than 90 minutes. approximately 6.9% of stemi patients treated with thrombolytics present with a new-onset atrioventricular block [3]. therefore, thrombolysis does not always ensure event-free survival. the immediate prognosis in stemi patients is inversely related to the extent of myocardial damage. for a long time, the electrocardiogram (ecg) has been considered an essential part of diagnosis and initial evaluation for patients with chest pain. serial ecg alterations are identified by leads facing the ischemic zone shortly after the blockage of a coronary artery. additionally, the ecg is useful in determining ___________________________________________________ mamathac04@gmail.com 1department of cardiology, mahatma gandhi memorial hospital, warangal, telangana506002, india a full list of author information is available at the end of the article 10.47108/jidhealth.vol5.iss4.253 http://www.jidhealth.com/ reddy m, et al., journal of ideas in health (2022); 5(4):760-765 761 the size of the myocardial ischemic area at risk (aar), distinguishing between transmural and subendocardial ischemia, and confirming the presence of prior infarctions using abnormal q waves in leads unrelated to the current infarction [5]. methods that could swiftly evaluate the amount of damaged myocardium and thus identify individuals most likely to benefit from reperfusion therapy would be helpful in clinical practice. some various models and scores predict the myocardial aar and subsequent mortality in stemi patients undergoing thrombolysis. studies have attempted to use the admission ecg to calculate the ischemic aar [6-8]. ecg methods to assess aar include the aldrich score [9]. sclarovsky-birnbaum ischemia grading (sb-ig) algorithm [10], presence of q waves [11], total st-segment deviation [12], and the number of leads with st-segment elevation (ste) in anterior wall myocardial infarction (awmi). another important model that predicts mortality is the timi risk index (tri) [13], which is not based on ecg changes. these methods use complex algorithms or formulae using simple parameters such as age, systolic blood pressure, etc., to predict a patient's mortality risk by expressing a numerical value calculated at the time of admission. the purpose of the current study was to compare the predictive abilities of these seven risk scores and parameters in determining seven-day mortality in stemi patients undergoing thrombolysis. methods study design and population between november 2019 and november 2021, a prospective, single-center, case-control study was performed at mgm hospital, warangal, india. a total of 100 stemi patients were enrolled in the study. cases were defined as stemi patients who died within seven days of thrombolysis, and controls were defined as stemi patients who survived even after seven days of thrombolysis. inclusion and exclusion criteria patients with stemi who presented within the window period of 12 hours [14] for thrombolysis were included. those presenting with stemi after the window period or those with a contraindication to thrombolysis were excluded from the study. measurements at the time of admission, aldrich score, tri, sb-ig, presence of q waves, total st-segment deviation, and the number of leads with ste in awmi were calculated (tables 1-3). table 1: timi risk index and its correlation with the risk of death. (reproduced from morrow et al. [15]) tri risk group risk of death 24 h in-hospital 30 days ≤12.5 1 0.2 0.6 0.8 >12.517.5 2 0.4 1.5 1.9 >17.522.5 3 1.0 3.1 3.3 >22.5-30 4 2.4 6.5 7.3 >30 5 6.9 15.8 17.4 tri: thrombolysis in myocardial infarction risk index table 2: sb-ig algorithm and their observations on the ecg (taken from birnbaum et al. [16]) sb-ig algorithm observation no ischemia baseline grade i ischemia tall symmetrical t wave without st elevation grade ii ischemia st elevation ≥0.1 mv without distortion of the terminal portion of the qrs wave grade iii ischemia st elevation with distortion of the terminal portion of the qrs (emergence of the j point ≥50% of the r wave in leads with qr configuration), or disappearance of the s wave in leads with an rs configuration table 3: correlation of st deviation with ami size (reproduced from aldrich et al. [6]) ami location st parameters r anterior number of leads with st↑ 0.72 σst↑ all leads 0.52 σst↑ v1 through v3 0.38 σst↑ v1 through v6 0.48 σst↑ v1 through v3, i, avl 0.46 inferior number of leads with stδ 0.50 σst↑ all leads 0.61 σst↑ all leads + σst↓ v1 through v3 0.60 σst↑ ii, iii, avf 0.61 ↑ ii, iii, avf + σst↓ v1 through v3 0.59 q waves were considered pathological if they were>40 ms (1 mm) wide, >2 mm deep, > 25% of the depth of the qrs complex, or seen in leads v1 through v3 [17]. sb-ig was estimated using the classification as follows: 1) grade itall, peaked, symmetrical t waves, 2) grade iislope elevation of st segment, 3) grade iiidistortion of the terminal qrs complex in the form of j point elevation of >50% of the preceding r wave or loss of normal s wave. tri, aldrich score, and st segment deviation were calculated using the following formulae: tri = heart rate in beats per min x [(age/10)2]/systolic blood pressure aldrich score = acute myocardial infarct size (anterior) = 3[1.5(number leads st↑) – 0.4]; (inferior) = 3[0.6(∑st↑ ii, iii, avf) + 2.0] st segment deviation = 3[0.22 (σst↓ + σst↑) − 0.02], where ↓ indicates depression and ↑ elevation, derived from measurements on the initial ecg, predicts the size of the ami in the percentage of the left ventricle as estimated on the final ecg. the quantitative initial st-segment deviation correlates linearly to the final ami size in patients with maximum stsegment depression in leads v1 through v3 [18]. statistical analysis all variables were analyzed and expressed as numbers (n). continuous variables displaying normal distribution were expressed as mean ± sd. the chi-square test and independent ttest were used to compare the demographic characteristics of the two groups. a p-value less than 0.05 was considered reddy m, et al., journal of ideas in health (2022); 5(4):760-765 762 statistically significant. roc curves were generated, and the aucs were calculated to compare the accuracies of scores and ecg parameters. statistical analyses were performed using statistical package for social sciences version 20.0 (ibm, chicago, il, usa). results descriptive and general characteristics of related factors in this study, 100 stemi patients were enrolled at our institute. out of 100 patients, 50 were cases (patients who died seven days after thrombolysis), and 50 were controls (patients who survived seven days after thrombolysis). the mean age of the case group was 55.3 ± 11.6 years, and that of the control group was 55.5 ± 10.1 years (table 1). the case group comprised 27 females (54%) and 23 males (46%), and the control group had 17 females (34%) and 33 males (66%) (table 4). table 4: baseline characteristics of patients (n=100) category group p-value case (n = 50) control (n = 50) age (years), n (%) ≤ 40 2 (4.0) 5 (10.0) 0.356 41-50 17 (34.0) 9 (18.0) 51-60 17 (34.0) 22 (44.0) 61-70 12 (24.0) 12 (24.0) > 70 2 (4.0) 2 (4.0) mean (sd) 55.3 (10.1) 55.5 (11.6) females, n (%) 27 (54.0) 17 (34.0) 0.044 ste in r, n (%) yes 8 (16.0) 00 no 12 (24.0) 00 p-value calculated using chi-square test; ste: st elevation as shown in table 5, q-wave was observed in 33 patients (66%) in the case group and 31 patients (62%) in the control group (p = 0.676). the mean length of r-waves in awmi was 16.3 ± 10.5 mm in the case group and 27.1 ± 21.3 mm in the control group (p = 0.019) (table 2). in a comparison of scores, the mean tri was 35.4 ± 22.7 in the case group and 22.3 ± 13.7 in the control group (p = 0.001) (table 2). the mean sb-ig system was 2.9 ± 0.3 in the case group and 2.7 ± 0.5 in the control group (p = 0.021) (table 5). the area under the receiver operating characteristics (roc) curve for various mortality prediction scores are given in table 2 and figure 1. highest auc was observed for tri (c = 0.68), followed by the sb-ig algorithm (c = 0.58), the sum of r waves in awmi (c = 0.50), the number of leads with ste in awmi (c = 0.47), total st segment deviation (c = 0.47), aldrich score for awmi (c = 0.43), presence of q waves (c = 0.40) aldrich score for inferior wall mi (c = 0.32). discussion in this study, we tried to study the intentions of hcps, including the global burden of the acute coronary syndrome (acs) is increasing rapidly. stemi is the most serious presentation of acs [3]. the success of reperfusion therapy, either using thrombolytics or pci, depends upon various factors such as age, gender, ischemia time, ischemic preconditioning, and collateral and residual antegrade flow [10,19,21]. in this study, patients who underwent thrombolysis for stemi were included. we identified the power of various scores and ecg-based parameters such as aldrich score, tri, sb-ig algorithm, presence of q-waves, the sum of r waves, total stsegment deviation, and the number of leads with ste in awmi in predicting the in-hospital outcomes in stemi patients undergoing thrombolysis. we found that tri was better at predicting seven-day mortality than the other parameters based on the area under the roc curve (c = 0.68). the mean age of cases was 55.3 ± 10.1 years, and controls were 55.5 ± 11.6 years. this was similar to the grace registry [22] had a mean age of 64 ± 13 years for stemi patients. another study by aziz et al. [23] had a mean age of 56.6 ± 11.7 years for stemi patients. in the current study, we did not observe a significant increase in mortality rate with an increase in age. however, according to the gusto-i trial [24], which included patients with acute myocardial infarction (ami), the increase in mortality with the increase in age was significant (p < 0.001). this may be due to the inclusion of patients ≥ 85 years in the gusto-i trial, which were not present in our study. tri had the best ability to discriminate between cases and controls (p = 0.0001) regarding in-hospital outcomes. additionally, it was the only predictor that was able to approach the acceptable c-statistic threshold of 0.7 [25], suggesting that it was moderately accurate in predicting seven-day mortality. a simple bed-side tool, tri has been studied extensively as a predictor of 30-day mortality. morrow et al. [24], in their study to validate timi risk score in stemi patients, found that the score showed strong 30-day prognostic capacity overall (c = 0.74 vs. 0.78 in derivation set) and among patients receiving acute reperfusion therapy (c = 0.79). in the same study, mortality prediction in patients not receiving reperfusion therapy was not as robust (c = 0.65) [26]. in a study by ruff et al. [27], tri was a good predictor of all-cause death. they found a strong relationship between increasing tri and 30-day mortality (1.2%-20.7%, p < 0.0001) [27]. a lower c-statistic value for tri in the current study compared to the studies mentioned above may be due to the differences in study duration. in this study, we predict sevenday outcomes, whereas most studies conducted earlier have studied 30-day outcomes. nevertheless, tri had the highest discriminative performance of all models assessed according to c-statistics. in 1993, birnbaum, sclarovsky, and colleagues published their findings about the utility of the initial ecg pattern in predicting in-hospital mortality in patients with an evolving anterior wall ami [21]. the algorithm helps in predicting the extent of ischemia, which can be differentiated into three grades based on the relation between the acute appearances of the t wave, the st segment, and the qrs complex. the sb-ig algorithm was evaluated by hasdai et al. [28] in patients with inferior wall ami. it was found that patients with minimal ste were at the highest risk for inhospital mortality. all other parameters tested in this study, i.e., aldrich score for awmi, aldrich score for iwmi, presence of q-waves, the sum of r waves in awmi, number of leads with ste in awmi, and total st-segment deviation performed poorly in roc analysis with c-statistics 0.43, 0.32, 0.40, 0.50, 0.47 and 0.47, respectively. the aldrich score estimates myocardial aar based on ste, and studies have indicated that this score is unstable with time [29]. aldrich et al. [6] found that reddy m, et al., journal of ideas in health (2022); 5(4):760-765 763 the number of leads with ste in awmi was an important variable (r = 0.72) in predicting ami size. koivula et al. [30], in their study on finding the prognostic role of q-waves in stemi patients, found that patients with q-waves had larger infarct areas, which could explain the high one-year mortality seen in these patients. in their study on the prognostic significance of st-segment deviation in stemi patients, de luca et al. [31] found that st-segment deviation had good prognostic utility based on the area under the roc curve (c = 0.73) in terms of one-year morality. in another study by daly et al. [32], st-segment deviation had poor prognostic utility (c = 0.61) in stemi patients. the applications of this study need to be weighed against the limitations. firstly, this was a single-center study with a limited number of patients. this restricts its applicability to the population in general. secondly, we did not consider the effect of age, gender, ischemic preconditioning, and collateral and residual antegrade flow on the success of thrombolytic therapy. last, we were unable to perform 30-day and long-term followup, which should be aimed at further studies. table 5: comparison of scores and ecg parameters between the study groups score, mean (sd) group c-statistic p-value case (n = 50) control (n = 50) tri 35.4 (22.7) 22.3 (13.7) 0.677 0.001 aldrich score (awmi) 24.0 (7.2) 25.1 (7.34) 0.431 0.590 aldrich score (iwmi) 18.1 (17.0) 21.8 (6.3) 0.321 0.071 sb-ig algorithm 2.9 (0.3) 2.7 (0.5) 0.582 0.021 presence of q waves, n (%) 33 (66.0) 31 (62.0) 0.401 0.676 sum of r waves in awmi 16.3 (10.5) 27.1 (21.3) 0.498 0.019 number of leads with ste in awmi 5.7 (1.5) 5.9 (1.6) 0.471 0.778 total st-segment deviation 20.3 (9.3) 21.5 (10.4) 0.465 0.552 tri: thrombolysis in myocardial infarction risk index; awmi: anterior wall myocardial infarction; iwmi: inferior wall myocardial infarction; sb-ig: sclarovskybirnbaum ischemia grading; ste: st elevation figure 1: receiver operating characteristics curve for a) timi risk index; b) aldrich score for inferior wall myocardial infarction; c) aldrich score for anterior wall myocardial infarction (awmi); d) sclarovsky-birnbaum score; e) total st deviation; and f) number of leads with st elevation in awmi. reddy m, et al., journal of ideas in health (2022); 5(4):760-765 764 conclusion amongst various predictors of outcomes in patients receiving thrombolysis for stemi, tri and sb-ig algorithms had moderate accuracy in predicting seven-day mortality. other scores and ecg parameters, viz. aldrich score, presence of qwaves, the sum of r waves in awmi, total st-segment deviation, and the number of leads with ste in awmi had very poor accuracy in predicting in-hospital outcomes. however, more extensive studies with longer durations are required to validate our findings. abbreviation stemi: st-elevation myocardial infarction; ecg: electrocardiogram; tri: timi risk index; sb-ig: sclarovsky-birnbaum ischemia grading algorithm; ste: st-segment elevation; mi: myocardial infarction awmi: anterior wall mi; iwmi: inferior wall mi; cvd: cardiovascular diseases; cad: coronary artery disease; aar: area at risk. declaration acknowledgment none. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing mamathac04@gmail.com. authors’ contributions all authors have contributed equally in designing, writing, the analysis and interpretation of the study and drafting and reviewing the article. all authors read and approved the final version of the manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the protocol of the study was approved by the institutional ethics committee of mgm hospital, warangal, india (19100003008d; approved on 24/10/2019). written informed consent was obtained from all participants or their legal representatives. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of cardiology, mahatma gandhi memorial hospital, warangal, telangana506002, india. 2department of general medicine, mahatma gandhi memorial hospital, warangal, telangana506002, india. article info received: 13 september 2022 accepted: 26 november 2022 published: 10 december 2022 references 1. world health organization, cardiovascular diseases (cvds). 11 june 2021 [cited 2022 8 august]; available from: https://www.who.int/news-room/fact-sheets/detail/cardiovasculardiseases(cvds)#:~:text=cardiovascular%20diseases%20(cvds)%20are%2 0the,-%20and%20middle-income%20countries. 2. mishra va, kinare ab, pal j, tripathi vd, sharma rs, and jain pk. study of coronary artery disease in young population of central india. j res med sci, 2021;9(1):73. doi: 10.18203/23206012.ijrms20205426 3. vogel b, claessen be, arnold sv, chan d, cohen dj, giannitsis e, gibson cm, goto s, katus ha, and kerneis m. st-segment elevation myocardial infarction. nat rev dis primers, 2019;5(1):1-20. doi: 10.1038/s41572-019-0090-3 4. gokhroo r, gupta s, bisht ds, and padmanabhan d. a study of coronary artery patency in relation to the index event in patients with myocardial infarction thrombolysed with streptokinase. heart asia, 2014;6(1):55-58. doi: 10.1136/heartasia-2014-010494 5. birnbaum y and drew bj. the electrocardiogram in st elevation acute myocardial infarction: correlation with coronary anatomy and prognosis. postgrad med j, 2003;79(935):490-504. doi: 10.1136/pmj.79.935.490 6. aldrich hr, wagner nb, boswick j, corsa at, jones mg, grande p, lee kl, and wagner gs. use of initial st-segment deviation for prediction of final electrocardiographic size of acute myocardial infarcts. am j cardiol, 1988;61(10):749-53. doi: 10.1016/0002-9149(88)91060-0 7. christian tf, gibbons rj, clements ip, berger pb, selvester rh, wagner gs. estimates of myocardium at risk and collateral flow in acute myocardial infarction using electrocardiographic indexes with comparison to radionuclide and angiographic measures. j am coll cardiol, 1995;26(2):388-93. doi: 10.1016/07351097(95)80011-5 8. willems jl, willems rj, willems gm, arnold a, van de werf f,nd verstraete mf. significance of initial st segment elevation and depression for the management of thrombolytic therapy in acute myocardial infarction. european cooperative study group for recombinant tissue-type plasminogen activator. circulation, 1990;82(4):1147-58. doi: 10.1161/01.cir.82.4.1147 9. sejersten m, fakhri y, pape m, jensen se, heiberg e, engblom h, hall ts, atar d, and clemmensen p. myocardium at risk assessed by electrocardiographic scores and cardiovascular magnetic resonance-a mitocare substudy. j electrocardiol, 2017;50(6):725-31. doi: 10.1016/j.jelectrocard.2017.08.019 10. billgren t, birnbaum y, sgarbossa eb, sejersten m, hill ne, engblom h, maynard c, pahlm o, wagner gs. refinement and interobserver agreement for the electrocardiographic sclarovskybirnbaum ischemia grading system. j electrocardiol, 2004;37(3):149-56. doi: 10.1016/j.jelectrocard.2004.02.005 11. kochar a, granger cb. q waves at presentation in patients with st-segment–elevation myocardial infarction: an underappreciated marker of risk. 2017, am heart assoc. p. e006085. doi: 10.1161/circinterventions.117.006085 12. deshpande a, birnbaum y. st-segment elevation: distinguishing st elevation myocardial infarction from st elevation secondary to nonischemic etiologies. world j cardiol, 2014;6(10):1067. doi: 10.4330/wjc. v6.i10.1067 13. supeł k, kacprzak m, zielińska m. shock index and timi risk index as valuable prognostic tools in patients with acute coronary syndrome complicated by cardiogenic shock. plos one, 2020;15(1): e0227374. doi: 10.1371/journal.pone.0227374 14. white hd, van de werf fj. thrombolysis for acute myocardial infarction. circulation, 1998;97(16):1632-46. doi: 10.1161/01.cir.97.16.1632 reddy m, et al., journal of ideas in health (2022); 5(4):760-765 765 15. morrow da, antman em, giugliano rp, cairns r, charlesworth a, murphy sa, de lemos ja, mccabe ch, braunwald e. a simple risk index for rapid initial triage of patients with stelevation myocardial infarction: an intime ii substudy. the lancet, 2001;358(9293):1571-75. doi: 10.1016/s01406736(01)06649-1 16. birnbaum y, sclarovsky s. the grades of ischemia on the presenting electrocardiogram of patients with st elevation acute myocardial infarction. journal of electrocardiology, 2001;34(4):17-26. doi: 10.1054/jelc.2001.28819 17. burns e and buttner r, q wave. 2021 [cited november 25, 2022; available from: https://litfl.com/q-wave-ecglibrary/#:~:text=q%20waves%20are%20considered%20pathologi cal,of%20depth%20of%20qrs%20complex. 18. ripa rs, holmvang l, maynard c, sejersten m, clemmensen p, grande p, lindahl b, lagerqvist b, wallentin l, wagner gs. consideration of the total st-segment deviation on the initial electrocardiogram for predicting final acute posterior myocardial infarct size in patients with maximum st-segment deviation as depression in leads v1 through v3. a frisc ii substudy. journal of electrocardiology, 2005;38(3):180-86. doi: 10.1016/j.jelectrocard.2005.03.011 19. white hd, barbash gi, califf rm, simes rj, granger cb, weaver wd, kleiman ns, aylward pe, gore jm, vahanian a. age and outcome with contemporary thrombolytic therapy: results from the gusto-i trial. circulation, 1996;94(8):1826-33. doi: 10.1161/01.cir.94.8.1826 20. cenko e, yoon j, kedev s, stankovic g, vasiljevic z, krljanac g, kalpak o, ricci b, miličić d, manfrini o. sex differences in outcomes after stemi: effect modification by treatment strategy and age. jama intern med, 2018;178(5):632-39. doi: 10.1001/jamainternmed.2018.0514 21. birnbaum y, sclarovsky s, blum a, mager a, and gabbay u, prognostic significance of the initial electrocardiographic pattern in a first acute anterior wall myocardial infarction. chest, 1993;103(6):1681-87. doi: 10.1378/chest.103.6.1681 22. fox ka, goodman sg, klein w, brieger d, steg pg, dabbous o, and avezum a, management of acute coronary syndromes. variations in practice and outcome. findings from the global registry of acute coronary events (grace). eur heart j, 2002;23(15):1177-89. doi: 10.1053/euhj.2001.3081 23. aziz f, malek s, ibrahim ks, raja shariff re, wan ahmad wa, ali rm, liu kt, selvaraj g, kasim s. short-and long-term mortality prediction after an acute st-elevation myocardial infarction (stemi) in asians: a machine learning approach. plos one, 2021;16(8): e0254894. doi: 10.1371/journal.pone.0254894 24. holmes jr dr, bates er, kleiman ns, sadowski z, horgan jh, morris dc, califf rm, berger pb, topol ej, the gusto-i investigators. contemporary reperfusion therapy for cardiogenic shock: the gusto-i trial experience. j am coll cardiol, 1995;26(3):668-74. doi: 10.1016/0735-1097(95)00215-p 25. lavalley mp. logistic regression. circulation, 2008;117(18):2395-99. doi: 10.1161/circulationaha.106.682658 26. morrow da, antman em, parsons l, de lemos ja, cannon cp, giugliano rp, mccabe ch, barron hv, braunwald e. application of the timi risk score for st-elevation mi in the national registry of myocardial infarction 3. jama, 2001;286(11):1356-59. doi: 10.1001/jama.286.11.1356 27. ruff ct, wiviott sd, morrow da, mohanavelu s, murphy sa, antman em, braunwald e. extract-timi 25 investigators, timi risk index and the benefit of enoxaparin in patients with stelevation myocardial infarction. am j med, 2007;120(11):993-98. doi: 10.1016/j.amjmed.2007.08.020 28. hasdai d, sclarovsky s, solodky a, sulkes j, birnbaum y. prognostic significance of the initial electrocardiographic pattern in patients with inferior wall acute myocardial infarction. clin cardiol, 1996;19(1):31-36. doi: 10.1002/clc.4960190107 29. körver fw, hassell m, smulders m, bekkers s, gorgels a. correlating both aldrich and hellemond score with cardiac magnetic resonance imaging endocardial surface area calculations in the estimation of the area at risk. electrocardiography scores and endocardial surface area calculations: do they correlate? j electrocardiol, 2013;46(3):229-34. doi: 10.1016/j.jelectrocard.2013.02.012 30. koivula k, nikus k, viikilä j, lilleberg j, huhtala h, birnbaum y, eskola m. comparison of the prognostic role of q waves and inverted t waves in the presenting ecg of stemi patients. ann noninvasive electrocardiol, 2019;24(1):e12585. doi: 10.1111/anec.12585 31. de luca g, maas ac, suryapranata h, ottervanger jp, hoorntje jc, gosselink am, dambrink jh, de boer mj, and van't hof aw, prognostic significance of residual cumulative st-segment deviation after mechanical reperfusion in patients with stsegment elevation myocardial infarction. am heart j, 2005;150(6):1248-54. doi: 10.1016/j.ahj.2005.01.056 32. daly m, adgey j, harbinson m. improved detection of acute myocardial infarction in patients with chest pain and significant left main stem coronary stenosis. qjm: an international journal of medicine, 2012;105(2):127-35. doi: 10.1093/qjmed/hcr134 https://doi.org/10.47108/jidhealth.vol6.iss1.267 çelikkaya eb, journal of ideas in health (2023); 6(1):806-813 © the author(s). 2023 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access evaluation of oncology-related healthcare professionals' knowledge and practices on sustainable nutrition, ankara, turkey emine balyan çelikkaya1* abstract background: increasing population, limited resources, and climate change require adopting more sustainable diets. this study aims to evaluate health professionals' knowledge levels and practices on sustainable nutrition. methods: a cross-sectional study was conducted between january 2022 and may 2022 at dr. abdurrahman yurtaslan oncology training and research hospital in ankara. the research was performed by using the "stretched sampling method". a semi-structured and self-reported online survey was recruited to collect data from healthcare professionals. data from 298 participants were subjected to descriptive and univariate analyses to evaluate differences in knowledge mean scores and scofi scores. the data analysis results with the spss 26.0 program were accepted as a 95% confidence interval, with significance p≤0.05. results: a total of 298 people participated in the study. the mean age of respondents was 36 years (13±10.8). more than two-thirds (79.2%) were females, more than half (52%) were nurses, 20.5% were doctors, 60.4% had a bachelor's degree, % and 12.8 had a master's degree. sustainable nutrition knowledge and scofi mean scores were 10.71±5.3 (0-24) and 54.09±13.2, respectively. 37.9% of the participants stated that they had heard of the concept of sustainable nutrition before. the sustainable nutrition knowledge of females was lower, and the scofi score was higher (p>0.05). the scofi score of the 18-25 age group was lower than the other age groups (p<0.05). sustainable nutrition knowledge means scores increased as the education level increased (p<0.05). dieticians had the highest sustainable nutrition knowledge and scofi score (p<0.05). the scofi score of those working in the surgery room and intensive care unit was lower than the other units (p<0.05). conclusion: training for healthcare professionals might increase sustainable nutrition knowledge and awareness. keywords: environment, hospital, oncology, healthcare professional, sustainable nutrition, turkey background the concept of sustainability is a term it has been heard in many areas recently. it first appeared in the brundtland report titled "our common future," prepared by united nations (un) world commission on environment and development in 1987. the concept of sustainability was mentioned as sustainable development. it was defined as "development that meets the needs of the present without compromising the ability of future generations to meet their needs" [1]. this requires the effective use of our existing resources by current and future generations. the concept of sustainability was born with the concern that our natural resources could not meet our needs [2]. the increasing population, climate changes, and limited resources raise the question of whether we can reach healthy and safe food in the future. what kind of problems will arise 100 years from now if our current nutritional status continues? what can be the impact of food on the environment from production to our table? these questions reveal the concept of sustainable nutrition. the food and agriculture organization (fao) of the united nations developed the concept of sustainable nutrition within the scope of the symposium held in 2010, and the following definition was accepted. sustainable diets are "diets with a low environmental impact that contribute to food and nutrition security and wellness for current and future generations. sustainable diets are protective and respectful of biodiversity and ecosystems; culturally acceptable, accessible, economically fair and affordable; diets that use natural and human resources appropriately" [3]. ___________________________________________________ dyteminebalyan@gmail.com 1department of public health, ankara yildirim beyazıt university institute of health sciences, ankara, turkey. 2dr. abdurrahman yurtaslan oncology trh, ankara, turkey. full list of author information is available at the end of the article 10.47108/jidhealth.vol6.iss1.267 http://www.jidhealth.com/ çelikkaya eb, journal of ideas in health (2023); 6(1):806-813 807 the number of undernourished people around the world is substantial. one out of every three people has symptoms of malnutrition, such as hunger and stunting, and being overweight or obese. more than 830 million people go to bed hungry every day [4]. four million people lose their life worldwide each year due to being overweight, obesity, and related diseases. at the same time, the global burden of foodborne diseases is that all forms of malnutrition cost us$3.5 trillion per year, and overweight and obesity alone cost us$500 billion per year [5]. sustainable diets are not only concerned with people's health and nutritional status but also with the environmental effects of food [6]. from production to distribution, the global food system is responsible for approximately one-third of anthropogenic greenhouse gas emissions worldwide [7]. agricultural lands use 70% of freshwater [8]. however, agriculture is an essential source of water pollution from pesticides and other pollutants [9]. one-third of the food produced worldwide is wasted, which puts an extra burden on the environment [10]. this study was carried out to evaluate the knowledge and practices of health professionals, who are expected to be an example to society about sustainable nutrition, and to examine its relationship with sociodemographic characteristics. methods study design a cross-sectional study was conducted between january 2022 and may 2022 at dr. abdurrahman yurtaslan oncology training and research hospital in ankara. the data were prepared electronically due to the covid-19 pandemic, and the access address of questionnaires was sent to participants via email or sms. inclusion and exclusion criteria all healthcare professionals who graduated from any department of health working in dr. abdurrahman yurtaslan oncology training and research hospital, both gender and willing to participate, were included in the research. however, health professionals working in other hospitals, non-health workers, missing data, and those unwilling to participate were included in the study. sample size the population of the research is n:1305. the sample size calculator arrived at 297 participants, using a margin of error of ±5.0%, a confidence level of 95%, a 50% response distribution, and 1305 people [11]. a total of 298 people responded to the survey. study tool first section: in this section, questions were asked to determine demographic characteristics such as gender, age, marital status, educational status, occupation, and income level. second sections: in this section, there are 13 main questions and 11 sub-questions to measure the level of knowledge about sustainable nutrition. since there is no scale measuring the level of sustainable nutrition knowledge, the researcher prepared the questions in accordance with the literature [3, 4, 12, 13]. scoring is calculated as 1 point for the "yes" answer, 0 for "no" and "i have no idea answer". there are three negative statements, and these statements are scored as 1 point for the "no" answer and 0 points for the "yes" and "i have no idea" answers. cronbach's alpha value was found to be 0.890. third sections: in this section, the sustainable food consumption index (scofi) prepared as the 2nd intellectual output of the project titled "assessment and changing adult behaviors on sustainable consumption of food products" implemented within the scope of erasmus + ka204 strategic partnerships adult education on sustainable nutrition practices was used. scofi aims to measure the practices of individuals on sustainable food consumption [14]. the reliability analysis of the scale found the cronbach's alpha value for turkey to be 0.9. the construct validity of the index was tested with exploratory factor analysis (efa) and confirmatory factor analysis (cfa). kmo value is .95, and bartlett sphericity test (χ2 = 12500.96; p = .00) was found significant. when the findings obtained from the cfa were evaluated, the χ2 / sd ratio (2336,38 / 626) was found to be 3.73 [15]. in our reliability analysis, cronbach's alpha value was 0.931. dependent and independent variables dependent variables are the sustainable nutrition knowledge mean score and sustainable food consumption index (scofi) score, while independent variables are gender, marital status, age, education level, occupation, etc. demographic features. statistical analysis the collected data were analyzed by using the spss version 26.0 program. in the descriptive results section, categorical variables were presented as numbers and percentages, and continuous variables were presented as mean ± standard deviation. we found that the knowledge level-dependent variables had a kolmogorov-smirnov normal distribution. however, the sustainable food consumption index (scofi) dependent variable did not have a kolmogorov-smirnov normal distribution. mann-whitney u test, kruskal-wallis test, independent sample t-test, and one-way anova (one-way analysis of variance) test were used for statistical analysis. the statistical significance threshold was determined as p≤0.05. results sociodemographic characteristics 236 (79.2%) and 62 (20.8%) of the 298 people who participated in the study were female and male, respectively. the mean age was 36.13±10.8 years. 57.4% of the participants are married, 60.4% have a bachelor's degree, 52.0% are nurses, and 56% have a monthly income of 7001-10000tl. 45.3%of they work in the clinical unit. the characteristics of the participants are shown in table 1. 62.1% declared that they had not heard of the concept of sustainable nutrition before. those who stated that they heard received information from internet sources. the opinions of the health professionals participating in the study about the elements of sustainable nutrition were analyzed statistically. considering the responses, the statement "should promote a healthy life" was market at the most 245 (14.3%), and the statement "should have a low environmental impact" was marked the least by 73 (4.3%) (table 2, table 3). çelikkaya eb, journal of ideas in health (2023); 6(1):806-813 808 level of knowledge the sustainable nutrition knowledge mean score was 10.71±5.3 (range: 0-24). the participants generally gave 44.62% (10.71/24*100) correct answers. sustainable nutrition knowledge mean scores of men (11.31±5.5), 46-55 age group (12.30±5.3), widowed individuals (13±0), monthly income of 10001 tl and above (11.89 ± 5.7) are higher (p> 0.05). sustainable nutrition knowledge mean scores increase as the education level increases (p=0.003). dietitians are the occupational group with the highest sustainable nutrition knowledge scores (15.09 ± 6.5, p=0.001). the distribution of the participants' mean knowledge scores by sociodemographic structure is shown in table 4. sustainable nutrition practices sustainable nutrition practices mean score was 54.09±13.2 (0100). participants generally gave correct answers by 54.09% (54.09/100*100). the sustainable food consumption index score of females, widowed persons, and doctorate degrees is higher (p>0.05). the scofi score of the 18-25 age group (49.64±14.6) was lower than the other age groups (p=0.01). dietitians have the highest scofi score (66.25±6.7, p=0.047) among the health professionals. the scofi score of individuals in the operating room and intensive care unit (48.46±12.8) was lower than those in other units (p=0.033). the distribution of the participants' scofi scores by sociodemographic structure is shown in table 5. table 1. the distribution of participants according to sociodemographic characteristics (n=298) variable categorized variables n % gender female 236 79.2 male 62 20.8 age group 18-25 68 22.8 26-35 85 28.5 36-45 83 27.9 46-55 46 15.4 56-65 16 5.4 marital status married 171 57.4 single 110 36.9 divorced 15 5 widow 2 0.7 education vocational school of health 5 1.7 associate degree 29 9.7 bachelor’s degree 180 60.4 master’s degree 38 12.8 doctorate degree 46 15.4 job specialist doctor 42 14.1 doctor 19 6.4 nurse 155 52 health officer 26 8.7 nutritionist 11 3.7 pharmacist 10 3.4 laboratory technician 14 4.7 other* 21 7 monthly income 3001-5000 tl 6 2 5001-7000 tl 63 21.1 7001-10000 tl 167 56 10001 tl or more 62 20.8 unit of work policlinic 67 22.5 clinic 135 45.3 emergency 12 4 lab 26 8.7 operating room-ic*** 27 9.1 other** 31 10.4 total 298 100 other*physiotherapist, psychologist, medical secretary, audiometry technician, health technician, occupational therapist, biologist, speech and language therapist other** outpatient chemotherapy unit, clinical research unit, dining hall, patient rights, social service unit, transfusion center, audiology, administrative unit *** intensive care çelikkaya eb, journal of ideas in health (2023); 6(1):806-813 809 table 2. distribution of health professionals’ hearing about the concept of sustainable nutrition and distribution of the resources they heard hearing the concept of sustainable nutrition n (%) yes 113(37.9) no 185(62.1) information resources internet 69(28.7) tv news 26(10.8) social media 43(17.9) friend/environment 20(8.3) newspaper/magazine 9(3.8) scientific publications 31(12.9) from health professionals 39(16.3) other 3(1.3) table 3. distribution of statements made by health professionals within the scope of the elements included in sustainable nutrition statements n (%) it should have a low environmental impact 73(4.3) include seasonal foods 205(12.0) promote healthy living 245(14.3) it should be economical 179(10.4) provide food safety 194(11.3) it should be suitable for traditional foods 89(5.2) prevent food waste 192(11.2) it should be accessible to everyone 188(11.0) must meet nutritional needs 159(9.3) local production should be supported 77(4.5) prevent nutritional diseases 111(6.5) other 2(9.1) discussion the literature on sustainable nutrition is quite scarce. this indicates that it is a developing field of study. the literature has not found a study on sustainable nutrition in healthcare workers. our study can help fill this gap in the literature. in a study conducted by gülsöz on individuals aged 20 and over in turkey in 2017, 76.0% (n=312) of the participants stated that they had not heard of the concept of sustainable nutrition before, while 24.0% (n=100) stated that they had heard of it [12]. it is thought that the higher rate of hearing the concept of sustainable nutrition in our study is because our sample is health professionals. in the study conducted by engin on bachelor's degree students in turkey in 2022, it was seen that the concept of sustainable nutrition was heard on social media at a rate of 33.0%. it is estimated that it may be related to the fact that bachelor's degree students spend more time on social media due to their age. they stated that they heard this from health professionals (16.0%), publications such as newspapers and magazines (14.0%), scientific publications (14.0%), courses and training they took in bachelor's degree education (12%), and television (9.0%), respectively [16]. the rate of courses taken in bachelor's degree education was higher than that of health professionals. this may be because sustainable nutrition has been included in the course contents of some health departments recently. when the answers of the health professionals participating in the study about the elements of sustainable nutrition were examined, the statement "promote healthy life" was marked the most, and the statement "should have a low environmental impact" was marked the least. the data from akay's study (turkey) on university students studying health in 2020 resembles the current study. the students declared that sustainable nutrition should again most often promote healthy living and have the least environmental impact [13]. in another study, the spanish population surveyed most associated a sustainable diet with "plenty of fresh produce", " respect for biodiversity," and "rich in vegetables"; least associated with "cultural aspects of diet", "simple (consist of few ingredients) and "environmental impact" [17]. this shows that the relationship between sustainable nutrition and the environment is not absolutely known. studies are needed to inform health professionals about the environmental impact of sustainable nutrition. no significant relationship was found between healthcare professionals' sustainable nutrition knowledge levels and practices and gender and marital status. considering similar studies; in a study with the participation of 388 people from 5 different countries (slovakia, turkey, denmark, sweden, and austria), which was prepared within the scope of the suscof erasmus+ project, to evaluate the attitudes and behaviors of adults towards sustainable food consumption, no significant difference was found between the gender variable. considering marital status, it is stated that married individuals have more positive behaviors toward sustainable consumption [18]. a study conducted with 230 bachelor's degree students in california stated no significant difference between men and females, single and married students in food sustainability knowledge [19]. in gülsöz's study in turkey, a significant difference was observed between gender and the level of sustainable nutrition knowledge, and it was seen that 38.0% of females and 22.0% of men had adequate, sustainable nutrition levels [12]. the reason for the difference may be that most of the sample in our study was female, which may have prevented a statistical difference from occurring. while people's sustainable food consumption index score increases with age, surprisingly, the 56-65 age group scores decreased. in atar’s study in turkey, no significant relationship was found between sustainable nutrition knowledge levels and age; as age increases, the proportion of participants with a higher-than-average level of knowledge decreases [20]. dietitians are important health professionals to promote sustainable nutrition in health institutions [21]. in one-on-one consultancy services, they can create sustainable diets that have a low environmental impact and encourage healthy eating, minimize food waste in kitchen services in their institutions, plan menus suitable for sustainable diets, and increase the awareness of employees and patients by providing both inhouse and external training. in our study, dietitians' sustainable nutrition knowledge and practice scores were higher than other occupational groups. this is an expected result, but whether dietitians reflect sustainable nutrition knowledge and practices in their work is unknown. in the study conducted by wilson et al. in canada, it is seen that dietitians' recommendations about sustainable diets are left to their own self-efficacy and personal preferences. in the same study, it was stated that the reason why dietitians recommend reducing meat consumption is related to health rather than environmental impact [22]. çelikkaya eb, journal of ideas in health (2023); 6(1):806-813 810 table 4. distribution of sustainable nutrition knowledge levels of health professionals according to sociodemographic characteristics variable categorized variables n mean knowledge score (± sd) gender female 236 10.56±5.3 male 62 11.31±5.5 t / p 0.196/0.658 age group 18-25 68 10.44±5 26-35 85 10.67±5.2 36-45 83 10±5.4 46-55 46 12.30±5.3 56-65 16 11.19±6.1 f / p 1.496/0.203 marital status married 171 10.231±5.2 single 110 11.59±5.3 divorced 15 9.47±5.8 widow 2 13±0 f / p 1.895/0.131 education vocational school of health¹ 5 7.8±3.4 associate degree² 29 7.83±4.3 bachelor’s degree³ 180 10.67±5.1 master’s degree⁴ 38 11.34±5.5 doctorate degree⁵ 46 12.48±5.8 f / p* 4.090/0.003 posthoc 5>2 job specialist doctor¹ 42 11.93 ± 5.6 doctor² 19 13.11 ± 5.7 nurse³ 155 9.97 ± 4.9 health officer⁴ 26 12.19 ± 5.7 nutritionist⁵ 11 15.09 ± 6.5 pharmacist⁶ 10 9.8 ± 5 laboratory technician⁷ 14 8.36 ± 4 other⁸ 21 9.48 ± 4.8 f / p** 3.446/0.001 posthoc 5>3 5>7 monthly income 3001-5000 tl 6 10.33 ± 7.5 5001-7000 tl 63 10.56 ± 4.8 7001-10000 tl 167 10.35 ± 5.3 10001 tl or more 62 11.89 ± 5.7 f / p 1.308/0.272 unit of work policlinic 67 11.72 ± 5.1 clinic 135 10.16 ± 5.2 emergency 12 11.92 ± 7.5 lab 26 10.31 ± 4.8 operating room-ic 27 10.74 ± 5 other 31 10.81 ± 6.1 f / p 0.931/0.461 in the study conducted by wang et al. [23]in china by using sustainability assessment of food consumption of a group of more than 30,000 people, whose food consumption data and socioeconomic information were obtained from the china health and nutrition survey for the period 1997–2011, although the low-income and low-education group is much more sustainable than the higher income and higher education group, is has been stated that the sustainability of food consumption has decreased significantly over the years in all groups [23]. the sustainable food consumption index score of participants in the operating room and intensive care unit were significantly lower than those in other units. in alemdağ's study in turkey [24], it was stated that the healthy lifestyle behaviors of the health personnel working in the operating room were moderate, they could not use their knowledge in daily life, and the reason for this could be related to the intense work schedule and the stress of the cases [24]. in kalın's study in turkey [24], it was observed that as the stress level of operating room nurses increased, healthy lifestyle behaviors decreased [25]. çelikkaya eb, journal of ideas in health (2023); 6(1):806-813 811 table 5. distribution of scofi scores of healthcare professionals by sociodemographic characteristics variable categorized variables n mean scofi score (± sd) p value gender female 236 54.86±12.4 0.103 male 62 51.14±15.9 age group 18-25 68 49.64±14.6 0.01** 26-35 85 53.69±13.7 36-45 83 55.45±12 46-55 46 58.57±11.1 56-65 16 54.09±13.2 marital status married 171 54.79±12.9 0.129 single 110 52.51±14.6 divorced 15 55.9±8.7 widow 2 67.82±3.3 education vocational school of health 5 54.24±13.8 0.18 associate degree 29 48.95±13.4 bachelor’s degree 180 54.12±13.6 master’s degree 38 54.53±12.8 doctorate degree 46 56.81±11.6 job specialist doctor 42 56.09±11.7 0.047* doctor 19 55.23±11.8 nurse 155 52.46±13.8 health officer 26 54.46±13.2 nutritionist 11 66.25±6.7 pharmacist 10 50.62±19.9 laboratory technician 14 56.77±8.6 other 21 54.43±11.6 monthly income 3001-5000 tl 6 54.01±14.8 0.829 5001-7000 tl 63 51.93±15.78 7001-10000 tl 167 54.27±12.7 10001 tl or more 62 55.81±11.5 unit of work policlinic 67 56.16±11.4 0.033* clinic 135 52.77±14.3 emergency 12 58.35±14 lab 26 56.93±9.6 operating room-ic 27 48.46±12.8 other 31 54.09±13.2 in the study of gençgün in turkey [26], he mentioned that the healthy lifestyle behaviors of the operating room and intensive care nurses are still at a moderate level. this situation is lower than expected, possibly because the difficulty of working conditions prevents them from experiencing their knowledge in daily life [26]. due to similar reasons, operating room and intensive care workers may have lower scores than other units because they cannot spare time for sustainable practices. more detailed studies can be done on this subject. studies have shown that diet can prevent most cancer cases [27]. vineis et al. [28] examined the relationship between cancer and climate change. they mentioned that reducing the compounds released into the atmosphere and contributing to climate change will reduce the risk of many non-communicable diseases, including cancer [28]. considering the positive effects of sustainable diets on the environment and health, it is important for the health professionals working in the oncology hospital to have sufficient knowledge of sustainable nutrition for their patients. simões et al.'s study [29] determined that insulin-like growth factor 1 (igf-1), glycemia, and total cholesterol decreased at çelikkaya eb, journal of ideas in health (2023); 6(1):806-813 812 the end of the intervention in a breast cancer patient who switched from a western-style diet to a plant-based diet [29]. sustainable diets that encourage the overconsumption of plant foods may benefit cancer patients. the lack of a standard scale to measure the level of sustainable nutrition knowledge in the literature and the inability to reach our entire universe due to covid-19 conditions constitute the limitations of the research. a large number of females impacted our study. the height and weight status of the participants were taken according to their statements. in addition, the fact that our study has a crosssectional design creates a limitation in revealing causality. conclusion as a result, 62.1% of healthcare professionals have yet to hear of sustainable nutrition. it was observed that only 44.6% of the participants had sufficient sustainable nutrition knowledge, and 54.1% had sufficient sustainable nutrition practices. more than sustainable nutrition knowledge and practices of health professionals is required. hospitals are important institutions for promoting sustainable nutrition. training should be given to increase health professionals' sustainable nutrition knowledge level, who is expected to be an example to society. sustainable nutrition should be added to the bachelor’s degree education curriculum, especially in health departments. strategies and policies for sustainable nutrition should be developed, and health professionals should be pioneers.. abbreviation trh: training and research hospital; scofi: sustainable food consumption index; spss: statistical package for the social sciences; un: united nations; wced: world commission on environment and development; fao: food and agriculture organization; abd: united states of america; sd: standard deviation; suscof: sustainable consumption of food; igf-1: insulin-like growth factor; covid-19: coronavirus disease-2019 declaration acknowledgment we thank all the health personnel who participated in our survey. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing dyteminebalyan@gmail.com authors’ contributions emine balyan çelikkaya (ebc) is the responsible author for the concept, design, literature search, data analysis, data acquisition, manuscript writing, editing, and reviewing. ebc has read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the protocol was approved by ankara yıldırım beyazıt university ethics committee (ref: sr/33 at 29november-2021); in addition, web-based informed consent was obtained from each participant after the study objectives and confidentiality guarantee was explained. consent for publication not applicable competing interest the authors declare that they have no competing interest. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of public health, ankara yildirim beyazıt university institute of health sciences, ankara, turkey. 2dr. abdurrahman yurtaslan oncology trh, ankara, turkey. article info received: 07 december 2022 accepted: 15 february 2023 published: 18 march 2023 references 1. wced u. brundtland report-our common future; 1987. available from: https://sustainabledevelopment.un.org/content/documents/ 5987our-common-future.pdf [accessed on 5 november 2022] 2. şen h, kaya a, alpaslan b. a historical and current perspective on sustainability (sürdürülebilirlik üzerine tarihsel ve güncel bir perspektif). ekonomik yaklaşım derneği. 2018; 29:1-47. doi: 10.5455/ey.39101 3. fao. sustaınable dıets and bıodıversıty; 2010. roma. available from: https://www.fao.org/3/i3004e/i3004e00.pdf [accessed on 13 november 2022] 4. fao/who. sustainable healthy diets – guiding principles; 2019. roma. available from: https://www.fao.org/3/ca6640en/ca6640en.pdf [accessed on 16 november 2022] 5. global panel on agriculture and food systems for nutrition. the cost of malnutrition; 2016. london, uk. available from: https://www.glopan.org/cost-ofmalnutrition/#:~:text=the%20estimated%20impact%20on %20the,or%20us%24500%20per%20individual. [accessed on 16 november 2022] 6. perignon m, vieux f, soler lg, masset g, darmon n. improving diet sustainability through evolution of food choices: review of epidemiological studies on the environmental impact of diets. nutrition reviews. 2017;75(1):2-17. doi: 10.1093/nutrit/nuw043 7. tubiello fn, rosenzweig c, conchedda g, karl k, gütschow j, xueyao p, et al. greenhouse gas emissions çelikkaya eb, journal of ideas in health (2023); 6(1):806-813 813 from food systems: building the evidence base. environmental research letters. 2021;16(6):065007. doi: 10.1088/1748-9326/ac018e 8. fao. the state of the world's land and water resources for food and agrıculture; 2011. available from: https://www.fao.org/land-water/solaw2021/en/ [accessed on 5 november 2022] 9. fao. water for sustainable food and agriculture; 2017. roma. available from: https://www.fao.org/3/i7959e/i7959e.pdf [accessed on 5 november 2022] 10. willett w, rockström j, loken b, springmann m, lang t, vermeulen s, et al. food in the anthropocene: the eatlancet commission on healthy diets from sustainable food systems. lancet. 2019;393(10170):447-92. doi: 10.1016/s0140-6736(18)31788-4 11. sample size calculator by raosoft, inc.; 2021. available from: http://www.raosoft.com/samplesize.html [accessed on 15 february 2023] 12. gülsöz s. the evaluation of the levels of knowledge and practice on sustainable nutrition of individuals' aged twenty years and over. m.sc. thesis, the university of başkent.2017. available from: https://tez.yok.gov.tr/ulusaltezmerkezi/tezsorgusonucye ni.jsp [accessed on 22 november 2022] 13. akay g. evaluation of the knowledge levels of university students studying health about sustainable nutrition and environment relationship. m.sc. thesis, the university of necmettin erbakan.2020. available from: https://tez.yok.gov.tr/ulusaltezmerkezi/tezsorgusonucye ni.jsp [accessed on 22 november 2022] 14. erasmus+ program of the european union. sustainable consumption of food index; 2020. available from: http://suscof.com/index.php/cikti-2-scofi-indeks/ [accessed on 21 november 2022] 15. erasmus+ program of the european union. the scofi tecnical notes and calculatıon; 2020. available from: http://suscof.com/index.php/en/output-2-the-scofi-index/ [accessed on 21 november 2022] 16. engin ş. the relationship between knowledge and behaviors on sustainable nutrition with food preferences of bahçeşehir university undergraduate students. m.sc. thesis, the university of bahçeşehir.2022. available from: https://tez.yok.gov.tr/ulusaltezmerkezi/tezsorgusonucye ni.jsp [accessed on 22 november 2022] 17. garcía-gonzález á, achón m, carretero krug a, varelamoreiras g, alonso-aperte e. food sustainability knowledge and attitudes in the spanish adult population: a cross-sectional study. nutrients. 2020;12(10). doi: 10.3390/nu12103154 18. erasmus+ program of the european union. sustainable consumption of food need analysıs report; 2019. available from: http://suscof.com/index.php/en/output-12/ [accessed on 22 november 2022] 19. torabian-riasati s, lippman s, nisnevich y, plunkett s. food sustainability knowledge and ıts relationship with dietary habits of college students. austin j nutri food sci. 2017;5(2): 1089. 20. atar a. evaluation of corporate company employees' knowledge, attitudes and behaviors about sustainable nutrition. m.sc. thesis, the university of i̇stanbul medipol.2021. available from: https://tez.yok.gov.tr/ulusaltezmerkezi/tezsorgusonucye ni.jsp [accessed on 22 november 2022] 21. alberdi g, begiristain-zubillaga m. the promotion of sustainable diets in the healthcare system and ımplications for health professionals: a scoping review. nutrients. 2021;13(3):747. doi: 10.3390/nu13030747 22. wilson ed, garcia ac. environmentally friendly health care food services: a survey of beliefs, behaviours, and attitudes. can j diet pract res. 2011;72(3):117-22. doi: 10.3148/72.3.2011.117 23. wang l, huang w, zhao c, hu y, cui s. exploring the environment-nutrition-obesity effects associated with food consumption in different groups in china. j environ manage. 2022; 317:115287. doi: 10.1016/j.jenvman.2022.115287 24. alemdağ m. health promoting lifestyle behaviors of healthcare personnel working in the operating theatre and determination of the related factors. m.sc. thesis, the university of ankara yıldırım beyazıt.2019. available from: https://tez.yok.gov.tr/ulusaltezmerkezi/tezsorgusonucye ni.jsp [accessed on 22 november 2022] 25. kalın z. the effect of stress levels of operating room nurses on healthy lifestyle behaviors in the covi̇d-19 pandemic. m.sc. thesis, the university of i̇stanbul.2022. available from: https://tez.yok.gov.tr/ulusaltezmerkezi/tezsorgusonucye ni.jsp [accessed on 22 november 2022] 26. gençgün f. an assessment of healthy lifestyle behaviour in surgical and intensive care nurses. m.sc. thesis, the university of okan.2018. available from: https://tez.yok.gov.tr/ulusaltezmerkezi/tezsorgusonucye ni.jsp [accessed on 23 november 2022] 27. el-sherif a, el-sherif s, taylor ah, ayakannu t. ovarian cancer: lifestyle, diet and nutrition. nutrition and cancer. 2021;73(7):1092-107. doi: 10.1080/01635581.2020.1792948 28. vineis p, huybrechts i, millett c, weiderpass e. climate change and cancer: converging policies. molecular oncology. 2021;15(3):764-9. doi: https://doi.org/10.1002/1878-0261.12781 29. simões lmfr, tavares nar, ferreira-pêgo c. plantbased diet and igf-1 modulation on her2-positive breast cancer: a lifestyle medicine nutrition approach in oncology. american journal of lifestyle medicine. 2021;16(1):36-45. doi: 10.1177/15598276211023048 https://doi.org/10.47108/jidhealth.vol5.iss4.266 yahyaa bt, et al., journal of ideas in health 2022;5(4):794-799 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access impact of family structure and sociodemographic characteristics on parents headed families in ramadi city, iraq badea'a thamir yahyaa1, ru'ya abdulhadi al-rawi1, mustafa yaseen taha2, yaseen t. sarhan1, ban nadum abdul fatah1, ahmed k. al-delaimy1, mustafa ali mustafa al-samarrai1, omar rashid mukhlif3, mahasin a. al-taha1 abstract background: several factors in the family profile contribute significantly to determining the effective policy when heading the family. this study aims to evaluate the sociodemographic and economic burdens on parents-headed families in ramadi city, west of iraq. methods: a prospective cross-sectional household-based survey was conducted from 1st to 28th february 2019 among iraqi people residents in ramadi city, anbar province. a multistage sampling technique was recruited to identify the eligible sample. a semi-structured questionnaire was used to interview (face-to-face) the respondents. data from 267 households have undergone univariate and bivariate analyses. multiple logistic regression, odds ratio (or), and confidence intervals (cis) were estimated to explore the predicting variables. the statistically significant is considered at less than 0.05. results: the mean age of respondents was 43.88 (± 12.1) years (range: 25 to 69 years). out of the total surveyed people, 52.8% were young (less than 44 years), male-headed families (59.6%), low educated level (65.5%), unemployed (52.4%), married (67.4%) and headed big families of seven members and above (43.1%). history of chronic diseases and smoking habits was positive among 46.4% and 45.7% of respondents, respectively. findings of the binary logistic regressions showed that history of smoking (or = 7.201, 95% ci: 3.254 to15.936), families of 7 members and above (or = 6.239, 95% ci: 2.938 to 13.250), unhappy (or = 5.237, 95% ci: 2.140 to 12.818), aged 44 years and above (or = 3.518, 95% ci: 1.581 to 7.829), being single (unmarried, divorced, widow) (or = 2.697, 95% ci: 1.230 to 5.914), and had a monthly income of less than usd400 (or = 2.333, 95% ci: 1.112 to 4.859) are significantly associated with female-headed family. conclusion: priority must be given to some elements such as genetic, physical differences, biopsychosocial factors, and the economic situation when discussing parents' behavior in heading the family. keywords: family profile, sociodemographic factors, gender, head of family, society, iraq background the family forms an indispensable unit in building a society in many cultures, especially in arab communities. therefore, any society's development depends on the family's success in building its components. the iraqi family is distinguished by the number of its members and its close association with the restoration of society [1]. however, the rapid developments in technology, accelerated lifestyle changes, successive wars, displacement, malnutrition, unsafe drinking water, and poor medical and healthcare services were existential challenges that led to the restructuring of the family entity, such as the early separation of children from the family and appearance of single-head families [2,3,4]. united nations development program (undp) reported in 2013 that for every ten iraqi families, one family is headed by the female gender [5]. most of these women were either widow, divorced or responsible for caring for their unwell husbands. iraq's security and economic disturbances burdened poor families and doubled the incidence of chronic diseases. hussain and lafta [6] found that the incidence of cardiovascular disease and diabetes had significantly increased after 2003. a report by who (2016) found that non-communicable diseases (ncds) were responsible for about 55.0% of total death among iraqi ___________________________________________________ med.badeaa.thamir@uoanbar.edu.iq 1department of family and community medicine, faculty of medicine, anbar university, anbar, iraq a full list of author information is available at the end of the article 10.47108/jidhealth.vol5.iss4.266 http://www.jidhealth.com/ yahyaa bt, et al., journal of ideas in health (2022); 5(4):794-799 795 people in 2016 [7]. ncds are directly related to the lifestyle and behavior of individuals and society. bad dietary choices, physical inactivity, heavy smoking, and drug and alcohol addiction are the common predictors of ncds [8]. the prevalence of obesity (body mass index, bmi ≥30 kg/m2) in iraq was 66.9% in a national survey (2005–2006) [9] and 33.9% in a 2015 national survey [10]. the trend in iraq seems higher than the global trend of obesity which reported a male prevalence of 10.8% and a female prevalence of 14.9% [11]. according to the world bank report, the prevalence of tobacco smoking in iraq was 18.5% in 2020 [12]. there is a noticeable increase in nicotine consumption rates in areas experiencing conflict. the problem of tobacco smoking in iraq is complicated due to the continuity of internal conflicts for many years [13]. the iraqi family often witnesses the addition of new individuals to the list of smokers with the deterioration of the economic, security, and service situation. previous studies have shown the psychosocial and economic burdens of displacement on the iraqi family, especially when the family must rehabilitate the destroyed house or rent another house [3,4]. forced displacement with the lack of alternatives to provide safety and suitable living generated unbearable challenges for the head of the family. many of them were victims of chronic diseases and mental disorders. this study aims to assess the effect of the family structure and sociodemographic factors on the head of a family in ramadi city, iraq. methods study design and population we conducted a prospective cross-sectional household-based survey from 1st to 28th february 2019 among iraqi people residents in the al-tameem neighborhood in the city center of ramadi, anbar province. the sampling method was a face-toface survey of heads of households using a multistage sampling technique. ramadi city has sixteen neighborhoods; then, we randomly selected one neighborhood; then, we theoretically divided the selected neighborhood into four quarters; then, from each quarter, we selected eight blocks; and then we selected ten houses from each selected block; then, one head of house interviewed. a well-trained team of interviewers was recruited to explain the objectives and conditions of the study. moreover, the interviewers assure respondents' freedom to participate or withdraw and that all information and opinions gathered would be anonymous, confidential, and used for the purpose of research". the weekend days (friday and saturday) were the favored dates to meet the most eligible house heads. in some cases, it is agreed with the respondent on the place and the appropriate date for the interview later. the authors ensured supervision during all stages of the study, including the data collection phase. out of 320 visited households, 290 agreed on the interview. the total population was 267 after excluding 23 uncompleted questionnaires. inclusion and exclusion criteria all iraqi people, households, both genders, at least 18 years old or older, and willing to participate are included in the study. at the same time, we excluded incomplete data, non-household family members, mentally unstable, and those not willing to participate. sample size the sample size calculator arrived at 264 participants, using a margin of error of ± 6%, a confidence level of 95%, and a 50% response distribution [14]. non-response correction = 10%. thus, the total sample size was (264+26) 290. supervision during the data collection phase was ensured in all stages. after excluding 23 incomplete documents, the sample was 267 for final analysis. study instrument the data was collected using a semi-structured household questionnaire. the english language was used to prepare the questionnaire and then translated into the local native language (arabic). content validity was ensured, and cronbach alpha reliability reached 72.6. a pilot test was performed among fifteen heads of households who were not included in the study. the questionnaire has three components; the first part is the sociodemographic and economic factors. the second part included one closed-ended question used to self-rank the health status. moreover, a consent form must be signed before heads of households are allowed to participate in the study. dependent variable the dependent variable was the gender of the head of the household as "male" and "female". in our study, the head of the household was defined as the individual who provides support and is responsible for governing a group of family members, such as "dependent children, grandchildren, parents, or other relatives" [15]. independent variables for the purpose of analysis, some of the sociodemographic variables were exposed to categorization. the age variable was categorized into two groups codded "one" for respondents aged less than 44 years and coded "zero" for those aged 44 years and above. the health of respondents was categorized as "healthy" and coded "one" and "unhealthy" and coded "zero" marital status was captured as binary, and a value of "zero" was used for married participants and the unmarried, widows, divorced considered "single" and coded "one". we defined consanguineous marriage as a union (marriage) between two persons who are closely related as second cousins or closer. the head of household with consanguineous marriage was coded "0", and those without were coded "1". the big families having seven members and more (including the parent and grandparents) have been coded with "zero", while the families with less than seven members cod were ed with"1". chronic disease variable was defined as a condition that "last one year or more and require ongoing medical attention or limit activities of daily living or both" [16] such as dancer, diabetes, high blood pressure, cardiovascular diseases, etc. respondents with at least one chronic disease were coded "zero," and those with no chronic illness were coded "1". the head of household with a history of tobacco smoking, hookah, electronic cigarette, etc., was coded "zero," and those with a history of smoking were coded "one". respondents who described themselves as happy were coded "one," and unhappy respondents were coded "zero". at the time of data collection (1st january 2021), the exchange rate of iraqi dinar (iqd)1 = united states dollar (usd) 0.0008. therefore, the monthly income (including all incentives yahyaa bt, et al., journal of ideas in health (2022); 5(4):794-799 796 and bounces) of our respondents was coded "zero" for those who earned less than usd 400 (iqd 600,000) and coded "one" for those who earned more than usd 400. the occupation was recorded and coded into "one" for is currently employed (has a fixed employment in the government of private sectors) and the code of "zero" for those currently unemployed. statistical analysis the data were analyzed using ibm spss version 16. categorical variables are presented in terms of frequencies and percentages. bivariate analyses were performed using the chisquare test for the categorized variables. in the multiple logistic regression, odds ratio (or) and confidence intervals (cis) were estimated, and only the variables with a p-value of < 0.05 were recruited to explore the factors that predict female-headed households. the statistically significant is considered at less than 0.05. results descriptive and general characteristics of related factors three hundred and sixty-seven heads of households have been surveyed. the mean age was 43.88 (± 12.1) years, ranging from 25 to 69 years old. most of the respondents were males (59.6%), aged less than 44 years old (52.8%), married (67.4%), and with a history of consanguineous marriage among 56.6% of them. most household respondents had a low educated level (65.5%), with big families of seven members and above (43.1%), were exposed to internal displacement (49.1%), and described themselves as unhappy people (68.2%). history of chronic diseases and smoking habits was positive among 46.4% and 45.7% of respondents, respectively. however, 63.3% of them ranked themselves as healthy. concerning the economic situation, more than half of the respondents were unemployed (52.4%), with a monthly salary exceeding usd 400 (57.7%) (table 1). table 1 univariate and bivariate analysis of household-related factors (n=367) factors category total (n=267) female 108(40.4) male 159(59.6) χ2 p age <44 years 141(52.8) 30(21.3) 111(78.7) 45.60 0.000 >44 years 126(47.2) 78(61.9) 48(38.1) health unhealthy 98(36.7) 51(52.0) 47(48.0) 8.64 0.004 healthy 169(63.3) 57(33.7) 112(66.3) marital status single 87(32.6) 50(57.5) 37(42.5) 15.52 0.000 married 180 (67.4) 58(32.2) 122(67.8) consanguineous marriage yes 112(41.9) 39(34.8) 73(65.2) 2.54 0.111 no 155(58.1) 69(44.5) 86 (55.5) family members > 7 115(43.1) 83(72.2) 32(27.8) 84.40 0.000 < 7 152(56.9) 25(16.4) 127(83.6) chronic diseases yes 124(46.4) 81(65.3) 43(34.7) 59.46 0.000 no 143(53.6) 27(18.9) 116(81.1) smoking habits yes 122(45.7) 70(57.4) 52(42.6) 26.72 0.000 no 145(54.5) 38(26.2) 107(73.8) educational level low 175(65.5) 67(38.3) 108(61.7) 0.99 0.320 high 92(34.5) 41(44.6) 51(55.4) employment unemployed 140(52.4) 65(46.4) 75(53.6) 4.37 0.037 employed 127(47.6) 43(33.9) 84(66.1) happiness unhappy 182(68.2) 90(49.5) 92(50.5) 19.23 0.000 happy 85(31.8) 18(21.2) 67(78.8) displacement yes 131(49.1) 68(51.9) 63(48.1) 14.00 0.000 no 136(50.9) 40(29.4) 96(70.6) income level usd<400 113(42.3) 57(50.4) 56(49.6) 8.12 0.004 usd>400 154(57.7) 51(33.1) 103(66.9) factors associated with gender in bivariate analysis cross tabulation showed that only unhealthy respondents (chisquare test (χ2 = 8.64, p = 0.004), who were aged 44 years and above (χ2 = 45.60, p < 0.001), being single (χ2 = 15.52, p < 0.001), big family of seven members and above (χ2 = 84.40, p < 0.001), chronic diseases (χ2 = 59.46, p < 0.001), smoking habits (χ2 = 26.72, p < 0.001), unemployed (χ2 = 4.37, p = 0.037), unhappy (χ2 = 19.23, p < 0.001), internally displaced (χ2 = 14.00, p < 0.001), and monthly income of usd<400 (χ2 = 8.12, p = 0.004) have significantly associated with female gender (table 1). factors associated with female-headed households in multiple logistic regression in the multivariable logistic regressions, the head of household who had a history of smoking (or = 7.201, 95% ci: 3.254 to15.936) belonged to a big family of 7 members and above (or = 6.239, 95% ci: 2.938 to 13.250), and rated himself as unhappy (or = 5.237, 95% ci: 2.140 to 12.818), had the highest odds ratios, respectively. at the same time, the head of household aged 44 years and above (or = 3.518, 95% ci: 1.581 to 7.829), being single (unmarried, divorced, widow) (or = 2.697, 95% ci: 1.230 to 5.914), had a monthly income of less than usd400 (or = 2.333, 95% ci: 1.112 to 4.859) had the lowest odds ratios, respectively. the hosmer and lemeshow test indicated a good fit (p = 0.626). the total model was significant (p = < 0.001) and accounted for 63.1% of the variance (nagelkerke r square = 0.631). yahyaa bt, et al., journal of ideas in health (2022); 5(4):794-799 797 table 2. factors associated with female-headed households in multiple logistic regression (n=267) variables categories b s.e. wald p-value exp(b) 95% ci age 44 years and above 1.258 0.408 9.498 0.002 3.518 1.581-7.829 less than 44 years reference marital status single (divorced, widow) 0.992 0.401 6.135 0.013 2.697 1.230-5.914 married reference family members seven members and above 1.831 0.384 22.700 0.000 6.239 2.938-13.250 less than 7 reference chronic disease yes 1.171 0.413 8.057 0.005 3.226 1.437-7.241 no reference tobacco smoking yes 1. 974 0.405 23.726 0.000 7.201 3.254-15.936 no reference happiness unhappy 1.565 0.457 13.143 0.000 5.237 2.140-12.818 happy reference monthly income less than usd400 0.847 0.378 5.019 0.025 2.333 1.112-4.859 usd400 and above reference discussion in this study, we tried to discuss the impact of family structure and sociodemographic factors on the head of household in iraq. among 267 surveyed households, 59.6% were male-headed households, and 40.4% were female-headed households. our finding was incompatible with previous reports of 10.0% and 7.7% female-headed families in iraq, which have been issued by the united nation office for coordination and humanitarian affairs (ocha), inter-agency information and analysis unit (iau), and mopdc-cso (central statistical organization) in 2010, respectively [17,18]. taking into account the difference in the sample and the region at the local level, the percentage of families headed by females varies greatly at the global level. the past five decades have witnessed a sharp increase and difference in proportions with a difference in societies worldwide [19]. our study is largely corresponding to the global trend estimating that 33.0%-50.0% of families are headed by females [19,20]. a report from the world health organization [21] indicated that "as people age, they become more vulnerable to diseases and disability". similarly, our finding showed that respondents aged 44 years and above were 3.518 times more female-headed than maleheaded families. many iraqi families had lost their fathers due to repeated wars over the past four decades, which led to a cumulative number of families headed by females. moreover, logistic regression showed 2.697 times of single (divorced, widow) female-headed families than their counterparts. in fact, recent official statistics showed high divorce rates in iraqi society; however, most young widows are desirable for marriage, especially by relatives, due to the high percentages of consanguineous marriage, the conservative advantage in iraqi society, and the keenness to take care of orphans [1]. therefore, the chances of marriage might be less among widows and divorced women aged forty years and above, especially in large families. an iraqi family's average number of members is six or seven [1]. part of our results showed that families of 7 members and above were 6.239 times more female-headed families than male-headed families, which puts an additional burden on the woman's shoulders. women-headed families suffer daily to provide food, water, education, and health care [22]. the higher the number of family members, the higher the needs and the more difficult administration. many poor families were forced to allow their young children to work to earn an extra income for the family. similarly, our study showed that 2.333 times female-headed families had family income less than usd400 than males. unfortunately, children are vulnerable to different social problems that may include smoking, drinking alcohol, and even drug use [23]. these problems require radical solutions that are difficult for a family headed by a female. despite that health status was not a predictor of gender in binary logistic regression, yet, in cross-tabulation, the chi-square test (χ2 = 8.64, p = 0.004) was statistically different in gender. among 267 surveyed heads of households, 63.3% were healthy, and 36.7% were unhealthy. similarly, a previous study conducted by ali jadoo et al. [24] in outpatient clinics in iraq, found that 46.4% of patients were unhealthy. moreover, our results found that chronic disease was a predictor factor for gender. chronic disease was 3.226 times more among female headed families than male-headed families. previous studies have confirmed that the performance of the family and the management of family problems, such as social, emotional, and behavioral in children, are negatively affected by chronic parental disease [25,26,27,28]. the longer the duration of the disease and its intensity in the parents, the more negative effects on the children [26,27]. girls are more vulnerable to weak development than boys in families led by chronically ill women [26,28,29]. unfortunately, most smoking parents lack the real desire to cease smoking. children are more likely to be exposed to environmental tobacco smoke (ets) from parents. there is a big gap in prevalence of cigarette smoking between iraqi males (35.0%) and females 2.0% in 2020 [12]. however, the finding of the current study found that the smoking odds ratio was 7.201 times among female headed families than among males. the desire for smoking arises in both sexes in early puberty due to the influence of peers. however, resorting to smoking in later stages has a direct relationship to the social and economic situation [30]. several studies have indicated the existence of mental problems in families headed by one of the parents, with a significant increase in the prevalence of psychological problems and depression in families headed by females compared to males [31,32]. yahyaa bt, et al., journal of ideas in health (2022); 5(4):794-799 798 conclusion more than one-third of surveyed families were low educated, young age and female-headed. history of smoking, families of 7 members and above, unhappy, aged 44 years and above, being single (unmarried, divorced, widow and had a monthly income of less than usd400 were the prominent variables significantly associated with female-headed family. abbreviation or: odds ratio; cis: confidence intervals; ncds: non-communicable diseases; bmi: body mass index; who: world health organization declaration acknowledgment none. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing med.badeaa.thamir@uoanbar.edu.iq. authors’ contributions all authors have contributed equally in designing, writing, analyzing, interpreting the study, and drafting and reviewing the article. all authors read and approved the final version of the manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki, and the protocol was approved by the ethics committee of the scientific issues and postgraduate studies unit (psu), college of medicine, university of anbar (ref: sr/207 at 21-jaunary -2019). moreover, written informed consent obtained from each participant after explanation of the study objectives and the guarantee of secrecy. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of family and community medicine, faculty of medicine, anbar university, anbar, iraq. 2resident medical officer, armadale hospital, wa, australia. article info received: 28 november 2022 accepted: 27 december 2022 published: 29 december 2022 references 1. yahyaa bt, al-samarrai mam, ali jadoo sa. prevalence and perception of women about consanguineous marriage in al ramadi city. indian journal of public health research and development 2019;10(4): 567-573. 2. ibrahim nm, khalil ns, tawfeeq rs. assessment of malnutrition among the internally displaced old age people in the tikrit city, iraq. journal of ideas in health. 2019 may 27 [cited 2022 jun. 18];2(1):65-9. doi: 10.47108/jidhealth.vol2.iss1.15 3. ali jadoo sa, sarhan yt, al-samarrai mam, al-taha ma, al any bn, soofi ak, yahyaa bt, al-rawi ra. the impact of displacement on the social, economic and health situation on a sample of internally displaced families in anbar province, iraq. journal of ideas in health. 2019 may 8 [cited 2022 jun. 15];2(1):56-9. doi: 10.47108/jidhealth.vol2.iss1.16 4. al-samarrai mam, alany bn, al-delaimy ak, yahyaa bt, ali jadoo sa. impact of internal displacement on psychosocial and health status of students residing in anbar university, iraq hostel. journal of ideas in health. 2020 may 25 [cited 2022 jun. 15];3(1):140-4. doi: 10.47108/jidhealth.vol3.iss1.25 5. gender in focus. undp iraq, available at: www.iq.undp.org/content/dam/iraq/docs/gender_final.pd [accessed 17 june 2022]. 6. hussain am, lafta rk. burden of non-communicable diseases in iraq after the 2003 war. saudi med j. 2019 jan;40(1):72-78. doi: 10.15537/smj.2019.1.23463. 7. world health organization. (2018). non-communicable diseases country profiles 2018. world health organization. https://apps.who.int/iris/handle/10665/274512. license: cc bync-sa 3.0 igo, iraq profile, page109, available online: file:///c:/users/drsaa/downloads/9789241514620-eng.pdf [accessed on 18 june 2022]. 8. world health organization (who), non-communicable diseases: risk factors. available online: https://www.who.int/data/gho/data/themes/topics/topicdetails/gho/ncd-risk-factors. [accessed on 18 june 2022]. 9. ministry of health of iraq chronic non-communicable diseases risk factors survey in iraq, 2006. available online: http://www.who.int/chp/steps/iraqstepsreport2006.pdf [accessed on 18 june 2022]. 10. pengpid s, peltzer k. overweight and obesity among adults in iraq: prevalence and correlates from a national survey in 2015. int j environ res public health. 2021 apr 15;18(8):4198. doi: 10.3390/ijerph18084198. 11. ncd risk factor collaboration (ncd-risc) trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 million participants. lancet. 2016; 387:1377–1396. doi: 10.1016/s0140-6736(16)30054-x. 12. the world bank, prevalence of current tobacco use (% of adults) – iraq. available from: https://data.worldbank.org/indicator/sh.prv.smok?locations=i q [accessed on 18 june 2022]. 13. hussain z, sullivan r. tobacco in post-conflict settings: the case of iraq. ecancermedicalscience. 2017 apr 28; 11:735. doi: 10.3332/ecancer.2017.735. pmid: 28596801; pmcid: pmc5440183. yahyaa bt, et al., journal of ideas in health (2022); 5(4):794-799 799 14. raosoft, sample size calculator. available from: http://www.raosoft.com/samplesize.html?nosurvey [accessed on 06 june 2021]. 15. yourdictionary, head-of-household definition. available from: https://www.yourdictionary.com/head-of-household [accessed on 7 june 2022]. 16. center for disease control and prevention (cdc), national center for chronic disease prevention and health promotion (nccdphp), about chronic diseases. available from: https://www.cdc.gov/chronicdisease/about/index.htm [accessed on 7 june 2022]. 17. united nations office for coordination and humanitarian affairs (ocha), inter-agency information and analysis unit (iau), iraqi women: figures & facts. available from: file:///c:/users/drsaa/downloads/9ff462d0a9fbfa0749257573 0052330c-full_report.pdf [accessed on 22 june 2022] 18. mopdc-cso (central statistical organization), 2010. iraq the results of buildings, dwellings and establishment census and households listing within the project of population and housing census (phc 2010) iraq. 19. lichter dt, mclaughlin dk, ribar dc. welfare and the rise in female headed families. american journal of sociology1997; 103(1): 112-143. doi: 10.1086/231173. 20. working and living arrangement of single mother households and social support in mexico city. summer research report. austin, tx: center for latin america social policy, university of texas at austin; 2006. 21. world health organization, europe, risk factors of ill health among older people. available from: https://www.who.int/europe/news-room/fact-sheets/item/riskfactors-of-ill-health-among-older-people [accessed on 8 june 2022]. 22. icrc (international committee of the red crescent), gorilla's guides, 2011. iraq: women struggle to make ends meet. available from: http://www.icrc.org/eng/assets/files/2011/iraq-update-0102-2011-icrc-eng.pdf. [accessed on 22 june 2022]. 23. shlash a, abdul hameed s, sweadan a. 1998. impact of poverty on women-headed families: a field study. a study carried out by the continuous human developmental net in iraq, with the cooperation of the escwa and the undp. 24. ali jadoo sa, yaseen sm, al-samarrai mam, mahmood as. patient satisfaction in outpatient medical care: the case of iraq. journal of ideas in health. 2020 aug. 26 [cited 2022 jun. 8];3(2):176-82. doi: 10.47108/jidhealth.vol3.iss2.44. 25. kaasbøll j, skokauskas n, lydersen s, sund am. parental chronic illness, internalizing problems in young adulthood and the mediating role of adolescent attachment to parents: a prospective cohort study. front psychiatry. 2021 dec 31; 12:807563. doi: 10.3389/fpsyt.2021.807563. 26. sieh ds, meijer am, oort fj, visser-meily jma, leij dav. problem behavior in children of chronically ill parents: a metaanalysis. clin child fam psychol rev. (2010) 13:384–97. doi: 10.1007/s10567-010-0074-z. 27. chen cy-c. effects of parental chronic illness on children's psychosocial and educational functioning: a literature review. contemp school psychol. (2017) 21:166–76. doi: 10.1007/s40688-016-0109-7. 28. pakenham ki, cox s. the effects of parental illness and other ill family members on the adjustment of children. ann behav med. (2014) 48:424–37. doi: 10.1007/s12160-014-9622-y. 29. bell mf, bayliss dm, glauert r, ohan jl. developmental vulnerabilities in children of chronically ill parents: a populationbased linked data study. j epidemiol commun health. (2019) 73:393. doi: 10.1136/jech-2018-210992 30. amato pr, kane jb, james s. reconsidering the “good divorce”. fam relat. 2011;60(5):511–24. 31. wade tj, veldhuizen s, cairney j. prevalence of psychiatric disorder in lone fathers and mothers: examining the intersection of gender and family structure on mental health. can j psychiatry. 2011 sep;56(9):567-73. doi: 10.1177/070674371105600908. 32. barrett ae, turner rj. family structure and mental health: the mediating effects of socioeconomic status, family process, and social stress. j health soc behav. 2005 jun;46(2):156-69. doi: 10.1177/002214650504600203. https://doi.org/10.47108/jidhealth.vol6.iss2.280 bulguroglu hi, et al., journal of ideas in health (2023); 6(2):847-853 © the author(s). 2023 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access investigation of the effects of kinesiophobia level on physical activity and quality of life in university students halil ibrahim bulguroglu1*, merve bulguroglu1, sezen dincer1, cansu gevrek aslan2, serenay zorlu1, kübra kendal3 abstract background: kinesiophobia, which is called activity avoidance, is a condition that may cause university students to stay away from physical activity more. this study aimed to understand how physical activity and quality of life levels of university students with different levels of kinesiophobia are affected. methods: our study included 395 students who were studying at ankara medipol university in the 2022-2023 academic year and were accepted to participate in our study. the kinesiophobia, physical activity and quality of life levels of the students were evaluated with questionnaires. demographic characteristics of students were analyzed using chi-square and mann-whitney u tests. spearman correlation analysis was used for the correlation between the scores of the scales, and mann-whitney u was used for comparing physical activity levels and quality of life according to kinesiophobia levels. statistical significance was set as p<0.05. results: among the students who participated in our study, 226 (57.22%) students had high kinesiophobia levels and 169 (42.78%) had low kinesiophobia levels. while 74.3% of people with high kinesiophobia levels were women, 67.5% of participants with low kinesiophobia levels were women. age and bmi levels of the participants in both groups were similar (p>0.05). in our study, while all parameters of whoqol and tks were correlated with each other, only physical and psychosocial sub-parameters of whoqol and ipaq were correlated (p<0.05). according to the results obtained from the study, the physical activity amount and quality of life scores of the students with lower kinesiophobia levels were found to be higher (p<0.05). conclusion: as a result, different levels of kinesiophobia in university students can affect the amount of physical activity and quality of life of students. it is essential to keep students away from the vicious circle of kinesiophobia and lack of physical activity and to direct them to physical activities. keywords: university students, kinesiophobia, physical activity, quality of life, turkiye. background university years, one of the critical periods of young adulthood, is when individuals make decisions that directly affect their lives and gain professional skills that they will continue to apply. these are not only the years in which individuals develop themselves in terms of education but also the period in which they mature in many ways and prepare themselves for the rest of life [1]. it is known that individuals who can spend this period with maximum contribution can more easily cope with both physical and social difficulties that they may encounter in the rest of their lives. there are harmful habits, valuable methods, and habits that individuals can add to their lives during this period. the most basic way to prevent these harmful habits is to turn to physical activity [2]. studies on physical activity, defined as bodily movements that require muscle and joint movement with energy expenditure above the basal metabolism level, have reported that physically active university students have less harmful habits and are more successful in both academic and social dimensions. as a result, it is stated that the quality-of-life levels are higher. however, in most studies, it is stated that the physical activities of university students need to be increased and that students should be directed to physical activities [3,4]. some situations may cause students to stay away from the activity. especially the covid-19 ___________________________________________________ fztibrahim@hotmail.com 1department of physiotherapy and rehabilitation, faculty of health sciences, ankara medipol university, ankara, turkey. a full list of author information is available at the end of the article 10.47108/jidhealth.vol6.iss2.280 http://www.jidhealth.com/ bulguroglu hi, et al., journal of ideas in health (2023); 6(2):847-853 848 pandemic and the distance education process we have been through have caused students to move away from physical activity even more. the withdrawal from this physical activity caused the students to be exposed to more depression and a decrease in their life satisfaction levels [4]. physical inactivity may also cause some complications for students. one of these complications is kinesiophobia. kinesiophobia, a term first used by kori et al. in 1990, is a person's fear of performing physical movement resulting from susceptibility to pain or re-injury [5]. kinesiophobia causes functional disability by causing a decrease in movement from individuals, which leads to a decrease in the quality of life of individuals. kinesiophobia not only causes physical problems but also prevents the individual from socializing. this situation leads to a further decrease in the quality of life and causes an increase in depression in individuals [6]. mood disorders and declines in quality of life, especially in university students, will bring many problems in students, especially their academic status [7]. although the basis of kinesiophobia is the painful condition experienced, it may not always occur after a painful process. kinesiophobia is associated with the amygdala and insula region of the brain, especially the limbic system structures. the amygdala and insula regions control impulses related to emotion, survival, and memory. in other words, it is thought that kinesiophobia, which means the fear of re-injury, may have increased with the fear of getting sick or harming other individuals, especially during the pandemic. staying away from physical activity can turn into movement avoidance behavior and cause the continuation of the cycle of fear of movement [8]. at the same time, physical activity is one of the most effective methods to combat kinesiophobia. studies have shown that after the covid-19 process, kinesiophobia and physical activity decrease in people who had covid-19 [9,10]. it has been shown in the literature that individuals who are physically active in their youth have lower levels of kinesiophobia at later ages [11]. clarifying the relationship between kinesiophobia, lack of physical activity, and quality of life in university students will facilitate the development of individual and targeted treatment approaches and increase students' quality of life. understanding the active promotion of health and well-being among college students and quality of life is integral to countering adverse health outcomes in education and postgraduate adulthood. although it is reported in the literature that physical activity is an important parameter affecting the quality of life of university students, it has been stated that there is a need for studies with larger sample groups and the factors affecting different dimensions of quality of life [12]. in addition, no study has been found in the literature examining the effects of kinesiophobia on university students. for this reason, our study aims to examine how the physical activity levels and quality of life of university students, who experience changes in many areas in order to adapt to a new order in their lives, are affected by different levels of kinesiophobia and to make suggestions to increase the wellbeing of students. methods study design and setting our study, planned as cross-sectional research, included 395 students aged 18-30, who were studying at ankara medipol university in the 1st, 2nd, and 3rd grades between 2022 and 2023, and who agreed to participate in the study and did not use any medication. the questionnaires in the study were filled with the students by face-to-face interview method. first, the purpose and content of the questionnaire were explained to the students, and they were asked to fill in the questionnaire themselves. inclusion and exclusion criteria this study included 1st, 2nd, and 3rd-year students at ankara medipol university, who agreed to participate and did not use medication. however, students with neurological or chronic systemic disease, diagnosed psychiatric disease, history of trauma in the last six months, and musculoskeletal surgery were excluded. sample size in our study, in which the primary measurement parameter was determined as the quality of life, it was determined that a total of 342 individuals were needed in the study, with 80.0% power (three groups, alpha= 0.05, bidirectional), the effect size of cohen's f: 0.16, according to the analysis performed in the g* power program. study tool the demographic information of the individuals included in the study was recorded. in addition, kinesiophobia levels, physical activity levels, and quality of life were evaluated by questionnaire forms. the kinesiophobia levels of the participants were measured with the tampa kinesiophobia scale (tks), which consists of 17 questions. it uses a 4-point likert scale. while the score that can be obtained from the scale varies between 17-68, a high score indicates a high level of kinesiophobia [13]. participants were grouped as "high-level kinesiophobia" with a score of 37 points and above and as "lowlevel kinesiophobia" with a score below 37 points. the turkish version of the scale was used in our study [14], and the cronbach alpha value was 0.783. the international physical activity questionnaire (ipaq), which consists of seven questions and provides information about the time people spend in moderate to vigorous activities, was used to evaluate the level of physical activity in our study [15]. the amount of activity was recorded by asking the students the time spent in the last seven days in the questions covering the four areas of physical activity (work, transportation, housework/gardening, and leisure activities). the turkish version of the questionnaire used in our study evaluates individuals as being physically inactive, having low physical activity levels, and having sufficient physical activity levels [16]. the quality of life of individuals was evaluated with the world health organization quality of life scale-short form (whoqol-bref) consisting of 27 items and five sub-dimensions [17]. in a scale where each question is scored on a likert scale between 1 and 5, each sub-dimension independently expresses the quality of life in its field. as the score obtained from the scale increases, the quality-of-life increases. the turkish version of the scale was used in our study [18], and the cronbach alpha value was found to be 0.812. statistical analysis the initial data were entered into excel database for storage and management. then data were transferred into spss version bulguroglu hi, et al., journal of ideas in health (2023); 6(2):847-853 849 23.0 (spss inc., chicago, il, usa) to perform the statistical analysis. mann whitney u test, and chi-square tests were used to compare socio-demographic variables in relation to level of kinesiophobia. the spearman correlation analysis was performed between the tampa kinesiophobia scale (tks) items, the international physical activity questionnaire (ipaq), and the world health organization quality of life scale-short form (whoqol-bref). the mann whitney u test was performed to compare the mean of the different scales used in the study. results socio-demographic characteristics of study participants three hundreds and ninety-five volunteer university students with mean age 20 (ranged 18-29) years have been included. most of them (71.39%) were women, age, bmi, gender, and smoking status of individuals according to their kinesiophobia levels are given in table 1. about 42.78% of the students participating in our study had a low level of kinesiophobia, and 57.22% had a high level of kinesiophobia. there was no statistical difference was observed in the two groups' age (p=0.055) and bmi (p=0.401) compared with the mannwhitney u test according to kinesiophobia levels. while no difference was observed between the gender differences of the two groups compared with the chi-square test (p=0.134), there was a significant difference in smoking in the group with high kinesiophobia (p=0.028). the results of the evaluation methods used in the study were correlated with each other by spearman correlation analysis. there was a significant positive correlation between ipaq and whoqol-physical health (r=0.13, p=0.008) and whoqolpsychological health (r=0.13, p=0.008) (table 2). a significant negative correlation was observed between tks and whoqol sub-parameters of physical health (r= -0.33, p=0.001), psychosocial health (r= -0.26, p=0.001), social relationship (r= 0.17, p=0.001) and environmental health (r= -0.20, p=0.001) (table 2). the student's physical activity levels were compared according to their kinesiophobia levels. a significant difference was found in favor of the group with low-level kinesiophobia (p=0.043) (table 3). when the scores of the students in the subdimensions of whoqol were compared according to the level of kinesiophobia, a difference was found in favor of the group with the low level of fear of movement in the sub-parameters of physical health (p=0.001), psychosocial health (p=0.001), social relationship (p=0.014), and environmental health (p=0.011) (table 3). table 1: demographic characteristics of students by kinesiophobia levels variables categories low level kinesiophobia (n=169) median (min-max) high level kinesiophobia (n=226) median (min-max) p – value age (years) 20 (18-29) 20 (18-28) 0.055a bmi (kg/m2) 22.10 (14.88-35.76) 21.49 (14.53-33.68) 0.401a gender n (%) female 114(67.5) 168(74.3) 0.134b male 55(32.5) 58(25.7) smoking n (%) yes 37(21.9) 72(31.9) 0.028b no 132(78.1) 154(68.1) n: sample size, min-max: minimum-maximum, cm: centimeter, kg: kilogram, bmi: body mass index, a: mann whitney u test, b: chi-square tests discussion this study showed that the physical activity levels and quality of life of university students with different levels of kinesiophobia changed. while the demographic characteristics of the students in the groups with low kinesiophobia levels and high levels of kinesiophobia were similar, smoking was higher in those with high kinesiophobia levels. although no study in the literature questioned smoking in university students according to kinesiophobia levels, studies have reported that low physical activity, known as a result of kinesiophobia, is associated with smoking [19]. in our study, we found that students with higher kinesiophobia levels were more likely to smoke. the activity avoidance syndrome in the students may have led them to more negative habits. the lack of activity may have reduced the individual's gains from physical activity and increased the probability of the participants turning to harmful habits. our study observed a positive correlation between ipaq and whoqol's physical (r=0.13, p=0.008) and psychological health (r=0.13, p=0.008) sub-parameters. similar to the results of our study, many studies have shown that physical activity is positively associated with quality of life [20-23]. physical health begins with the individual's outward appearance and is completed with developing his inner world. physical activity provides physical development and helps individuals complete their mental development, especially when done regularly. physical activity's physical and mental benefits to individuals increase their life satisfaction levels. in addition, the belief and self-confidence provided by physical activity enable individuals to cope with adverse situations that may occur [21-23]. quality of life is the increase in the satisfaction level of individuals in all areas of life. in addition to the benefits inherent in physical activity, it affects all areas of individuals and helps increase their life satisfaction [24]. one of the important reasons for decreased physical activity is kinesiophobia in individuals. in our study, a significant negative correlation was observed between tks and whoqol subparameters of physical health (r= -0.33, p=0.001), psychosocial health (r= -0.26, p=0.001), social relationship (r= -0.17, p=0.001) and environmental health (r= -0.20, p=0.001). similar to the results of our study, it has been shown in the literature [25,26] that staying away from activities as a result of the development of kinesiophobia affects both the mental and physical development of individuals, reduces their ability to adapt to developing situations, and as a result, affects the satisfaction levels of individuals with life. bulguroglu hi, et al., journal of ideas in health (2023); 6(2):847-853 850 table 2. results of pearson correlation between the different scales’ scores ipaq tks whoqolphysical health whoqolpsychological health whoqol-social relationships whoqolenvironmental health r p r p r p r p r p r p ipaq -0.09 0.050 0.13 0.008* 0.13 0.008* 0.06 0.222 0.05 0.323 tks -0.09 0.050 0.33 0.001* -0.26 0.001* -0.17 0.001* -0.20 0.001* whoqolphysical health 0.13 0.008* -0.33 0.001* 0.56 0.001* 0.39 0.001* 0.52 0.001* whoqolpsychological health 0.13 0.008* -0.26 0.001* 0.56 0.001* 0.46 0.001* 0.49 0.001* whoqolsocial relationships 0.06 0.222 -0.17 0.001* 0.39 0.001* 0.46 0.001* 0.53 0.001* whoqolenvironmental health 0.05 0.323 -0.20 0.001* 0.52 0.001* 0.49 0.001* 0.53 0.001* spearman correlation analysis, ipaq: international physical activity questionnaire, tks: tampa kinesiophobia scale, whoqol: world health organization quality of life questionnaire, r: correlation coefficient our study observed that the physical activity levels of university students with low levels of kinesiophobia were higher (p=0.043). although there is no study evaluating physical activity levels in university students according to kinesiophobia levels, studies show that an increase in kinesiophobia levels causes a decrease in physical activity [5,11]. a vicious circle exists between kinesiophobia, movement phobia, and lack of physical activity. the fewer physical activities of individuals, the higher their level of kinesiophobia [27]. it is known that the university period can turn into a period in which technology is used a lot and students are increasingly away from physical activity [28]. this situation will bring along the discomforts of all systems, especially the musculoskeletal system. these discomforts may increase the reluctance to move in students [29]. in our study, the higher level of physical activity in students with lower kinesiophobia levels may have helped reduce kinesiophobia levels thanks to the physical, mental, and social benefits of physical activity. table 3: comparison of physical activity levels and quality of life according to students' kinesiophobia levels. low level kinesiophobia (n=169) median (min-max) high level kinesiophobia (n=226) median (min-max) z p ipaq 1668(0-19102) 1386(0-9252) -2.028 0.043 whoqol-physical health 75(19-100) 69(6-100) -5.060 0.001 whoqol-psychological health 63(19-100) 56(6-100) -3.868 0.001 whoqol-social relationships 75(19-100) 69(19-100) -2.464 0.014 whoqol-environmental health 69(19-100) 63(19-100) -2.548 0.011 mann whitney u test, ipaq: international physical activity questionnaire, whoqol: world health organization quality of life questionnaire, min-max: minimummaximum thus, students can avoid the vicious circle of kinesiophobia and lack of physical activity. studies between kinesiophobia and quality of life show that kinesiophobia minimizes the benefits of physical activity and reduces the quality of life due to decreased participation in physical activity [30,31]. physical activity not only provides physiological benefits but also improves students' social participation. social participation of students during university years, one of the most critical processes of maturation, will ensure that students' mental states, self-confidence, and environmental adaptations will be stronger. this will help them to maximize their level of satisfaction with life [32]. our study observed that university students with lowlevel kinesiophobia had higher quality of life. this result is because students with low kinesiophobia are more active and can adapt to developing processes, an achievement of physical activity. in addition, physical activity improves students' physical and mental health and increases their selfconfidence [33]. in this case, it reduces the students' avoidance of movements, the levels of kinesiophobia, and their participation in all areas of life, thus increasing the students' quality of life. university years are a period that sheds light on the future and may affect students' future lives. we, health professionals, and all segments of society must break the vicious circle of kinesiophobia-physical activity inadequacy to protect students from harmful habits and increase their social participation. bulguroglu hi, et al., journal of ideas in health (2023); 6(2):847-853 851 the most important limitation of our study is that the participating students were not classified according to the departments they studied. another limitation of our study is that we did not question a musculoskeletal problem that could affect the kinesiophobia levels of the participants at the time of measurement. conclusion in this study, the importance of doing physical activity in order to gain healthy habits and reduce the kinesiophobia at university age was emphasized once again. as a result, our study will guide the literature on the necessity of directing university students to various physical activities to increase their quality of life and protect them from the vicious circle of fear-physical inactivity. also, future studies may explore the relationship between kinesiophobia and the quality of life of different types of physical activity, as well as the long-term effects of physical activity on college students' kinesiophobia. in conclusion, this study emphasizes the necessity of increasing physical activity levels in university students. it emphasizes the importance of physical activity in maintaining kinesiophobia and quality of life. abbreviation ipaq: international physical activity questionnaire; tks: tampa kinesiophobia scale; whoqol-bref: world health organization quality of life scale-short form; bmi: body mass index; covid-19: coronavirus disease of 2019. declaration acknowledgment none. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing fztibrahim@hotmail.com authors’ contributions halil ibrahim bulguroglu (h.i.b.) is the responsible author for creating the idea of the study and bringing it to the literature. merve bulguroglu (m.b.) participated in organizing the study method, creation of evaluation forms. sezen dincer (s.d.) participated in reaching the individuals who will participate in the study, organizing the study method. cansu gevrek aslan (c.g.a.) participated in entering the data into the system analyzing the data. serenay zorlu (s.z.) participated in making the necessary evaluations of the individuals for the study. kübra kendal (k.k.) participated in analyzing the data. all authors read and approved the final version of the manuscript. ethics approval and consent to participate the study was conducted in accordance with the ethical principles of the declaration of helsinki (2013). the protocol of the study was approved by the non-interventional clinical research ethics committee of ankara medipol university (14/02/2023, numbered 22) in accordance with the helsinki declaration. all individuals were informed about the study, and an ''informed consent form'' was signed. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of physiotherapy and rehabilitation, faculty of health sciences, ankara medipol university, ankara, turkey. 2department of therapy and rehabilitation, programme of physiotherapy, vocational school of health services, ankara medipol university, ankara, turkey. 3department of physiotherapy and rehabilitation, faculty of health sciences, i̇stanbul okan university, i̇stanbul, turkey. article info received: 08 march 2023 accepted: 26 april 2023 published: 23 may 2023 references 1. moscardini ao, strachan r, vlasova t. the role of universities in modern society. studies in higher education. 2022;47(4):812-830. doi: https://doi.org/10.1080/03075079.2020.1807493. 2. campos-uscanga y, gutiérrez-ospina g, morales-romero j, romo-gonzález t. self-regulation of eating and physical activity is lower in obese female college students as compared to their normal weight counterparts. eat weight disord. 2017;22(2):311-319. doi: 10.1007/s40519016-0338-9. 3. ma ps, so wy, choi h. using the health belief model to assess the physical exercise behaviors of international students in south korea during the pandemic. healthcare (basel). 2023;11(4):469. doi: 10.3390/healthcare11040469. 4. kosendiak aa, adamczak b, kontek s, kuźnik z, roman m, gostkowski m, niedziółka a. level of physical activity, sleep quality and use of personal protective equipment of students at wroclaw medical university during the covid-19 pandemic. int j environ res public health. 2023;20(3):2406. doi: 10.3390/ijerph20032406. 5. naugle km, blythe c, naugle ke, keith n, riley za. kinesiophobia predicts physical function and physical activity levels in chronic pain-free older adults. front mailto:fztibrahim@hotmail.com bulguroglu hi, et al., journal of ideas in health (2023); 6(2):847-853 852 pain res (lausanne). 2022; 3:874205. doi: 10.3389/fpain.2022.874205. 6. antunes rs, de macedo bg, amaral tda s, gomes hde a, pereira ls, rocha fl. pain, kinesiophobia and quality of life in chronic low back pain and depression. acta ortop bras. 2013;21(1):27-9. doi: 10.1590/s141378522013000100005. 7. wagner f, wagner rg, kolanisi u, makuapane lp, masango m, gómez-olivé fx. the relationship between depression symptoms and academic performance among first-year undergraduate students at a south african university: a cross-sectional study. bmc public health. 2022;22(1):2067. doi: 10.1186/s12889-022-14517-7. 8. altunhan, a, abanoz h. investigation of kinesiophobia and depression levels of wrestlers returning to sports after injury. pakistan j. medical health sci. 2022;16(02):380-383. doi: https://doi.org/10.53350/pjmhs22162380. 9. bargı g. kinesiophobia, physical activity, depression, anxiety and stress levels in post covid-19 individuals: a cross-sectional study. j. health sci. kocaeli univ. 2022;8(3):233-238. doi: https://doi.org/10.30934/kusbed.1136101. 10. herrero-montes m, fernández-de-las-peñas c, ferrerpargada d, izquierdo-cuervo s, abascal-bolado b, valera-calero ja, paras-bravo p. association of kinesiophobia with catastrophism and sensitizationassociated symptoms in covid-19 survivors with postcovid pain. diagnostics. 2023;13(5):847. doi: https://doi.org/ 10.3390/diagnostics13050847. 11. saulicz m, saulicz e, knapik a, linek p, rottermund j, myśliwiec a, wolny t. impact of physical activity and fitness on the level of kinesiophobia in women of perimenopausal age. prz menopauzalny. 2016;15(2):10411. doi: 10.5114/pm.2016.61193. 12. nowak pf, bożek a, blukacz m. physical activity, sedentary behavior, and quality of life among university students. biomed res int. 2019; 2019:9791281. doi: 10.1155/2019/9791281. 13. vlaeyen jws, linton sj. fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. pain. 2000 apr;85(3):317-332. doi: 10.1016/s0304-3959(99)00242-0. 14. yilmaz o, yakut y, uygur f, ulug n. turkish version of the tampa scale for kinesiophobia and its test-retest reliability. turk j physiother rehabil. 2011;22(1):44-49. doi: 10.1016/s1754-3207(11)70544-2. 15. craig cl, marshall al, sjöström m, bauman ae, booth ml, ainsworth be, pratt m, ekelund u, yngve a, sallis jf, oja p. international physical activity questionnaire: 12country reliability and validity. med sci sports exerc. 2003;35(8):1381-95. doi: 10.1249/01.mss.0000078924. 61453.fb. 16. saglam m, arikan h, savci s, inal-ince d, bosnak-guclu m, karabulut e, tokgozoglu l. international physical activity questionnaire: reliability and validity of the turkish version. percept mot skills. 2010;111(1):278-84. doi: 10.2466/06.08.pms.111.4.278-284. 17. development of the world health organization whoqol-bref quality of life assessment. the whoqol group. psychol med. 1998;28(3):551-8. doi: 10.1017/s0033291798006667. 18. eser e, fidaner h, fidaner c, eser sy, elbi h, göker e. whoqol-100 ve whoqol-bref'in psikometrik özellikleri. psikiyatri psikoloji psikofarmakoloji (3p) dergisi. 1999;7(suppl 2):23-40 [in turkish]. 19. heydari g, hosseini m, yousefifard m, asady h, baikpour m, barat a. smoking and physical activity in healthy adults: a cross-sectional study in tehran. tanaffos. 2015;14(4):238-45. 20. marquez dx, aguiñaga s, vásquez pm, conroy de, erickson ki, hillman c, stillman cm, ballard rm, sheppard bb, petruzzello sj, king ac, powell ke. a systematic review of physical activity and quality of life and well-being. transl behav med. 2020;10(5):1098-1109. doi: 10.1093/tbm/ibz198. 21. klepac pogrmilovic b, ramirez varela a, pratt m, milton k, bauman a, biddle sjh, pedisic z. national physical activity and sedentary behaviour policies in 76 countries: availability, comprehensiveness, implementation, and effectiveness. int j behav nutr phys act. 2020;17(1):116. doi: 10.1186/s12966-020-01022-6. 22. lubans d, richards j, hillman c, faulkner g, beauchamp m, nilsson m, kelly p, smith j, raine l, biddle s. physical activity for cognitive and mental health in youth: a systematic review of mechanisms. pediatrics. 2016;138(3):e20161642. doi:10.1542/peds.2016-1642 23. jönsson t, ekvall hansson e, thorstensson ca, eek f, bergman p, dahlberg le. the effect of education and supervised exercise on physical activity, pain, quality of life and self-efficacy an intervention study with a reference group. bmc musculoskelet disord. 2018;19(1):198. doi:10.1186/s12891-018-2098-3 24. an hy, chen w, wang cw, yang hf, huang wt, fan sy. the relationships between physical activity and life satisfaction and happiness among young, middle-aged, and older adults. int j environ res public health. 2020;17(13):4817. doi: 10.3390/ijerph17134817. 25. saulicz m, saulicz e, knapik a, linek p, rottermund j, myśliwiec a, wolny t. impact of physical activity and fitness on the level of kinesiophobia in women of perimenopausal age. prz menopauzalny. 2016;15(2):104111. doi:10.5114/pm.2016.61193 26. pazzinatto mf, rio ek, crossley km, coburn sl, johnston r, jones dm, kemp jl. the relationship between kinesiophobia and self-reported outcomes and physical function differs between women and men with femoroacetabular impingement syndrome. braz j phys ther. 2022;26(2):100396. doi: 10.1016/j.bjpt.2022.100396 27. leon-llamas jl, murillo-garcia a, villafaina s, domínguez-muñoz fj, morenas j, gusi n. relationship between kinesiophobia and mobility, impact of the disease, and fear of falling in women with and without fibromyalgia: a cross-sectional study. int j environ res public health. 2022;19(14):8257. doi: 10.3390/ijerph19148257. 28. gao z, lee je. emerging technology in promoting physical activity and health: challenges and opportunities. j clin med. 2019;8(11):1830. doi: 10.3390/jcm8111830. bulguroglu hi, et al., journal of ideas in health (2023); 6(2):847-853 853 29. kitis a, buker n, unal a, savkın r. effects of musculoskeletal system problems on quality of life and depression in students preparing for university entrance exam. korean j pain. 2017;30(3):192-196. doi: 10.3344/kjp.2017.30.3.192. 30. altug f, unal a, kilavuz g, kavlak e, citisli v, cavlak u. investigation of the relationship between kinesiophobia, physical activity level and quality of life in patients with chronic low back pain1. j back musculoskelet rehabil. 2016;29(3):527-31. doi: 10.3233/bmr-150653. 31. ozer ay, karaca s, senocak e, oguz s, polat mg. does kinesiophobia limit physical activity and quality of life in asthmatic patients? int j rehabil res. 2022;45(3):230-236. doi: 10.1097/mrr.0000000000000534. 32. eime rm, young ja, harvey jt, charity mj, payne wr. a systematic review of the psychological and social benefits of participation in sport for children and adolescents: informing development of a conceptual model of health through sport. int j behav nutr phys act. 2013; 10:98. doi: 10.1186/1479-5868-10-98. 33. fernández-bustos jg, infantes-paniagua á, cuevas r, contreras or. effect of physical activity on selfconcept: theoretical model on the mediation of body image and physical self-concept in adolescents. front psychol. 2019; 10:1537. doi: 10.3389/fpsyg.2019.01537. https://doi.org/10.47108/jidhealth.vol4.issspecial3.156 joseph hb, et al. journal of ideas in health 2021;4(special 3):443-449 © the author(s). 2021 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access children’s online learning during covid-19 pandemic: experiences and satisfaction encountered by indian parents hepsi bai joseph1*, sandhiya kuppuswamy1 , asha prabhakar shetty1 abstract background: online learning by children is pressure for children as well as parents. the covid-19 lockdown was ended up putting much stress on parents in india. the current study aimed to assess the parental experience and satisfaction on online learning for their children during covid -19 pandemic lockdown. methods: a cross-sectional web-based survey was conducted among 300 parents of children who attended online learning during the covid -19 pandemic lockdown. the data was collected using the snowball sampling technique. the survey tool consists of a sociodemographic questionnaire, self-report scales on parent's satisfaction and experiences. the collected data were analyzed using descriptive statistics, including mean, frequency, percentage, and inferential statistics such as the chi-square test. results: out of 300 parents surveyed, 72% were mothers, 65.6% of children who attended online classes were from primary class, through zoom platform (52.2%) using an android mobile phone (71.1%) for a mean duration of 180±30 minutes. 80.4% of parents preferred the traditional learning method comparing to online classes for their children. more than half (52.2%) of parents reported that they were partially satisfied with children's online learning, whereas 26% were not satisfied. more than half of the parents (61.1%) experienced a great challenge and burden of online learning. conclusion: parents were worried that prolonged exposure to screen devices in online learning might affect child health's visual, physical, and psychological aspects. keywords: parental satisfaction, experience, online class, covid-19 pandemic, lockdown, india background preceding years, online education of young children using digital devices and technologies was debated among educators, parents, scholars, stakeholders, and policymakers [1]. it was discussed that while digital learning would present the advantage of assisting the young children in appreciating and understanding various concepts and abstracts with the involvement of critical thinking and problem-solving activities, it may also prove to be disadvantageous as exposing the young children to online learning might affect their social and emotional readiness to school [2]. however, the demand for online education was not much utilized in the education system before the covid-19 pandemic. as the covid-19 pandemic was declared as a public health emergency by the world health organization (who), the education system shattered universally. in order to respond and to break pandemic spread universally, facility restrictions and closures were implemented by all the nations. according to united nations education scientific and cultural organization, the education system worldwide got affected by ninety percent of the world's student population as a victim and threatened students' future education rights [3]. this was highly essential to motivate social distancing and ineffective transmission of this contagious virus [4]. as an alternative way, all schools and universities adopted various teaching methods through the internet. various online resources, including online libraries, video lectures, online channels, and television broadcasts, were introduced in various countries to continue education [5]. universal school closures resulted in a shift from the traditional classroom to remote learning environments. unfortunately for this sudden shift of ___________________________________________________ nurs_hepsi@aiimsbhubaneswar.edu.in 1сollege of nursing, all india institute of medical sciences, bhubaneswar, odisha, india. full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol4.issspecial3.156 http://www.jidhealth.com/ joseph hb, et al. journal of ideas in health (2021); 4(special 3):443-449 444 education process, the teachers, families, and students were unprepared; the role of parental involvement in engaging and assisting at various levels and type of e-learning was the prime need. pandemic and remote learning in india the indian government too announced nationwide lockdown and advised to continue the education via emode. schools and universities-initiated learning through digital mediums to manage such crises. amid the pandemic, physical, mental, and financial resources were in high demand for parents to fulfill children's online education. parents' physical presence throughout the online classes, finance in the procurement of a smartphone with internet facility and assist, support online classes for children without proper instructions and guidelines were significant challenges to handle. the pandemic scenario placed the burden on caregivers and parents by supporting the children with alien technology, assisting in the new learning environment, providing digital technologies. in addition, parents took the role of secondary teachers by clarifying their doubts, recharging the internet for remote learning at home. this was a new experience for the parents, and there was a wide gap in the literature on this topic [6]. in his pre-pandemic survey, borup j. [7] identified the various role of parents in elearning as organizing and managing children's schedules, monitoring, and motivating child's engagement, nurturing relationships, interacting, and instructing children as needed. unfortunately, it was the first attempt indian parents to assist children in virtual learning during the covid pandemic from march 2020. moreover, it was a new experience for them without prior guidance. it is worthy of studying their experiences and concerns with students and parents concerning educational, physical, and psychological for the comprehensive enhancement of its development in the future. in india, the 2nd upsurge of covid-19 continued after a year of pandemic and settled by the second half of 2021. schools and universities are still in a dilemma with the reopening plan. irrespective of the situation, the education system should also remember the pandemic experiences even after getting rid of the pandemic. such a health emergency can knock anytime in the future leads to furthermore, high chance of getting school closures. hence, evaluating parent's experience during this situation would help prepare better to handle online learning strategies [8]. therefore, the researchers are interested in studying the parents' experience and satisfaction with children's remote learning at the residence during the covid-19 pandemic. methods participants a web-based survey using a cross-sectional design was conducted among 300 indian parents of children from academic grade 1st to 12th attending remote learning during the covid-19 pandemic. data were obtained during the first wave of the covid-19 pandemic between july to december 2020. the study covered parents of children attending remote learning during the covid-19 pandemic. three hundred and eighty respondents filled the proforma, where only 300 were complete. inclusion criteria the study included parents of school children who attended remote learning during the covid-19 pandemic and the parents who had internet facilities to access through whatsapp, facebook, and e-mail. inclusion criteria the parents excluded parents of children attending remote learning at the collegiate level; parents had children who attended remote learning during the covid-19 pandemic but could not read and respond to the questionnaire in english. instrument the present study used self-report tools consisted of a sociodemographic questionnaire to collect information of the parents and children, including parental role (father/mother), working status, educational qualification, child's academic grade, device and online platform used, duration of the online class in a day. a self-report scale was used to measure parental satisfaction on children's remote learning during the covi-19 pandemic, which consists of five items, including "satisfaction on child's study behavior during online class", “the achievement of learning objectives during online class”, “teacher-student interaction during online class”, “quality of teaching in online class” and the fifth question was devoted to exploring the “overall satisfaction of parents towards online learning”. parents responded to h their children's remote learning satisfaction g as "well satisfied, partially satisfied, and not at all satisfied" for those five questions. frequency and percentage were employed to analyze each item on the satisfaction of parents. a self-report scale comprising ten items with a "yes/ no" option was recruited to identify parents' experience on children's remote learning. statements included were parents experience of "assisting online classes for my child affect my household work," “assisting online classes for my child affect my household work," “i need to recharge extra for the internet," “my child is not attentive during online classes”, “my presence is needed from start to end during my child's online class”, “my child finds it difficult to cope up with online classes”, “the home environment is not comfortable for attending online class for my child”, “my child finds difficulty in the completion of assignments, homework due to the online mode of teaching” and so on. reliability and validity both the self-report scale found valid and reliable. the split-half method was employed to determine the reliability, and it was established for the parent's satisfaction tool (r=0.85) and the parent's experience tool (r=0.90). the tools were submitted to five experts for content validation, and the validity was calculated by the number of experts agreeing on the relevancy of each item, divided by the total number of experts. the content validity index (cvi) for the tool was 0.88. the tools were prepared in english. five parents were selected to assess the readability and found the tools were readable. a web-based pilot survey was conducted among 15 parents to determine the tools' clarity, relevance, and acceptability, and they were not included in the main study. data collection procedure after obtaining ethical permission the researchers planned to collect data through an online platform due to the pandemic situation using a google form, with a consent form appended to joseph hb, et al. journal of ideas in health (2021); 4(special 3):443-449 445 it. the sampling technique adopted was snowball sampling to locate the responders. the link was forwarded to people apart from the first point of contact. on clicking the link, the participants got auto directed to the study's detail and consent on receiving and clicking the link. once the participants agree to participate, they need to fill up the baseline information of the parents and remote learning characteristics followed by remote learning experience and its satisfaction tool. statistical analysis the received data were coded and entered in a microsoft excel sheet and analyzed using r software. descriptive statistics were used to estimate the parental experiences and satisfaction towards remote learning. inferential statistics, chi-square test, was used to find the association between parents' overall satisfaction with characteristics of parents. results out of 300 surveyed parents (72.1%), were mothers, graduates (47.8%), employed (78.7%), from the health field (32.6%). moreover, more than half of the respondents (54.8%) were attending jobs in the pandemic lockdown (table 1). table 1. background information about parents (n=300) parental characteristics n (%) parental role in the online survey a) father 84 (27.9) b) mother 216(72.1) parental educational status a) school 28(9.3) b) diploma 16(5.4) c) graduate 113(37.5) d) postgraduate 143(47.8) parents working status a) working 236(78.7) b) not working 64(21.3) parents working field a) health field 98(32.6) b) teaching field 76(25.3) c) business 28(9.3) d) daily wage 34(11.4) e) housewife/ homemaker & others 64(21.0) parents attending work during the lockdown. a) yes 165(54.8) b) no 135(45.2) most of the parents (53.5%) had single child took part in remote learning, and most of the children were studying in primary class (65.6%). besides, sixty-nine percentage of mothers accompanied their children's remote learning, using android mobile (71.1%), in zoom app (52.2%). nearly half of the parents (50.2%) did not face any difficulty sharing digital devices as they had a single child, whereas 84 (27.9%) parents had problems sharing devices for their children during remote learning (table 2). table 2. child’s remote learning characteristics (n=300) remote learning characteristics n (%) no of children attending online classes in a home a) 1 161(53.5) c) 2 116(38.9) d) 3 15(5.0) d) more than 3 8(2.6) child’s education a) primary class 197(65.6) b) middle school 72(23.9) c) high school & secondary 31(10.5) a person accompanied during online class a) father 56(17.6) b) mother 206(68.8) c) other 41(13.6) the device used for attending the online class a) mobile phone (android) 214(71.1) b) tablet/i pad 22(7.3) c) laptop 55(18.6) d) desktop 9(3.0) the platform used for online learning for children a) zoom app 157(52.2) b) cisco webex 23(8.0) c) google meet 55(18.3) d) others 65(21.5) status of sharing the digital device for the online class a) no problem, i have a single child to attend the online class 150(50.2) b) yes, i have problem sharing devices for my children 84(27.9) c) no, i have adequate devices for each child to attend online classes 66(21.9) table 3 showed that more than half (50.5%) of the parents were partially satisfied with online learning in terms of the child’s study behavior, achieving learning objectives in every class (54.7%), teacher-student interaction (36.0%), and quality of teaching (50.0%). moreover, 20.0% of the parents showed overall satisfaction with children’s online learning compared to 50.0% and 30% who were partially satisfied and not at all satisfied, respectively. table 3 parents satisfaction with their children remote learning (n=300) no. items satisfied n (%) partially satisfied n (%) not satisfied n (%) 1 study behavior of child during online class 86 (28.9%) 152 (50.5%) 62(20.6%) 2 learning objectives achieved in every class 84 (28.3%) 164 (54.7%) 52 (17%) 3 teacher-student interaction in an online class 104(35%) 108 (36%) 88 (29%) 4. quality of teaching online 86(29.2%) 149 (50%) 65(20.8%) 5 the overall satisfaction of the parents towards the children’s online learning 60(20.0%) 150(50.0) 90(30.0%) joseph hb, et al. journal of ideas in health (2021); 4(special 3):443-449 446 table 4 showed that more than two-third of the parents (69.3%) reported due to their job, they have to depend on others for assisting/accompanying children for an online class. parents experienced their presence required to be with children all the time during children's online classes, and 61.1% of parents experienced home-schooling as a great challenge and burden to them. more than half of the parents (60.5%) reported that their children found it difficult to cope with online classes. table 4: parental experience on remote learning for their children during covid-19 pandemic lockdown (n=300) parental experiences yes n (%) no n (%) assisting online classes for my child affect my household work. 165 (5.5) 135(44.5) for my child's online class, i need to recharge extra for the internet 146 (49) 154 (51.0) my child is not attentive during online classes. 138(46.6) 162(53.4) i have to be there all the time from beginning to end during my child's online class. 188 (63.4) 112(36.6) due to my job, i am unable to help my child in an online class 210(69.3) 90(30.7) due to my job, i have to depend on others to assist/accompany my child for an online class due to my job. 164(55.6) 136(44.4) the home environment is not comfortable for attending online classes for my child. 132(44.8) 168(55.2) home-schooling is a great challenge and burden for me. 186(61.1) 114(38.9) my child finds it difficult to cope up with online classes. 178(60.5) 122(39.5) my child finds difficulty in the completion of assignments, homework due to the online mode of teaching. 155(52.7) 145(47.3) discussion parents satisfaction with children's remote learning the covid-19 pandemic entirely changed many directions of our lives. furthermore, social distancing and lockdown policies have markedly derailed usual educational practices. consequently, there was an urgent need to revolutionize and execute substitute education as online or remote learning for children. regarding parent’s satisfaction with children's remote learning, nearly half of the parents were partially satisfied with their children's remote learning study behavior (50.5%), achieving learning objectives in every class (54.7%). concerning teacher-student interaction, 36% of parents were partially satisfied, and around 50% of parents were also somewhat satisfied with the quality of teaching through remote learning. similarly, studies found that parental belief in remote learning for their children was less effective. they also believed that remote learning lacked in the learning environment and social interaction to entertain children, resulting in deprived knowledge [8]. due to lockdown, there was a sudden shift from traditional learning to remote learning. parents have not prepared for themselves, their children, and the environment. on top of that, the lack of parental and students' orientation in handling technology could explain why indian parents are not completely satisfied with their children's remote learning. moreover, a significant number of schools have not even considered it. the findings reported by the parents might be due to their inexperience with this remote learning. as the day goes, parents and children might be acquainted with the new scenario. moreover, children's early childhood practices and outdoor activities (free play) got arrested because of the covid 19 pandemics. arnott and yelland [2] stated that challenges remain in our understanding of childhoods in the 21st century and integrating new technologies in children's learning cultures. the use of digital technology by young children was inappropriate and induced confusion for those seeking digital technologies into young children's learning [9-11]. hence, it's essential to utilize digital technology productively and hasslefree for learning purposes. erdogan ni et al. [10] and house r. [11] emphasized the reconceptualization of "childhood" and "play" in the digital age in order to support children, parents, and teachers to use new technologies better. besides, most children were from primary class, and parental expectations towards children's study behavior, interactions, quality teaching, and learning might be disappointing due to the home environment, new to technology. sharma and kiran [12] also found in india that parents of children who studied in primary class were less satisfied than children studying in higher and higher secondary classes. furthermore, the school's effectiveness in handling doubts, learning atmosphere, and help in remote learning technology positively influenced the parents' general satisfaction with remote learning [13]. in addition, lack of interactivity and social isolation as the parents' primary shortcomings of remote learning [14]. school authorities have not looked into these matters even though enormous advancements occurred in online and digital technology. as it is understood, lack of interactivity and social isolation was the disadvantage of remote learning. it's prime time to research interventions to overcome such challenges to protect children's psychological health. more than half of the participants were partially satisfied (50.0%) with remote learning of their children, whereas 30.0% of parents were not all satisfied. during the lockdown, a survey conducted in the united kingdom revealed that nearly half of parents were dissatisfied with their child's development and progress since lockdown— social interaction with teachers and missing their friends, reported by 82% of children [15]. due to lack of motivation and boredom in studies, most parents were worried that their child's education had been set back [16]. correspondingly, the parents' overall satisfaction was associated with the remote learning support rendered by the school, instructional programs, and social communications [17]. in a survey report from india by kumar a and kumar s [18] in 2020, a parent stated that home learning could not substitute classroom learning. it has its drawbacks, such as the absence of socialization and no direct interaction with teachers and peers. parents' role has been extended and transferred from parents to teachers, and they had experienced difficulty teaching new academic aspects from home to younger children. certain factors like willingness to online classes, weekly timing, outputs as offline classes, equipment, syllabus contents, health hazard, parents' involvement, disturbance in parent’s job, class activities, and joseph hb, et al. journal of ideas in health (2021); 4(special 3):443-449 447 favor of blended learning under an exceptional circumstance just like a pandemic, covid-19 also related with parent’s satisfaction [19]. experience of indian parents on remote learning school education has been badly hit due to the outbreak of the corona pandemic, with millions of students stranded at home, staring at the screens, and receiving instruction passively. covid-19 has caused massive disruption with tough challenges for the entire education system across the world. since indian teachers and students are habituated to daily meetings and interactions carrying out the teaching and learning activities in the classroom, it is challenging to engage young children [20]. covid-19 pandemic stimulated a widespread, abrupt, and the intense digital revolution in the community. it forced schools and families to adopt an unexpected digital surge in everyone's day-to-day life journey. abruptly the whole young parent community had to initiate to handle and cope with online-digital tools to facilitate their offspring in remote learning [21]. parents agreed that they must assist their child's remote learning that affects their household work. most of the parents accompanied their children from beginning to end of an online class. most of the employed parents expressed that they need to depend on others to assist their children's remote learning and felt they could not help their child in an online class. mothers who looked after household chores in the absence of a maid or cook and sharing time with children's online classes struggled a lot during the lockdown period. it is predominantly tricky for working parents, particularly those working in the health care sector; they need to balance both. this situation emotionally and psychologically drained them. on the other hand, remote learning is an opportunity for parents to spend more time with children and understand their learning abilities, and it may be applicable for non-working parents [18]. nearly half of the parents (49.0%) had experienced difficulty recharging extra for the internet. there was a need for additional smartphones or other digital devices to attend the remote learning and recharge extra for internet for those parents who had more than one school-going child at home. moreover, there is much more challenge for the parents in procuring digital gadgets and providing network connectivity in rural areas. indian government implemented another strategy to cover urban and rural students without network or smartphone facilities by telecasting online classes in a scheduled way from academic grade i to grade xii to all states of india. the sad part of this strategy implementation furthermore challenging because the economically weaker section (ews) of the society were unable to explore these online/telecasted resources due to unavailability of required infrastructure, including television, laptop, tablets, smartphone, internet, and electricity facility for those children residing in rural, hilly, and tribal areas [21]. parents also shared that their children faced difficulty completing assignments and homework due to their online learning mode. this was evident in not only school children but also collegiate level students [22]. parents found the hasty closure of the educational institutions quite distressing and worried about their children's daily schedule. parents understood that the systematic practice of weekdays schedule was possible only through schools. this facilitated children's understanding of the value of time, schedule, and assignment completion within the stipulated time [23]. a study conducted among indonesian parents also revealed that parents had concerns about learning outcomes, balancing responsibilities, accessibility, and learner motivation [24]. students should be encouraged to use their textbooks and notebooks and avoid all digital devices for homework. handling online technology by inexperienced parents can keep in touch with fellow parents without a parental orientation program. parents felt their children were not attentive during online classes and engaged in prolonged screen time. parents shared their concerns about the lengthy screen time of engaging in digital gadgets. in addition to online learning, they can be involved in old teaching techniques with a copy of worksheets and engage them in the reading paper, books, and online so that screen time can be limited. "digital quarantine" also helped them reduce distractions and focus on their classes [25]. the present study's limitation includes the small sample size, and the online survey may not represent the overall parents residing in the semiurban, rural, hilly, and tribal areas. factors influencing parental satisfaction, perception need to be studied for better understanding. socially desirable bias may result from online surveys, and it is better to research child's and teacher's satisfaction towards remote teaching and learning. the study's strength is that no such research has been reported from india related to parental satisfaction, experience on remote learning. the study revealed working parents' experience, especially from the health field, their concerns, and their online learning challenges. conclusion even though remote learning is gaining popularity, it was observed that indian parents faced challenges and problems during its implementation for their children during the covid pandemic. parents were not ready to accept remote learning than traditional classroom teaching methods due to sudden impose. parents were concerned about children's future education, general health, vision, and teacher peer relationships. the success of remote learning relies upon the cooperation of the school authority, teachers, parents, students, and the environment. conducting parent-teacher meetings online and listening to parental concerns and school management frame strategies do not burden the children and parents with online classes and exams. abbreviation covid-19: corona virus disease -19; who: world health organization; unesco: united nations education scientific and cultural organization; ews: economically weaker section declaration acknowledgment none. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing nurs_hepsi@aiimsbhubaneswar.edu.in joseph hb, et al. journal of ideas in health (2021); 4(special 3):443-449 448 authors’ contributions all authors contributed to the study's conception and design. hepsi bai joseph (hbj), sandhiya k (sk) performed material preparation, data collection, and analysis. hepsi bai joseph (hbj), and sandhiya k (sk), wrote the first draft of the manuscript. asha p shetty (aps) revised it critically for important intellectual content. all authors commented on previous versions of the manuscript. all authors substantially contributed to the study and approved its submission. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the ethical permission was obtained from the institutional ethics committee of aiims bhubaneswar (project no. t/im-nf/nursing/2020/66). consent for publication not applicable competing interest the authors declare that they have no competing interest. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1сollege of nursing, all india institute of medical sciences, bhubaneswar, odisha, india article info received: 07 august 2021 accepted: 07 september 2021 published: 22 september 2021 references 1. aubrey c, dahl s. a review of the evidence on the use of ict in the early years foundation stage.2008. retrieved from the university of warwick, coventry: http://www.becta.org.uk 2. arnott l, yelland nj. multimodal lifeworlds: pedagogies for play inquiries and explorations. journal of early childhood education research. 2020 feb 29;9(1):124-46 retrieved from https://jecer.org/multimodal-lifeworlds-pedagogies-for-playinquiries-and-explorations/ 3. edwards s, skouteris h, rutherford l, cutter-mackenzie a. ‘it's all about ben10™’: children's play, health and sustainability decisions in the early years. early child development and care. 2013 feb 1;183(2):280-93. doi: 10.1080/03004430.2012.671816 4. unesco. covid-19 educational disruption and response.2020. retrieved from https://en.unesco.org/news/covid-19-educationaldisruption-and-response. 5. viner rm, russell sj, croker h, packer j, ward j, stansfield c, et al. school closure and management practices during coronavirus outbreaks including covid-19: a rapid systematic review. the lancet child & adolescent health. 2020 may 1;4(5):397-404. http://dx.doi.org/10.1016/s2352-4642(20)30095x 6. el firdoussi s, lachgar m, kabaili h, rochdi a, goujdami d, el firdoussi l. assessing distance learning in higher education during the covid-19 pandemic. education research international. 2020 oct;2020. https://doi.org/10.1155/2020/8890633 7. borup j. teacher perceptions of learner-learner engagement at a cyber high school. international review of research in open and distributed learning. 2016;17(3):231-50. https://doi.org/10.19173/irrodl.v17i3.2361 8. hodges c, moore s, lockee b, trust t, bond a. the difference between emergency remote teaching and online learning. educause review. 2020 mar 27;27(1):1-9. retrieved from https://er.educause.edu/articles/2020/3/the-difference-betweenemergency-remote-teaching-and-online-learning 9. dong c, cao s, li h. young children’s online learning during covid-19 pandemic: chinese parents’ beliefs and attitudes. children and youth services review. 2020 nov 1; 118:105440. https:// doi. org/10. 1016/j. child youth. 2020. 105440. 10. erdogan ni, johnson je, dong pi, qiu z. do parents prefer digital play? examination of parental preferences and beliefs in four nations. early childhood education journal. 2019 mar;47(2):131-42. 11. house r. the inappropriateness of ict in early childhood: arguments from philosophy, pedagogy, and developmental research. in contemporary debates in childhood education and development 2012 jun 14 (pp. 119-134). routledge. 12. sharma i, kiran d. study of parent’s satisfaction for online classes under lockdown due to covid-19 in india. journal of statistics and management systems. 2021 jan 2;24(1):17-36. 13. khurana c. exploring the role of multimedia in enhancing social presence in an asynchronous online course (doctoral dissertation, rutgers university-graduate school-new brunswick). 2016. https://doi.org/10.7282/t3n018q3 14. cathy parnham. nearly half of parents unhappy with remote learning during lockdown -education technology.2020. https://edtechnology.co.uk/headlines/nearly-half-of-parentsunhappy-with-remote-learning-during-lockdown/ 15. sharma, k.why online classes may not be such a good idea after all, especially for kids. the print. 2020. https://theprint.in/india/education/why-online-classes-may-not-besuch-a-good-idea-after-all-especially-for-kids/406979/ 16. warner butz, c. student and parent satisfaction with online education at the student and parent satisfaction with online education at the elementary and secondary levels elementary and secondary levels. 2020. https://doi.org/10.25669/p2p9-49f9 17. chakrabarthy r. how online courses are a boon for mothers juggling jobs, chores and homework during lockdown.2020. https://www.indiatoday.in/educationtoday/featurephilia/story/how-online-courses-are-a-boon-foroverworked-parents-during-lockdown-1671038-2020-04-25 18. kumar a, kumar s. factors determining the parents’ satisfaction for online primary education during a pandemic (covid-19). iosr journal of humanities and social science 2020. 25, 27–35. https://doi.org/10.9790/0837-2508052735 19. malik s, tyagi hk. a study of parent’s opinion on online teaching in delhi-ncr schools. indian journal of science and joseph hb, et al. journal of ideas in health (2021); 4(special 3):443-449 449 technology. 2020 dec 3;13(42):4351-63. https://doi.org/10.17485/ijst/v13i42.1664 20. aliyyah rr, rachmadtullah r, samsudin a, syaodih e, nurtanto m, tambunan ar. the perceptions of primary school teachers of online learning during the covid-19 pandemic period: a case study in indonesia. journal of ethnic and cultural studies. 2020 aug 1;7(2):90-109. https://eric.ed.gov/?id=ed606349 21. kunju ss. difficult, but, new experience: parents on homeschooling during lockdown. 2020, nd tv education. available at https://www.ndtv.com/education/home-schooling-duringlockdown-difficult-but-new-experience-say-parents-2213907 22. rafi a, varghese p, kuttichira p. concerns and confidences expressed by teaching staff about the shift of medical education to online mode in south india during the covid 19 pandemic. journal of ideas in health. [internet]. 24dec.2020 [29aug.2021;3(special2):272-5. https://www.jidhealth.com/index.php/jidhealth/article/view/81 23. bhamani s, makhdoom az, bharuchi v, ali n, kaleem s, ahmed d. home learning in times of covid: experiences of parents. journal of education and educational development. 2020 jul 7;7(1):9-26. https://doi.org/10.22555/joeed.v7i1.3260 24. garbe a, ogurlu u, logan n, cook p. covid-19 and remote learning: experiences of parents with children during the pandemic. american journal of qualitative research. 2020 aug 9;4(3):45-65. https://doi.org/10.29333/ajqr/8471 25. times of india. tips for parents to help their children navigate online learning during the lockdown times of india. . (2020, april 2). https://timesofindia.indiatimes.com/lifestyle/parenting/toddler-year-and-beyond/tips-for-parents-to-helptheir-children-navigate-online-learning-during-thelockdown/articleshow/74943205.cms https://doi.org/10.47108/jidhealth.vol6.iss2.281 visuddho v, et al., journal of ideas in health (2023); 6(2):854-860 © the author(s). 2023 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access determinant factors of treatment adherence of hypertensive patients in a rural area of indonesia visuddho visuddho1, putu astiswari permata kurniawan1, salsabilla firdausi rafidah1, ramadhani rizki zamzam1, ezrin syariman bin roslan1, muhammad raihan habibi1, muhammad gazi yasargil1, atika atika2*, atni supratiwi3 abstract background: the surging prevalence of hypertension due to lifestyle brought forth an increase in degenerative diseases. adherence is important in achieving the effectiveness of therapy. this study aims to analyze the factors affecting medication adherence in patients with hypertension. methods: a cross-sectional study was conducted between 20-24 february 2023 at turirejo village, lawang district, malang, indonesia. participants were hypertensive patients currently receiving treatment. the mmas-8 questionnaire was used to classify adherence to medication for hypertension. analysis with binary logistic regression test was performed on variables to display odds ratio values was conducted at a significance level of p<0.05. results: a total of 37 adults diagnosed with hypertension participated in this study. patients were dominantly consisting of elderly (≥ 56 years old; 73.0%) and females (86.0%). seventy-six percent of patients have low adherence, twenty-four percent of patients have moderate adherence, and no patient has high adherence. duration of illness, knowledge, and attitude variables significantly affect adherence (low and moderate) to medication for hypertension. multivariate analysis showed that patients with a duration of illness above 10 years (adjusted or 18.27; 95% ci 1.72-194.47; p-value 0.016) and positive attitude towards treatment (adjusted or 12.76; 95% ci 1.25-130.40; p-value 0.032, respectively) increase the possibility of moderate adherence towards the medication of hypertension. conclusion: improvements in factors that affect adherence to hypertension treatment are needed to increase the success of the non-communicable disease prevention program. further research in identifying factors of economic capacity and access to health service providers is needed to validate the results of this study. keywords: hypertension, medication adherence, knowledge, attitude, duration of illness, indonesia background indonesia is currently facing a shift in disease patterns, from communicable diseases to non-communicable diseases. the increase in the prevalence of non-communicable diseases occurs as a result of unhealthy lifestyles triggered by urbanization, modernization, and globalization. increasing life expectancy in line with socio-economic improvements and health services, has the consequence of increasing degenerative diseases [1]. hypertension is one of the most common and most common cardiovascular diseases in society and is the biggest cause of premature death in the world. around 1.28 billion adults aged 30-79 years in the world suffer from hypertension [2]. as many as 8.4% of the population aged ≥18 years in indonesia suffer from hypertension [3]. patient compliance in carrying out the recommended therapy is a common problem. several factors such as the length of time a person suffers from hypertension or the many types of antihypertensive drugs used will reduce the level of adherence to treatment [4–6]. through discussions with turirejo village officials and a preliminary study on february 20, 2023, the researchers were able to collect survey results from the 31 respondents. the results of the preliminary study found that the most common diseases encountered were hypertension (12 people; 38.7%), diabetes (4 people; 12.9%), and acute respiratory ___________________________________________________ atika@fk.unair.ac.id 2department of public health, faculty of medicine universitas airlangga, surabaya – 6013, indonesia a full list of author information is available at the end of the article file:///c:/users/drsaa/downloads/10.47108/jidhealth.vol6.iss2.281 http://www.jidhealth.com/ visuddho v, et al., journal of ideas in health (2023); 6(2):854-860 855 infections (5 people; 16.1%), and six of 12 patients with hypertension (50%) patients felt that they were not taking antihypertensive drugs regularly. knowledge and awareness of a person's illness are important factors in medication adherence [6]. lack of knowledge regarding the course of the disease, hypertension therapy, and a healthy lifestyle will worsen the effectiveness of therapy in patients [7]. other factors, such as gender, age, place of residence, medical expenses, and socioeconomic status were found to affect medication adherence in hypertension patients [8]. it is necessary to identify factors of adherence of hypertensive patients in using drugs, in an effort to plan a more comprehensive therapeutic strategy in order to increase the effectiveness of therapy. therefore, this study aims to analyze the factors that influence adherence to hypertension treatment in hypertension sufferers in turirejo village. methods study design and setting this research is an observational analytic study with a crosssectional study design. the research took place between 20-24 february 2023 at turirejo village, lawang district, malang, indonesia. the research used primary data collected using a questionnaire instrument which was answered by respondents through face-to-face interviews with five medical students. each interviewer spread in a region of turirejo village accompanied by local health cadres to each patient's home. the sampling technique was carried out using the consecutive sampling method, collecting one by one respondent for one day. study location turirejo village is one of ten villages and two sub-districts located in lawang district, malang regency. topographically, turirejo village is plain with an average elevation of approximately 491 m above sea level. the condition of the land in turirejo village is classified as hilly, the soil surface is brown with a slope of less than 15.0%. the average temperature is 22°c to 32°c, with a tropical climate and an average rainfall of 160 mm/year. the livelihoods of the residents of the turirejo village area range from civil servants, police, private employees, farmers, farm laborers, traders, breeders, transportation services, entrepreneurs, and others. in terms of facilities and infrastructure, turirejo village has health facilities, namely the ponkesdes of turirejo village, lawang district [9]. inclusion and exclusion criteria the population in this study were adult hypertensive patients (over 18 years) registered at the turirejo ponkesdes in 2022, totaling 112 people. the inclusion criteria were hypertensive patients who were registered in the data and coverage of the ponkesdes (village health board) of turirejo village who were currently in turirejo village. exclusion criteria were participants who did not give consent to participate in the study, patients who could not be found, or patients who had never received treatment for hypertension. sample size the sample size was obtained by five to ten rules of thumb for determining sample size roscoe [10]. since there are six variables included for regression analysis, by the rule of five, there are a minimum of 30 samples included in this study. roscoe suggested that a sample size greater than 30 and less than 500 is suitable for most behavioral studies [10]. study tool and the variables the dependent variable in this study was adherence to treatment. compliance was measured using a questionnaire that was compiled based on a previous study [11]. this questionnaire has been tested for construct validity and reliability by previous studies [12]. the results of the analysis showed that the mmas8 questionnaire used was valid with the r count of all questions > r table (0.355) at a significance of 0.05. the results of the analysis also show that the instrument is reliable with a reliability coefficient of 0.729 [12] assessment of adherence to hypertension treatment was carried out using the mmas-8 which included eight questions (table 2). questions number 1-7 use "yes" and "no" answer choices, while question number 8 has 5 answer choices, namely always, usually, sometimes, occasionally, and never. respondents are said to have high compliance if they have a score of 8, moderate compliance with a score of 6-7, and low compliance if a score < 6 [11]. the independent variables in this study were age, education level, length of illness with hypertension, participation with health insurance, knowledge of hypertension treatment, and attitude towards hypertension treatment. knowledge of hypertension treatment was measured using a questionnaire that was prepared based on questions regarding the basic knowledge that hypertension sufferers need to know regarding hypertension treatment (table 3). the questionnaire consists of 8 questions, with each correct answer given a value of 1. the validity and reliability test found that all questions were valid with a cronbach alpha value = 0.619. if the total score is correct ≥7 then the respondent's knowledge is categorized as good, whereas if the total score is correct <7 then the respondent's knowledge is categorized as lacking. attitudes toward treatment were measured using a questionnaire compiled based on statements that should be made by hypertensive patients (table 4). the questionnaire consists of 8 statements with answers in the form of a likert scale (1-4). the maximum total score from the accumulation of the likert scale is 32. the validity and reliability tests found that all questions were valid with a cronbach alpha value = 0.691. if the total score is ≥25 then the attitude of the respondent is categorized as positive, whereas if the total score is <25 then the attitude of the respondent is categorized as negative. statistical analysis analysis was performed using ibm spss statistics ver. software. 23. variables with nominal and ordinal data scales are presented in the form of amounts and percentages. each independent variable was subjected to a bivariate logistic regression test on the dependent variable to display the odds ratio (or) value. the independent variable with the results of the bivariate logistic regression test that has a p-value <0.25 will be subjected to a multivariate logistic regression test with the backward entry method based on the likelihood ratio. all analyzes were performed at a significance level of p < 0.05 with 95% confidence intervals. results socio-demographic characteristics of study participants visuddho v, et al., journal of ideas in health (2023); 6(2):854-860 856 a total of 37 adult hypertensive patients out of 112 patients diagnosed with hypertension at the turirejo ponkesdes participated in this study (table 1). most of the participants were over 56 years old (73.0%) and had less than 9 years of education (73.0%). there were 29 patients (73.0%) who had been sick for less than 10 years and the rest (27.0%) had had hypertension for more than 10 years. more than half of the participants (57.0%) took part in a health insurance program. the average knowledge score of all participants was 5.83 ± 1.8 with the distribution of the number of participants with a score below 7 of 19 people (51.0%) and a score above or equal to 7 of 18 people (49.0%). the average attitude score of all participants was 24.14 ± 4.2 with the distribution of the number of participants with a score below 25 of 28 people (76.0%) and a score above or equal to 25 of 9 people (24.0%). from the results of adherence calculated by the mmas-8 score, there were no patients who had high compliance or a score of 8. most of the participants had low adherence (76.0%) and the rest had moderate adherence (24.0%). table 2-4 described the distribution of answers to the knowledge, attitude, and mmas-8 questionnaire. we found that most patients were disobedient because they forgot to take their medication (76.0%) and stopped their medication on their own because they felt their condition was improving (controlled blood pressure) (76.0%). the statement that most patients obeyed was not forgetting to bring medicine when traveling (59.0%). table 1: demographics and other characteristics of the sample (n=37) variables categories n (%) age < 56 years old 10 (27%) ≥ 56 years old 27 (73%) gender male 5 (14%) female 32 (86%) educational level < 9 years 27 (73%) ≥ 9 years 10 (27%) duration of illness < 10 years 29 (78%) ≥ 10 years 8 (22%) health insurance participation nonparticipant 16 (43%) participant 21 (57%) knowledge of hypertension medication score < 7 19 (51%) score ≥ 7 18(49%) attitude towards hypertension medication score < 25 21 (57%) score ≥ 25 16 (43%) medication adherence low adherence 28 (76%) mid adherence 9 (24%) high adherence 0 table 2: distribution of answers to the mmas-8 questionnaire no. mmas-8 non-compliant n (%) compliant n (%) 1. do you sometimes forget to take your pills? 28 (76) 9 (24) 2. people sometimes miss taking their medications for reasons other than forgetting. thinking over the past two weeks, were there any days when you didn't take your medicine? 23 (62) 14 (38) 3. have you ever cut back or stopped taking your medicine without telling your doctor because you felt worse when you took it? 23 (62) 14 (38) 4. when you travel or leave home, do you sometimes forget to bring along your medicine? 15 (41) 22 (59) 5. did you take all your medicine yesterday? 18 (49) 19 (51) 6. when you feel like your symptoms are under control, do you sometimes stop taking your medicine? 28 (76) 9 (24) 7. taking medicine every day is a real inconvenience for some people. have you ever felt hassled about sticking to your treatment plan? 20 (54) 17 (46) 8. how often do you have difficulty remembering to take all your medicine? (a) never/rarely; (b) once in a while; (c) sometimes; (d) usually; (e) all the time. 23 (62) 14 (38) table 3: distribution of answers for knowledge regarding hypertension treatment questionnaire no questions correct answer n (%) wrong answer n (%) 1. can antihypertensive drugs be taken without a doctor's advice? 23 (62) 14 (37) 2. are antihypertensive drugs only taken when there are symptoms? 21 (56) 16 (43) 3. do antihypertensive drugs still need to be consumed even though you exercise routinely? 28 (75) 9 (24) 4. do antihypertensive (high blood pressure) drugs have to be taken at the same time every day? 24 (64) 13 (35) 5. is taking antihypertensive medication addictive? 29 (78) 8 (21) 6. do people who have long suffered from hypertension (high blood pressure) still need to take medication? 28 (75) 9 (24) 7. can antihypertensive drugs (high blood pressure) be added alone if there are symptoms of dizziness? 31 (83) 6 (16) 8. do people with hypertension have to come to the doctor regularly? 32 (86) 5 (13) visuddho v, et al., journal of ideas in health (2023); 6(2):854-860 857 table 4: distribution of answers for attitude regarding hypertension treatment questionnaire no. statement strongly disagree (%) disagree (%) agree (%) strongly agree (%) 1. i want to take antihypertensive (high blood pressure) medication every day to maintain my health 3 (8) 6 (16) 13 (35) 15 (40) 2. i don't take antihypertensive medication (high blood pressure) if there are no complaints 9 (24) 14 (37) 7 (18) 7 (18) 3. i feel that taking medication every day interferes with my daily activities 5 (13) 6 (16) 13 (35) 13 (35) 4. i feel that taking the antihypertensive medication regularly can damage my kidneys 4 (10) 10 (27) 11 (29) 12 (32) 5. i want to regularly check with the doctor for the treatment of hypertension (high blood pressure) 2 (5) 3 (8) 14 (37) 18 (48) 6. i feel that my hypertension (high blood pressure) will get better if i take medication regularly 1 (2) 0 (0) 7 (18) 29 (78) 7. i will continue to take antihypertensive medication even though my blood pressure is normal 10 (27) 6 (16) 11 (29) 10 (27) 8. if i forget to take my antihypertensive medication, i feel the need to double the dose of the next 0 (0) 4 (10) 13 (35) 20 (54) bivariate analysis bivariate analysis shows the effect of the independent variables on the dependent variable (table 5). there was no significant effect of age, education, and health insurance participation on participant compliance in treating hypertension. the length of illness variable, knowledge score, and attitude score had a significant effect on participant adherence in carrying out hypertension treatment. multivariate analysis multivariate analysis using multiple logistic regression was performed to look for factors that simultaneously affect adherence to hypertension treatment. there are three steps in the multivariate logistic regression analysis test; the first step was followed by four independent variables (age, length of illness, knowledge, and attitude). the final step leaves two variables, namely length of illness and attitude (table 6). the omnibus tests and the hosmer and lemeshow tests show that the analytical model formed is fit to the data. participants with an illness of more than 10 years were eighteen times more obedient than participants with an illness of less than 10 years (adjusted or 18.27; 95% ci 1.72-194.47; p=0.02). participants with an attitude score of more than or equal to 25 were twelve times more obedient than participants with an attitude score below 25 (adjusted or 12.76; 95% ci 1.25-130.40; p=0.03). it can be concluded that the longer the illness and the higher the attitude score, the more likely the participants are to comply with hypertension treatment. the constants of the multivariate binary logistic regression mathematical model are negative. this means that before the addition of the variable length of illness or attitudes toward hypertension treatment, there were already other factors that lead to low adherence. supported by nagelkerke r square of 46.3%, there are still many factors that have not been successfully included in this analysis model. table 5: result of bivariate analysis (n=37) variables categories low adherence n (%) mid adherence n (%) β or (95% ci) p-value age < 56 years old 9(90) 1(10) 1.33 3.79 (0.41-35.07) 0.241 ≥ 56 years old 19 (70.3) 8(29.7) education < 9 years 21 (77.8) 6 (22.2) 0.41 1.50 (0.29-7.65) 0.626 ≥ 9 years 7 (70) 3 (30) duration of illness < 10 years 25 (86.2) 4 (13.8) 2.34 10.42 (1.76-61.67) 0.010* ≥ 10 years 3 (37.5) 5 (62.5) health insurance participation non-participant 12 (75) 4 (25) -0.07 0.94 (0.20-4.26) 0.933 participant 16 (76.2) 5 (23.8) knowledge of hypertension medication score < 7 18 (94.7) 1 (5.3) 2.67 14.40 (1.57-132.31) 0.018* score ≥ 7 10 (55.6) 8 (44.4) attitude towards hypertension medication score < 25 19 (90.5) 2 (9.5) 2 7.39 (1.27-42.96) 0.026* score ≥ 25 9 (56.3) 7 (43.7) visuddho v, et al., journal of ideas in health (2023); 6(2):854-860 858 *significant p<0,05 table 6: results of multivariate binary logistic regression (n=37) variables categories β adjusted or (95% ci) p-value duration of illness ≥ 10 years 2.91 18.27 1.72-194.47 0.016 < 10 years reference attitude towards hypertension medication score < 25 2,55 12,76 (1,25-130,40) 0,032* score ≥ 25 reference *significant p<0.05. only significant variables are included in the table. discussion the health behavior of an individual is influenced by several factors. this study measured the influence of factors on medication adherence, including the level of knowledge, attitudes, and demographic factors. in this study, most of the participants had low adherence according to the results of the preliminary studies conducted. based on data from the results of the distribution of answers to the mmas-8 questionnaire, it was found that most patients did not comply because they forgot to take their medication and stopped their own medication because they felt that their condition was improving (controlled blood pressure). patients with hypertension in general are often accompanied by other comorbid diseases [12]. this causes a large number of drugs to be taken together with hypertension drugs so that many patients are confused or even forget to take their medication [12]. the study by vrijens et al. [13] stated that the burden of more pills makes the habit of taking daily medication more complicated, often a barrier to optimal medication adherence. respondents who stopped selfmedication could be due to a misunderstanding about the absence of symptoms as a cure [14, 15]. the wrong perception that hypertension drugs are ineffective in controlling blood pressure also plays a role in non-compliance [16, 17]. ineffective communication between patients and health workers can hinder the delivery of disease-related education, including the importance of taking antihypertensive drug therapy in asymptomatic conditions [18]. the results of this study found that older respondents (≥56 years) had better adherence (22%) than respondents aged <56 years (3%), although there was no significant difference. the insignificant effect of age can occur due to factors that both encourage and hinder adherence in older and younger groups [18, 19]. the factors that encourage adherence in the older age group are better health awareness and the presence of cadres who often conduct counseling and encourage people to comply with taking medication [20, 21]. obstacles are decreased cognitive ability, physical function, difficulty swallowing medication, ability to care for oneself, and a lower likelihood of living with other people [22–24]. the results showed that there was no significant relationship between recent education and adherence to taking antihypertensive medication [25]. even though a higher level of education is considered to have more potential to maintain health, people with low levels of education are also considered to be able to access health information just as well [26]. the existence of counseling for various groups of people can be a reason for the balance of information between groups of community education. insurance participation has no significant effect on adherence to hypertension treatment [27,28]. this is due to the small number of people using insurance, namely those living in rural areas. people tend to choose to buy their own medicines at pharmacies compared to coming to take advantage of health insurance [29]. another factor is the government's policy regarding the price of drugs, which refers to drug price margins that can be reached by the public, making it easier to buy drugs independently [30]. in this study, the patient's length of time with hypertension affects adherence to hypertension treatment. this is similar to previous studies [31-34]. the longer a person suffers from a disease, the more knowledge and understanding he will have about the disease [5]. greater concern about symptoms due to hypertension can also increase adherence [34-35]. health knowledge is defined as all the results of finding out about an object, therefore health knowledge is the result of finding out with all the senses about health [36] patients with a good level of knowledge generally have better adherence [37,38]. this is because these patients understand more about how to treat hypertension and the dangers if not routinely treated [37]. patients with more knowledge can also discuss with health workers to determine the most suitable treatment method [38-40]. similar to knowledge, there is a significant relationship between patient attitudes and adherence to hypertension treatment [41]. this is because attitude statements show an individual's tendency to act [42]. both attitude and duration of illness can interact to influence adherence. patients who are sick longer generally gain more experience so that they have a positive attitude [31]. in addition, patients who were ill for longer were found to have a good doctor-patient relationship and have greater confidence in the doctor's advice [31]. patients with long-standing hypertension are more prone to complications, thus adding to the patient's consideration to continue to comply to avoid complications [43]. this research has several drawbacks. first, the number of hypertensive patients participating in this study is still limited, this is because the population of hypertensive patients is limited and the public's willingness to be interviewed is quite low. second, there are still many factors that have not been identified, such as the economy, distance to health access, availability of companions, and places to buy medicines. third, the questionnaire used in this study was in the form of a closed questionnaire. this resulted in not conducting in-depth interviews for every answer regarding the factors that influence compliance. in-depth interviews are expected to help identify the reasons for their decision. conclusion length of hypertension illness, knowledge of hypertension treatment, and attitudes regarding hypertension treatment affect adherence to hypertension treatment in hypertensive patients in turirejo village. this research supports an increase in service and assistance for cadres, especially for the elderly, most of visuddho v, et al., journal of ideas in health (2023); 6(2):854-860 859 whom are hypertensive patients. further research by including variables such as economy, distance to health access, presence of companions, and places of purchase of drugs accompanied by indepth interviews with open questionnaires is needed to validate the results we are doing. abbreviation mmas-8: morisky medication adherence scale-8; or: odds ratio declaration acknowledgment we acknowledged the contribution of the turirejo village government and health cadre in providing the demographical data and access for conducting this study. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing visuddho2018@fk.unair.ac.id authors’ contributions visuddho visuddho and putu astiswari permata kurniawan participated in conceptualization, methodology, formal analysis, project administration, writing, and original drafting. salsabilla firdausi rafidah, ramadhani rizki zamzam, ezrin syariman bin roslan, muhammad raihan habibi, and muhammad gazi yasargil participated in conceptualization, data curation, writing, and original drafting. atika, atni supratiwi participated in conceptualization, methodology, writing, review, and editing. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the protocol was granted by the health research ethical committee of the faculty of medicine airlangga university, indonesia (51/ec/kepk/fkua/2023). consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1medical program, faculty of medicine universitas airlangga, surabaya, indonesia. 2department of public health, faculty of medicine universitas airlangga, surabaya, indonesia. 3upt, latkesmas murnajati lawang, malang, indonesia. article info received: 20 march 2023 accepted: 17 may 2023 published: 26 may 2023 references 1. ministry of health of the republic of indonesia. pedoman teknis penemuan dan tatalaksana hipertensi. jakarta: 2013. 2. world health organization. hypertension 2021. https://www.who.int/news-room/fact-sheets/detail/hypertension (accessed march 5, 2023). 3. badan penelitian dan pengembangan kesehatan kementerian kesehatan ri. riset kesehatan dasar 2018. jakarta: lembaga penerbit bdan penelitian dan pengembangan kesehatan (lpb); 2019. 4. apriliyani w, ramatillah dl. evaluasi tingkat kepatuhan penggunaan antihipertensi pada pasien hipertensi menggunakan kuesioner mmas-8 di penang malaysia. social clinical pharmacy indonesia journal. 2020;5(1):23–33. https://doi.org/10.52447/scpij.v5i1.1863 5. pan j, wu l, wang h, lei t, hu b, xue x, et al. determinants of hypertension treatment adherence among a chinese population using the therapeutic adherence scale for hypertensive patients. medicine. 2019;98(27):1–7. https://doi.org/10.1097/md.0000000000016116 6. viera aj, cohen lw, mitchell cm, sloane pd. high blood pressure knowledge among primary care patients with known hypertension: a north carolina family medicine research network (nc-fm-rn) study. journal of the american board of family medicine. 2008;21(4):300–8. https://doi.org/10.3122/jabfm.2008.04.070254 7. paczkowska a, hoffmann k, kus k, kopciuch d, zaprutko t, ratajczak p, et al. impact of patient knowledge on hypertension treatment adherence and efficacy: a single-centre study in poland. int j med sci. 2021;18(3):852–60. https://doi.org/10.7150/ijms.48139 8. choudhry nk, kronish im, vongpatanasin w, ferdinand kc, pavlik vn, egan bm, et al. medication adherence and blood pressure control: a scientific statement from the american heart association. hypertension. 2022;79(1):e1–14. https://doi.org/10.1161/hyp.0000000000000203 9. morisky de, ang a, krousel-wood m, ward hj. predictive validity of a medication adherence measure in an outpatient setting. the journal of clinical hypertension. 2008;10(5):348–54. https://doi.org/10.1111/j.1751-7176.2008.07572.x 10. rosyida l, priyandani y, sulistyarini a, nita y. kepatuhan pasien pada penggunaan obat antidiabetes dengan metode pill-count dan mmas-8 di puskesmas kedurus surabaya. jurnal farmasi komunitas. 2015;2(2):36–41. 11. malang regency government health office. profil kesehatan desa turirejo tahun 2022. malang: 2023. 12. imanda m, darliana d, ahyana. kepatuhan minum obat pasien hipertensi. jurnal ilmiah mahasiswa fakultas keperawatan. 2021;5(1):187–96. 13. vrijens b, antoniou s, burnier m, de la sierra a, volpe m. current situation of medication adherence in hypertension. front pharmacol. 2017; 8:1–8. https://doi.org/10.3389/fphar.2017.00100. 14. burnier m, egan bm. adherence in hypertension: a review of prevalence, risk factors, impact, and management. circ res. 2019;124(7):1124–40. https://doi.org/10.1161/circresaha.118.313220. 15. hill mn, miller nh, degeest s. adherence and persistence with taking medication to control high blood pressure. journal of the visuddho v, et al., journal of ideas in health (2023); 6(2):854-860 860 american society of hypertension. 2011;5(1):56–63. https://doi.org/10.1016/j.jash.2011.01.001. 16. burnier m. drug adherence in hypertension. pharmacol res. 2017;125:142–9. https://doi.org/10.1007/978-3-319-15961-4_43. 17. haskard zolnierek kb, dimatteo mr. physician communication and patient adherence to treatment: a meta-analysis. med care. 2009;47(8):826–34. https://doi.org/10.1097/mlr.0b013e31819a5acc. 18. bakurawang in, agustine u. kepatuhan minum obat pada penderita hipertensi yang berobat ke balai pengobatan yayasan pelayanan kasih a dan a rahmat waingapu. jurnal kesehatan primer. 2016;1(2):114–22. https://doi.org/10.5281/jkp.v1i2.74. 19. algabbani fm, algabbani am. treatment adherence among patients with hypertension: findings from a cross-sectional study. clin hypertens. 2020;26(1):1–9. https://doi.org/10.1186/s40885020-00151-1. 20. natasya de. pengaruh pemberian edukasi kesehatan pada kader posyandu lansia terhadap peran kader dan kepatuhan minum obat pasien hipertensi yang mengikuti posyandu lansia. universitas brawijaya, 2018. 21. janz nk, becker mh. the health belief model: a decade later. health educ q. 1984;11(1):1–47. https://doi.org/10.1177/109019818401100101. 22. jackevicius ca, mamdani m, tu j v. adherence with statin therapy in elderly patients with and without acute coronary syndromes. j am med assoc. 2002;288(4):462–7. https://doi.org/10.1001/jama.288.4.462. 23. lam p, lum c, leung m. drug non-adherence and associated risk factors among chinese geriatric patients in hong kong. hong kong medical journal. 2007;13(4):284–92. 24. lee sunmin, jeong k-h, lee seoyoon, park h. a study on types of medication adherence in hypertension among older patients and influencing factors. healthcare. 2022;10(11):2322. https://doi.org/10.3390/healthcare10112322. 25. indriana n, swandari mtk, pertiwi y. hubungan tingkat pengetahuan dengan kepatuhan minum obat pada pasien hipertensi di rumah sakit x cilacap. jurnal ilmiah jophus: journal of pharmacy umus. 2020;2(1):1–10. https://doi.org/10.46772/jophus.v2i01.266. 26. sihombing tfh, artini iga. tingkat pengetahuan mengenai hipertensi dan pola kepatuhan pengobatan pada penderita hipertensi yang berkunjung ke tenda tensi tim bantuan medis janar dūta fakultas kedokteran universitas udayana. e-jurnal medika. 2017;6(12):164–9. 27. makatindu mg, nurmansyah m, bidjuni h. identifikasi faktor pendukung yang berhubungan dengan minum obat pada penderita hiperensi di puskesmas tatelu kabupaten minahasa utara. jurnal keperawatan. 2021;9(1):19–26. https://doi.org/10.35790/jkp.v9i1.36765. 28. liberty ia, pariyana, roflin e, waris l. determinan kepatuhan berobat pasien hipertensi pada fasilitas kesehatan tingkat i. jurnal penelitian dan pengembangan pelayanan kesehatan. 2017; 1:58–65. https://doi.org/10.22435/jpppk.v1i1.428. 29. susilo ai, meinisasti r. analisa praktik swamedikasi di kota bengkulu. journal of nursing and public health. 2022;10(2):242– 54. https://doi.org/10.37676/jnph.v10i2.3203. 30. suryani a, hasanbasri m, priyatni n. pelaksanaan kebijakan obat generik di apotek kabupaten pelalawan provinsi riau. jurnal kebijakan kesehatan indonesia. 2013;2(2):53–60. 31. lee gky, wang hhx, liu kql, cheung y, morisky de, wong mcs. determinants of medication adherence to antihypertensive medications among a chinese population using morisky medication adherence scale. plos one. 2013;8(4). https://doi.org/10.1371/journal.pone.0062775. 32. boratas s, kilic hf. evaluation of medication adherence in hypertensive patients and influential factors. pak j med sci. 2018;34(4):959–63. https://doi.org/10.12669/pjms.344.14994. 33. uchmanowicz b, chudiak a, uchmanowicz i, rosińczuk j, froelicher es. factors influencing adherence to treatment in older adults with hypertension. clin interv aging.2018;13:2425–41. https://doi.org/10.2147/cia.s182881. 34. listiana d, effendi s, saputra ye. faktor-faktor yang berhubungan dengan kepatuhan penderita hipertensi dalam menjalani pengobatan di puskesmas karang dapo kabupaten muratara. journal of nursing and public health.2020;8(1):11–22. https://doi.org/10.37676/jnph.v8i1.1005. 35. ihwatun s, ginandjar p, saraswati ld, udiyono a. faktor-faktor yang berhubungan dengan kepatuhan pengobatan pada penderita hipertensi di wilayah kerja puskesmas pudakpayung kota semarang tahun 2019. jurnal kesehatan masyarakat. 2020;8(3):352–59. https://doi.org/10.14710/jkm.v8i3.26396 36. octaviana dr, ramadhani ra. hakikat manusia: pengetahuan (knowladge), ilmu pengetahuan (sains), filsafat dan agama. jurnal tawadhu. 2021;5(2):143–59. https://doi.org/10.52802/twd.v5i2.227 37. dilianty om, sianturi sr, marlina pw. peningkatan kepatuhan berobat melalui edukasi bagi penderita hipertensi di kabupaten flores timur. jurnal ilmiah kesehatan keperawatan. 2019;15(2):55–63. https://doi.org/10.26753/jikk.v15i2.305 38. wulansari j, ichsan b, usdiana d. hubungan pengetahuan tentang hipertensi dengan pengendalian tekanan darah pada pasien hipertensi di poliklinik penyakit dalam rsud dr.moewardi surakarta. biomedika. 2013;5(1):17–22. https://doi.org/10.23917/biomedika.v5i1.271. 39. nurhanani r, susanto hs, udiyono a. hubungan faktor pengetahuan dengan tingkat kepatuhan minum obat antihipertensi (studi pada pasien hipertensi essential di wilayah kerja puskesmas bandarharjo kota semarang). jurnal kesehatan masyarakat. 2020;8(1):114–21. https://doi.org/10.14710/jkm.v8i1.25932. 40. padaunan e, pitoy ff, wongkar gh. pengetahuan penderita hipertensi tentang penyakitnya terhadap kepatuhan obat. jurnal skolastik keperawatan. 2022;8(1):10–8. https://doi.org/10.35974/jsk.v8i1.2847 41. tambunan a. hubungan pengetahuan dan sikap terhadap kepatuhan pasien tbc di upt puskesmas belawan. institut kesehatan helvetia, 2019. 42. notoatmodjo s. promosi kesehatan dan perilaku kesehatan. jakarta: pt. rineka cipta; 2012. 43. oh js, lee ch, park j il, park hk, hwang jk. hypertensionmediated organ damage and long-term cardiovascular outcomes in asian hypertensive patients without prior cardiovascular disease. j korean med sci. 2020;35(48):1–11. https://doi.org/10.3346/jkms.2020.35.e400 https://doi.org/10.47108/jidhealth.vol6.iss2.269 hakami e, et al., journal of ideas in health (2023); 6(2):828-835 © the author(s). 2023 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access the prevalence of depression and anxiety in nurses caring for covid-19 patients in saudi arabia: a single center experience emad hakami1, ahlam alsomali1, mohammed senitan2 abstract background: healthcare workers in direct contact with confirmed covid-19 patients often face a negative impact on psychological health. this study aims to examine the prevalence of anxiety and depression among nurses caring for covid-19 patients. methods: a cross-sectional survey was conducted during the covid-19 pandemic from january 2022 to april 2022 at king faisal specialist hospital and research center in riyadh, saudi arabia. the prevalence of depression and anxiety was assessed using the patient health questionnaire (phq-9), and the generalized anxiety disorder-7 (gad7) questionnaire. kruskal–wallis’s test was used to compare the total scores of the phq-9 and gad-7 with respect to demographic characteristics. p<0.05 was considered statistically significant. results: a total of 123 nurses were included in the study. most of them were females (69.92%), aged 30–39 years (45.53%), had a bachelor's degree in nursing (75.61%), and had more than ten years of experience (3830.89%). the depression and anxiety prevalence in the study was 78.1% and 72.4%, respectively. nurses aged 30–39 years were significantly associated with depressive symptoms. female nurses showed significantly higher scores for depression and anxiety than males 74.42% and 67.45%, respectively. conclusion: the findings suggest that nurses are at risk for developing depression and anxiety. therefore, regular mental health screening is necessary for nurses, particularly during a pandemic. keywords: depression, anxiety, healthcare workers, covid-19, pandemic, saudi arabia background in march 2020, the world health organization (who) declared the coronavirus disease 2019 (covid-19) a pandemic [1]. the disease affected over 600 million people worldwide and caused over 6 million deaths. saudi arabia reported over 800,000 cases and 9000 deaths [2]. pandemics present unique challenges to healthcare providers, as the treatment course is often unknown, social isolation is required following symptom onset, and frontline healthcare providers are concerned not only with their patients' safety but also their own and family members' health. furthermore, many healthcare providers are suddenly required to engage in unfamiliar activities in stressful settings, such as high-risk, high-intensity units, which are likely to be associated with higher levels of psychological distress. these characteristics of an outbreak diminish the availability of social support, such as assistance from coworkers and families, which is believed to mitigate the detrimental effects of stress [3]. healthcare providers are expected to work long hours under extreme stress in pandemic situations. when treating sick patients, they are at risk of becoming infected. they are also exposed to fake news and rumors, which increases their anxiety. working in such an environment increases the risk of various psychological and mental illnesses as well as physical and emotional distress [4]. globally, several populations have experienced a negative impact on psychological health related to the pandemic [5]. among them, frontline healthcare workers are at high risk because of direct exposure to patients and increased workload [5]. infectious disease outbreaks are known to have a psychological impact on healthcare workers and the general population [6]. ___________________________________________________ nurseemad@gmail.com 1department of cardiovascular nursing king faisal specialist hospital and research center, riyadh, saudi arabia a full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol6.iss2.269 http://www.jidhealth.com/ hakami e, et al., journal of ideas in health (2023); 6(1):828-835 829 in al thobaity and alshammari's study [7], it was found that depression and anxiety are among the most common issues nurses face when dealing with covid-19 patients. the psychological reactions of healthcare providers to covid-19 are complex. according to a review of 44 studies [8], severe anxiety symptoms were reported in 45% of healthcare workers. additionally, depressive symptoms were reported to be ranging from 27.5%–50.7% [8]. individual and work-related features, such as the level of exposure to infected patients, are considered risk factors for negative psychological states. in a study of 502 healthcare providers working in direct contact with confirmed cases of covid-19, 51.4% reported having anxiety, with 25.1% having mild, 11% having moderate, and 15.3% having severe anxiety. the prevalence of depression among healthcare workers during the covid-19 outbreak was found to be moderate to very severe [6]. the poor infectivity and mortality rate put incredible pressure on all medical teams [8]. the source of anxiety among nurses varies between fear of susceptibility to infection and the possibility of death [8]. nurses are mainly concerned with spreading the infection to vulnerable family members, such as the elderly, immunocompromised, and young children [8]. nursing workload, fear of infection, and poor family relationships were associated with a higher risk of depressive symptoms. nurses working in highand low-risk covid-19 areas showed a higher level of depression than those working in middle-risk covid-19 areas. the city of residence and type of hospital also influence the risk of depression; a higher risk was observed among those working in general tertiary hospitals [9]. we believe that as the pandemic worsens and the number of cases increases exponentially, the psychological impact and actual pressure faced by healthcare professionals in each country will also increase [8]. this study aimed to determine the prevalence of anxiety and depressive symptoms among nurses and to evaluate the depression and anxiety levels among nurses caring for confirmed cases of covid-19 at king faisal specialist hospital and research centre riyadh. methods study design and setting data for this study were collected via a cross-sectional survey during the covid-19 pandemic from january 2022 to april 2022 at king faisal specialist hospital and research center in riyadh, saudi arabia. inclusion and exclusion criteria all nurses involved in the directed care of confirmed cases of covid-19 for more than two hours at king faisal specialist hospital and research center in riyadh city were included in the study. however, nurses who did not work with confirmed cases of covid-19, nurses who did not spend more than two hours with confirmed cases of covid-19 patients, not nurses, missing data were excluded from the study. recruitment convenience sampling and redcap were used to recruit participants. an online survey was mailed to all nurses who were working or had worked with confirmed covid-19 cases in the east wing at king faisal specialist hospital and research center riyadh, arranged in collaboration with the internal communication channels of the hospital. the questionnaire link: https://redcap.kfshrc.edu.sa/surveys/?s=ra7nkljc7p sample size the sample size was calculated using raosoft software [10]; it was estimated at the 90% confidence level with an estimated 50% response distribution and a margin of error of 7%. the minimum required sample size was 138. study tool the english version of the questionnaire, containing the following three components, was disseminated among the nurses: 1. sociodemographic characteristics, including age, gender, education level, years of experience, medical history, nationality, and residency. 2. the patient health questionnaire-9 (phq-9) an english version of the tool was used in the study and this tool is a widely used and valid tool for detecting depressive symptoms, comprises nine items rated on a likert scale from 0 (not experienced at all) to 3 (experienced nearly daily). these items detect depressive symptoms that have occurred during the last two weeks. the maximum total score is 27; the total score is classified as mild (5–9), moderate (10–14), moderately severe (15–19), or severe (20–27). the scale's internal consistency was indicated by a cronbach's alpha of 0.89 [11]. the diagnostic validity of the phq-9 has been established in studies involving eight primary care and seven obstetric clinics [12]. the internal reliability of the phq-9 was excellent, with a cronbach's α of 0.89 in the phq primary care study and 0.86 in the phq obgyn study. test-retest reliability of the phq-9 was also excellent [12]. 3. the generalized anxiety disorder-7 (gad-7) questionnaire is a valid tool for detecting anxiety, comprising seven items rated on a likert scale. the maximum total score is 21; the total score is classified as mild (5–9), moderate (10–14), or severe (15–21). internal consistency was evaluated using cronbach’s alpha α = 0.95 [3]. the diagnostic validity of the gad-7 was established in studies involving 15 primary care clinics in the united states from november 2004 to june 2005 [3]. the tool has good reliability as well as criterion, construct, factorial, and procedural validity [3]. statistical analysis the principal investigator collected the questionnaires. the data were entered into a password-protected excel database for management and storage. double data entry was performed to ensure data accuracy. the investigator extracted data from the questionnaires to examine the two outcomes of interest: depression and anxiety levels. statistical analysis was performed using spss version 23.0 (spss inc., chicago, il, usa). we calculated the percentages and frequencies of all nominal variables for the phq-9 and gad-7 items. in addition, the mean, median, and standard deviation ranges of the phq-9 and gad-7 total scores were calculated. furthermore, the nonparametric kruskal–wallis’s test was used to compare the total scores of the phq-9 and gad-7 with respect to demographic characteristics. hakami e, et al., journal of ideas in health (2023); 6(1):828-835 830 results socio-demographic characteristics of study participants onehundred and twenty-three nurses responded to the survey. the sociodemographic characteristics of the sample are shown in table 1. the majority of the respondents were female (86; 69.92%), and aged 30–39 years (56; 45.53%). most respondents held a bachelor's degree in nursing (93; 75.61%); 57 (46.34%) nurses were from saudi arabia, and most lived in private houses outside the hospital premises (88; 71.54%). the majority of the nurses had over 10 years of experience (38; 30.89%). table 1: frequencies and percentage of demographics characteristics (n=123) variable categories n % gender male 37 30.08 female 86 69.92 age groups 18–29 31 25.20 30–39 56 45.53 40–49 26 21.14 50+ 10 8.13 educational levels diploma in nursing 21 17.07 bachelors in nursing 93 75.61 master’s degree 9 7.32 nationality saudi arabia 57 46.34 india 17 13.82 philippine 20 16.26 pakistan 2 1.63 jordan 3 2.44 other 24 19.51 residency hospital housing 35 28.46 outside housing 88 71.54 years of experience 1-3 29 23.58 4-6 30 24.39 7-10 26 21.14 10+ 38 30.89 the nurses who presented with depressive disorder obtained a mean score of 10.1 (sd 6.16) (table 2). the number (percentage) of nurses with minimal, mild, moderate, moderately severe, and severe depression were 27 (21.95%), 32 (26.02%), 41 (33.33%), 10 (8.13%), and 13 (10.57%), respectively. moreover, the nurses who presented with anxiety disorder obtained a mean score of 8.13 (sd 5.46) (table 2). the number (percentage) of nurses with minimal, mild, moderate, and severe anxiety levels were 34 (27.64%), 41 (33.33%), 33 (26.83%), and 15 (12.2%), respectively. table 2: depression and anxiety among nurses (n=123) statistics phq-9 scores gad-7 scores observation 123 123 mean (standard deviation) 10.11 (6.17) 8.14 (5.47) median 10 8 interquartile range 6-13 3-12 minimum -maximum 1-27 0-12 differences in depression level based on sociodemographic characteristics several sociodemographic variables were significantly associated with depression (table 3). the chi-square test showed a significant association between depressive symptoms and gender: 25 (29.07%) female nurses reported mild depression while 19 (51.35%) male nurses reported moderate depression (p = 0.001). furthermore, among nurses aged 30–39 years, 19 (33.93%) demonstrated mild depression (p = 0.084). among nurses with a bachelor’s degree, 36 (38.71%) had moderate depression (p = 0.577). among saudi nurses, 25 (43.86%) showed moderate depression (p = 0.247). among nurses living in private houses, 29 (32.95%) reported moderate depression (p = 0.076). fifteen (50%) nurses with experience ranging from 4–6 years demonstrated moderate depression (p = 0.438). differences in anxiety based on sociodemographic characteristics several sociodemographic variables were significantly associated with anxiety (table 4). female nurses were more anxious than males: 27 female (31.4%) and 14 male nurses (37.84%) reported mild anxiety (p = 0.319). among nurses aged 30–39 years, 24 (42.86%) reported mild anxiety (p = 0.003). among nurses with a bachelor’s degree, 30 (32.26%) had mild anxiety (p= 0.206). among saudi nurses, 22 (38.6%) demonstrated moderate anxiety (p = 0.003). among nurses living in private houses, 28 (31.82%) displayed mild anxiety (p = 0.003). among nurses with over 10 years of experience, 16 (42.11%) demonstrated mild anxiety (p = 0.049). depression and anxiety based on demographic characteristics the wilcoxon signed-rank test revealed a statistically significant difference in the mean depression score between nurses living in hospital housing and private housing (p = 0.0246; table 5 and table 6), indicating that nurses’ housing situation had a significant effect on depression scores. the kruskal–wallis’s test revealed that the individuals’ median depression scores were not the same across age groups (p = 0.0138) and nationality (p=0.0016), which suggests a statistically significant difference in median scores between two or more age groups, as well as nationality. furthermore, the wilcoxon signed-rank test revealed a statistically significant difference in the mean anxiety score between nurses living in hospital housing and private housing (p = 0.0001). this indicates that nurses’ housing situations significantly affected anxiety scores. the kruskal–wallis’s test revealed that the individuals’ median anxiety scores were not the same across age groups (p = 0.0014) and nationality (p=0.0001), which suggests a statistically significant difference in median scores between two or more age groups, as well as nationality. discussion it is crucial to evaluate mental health conditions among nurses owing to the potential impact of mental health on their health and the quality of patient care. to the best of our knowledge, no study in saudi arabia has examined the prevalence of depression and anxiety in nurses. hakami e, et al., journal of ideas in health (2023); 6(1):828-835 831 table 3. cross classification between phq-9 and demographic data (n=123) variable categories minimal depression mild depression moderate depression moderately severe depression severe depression total p-value n (%) n (%) n (%) n (%) n (%) n (%) gender male 5 (13.51) 7(18.92) 19(51.35) 6(16.22) 0(0) 37(30.08) 0.001* female 22(25.58) 25(29.07) 22(25.58) 4(4.65) 13(15.12) 86(69.92) age groups 18–29 2(6.45) 5(16.13) 14(45.16) 4(12.9) 6(19.35) 31(25.20) 0.084 30–39 11(19.64) 19(33.93) 17(30.36) 5(8.93) 4(7.14) 56(45.53) 40–49 9(34.62) 6(23.08) 8(30.77) 1(3.85) 2(7.69) 26(21.14) 50+ 5(50) 2(20) 2(20) 0(0) 1(10) 10(8.13) educational levels diploma in nursing 6(28.57) 7(33.33) 3(14.29) 2(9.52) 3(14.29) 21(17.07) bachelors in nursing 18(19.35) 22(23.66) 36(38.71) 8(8.6) 9(9.68) 93(75.61) 0.577 master’s degree 3(33.33) 3(33.33) 2(22.22) 0(0) 1(11.11) 9(7.32) nationality saudi arabia 6(10.53) 10(17.54) 25(43.86) 7(12.28) 9(15.79) 57(46.34) 0.247 india 6(35.29) 5(29.41) 3(17.65) 1(5.88) 2(11.76) 17(13.82) philippines 4(20) 8(40) 6(30) 1(5) 1(5) 20(16.26) pakistan 0(0) 1(50) 1(50) 0(0) 0(0) 2(1.63) jordan 1(33.33) 1(33.33) 1(33.33) 0(0) 0(0) 3(2.44) others 10(41.67) 7(29.17) 5(20.83) 1(4.17) 1(4.17) 24(19.51) residency hospital housing 12(34.29) 9(25.71) 12(34.29) 0(0) 2(5.71) 35(28.46) 0.076 private housing 15(17.05) 23(26.14) 29(32.95) 10(11.36) 11(12.5) 88(71.54) years of experience 1–3 5(17.24) 8(27.59) 9(31.03) 4(13.79) 3(10.34) 29(23.58) 0.438 4–6 4(13.33) 6(20) 15(50) 2(6.67) 3(10) 30(24.39) 7–10 5(19.23) 8(30.77) 6(23.08) 3(11.54) 4(15.38) 26(21.14) 10+ 13(34.21) 10(26.32) 11(28.95) 1(2.63) 3(7.89) 38(30.89) therefore, this study is the first to evaluate the prevalence of depression and anxiety among nurses working at king faisal specialist hospital and research center in riyadh, saudi arabia, during the covid-19 pandemic. based on a cutoff value of 5, we found that depression and anxiety were highly prevalent among the nurses. these results are consistent with previous studies [1,6,9]. an iranian study on 441 nurses during the covid-19 pandemic reported a high prevalence of psychiatric symptoms, mainly depression and anxiety [13]. additionally, research from saudi arabia has shown that, during the covid-19 outbreak, nurses had higher depression and anxiety scores than other healthcare providers; furthermore, nurses had moderate to severe levels of depression and anxiety [14]. another study on 3,228 nurses in sichuan province and wuhan city during the covid-19 outbreak reported a total prevalence of 34.3% and 18.1% for anxiety and depression, respectively, and a prevalence of 47.1% and 28.4%, respectively, among nurses who cared for covid-19 patients [15]. our results revealed a significant association between depression symptoms and nurses’ gender. women showed higher scores for depression and anxiety than men. furthermore, nurses aged 30–39 years reported mild depression. similar results were reported in al ateeq et al.'s study [6], which surveyed 502 healthcare providers during the covid-19 pandemic and found that women had higher scores for depression and anxiety than men. similarly, higher scores were reported by healthcare providers aged 30–39 years. in zheng et al.'s study [16] they also found that perceived health status was related to age and gender among chinese nurses. our results also demonstrated a significant association between anxiety symptoms and nurses’ age, region of origin, residence, and experience. similarly, a previous study showed that depression and anxiety were significantly associated with work experience [17]. this study revealed that nurses' housing situation significantly affected depression, anxiety, and anxietydepression levels. as saudi nurses comprised almost half of the study sample, this result could be explained by cultural norms and differences in living conditions between saudi and nonsaudi nurses. most non-saudi nurses are ex-pats who are likely to live alone and have families living in their home countries. hence, they are less likely to worry about the risk of infecting their family members and loved ones than saudi healthcare workers who live with their families and tend to have an active social life [18]. hakami e, et al., journal of ideas in health (2023); 6(1):828-835 832 table 4. cross classification between gad-7 and demographic data (n=123) variable categories minimal anxiety mild anxiety moderate anxiety severe anxiety total p-value n (%) n (%) n (%) n (%) n (%) gender male 6(16.22) 14(37.84) 12(32.43) 5(13.51) 37(30.08) 0.319 female 28(32.56) 27(31.4) 21(24.42) 10(11.63) 86(69.92) age groups 18–29 5(16.13) 6(19.35) 11(35.48) 9(29.03) 31(25.20) 0.003* 30–39 14(25) 24(42.86) 14(25) 4(7.14) 56(45.53) 40–49 8(30.77) 8(30.77) 8(30.77) 2(7.69) 26(21.14) 50+ 7(70) 3(0) 0(0) 0(0) 10(8.13) educational levels diploma in nursing 8(38.1) 10(47.62) 2(9.52) 1(4.76) 21(17.07) 0.206 bachelors in nursing 23(24.73) 30(32.26) 28(30.11) 12(12.9) 93(75.61) master’s degree 3(33.33) 1(11.11) 3(33.33) 2(22.22) 9(7.32) nationality saudi arabia 8(14.04) 14(24.56) 22(38.6) 13(22.81) 57(46.34) 0.003* india 6(35.59) 6(35.29) 4(23.53) 1(5.88) 17(13.82) philippines 7(35) 8(40) 4(20) 1(5) 20(16.26) pakistan 0(0) 1(50) 1(50) 0(0) 2(1.63) jordan 0(0) 2(66.67) 1(33.33) 0(0) 3(2.44) others 13(54.17) 10(41.67) 1(4.17) 0(0) 24(19.51) residency hospital housing 16(45.71) 13(37.14) 6(17.14) 0(0) 35(28.46) 0.003* private housing 18(20.45) 28(31.82) 27(30.68) 15(17.05) 88(71.54) years of experience 1–3 9(31.03) 6(20.69) 6(20.69) 8(27.59) 29(23.58) 0.049* 4–6 6(20) 8(26.67) 13(43.33) 3(10) 30(24.39) 7–10 6(23.08) 11(42.31) 7(26.92) 2(7.69) 26(21.14) 10+ 13(34.21) 16(42.11) 7(18.42) 2(5.26) 38(30.89) unsurprisingly, nurses reported significantly high scores for depression and anxiety. nurses are at a higher risk of developing emotional distress, leading to depression and anxiety, due to work-related stress [1]. risk factors, such as covid-19-related stress and poor relationship with family, appeared to increase the risk of developing depression among chinese nurses while working in high-risk covid-19 wards, city of residence, and type of hospital also influenced the risk of depression [1]; furthermore, nursing workload and fear of infection increased the risk of anxiety [1]. a saudi arabian study found that a middle eastern nationality, divorced or widowed marital status, lack of physical activity, and smoking were risk factors for anxiety and depression among nursing staff [19]. in dai et al.’s study [20] they found that nurses working night shifts report more depressive symptoms than those working day shifts only; the higher rates of depressive symptoms in nurses working night shifts might be associated with poorer sleep quality due to night shifts. additionally, nurses are considered frontline workers directly involved in treating patients with covid-19, which may increase their fear of being infected and transmitting the infection to family members or others. these factors put nurses at risk for psychological and emotional problems [21]. some limitations of this study must be noted. first, as this survey was conducted in a single center, the findings cannot be generalized to other centers that were more affected. second, this study did not seek information on any mental health conditions that respondents may have had before the pandemic or respondents’ experience of working during such a pandemic. finally, the cross-sectional nature of this study precludes causal inferences. longitudinal investigations on the long-term impact of pandemics on nurses’ psychological health are warranted. conclusion in this study, depression and anxiety symptoms were highly prevalent among nurses, which ranged from mild to severe. therefore, more attention should be paid to the mental health of female nurses and those aged 30–39 years, as these groups showed high depression and anxiety levels. furthermore, nurses’ housing situation had a significant effect on depression and anxiety levels. in addition to advocating for solidarity, altruism, and social inclusion, promoting healthcare services as a humanitarian and national duty may help make it a more meaningful experience for nurses. mental health screening should be conducted regularly for nurses, particularly during pandemic situations. psychiatric and psychotherapeutic interventions can be provided to help them cope with the covid-19 pandemic. it is also crucial to meet healthcare providers’ physical needs, including sufficient sleep, safe times, and places to rest. finally, longitudinal research is needed to track nurses’ mental health symptoms and develop evidence-based interventions. hakami e, et al., journal of ideas in health (2023); 6(1):828-835 833 table 5: phq-9 scores and demographic characteristics (n=123) variable categories median iqr p-value test q25 q75 gender male 10 8 12 0.2811 mann-whitney female 9 4 13 age groups 18–29 11 10 18 0.0138* kruskal wallis 30–39 9 6 11 40–49 8 4 12 50+ 5 3 13 educational levels diploma in nursing 6 4 4 0.3369 kruskal wallis bachelors in nursing 7 10 13 master’s degree 9 3 10 nationality saudi arabia 11 9 16 0.0016* kruskal wallis india 8 3 11 philippines 8 6 10.5 pakistan 9.5 7 12 jordan 9 3 10 others 6 2.5 10.5 residency hospital housing 7 3 12 0.0246* mann-whitney private housing 10 7 14 years of experience 1–3 10 7 14 0.3072 kruskal wallis 4–6 10 8 11 7–10 9.5 7 15 10+ 8 3 13 table 6: gad-7 scores and demographic characteristics (n=123) variable categories median iqr p-value test value q1 q3 gender male 9 7 12 0.0751 mann-whitney female 7 2 11 age groups 18–29 11 9 15 0.0014* kruskal wallis 30–39 7 4 10.5 40–49 7 3 12 50+ 3 2 5 educational levels diploma in nursing 6 2 7 0.0518 kruskal wallis bachelors in nursing 9 5 12 master’s degree 10 2 12 nationality saudi arabia 11 7 14 0.0001* kruskal wallis india 7 3 10 philippines 6 2 9.5 pakistan 10.5 7 14 jordan 9 7 11 others 3 1.5 7 residency hospital housing 5 2 8 0.0001* mann-whitney private housing 9 5.5 13 years of experience 1–3 9 3 16 0.2061 kruskal wallis 4–6 10 7 12 7–10 7 5 11 10+ 7 2 9 abbreviation kfsh&rc-r: king faisal specialist hospital and research center riyadh; phq-9: patient-health questionnaire; gad7: generalized anxiety disorder 7; spss: statistical package for the social sciences; who: world health organization; sars: severe acute respiratory syndrome; mers: middle east respiratory syndrome; irb: institutional review board. declaration acknowledgment i would like to express my deep gratitude to professor dr. mohammed senitan, my research supervisor, for his patient guidance, enthusiastic encouragement, and valuable critiques of this research work. i would also like to thank dr. nahed alsayed, for her advice and assistance in keeping my progress on schedule. my thanks are also extended to dr. edward devol and ms. leena zeyad for their help in doing the data analysis. finally, i wish to thank my colleague ms. ahlam alsomali for her support and encouragement throughout my study. funding the authors received no financial support for their research, authorship, and/or publication of this article. hakami e, et al., journal of ideas in health (2023); 6(1):828-835 834 availability of data and materials data will be available by emailing nurseemad@gmail.com authors’ contributions emad hakami is the responsible author for the concept, design, literature search, data analysis, data acquisition, manuscript writing, editing, and reviewing. ebc has read and approved the final manuscript. ahlam alsomali is responsible for writing, editing, and reviewing the content of the manuscript. mohammed senitan is responsible for the manuscript review. ethics approval and consent to participate the study was conducted in accordance with the ethical principles of the declaration of helsinki (2013), the ich harmonized tripartite good clinical practice guidelines, the policies and guidelines of the research advisory committee of the king faisal specialist hospital and research center in riyadh, and the laws of saudi arabia. institutional review board (irb) approval was acquired from the king faisal specialist hospital and research center, riyadh, before starting the study (reference number 2221044 on march 14, 2022). consent forms were signed by participants who agreed to participate in the study after they had read the research objectives. they were informed that they had the right to withdraw from the study at any time without any consequences. data were analyzed anonymously and handled following the research board’s enforced safeguards. data were safe and were not revealed by anyone other than the investigators. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of cardiovascular nursing king faisal specialist hospital and research center, riyadh, saudi arabia. 2department of public health, faculty of health sciences saudi electronic university, riyadh, saudi arabia. article info received: 22 december 2022 accepted: 02 march 2023 published: 10 may 2023 references 1. pouralizadeh m, bostani z, maroufizadeh s, ghanbari a, khoshbakht m, alavi sa, ashrafi s. anxiety and depression and the related factors in nurses of guilan university of medical sciences hospitals during covid19: a web-based cross-sectional study. international journal of africa nursing sciences, 2020; 13, 100233. https://doi.org/10.1016/j.ijans.2020.100233. 2. who (n.d.). saudi arabia: who coronavirus disease (covid-19) dashboard with vaccination data. world health organization. retrieved january 13, 2022, from: https://covid19.who.int/region/emro/country/sa. 3. spitzer rl, kroenke k, williams jb, löwe b. a brief measure for assessing generalized anxiety disorder. archives of internal medicine 2006; 166(10): 1092. https://doi.org/10.1001/archinte.166.10.1092. 4. stuijfzand s, deforges c, sandoz v, sajin c-t, jaques c, elmers j, horsch a. psychological impact of an epidemic/pandemic on the mental health of healthcare professionals: a rapid review. bmc public health, 2020; 20(1). https://doi.org/10.1186/s12889-020-09322-z. 5. alonso j, vilagut g, mortier p, ferrer m, alayo i, aragón-peña, a, aragonès e, campos m, cura-gonzález id, emparanza ji, espuga m, forjaz mj, gonzález-pinto a, haro jm, lópez-fresneña n, salázar ad, molina jd, ortí-lucas rm, parellada m, … pérez-solà v. mental health impact of the first wave of covid-19 pandemic on spanish healthcare workers: a large cross-sectional survey. revista de psiquiatría y salud mental, 2021; 14(2): 90–105. https://doi.org/10.1016/j.rpsm.2020.12.001. 6. al ateeq da, aljhani s, althiyabi i, majzoub s. mental health among healthcare providers during coronavirus disease (covid-19) outbreak in saudi arabia. journal of infection and public health 2020; 13(10), 1432–1437. https://doi.org/10.1016/j.jiph.2020.08.013. 7. al thobaity a, alshammari f. nurses on the frontline against the covid-19 pandemic: an integrative review. dubai medical journal 2020; 3(3): 87–92. https://doi.org/10.1159/000509361. 8. abbas ma, abu zaid lz, hussaein m, bakheet kh, amp; alhamdan na. anxiety and depression among nursing staff at king fahad medical city, kingdom of saudi arabia. wei international academic conference proceedings (2013). available at: https://doi.org/https://www.westeastinstitute.com/wpcontent/uploads/2013/07/lamiaa-z.pdf (accessed on 20 march 2022). 9. zakeri ma, rahiminezhad e, salehi f, ganjeh h, dehghan m. burnout, anxiety, stress, and depression among iranian nurses: before and during the first wave of the covid-19 pandemic. frontiers in psychology, 12 (2021). https://doi.org/10.3389/fpsyg.2021.789737. 10. raosoft (2004) sample size calculator. raosoft, inc. makes high quality web survey software. retrieved from: http://www.raosoft.com/samplesize.html (14 january 2022). 11. li z, ge j, yang m, feng j, qiao m, jiang r, bi j, zhan g, xu x, wang l, zhou q, zhou c, pan y, liu s, zhang h, yang j, zhu b, hu y, hashimoto k, jia y, wang h, wang r, liu c, yang c. vicarious traumatization in the general public, members, and non-members of medical teams aiding in covid-19 control. brain behav immun. 2020 aug; 88:916-919. doi: 10.1016/j.bbi.2020.03.007. hakami e, et al., journal of ideas in health (2023); 6(1):828-835 835 12. kroenke k, spitzer rl, williams jb. the phq-9. journal of general internal medicine 2001; 16(9): 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x. 13. fernandez r, lord h, halcomb e, moxham l, middleton r, alananzeh i, amp; ellwood l. implications for covid19: a systematic review of nurses’ experiences of working in acute care hospital settings during a respiratory pandemic. international journal of nursing studies 2020; 111:103637. https://doi.org/10.1016/j.ijnurstu.2020.103637 14. chew nws, lee gkh, tan byq, jing m, goh y, ngiam njh, yeo lll, ahmad a, ahmed khan f, napolean shanmugam g, sharma ak, komalkumar rn, meenakshi pv, shah k, patel b, chan bpl, sunny s, chandra b, ong jjy, paliwal pr, wong lyh, sagayanathan r, chen jt, ying ng ay, teoh hl, tsivgoulis g, ho cs, ho rc, sharma vk. a multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid-19 outbreak. brain behav immun. 2020 aug; 88:559-565. doi: 10.1016/j.bbi.2020.04.049. 15. fiabane e, giorgi i, sguazzin c, argentero p. work engagement and occupational stress in nurses and other healthcare workers: the role of organisational and personal factors. j clin nurs. 2013 sep;22(17-18):2614-24. doi: 10.1111/jocn.12084. 16. zheng r, zhou y, fu y, xiang q, cheng f, chen h, xu h, fu l, wu x, feng m, ye l, tian y, deng r, liu s, jiang y, yu c, li j. prevalence and associated factors of depression and anxiety among nurses during the outbreak of covid-19 in china: a cross-sectional study. int j nurs stud. 2021 feb; 114:103809. doi: 10.1016/j.ijnurstu.2020.103809. 17. naar i (2020) timeline: here are all the measures taken by saudi arabia to combat the coronavirus. al arabiya english. retrieved from: https://english.alarabiya.net/features/2020/03/28/timelinesaudi-arabia-s-proactive-measures-to-combat-thecovid-19-coronavirus (14 january 2022) 18. abolfotouh ma, almutairi af, banimustafa aa, hussein ma. perception and attitude of healthcare workers in saudi arabia with regard to covid-19 pandemic and potential associated predictors. bmc infect dis. 2020 sep 29;20(1):719. doi: 10.1186/s12879-020-05443-3. 19. löwe b, gräfe k, zipfel s, witte s, loerch b, herzog w. diagnosing icd-10 depressive episodes: superior criterion validity of the patient health questionnaire. psychother psychosom. 2004 nov-dec;73(6):386-90. doi: 10.1159/000080393. 20. dai c, qiu h, huang q, hu p, hong x, tu j, xie q, li h, ren w, ni s, chen f. the effect of night shift on sleep quality and depressive symptoms among chinese nurses. neuropsychiatr dis treat. 2019 feb 7; 15:435-440. doi: 10.2147/ndt.s190689. 21. moussa ml, moussa fl, alharbi ha, omer t, khallaf sa, al harbi hs, albarqi aa. fear of nurses during covid-19 pandemic in saudi arabia: a cross-sectional assessment. front psychol. 2021 oct 14; 12:736103. doi: 10.3389/fpsyg.2021.736103. https://doi.org/10.47108/jidhealth.vol4.iss3.150 gambo s, shem w, journal of ideas in health 2021;4(3):432-437 © the author(s). 2021 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access social media and the spread of covid-19 conspiracy theories in nigeria sarah gambo1*, woyopwa shem1 abstract background: amidst the recent outbreak of the covid-19 pandemic, there seems to be an avalanche of conspiracy theories that abound on social media platforms, and this subject attracted a lot of research interest. this study aimed to examine the "social media and the spread covid-19 conspiracy theories in nigeria" in light of the above. methods: the study adopted a qualitative design in order to explore the subject matter thoroughly. thirty-five participants were conveniently sampled, and interviews were conducted to retrieved data from the participants. results: findings of this study revealed that there is a prevalence of conspiracy theories that have saturated social media ever since the outbreak of the covid-19 pandemic. it was also found that ignorance, religious fanaticism, lack of censorship, and insufficient counter information on social media platforms are some of the possible factors that aided the spread of covid-19 conspiracy theories among nigerian social media users. conclusion: this study recommends, among other things, that there is a swift need to curtail the spread of conspiracy theories through consistent dissemination of counter-information by both individuals and agencies like the national orientation agency (noa) and the nigerian centre for disease and control (ncdc). keywords: social media, conspiracy theories, covid-19, pandemic, nigeria background 'if you want the truth to go round the world, you must hire an express train to pull it; but if you want a lie to go round the world, it will fly; it is as light as a feather, and a breath will carry it. it is well said in the old proverb, "a lie will go round the world while the truth is pulling its boots on" [1]. from the above assertion, it is apposite to infer that amidst the present advancement in the area of information communication technology, social media serve as that "breath" that carries lies across the globe. in other words, evidence from extant studies revealed that social media serves as an aircraft that carries lies in the form of conspiracy theories and misinformation worldwide. varis p. [2] substantiates that social media platform play an enormous role in spreading conspiracy theories and the exposure they get. faddoul m, et al. [3] corroborate that conspiracy theories have continued to flourish on social media, raising fear and anxiety that such content is fueling the spread of disinformation. as such, rampersad g, et al. [4] affirm that social media serve as a medium for swift dissemination of misinformation and fake news. since the beginning of the novel coronavirus disease (covid-19) epidemic, which started in december 2019 in wuhan, the capital of hubei, china [5], misinformation has been spreading uninhibited over traditional and social media at a rapid pace [6]. according to bamidele m. [7], the world is currently under the siege of the coronavirus (covid-19), a deadly disease that the world health organization (who) has declared a pandemic. bamidele m. [7] added that the number of confirmed cases of infections and deaths has left many in panic and served as the catalyst to breed various forms of conspiracy theories and myths. ghalib and take [8] corroborates that the covid-19 outbreak has sparked what the world health organization (who) called "infordemic" an overwhelming amount of information on social media and website”. apuke and omar [9] expressed worry over this overwhelming amount of information on social media when they postulated that social misinformation had stimulated the public regarding covid-19. according to extant studies [3,5], there is an avalanche of rumors and conspiracy theories circulating the internet. in fact, it has become tricky to differentiate between fake news from factual reportage [10]. in light of the above, lampos et al. [12] argued that as the cases of covid-19 worldwide increased, the spread of misinformation concerning the virus increased. ___________________________________________________ gamssarah@gmail.com 1faculty of communication and media studies, taraba state university, taraba state, nigeria. full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol4.iss3.150 http://www.jidhealth.com/ gambo s, shem w, journal of ideas in health (2021); 4(3):432-437 433 social media platforms such as youtube and twitter provide direct access to an unprecedented amount of content and may amplify rumors and questionable information [13]. therefore, suffice it to infer that individual online, knowingly, and unknowingly, spread information at an alarming rate, which could be dangerous or misleading [14]. simply put, social media has become a channel for rapidly increasing rumors and deliberate misinformation, and many are deploying sites such as facebook, twitter, youtube, and whatsapp to create a state of panic and confusion, especially amidst the recent outbreak of the coronavirus pandemic. pennycook g, et al. [15] affirm that misinformation can amplify humanity's greatest challenges. they further argued that a significant topical example of this is the covid-19 pandemic, which has nurtured an avalanche of fabrications even as truth has increasingly become a matter of life-and-death. a study conducted by gallup/knight foundation [16] revealed that overall, americans believe 39.0% of the news they see on television, read in newspapers, or hear on the radio is misinformation. furthermore, [16] findings revealed that americans estimate that nearly two-thirds of the news they see on social media is misinformation. from the foregoing, it is apt to investigate why social media platforms serve as carriers of conspiracy theories and misinformation, which eventually result in panic among the public. purpose of the study the core purpose of this current study is to investigate why and how social media platforms foster conspiracy theories, especially amidst the covid-19 outbreak. however, the specific objectives are: 1.to find out whether there are pervasiveness conspiracy theories on covid-19 in social media; 2.to ascertain possible factors responsible for the spread of conspiracy theories on covid-19 in social media platforms; 3.to suggest possible measures on how to curb the spread of conspiracy theories on social media platforms. literature review there are extant studies on social media, conspiracy theories, and covid-19. hence, the researchers deem it is apt to review this literature for clarity on the subject matter. the literature is reviewed in the following sub-themes: social media, conspiracy theories, and covid-19: a conceptual review. social media, conspiracy theories and covid-19: a conceptual review 1. social media: despite the plethora of extant studies on social media, it is obvious that the concept of "social media" has no universally accepted definition because; the term social media is used differently by people in various contexts that are in tandem with their perspectives [17]. for instance, to kaplan and haenlein [18], social media is "a group of internet-based applications that are built on the ideological and technological foundations of web 2.0 and that allow the creation and exchange of user generated content” while baltatzis p. [19] defined social media as an "online platforms that promote participation, openness, conversation, and connectedness". buettner r. [20] opined that social media is a computermediated tool that has the potency to its users to generate and share information, career interests, etc. baltatzis p. [19] defined social media as a medium where people communicate, utilizing online platforms while they are connected to the internet. from the above definitions, it could be deduced that social media platforms are actually internet-based applications that allow users to create, share and disseminate information freely. suffice it to say that the social media platforms allow its users both old and young, literate and illiterate, propagandist, and counter spin to share and disseminate information. brindha md, et al. [14] claim surface in the form of conspiracy theories. based on the above definitions, it is apposite to infer that social media has various features that may contribute to making the medium a carrier of conspiracy theories. 2. conspiracy theory: the words rumor, and conspiracy theories are closely tied [22]. runnels [22] further argued that rumors serve as one catalyst that fosters the spread of conspiracy theories. in his words, he captured it this: rumours provide a mechanism by which a conspiracy theory spreads through a population. for example, various conspiracy theories on the internet attempt to identify the "real" culprits behind 9/11, but, in this author's opinion, those theories are typically summed up and spread by the rumor that 9/11 was an inside job (p10). according to cass and adrian [23], a conspiracy theory is “an effort to explain some event or practice by reference to the machinations of powerful people, who have also managed to conceal their role”. bale jm. [24] defines conspiracy theory as the certainty, assurance, or “certainty that a group of actors meets in secret agreement with the purpose of attaining some selfish but malicious goal”. oxford english dictionary defines conspiracy theory as “the theory that an event or phenomenon occurs as a result of a conspiracy between interested parties”. “conspiracy theories” refers to any effort to explain the rationale behind the occurrence of social or political circumstances with claims of secret plots by either two or more powerful actors [25]. suffice it to say that a conspiracy theory is an explanation for an event or occurrence based on a malicious plot with the sole aim of achieving a specific goal. prooijen and vogt [26] postulated that “conspiracy theories make an assumption of how people, objects, or events are causally interconnected”. this implies that initiators of conspiracy theories give convincing yet pseudo reasons for people to believe their explanation of events or occurrences. notwithstanding, lewandowsky [27] argued that “conspiracy theories are not always the result of genuinely held false beliefs”. lewandowsky [27] noted that conspiracy theories could be intentionally constructed or amplified for strategic, political reasons. 3. covid-19: "in december 2019, cluster phenomena cases appeared in china, and its shape was like crown and crown mean corona, so its name was given corona virus” [28]. coronaviruses are a family of viruses that cause respiratory symptoms [29]. the most recent outbreak of the virus in late december 2019 is named covid-19. (khan, 2020, p.2) opined that the symptoms include cough, pneumonia, fever, shortness of breathing, and throat sore. theoretical underpinning the uses and gratification theory (ugt) was found suitable for this research study. the uses and gratification theory was developed by katz, blumler, and gurevitch in 1974 [29]. the gambo s, shem w, journal of ideas in health (2021); 4(3):432-437 434 uses and gratifications theory basically focused on how and why the audience uses the media (klapper, 1963). commenting on the uses and gratification theory, mcquail [30] stated that the central question posed by the uses and gratification theory is "why do people use media, and what do they use them for?" simply put, the uses and gratification theory is built on the premise that people use the media not just for using sake but as a result of the satisfaction they obtained from the media [31] in his view, mohammed a. [17] opined that the audiences select the medium and even what content is most suitable to their personal desires. when the uses and gratification theory was propounded, it was used to study audiences for traditional media [31], but today, it is relevant in the study of issues relating to social media forms. the veracity of the above is linked to the fact that social media users these days also select which platform gratifies them. the uses and gratifications theory finds strength in describing how media audiences seek information and use it to satisfy their personal goals [17]. in light of the above, baran and davis [32] state that the uses and gratification theory acknowledged the intellectuality of the audience and their ability to consume only what is needful for them. from the above, it is obvious that there is a nexus between the uses and gratifications theory and this current research study despite the existing differences between new media and traditional media. this theory finds relevance in this current study because of its interactive processes. this can be further buttressed that the new wave in research on communication and media studies focuses on how audiences interact with and are influenced by the type of media they choose. suffice it to say that the applicability of the uses and gratification to this current becomes palpable because most conspirators or initiators of conspiracy theories or misinformation used the social media platforms to satisfy their gratification. furthermore, the conspiracy theories tend to spread like wildfire due to the gratification that other users may find in sharing them with family and friends. methods a qualitative research design was used in other gather data for this research study. purposely, the phenomenological method was used to understand how participants make meaning of the phenomenon studied. brindha md, et al. [14] state that phenomenology effectively studies a small number of subjects which is why thirty-five participants were selected conveniently and interviewed. the rationale behind the use of interview is simply because interview has the potency to unravel or bring out hidden feelings, attitudes, and beliefs that an interviewee is unaware of [33]. further to the above reason, the researchers observed that limited extant related studies adopted this method to explore the theme under investigation, which is "social media and the spread of conspiracy theories on covid-19 pandemic in nigeria”. participant and sampling the participants of this study were conveniently drawn from yola, adamawa state, nigeria. yola is the state capital (headquarters) of adamawa state, nigeria. the rationale behind choosing participants from the above location is due to convenience and the location's proximity to the researchers. as discussed earlier, the thirty-five participants conveniently selected and deemed apt for this study volunteered to participate in this research study. it is also pertinent to note that all the selected participants were active social media users. ten of them were academicians specializing in communication and media studies, which put them in a vantage position to contribute meaningfully to this research study. out of the 35 participants (n=17) were male and (n=18) were female. in terms of educational qualification (n=22), participants had at least a high school certificate as their highest educational qualification while (n=12) had a college degree as their highest qualification (8 had master’s degree while 6 bachelor’s degrees). it is apposite to note that the entire participants were coded as participant 1, 2 3....and so on. the above is in tandem with the conventional practice of qualitative research which most often than not, researchers assured the participants of anonymity with the sole aim of encouraging them to conveniently unravel information that would be of enormous significance in achieving the purpose of the study. data collection procedure the researchers adopted face-face semi-structured interviews to retrieved data for this study. the interviews lasted for approximately one month (four weeks). three communication research experts scrutinized the interview question guide, and a pre-test was conducted using 10 participants who were not part of the sampled respondent. the interviews were conducted with the help of two research assistants that aided in recording the interviews on tape as the researchers conduct the interviews. it is worthy to note that each interview session lasted between thirty minutes to one hour, and the recorded interviews were later transcribed verbatim. data analysis in order to analyze the data retrieved for this study, the researchers, with the help of research assistants, meticulously transcribed all recorded interviews, after which the data were interpreted and discussed thematically with the help of extant related studies. four sub-themes were identified, interpreted, and discussed in tandem with the objective of this study. these sub-themes include the presence of conspiracy theories on covid-19 on social media platforms, possible factors that foster the spread of conspiracy theories on covid-19, and possible measures on how to curb the spread of conspiracy theories on social media platforms. results and discussion this section is organized and segmented into three sub-themes to interpret and explicate the study results thoroughly. the three sub-themes were actually coined out of the objectives of this current study. the sub-themes are: 1. presence of covid-19 conspiracy theories on social media platforms. 2. factors responsible for the spread of covid-19 conspiracy theories on social media. 3. possible measures on how to curb the spread of conspiracy theories on social media platforms. the first sub-theme seeks to ascertain whether conspiracy theories on covid-19 abound on social media platforms, as some of the reviewed literature claimed. in contrast, the second sub-theme discussed some of the possible factors responsible gambo s, shem w, journal of ideas in health (2021); 4(3):432-437 435 for spreading covid-19 conspiracy theories on social media platforms. the third sub-theme sought to proffer a solution on how to curb the spread of covid-19 conspiracy theories among nigerian social media users. table 1: participants’ responses s/n statements response 1 was bioengineered in a lab in wuhan, china 35 participants said yes while 0 said no 2 5 g technology causes coronavirus 28 participants said yes while seven said no 3 nostradamus predict coronavirus 19 participants said yes while 16 said no 4 coronavirus is a death sentence 18 participants said yes while 17 said no 5 coronavirus is an airborne hiv 21 participants said yes while 14 said no 6. bill gates orchestrates coronavirus 19 participants said yes while 16 said no 7. coronavirus is spread via corona beers and cured with garlic water 22 participants said yes while 13 said no 8. coronavirus is here to teach us a lesson 23 participants said yes while 12 said no source: authors interview, 2020 presence of covid-19 conspiracy theories on social media platforms additionally, it was found that the majority of the participants did not just concur that conspiracy theories exist on social media platforms but that there is a high degree of these conspiracy theories flooding the social media platforms. one of the interviewed participants claimed that: there is much information on social media platforms since the outbreak of the coronavirus. even though some of this information may be factual yet i strongly believe that the majority of them are pseudo, misinforming, and sound illogical. in fact, i have seen and read almost all the conspiracy theories you outlined earlier either through my facebook account or whatsapp. [participant 12]. substantiating the overhead view, another interviewee affirmed that: social media, especially facebook and whatsapp, are saturated with many conspiracy theories on the new coronavirus; in fact, these theories are so many that you do not know which one to believe. [participant 7]. similarly, another participant stated that: asking one whether conspiracy theories abound on social media platforms seems to be a waste of time because we all know that social media platforms accommodate conspiracy theories, especially amidst the outbreak of covid-19. [participant 5]. based on the above findings, it is palpable to infer that there is certainly an overwhelming presence of conspiracy theories on different social media platforms. therefore, it is apposite to infer that the above findings conceded with studies that unraveled that conspiracy theories exist on social media platforms. for instance, ghada and takshe [8] claimed that the covid-19 outbreak has sparked what the world health organization (who) called "infordemic" an overwhelming amount of information on social media and website”. similarly, a study conducted by dopoux p, et al. [34] revealed that: within weeks of the emergence of the novel coronavirus covid-19 in china, misleading rumors and conspiracy theories about the origin circulated the globe paired with fearmongering, racism, and mass purchase of face masks, all closely linked to the new "infomedia" ecosystems of the 21st century marked by social media (p1). the above implies that the social media platforms are part of the factors that give prominence and acceptance to covid-19 conspiracy theories. factors responsible for the spread of conspiracy theories on social media here, the interviewed participants were asked to identify some possible factors that tend to promote the spread of covid-19 conspiracy theories on social media platforms in nigeria. the majority of the participant pinpointed ignorance and religious fanaticism as the core factors that aided the spread of conspiracy theories related to covid-19 among nigerian social media users. the above finding conceded with some media reportage. for instance, "the guardian" reported on monday, being the 18th of may 2020, that a religious-based television channel was sanction for airing "potentially harmful statements" about the covid-19 pandemic, including baseless conspiracy that the virus is linked to the rollout of 5g phone networks. in respect of the above view, one of the interviewed participants states that: religious fanaticism is one of the factors that may perhaps promote the spread of covid-19 conspiracy theories on social media platforms in nigeria. the fact is that nigerians are religious people; hence they tend to believe their religious leaders more than any other authority. furthermore, it is quite unfortunate that some of the religious leaders from the two dominant religions in nigeria still hold on to specific conspiracy theories. some of them do not even believe that the virus exists. [participant 10]. supporting the above view, another participant said: ignorance and religious fanaticism are two significant promoters of conspiracy theories among nigerian social media users. although nigerians can be obsessive with their religious beliefs, they also have a poor reading culture. albeit this claim could be argued but with my experience as an academician, i can boldly say that nigerians have a poor reading culture. therefore, i am pretty sure that the majority of nigerians may not take time to read about the coronavirus from reliable sources (websites) such as world health organizations or nigerian centre for disease and control but will prefer to rely upon and share the information they got from social media platforms of which most of this information on social media are pseudo and unreliable.[participant 15]. the above participant further notes that because nigerians have poor reading culture hence, they could easily be convinced by their religious leaders, who in most cases are just like their demigod. the above scenario may result in some superstitious beliefs. for instance, at the early stage of the covid-19 outbreak, there are superstitious believes trending among social media users in nigeria that the virus is a sort of punishment from god and that the virus has been prophesied long ago. other factors responsible for the spread of conspiracy theories gambo s, shem w, journal of ideas in health (2021); 4(3):432-437 436 that were pinpointed by other interviewed participants include lack of censorship and insufficient counter information by relevant agencies. one of the participants claimed that: lack of sufficient counter information is one of the factors that may be responsible for promoting conspiracy theories among nigerian social media users. in fact, one can boldly say that agencies like national orientation agencies and nigerian centre for disease and control are not disseminating adequate information that would counteract the covid-19 conspiracy theories that saturate social media. moreover, i think that is one of the reasons or catalysts responsible for the spread of misinformation on coronavirus among nigerians. [participant 35]. another participant also notes that: i must confess that nigerians still lack adequate awareness of covid-19 because most of the so-called awareness campaigns on the covid-19 pandemic are always urban-oriented. moreover, we all know that about 70.0% of nigerians reside in rural areas, and it is important to state that these ruralites also make use of social media to disseminate information concerning the virus. all i am trying to say is that if the ruralite is not informed and enlightened, then they may likely share or believe any information they got from social media platforms. [participant 27]. the implication of the above is the need for public enlightenment in every nook and cranny of nigeria. this would help to counteract any misinformation about corona on both social media and conventional media. possible measures on how to curb the spread of conspiracy theories on social media platforms. here, emphasis is given to those participants who have a background in media and communication studies. the participants were asked to pinpoint some of the possible ways to effectively curb the spread of conspiracy theories on social media platforms in nigeria. it was found that the majority of the participants were of the opinion that the consistent dissemination of counter-information, censorship of social media platforms, educating citizen journalists, and public enlightenment are some of the possible ways to curb the spread of conspiracy theory on social media platforms in nigeria. one of the participants suggested thus: i think one of the possible ways to check the spread of conspiracy theories in an environment like nigeria is by consistently enlightening the public with sufficient information that could counter the conspiracy theories. this is because, from comments of some of my facebook friends, i figured out that most of the social media users in nigeria lack sufficient counter information on some of these conspiracy theories, and that is why they tend to like and share conspiracy theories on social media platforms. [participant 18]. another participant suggested that: the major problem with social media usage in nigeria is lack of censorship. even though censorship may hamper the citizens' fundamental human rights, but it is also important to note that our freedom should have limits, especially in a situation where freedom is likely becoming inimical to the growing society. the early a law is enacted on social media using the better for all of us. [participants 26]. another participant added that to effectively combat the spread of covid-19 conspiracy theories on social media platforms in nigeria, the conventional media has a role to play through consistent campaigns on radio and television to counteract conspiracy theories on different social media platforms. based on the above, this present study has shown that conspiracy theories can effectively be managed or curbed through censorship, consistent dissemination of information that debunks or counter the conspiracy theories, and public enlightenment. conclusion from the findings of this study, it is evident that ever since the outbreak of the covid-19 pandemic, there is an overwhelming presence of conspiracy theories on social media platforms in nigeria and the world at large. it is also pertinent to note that ignorance, religious fanaticism, lack of censorship, and insufficient counter information on social media platforms are some of the possible factors that aided the spread of covid-19 conspiracy theories among social media users in nigeria. in light of the above, this study recommends, among other things, that there is a swift need to curtail the spread of these conspiracy theories through consistent dissemination of counter-information by individuals and relevant agencies such as the nigerian centre for disease and control and national orientation agency. furthermore, there is also the need to censor social media platforms by checkmating what should be disseminated by users and what should not be disseminated. in other words, both social media companies and individuals are responsible for ensuring the fight against misinformation concerning conspiracy theories online. abbreviation noa: national orientation agency; ncdc: nigerian centre for disease and control; covid-19: coronavirus disease-19; who: world health organization declaration acknowledgment the authors would like to express gratitude to participants who helped in filling the google form. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing shem.woyopwa@yahoo.com authors’ contributions sarah gambo (sg) and shem woyopwa (sw) were the study designers, coordinating all aspects of the research and drafting and reviewing the article. all authors (sarah gambo and woyopwa shem) have read, contributed to amending, and collectively approved the final version of the manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. on the date of 12th june 2020, (meeting number 2020/01/08) department of mass communication scientific research and publication ethics committee has granted sarah gambo and woyopwa shem the ethical approval to conduct a research on “social media and the spread of covid-19 conspiracy theories in nigeria." this decision has been taken by the chairman of the ethics committee, taraba state university, jalingo, nigeria, dr. chiakaan jacob gbaden. (reference no.: fcms/rch/2020-0345). the participants were assured of confidentiality as stated in the google form. gambo s, shem w, journal of ideas in health (2021); 4(3):432-437 437 consent for publication not applicable competing interest the authors declare that they have no competing interest. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1faculty of communication and media studies, taraba state university, taraba state, nigeria. article info received: 14 july 2021 accepted: 10 august 2021 published: 20 august 2021 references 1. spurgeon h. (1859) quoted in ratcliffe s (2000) concise oxford dictionary of thematic quotations, usa: oxford university press. 2. varis p. conspiracy theorising online. diggit magazine. 2018. available from: https://www.diggitmagazine.com/articles/conspiracy-theorisingonline 3. faddoul m, chaslot g, farid h. a longitudinal analysis of youtube’s promotion of conspiracy theories. arxiv preprint arxiv:2003.03318, (2020). retrieved from https://arxiv.org/pdf/2003.03319 4. rampersad g, althiyabi t, warner-søderholm g, bertsch a, sawe e, lee dd, et al. birds of a feather: homophily in social networks. computers in human behavior. 2019;9(1):1–9. doi: 10.1126/science.aao2998. 5. mejova y, kalimeri k. advertisers jump on coronavirus bandwagon: politics, news, and business. arxiv preprint arxiv:2003.00923, (2020). retrieve from https://arxiv.org/pdf/2003.00923 6. kouzy r, abi jaoude j, kraitem a, el alam mb, karam b, adib e, et al. coronavirus goes viral: quantifying the covid-19 misinformation epidemic on twitter. cureus. 2020 mar 13;12(3):e7255. doi: 10.7759/cureus. 7. bamidele m. 4 conspiracy theories on corona virus. 22 march 2020. available from: https://guardian.ng/life/conspiracy-theorieson-coronavirus/amp/ 8. ghada ma, takshe aa. covid-19: virus or viral conspiracy theories?ajbsr2020;8(2). doi:10.34297/ajbsr.2020.08.001252 9. apuke od, omar b. modelling the antecedent factors that affect online fake news sharing on covid-19: the moderating role of fake news knowledge. health education research 2020; 35(5): 490-503. https://doi.org/10.1093/her/cyaa030 10. zhou w, wang a, xia f, xiao y, tang s. effects of media reporting on mitigating spread of covid-19 in the early phase of the outbreak. mathematical biosciences and engineering2020;17(3):2693–2707. https://doi.org/10.3934/mbe.2020147 11. lampos v, moura s, yom-tov e, cox ij, mckendry r. tracking covid-19 using online search. npj digit. med.2021; 4: 17. https://doi.org/10.1038/s41746-021-00384-w 12. zulkifli na, sivapatham s, guan nc. brief psychotic disorder in relation to coronavirus covid-19 outbreaks: a case report. malay j psychiatry2020; 29:1-6 13. cinelli m, quattrociocchi w, galeazzi , valensise c, brugnoli e, et al. the covid-19 social media infodemic. sci rep2020; 10: 16598. https://doi.org/10.1038/s41598-020-73510-5 14. brindha md, jayaseelan r, kadeswara s. social media reigned by information or misinformation about covid-19: a phenomenological study. ssrn electronic journal 2020; 09(03):585-602. doi: 10.2139/ssrn.3596058 15. pennycook g, mcphetres j, zhang y, lu jg, rand dg. fighting covid-19 misinformation on social media: experimental evidence for a scalable accuracy-nudge intervention. psychol sci. 2020 jul;31(7):770-780. doi: 10.1177/0956797620939054. 16. knight foundation (2018) americans’ views: trust media and democracy. usa: gallup/knight foundation. available from: https://knightfoundation.org/reports/american-views-trust-mediaand-democracy/ 17. mohammed a. social media use among nigerian students abroad. submitted to the institute of graduate studies and research in partial fulfillment of the requirements for the degree of master of arts in communication and media studies eastern mediterranean university, gazimağusa, north cyprus, 2015. http://hdl.handle.net/11129/2733 18. kaplan am, haenlein m. users of the world unite! the challenges and opportunities of social media. business horizon 2010; 53(1): 59–68. https://doi.org/10.1016/j.bushor.2009.09.003 19. baltatzis p. is blogging innovation journalism? innovation journalism2006;3(4).available from: http://www.ufrgs.br/limc/participativo/pdf/blogging.pdf 20. buettner r. personality as a predictor of business social media usage: an empirical investigation of xing usage patterns 2016; pacis 2016 proceedings. 163. https://aisel.aisnet.org/pacis2016/163 21. cox jt, rethman km. setting expectations: social networking at work. ohio lawyer, 17-19. 2011. 22. runnels rc. iran's social media message and its connection to conspiracy theories. nps archive: calhoun 2015. available from https://calhoun.nps.edu/handle/10945/48134 23. cass rs, adrian v. conspiracy theories: causes and cures. journal of political philosophy 2009:17(2):4. 24. bale jm. political paranoia v. political realism: on distinguishing between bogus conspiracy theories and genuine conspiratorial politics. patterns of prejudice2020; 41(1): 45-60. https://doi.org/10.1080/00313220601118751 25. byford j. conspiracy theories: a critical introduction. 2011 uk: palgrave macmillan. 26. van prooijen jw, van vugt m. conspiracy theories: evolved functions and psychological mechanisms. perspect psychol sci. 2018 nov;13(6):770-788. doi: 10.1177/1745691618774270. 27. lewandowsky s. the “post-truth” world, misinformation, and information literacy: a perspective from cognitive science. in s. goldstein (ed.), informed societies-why information literacy matters for citizenship, participation, and democracy. facet. 2020. 28. cinelli m, quattrociocchi w, galeazzi a, valensise cm, brugnoli e. the covid-19 social media infodemic. arxiv preprint arxiv:2003.05004, 2020. avilable from: https://arxiv.org/pdf/2003.05004.pdf?fbclid=iwar08xvupifbp5q khwp3fpqu7j6oa swtpoljiig6pigumffqfnvrmi5z8sho in may 2020 29. wimmer rd, dominick jr. mass media research: an introduction. 2011 wadsworth cengage learning. 30. mcquail, d. mcquail’s mass communication theory (6th edition) thousand oaks, 2010: sage publications inc. 31. pwashikai g, shem w. appraising the role and challenges of social media platforms in consolidating democracy in nigeria. tsu journal of communication and media studies 2019; 2(1): 188-196. 32. baran s, davis d. mass communication theory: foundations, ferment, and future. cengage learning, 2011. 33. national open university of nigeria. lecture note on mass communication research. 2011 noun. 34. dopoux p, larson j, unnikrishnan s, woods w. fighting covid19 in africa will be different. march 26, 2020-06-17. https://doi.org/10.47108/jidhealth.vol5.issspecial1.230 ali jadoo sa, et al., journal of ideas in health 2022;5(special 1):700-706 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access attitude and intention of iraqi healthcare providers to get vaccinated against covid-19: a cross-sectional study saad ahmed ali jadoo1, mustafa ali mustafa al-samarrai2, badeaa thamer yahyaa2, adil hassan al-hussainy3, ismail ibrahim latif 3, shukur mahmood yaseen4 abstract background: international efforts to confront the covid-19 pandemic are joining forces by accelerating the pace of vaccination. this study aims to explore the attitude and the intent to get vaccinated against covid-19 among healthcare providers (hcps) in iraq. methods: a cross-sectional survey was conducted in january 2021 using web-based facilities to access the respondents. the data were collected through a semi-structured and self-administered questionnaire, including sociodemographic and close-ended questions related to attitude and intention toward covid-19 vaccination. bivariate and multivariate logistic regression were recruited to predict variables. the statistical significance is considered at less than 0.05. results: data of 209 hcps with a mean age of 45.12 (± 6.37) years have undergone final analysis. most of the hcps were males (112, 53.6%) and nurses (110, 52.6%), who had close contact (64.6%) with covid-19 patients, and forty percent have been infected with covid-19. overall, 115 hcps (58.0%) reported intention to get vaccinated compared to 94 (42.0%) who declined vaccination. variables associated with intention to get vaccinated among hcps were high attitude toward covid-19 vaccination (odds ratio (or) =  1.740, 95% confidence interval (ci): 0.799, 3.786), aged less than 45 years (or = 3.713; 95% ci: 1.647, 8.367), married (or = 2.155; 95% ci: 0.984, 4.720), highly educated (or = 2.657; 95% ci: 1.202, 5.871), doctors (or = 3.153; 95% ci: 1.428, 6.963), contracted with covid-19 (or = 4.119; 95% ci: 1.623, 10.455), directly engaged in management of covid-19 patients (or = 3.962; 95% ci: 1.569, 10.005), and had lost a close relative due to covid-19 (or = 5.698; 95% ci: 1.506, 12.564). conclusion: the urgent need to improve the covid-19 vaccine uptake rates among iraqis requires a positive attitude and a high vaccination rate among hcps. keywords: vaccine, intention, covid-19, attitude, healthcare providers, iraq background severe acute respiratory syndrome 2 (sars-cov-2) and the accompanied successive waves of the global pandemic have revealed the fragility of most health systems in developed and developing countries alike [1,2]. older adults with chronic diseases and healthcare professionals were ranked among the highest risk groups for sars-cov-2 exposure and clinical disease onset [3]. moreover, high absenteeism rates were recorded among health care providers (hcps) for many reasons, such as exposure to covid-19 infection and isolation as a precaution to prevent the spread of infection [4,5]. since the declaration of coronavirus as a global pandemic on 11th march 2020, hundreds of thousands of patients have had an influx of health care facilities in large parts of the world simultaneously, causing enormous pressure on healthcare facilities and hcps, respectively [6,7,8]. there is no doubt that healthcare providers constitute the highest priority group for coronavirus vaccination [8,9]. moreover, the vaccination process within the health care services must be qualified and already immunized cadres before launching the vaccination campaign [10]. furthermore, the challenging work environment and the potential to put hcps, and their families at risk of infection make the principle of reciprocity a logical explanation for exceptional priority [10]. hcps acknowledged the expected benefits of receiving the vaccine for themselves and health care systems. of course, the ___________________________________________________ drsaadalezzi@gmail.com 1department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey a full list of author information is available at the end of the article 10.47108/jidhealth.vol5.issspecial1.230 http://www.jidhealth.com/ ali jadoo sa, et al., journal of ideas in health (2022); 5(special 1):700-706 701 attitudes of healthcare providers will be reflected in the acceptance rates of covid-19 vaccines within the general population, as they are reliable sources of information about the covid-19 infection and the vaccines, respectively [11,12]. the first confirmed case of corona in iraq was announced in march 2020 [13]. the iraqis showed sufficient awareness of the pandemic, but the commitment to the instructions of the health administration was less than required [14,15]. the multiple waves of the pandemic affected the already crumbling iraqi health system [16]. most iraqis prefer to visit private clinics rather than public health institutions because of the chronic shortage of health facilities, including human resource health. moreover, many iraqis consider the infection with covid19 as a social stigma, which has further contributed to worsening the health situation [17]. unfortunately, the noncompliance of many iraqi people with preventive measures made public health institutions a source of infection. most healthcare providers have contracted covid-19 and become carriers of the infection in their environments [17]. the increased workload and the absence of the necessary legal legislation to protect hcps forced many of them to leave work due to the repeated occurrence of workplace violence by patients and their relatives [18]. the rumors about the coronavirus's source and the lack of benefit from receiving the vaccine reduced the rate of receiving the vaccine among the general iraqi society. in light of the widespread reluctance to receive the coronavirus vaccine in iraq, the alarming rise in the spread of the emerging coronavirus infection covid-19, and the urgent need to increase vaccine acceptance rates to achieve herd immunity, knowing the rate of intention to accept the coronavirus vaccine among hcps has become inevitable. methods study population and sample we conducted a cross-sectional web-based study from 1st to 28th february 2021 among healthcare providers to explore the intention to get vaccinated against covid-19. the present study was part of a large national initiative [15]. the data was collected from three provinces, including anbar in the west, diyala in the east, and salahuddin in the north of iraq. inclusion and exclusion criteria all iraqi healthcare providers of both genders, employed and unemployed, private and public sectors, academic and nonacademic institutions, and willing to participate are included in the study. at the same time, we excluded incomplete data, students in the medical field, some health units such as recorders, cleaners, and porters, and those not willing to participate. sample size the sample size calculator arrived at 195 participants, using a margin of error of ± 7%, a confidence level of 95%, and a 50% response distribution [20]. non-response correction = 10%. thus, the total sample size was (195+20) 215. supervision during the data collection phase was ensured in all stages. after excluding six incomplete documents, the sample was 209 for final analysis. study instrument in this study, the authors developed a semi-structured questionnaire recruiting different items from previously published related articles [21-35]. the social media available in iraq, such as whatsapp, viber, and facebook, were used to facilitate access to the participants. the questionnaire was prepared in english and then translated into arabic to be used through the google form link after garnering the content validity [36], and cronbach alpha reliability was 74.2. on the first page of the survey, we included the full details about the purpose of the study and how to answer the questions, along with "assurance of the freedom to participate or withdraw and that all information and opinions submitted would be anonymous and confidential". moreover, a consent form must be signed before respondents can participate in the study. the questionnaire's three main sections are the sociodemographic factors, closed-ended questions used to evaluate the attitude (12 questions), and the intention to be vaccinated (5 questions) in the second and third sections, respectively. dependent variable the dependent variable was the "intention to get vaccinated". we have recruited five questions to determine the intention of healthcare providers to get vaccinated: "i predict i will receive the vaccine against covid-19", "i plan to receive the vaccine against covid-19", "i prefer to receive the vaccine against covid-19 after a while" and "i think it is time to get a vaccine against covid-19". the responses were given in the form of "strongly disagree", "disagree", "do not know", "agree", and 'strongly agree". for the purpose of analysis, the median was used to cut off the intention of vaccination into a high intention (median and above) and low intention (below the median). attitude toward covid-19 vaccination the attitude was measured using twelve questions adopted from an earlier published article. the responses were given as “strongly disagree”, “disagree”, “don’t know”, “agree”, ‘strongly agree”. independent variables for the purpose of analysis, some of the sociodemographic variables were exposed to categorization. the age variable was reported in five groups: "25–34", "35-44", "45-54", "55 years and above; however, the age was categorized into two groups codded "zero" for respondents aged less than 45 years and coded "one" for those aged 45 years and above. the gender was coded as "zero" for males, and "one" for females. marital status was captured as binary, and a value of one was used for married participants codded "one" and those who are single, widows, divorced considered unmarried and coded "zero". the place where people resident was either rural and coded "zero" or urban and coded "one". at the time of data collection (1st january 2021), the exchange rate of iraqi dinar (iqd)1 = united states dollar (usd) 0.0008. therefore the monthly income (including all incentives and bounces) of our respondents was coded "zero" for those who earned less than usd 400 (iqd 600,000) and coded "one" for those who earned more than usd 400. the occupation was recorded and coded into "one" for doctors (physician, dentist, pharmacist) and the code of "zero" for nurses from all departments. ali jadoo sa, et al., journal of ideas in health (2022); 5(special 1):700-706 702 years of experience are categorized into "less than ten years" and have been coded "zero" and coded "one" to the experience of "10 years and above". the self-rated health status was reported on a scale ranging from "very bad" to "very good," a scale ranging from "1" to "5". moreover, the self-rated health status was categorized into poor health (very bad, bad, moderate) and good health (good and very good). statistical analysis the data was analyzed using the ibm spss version 16. categorical variables are presented in terms of frequencies and percentages. bivariate analyses were performed using the independent t-test for continuous variables (normal distributed”, and the chi-square test for the categorized variables. in the multiple logistic regression, odds ratio (or) and confidence intervals (cis) were estimated, and only the variables with a pvalue of < 0.05 were recruited to explore the factors that predict “hcp’s intention to get vaccinated” against covid-19. the statistically significant is considered at less than 0.05. results descriptive and general characteristics of related factors two hundred and nine completed questionnaires underwent the final analysis. the residents' mean age was 45.12 (± 6.37), ranging from 24 to 63 years old. more than half of healthcare providers were males (53.6%), nurses (52.6%), aged less than 45 years old (58.4%), married (55.5%), and low educated level (54.5%). most of our respondents had the experience of 10 years and above (60.3%), with a monthly salary exceeding usd 400 (61.7%), and 75.1% of them ranked themselves as healthy. out of the total sample, 40.7% reported they had contracted the covid-19 infection, 64.6% of them managed covid-19 patients directly, and 19.6% of them had lost one or more of their relatives in iraq due to covid-19 infection (table 1). table 1: bivariate analysis of predictors in intention to get vaccinated (n=209) factors category total (n=209) no yes χ2 pvalue age >45 87(41.6) 20(23.0) 67(77.0) 12.293 0.000 <45 122(58.4) 57(46.7) 65(53.3) gender female 97(46.4) 32(33.0) 65(67.0) 1.155 0.316 male 112(53.6) 45(40.2) 67(59.8) marital status married 116(55.5) 31(26.7) 85(73.3) 11.469 0.001 single 93(44.5) 46(49.5) 47(50.5) educational level high 95(45.5) 23(24.2) 72(75.8) 11.943 0.001 low 114(54.5) 54(47.4) 60(52.6) residency place urban 134(64.1) 54(40.3) 80(59.7) 1.917 0.181 rural 75(35.9) 23(30.7) 52(69.3) occupation doctor 99(47.4) 24(24.2) 75(75.8) 12.833 0.001 nurses 110(52.6) 53(48.2) 57(51.8) experience > 10 years 126(60.3) 45(35.7) 81(64.3) 0.173 0.770 <10 years 83(39.7) 32(38.6) 51(61.4) income level usd>400 129(61.7) 45(34.9) 84(65.1) 0.555 0.465 usd<400 80(38.3) 32(40.0) 48(60.0) self-ranked health good health 157(75.1) 59(37.6) 98(62.4) 0.148 0.743 poor health 52(24.9) 18(34.6) 34(65.4) have you been infected with covid-19? yes 85(40.7) 10(11.8) 75(88.2) 38.720 0.000 no 124(59.3) 67(54.0) 57(46.0) have you been in direct contact with covid-19 patients? yes 135(64.6) 11(14.9) 63(85.1) 23.780 0.000 no 74(35.4) 66(48.9) 69(51.1) have you lost a relative due to covid-19? yes 41(19.6) 5 36 13.316 0.000 no 168(80.4) 72 96 intention to get vaccinated the mean value of intention to vaccination was 20.82(sd 2.32), and the median was 21.0. more than one-half of the healthcare providers (115, 58.0%) agreed that they actively intended to get vaccinated compared to (94, 42.0%) who disagreed. table 2: intention to get vaccinated among healthcare providers (n=209) no. questions *sd(%) d(%) nk(%) a(%) sa(%) 1. i intend to receive the vaccine against covid-19 4(1.9) 6(2.9) 9(4.3) 99(47.4) 91(43.5) 2. i predict i will receive the vaccine against covid-19 5(2.4) 3(1.4) 6(2.9) 87(41.6) 108(51.7) 3. i plan to receive the vaccine against covid-19 2(1.0) 11(5.3) 45(21.5) 114(54.5) 37(17.7) 4. i prefer to receive the vaccine against covid-19 after a while 2(1.0) 3(1.4) 32(15.3) 118(56.5) 54(25.8) 5. i think it is time to get a vaccine against covid-19 3(1.4) 6(2.9) 8(3.8) 103(49.3) 89(42.6) *sd: strongly disagree; d: disagree; nk: do not know; a: agree; sa: strongly agree ali jadoo sa, et al., journal of ideas in health (2022); 5(special 1):700-706 703 attitude toward covid-19 vaccination an independent-sample t-test was run to determine if there were differences in attitude toward covid-19 vaccination between healthcare providers who actively intended to get vaccinated and their counterparts. the attitude was more among healthcare providers who were actively intending to get vaccinated (m = 44.74, sd = 3.92) than healthcare providers who were not actively intending to get vaccinated (m = 41.00, sd = 3.15), a statistically significant difference (m = 3.74, 95% ci (2.70, 4.77), t (187.088) = 7.560, p < 0.001). most of the respondents (83.7%) agreed or strongly agreed with the possibility that the vaccines reduce the incidence of covid-19, and they believed (80.4%) that the vaccine would protect them. nearly sixty percent (58.3%) of the participants do not have enough information about the vaccine, which made the majority (84.2%) of them prefer other people to get the vaccine first. however, the opportunity to choose the type of vaccine raised the likelihood of accepting the vaccine among 78.5% of respondents. three-quarters of respondents (75.1%) disclose that the media has an impact on accepting or rejecting the vaccine, destabilizing the confidence in vaccine-producing pharma companies among 67.9% of respondents. more than seventy percent (72.8%) of the respondents were worried because the vaccine was new and was produced in a short time. therefore, 25.4% of them thought the vaccine's risks were greater than its benefits. fifty-five percent (55.0%) preferred to develop natural immunity by getting covid-19, either because they believe that covid-19 is not dangerous in 446.4% of them or because they had a bad reaction to a vaccine in the past. table 3: intention to get vaccinated among healthcare providers (n=209) *sd: strongly disagree; d: disagree; nk: do not know; a: agree; sa: strongly agree factors associated with intention to get vaccinated in bivariate analysis cross tabulation showed that only doctors (chi-square test (χ2) =  12.833, p = 0.001) who were aged 40 years old and above (χ2 = 12.293, p < 0.001), being married (χ2 = 11.469, p = 0.001), high educated level (χ2 = 11.943, p = 0.001), being infected with covid-19 (χ2 = 38.720, p < 0.001), had direct contact with covid-19 patients (χ2 = 23.780, p < 0.001), and had lost one or more close-relative due to covid-19 (χ2 = 13.316, p < 0.027), were significantly associated with the intention to get vaccinated against covid-19 (table 1). factors associated with intention to get vaccinated in multiple logistic regression in the multivariable logistic regressions, attitude toward covid-19 vaccination (odds ratio (or) = 1.740, 95% ci: 0.799 to 3.786) with the other seven variables was associated significantly with the intention to get vaccinated (p < 0.05). the healthcare providers who lost close-relative due to covid-19 (or = 5.698, 95% ci: 1.506 to 12.564), being infected with covid-19 (or = 4.119, 95% ci: 1.623 to 10.455) and were in direct contact with covid-19 patients (or = 3.962, 95% ci: 1.569 to 10.005) had the highest odds ratios. at the same time, the married healthcare providers (or = 2.155, 95% ci: 0.984 to 4.720) with a positive attitude toward covid-19 vaccination (or = 1.193, 95% ci: 1.076-to 1.334) had the lowest odds ratios. the hosmer and lemeshow test indicated a good fit (p = 0.344). the total model was significant (p = < 0.001) and accounted for 55.8% of the variance (nagelkerke r square = 0.558). discussion in this study, we tried to study the intentions of hcps, including doctors and nurses, in iraq to receive the covid-19 vaccine. many factors are discussed to understand the motives that may contribute to the decision-making process regarding the acceptance or rejection of the vaccine among hcps. previous studies [3,7-10] have acknowledged the distinct role of health professionals in addressing the covid-19 pandemic, which made them the most vulnerable professions to infection with the virus. no doubt they have the priority in receiving the vaccine because they are the front line of defense when responding to the pandemic. moreover, community health promotion and protection depend mainly on healthy and highly educated hcps prescribing treatment and administering vaccinations to patients. our results showed that the intention to receive the covid-19 vaccine exceeded half of those surveyed (115, 58.0%). no. questions *sd(%) d(%) nk(%) a(%) sa(%) 1. vaccines might substantially reduce the incidence of covid-19 9(4.3) 14(6.7) 11(5.3) 92(44.0) 83(39.7) 2. i think the vaccine will protect me 13(6.2) 12(5.7) 16(7.7) 73(34.9) 95(45.5) 3. have a lack of information about the vaccine. 9(4.3) 17(8.1) 61(29.2) 87(41.6) 35(16.7) 4. prefer other people to get the vaccine first 4(1.9) 16(7.7) 13(6.2) 114(54.5) 62(29.7) 5. opportunity to choose the type of vaccine to help you accept the corona vaccine 7(3.3) 13(6.2) 25(12.0) 132(63.2) 32(15.3) 6. the media has an influence on the acceptance or rejection of the corona vaccine 8(3.8) 12(5.7) 32(15.3) 107(51.2) 50(23.9) 7. do not trust vaccine-producing pharma companies. 20(9.6) 25(12.0) 22(10.5) 82(39.2) 60(28.7) 8. be concerned because this is a new vaccine produced in a short time. 14(4.3) 17(8.1) 26(12.4) 67(32.1) 85(40.7) 9. the risks of the vaccine are greater than its benefits. 24(11.5) 54(25.8) 78(37.3) 24(11.5) 29(13.9) 10. prefer to develop natural immunity by getting covid-19. 7(3.3) 31(14.8) 56(26.8) 86(41.1) 29(13.9) 11. believe covid-19 is not dangerous for me. 5(2.4) 62(29.7) 45(21.5) 79(37.8) 18 (8.6) 12 had a bad reaction to a vaccine in the past. 26(12.4) 79(37.8) 41(19.6) 42(20.1) 21(10.0) ali jadoo sa, et al., journal of ideas in health (2022); 5(special 1):700-706 704 table 4: factors associated with intention to get vaccinated in multiple logistic regression (n=209) variables b s.e. wald p-value or 95% ci attitude 0.176 0.397 9.610 0.002 1.193 1.076-1.334 < 45 years 1.312 0.415 10.012 0.002 3.713 1.647-8.367 45 years and above reference married 0.768 0.400 3.685 0.039 2.155 0.984-4.720 single reference high education 0. 977 0.405 5.835 0.016 2.657 1.202-5.871 low education doctors 1.148 0.404 8.068 0.005 3.153 1.428-6.963 nurses reference infected with covid-19? 1.416 0.475 8.875 0.003 4.119 1.623-10.455 no reference direct contact with covid-19 patients? 1.377 0.473 8.483 0.004 3.962 1.569-10.005 no reference lost a close relative due to covid-19? 1.740 0.679 6.568 0.010 5.698 1.506-12.564 no reference such findings were greater than the studies conducted in america, ethiopia, greece, and palestine [21,22,23,24], which confirmed that the rate of willingness to accept the vaccine was 36%, 53.1%, 51.1%, 37.8% and respectively. several reasons might back behind such positive behavior of iraqi hcps, including the period of collecting information, the availability of several types of vaccines, the steady increase in morbidity and mortality rates due to successive waves of the pandemic, and the absence of effective treatment for coronavirus except for the vaccine. however, our results are still far from those recorded in canada (80.9%), french (76.9%), scotland (77.6%) and italy (74.0%) [25,26,27,28]. as mentioned above, the variant in results may also be attributed to the difference in time and study design, the target population in terms of type and sample size, and the extent of the coronavirus spread and its impact on the health system, social and economic status, as happened in many european countries compared to the countries of the middle east. according to this study, the attitude of health professionals had an impact on the intention to accept the covid-19 vaccine. the results of the logistic regression analysis showed that the intention to get vaccinated increases at a rate of 1.1 whenever the attitude towards the covid-19 vaccine positively improves. the results of our study correspond to several studies conducted in china [29], italy [30], and the united kingdom [31], also confirming that the negative attitude towards the vaccine significantly weakened the intention to uptake the vaccine against the covid-19 infection. the possibility that sociodemographic factors are determinants of covid-19 vaccine acceptance was studied at the bivariate and multivariate analysis levels. married doctors aged 45 years old and above with high educated degrees were significantly associated with high intention to get vaccinated against covid-19. in their systematic research, li m et al. [32] indicated that elderly male doctors have a positive view towards covid-19 vaccination compared to female nurses, who showed a greater hesitancy. younger participants (<45) had 3.7 times the likelihood of accepting the vaccine than the old age group. similar findings were reported in studies from palestine [24] and the usa [33]. accepting the vaccine than the old age group. likewise, to earlier studies conducted in greece [23], palestine [24], the usa [33], congo [34], and france [35], we found that doctors had 3.153 times the likelihood of having the intention to get vaccinated compared to nurses. although the study of perceived risk was not a target of our study, however, we found that the hcps who had been infected with covid-19 and those who engaged in the management of patients with covid-19, and those who had lost a close relative due to covid-19 showed 4.119, 3.962 and 5.698-times likelihood intention to accept the vaccination compared to their counterparts, respectively. similar studies in ethiopia [22] and france [26] indicated that acceptance of the covid-19 vaccine among health professionals was associated with fear of covid-19 and perceived risk of infection. our study complaints some limitations. first, this study focused on analyzing the measured intention to get vaccinated against covid-19 rather than the actual intention; therefore, the actual behavior of iraqi hcps may be different from intentional measures. second, the response bias is possible because we had no information on non-responders and if they differed in some criteria from responders. third, the study's design is a cross-sectional model, which cannot establish a causal relationship between the variables. fourth, the small sample size and the study restriction on three governorates of iraq limit the generalization of study results at the national level. conclusion in conclusion, more than half of the participants in our study indicated that they intended to be vaccinated against covid19. the positive attitude of hcps had a direct effect on enhancing the intention to vaccinate. moreover, the multivariate logistic regression analysis showed attitudes toward covid-19 vaccination, age, marital status, educational level, occupation, being infected with covid-19, being in contact with covid19 patients, and losing a close relative due to covid-19 were the main predictors for accepting the vaccination. to raise vaccine uptake rates and improve awareness among hcps implementing evidence-based educational interventions contributes to alleviating the fears of the hesitant part. ali jadoo sa, et al., journal of ideas in health (2022); 5(special 1):700-706 705 abbreviation covid-19: coronavirus; hcps: healthcare providers; iqd: iraqi dinar; usd: united states dollar declaration acknowledgment none. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing dr.saadalezzi@gmail.com. authors’ contributions saad ahmed ali jadoo (saaj) was the designer of the study, coordinating all aspects of the research, the article's writing, the analysis and interpretation of the study and drafting and reviewing the article. mustafa ali mustafa al-samarrai (mama) and badeaa thamer yahyaa (bty) contributed to the study's concept, and arrangement. adil hassan al-hussainy (aha), ismail ibrahim latif (iil) and shukur mahmood yaseen (smy) contributed to interpretation of results and data collection. all authors have read and approved the final version of the manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the protocol of the study was approved by the ethics committee of the college of medicine, diyala university (ref: 1250 at 15-july-2020); the ethics committee of the scientific issues and postgraduate studies unit (psu), college of medicine, university of anbar (ref: sr/368 at 19-july-2020). moreover, web-based informed consent was obtained from each participant after explaining the study objectives and the guarantee of secrecy. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey. 2department of family and community medicine, faculty of medicine, anbar university, anbar, iraq. 3internal medical department, faculty of medicine, diyala university, iraq.4medical biology and anatomy department, faculty of medicine, diyala university, iraq article info received: 23 may 2022 accepted: 12 july 2022 published: 17 july 2022 references 1. jensen n, kelly ah, avendano m. the covid-19 pandemic underscores the need for an equity-focused global health agenda. humanit soc sci commun2021; 8, 15:1-6. https://doi.org/10.1057/s41599-020-00700-x. 2. ali jadoo sa. the second wave of covid-19 is knocking at the doors: have we learned the lesson? jidhealth [internet]. 2020 oct. 8;3(special1):183-4. doi: 10.47108/jidhealth.vol3.issspecial1.72. 3. walarine mt, k v bm. pandemic effect on the elderly and their caregivers. jidhealth [internet]. 2020 nov. 24;3(4):248-51. doi: 10.47108/jidhealth.vol3.iss4.76. 4. groenewold mr, burrer sl, ahmed f, uzicanin a, free h, luckhaupt se. increases in health-related workplace absenteeism among workers in essential critical infrastructure occupations during the covid-19 pandemic — united states, march–april 2020. mmwr morb mortal wkly rep 2020; 69:853–858. http://dx.doi.org/10.15585/mmwr.mm6927a1external icon. 5. maltezou hc, dedoukou x, tseroni m, tsonou p, raftopoulos v, papadima k, et al. sars-cov-2 infection in healthcare personnel with high-risk occupational exposure: evaluation of 7-day exclusion from work policy. clin infect dis 2020;71(12):3182– 3187. https://doi.org/10.1093/cid/ciaa888. 6. world health organization, who director-general's opening remarks at the media briefing on covid-19 -11 march 2020. available from: https://www.who.int/directorgeneral/speeches/detail/who-director-general-s-opening-remarksat-the-media-briefing-on-covid-19---11-march-2020 [accessed on 15 march 2021]. 7. verelst f, kuylen e, beutels p. indications for healthcare surge capacity in european countries facing an exponential increase in coronavirus disease (covid-19) cases, march 2020. euro surveill2020; 25:2000323. 8. yılmaz z, duman s, öztürk g, özdemir h, hogan g, karataş e. evaluating the home isolation of covid-19 patients in primary care. journal of ideas in health2021;4(2):357-64. https://doi.org/10.47108/jidhealth.vol4.iss2.106. 9. wilson nm, norton a, young fp, collins dw. airborne transmission of severe acute respiratory syndrome coronavirus-2 to healthcare workers: a narrative review. anesthesia. 2020 aug;75(8):1086-1095. doi: 10.1111/anae.15093. 10. johnson sb, butcher f. doctors during the covid-19 pandemic: what are their duties and what is owed to them? j med ethics2021; 47:12–15. http://dx.doi.org/10.1136/medethics-2020106266. 11. world health organization. world health organization strategic advisory group of experts on immunization roadmap for prioritizing uses of covid-19 vaccines in the context of limited supply. november 2020. version 1.1 13, https://www.who.int/docs/defaultsource/immunization/sage/covid/sage-prioritization-roadmapcovid19-vaccines.pdf?status=temp&sfvrsn=bf227443_2. [accessed 19 march 2021]. 12. danchin m, biezen r, manski-nankervis ja, kaufman j, leask j. preparing the public for covid-19 vaccines: how can general practitioners build vaccine confidence and optimize uptake for themselves and their patients? aust j gen pract. 2020 oct;49(10):625-629. doi: 10.31128/ajgp-08-20-5559. 13. united nations office for the coordination of humanitarian affairs (ocha), iraq: covid-19 situation report no.5, 12 march 2020. available from: file:///c:/users/drsaa/downloads/12032020_covid19_sitrep_n o5.pdf [accessed on 24 march 2021] 14. world health organization, early covid-19 preparation saved lives in iraq. available from: http://www.emro.who.int/irq/iraqnews/early-covid-19-preparation-saved-lives-in-iraq.html [accessed on 25 march 2021]. 15. ali jadoo sa, alhusseiny a, yaseen s, al-samarrai m, al-rawi r, al-delaimy a, abed m, hassooni h. knowledge, attitude, and practice toward covid-19 among iraqi people: a web-based cross-sectional study. journal of ideas in health.2020;3(special2):258-65. https://doi.org/10.47108/jidhealth.vol3.issspecial%202.59 ali jadoo sa, et al., journal of ideas in health (2022); 5(special 1):700-706 706 16. al-dahhan wh, al-mashhadani mh, raheem r, yousif e. iraq faces the covid-19 with limited health capabilities and major medical challenges. bionatura 2020;5(3):1271-1274. https://doi.org/10.21931/rb/2020.05.03.19 17. ali jadoo sa, alhusseiny a, yaseen s, al-samarrai m, mahmood a. evaluation of the health system in iraq from people's point of view: a comparative study of two different eras. journal of ideas in health2021;4(2):380-8. https://doi.org/10.47108/jidhealth.vol4.iss2.100. 18. alhusseiny a, latif i, ali jadoo sa. covid-19 in iraq: an estimated cost to treat patients at a private clinic. journal of ideas in health.2021;4(1):304-6. https://doi.org/10.47108/jidhealth.vol4.iss1.82. 19. ali jadoo sa, torun p, dastan i, al-samarrai m. impact of conflict related and workplace related violence on job satisfaction among physicians from iraq a descriptive cross-sectional multicentre study. journal of ideas in health2018;1(1):14-2. https://doi.org/10.47108/jidhealth.vol1.iss1.4 20. raosoft, sample size calculator. available from: http://www.raosoft.com/samplesize.html?nosurvey [accessed on 17-february 2021]. 21. shekhar r, sheikh ab, upadhyay s, singh m, kottewar s, mir h, barrett e, pal s. covid-19 vaccine acceptance among health care workers in the united states. vaccines (basel). 2021 feb 3;9(2):119. doi: 10.3390/vaccines9020119. 22. ahmed mh, kanfe sg, jarso mh. intention to receive vaccine against covid-19 and associated factors among health professionals working at public hospitals in resource limited settings. plos one. 2021 jul 12;16(7):e0254391. doi: 10.1371/journal.pone.0254391. 23. maltezou hc, pavli a, dedoukou x, georgakopoulou t, raftopoulos v, drositis i, et al. determinants of intention to get vaccinated against covid-19 among healthcare personnel in hospitals in greece. infect dis health. 2021 aug;26(3):189-197. doi: 10.1016/j.idh.2021.03.002. 24. maraqa b, nazzal z, rabi r, sarhan n, al-shakhra k, al-kaila m. covid-19 vaccine hesitancy among health care workers in palestine: a call for action. prev med. 2021 aug; 149:106618. doi: 10.1016/j.ypmed.2021.106618. 25. dzieciolowska s, hamel d, gadio s, dionne m, gagnon d, robitaille l, et al. covid-19 vaccine acceptance, hesitancy, and refusal among canadian healthcare workers: a multicenter survey. am j infect control. 2021 sep;49(9):1152-1157. doi: 10.1016/j.ajic.2021.04.079.. 26. gagneux-brunon a, detoc m, bruel s, tardy b, rozaire o, frappe p, et al. intention to get vaccinations against covid-19 in french healthcare workers during the first pandemic wave: a cross-sectional survey. j hosp infect. 2021; 108:168–73. https://doi.org/10.1016/j.jhin.2020.11.020 27. williams l, flowers p, mcleod j, young d, rollins l, the catalyst project team. social patterning and stability of intention to accept a covid-19 vaccine in scotland: will those most at risk accept a vaccine? vaccines (basel). 2021 jan 4;9(1):17. doi: 10.3390/vaccines9010017. 28. di martino g, di giovanni p, di girolamo a, scampoli p, cedrone f, d'addezio m, meo f, romano f, di sciascio mb, staniscia t. knowledge and attitude towards vaccination among healthcare workers: a multicenter cross-sectional study in a southern italian region. vaccines (basel). 2020 may 24;8(2):248. doi: 10.3390/vaccines8020248. 29. kwok ko, li kk, wei wi, tang a, wong sys, lee ss. editor's choice: influenza vaccine uptake, covid-19 vaccination intention and vaccine hesitancy among nurses: a survey. int j nurs stud. 2021 feb; 114:103854. doi: 10.1016/j.ijnurstu.2020.103854. 30. graffigna g, palamenghi l, boccia s, barello s. relationship between citizens’ health engagement and intention to take the covid-19 vaccine in italy: a mediation analysis. vaccines. 2020; 8(4):1–11. https://doi.org/10.3390/vaccines8040576 pmid: 33019663 31. paul e, steptoe a, fancourt d. attitudes towards vaccines and intention to vaccinate against covid-19: implications for public health communications. lancet reg health eur. 2021 feb; 1:100012. doi: 10.1016/j.lanepe.2020.100012. 32. li m, luo y, watson r, zheng y, ren j, tang j, chen y. healthcare workers' (hcws) attitudes and related factors towards covid-19 vaccination: a rapid systematic review. postgrad med j. 2021 jun 30: postgradmedj-2021-140195. doi: 10.1136/postgradmedj-2021-140195. 33. gadoth a, halbrook m, martin-blais r, gray a, tobin nh, ferbas kg, aldrovandi gm, rimoin aw. cross-sectional assessment of covid-19 vaccine acceptance among health care workers in los angeles. ann intern med. 2021 jun;174(6):882-885. doi: 10.7326/m20-7580. 34. kabamba nzaji m, kabamba ngombe l, ngoie mwamba g, banza ndala db, mbidi miema j, luhata lungoyo c, et al. acceptability of vaccination against covid-19 among healthcare workers in the democratic republic of the congo. pragmat obs res. 2020 oct 29; 11:103-109. doi: 10.2147/por.s271096. 35. dror aa, eisenbach n, taiber s, morozov ng, mizrachi m, zigron a, et al. vaccine hesitancy: the next challenge in the fight against covid-19. eur j epidemiol. 2020 aug;35(8):775-779. doi: 10.1007/s10654-020-00671-y. 36. ali jadoo sa, sulku sn, aljunid sm, dastan i. validity and reliability analysis of knowledge of, attitude toward and practice of a case-mix questionnaire among turkish healthcare providers. jheor. 2014;2(1):96–107. https://doi.org/10.47108/jidhealth.vol5.iss4.251 kasim hf, journal of ideas in health 2022;5(4):748-754 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access effects of cigarette smoking on the response of hypertensive patients to beta-adrenergic antagonists: a narrative review hala f. kasim1* abstract cigarette smoking is one of the hypertension risk factors which can adversely affect the quality of life. this review aimed to provide a brief overview of the link between smoking and hypertension. at the same time, raising questions about how smoking interacts with beta-adrenergic antagonists that are used as antihypertensive drugs. by searching for relevant studies through multiple search engines, there is inconsistent evidence about the effect of smoking on high blood pressure. mainly attributed to the availability of numerous confounding factors. however, cigarette smoking cannot be ignored because smoking exerts dual effects on hypertension as a disease and the treatment with antihypertensive drugs, particularly beta-adrenergic antagonists. the potential drug interaction can occur through pharmacokinetics and pharmacodynamics mechanisms resulting in influencing the efficacy of these drugs. it is necessary to have dosage modifications according to the patient's smoking status, whether in hospitals or outpatient clinics. keywords: cigarette smoking, beta-adrenergic antagonists, hypertension, drug response, iraq background according to the world health organization (who), the tobacco epidemic is one of public health's most significant threats. it is responsible for more than 8 million deaths annually [1]. globally, the major tobacco users live in lowand middleincome countries (lmics), whereas slowly but regularly decreased usage is reported in several high-income countries [1,2]. however, there is a trend toward reducing tobacco use due to efforts made by different countries to apply tobacco control measures [3]. in general, cigarette smoking is considered to be the most common form of tobacco use [1]. economically, tobacco use burdens the healthcare system, rendering the strategy of smoking cessation a highly costeffective way to decrease tobacco-related morbidity and mortality [1–3]. non-smokers can also be exposed (passive smoking) to the harmful effects of smoking on health [4]. passive smoking or second-hand (involuntary smoking) is when people breathe in the smoke released from a cigarette's burning end or other tobacco products, such as bidis and water pipes, and the smoke that the smoker exhales [1,4]. exposure to passive smoking is responsible for about 1.2 million deaths annually [1]. the cardiovascular system is one of the critical smoking-target organs [5], where the damage to the heart and blood vessels can be precipitated by either active or passive smoking [5,6]. although, it is unclear whether cigarette smoking has a long-term impact on blood pressure and the occurrence of hypertension [7]. there is no doubt that among cardiovascular parameters, tobacco smoke adversely impacts blood pressure [5]. furthermore, the interaction of cigarette smoking with antihypertensive drugs affects hypertensive patients' management, thus achieving the required therapeutic response [5,8]. this review aimed to provide a concise overview of the association between cigarette smoking and hypertension. also emphasized the potential interaction between smoking and beta-adrenergic antagonists used as antihypertensive drugs. methods we searched relevant studies through several available databases, including medline, pubmed, and google scholar. the related studies have undergone a carefully review to obtain all pertinent information. ___________________________________________________ halafouad9020@uomosul.edu.iq 1department of clinical pharmacy, college of pharmacy, university of mosul, nineveh, iraq a full list of author information is available at the end of the article. https://doi.org/10.47108/jidhealth.vol5.iss4.251 http://www.jidhealth.com/ kasim hf, journal of ideas in health (2022);5(4):748-754 749 an overview of hypertension according to the who guidelines, hypertension, as well-known as high blood pressure, is defined based on specific systolic or diastolic blood pressure or rein accordance with the reported use of antihypertensive medications [9]. at the same time, the international society of hypertension (ish) stated a more precise definition of hypertension as an office blood pressure reading of more than 140/90 mmhg [10]. based on the evidence, hypertension is considered a severe medical condition that causes a significant rise in the risk of heart, brain, kidneys, and other organ diseases [11]. over the past four decades, the global mean blood pressure of the population has remained constant or has been slightly reduced through the widespread use of antihypertensive medications [7]. about 1.28 billion adults between 30 and 79 years have hypertension, mostly about two-thirds within lmic; however, only 14.0% of conditions are under control [9,11]. the regional diversity in hypertension prevalence can be attributed to the differences in the efficacy of healthcare services provided among different countries [7]. in addition, variations exist in hypertension risk factors such as obesity, physical inactivity, alcohol use, tobacco consumption, and unhealthy diet [7,9]. evidence-based association of hypertension with cigarette smoking cigarette smoking impacts the risk and incidence of hypertension, causing a decrease in life expectancy and harmfully affecting the quality of life [12]. lmics are particularly concerned because the continuous increase in smoking behavior will increase the burden of health care for high blood pressure [13]. the results were still paradoxical based on recent data on the relationship between cigarette smoking and elevated blood pressure [14–17]. the possible reasons for such a discrepancy among studies can be attributed to the long-term and cumulative effects of current smoking on health which may not result immediately in deleterious conditions [12]. therefore, current smoking cannot, in common, be a direct indicator of chronic diseases initiated slowly [12]. there is either a dose-response association between smoking and a high risk of hypertension or an absence of such an association [16]. has been reported a weak positive relation between cigarette smoking and the risk of hypertension based on multiple prospective cohort studies [7]. the direct influence of cigarette smoking on hypertension cannot be sufficiently established because elevated blood pressure cannot be lowered by cessation of chronic smoking [7,18,19]. the role of smoking cessation programs regarding blood pressure remains uncertain [17]. as stated by li et al. [20], smoking cessation significantly decreases the risk of hypertension, and current smoking is not a risk factor for hypertension. there is a direct relationship between the duration of smoking and the occurrence of high blood pressure, even with quitting smoking, which highlights the constant harmful effect of smoking cigarettes. [19]. similarly, the study by zhang et al. [16] reported that cumulative exposure to cigarette smoking was related to increased systolic blood pressure in the chinese population, particularly the minority population. in contrast, another study illustrates that smoking is one of the prime preventable causes of hypertension, a condition that can be controlled to a large extent by smoking cessation [12]. whereby conducting a smoking cessation program, there was a significant improvement in systolic and diastolic blood pressure [17]. several confounding factors related to the lifestyle, diet, physical activity, and socioeconomic characteristics of individuals can affect the link between cigarette smoking and hypertension [15,21]. wang et al. [14] and lan et al. [15] report the absence of an association between cigarette smoking and high blood pressure. attributing the result to the existence of several confounding factors, such as alcohol consumption [14]. both cigarette smoking and alcohol consumption often occur synchronously. they are frequently associated with weak blood pressure control in males [14,19]. the males vs. females tend to be more smokers and alcohol consumers [19]. the variation in alcohol consumption and the metabolism patterns between males and females resulted in regular alcohol consumption on blood pressure levels [14]. the proposed mechanism suggests that the neurochemical action of nicotine and alcohol is commonly enhanced [14]. in contrast, nicotinic acetylcholine receptors (nachrs) influence alcohol consumption behaviors [14]. in addition to the effective treatment with antihypertensive drugs, it is necessary to intervene at the public health level to decrease the burden of cigarette smoking and alcohol consumption on blood pressure [14]. moreover, the overestimation of the relationship between smoking and blood pressure can be due to poor adherence to the used antihypertension medications [16]. female smokers have lower blood pressure, which is attributed to several factors, such as the physiological effects of daily cigarette smoking and the usual lifestyle, like diet and physical activity [15]. however, older females report a sharp increase in their systolic blood pressure compared to males [13], which might be related to hormonal changes during menopause [13]. therefore, an individual's age can confound the effect of smoking on blood pressure [16]. the aging process, rather than the cumulative effect of tobacco smoke, can further contribute to deteriorating health conditions [16]. a high body mass index is associated with elevated blood pressure because of the contributory effect of high adiposity levels [21]. thus, the lower body mass index induced by cigarette smoking makes lower blood pressure observed in smokers vs. non-smokers [13,16,21]. furthermore, the psychological status of individuals also plays a role [13]. where smokers’ individuals express themselves to be calmer and less stressed, and upon smoking cessation, there is an increase in their stress level [13]. because of the temporary excitement of smoking, smokers have an optimistic self-estimation of their health status. therefore, as smoking is continued, there is further masking of the early warning symptoms of some diseases [12]. furthermore, the reported current smoking status in the literature may not effectively reflect the consumption and may be closely uncorrelated with the current health status of participants [12]. substantial evidence is present about the harmful effects of cigarette smoking on the health of children and teenagers [22]. hypertension is reported in about 1% to 3% of children, where 80% of cases can occur because of several contributory factors [22]. these factors include socioeconomic and nutritional status, family history, body mass index, and smoking [22]. however, the effect of cigarette smoking remains unclear [22,23]. aryanpur et al. [22] conducted a meta-analysis of epidemiologic studies. the results revealed the absence of an kasim hf, journal of ideas in health (2022);5(4):748-754 750 association between smoking, whether active or passive smoking and the development of hypertension in children and adolescents. however, they reported increased systolic blood pressure levels because of passive smoking [22]. based on a cross-sectional study of us children and adolescents’ sample, levy et al. [23] suggest that exposure to tobacco smoke is related to high blood pressure. such finding demands particular attention at earlier ages to avoid further health complications at later ages [23]. it is plausible that reducing young people's exposure to tobacco smoke can reduce economic costs and protect people from high blood pressure and cardiovascular diseases in the future [23]. cigarette smoking and the cardiovascular system many chemical compounds of smoking, comprising more than 9000 entities, are generally concentrated and condensed in any tobacco mixture [5,24]. six of these compounds are responsible for structural and functional changes in the heart and blood vessels [5,24]. these compounds are mainly nicotine and carbon monoxide, oxidizing chemicals, volatile organic compounds, particulates, and heavy metals [6,24]. however, the effects vary depending on several factors associated with the type of smoking, the environment, and the exposed subject [5]. in general, the primary mechanisms of smoking-inducing cardiovascular disease are oxidative injury, endothelial damage and dysfunction, enhanced thrombosis, chronic inflammation, hemodynamic stress, adverse effects on blood lipids, insulin resistance and diabetes, decreased oxygen delivery by red blood cells and arrhythmogenesis with a potential increase in angiogenesis [6,18,24]. nicotine and carbon monoxide exert toxic effects on the heart and blood vessels through different mechanisms [6]. nicotine is the primary active component of tobacco smoke [25]. its main systemic hemodynamic effect is acute stimulation of the sympathetic nervous system resulting in increased release of norepinephrine from adrenergic neurons and epinephrine from the adrenal gland and vascular nerve endings [6,18,24,25]. these effects are mediated by stimulating the central and peripheral nervous system's nicotinic cholinergic receptors [24]. benowitz and burbank [24] reported that when the plasma epinephrine increased by more than 150% by cigarette smoking, the acute rise of cardiac work may result. mostly in terms of increased heart rate, myocardial contractility, and blood pressure stimulation, regardless of administering nicotine or tobacco smoke [24]. the evoked responses are originally transient but become repeatable as they are maintained by catecholamine release [6]. nicotine from cigarette smoking can also contribute to the pathophysiology of hypertension by causing direct endothelial damage [20]. the consequences are endothelial dysfunction, impairment of endothelium-dependent coronary vasodilation, and decreased nitric oxide production [6,20,24]. endothelial dysfunction usually occurs in active and passive cigarette smokers [24]. the main effects of carbon monoxide are removing oxygen from oxyhemoglobin, increasing carboxyhemoglobin concentrations, and causing tissue hypoxia [6]. because of carbon monoxide, the resultant hypoxemia can worsen preexisting conditions such as angina pectoris and congestive heart failure [24]. also, it contributes to smoking-related thrombogenesis by raising blood viscosity because of body compensation through increasing red blood cell mass [24]. the effects of nicotine and carbon monoxide on the heart and blood vessels help explain the damage seen in smokers or even in passive smokers [6]. acute exposure to cigarette smoke usually starts as a functional one but transiently affects the endothelium and myocardium [6]. it is identified among passive smokers who are either healthy non-smokers or those who suffer from ischemic heart disease [6]. management of hypertension under the influence of cigarette smoking the initiation of pharmacological treatment of hypertension is mainly considered when lifestyle modifications are ineffective in managing high blood pressure [10]. these lifestyle modifications involve smoking cessation, regular exercise, salt intake reduction, weight loss, alcohol restriction with a healthy diet, and drink intake [26]. like non-smoker hypertensive patients, smoker patients, specifically elderly heavy smokers, use antihypertensive drugs to control their hypertension [5]. when smoker hypertensive patients are treated, their response to antihypertensive drugs is typically affected [5]. the response of antihypertensive medications in smokers is either highly reduced, as seen mainly with beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors, and diuretics, or moderately reduced, as with calcium channel blockers [5]. the response of angiotensin receptor blockers drugs to smoking is not yet established [5]. modulation of pharmacological effects of beta-adrenergic antagonists under the influence of cigarette smoking among the main classes of antihypertensive drugs, betaadrenergic antagonists appear primarily affected by the adverse effects of smoking [5]. according to the who and ish guidelines, beta-adrenergic antagonists are mainly considered for hypertensive patients with cardiac conditions, like ischemic heart disease or heart failure [10]. once beta-antagonists bind to the beta-1 and beta-2 receptors, they inhibit effects mediated by binding epinephrine and norepinephrine to these receptors [27]. therefore, beta-antagonists can primarily reduce blood pressure by decreasing cardiac output and inhibiting renin release from the kidney, blocking the activity of beta-1 adrenoreceptors in the heart and kidney, respectively [27,28]. beta-antagonists also exhibit adverse chronotropic and inotropic effects on the heart [27,28]. these drugs can treat other conditions such as hyperthyroidism, essential tremor, glaucoma, and migraine prophylaxis [28]. beta-antagonists can be classified as nonselective agents; they bind to and induce antagonizing effects via beta-1 and beta-2 receptors, such as propranolol (a prototype of beta-antagonists), carvedilol, sotalol, and labetalol [27,28]. in contrast, the cardio-selective beta-antagonists can only bind to the beta-1 receptor, such as atenolol, bisoprolol, metoprolol, and esmolol [28]. beta-antagonists have additional alpha-1 receptor activity such as carvedilol and labetalol [28]. thus, they have a more distinct clinical effect on treating hypertension [27,28]. the interaction between smoking compounds and betaantagonists affects the action and efficacy of these drugs through pharmacokinetic and pharmacodynamic interaction mechanisms [8,29]. beta-antagonists are less effective in managing smokers' high blood pressure and heart rate reduction than non-smokers [5,25]. in contrast, it was found that there were no differences between smokers and non-smokers in kasim hf, journal of ideas in health (2022);5(4):748-754 751 clinical trials regarding the use of beta-antagonists for the primary prevention of myocardial infarction in hypertensive patients [25]. drug interaction is defined as interference of a patient’s response to a particular drug by co-administered drugs, dietary supplements, formulation excipients, disease, and environmental factors such as smoking [29,30]. it is essential to review the current smoking status of hypertensive patients to avoid an additional risk that may occur due to potential drug interactions with smoking [29,31], where it is possible to prevent any harm to patients because of a drug interaction [30]. the harmful effect can occur because increasing drug effects lead to toxicity or reduces the drug's effect, leading to therapeutic failure [30]. influence of cigarette smoking on the pharmacokinetic characteristics of drugs the principles of pharmacokinetics include absorption, distribution, metabolism, and elimination of drugs, meaning “what the body does to the drug” [8,30]. chemical compounds of smoking are responsible for pharmacokinetic interactions through the activity of cytochrome (cyp) p450 enzymes [29,31,32]. these enzymes are responsible for the metabolism of drugs and the detoxification of xenobiotics [33]. the interaction with cyp enzymes is mediated primarily by polycyclic aromatic hydrocarbons (pahs) of tobacco smoke [29,34]. the pahs compounds are products of the incomplete combustion of tobacco. they are considered some of the leading lung cancer-causing substances in tobacco smoke, also known as drug-metabolizing enzyme inducers [25,31,32]. mainly, pahs induce the activity of cyp1a1, 1a2 isoenzymes located in the liver, small intestine, and lung tissues, cyp 2b6 and possibly, cyp2e1 isoenzymes [29,32,35]. among beta-antagonists, two drugs are the major substrates of cyp1a2 enzymes, which are betaxolol (beta-1 selective adrenergic receptor blocking agent) and propranolol (a nonselective beta-adrenergic receptor blocking agent) [34]. cyp1a2 enzymes significantly metabolize these drugs, and by inducing these enzymes, the therapeutic efficacy is reduced because of decreasing the plasma concentration of substrate drugs [31,34]. the major substrate drugs are more likely affected by changes in smoking status compared to minor substrate drugs such as carvedilol which possess betaand alpha-adrenergic blocking activity [34]. several factors exist, leading to individual variation in pharmacokinetic drug interactions [34]. particularly for genetic polymorphisms of the cyp1a2 gene and the apparent racial differences in the distribution of cyp1a2 mutations [29]. moreover, the bioavailability of the components of cigarette smoke and the extent of inhalation affects enzyme induction [29]. where the induction of cyp1a2 activity by smoking occurs in a dose-dependent manner, smoking 1 to 5 cigarettes per day raises the activity of the cyp1a2 enzyme by about 1.2fold [35]. consumption of more than ten cigarettes per day is associated with maximum induction of cyp1a2 activity, about 1.7-fold [35]. it is still being determined whether or not the amount of cigarette smoking or the existence of inter-individual variations can impact cyp1a2 induction [29,34]. nevertheless, the evidence appears that in heavy smokers (more than 20 cigarettes/day) compared to light smokers, the activity of cyp1a2 is significantly high enough to result in a tremendous rise in the induction of drug metabolism and, ultimately, the clearance of drugs [29,34]. co-administered other medicines can also impact the risk of cyp1a2 drug interactions [34] as several drugs and substances can also induce the cyp1a2 enzymes, such as char-grilled food, rifampin, carbamazepine, omeprazole, phenobarbital, and primidone [34,35]. among pahs compounds, mainly 3-methylphenanthrene can induce other metabolic enzymes, which are uridine diphosphate (udp)-glucuronosyltransferases (ugt) that are located primarily in the liver and catalyze glucuronidation reactions [25,31,36]. glucuronidation is a detoxifying mechanism that changes the physiological and pharmacological activities of chemicals within the body, making them have fewer biological activities [36]. numerous endogenous and exogenous compounds undergo glucuronidation, such as bilirubin, steroid hormones, fat-soluble vitamins, environmental toxins, and many medications [36]. multiple factors are responsible for the marked inter-individual variations in glucuronidation rates, such as age, disease, and xenobiotic exposure, which possibly can affect the capacity for drug metabolism [36]. smoking via pahs can induce the glucuronidation of propranolol, carried out by ugt1a9, ugt2b4, and ugt2b7 enzymes in the liver ugt1a10 enzyme, which exists extrahepatically [25,37]. as a result, it was reported that after administering a single dose of propranolol, the area under the curve was about 50.0% lower in smokers vs. non-smokers [25]. in contrast, oral clearance increased by about 77.0% [25]. most probably due to the dual effect on metabolic pathways of propranolol by increasing side-chain oxidation, which is catalyzed principally by cyp1a2 and, to some extent, by cyp2d6 [25,37]. also, changes in drug clearance might occur through the induction of glucuronidation, with no apparent effect on the ring oxidation metabolic pathway of propranolol [25,37]. no changes were reported in half-lives of propranolol between smokers and non-smokers, which means that the increase in oral clearance occurs because of an increase in firstpass metabolism [25,33]. other smoking compounds may also contribute to the interaction with hepatic enzymes but have fewer significant effects, such as acetone, pyridine, heavy metals, benzene, carbon monoxide, and nicotine [31]. it is essential to monitor patients' smoking status in a clinical setting [29,34], considering dosage modifications for smoker patients, particularly heavy smokers or those who start smoking [31,34]. however, the dose of propranolol, for example, may need to be increased to achieve the required therapeutic response [8,29]. those exposed to environmental smoking may also be subject to changes in drug metabolism because of the induction of hepatic cyp1a2 enzymes [34]. alternatively, dosage reduction may be required if cyp1a2 inhibitor drugs, such as amlodipine, cimetidine, ciprofloxacin, diclofenac, fluoxetine, fluvoxamine, or nifedipine are added to the therapeutic regimen or if patients stop smoking [31,34]. when smoking cessation occurs, the downregulation of the cyp1a2 enzymes occurs, depending mainly on the degree of change in cigarette smoking status compared to baseline [32]. therefore, it is essential to consider how quickly cyp1a2 enzymes return to normal after stopping smoking [31,34]. the turnover time of the cyp1a2 enzymes is about two days, and it usually takes kasim hf, journal of ideas in health (2022);5(4):748-754 752 several weeks to return the induction of cyp1a2 enzymes to normal metabolism [32,34]. therefore, within two to three days after smoking cessation, it may be essential to have an empirical dose reduction [32]. however, smoking cessation reduces propranolol clearance by about 77.0%, but the clinical effects of high plasma concentrations of the drug are difficult to anticipate [33] because propranolol dosage varies from 80 to 640 mg per day [33]. therefore, it is essential to monitor the signs and symptoms of propranolol overdose, such as bradycardia, fatigue, dizziness, and others, to consider a dose reduction of propranolol [33]. nicotine has no role in the induction of hepatic cyp1a2 enzymes [34]. therefore, using nicotine replacement therapy (nrt) products to help smoking cessation does not contribute to pharmacokinetic drug interaction as smoking [33,34]. however, nicotine appears to have a role in pharmacodynamic interaction with beta-adrenergic antagonists [31]. influence of cigarette smoking on the pharmacodynamic characteristics of drugs besides pharmacokinetic interaction between smoking and betaadrenergic antagonists, pharmacodynamic interactions may also occur [8]. pharmacodynamics means "what the drug does to the body", where pharmacodynamic interactions usually occur between drugs with either additive or opposing effects [30]. mostly, the brain is the organ that suffers from pharmacodynamic interactions [30]. smoking can contribute to such an interaction through the pharmacological effects of nicotine that may interfere with the therapeutic response to drugs [8,38]. as mentioned earlier, nicotine acutely raises blood pressure, heart rate, and myocardial contractility [25,38]. as a result of these effects, smoking reduces beta-adrenergic antagonists' effectiveness in controlling heart rate and blood pressure in smoker patients [8,38]. thus, these drugs may require a higher dose rate to achieve therapeutic responses [8]. another beta-antagonist, nebivolol, has beta-blocking and vasodilation effects [27]. the drugs also increase the forearm blood flow indicating a potential beneficial impact on smokinginduced endothelial dysfunction because of nicotine [38]. however, it was limited only to light smokers [5]. the acute effects of nicotine on the cardiovascular system, particularly an increase in heart rate, are identical between low and high nicotine levels [8]. therefore, such interaction can still exist in continuing or reducing the number of cigarettes smoked [8]. however, the maximum plasma concentration of nicotine is established quickly, within 5 minutes after cigarette smoking, which is responsible for nicotine's immediate maximal pharmacodynamic effect through tobacco smoking [32]. based on the evidence, upon smoking cessation, such kind of drug interaction is less likely to occur [8]. as the half-life of nicotine is about 2 hours, there is a rapid decrease in the acute pharmacological effects of nicotine [8]. anderson and chan [32] reported that the bioavailability of nicotine from cigarette smoking is about 80.0-90.0% higher than from products of nrt, which is about 55.0% from nicotine inhalers, 70.0% from nicotine nasal spray, 51.0%-78.0% from nicotine gum and 68.0%-100% from nicotine transdermal patches [32]. however, the products of nrt can raise heart rate by up to 10 to 15 beats and blood pressure by about 5 to 10 mmhg with less acute effect possibly obtained from transdermal nicotine patch [8]. nicotine concentrations from nrt are between one-third to two-thirds of cigarette smoking [8]. these lower nicotine concentrations may render the pharmacodynamic drug interactions of nrt less clinically significant [8]. smoker elderly patients and drug interactions old age is an additional factor that influences the extent of drug interaction, particularly between beta-adrenergic antagonists and smoking [5,39]. careful attention to elderly patients is needed, as with old age, there is a high prevalence of comorbid conditions with increasing numbers of prescribed drugs [33,39]. there are also changes in the pharmacodynamic effects of drugs, such as raising the activity of certain medications, such as central nervous system depressants at specific plasma concentrations [33]. the alteration of pharmacokinetics parameters in the elderly is of particular concern with the absorption of drugs, reducing renal drug elimination and hepatic drug clearance with alterations in body water and fat content [33]. these changes raise the drug's half-life, which ultimately increases the risk of the drug's toxicity and adverse effects, thus making the safety and efficacy of medications after smoking cessation challenging to predict [33,39]. in elderly patients, metabolic changes in response to propranolol infusion exist, reducing its effectiveness [5]. physiologically, it might be related to the impairment of the autonomic nervous system by disturbing the sensitivity of the baroreceptor reflex and reducing its function as a consequence of rising aortic stiffness [5]. which adversely impacts elderly patients when they are exposed to smoking [5]. conclusions cigarette smoking exerts potential impacts on blood pressure through several mechanisms. the presence of confounding factors further masks the clear relationship between cigarette smoking and the elevation of blood pressure. cigarette smoking can interact with antihypertensive drugs, primarily with betaadrenergic antagonists. the interaction occurs through pharmacokinetic and pharmacodynamic mechanisms. therefore, as smoking continues to persist globally, it is essential to monitor patients' smoking status in hospitals or outpatient clinics and to consider the dosage modification of beta-adrenergic antagonists according to their smoking status. this would ensure the effective and safe use of beta-antagonists for the treatment of hypertension in both active and passive smokers, with particular attention to elderly patients. further studies are required to emphasize the effect of cigarette smoking on different beta-antagonists used for the treatment of hypertension in both active and passive smoker patients. abbreviation who: world health organization; lmics: lowand middleincome countries; ish: international society of hypertension; cyp: cytochrome; pahs: polycyclic aromatic hydrocarbons; udp: uridine 5’-diphosphate; ugt: uridine diphosphate (udp)-glucuronosyltransferases; nrt: nicotine replacement therapy. declaration acknowledgment none. kasim hf, journal of ideas in health (2022);5(4):748-754 753 funding the author received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing halafouad9020@uomosul.edu.iq. authors’ contributions hala f. kasim (hfk) is the principal investigator of this manuscript (review article). hfk is the author responsible for the study concept, design, writing, reviewing, editing, and approving of the manuscript in its final form. hfk has read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, review articles need no ethics committee approval. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of clinical pharmacy, college of pharmacy, university of mosul, nineveh, iraq article info received: 28 august 2022 accepted: 06 november 2022 published: 23 november 2022 references 1. world health organization (who). tobacco, published may 24, 2022. [cited 2022 aug 20]. available from: https://www.who.int/news-room/fact-sheets/detail/tobacco. 2. perez-warnisher mt, de miguel mdpc, seijo lm. tobacco use worldwide: legislative efforts to curb consumption. ann glob heal. 2019;85(1):1-9. https://doi.org/10.5334/aogh.2417. 3. world health organisation (who) global report on trends in prevalence of tobacco use 2000-2025, fourth edition. geneva: world health organization. 4. hikita n, haruna m, matsuzaki m, sasagawa e, murata m, oidovsuren o, et al. prevalence and risk factors of second-hand smoke (shs) exposure among pregnant women in mongolia. sci rep. 2017;7(1):16426. http://dx.doi.org/10.1038/s41598-017-16643-4. 5. leone a. does smoking act as a friend or enemy of blood pressure? let release pandora’s box. cardiol res pract. 2011; 2011:1–7. http://dx.doi.org/10.4061/2011/264894. 6. leone a. smoking and hypertension. j cardiol curr res. 2015;2(2):00057. http://dx.doi.org/10.15406/jccr.2015.02.00057. 7. mills kt, stefanescu a, he j. the global epidemiology of hypertension. nat rev nephrol. 2020;16(4):223–37. http://dx.doi.org/10.1038/s41581-019-0244-2. 8. kroon la. drug interactions and smoking: raising awareness for acute and critical care providers. crit care nurs clin north am. 2006;18(1):53–62. http://dx.doi.org/10.1016/j.ccell.2005.11.007. 9. guideline for the pharmacological treatment of hypertension in adults. geneva: world health organization; 2021. license: cc by-nc-sa 3.0 igo. 10. nugroho p, andrew h, kohar k, noor ca, sutranto al. comparison between the world health organization (who) and international society of hypertension (ish) guidelines for hypertension. ann med. 2022;54(1):837–45. https://doi.org/10.1080/07853890.2022.2044510. 11. world health organization (who). hypertension, published aug 25, 2021. [cited 2022 aug 18]. available from: https://www.who.int/news-room/factsheets/detail/hypertension. 12. gao k, shi x, wang w. the life-course impact of smoking on hypertension, myocardial infarction, and respiratory diseases. sci rep. 2017; 7:4330. http://dx.doi.org/10.1038/s41598-017-04552-5. 13. andriani h, kosasih ri, putri s, kuo hw. effects of changes in smoking status on blood pressure among adult males and females in indonesia: a 15-year populationbased cohort study. bmj open. 2020;10: e038021. http://dx.doi.org/10.1136/ bmjopen-2020-038021 14. wang m, li w, zhou r, wang s, zheng h, jiang j, et al. the paradox association between smoking and blood pressure among half a million chinese people. int j environ res public health. 2020; 17:2824. http://dx.doi.org/10.3390/ijerph17082824 15. lan r, bulsara mk, pant pd, wallace hj. relationship between cigarette smoking and blood pressure in adults in nepal: a population-based cross-sectional study. plos glob public heal. 2021;1(11): e0000045. http://dx.doi.org/10.1371/journal.pgph.0000045 16. zhang y, feng y, chen s, liang s, wang s, xu k, et al. relationship between the duration of smoking and blood pressure in han and ethnic minority populations: a crosssectional study in china. bmc public health. 2021;21(1):135. https://doi.org/10.1186/s12889-02009975-w 17. tsai sy, huang wh, chan hl, hwang lc. the role of smoking cessation programs in lowering blood pressure: a retrospective cohort study. tob induc dis. 2021;19(october):82. https://doi.org/10.18332/tid/142664 kasim hf, journal of ideas in health (2022);5(4):748-754 754 18. virdis a, giannarelli c, neves mf, taddei s, ghiadoni l. cigarette smoking and hypertension. curr pharm des. 2010;16(23):2518–25. http://dx.doi.org/10.2174/138161210792062920. 19. kimani s, mirie w, chege m, okube ot, muniu s. association of lifestyle modification and pharmacological adherence on blood pressure control among patients with hypertension at kenyatta national hospital, kenya: a cross-sectional study. bmj open. 2019;9(1): e023995. https://doi.org/10.1136/ bmjopen-2018-023995. 20. li g, wang h, wang k, wang w, dong f, qian y, et al. the association between smoking and blood pressure in men: a cross-sectional study. bmc public health. 2017; 17:797. https://doi.org/10.1186/s12889-017-4802-x 21. linneberg a, jacobsen rk, skaaby t, taylor ae, fluharty me, jeppesen jl, et al. effect of smoking on blood pressure and resting heart rate: a mendelian randomization meta-analysis in the carta consortium. circ cardiovasc genet. 2015;8(6):832–41. https://doi.org/10.1161/circgenetics.115.001225 22. aryanpur m, yousefifard m, oraii a, heydari g, kazempour-dizaji m, sharifi h, et al. effect of passive exposure to cigarette smoke on blood pressure in children and adolescents: a meta-analysis of epidemiologic studies. bmc pediatr. 2019; 19:161. https://doi.org/10.1186/s12887-019-1506-7 23. levy r v., brathwaite ke, sarathy h, reidy k, kaskel fj, melamed ml. analysis of active and passive tobacco exposures and blood pressure in us children and adolescents. jama netw open. 2021;4(2):e2037936. https://doi.org/10.1001/jamanetworkopen.2020.37936 24. benowitz nl, burbank ad. cardiovascular toxicity of nicotine: implications for electronic cigarette use. trends cardiovasc med. 2016;26(6):515-23. http://dx.doi.org/10.1016/j.tcm.2016.03.001. 25. zevin s, benowitz nl. drug interactions with tobacco smoking an update. clin pharmacokinet. 1999;36(6):425– 38. http://dx.doi.org/10.2165/00003088-199936060-00004 26. unger t, borghi c, charchar f, khan na, poulter nr, prabhakaran d, et al. 2020 international society of hypertension global hypertension practice guidelines. hypertension. 2020; 75:1334–57. http://dx.doi.org/10.1161/hypertensionaha.120.150 26 27. benowitz nl. cardiovascular-renal drugs: antihypertensive agents. in: katzung bg, editor. basic & clinical pharmacology. new york: mcgraw-hill education; 2018. pp. 173–93. 28. farzam k, jan a. beta blockers. [updated 2022 july 21]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2022 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk532906/. 29. lucas c, martin j. smoking and drug interactions. aust prescr. 2013;36(3):102–4. http://dx.doi.org/10.18773/austprescr.2013.037. 30. snyder bd, polasek tm, doogue mp. drug interactions: principles and practice. aust prescr. 2012;35(3):85–8. http://dx.doi.org/10.18773/austprescr.2012.037. 31. kroon la. drug interactions with smoking. am j heal pharm. 2007;64(18):1917–21. http://dx.doi.org/10.2146/ajhp060414. 32. anderson gd, chan ln. pharmacokinetic drug interactions with tobacco, cannabinoids and smoking cessation products. clin pharmacokinet. 2016;55(11):1353–68. http://dx.doi.org/10.1007/s40262016-0400-9. 33. schaffer sd, yoon s, zadezensky i. a review of smoking cessation: potentially risky effects on prescribed medications. j clin nurs. 2009;18(11):1533–40. http://dx.doi.org/10.1111/j.1365-2702.2008.02724.x. 34. fankhauser mp. drug interactions with tobacco smoke: implications for patient care. curr psychiatr. 2013;12(1):12–6. 35. klomp f, wenzel c, drozdzik m, oswald s. drug-drug interactions involving intestinal and hepatic cyp1a enzymes. pharmaceutics. 2020;12(12):1201. http://dx.doi.org/10.3390/pharmaceutics12121201. 36. meech r, mackenzie pi. structure and function of uridine diphosphate glucuronosyltransferases. clin exp pharmacol physiol. 1997;24(12):907–15. http://dx.doi.org/10.1111/j.1440-1681.1997.tb02718.x. 37. thorn cf. propranolol pathway, pharmacokinetics. [cited 2022 aug 21]. available from: https://www.pharmgkb.org/pathway/pa166183426. 38. cohen dl, townsend rr. does cigarette use modify blood pressure measurement or the effectiveness of blood pressure medications? j clin hypertens. 2009;11(11):657– 8. http://dx.doi.org/10.1111/j.1751-7176.2009.00180.x. 39. teka f, teklay g, ayalew e, teshome t. potential drugdrug interactions among elderly patients admitted to medical ward of ayder referral hospital, northern ethiopia: a cross sectional study. bmc res notes. 2016; 9:431. http://dx.doi.org/10.1186/s13104-016-2238-5. https://doi.org/10.47108/jidhealth.vol4.iss2.119 ilesanmi os, et al., journal of ideas in health 2021;4(2):371-379 © the author(s). 2021 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access a systematic review of tobacco smoking cessation services in africa: practices and challenges faced by healthcare workers olayinka stephen ilesanmi1,2, victoria ifeoma agwai1, aanuoluwapo adeyimika afolabi1* abstract background: tobacco smoking is a global public health challenge, resulting in an estimated loss of 1.4 trillion united states dollars (usd), a preventable risk that can be achieved through tobacco cessation services. the study, therefore, aimed to review the most frequently used methods employed by healthcare workers (hcws) in providing tobacco cessation services and reported challenges in africa. methods: a systematic review was conducted using five electronic databases (pubmed, base, psycinfo, google scholar, and african journal online) for published studies on hcw’s practices and challenges on tobacco cessation in africa. we adopted a three-stage methodology to conduct the study, which identified articles using pre-defined key terms, screened articles to remove duplicates, and excluded irrelevant articles after reading the manuscripts’ titles and abstracts. results: we reviewed articles and found that 35.0% to 83.0% of hcws frequently asked their patients to quit smoking. also, 14.9% of hcws assisted smoking cessation among their patients, among whom 3.9% prescribed oral depressants and 2.8% prescribed nicotine replacement therapy (nrt). further, 17.0% of hcws had guidelines to help patients to cease smoking. challenges were lack of efficacy and training, lack of system support, low sense of responsibility by some physicians to incorporate the smoking cessation therapy to their patients, lack of attractive educational resources on smoking cessation, limited knowledge on effective intervention strategies, lack of guidelines, lack of specialists for smoking cessation, and unavailability of nrt. conclusion: follow-up should be commenced and intensified by hcws for smoking cessation among tobacco smokers. keywords: africa, healthcare workers, tobacco, tobacco cessation, tobacco smokers, systematic review background globally, about a billion people are estimated to die of tobacco smoking in the 21st century. most of the deaths occurring in low and middle-income countries [1]. more than 80.0% of the world's 1.3 billion tobacco users live in lowand middleincome countries [2]. tobacco use accounts for nearly 8 million deaths annually, which accounts for 7 million deaths from direct tobacco use and 1.2 million deaths of non-smokers exposed to passive smoking [2]. tobacco accounts for 20.0% of all adult male deaths and 5.0% of adult female deaths [1]. globally, 19.0% of adults currently smoke, with 22.0% from high-income countries, 19.5% in middle-income countries, and 11.0% in low-income countries [3]. the proportion of smoking among men is highest in middle-income countries (35.0%). however, more women (16.0%) smoke in high-income countries [3]. moreover, 24 million smokers are within the age range of 13-15 years, out of which 13 million use smokeless tobacco products [4]. tobacco smoking is a preventable cause of death, with 30% of deaths due to cancer [2]. tobacco smoking has resulted in an annual estimated loss of nearly 1.4 trillion usd in economic damage [5]. the cost of tobacco-related illnesses is exceptionally high, representing nearly 2.0% of global gross domestic products (gdp), while the health expenditure associated with smoking use represents 5.7% of total health expenditure [5]. globally, indirect costs of smoking are estimated to be about 1 trillion usd, with two-thirds of the cost attributed to premature mortality [5]. the decline of tobacco use in high-income countries is almost proportional to its increase in low and middle-income countries, particularly in africa, asia, and eastern europe [6]. tobacco use in africa has garnered little attention [7]. such little attention may be due to the perceived low smoking prevalence compared to other developing regions, alongside the more immediate burden of infectious diseases [7]. ___________________________________________________ afoaanade@gmail.com 1department of community medicine, college of medicine, university of ibadan, oyo state, nigeria full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol4.iss2.119 http://www.jidhealth.com/ ilesanmi os, et al, journal of ideas in health (2021); 4(2):371-379 372 “article 14 of the world health organization framework cessation on tobacco control states that each party shall take effective tobacco cessation promotive measures and adequate management for cases of tobacco dependence” [8]. notwithstanding, the report of the who on the global tobacco epidemic in 2017 indicated that ‘less than onethird of highincome countries, fewer than one in ten middle-income countries and one low-income country (senegal) offer complete tobacco cessation support [9]. in africa, tobacco cessation services are deterred by multiple challenges such as inadequate training of healthcare workers (hcws), competing for infectious disease burden, inadequate data, and lack of applicable local guidelines [4]. south africa is reportedly the only country with specific smoking cessation guidelines, with initiatives like quit lines and web-based platforms for smoking cessation. countries like sudan, tanzania, and nigeria do not have such specific guidelines or initiatives to integrate tobacco cessation services into their tobacco control strategies [9]. the who's 5a's model is an effective and well-designed method of providing cessation services [10]. the model was created for hcws to identify and assist individuals who use tobacco products and are ready to quit its use [11]: (i) ask: about their tobacco use; (ii) advise: should be specific and aimed at persuading the user to quit; (iii) assess: determine the user's willingness to quit; (iv) assist: the user should be supported in developing a quitting plan; and (v) arrange: for follow-up on quitting process [11]. the who toolkit for delivering these 5a's states that the national healthcare sector is well placed to lead the implementation of these measures, provide cessation services, and point out some of the roles hcws are to play in providing comprehensive tobacco control services [12]. these are founded on basic roles as educators, role models, opinion builders, clinicians, and leaders. it admonishes that all health professionals should address tobacco cessation activities as a component of their standard of care service, serve as tobaccofree models for the public, assess exposure to passive smoking, and provide information about avoiding all forms of exposure to tobacco [12]. literature regarding specific tobacco cessation interventions carried out in africa is not comprehensive enough to conclude what works and what does not [7,13]. studies have reported that cessation interventions are well established in developed countries with various literature on what services work through selected professionals on various groups of people [13-15]. reviews have been done on cessation services integrated through various cadres of health care providers and targeted at various groups of smokers, either based on health status and the age group or type of product used [15,16]. therefore, the study aimed to review the most frequently used methods employed by hcws in providing tobacco cessation services and reported challenges in africa. methods study design and procedure a systematic review of the literature was conducted using the guidelines outlined by the preferred reporting items for systematic reviews and meta-analyses (prisma) for assessment of intervention studies [17,18]. we reviewed all literature found irrespective of their study design. all literature that examined the mode of delivery of smoking cessation service, most used practices, population interventions are targeted, and the effectiveness of these interventions in africa was reviewed. inclusion criteria we included all studies on hcws’ practices on tobacco cessation in africa. all study designs used in conducting research, as long as they reported on smoking cessation activities in africa were also included in the search. exclusion criteria the exclusion criteria incorporate the following: (a) guidelines only explaining the appropriate measures to be taken by tobacco users., (b) studies focused on cessation attempts by tobacco users only., and (c) studies on tobacco use from the perspectives of the patients only. search for eligible literature the five highly-indexed electronic databases (pubmed, base, psycinfo, google scholar, and african journal online (ajol) have been searched for literature on hcw's practices, and tobacco cessation in africa. the database search was not limited to any date but was restricted to the english language for easy understanding of all the authors who participated in the literature search process. the strategy used for the search is described here: ‘healthcare workers’ or ‘tobacco’, 'health workers' or 'tobacco cessation, 'healthcare staff' and 'tobacco interruption', “healthcare workers’ and ‘tobacco cessation, as well as 'health staff' and ‘tobacco use control’. eligible literature was also selected from the reference list of articles that met the inclusion criteria. article screening and selection we used the five databases and searched the terms specified above to retrieve articles. we adopted a four-stage methodology to conduct the study (figure 1): step one: the identification of articles using pre-defined search criteria. a total of 6,693 articles were retrieved. step two: screening articles to remove duplicates and exclude articles after reading through the titles and abstracts according to the study's objectives to identify potentially relevant articles. thus, we excluded 6,653 articles that had unrelated themes to the study objectives. step three: we used the eligibility and inclusion criteria to review the full texts. here, 19 articles were excluded due to unmatched content. step four: in response to using the predefined exclusion criteria, 12 articles were excluded. thus, we included nine articles in the final in-depth review. data extraction from the recruited literature, details on the study type, characteristics of hcws, cadre in the healthcare profession, smoking cessation practices, and challenges faced regarding smoking cessation interventions were enlisted. authors’ role the review authors independently conducted the literature search and assessment of relevant literature for eligibility and inclusion. bias in the assessment has reduced with decision making through group discussions. in other cases, a third-party opinion was sought. ilesanmi os, et al, journal of ideas in health (2021); 4(2):371-379 373 results synopsis the systematic review focused on studies investigating the application of smoking cessation therapy by hcws in africa between 2004 and 2018 (table 1). we reviewed nine studies with a total population of 2,913 persons. four of the studies indicated that hcws frequently smoking cessation in their patients with a range of 35.0% to 83.0%. also, 23.0% to 61.3% of hcws advised their patients to quit smoking after assessment, while 14.9% of hcws assisted their patients to quit tobacco use and smoking. among the hcws, 3.9% prescribed oral depressants, while 2.8% prescribed nrt. a study revealed that 17.0% of hcws had guidelines to help patients quit tobacco use and smoking. two of the studies reported follow-up visits of patients (17.0% and 57.0%). challenges were lack of efficacy and training, lack of system support, limited consultation time, low sense of and responsibility by some physicians to incorporate the smoking cessation therapy to their patients. other challenges were lack of attractive educational resources on smoking cessation, limited knowledge of hcw on effective intervention strategies, lack of guidelines and dearth of smoking cessation specialists, and unavailability of nrt. description of retrieved literature in tandem with the study objectives dedeke et al. [19] was a cross-sectional study that described the challenges facing nigerian dentists in implementing tobacco cessation services. information was collected and collated from 205 dental trainees at a tertiary hospital. eighty-three percent (83.0%) of the dental trainees frequently asked their patients their smoking status, with less than 10.0% assisting patients to quit. a couple of reasons were viewed as impediments to smoking cessation practices, with lack of perceived efficacy and training as the most important hindrance and lack of reimbursement as the least. mostafa et al. [20] was a cross-sectional study designed to describe the effect of physicians' smoking status on their knowledge, behavior, and smoking cessation practice. the study revealed that 21.5% of respondents were current smokers, 8.3% former smokers, and 70.2% were never smokers. the study showed that a significant number of physicians either did not know or think that smoking affected the health worker, while 41.9% of physicians did not agree that advice from a health professional increased the chances of a smoker quitting. 27% of respondents did not think hcw should routinely ask their patients to quit smoking, and 27.4% did not think hcw should routinely provide smoking cessation advice. more than half (63.7%) of the physicians in the study did not firmly agree that their smoking status affected their cessation practice. murphy et al. [21] was a cross-sectional study carried out to assess midwives' knowledge, attitudes, and current practices in south africa to provide smoking cessation education or counseling to pregnant women. the study used qualitative methods to explain some of the data collected as 24 interviews were organized with midwives. fifty-eight percent (58.0%) reported that they held smoking cessation lessons at every visit and 30.0% at some visits if established that a patient smoke. less than a third (27.2%) of the midwives reported that they provided patients with educational resources about smoking cessation. although all midwives agreed that maternal smoking during pregnancy is harmful to the unborn child, about 75.0% of them reported wrong responses to statements regarding conditions caused by smoking in pregnancy, such as agreeing that smoking caused hypertension, pre-eclampsia, anemia, and congenital abnormalities. gichuki et al. [22] was a cross-sectional study that assessed hcws’ practices regarding smoking cessation practices in health facilities in kenya. participants were from 5 health cadres of hcws, including clinical officers, community health officers, dentists, nurses, and medical officers. information collected from 338 respondents showed that 35.0% reported consistently inquire about patients' smoking status while 43.5% consistently advised having to quit smoking and tobacco use. sixty-five percent of respondents reported tin setting never discussed the use of cessation medication, while 54.0% assisted patients to set quit dates, and 57.0% assessed patients’ progress during follow-up visits. the significant barriers to cessation practices were insufficient training and knowledge, lack of guidelines, and specialists in smoking cessation programs. okeke et al. [23] was a cross-sectional study carried out to determine the prevalence of smoking and tobacco use among hcws in kwazulu-natal, and their willingness and practice in offering assistance for patients to quit. the hcws were categorized as doctors, pharmacists, nurses, student nurses, allied health workers, and others (clerks and data capturers). when analyzed according to the professional category, others had the highest prevalence (27.3%) and student nurses the lowest (7.5%). when current, former, and never smokers were compared, never smokers more regularly counseled their patients to quit smoking. only 22.3% of all hcw in the study followed up on their smoking patients that were advised to quit. the most recommended nrt were nicotine gum and lozenges with spray, while inhaler was the least. uti and sofola [24] was a cross-sectional study that assessed the attitude and practices of the dentist and dental students in nigeria in providing smoking cessation in the dental setting and the likely barriers to smoking cessation services. results showed that while a high proportion of respondents believed that cessation could be carried out in the clinic, none of the respondents strongly agreed that they were professionally responsible for encouraging or educating patients on tobacco cessation. regarding practice, more than ¾ of the respondents reported having advised at least one patient to quit smoking. the major barriers reported were lack of time, lack of necessary figure 1 prisma 2009 diagram total number of articles reviewed (n = 6693) i d e n ti f ic a ti o n review of articles titles and abstract n=40 s c r e e n in g review of the full-text articles (n = 21) e li g ib il it y i n c lu d e d final in-depth review (n = 9) 19 articles excluded due to unmatched content 12 articles rejected based on exclusion crtiteria 6653 articles ineligible due to unrelated themes ilesanmi os, et al, journal of ideas in health (2021); 4(2):371-379 374 materials, and lack of knowledge on smoking cessation. jamda et al. [25] was a cross-sectional study that assessed the provision of health facility-based smoking cessation services and the competence of the hcw to provide these services. five percent of the respondents reported having received training on tobacco control. 40% of the hcw had high knowledge, 23.6% had a positive attitude, and 7.7% had good tobacco cessation practice. desalu et al. [26] conducted a snap-shot study to evaluate the knowledge and practices of smoking cessation among nigerian physicians. information collected from 436 physicians was assessed, and 86.7% asked their patients about their smoking status. also, 61.3% advised their patients briefly to quit, 14.9% set target dates, 3.7% prescribed oral antidepressants, and 2.8% prescribed nrt. however, 70.7% did not schedule follow-up visits with their patients, 17.6% scheduled follow-up visits, and 11.9% did not see the relevance of the visit. the major perceived barriers were poor knowledge of smoking cessation (66.3%), lack of time (12.6%), and unavailability of nrt (4.6%). nollen et al. [27] was a crosssectional study aimed at understanding the workplace smoking policies and cessation practices of physicians in nigeria. information collected from 379 respondents cut across two major teaching hospitals in the southwest. results indicate 81.0% of physicians reported assessing their patient's smoking status, and their patients asked 9.0% for assistance to quit. ninety-five percent (95.0%) of respondents thought counseling was effective, 17.0% were reported to have any guideline to help smokers quit, while less than one percent (0.79%) prescribed pharmaco-therapy. regarding workplace smoking policy, 52.0% reported practicing in a completely non-smoking building, 41.0% had no established smoking policy, and 3% reported having designated smoking areas. discussion given the who 5a's model for providing cessation services, hcws are critical in implementation [12]. their access to and relationship with their patients positions them to ask about smoking status, advise smoking patients to quit, assess willingness to take advice, and then assist and arrange for a suitable quitting plan and process. a key observation made during the study is the limited literature covering africa that addresses the views of and actions taken by hcws in promoting smoking cessation among their patients. despite the paucity of research available, all the studies reported that a significant number of hcws made use of at least one of the 5a's strategies in promoting cessation among their patients. the most common strategy employed was asking about smoking status. although most hcws reported asking after patients’ smoking status, fewer went further to advise on smoking cessation, and even fewer assisted and arranged for the cessation procedure [19,22,23,26,27]. a massive lack of followup was noted among the hcws, and although questions were asked, solutions in most cases were not provided. such a sequence of events does not guarantee the success and practicality of smoking cessation among willing smokers. in the few situations where hcws assisted patients and arranged for cessation, different methods were employed to promote cessation. the use of educational materials, counseling, and recommendation of nrt with prescription of antidepressants were methods commonly employed by hcws [21,23,26]. however, hcws should be dynamic with each method while ensuring that the adopted method explicitly suits the situation at hand. the common barriers to the provision of smoking cessation services cited by hcws were poor knowledge of the practices and lack of training. other barriers included lack of time, lack of efficacy of interventions, unavailability of nrt, and educational resources. these barriers, however, need to be removed to ensure that the input of hcws regarding smoking cessation yields credible results. most hcws examined were found in tertiary and secondary institutions. physicians and dentists were the most common hcws studied. therefore, a gap in study is identified as the who has noted that 80.0% of all tobacco users per year would be accessed by primary hcws [12]. the one study carried out in a community setting was focused on the midwives and their role in providing cessation services for their patients [21]. interestingly, the study reported a high level of dedication by the midwives to ensure their patients quit smoking, especially during their pregnancy. the finding, therefore, posits that smoking cessation should not be limited to a specific period or certain population groups. instead, a concentric approach should be adopted to ensure that no one is missed out. given the recommendation of the who for hcws to be tobacco-free models for the general public [12], the smoking state of hcws was taken into consideration. only two studies reported a relationship between hcw's smoking status and cessation practice [20,23]. both studies, however, had conflicting conclusions as mostafa et al. [20] reported that physicians did not believe their smoking status affected their provision of cessation services while okeke et al. [23] reported that never smokers more frequently advised patients to quit smoking. mostafa et al. [20] and uti and sofola [24] also reported that a significant proportion of hcws did not agree that they were in a critical position to assist patients in quitting smoking. the finding suggests that the responsibility of smoking cessation is not known and assumed by many hcws and should therefore be looked into. conclusion in conclusion, the information gathered showed that although patients were asked, they were rarely followed up to set quit dates. such acts showed a lack of commitment on the part of the hcw to ensure these patients quit smoking. a couple of hcws even reported not considering it their responsibility to advise their patients on smoking cessation. the barriers highlighted above also need to be addressed to encourage the commitment of hcws to smoking cessation. training should be regularly organized for hcws to improve smoking cessation service delivery in their facilities. reviews should be conducted every six months to enable a report on the challenges facing hcws involved in the smoking cessation services and chart strategies to improve. hcws should also be empowered to serve as counselors for smokers who are willing to cease smoking. our study indicates a dearth in research that studies the role and action of hcws in providing smoking cessation services to their patients in africa. hence, there is need to provide adequate and accurate data in assessing the smoking cessation services provided by hcws in africa. we recommend that more studies be conducted to identify why hcws rarely move on to organize and promote tobacco cessation procedures among smokers. ilesanmi os, et al, journal of ideas in health (2021); 4(2):371-379 375 table 1. findings from studies conducted on health workers' practices in promoting smoking cessation in africa (n = 9) author (year) study design gender cadre objectives smoking cessation practices challenges quality assessment dedeke et al. [19] crosssectional male female dental trainees to determine the challenges facing nigerian dentists when implementing tobacco cessation services. eighty-three percent (83%) of respondents frequently asked their patients their smoking status, with less than 10% assisting patients to quit. the major barriers were lack of efficacy and training, lack of system support, and lack of time. lack of reimbursement was the least perceived barrier. the research methodology did not indicate the was no definition of good or poor cessation practice. mostafa et al. [20] crosssectional male female physicians to describe the effect of physicians' smoking status on their knowledge, attitude, and practice of smoking cessation. the study revealed that 21.5% of the physicians were current smokers, 8.3% quitted smoking, and 70.2% never smoked. a total of 33% of physicians either did not know or did not think that smoking affected the health of smokers. also, 41.9% of physicians disagreed that advice from a health professional increases the chances of a smoker quitting. 27% of the physicians did not think health workers should routinely question patients, while 27.4% did not think they should advise their patients on smoking cessation. also, 44.9% of physicians in the study did not always ask their patients if they smoked, 54.7% did not explain to them the consequences of smoking, 51.8% did not encourage them to quit, 71% did not educate them on the methods of smoking cessation. nearly two-thirds of respondents (63.7%) in this study did not think their smoking status affected their cessation practice. low sense of responsibility by some physicians to incorporate smoking cessation therapy into their patients. the sample was representative of the various specialties of physicians in the population. this study showed that the smoking status of the physicians did not significantly affect their cessation practices which are contrary to another study carried out in south africa [22], where the smoking status of the hcws had a significant effect on their cessation practice. murphy et al. [21] qualitative study female midwives to assess the knowledge, beliefs, attitudes, and current practices of midwives in south africa on the provision of smoking cessation education or counseling to pregnant women. the study revealed that 58.0% of the midwives discussed smoking at every visit and 30% at some visits when established that a patient smoke. less than a third (27.2%) of the midwives reported that they provided patients with educational resources about smoking cessation. although all midwives agreed that smoking in pregnancy is harmful to the unborn child, about 75% of them responded wrongly to statements regarding challenges reported were lack of attractive educational resources on smoking cessation, lack of consultation time, and lack of knowledge and training in effective intervention strategies. the study gave an in-depth on the sense of responsibility of midwives and actions taken to ensure the baby's safety and well-being. the qualitative method used in this study gave a deeper insight into the subject matter. ilesanmi os, et al, journal of ideas in health (2021); 4(2):371-379 376 conditions caused by smoking in pregnancy. the study indicated a positive attitude on providing smoking cessation advice to pregnant women. also, 31% of the midwives were offended with their patients when they did not take their advice, while the rest remain optimistic about influencing their patients to quit smoking. gichuki et al. [22] crosssectional study male female nurses, medical officers, clinical officers, dentists, and community oral health officers to assess the practices of healthcare workers in public health facilities of kiambu county regarding smoking cessation. to discover the perceived impediments to the provision of cessation services. this study indicated that 35% of healthcare workers consistently inquired about patients' smoking status, 43.5% advised smoking patients to quit consistently. more than half (64.5%) of respondents reported having never discussed the use of cessation medication (65%), assisted patients in setting quit date (54%) or following up on appointments to assess patients progress (57%). the major barriers perceived by respondents to cessation practices were insufficient training and knowledge, lack of guidelines, and dearth of smoking cessation specialists. stratification was not based on profession, which could have biased the study as different cadres act in different capacities for patients. okeke et al. [23] crosssectional male female nurses, doctors and student nurses to determine the prevalence of smoking and alcohol use among healthcare workers in kwazulu-natal, and their willingness and practice to offer assistance for patients to quit. when compared with former and current smokers, never smokers more regularly counseled patients to quit. only 22.3% of all hwc in this study followed up on their smoking patients who advised quitting. the most recommended nrt was nicotine gum and lozenges with sprays and inhalers the least. the analysis of cessation counseling was not done according to health cadres, and as such, there is no means of associating their practice to the profession. uti and sofola [24] crosssectional male female dentists and dental students to assess the attitude and practices of the dentist and dental students in nigeria in providing smoking cessation in the dental setting and the possible barriers to the provision of smoking cessation services. a high proportion (77%) of respondents believed that cessation could be carried out in the clinic. none of the respondents strongly agreed that they were professionally responsible for encouraging or educating patients on tobacco cessation practices. among the respondents, 86.1% disagreed that cessation counseling carried out in the dental clinic can impact the patients quit, and 87.5% of participants believed that cessation counseling is not important as the smoking patients are aware they should quit. regarding practice, more than 3/4 of the respondents reported having advised at least one patient to quit smoking. the majority of respondents the major hinderances to tobacco cessation provision cited were; lack of time, lack of necessary materials, and lack of knowledge on smoking cessation. this study represents both sexes, dental students and dentists. the study was conducted in one institution; thus, it cannot be generalized to the entire dental population. the study assessed the attitudes of respondents to tobacco cessation. however, the reported attitude of respondents did not ilesanmi os, et al, journal of ideas in health (2021); 4(2):371-379 377 (72.8%) were willing to provide cessation services to their patients whereas, 27.2% were not interested. correspond with their reported practice. jamda et al. [25] crosssectional study male female nurse, pharmacist, and physician to assess the provision of health facility-based smoking cessation services and competence of the health workers to provide these services. the study indicates that 5% of the respondents received training on tobacco control which was statistically insignificant. gender, age, marital status, and cadre were statistically significant sociodemographic factors that affected knowledge. gender and cadre were not significant for attitude while age and marital status were. religion, although not statistically significant in knowledge, was statistically significant for both attitude and practice. the study showed that 40% of respondents had high knowledge of cessation practice, 23.6% had a positive attitude, and 7.7% had good practice of tobacco cessation practice. the study sample was representative. the mean age of respondents was 36.65 years. there was no report of the average years of work experience. there was no definition of what constitutes high or low, poor or good, positive or negative knowledge, attitude, and tobacco cessation practice. desalu et al. [26] crosssectional studies male female physicians to evaluate the knowledge and practices of physicians regarding smoking cessation. sixty-eight percent (68%) of the healthcare workers did not know about smoking cessation therapy, while 30.3% were knowledgeable. the smoking status of patients was asked by 86.7% of healthcare workers. also, 61.3% of respondents advised their patients to cease smoking, 14.9% set target dates, 3.7% prescribed oral antidepressants, and 2.8% prescribed nrt. regarding follow-up, 70.7% of respondents did not schedule follow-up visits with their patients, 17.6% scheduled follow-up visits, and 11.9% did not see the relevance of the visit. the major challenges were poor knowledge of smoking cessation therapy (66.3%), insufficient time for counseling (12.6%), and unavailability of nrt (4.6%). there was no definition of smoking cessation therapy and what constituted good or poor knowledge of smoking cessation. nollen et al. [27] crosssectional study male female physicians to increase understanding of physicians smoking cessation practices and their workplace smoking policies. the study indicates that 81% of physicians assessed their patient's smoking status. counseling was said to be effective by 95% of respondents 17% of respondents had a guideline to help smokers quit, and 0.79% of respondents prescribed pharmaco-therapy. regarding workplace smoking policy, 53% reported practicing in a completely non-smoking building, 44% had no established smoking policy, and 3% reported having designated smoking areas. there was no analysis to show the relationship between the smoking policy in the hospital and the physicians smoking cessation practice. ilesanmi os, et al, journal of ideas in health (2021); 4(2):371-379 378 abbreviation usd: united states dollars; hcws: healthcare workers; nrt: nicotine replacement therapy; world health organization: who; gdp: gross domestic product; prisma: preferred reporting items for systematic reviews and meta-analyses; ajol: african journal online; psycinfo declaration acknowledgment not applicable. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing afoaanade@gmail.com authors’ contributions osi conceptualized the study. osi, via, and aaa participated in the literature review process. all authors edited the manuscript for critical intellectual content and approved the final version of the manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, review articles need no ethics committee approval. consent for publication not applicable competing interest the authors declares that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 11department of community medicine, college of medicine, university of ibadan, oyo state, nigeria; 2department of community medicine, college of medicine, university college hospital, ibadan, oyo state, nigeria. article info received: 02 april 2021 accepted: 01 may 2021 published: 16 may 2021 references 1. jha p, maclennan m, chaloupka fj, yurekli a, ramasundarahettige c, palipudi k, et al. global hazards of tobacco and the benefits of smoking cessation and tobacco taxes. in: cancer: disease control priorities. volume 3. edition 3. the international bank for reconstruction and development / the world bank; 2015. https://doi.org/10.1596/978-1-4648-0349-9_ch10. 2. perez-warnisher mt, de miguel m del pc, seijo lm. tobacco use worldwide: legislative efforts to curb consumption. ann glob health. 2018; 84(4): 571–579. https://doi.org/10.9204/aogh.2362. 3. world health organization. who report on the global tobacco epidemic, 2019. [internet]. the mpower package. geneva; 2019. available from: https://apps.who.int/iris/bitstream/handle/10665/325968/who-nmhpnd-2019.5-eng.pdf?ua=1 [accessed on 27 december 2020]. 4. world health organization. fact sheet on the sdgs: tobacco control. [intermet]. geneva; 2019. [internet]. geneva; 2019. available from: https://www.euro.who.int/en/media-centre/sections/factsheets/2019/fact-sheet-on-the-sdgs-tobacco-control-2019 [accessed on 27 december 2020]. 5. u.s. national cancer institute and world health organization. the economics of tobacco and tobacco control. national cancer institute tobacco control monograph 21. nih publication no. 16-ca-8029a. bethesda, md: u.s. department of health and human services, national institutes of health, national cancer institute; ch: world health organization, geneva, 2016. [internet]. available from: https://cancercontrol.cancer.gov/brp/tcrb/monographs/monograph-21 [accessed on 27 december 2020]. 6. network of african science academies. preventing a tobacco epidemic in africa: a call for effective action to support health, social and economic development. [internet]. 2014. available from: https://www.assaf.org.za/files/reports/africatobaccocontrolreportfina l1.pdf [accessed on 25 december 2020]. 7. blecher e, ross h. tobacco use in africa: tobacco control through prevention. american cancer society, inc. 2013. [cited 2021 march 15]. available from: file:///c:/users/hp/downloads/tobacco-use-inafrica-tobacco-control-through=prevention.pdf [accessed on 15 march 2021]. 8. world health organization. world no tobacco day. [internet]. geneva; 2012. available from: https://www.who.int/tobacco/wntd/2012/announcement/en/. published may 2012 [accessed on 20 december 2020]. 9. batini c, ahmed t, ameer s, kilonzo g, ozoh ob, van zyl-smit rn. smoking cessation on the african continent: challenges and opportunities. african journal of thoracic and critical care medicine. 2019;25(2):46. https://doi.org/10.7196/sarj.2019.v25i2.015. 10. van zyl-smit rn, allwood b, stickells d, symons g, abdoolgaffar s, murphy k, et al. south african tobacco smoking cessation clinical practice guideline. south african med j. 2013;103(11):869–76. https://doi.org/10.7196/samj.7484. 11. schellack n, bronkhorst e. smoking cessation. south african fam pract. 2015;57(1):39–42. 12. world health organization. toolkit for delivering the 5a's and 5r’s brief tobacco interventions in primary care. [internet]. geneva; 2014. available from: https://www.who.int/tobacco/publications/smoking_cessation/97892415 06953/en/ 13. ebbert jo, montori v, vickers ks, erwin pc, dale lc, stead lf. interventions for smokeless tobacco use cessation (review). cochrane database syst rev. 2007;4(cd004306). doi: 10.1002/14651858.cd004306.pub5 14. grimshaw gm, stanton a. tobacco cessation interventions for young people. cochrane database syst rev. 2006; (4): cd003289. doi: 10.1002/14651858.cd003289.pub6 ilesanmi os, et al, journal of ideas in health (2021); 4(2):371-379 379 15. carr ab, ebbert j. interventions for tobacco cessation in the dental setting: a systematic review. cochrane database syst rev. 2012;(6):cd005084. 16. stead lf, buitrago d, preciado n, sanchez g, hartmann-boyce j, lancaster t. physician advice for smoking cessation. cochrane database syst rev. 2013;2017(12). doi: 10.1002/14651858.cd000165.pub4 17. liberati a, altman dg, tetzlaff j, mulrow c, gøtzsche pc, ioannidis jpa, et al. the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. bmj 2009;339:b2700. https://doi.org/10.1136/bmj.b2700 18. saha s. a juxtaposition of safety outcomes between various doses of sodium-glucose co-transporter inhibitors, in insulin-treated type-1 diabetes mellitus patients: a protocol for systematic review and metaanalysis of randomized controlled trials. journal of ideas of health. 2020; 3(2):167-172. https://doi.org/10.47108/jidhealth.vol3.iss2.56 19. dedeke aa, popoola oa, adebiyi ao, asuzu mc. tobacco cessation services and related challenges among dentists in southwest nigeria. ann ibadan postgrad med. 2018;16(2):125–130. 20. mostafa ns, mome m. effect of physicians’ smoking status on their knowledge, attitude, opinions and practices of smoking cessation in a university hospital, in egypt. j egypt public health assoc. 2017;92(2):96–106. doi: 10.21608/epx.2018.8947 21. murphy k, steyn k, mathews c. the midwife’s role in providing smoking cessation interventions for pregnant women: the views of midwives working with high risk, disadvantaged women in public sector antenatal services in south africa. int j nurs stud. 2016;53:228– 237. doi: 10.1016/j.ijnurstu.2015.08.004 22. gichuki jw, opiyo r, mugyenyi p, namusisi k. healthcare providers’ level of involvement in provision of smoking cessation interventions in public health facilities. j public health africa. 2015;6(2):523. doi: 10.4081/jphia.2015.523 23. okeke p, ross a, esterhuizen t, van wyk j. tobacco and alcohol use among healthcare workers in three public hospitals in kwazulunatal, south africa. south african fam pract. 2014;54(1): 61-67. doi: 10.1080/20786204.2012.10874177 24. uti og, sofola oo. smoking cessation counseling in dentistry: attitudes of nigerian dentists and dental students. j dent educ. 2011;75(3):406–412. 25. jamda ma, bajoga u, gajida au. knowledge and practice of smoking cessation services among health care workers in abuja, federal capital territory, nigeria. j prim care community health. 2010;27:37–45. 26. desalu oo, adekoya ao, elegbede ao, dosunmu a, kolawole tf, nwogu kc. knowledge of and practices related to smoking cessation among physicians in nigeria. j bras pneumol. 2009;35(12):1198–203. doi: 10.1590/s1806-37132009001200006 27. nollen nl, adewale s, okuyemi ks, ahluwalia js, parakoyi a. workplace tobacco policies and smoking cessation practices of physicians. j natl med assoc. 2004;96(6):838-842. https://doi.org/10.47108/jidhealth.vol5.issspecial1.229 rashid mk, et al., journal of ideas in health 2022;5(special1):693-699 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access prevalence of text neck syndrome among iraqi medical students: a cross-sectional study muayad kadhim rashid1*, saad ahmed ali jadoo2, adil hassan al-hussainy1, ismail ibrahim latif1 abstract background: excessive use of portable electronic devices causes neck flexion and the emergence of text neck syndrome (tns). this study aims to explore the prevalence of tns among medical students during the covid-19 lockdown in iraq. methods: a prospective cross-sectional web-based study was conducted from 1st to 30th march 2022 at the faculty of medicine, diyala university, iraq. a self-administered questionnaire was distributed among the medical students using google form through social media (whatsapp group). the semi-structured questionnaire included the sociodemographic, the valid smartphone addiction scale-short version (sas-sv), and the neck disability index (ndi). univariate, bivariate, and multiple logistic regression were used to analyze the data. spss version 16. the statistical significance is considered at less than 0.05. results: out of 273 medical students included in the study, 59.3% were males, unmarried (88.3%), and from the 1st year (21.6%). the mean age of students was 21.27 ± 1.74 years. the prevalence of text neck syndrome was 64.5%. about two-thirds (61.5%) of students were addicted to their smartphones and used them more than five h/daily (63.7%). factors associated with neck disability were the students who did not warm up neck muscles before using the smartphone (or = 8.796, 95% ci: 1.724 to 24.884), addicted to the smartphone (or = 6.803, 95% ci: 3.455 to 13.397), experienced increase in daily hours using the smartphone during the covid-19 related quarantine (or = 5.370, 95% ci: 2.523 to 11.427), maintained smartphone use five hours and more daily (or = 2.818, 95% ci: 1.422 to 5.587), had neck pain (or = 2.876, 95% ci: 1.356 to 6.098), the female gender (or = 2.756, 95% ci: 1.221 to 6.221), and those who did not have a frequent break when using the smartphone (or = 2.693, 95% ci: 1.329 to 5.454). conclusion: in conclusion, the prevalence of neck disability was high among the surveyed medical students. addiction and excessive smartphone use with a lack of attention to warm up the neck muscles before usage was the most prominent predictors of neck disability. keywords: smartphone addiction, medical students, text neck syndrome, neck disability, neck pain, iraq background the study of medicine is a big challenge. the student spends a great effort and a long time searching for information. the time and how to exploit it is a determinant factor in the student's success. modern technology, such as mobile phones and the internet, formed a turning point in the curriculum of the study by providing, storing, and easy access to knowledge. the mobile phone was not limited to communication but an entertainment and education tool for different age groups [1]. previous studies indicate that the prevalence of using a smartphone was higher among medical students [2-11]. however, prolonged looking at the electronic devices leads to undesirable bending of the head and neck to the front in a declining position. neck pain (np), text neck (tn), and addiction were the expected consequences of excessive dependency on smartphones [6,11,12]. recently, covid-19 related quarantine and the online study have significantly increased the use rates of portable devices [2,13, 14]. meng s-q et al. [15], in their systematic review and meta-analysis, found that the prevalence of smartphone addiction was "26.99% (95% ci, 22.73-31.73)" in a global pooled population. the term 'text neck' defines the "neck pain" resulting from undesirable usage of portable electronic devices for long periods in an incorrect body position [16,17]. there is a significant relationship between the number of hours using the smartphone and the ___________________________________________________ dr.muayad67@gmail.com 1department of internal medicine, faculty of medicine, diyala university, iraq a full list of author information is available at the end of the article 10.47108/jidhealth.vol5.issspecial1.229 http://www.jidhealth.com/ rashid mk, et al., journal of ideas in health (2022); 5(special1):693-699 694 prevalence of addiction. the more hours of looking at electronic devices, the more likely to become addicted [18-22]. previous studies argued that the younger users of electronic devices are more likely to develop musculoskeletal symptoms because of the early launching of technology in their daily lives [23,24]. moreover, a non-practicing warm-up of neck muscles before using the smartphone or taking frequent breaks during smartphones raises the possibility of musculoskeletal and neurological neck problems, especially among young people. in light of the successive waves of covid-19 [25] and the procedures approved to combat the pandemic, such as the quarantine [26], most young users of mobile devices were university students who did not realize the health effect of incorrect use [27]. this study aimed to identify the prevalence of neck disability and the associated factors among medical students at the university of diyala, college of medicine, diyala, iraq. methods study population and sample a prospective cross-sectional study was conducted from 1st to 30th march 2022 among medical students at the faculty of medicine, university of diyala, iraq. a url link to the selfadministered questionnaire was created from google forum and submitted to the batch leader of each class to be distributed through whatsapp among the students. inclusion and exclusion criteria all undergraduate medical students in the faculty of medicine and willing to participate at the time of the data collection were included in the study. students who were unwilling to participate and the incomplete data were excluded from the study. special attention has been given to ensure that the participants did not have a past or recent history of trauma or surgery around the neck area. sample size the online raosoft sample size calculator was recruited to calculate the sample size [30]. based on the earlier prevalence (35.0%) of text neck syndrome reported in the united states [9], a 95% confidence level, and 6% margin of error, the minimum sample size needed for the current study was 240 + 24 (10% non-response) =264. therefore, a universal sampling technique was recruited, and all medical students were invited to participate. the study instrument the questionnaire is composed of three sections. the first section included the sociodemographic characteristics of respondents, such as age, gender, class, and whether they have contracted covid-19 or not. the second section included ndirelated factors such as the hours of daily use of the smartphone, the reasons behind using a smartphone, warming up neck muscles before using a mobile phone, taking breaks while using their cell phones, subjective neck pain, the neck position, and whether students experienced an increase in the daily use of the smartphone during the lockdown or not. the third section concerns the “sas-short version (sas-sv)”. the valid and reliable sas-sv [28] is composed of ten items. likert scale was recruited to score the scale; “1 = strongly disagree, 2 = disagree, 3 = weakly disagree, 4 = weakly agree, 5= agree, and 6= strongly agree”. the total score of sas-sv ranges from “10 to 60”. “the cutoff value was 31 for male and 33 for female students”. each respondent scoring above the cutoff value is at “high risk for smartphone addiction”. the fourth section has the ndi scale's valid version [29]. ten items are included in the ndi and scored 0 to 5 for each. the obtained total score ranged from 0 to 50. dependent variable the ndi total score subdivided into five categories of neck disability: a. 0–4 = no disability, b. 5–14 = mild disability, c. 15–24 = moderate disability, d. 25–34 = severe disability, and e. >34 = complete disability. for the purpose of analysis, the total score was categorized as “no neck disability” for the score (0-4), while the other scores considered "neck disability." independent variables the independent variables included the sociodemographic variables, the neck disability-related variables, and smartphone addiction. “female” and “male” giving for gender. marital status was categorized as “unmarried” for those who did not get married and "married" for the single, widow, and divorced. the response was “yes” or “no” for the following questions and statements: “have you contracted a covid-19 infection?”; “i feel pain at the back of the neck while using a smartphone?”; “usually, i warm up the neck before using the smartphone”; and “i frequently have breaks during the smartphone use”. the self-experience of respondents was “increased” or “no change” for the question: is there any difference in daily hours using the smartphone during the covid-19 quarantine? the selfestimation for the duration of daily hours using the smartphone was categorized into: “1-2 h/d”; “2-3 h/d”; “3-4 h/d”; “4-5 h/d” and “>5 h/d”. the five responses: “browsing internet”; “social media”; “education”; “gaming”; “calling”. regarding the neck position, while using the smartphone, students were shown an image of different neck positions (0°, 15°, 30°, 45°, and 60°) and asked to indicate their most frequent position when using their smartphones [figure 1]. figure 1: neck position while watching the smartphone statistical analysis data collected were analyzed using statistical package for social science (spss) program version 16.0 (spss inc., chicago, il, usa). normality tests were done, and all the quantitative data were normally distributed. the sample profile was obtained by frequency distribution and descriptive statistics of sociodemographic variables and ndi-related factors. chisquare tests were used in the bivariate analysis for binary or rashid mk, et al., journal of ideas in health (2022); 5(special1):693-699 695 categorical variables. significant factors predicting neck disability on bivariate analysis (p-value <0.05) were included in the multivariate model. multiple logistic regression analysis (enter technique) was performed to identify significant predictors of neck disability. in the "enter technique," the variables in the models which are not significant are removed one by one until a satisfactory model is obtained. the odds ratio and 95% confidence interval were calculated. an alpha level of p < 0.05 is considered to be statistically significant. results characteristics of the participants table 1 presents the sociodemographic factors. data of 273 medical students have undergone final analysis. the mean age of students was 21.27 ± 1.74 years. most of them were males (162, 59.3%), unmarried (88.3%), and from the 1st year (21.6%). about one-third (86, 31.5) of them contracted covid-19 infection (table 1). table 1: sociodemographic characteristics of respondents (n=273) variables categories n (%) age mean: 21.27 (+1.74) gender females 111(40.7) males 162(59.3) marital status married 31(11.4) unmarried (single) 242(88.6) class of study 1st year 59(21.6) 2nd year 47(17.2) 3rd year 48(17.6) 4th year 40(14.7) 5th year 38(13.9) 5th year 41(15.0) have you contracted a covid-19 infection? no 187(68.5) yes 86(31.5) sociodemographic factors associated with neck disability in bivariate analysis the mean score of sas-sv was 36.27 ± 3.25. the prevalence of text neck syndrome was 64.5%. among the participants, 116 (42.5%) had mild (5-14), 42 (15.4%) had moderate (15-24), and 18 (6.6%) had severe (25-34) neck disability. however, 97 (35.5%) had no disability (0-4). cross tabulation indicated that females (chi-square test (χ2) = 22.535, p < 0.001) and being infected with covid-19 (χ2 = 6.768, p = 0.009) were significantly associated with neck disability (table 2). table 2: characteristics of respondents associated with neck disability in bivariate analysis (n=273) variables categories total n (%) no disability disability chi square p-value gender females 111(40.7) 21(18.9) 90(81.1) 22.535 <0.001 males 162(59.3) 33(19.6) 135(80.4) marital status married 31(11.4) 10(32.3) 21(67.7) 0.164 0.686 unmarried (single) 242(88.6) 87(36.0) 155(64.0) have you contracted a covid-19 infection? yes 86(31.5) 21(24.4) 65(75.6) 6.768 0.009 no 187(68.5) 76(40.6) 111(59.4) factors associated with neck disability in bivariate analysis most of the respondents were addicted to their smartphones (61.5%). about two-thirds of students used their smartphones more than five h/daily (174, 63.7%). nearly half of students (127, 46.5%) complained of neck pain; however, the majority of them (257, 94.1%) did not practice warming up neck muscles or having breaks when using the smartphone (147, 53.8%). most students kept a 30° and 45° neck position while they used the smartphone (41.4%) and 27.8%, respectively. browsing the internet (98, 35.9%) and social media (77, 28.2%) were the top reasons to use a smartphone (table 3). cross tabulation indicated that students who were smartphone adductors (chisquare test (χ2) = 48.137, p < 0.001), had neck pain (χ2 = 21.115, p < 0.001), did not warm up neck muscles (χ2 = 11.558, p =0.001), using a smartphone more than five h/day (χ2 = 17.275, p =0.002), increased the daily using hours of the smartphone (χ2 = 17.902, p< 0.001), maintain a 60° neck position when using the smartphone (χ2 = 27.911, p< 0.001), browsing the internet (χ2 = 12.288, p = 0.015), were significantly associated with neck disability (table 3). factors associated with neck disability in multiple logistic regression table 4 shows the final model of the multiple logistic regressions. the students who did not warm up neck muscles before using the smartphone (or = 8.796, 95% ci: 1.724 to 24.884), addicted to the smartphone (or = 6.803, 95% ci: 3.455 to 13.397), and those who experienced an increase in daily hours using the smartphone during the covid-19 related quarantine (or = 5.370, 95% ci: 2.523 to 11.427), had the highest odds ratios. while those who maintained smartphone use for five hours and more daily (or = 2.818, 95% ci: 1.422 to 5.587) who had neck pain (or = 2.876, 95% ci: 1.356 to 6.098), the females (or = 2.756, 95% ci: 1.221 to 6.221), and did not have a break when using the smartphone (or = 2.693, 95% ci: 1.329 to 5.454), had the lowest odds ratios. the hosmer and lemeshow test indicated a good fit (p = 0.365). the total model was significant (p <0.001) and accounted for 50.2% of the variance (nagelkerke r square = 0.502). rashid mk, et al., journal of ideas in health (2022); 5(special1):693-699 696 table 3: neck disability associated factors in bivariate analysis (n=273) variables categories n (%) no disability disability chi square p-value sas-sv no addiction 105(38.5) 64(61.0) 41(39.0) 48.137 <0.001 addiction 168(61.5) 33(19.6) 135(80.4) neck pain yes 97(35.5) 27(21.3) 100(78.7) 21.115 <0.001 no 176(64.5) 70(47.9) 76(52.1) warm-up neck muscle no 257(94.1) 85(33.1) 172(66.9) 11.558 0.001 yes 16(5.9) 12(75.0) 4(25.0) duration of smartphone use daily 1-2 h/d 6(2.2) 4(66.7) 2(33.3) 17.275 0.002 2-3 h/d 14(5.1) 11(78.6) 3(21.4) 3-4 h/d 23(8.4) 9(39.1) 14(60.9) 4-5 h/d 56(20.5) 22(39.3) 34(60.7) >5 h/d 174(63.7) 51(29.3) 123(70.7) duration of smartphone daily use during the lockdown increased 197(72.2) 55(27.9) 142(72.1) 17.902 <0.001 no change 76(27.8) 42(55.3) 34(44.7) neck position during smartphone use 0 degree 15 (5.5) 14(93.3) 1(6.7) 27.911 <0.001 15 degrees 52(19.0) 20(38.5) 32(61.5) 30 degrees 113(41.4) 31(27.4) 82(72.6) 45 degrees 76(27.8) 29(38.2) 47(61.8) 60 degrees 17(6.2) 3(17.6) 14(82.4) breaks from smartphone yes 126(46.2) 41(32.5) 85(67.5) 0.914 0.339 no 147(53.8) 56(38.1) 91(61.9) purpose of smartphone use browsing internet 98(35.9) 26(26.5) 72(73.5) 12.288 0.015 social media 77(28.2) 35(45.5) 42(54.5) education 49(17.9) 23(46.9) 26(53.1) gaming 39(14.3) 9(23.1) 30(76.9) calling 10(3.7) 4(50.0) 6(60.0) table 4: predictors of neck disability in multiple logistic regression (n=273) variable b se. wald sig. exp(b) 95.0% for exp(b) lower-upper females 1.014 0.415 5.959 0.015 2.756 1.221-6.221 males reference neck pain 1.056 0.383 7.590 0.006 2.876 1.356-6.098 no pain reference no warming 2.174 0.832 6.836 0.009 8.796 1.724-24.884 warming reference > 5 h/ daily use 1.036 0.349 8.808 0.003 2.818 1.422-5.587 >5 h/daily use reference addiction to smartphone 1.917 0.346 30.752 0.000 6.803 3.455-13.397 no addiction reference increased daily use during the quarantine 1.681 0.385 19.030 0.000 5.370 2.523-11.427 no change reference no break during the use of a smartphone 0.990 0.360 7.564 0.006 2.693 1.329-5.454 have frequent breaks reference discussion in this study, about two-thirds (64.5%) of surveyed medical students presented with text neck syndrome. similar prevalence was reported in studies from jourdan (65%) [2], saudi arabia (68.1%, 44.8%)) [3,4], south africa (66.2%) [5]. however, our finding is higher than that reported in ethiopia (49.2%) [6], pakistan (43.6%) [7], brazil (55.44%) [8], united states (35.0%) [9], australia (52.8%) [10], but lower than prevalence reported in turkey (71.7%) [11]. many educational institutions, including universities, increasingly rely on the internet to communicate with students through email or social communication groups such as whatsapp. educational materials, tasks, and curriculum guidance are notified through the internet. therefore, students found it easy to handle a small and smart device that meets all/her educational and recreational needs instead of older devices such as laptops and desktops. furthermore, most of our respondents experienced "mild neck rashid mk, et al., journal of ideas in health (2022); 5(special1):693-699 697 disability" (49.5%). such finding was supported by earlier studies conducted in saudi arabia (49.5%) [3], india (42.5%) [31], korea (32.5%) [ 32]. more than sixty percent (61.5%) of our sample reported smartphone addiction. our findings, like several studies, exceeded the global trend (26.99%) of smartphone addiction [15]. alsiwed et al. [3] reported that 63.1% of medical students in saudi arabia (2021), liu et al. [33] reported 39.7% among chinees students (2022), eldesokey et al. [34] reported 53.6% among egyptian students (2021), and dhamija et al. [35] reported 52.0% among indian students (2021). however, a lower trend of smartphone addiction was reported by previous studies conducted by szpakow et al. [36] among belarus students (10.0%) in 2011, dixit et al. [37], among indian students (37.0%) in 2010, khan mm [38], among tunisian students (31.7) in 2008, and lee et al. [39], among korean students (16.0%) in 2007. in light of the events mentioned above, there has been a steady increase in the prevalence of smartphones among medical students in the last decade. suppose we excluded the reasons related to the characteristics of the population, the sample size, and the tools employed to assess the levels of addiction. in that case, the significant increase in smartphone use rates between 2020-2022 could be attributed to covid-19-related lockdown. part of our results reinforces this hypothesis, as about seventy percent (72.2%) of students disclosed that they used their smartphones during the lockdown period more than before. more than onethird (35.9%) of our sample browse the internet and 28.2% use smartphones for social media. in a similar situation to the covid-19 quarantine, a previously conducted study in iraq among internally displaced people showed that 29.3% of university students used smartphones for social media as alternatives to their previous social life [40]. saadeh et al. [27] found that about 85.0% of 6,157 surveyed undergraduate students in jourdan had “increased or greatly increased” the usage of smartphones during the covid-19-related quarantine. perhaps the most prominent indicator of smartphone addiction was the long period of watching a smartphone. several studies reported the likelihood of musculoskeletal disorders with an increased number of daily hours using the smartphone. our result showed that most students (84.2%) were using smartphones for four hours and more daily, and those who were using smartphones 5 hours daily had 2.818 times more likely to increase neck disability. similarly, bavli et al. [21] found that 36.3% of turkish students used smartphones for an average of 4 to 6 h daily; however, the daily use of 9 hours or more was statistically significant with high addiction points. alsiwed et al. [3] found that 58.2% of medical students used smartphones for more than five h per day. another study from saudi arabia found that 67.0% of respondents were smartphone-addicted, with average use of 6–11 h per day [19]. damasceno et al. [41] found that brazilian young people spent more than four h per day on smartphones. another korean study [42] indicated that most surveyed university students used their smartphones for more than four hours daily. authors also found a positive correlation between the length of use and the appearance of musculoskeletal symptoms, including painful shoulders and neck. most of our survey students (113, 41.4%) used smartphones at the "30° neck position". cross tabulation showed that users of smartphones at "60° neck position" were more likely to develop neck disability than users at "15°, 30°, and 45° neck positions”. our result was in line with alsiwed et al. [3]. about 35.5% of our sample had neck pain with an odds ratio of 2.876 times likely to induce neck disability. ethiopian study [6] found that 49.2% of medical students had neck pain with an odds ratio of 1.502 times more likely to induce neck pain when the duration of reading was 3 hours and more daily. a jordanian study conducted by al-hadidi et al. [43] reported a significant association between the duration of use and the severity of neck pain and pain duration. moreover, 44.6% of students forced analgesia when the severity of the pan exceeds four degrees. among the results of this study, only 16(5.9%) warmed up neck muscles before using the phone, and 126 (46.2%) had breaks when using the phone. similarly, alsiwed et al. [3] found that 7.5% of saudi students warmed up their neck muscles before using the smartphone, and 61.0 % had frequent breaks when using smartphones. ali chaudary et al. [7] found that among five hundred pakistani medical students, 6.0% tended to warm up the neck muscles before using a smartphone, and 12.0% abandoned the phone for a while to give a chance for neck muscles' relaxation. moreover, an exciting finding in our multiple logistic regression showed that medical students who did not practice warm-up of neck muscle and did have frequent breaks had an odds ratio of 8.796 and 2.693 times to develop neck disability, respectively. excessive use of the phones without rest periods to relax and warm up the neck muscles was significantly associated with symptomatic musculoskeletal injuries. at the same time, taking breaks every 20 min use is a protective action against the liable neck disability due to incorrect posture and prolonged use of portable devices [44]. the bivariate analysis found a statistically significant relationship between gender and neck disability (p < 0.001). moreover, females had an odds ratio of 2.756 times to develop neck disability than males in logistic recession. similarly, the results of the korean study showed that the average score of ndi among female students was significantly higher than their counterparts (p < 0.05) [32]. our finding is also consistent with a previous study conducted in jourdan [43], which concluded that female students spend more time browsing smartphones than male students (p = 0.005). some limitations were reported in the current study. first, we conducted the study during the covid-19 pandemic, forcing us to choose an online survey. second, it was impossible to “measure neck posture during smartphone use” because of covid-19. third, the sample was medical students; therefore, the study might not represent the total iraqi population. conclusion in conclusion, the prevalence of text neck syndrome among iraqi medical students was high (64.5%) but in line with several neighboring and international findings. most medical students were smartphone adductors (61.5%) using the phone for more than five h/daily (63.7%). moreover, multiple logistic regression revealed that neck disability was significantly associated with "not warming up neck muscle before using the smartphone," "addiction to smartphone", "increased daily hours using the smartphone during the covid-19 related quarantine", "using the phone for five hours and more daily", "neck pain", "female gender" and "have no frequent breaks during the smartphone usage." rashid mk, et al., journal of ideas in health (2022); 5(special1):693-699 698 abbreviation covid-19: coronavirus; sas-sv: smartphone addiction scale-short version; ndi: neck disability index; iqd: iraqi dinar declaration acknowledgment we would like to thank the all-medical students for their kind participation in the study. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing dr.muayad67@gmail.com. authors’ contributions all muayad kadhim rashid (mkr) and saad ahmed ali jadoo (saaj) were the study's designers, coordinating all aspects of the research and drafting and reviewing the article. adil hassan alhussainy (aha) and ismail ibrahim latif (iil contributed to the study's concept, arrangement, and data collection. saad ahmed ali jadoo (saaj) contributed to the analysis and interpretation of the study and the article's writing. all authors have read and approved the final version of the manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the protocol of the study was approved by the ethics committee of the college of medicine, diyala university (ref: 1370 on 15th october 2021). moreover, web-based informed consent was obtained from each participant after explaining the study objectives and the guarantee of secrecy. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of internal medicine, physical medicine, faculty of medicine, diyala university, iraq.2department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey. article info received: 23 may 2022 accepted: 12 july 2022 published: 17 july 2022 references 1. moran j, briscoe g, peglow s. current technology in advancing medical education: perspectives for learning and providing care. acad psychiatry. 2018 dec;42(6):796-799. doi: 10.1007/s40596018-0946-y. 2. salameh ma, boyajian sd, odeh hn, amaireh ea, funjan ki, al-shatanawi tn. increased incidence of musculoskeletal pain in medical students during distance learning necessitated by the covid-19 pandemic. clin anat. 2022 may;35(4):529-536. doi: 10.1002/ca.23851. 3. alsiwed kt, alsarwani rm, alshaikh sa, howaidi ra, aljahdali aj, bassi mm. the prevalence of text neck syndrome and its association with smartphone use among medical students in jeddah, saudi arabia. j musculoskelet surg res 2021;5(4):26672. doi:10.25259/jmsr_99_2021. 4. dighriri yh, akkur ma, alharbi sa, madkhali na, matabi ki, mahfouz ms. prevalence and associated factors of neck, shoulder, and low-back pains among medical students at jazan university, saudi arabia: a cross-sectional study. j family med prim care. 2019 dec 10;8(12):3826-3831. doi: 10.4103/jfmpc.jfmpc_721_19. 5. ogunlana mo, govender p, oyewole oo. prevalence and patterns of musculoskeletal pain among undergraduate students of occupational therapy and physiotherapy in a south african university. hong kong physiother j. 2021 jun;41(1):35-43. doi: 10.1142/s1013702521500037. 6. weleslassie gg, meles hg, haile tg, hagos gk. burden of neck pain among medical students in ethiopia. bmc musculoskelet disord. 2020 jan 8;21(1):14. doi: 10.1186/s12891-019-3018-x. 7. ali chaudary a, aslam f, ali a, asghar ar, bashir h, awais a, et al. frequency of text neck syndrome in medical students due to excessive usage of electronic devices. jpoa [internet]. 2019 oct. 30;31(02):79-82. 8. silva al, smaidi k, pires mhr, pires oc. prevalence of chronic pain and associated factors among medical students. revista dor. 2017;18(2):108–11. 9. du jy, aichmair a, schroeder je, kiely pd, nguyen jt, et al. neck pain and low back pain in medical students: a crosssectional study. int arch public health community med2107; 1(1):1-9. doi.org/10.23937/iaphcm-2017/1710002. 10. smith dr, leggat p. prevalence and distribution of musculoskeletal pain among australian medical students. j musculoskeletal pain. 2007;15(4):39–46. doi: 10.1300/j094v15n04_05. 11. güneş s, ulusoy bh, aygen e, murat e, köklüoğlu b, kuzyaka ba, et al. musculoskeletal system pain and related factors during online education in the covid-19 pandemic among ankara university faculty of medicine students, turkey. j ankara univ fac med 2022; 75:36-41. doi: 10.4274/atfm.galenos.2021.93898 12. dolah j, loh jo yie j, lee shiau gee l. improving knowledge of text neck and neck pain using interactive smartphone application for undergraduate students in universiti sains malaysia. gendang alam; 2020:143-158. https://doi.org/10.51200/ga.vi.2522. 13. mathew k v b, walarine mt. neck pain among smartphone users: an imminent public health issue during the pandemic time. journal of ideas in health 2020 sep. 29;3(special1):201-4. doi: 10.47108/jidhealth.vol3.issspecial1.65. 14. rafi am, varghese pr, kuttichira p. concerns and confidences expressed by teaching staff about the shift of medical education to online mode in south india during the covid 19 pandemic. journal of ideas in health 2020 dec. 24;3(special2):272-5. https://doi.org/10.47108/jidhealth.vol3.issspecial2.81. 15. meng sq, cheng jl, li yy, yang xq, zheng jw, chang xw, shi y, chen y, lu l, sun y, bao yp, shi j. global prevalence of digital addiction in general population: a systematic review and meta-analysis. clin psychol rev. 2022 mar; 92:102128. doi: 10.1016/j.cpr.2022.102128. 16. portelli a, reid sa. cervical proprioception in a young population who spend long periods on mobile devices: a 2-group comparative observational study. j manipulative physiol ther. 2018 feb;41(2):123-128. doi: 10.1016/j.jmpt.2017.10.004. 17. lee s, choi yh, kim j. effects of the cervical flexion angle during smartphone use on muscle fatigue and pain in the cervical erector spinae and upper trapezius in normal adults in their 20s. j phys ther sci. 2017 may;29(5):921-923. doi: 10.1589/jpts.29.921. 18. zhong y, ma h, liang y-f, liao c-j, zhang c-c, jiang w-j. prevalence of smartphone addiction among asian medical students: a meta-analysis of multinational observational studies. international journal of social psychiatry. april 2022. doi:10.1177/00207640221089535 rashid mk, et al., journal of ideas in health (2022); 5(special1):693-699 699 19. alotaibi ms, fox m, coman r, ratan za, hosseinzadeh h. smartphone addiction prevalence and its association on academic performance, physical health, and mental well-being among university students in umm al-qura university (uqu), saudi arabia. int j environ res public health. 2022 mar 21;19(6):3710. doi: 10.3390/ijerph19063710. 20. sohn sy, krasnoff l, rees p, kalk nj, carter b. the association between smartphone addiction and sleep: a uk cross-sectional study of young adults. front psychiatry. 2021 mar 2; 12:629407. doi: 10.3389/fpsyt.2021.629407. 21. bavli ö, katra h, günar bb. investigation of smartphone addiction levels among university students. international journal of cultural and social studies 2018; 4 (1):326-333. 22. alhazmi aa, alzahrani sh, baig m, salawati em, alkatheri a. prevalence and factors associated with smartphone addiction among medical students at king abdulaziz university, jeddah. pak j med sci. 2018 jul-aug;34(4):984-988. doi: 10.12669/pjms.344.15294. 23. regiani bueno g, garcia lf, marques gomes bertolini sm, rodrigues lucena tf. the head down generation: musculoskeletal symptoms and the use of smartphones among young university students. telemed j e health. 2019 nov;25(11):1049-1056. doi: 10.1089/tmj.2018.0231. 24. shin ly. a comparative study of mobile internet usage between the u.s. and korea. journal of european psychology students2014; 5(3): 46–55. doi: http://doi.org/10.5334/jeps.cg. 25. ali jadoo sa. the second wave of covid-19 is knocking at the doors: have we learned the lesson? journal of ideas in health 2020 oct. 8;3(special1):183-4. doi: 10.47108/jidhealth.vol3.issspecial1.72. 26. bhandari s, shaktawat as, patel b, dube a, kakkar s, tak a, gupta j, rankawat g. the sequel to covid-19: the antithesis to life. jidhealth [internet]. 2020 oct. 1;3(special1):205-12. doi: 10.47108/jidhealth.vol3.issspecial1.69. 27. saadeh h, al fayez rq, al refaei a, shewaikani n, khawaldah h, abu-shanab s, al-hussaini m. smartphone use among university students during covid-19 quarantine: an ethical trigger. front public health. 2021 jul 26; 9:600134. doi: 10.3389/fpubh.2021.600134. 28. kwon m, kim dj, cho h, yang s. the smartphone addiction scale: development and validation of a short version for adolescents. plos one 2013;8: e83558. https://doi.org/10.1371/journal.pone.0083558. 29. awwad wm, alabdulkarim nh, alhaidri ne. exploratory and confirmatory factor analysis of the arabic neck disability index: a cross-sectional study. j musculoskelet surg res 2021; 5:171-7. doi:10.25259/jmsr_54_2021. 30. sample size calculator by raosoft, inc.; 2021. available from: http://www.raosoft.com/samplesize.html. [accessed on 19 september 2021]. 31. ahmed s, akter r, pokhrel n, samuel aj. prevalence of text neck syndrome and sms thumb among smartphone users in college-going students: a cross-sectional survey study. j public health (berl.)2021; 29: 411–416. https://doi.org/10.1007/s10389019-01139-4 32. lee ji, song hs. the correlation analysis between hours of smartphone use and neck pain in the gachon university students. the acupuncture 2014; 31(2): 99-109. doi: 10.13045/acupunct.2014028. 33. liu h, zhou z, zhu e, huang l, zhang m. smartphone addiction and its associated factors among freshmen medical students in china: a cross-sectional study. bmc psychiatry. 2022 may 2;22(1):308. doi: 10.1186/s12888-022-03957-5. 34. eldesokey s, gomaa z, sabri y, el-gilany ah, elwasify m. smartphone addiction among medical students in mansoura university. egypt j psychiatr 2021; 42:50-6. doi: 10.4103/ejpsy.ejpsy_47_20. 35. dhamija s, shailaja b, chaudhari b, chaudhury s, saldanha d. prevalence of smartphone addiction and its relation with sleep disturbance and low self-esteem among medical college students. ind psychiatry j 2021;30, suppl s1:189-94 36. szpakow a, stryzhak a, prokopowicz w. evaluation of threat of mobile phone – addiction among belarusian university students. prog health sci. 2011; 1:96e101. 37. dixit s, shukla h, bhagwat ak, bindal a, goyal a, zaidi ak, et al. a study to evaluate mobile phone dependence among students of a medical college and associated hospital of central india. indian j community med. 2010; 35:339341. doi: 10.18203/23206012.ijrms20170143. 38. khan mm. adverse effects of excessive mobile phone use. int j occup med environ health. 2008;21(4):289-93. doi: 10.2478/v10001-008-0028-6. 39. lee h, kim ms, son hk, ahn s, kim js, kim yh. discriminating power of sociodemographic and psychological variables on addictive use of cellular phones among middle school students. taehan kanho hakhoe chi. 2007 oct;37(6):957-65. korean. doi: 10.4040/jkan.2007.37.6.957. 40. al-samarrai mam, alany bn, al-delaimy ak, yahyaa bt, ali jadoo sa. impact of internal displacement on psychosocial and health status of students residing in the hostel of anbar university, iraq. journal of ideas in health 2020 may 25;3(1):140-4. 41. damasceno gm, ferreira as, nogueira la, reis fj, andrade ic, meziat-filho n. text neck and neck pain in 18-21-year-old young adults. eur spine j 2018; 27:1249-54. doi: 10.1007/s00586-0175444-5. 42. kim hj, kim js. the relationship between smartphone use and subjective musculoskeletal symptoms and university students. j phys ther sci. 2015 mar;27(3):575-9. doi: 10.1589/jpts. 43. al-hadidi f, bsisu i, alryalat sa, al-zu’bi b, bsisu r, hamdan m, et al. association between mobile phone use and neck pain in university students: a cross-sectional study using numeric rating scale for evaluation of neck pain. plos one 2019;14: e0217231. doi: 10.1371/journal.pone.0217231. 44. kim sy, koo sj. effect of duration of smartphone use on muscle fatigue and pain caused by forward head posture in adults. j phys ther sci. 2016 jun;28(6):1669-72. doi: 10.1589/jpts.28.1669. https://doi.org/10.47108/jidhealth.vol4.iss2.106 yılmaz zu, et al., journal of ideas in health 2021;4(2):357-364 © the author(s). 2021 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access evaluating the home isolation of covid-19 patients in primary care zeynep unus yılmaz1, sevgi duman1*, güzin zeren öztürk1, hacı mustafa özdemir2, gözde günindi hogan1, elifkarataş1 abstract background: this study aims to evaluate the effectiveness of home isolation and medical follow-up by analyzing data collected over the phone from isolated individuals. methods: a cross-sectional phone-based survey designed to evaluate the home isolated covid-19 suspected patients at the şişli hamidiye etfal family health center in istanbul city between 16th march 5th may 2020. a semistructured questionnaire and the universal sampling technique were recruited to collect data about the sociodemographic and the covid-19 related laboratory and clinical findings. the spss for windows program was used to perform a univariate and bivariate statistical analysis. the statistical alpha significance level was accepted at less than 0.05. results: a total of 463 confirmed, probable, or suspected cases of covid-19 took part in this study with a mean age of 35.38 ∓17.1 (range: 0-86 years). tow-third 310 (67.0%) underwent the pcr tests, and 67 (21.6%) confirmed positive results. moreover, one-third (159, 34.3%) exposed to ct scans; however, 51(32.3%) were compatible with covid-19. the median age of individuals with pcr positive was 38 years. more than half (40, 59.7%) were males, compared to 27 (40.3%) were females. there was no significant relationship between pcr positivity and pandemic period, age, or gender (p = 0.149; p = 0.545; p = 0.285), respectively. although older individuals had a higher rate of ct scan compatible with covid-19, the relation between increased age and covid-19 compatible ct was found not to be statistically significant (p = 0.053). moreover, there was significant relationship between ct scan positivity and coughing, the tobacco smoking and diabetes (p = 0.003; p = 0.032; p = 0.016), respectively. conclusion: combining pcr, symptoms, and ct together doubles the likelihood of a correct diagnosis. quarantined patients must be regularly monitored. keywords: covid-19, patients, isolation, primary care, istanbul, turkey background a new type of coronavirus, sars-cov-2, was first isolated during an investigation into an outbreak of pneumonia cases of unknown etiology that occurred on 31st december 2019 in wuhan, china [1]. the world health organization (who) named the disease caused by this virus covid-19 on 11th february 2020 [2]. the world was not ready to face a global crisis in a unified manner. the virus spread rapidly in most countries of the world [3]. the who officially declared covid-19 as a pandemic on the 11th of march 2020, the day when the first positive case was detected in turkey [4]. turkey was among the first countries that start preparing and planning early to control the spread of the virus and its impact. turkey has adopted the filiation technique to prevent the spread of coronavirus disease by cutting the chain of transmission by systematically tracking and isolating vulnerable individuals who have been in contact with any confirmed cases. the peak level of covid-19 in turkey was reached 25 days after the first fatality was recorded on 11th april 2020 [5]. according to the 'covid-19 (sars-cov-2) infection guide' published by the scientific committee in the ministry of health in turkey, the following groups were treated as definite cases and isolated at home for 14 days [6]; people who came from abroad, those who had come into contact with confirmed cases and people with a confirmed diagnosis. this process was controlled by phone calls made by family physicians to people in isolation, in line with the guidelines. these additional control measures started on 16 march 2020; their purpose was to assess individuals' condition, increase compliance with the isolation rules, and reduce the circulation of the virus, reducing the number of new cases [7]. this study aims to evaluate the effectiveness of home isolation, and medical follow-up was done for a sample of patients recorded in the primary health care services in the şişli hamidiye etfal family health center in istanbul city, turkey. ___________________________________________________ drsevgiduman@hotmail.com 1family medicine depertmant, şişli hamidiye etfal research and training hospital, i̇stanbul, turkey a full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol4.iss2.106 http://www.jidhealth.com/ yılmaz, zu, et al., journal of ideas in health (2021); 4(1):357-364 358 methods study population and sample a retrospective and descriptive study designed to evaluate the isolated home covid-19 confirmed, probable, or suspected cases in istanbul city between march 16 and may 5, 2020. this study was conducted on patients registered in şişli hamidiye etfal family health center; is a public primary healthcare center located in the sisli city, the european side of istanbul. it is a family health center with seven doctors and seven nurses, providing primary health care services to approximately 20,000 people. inclusion and exclusion criteria all confirmed, probable, or suspected cases of covid-19, both gender and all ages who were isolated at home, under treatment and following up by the family physicians over the phone between 1st and 30th april 2020, and willing to participate are included in the study. patients who were unwilling to participate and those with missing data are excluded from the study. the sampling technique the universal sampling technique was recruited to collect data from all (confirmed, probable, or suspicious covid-19 patients) who were already recorded at the şişli hamidiye etfal family health center, istanbul, turkey. family physicians used the available data to contact patients directly via the phone during the regular follow-up to progress covid-19 infection. data collection tools individuals isolated at home were followed up via phone calls. the respondents were asked to answer a total of 13 questions in four different parts and giving responses as either "yes" or "no". the first section contained information about the participants' social and demographic characteristics, including citizenship number, age, and gender. the second section was about the participants' case types (confirmed, probable, or suspicious covid-19 cases), nasopharyngeal pcr (polymerase chain reaction) test results, computed tomography (ct) scan findings, treatment status, comorbidities, tobacco smoking, and the people with whom they live. in the third part, the focus was on the three main symptoms of covid-19 (fever, cough, shortness of breath), length of the symptom, and whether the symptoms appeared in other family members or not. the fourth section contained information about compliance with specified quarantine rules, i.e., not leaving the house, not accepting visitors, being alone in a separate room to other members of the household, sufficiently ventilating the room, wearing a medical mask in all common areas of the house, cleaning the areas like wc/bathroom after each use, hand hygiene, separate use of household items such as plates, glasses, and towels. statistical analysis the spss for windows program was used for statistical analysis. descriptive statistics of evaluation results are given as a number and percentage for categorical variables such as mean, standard deviation, and minimum, maximum for numerical variables. the differences between the rates of categorical variables in independent groups were tested with chi-square analysis. the correlated parameters were also evaluated by regression analysis. statistical alpha significance level was accepted as p <0.05. results characteristics of the participants out of 1150 eligible women, 906 were included in the study (response rate 60.4%). the mean age was 29.59 (±4.74 years). most of the respondents were high educated (75.2%), housewives (86.1%), nuclear family (96.1%), and low-income (≤4400 tl) families (53.9%). most of the respondents neither having a history of psychiatric disease (95.9%) nor having a family member with a history of psychiatric disease (87.3 out of 463 people who were followed up in isolation and defined as a confirmed, probable, or suspicious covid-19 cases, 211 (45.6%) of them were in contact with confirmed cases, 56 (12.1%) were confirmed cases, and 196 (42.3%) were suspicious cases. the average age of the individuals was 35.38 ∓17.1 (0-86 years). more than half (249, 53.8%) of the followed-up patients were males, most diagnosed after the peak period (290, 63%), and the majority were living with their immediate families (396, 85.5%). about one-quarter (114, 24.62%) of them reported at least one comorbidity and history of tobacco smoking (103, 22.2%) with an average of 16.19∓12.3 cigarettes per day in a range of 1-65 cigarettes daily (table 1). table 1 socio-demographic factors (n=463) variables category n (%) covid-19 cases contact with confirmed cases 211 (45.6) confirmed cases 56 (12.1) suspicious cases 196 (42.3) gender male 249(53.8) female 214 (46.2) time of diagnosis before the peak 173 (37.0) after the peak 290 (63.0) living situation alone 22 (4.8) with their immediate families 396 (85.5) with their extended families 45 (9.7) co-morbidities no 349 (75.4) yes 114 (24.6) yes (n=114) having only one comorbidity 82 (17.7) having two co-morbidities 26 (5.6) having three and more comorbidities 6 (1.3) co-morbidities (n=114) high blood pressure (hypertension) 41 (8.9) diabetic disease 26 (5.6) heart disease 7 (1.5) lung disease 35 (7.6) others 43 (9.3) tobacco smoking no 360 (77.8) yes 103 (22.2) yılmaz, zu, et al., journal of ideas in health (2021); 4(1):357-364 359 covid-19 related symptoms and the associated factors out of total patients, 79 (17.1%) were symptomatic. most of them presented with cough (30.0%), shortness of breath (19.5%), weakness (11.1%), fever (9.5%), and sore throat (8.4%), respectively (figure 1). moreover, 18 (3.9%) of the patient who was followed up in isolation had a fever which lasted for an average of 4.17∓2.3 (1-7 days) days. cough has lasted for an average of 8,43∓9,6 (1-36 days) in 57 (12.3%) patients. the long-lasting symptom was shortness of breath for an average of 20.53∓19.4 (3-60 days). figure 1 frequency distribution of symptoms out of 310 (67.0%) of the followed patients underwent pcr test, and about one-fifth (67, 21.6%) confirmed positive results. moreover, one-third(159, 34.3%) exposed to ct scan; however, 51(32.3%) were compatible with covid-19 (figure 2) figure 2 the flow chart of the included cases table 2 presents the relationship between the pcr results, ct findings, and the main symptoms associated with covid-19. the relationship between having a cough and a pcr positive test was significant (p= 0.003). about two-quarter 41 (61.2%) of the pcr positive individuals were symptomatic, for which the most common symptom was cough (19, 28.4)). moreover, more than half (28, 54.9%) of the positive ct finding patients were symptomatic, for which the most common symptom was cough (22, 20.6%). compliance with isolation rules during the lockdown period, most of the patients followed up in this study showed high compliance with the isolation rules. however, 21.2% of them left their house at least once, and 1.9% received visitors. two-thirds, 65.4% followed social distancing rules; however, 43.8%did not wear masks when being in public areas. more than ninety percent of the patients were paying attention to ventilation rooms, cleanness at individual and family levels (table 3). table 4 presents the relationship between pcr results and compliance with the isolation rules. chi-square test showed that a patient who is going out of the house is significantly associated with positive pcr (p <0.001). however, the patients who are staying alone in a separate room (p<0.001), using a medical mask (p<0.001), cares about toilet/bathroom hygiene (p=0.006), and those who separate use of items such as plates, glasses, and towels (p=0.015). table 5 presents the descriptive of comorbidities, tobacco smoking, and medication used in relation to pcr results. out of 67 (%) pcr positive patients, 12 (27.0%) were hypertensive, 3 (23.0%) chronic lung disease, 7 (%) diabetic patients and 2 () heart disease. when the co-morbidities were examined separately, there was a significant relationship between the hypertensive patients and the pcr positivity (p = 0.021). out of 67 (%) pcr positive patients, 9 (13.4%) were tobacco smokers. there was a significant relationship between smoking and pcr positivity (p = 0.024). out of 463 patients followed in this study, 91 (19.7%) of them used medication. most of them (67, 73.6%) were pcr positive, while 24 (26.4%) were pcr negative but had positive ct findings. hydroxychloroquine, oseltamivir, and favipiravir were used to treat 91,18, 5 patients, respectively. association of sociodemographic and clinical variables with the positive pcr and ct the median age of individuals with pcr positive was 38 years. more than half (40, 59.7%) were males, compared to 27 (40.3%) were females. there was no significant relationship between pcr positivity and pandemic period, age, or gender (p = 0.149; p = 0.545; p = 0.285), respectively. although older individuals had a higher rate of ct scan compatible with covid-19, the relation between increased age and covid-19 compatible ct was found not to be statistically significant (p = 0.053). moreover, there was a significant relationship between ct scan positivity and tobacco smoking and diabetes (p = 0.032; p = 0.016), respectively. however, analysis found no significant relationship between ct scan positivity and gender, hypertension, heart disease, lung disease (p = 0.132; p = 0.214; p = 0.707; p = 0.093), respectively. discussion in this study, more than half (59.7%) of patients with a positive pcr were males with a median age of 38 years, which is younger than that reported in the united states (48 years) by stokes et al. [8] and that reported in china (49.6 years) by yang et al. [9]. in our sample, the median age was younger than earlier studies because the pcr positive patients consisted of only those who were followed up during home-based selfisolation and did not require hospitalization. 30 19.5 11.1 9.5 8.4 5.8 4.8 1.6 1.6 1.6 6.3 cough shortness of breath weakness fever sore throat head ache nausea diarrhia anosmia ache others 0 20 40 463 included patients 310 pcr tested 153 pcr non-tested 243 negative pcr 67 positive pcr 124 had no ct 26 positive ct 25 positive ct 27 had no ct 119 had ct 40 had ct 51 total positive ct yılmaz, zu, et al., journal of ideas in health (2021); 4(1):357-364 360 table 2 association of pcr results and ct findings with main covid-19 symptoms symptoms category pcr +ve pcr -ve p category ct +ve ct -ve p-value n(%) n(%) n(%) n(%) total observation n=310 67 (21.6) 243(78.4) n=158 51(32.3) 107(67.7) fever yes 6 (9.0) 10(4.1) 0.113 yes 4(7.8) 7(6.5) 0.747 no 61(91.0) 233(95.9) no 47(92.2) 100(93.5) cough yes 19(28.4) 32(13.2) 0.003 yes 22(20.6) 13(25.5) 0.485 no 48(71.6) 211(86.8) no 85(79.4) 38(74.5) shortness of breath yes 6(9.0) 30(12.3) 0.443 yes 7(13.7) 21(19.6) 0.364 no 61(91.0) 213(87.7) no 44(86.3) 86(80.4) pcr: polymerase chain reaction; ct: computed tomography table 3 compliance with isolation rules(n=463) isolation rules yes n(%) no n(%) leaving home at least once 98 (21.2) 365(78.8) accepted visitors 9 (1.9%) 454(98.1) obeying to the social distancing rules 303(65.4) 160 (34.6) ventilating the room at the recommended frequency 452(97.6) 11 (2.4) wearing masks in the common areas 260(56.2) 203 (43.8) cleaning the common areas such as the bathroom after each use 419(90.5) 44 (9.5) paying attention to the separate use of household items such as plates, glasses, and towels 427(92.2) 36 (7.8) moreover, the scientific literature explains the increase in pcr positivity in men due to more concentrations of angiotensinconverting enzyme 2 (ace2) in their blood than in women. the abundance of ace2 allows a higher level of the coronavirus to be transmitted to healthy cells, making them more susceptible to covid-19. the prevalence rate of tobacco smoking is higher among men than women, which increases their risk of lung disease [10], while women have a high level of immunity due to an increase in the x chromosome [11]. previous studies found that women are more committed to protection standards from the coronavirus than men [12,13,14]. furthermore, men are more commonly employed in jobs outside the home and most likely subjected to less social distancing rules. at the time of this study, out of 310 patients who underwent to pcr test, 67 (21.6%) returned a positive result. our findings rated higher than the global percent (7.0%) [15] and the official turkish rate (6.3%) [16]. this difference is because the individuals who have been followed up all considered to be likely causes. likewise to our findings, several studies [8, 9,17,18 ] reported that cardiovascular disease (hypertension and coronary heart disease), diabetes, and chronic lung diseases are the most common comorbidities related to covid-19 pcr positive cases. stokes et al. [8], in their report, found that cardiovascular disease, diabetes, and chronic lung diseases rated 32%, 32%, and 18%, respectively, among united states pcr positive cases. yang et al. [9], in their meta-analysis, reported that hypertension (21.1%), diabetes (9.7%), and cardiovascular diseases (8.4%) are in the top list of pcr positive related comorbidities. zhou et al. [17] also reported hypertension, diabetes, and coronary heart disease diagnosed in 30%, 19%, and 8%, of the pcr positive cases, respectively. in the bivariate analysis, we found a statistically significant relationship between hypertension and pcr positive patients. wang et al. [18] found that the coronavirus worsens with high blood pressure. more than 26.0% of the total population have hypertension [19] and common among adults [20]. moreover, lippi et al. [21] have stressed that the mechanism of action of the enzyme ace2 explains its role in explaining the relationship between high blood pressure and infection with covid-19. among the 67 pcr positive studied patients, 9 (13.4%) had a positive history of tobacco smoking; however, the rate was lower than the national rate of tobacco smoking (29.3%) reported in 2018 [22]. zhang et al. [19, 23] reported a rate of 7.0% tobacco smokers among the covid-19 patients, which is lower than the rate of adult smoking prevalence (27.7%) in china [24]. moreover, in our study, we found a significant relationship between non-tobacco smoking and pcr positivity (p = 0.024). unlike our results, zhao et al. [25] and zhang et al. [23] found a statistically significant relationship between tobacco smoking and the severity of covid-19 disease among patients. different findings were reported by vardavas et al. [26], who calculated a relative risk indicating a non-significant relationship between tobacco smoking and the severity of covid-19. however, simons et al. [27] concluded that there was significant uncertainty in the relationship between tobacco smoking and covid-19 results. the symptoms of covid-19 occurred in most cases approximately 4 to 5 days after exposure. similarly, li et al. [28] reported a mean incubation period of 5.2 days in china. asymptomatic infections frequency is unknown, but several studies in various settings show that they are common. mizumoto et al. [29] estimated the asymptomatic proportion among the japanese people was 17.9%. our findings showed that 26 (38.8%) of the pcr-positive individuals were asymptomatic. however, the most common symptom was cough. similarly to previous studies, the symptomatic cases presented with fever (43.0%), cough (50.0%) and/or shortness of breath (29.0%), upper respiratory symptoms (20.0%), headache (34.0%), myalgia (36.0%), diarrhea (19.0%), nauseavomiting (12.0%) and loss of sense of smell or taste (10.0%) are also common [4, 30]. the american association of infectious diseases (idsa) recommends testing nasopharyngeal specimens instead of the oropharyngeal specimen (or saliva) due to lower sensitivity to oropharyngeal specimens and lack data on the accuracy of saliva specimens [31]. yılmaz, zu, et al., journal of ideas in health (2021); 4(1):357-364 361 table 4 relationship between pcr results and compliance with isolation rules (n=310) variables category pcr + pcr p-value n(%) n(%) total observation n=310 67 (21.6) 243(78.4) going out of the house yes 4(6.0) 69(28.4) 0.000 no 63(94.0) 174(71.6) visitor acceptance yes 3(4.5) 4(1.6) 0.167 no 64(95.5) 239(98.4) staying alone in a separate room yes 60(89.6) 148(60.9) 0.000 no 7(10.4) 95(39.1) the ventilation of the room yes 66(98.5) 235(96.7) 0.437 no 1(1.5) 8(3.3) using medical mask yes 56(83.6) 119(49.0) 0.000 no 11(16.4) 124(51.0) cleaning wc/bathroom yes 66(98.5) 211(86.8) 0.006 no 1(1.5) 32(13.2) hand hygiene yes 66(98.5) 236(97.1) 0.526 no 1(1.5) 7(2.9) separate use of items such as plates, glasses, and towels yes 67(100) 223(91.8) 0.015 no 0 20 (8.2) table 5 descriptive of co-morbidities, tobacco smoking, and medication used in relation to pcr results *individuals with negative pcr results but positive ct. fang et al. [34] reported that among 51 patients hospitalized in china with fever or acute respiratory symptoms and ultimately a positive pcr test, the initial pcr test was negative in 15 patients (29.0%), and they were subsequently diagnosed only after repeated tests. similarly, lee et al. [35] found that the first nasopharyngeal test was 11% negative among 70 singaporean patients. long et al. [36] examined the rates of conversion from negative to positive np sars-cov-2 rt-pcr. the authors found that 3.5% of the 626 patients retested who underwent repeated nasopharyngeal pcr tests within seven days of the first negative test in the usa were eventually found to be positive. the test's sensitivity will most likely depend on the type and quality of the sample, the duration of the disease during the test, and the specific assay. however, chest ct abnormalities were also identified before symptoms developed and even before pcr positivity was detected [37]. chest ct scan is a vital component in the diagnostic algorithm for patients suspected of covid-19 infection. however, it has limited sensitivity and negative predictive value after the onset of symptoms and is therefore not a reliable, independent tool to rule out covid-19 infection [38]. in the context of the typical clinical presentation and exposure to other people with covid-19, the ct scan features of viral pneumonia may be strong indicators for covid-19 infection despite negative pcr results. in these cases, even though literature recommends repeated stick testing and patient isolation [38]. in turkey, these cases were treated as positive cases of covid-19 [39]. in this study, 24 patients with ct findings and symptom positivity were treated for covid-19 even though their pcr results were negative. kenny and his colleagues [40] concluded that respiratory function decreased significantly among smokers and diabetics patients for ten years or more, with a clear association with a significant reduction in quality of life and impaired ability to exercise. also, there was a suppression of the immune system by diabetes [41] and a negative effect of smoking on the lungs [42]. in this study, the positivity of ct findings was found to be associated with smoking and diabetes. considering the results mentioned above, we believe that the evaluation of symptoms, pcr, and ct scan together in covid-19 diagnosis will variables categories pcr non pcr total total observation n =463 positive n=67 negative n=243 n=153 co-morbidities hypertension 12(17.9) 20(8.2) 9(5.9) 41 chronic lung disease 3(4.5) 26(10.7) 6(3.9) 35 diabetes 7(10.4) 13(5.3) 6(3.9) 26 heart disease 2(3.0) 4(1.6) 1(0.7) 7 others 5(7.5) 31(12.7) 7(4.6) 43 healthy individuals 38(56.7) 149(61.3) 124(81.0) 311 tobacco smoker 9(13.4) 65(26.7) 29(19.0) 103 non-smokers 58(86.6) 178(73.3) 124(81.0) 360 used medication 67(100) 24(9.9)* 0 91 non used medication 0 219(90.1) 153(100) 372 yılmaz, zu, et al., journal of ideas in health (2021); 4(1):357-364 362 generally facilitate the diagnosis and should be evaluated simultaneously, especially in individuals with cough. patients suspected or confirmed with covid-19 (including those waiting for test results) should stay at home and isolate themselves from other people and animals at home. it is suggested that the patient should be placed alone in a wellventilated room, leaving a distance of at least 1 meter (e.g., sleeping in a separate bed) if a separate room is not possible. it is also recommended to limit the patient's movement at home and to minimize the shared space. if those who share a living space with these people need to be in the same room, the world health organization (who) recommends these people wear a medical mask [43]. it also recommends not allowing visitors, applying hand hygiene after any contact, and using disposable paper towels to dry hands. if these are not available, using clean towels and changing them frequently, using special food utensils for the patient, and cleaning the surfaces where the patient touches the room, for example, bathrooms and toilets, with hypochlorite containing 0.1% sodium are also recommended. in order to be released from home isolation, a negative pcr result must be obtained at least twice from patients, with the samples being taken 24 hours apart [44]. this study complaint of some limitations. since only phone calls are used to follow-up of isolation patients, the data are based on the verbal statements of the patients. this situation creates a limitation in terms of the accuracy of the information. policy implication given the instructions and the guide prepared in turkey [6,7,16], the recommendations of the world health organization and the center for disease control, the health status of the isolated individuals were followed up. all data in this study were recorded during the first call to patients. some of the home isolation patients were not compliant with the isolation rules at the time of the first call because they have difficulty adapting to the various aspects of quarantine. however, the subsequent calls showed that patients' compliance had increased in almost all instances. it was also observed that individuals with pcr positivity had higher levels of compliance with the isolation rules. this study indicated two reasons for the increased compliance with the isolation rules found in the subsequent phone interviews; the patients might become more are aware of the seriousness of the disease and better understand the severity of the disease due to their treatment; and the role of the regular follow-up of the patients by phone. conclusion this study found that men are more commonly infected with covid-19 than women. patients with a positive history of chronic diseases, especially hypertension, are more likely to contract the disease. moreover, it was determined that the combination of pcr tests, symptoms, and ct scans would increase the likelihood of a correct diagnosis. although it increases the workload of family physicians and public health specialists, the continued observation and follow-up of the quarantined covid-19 patients increase their compliance with the isolation regulations. moreover, to reduce the workload of family doctors and public health professionals, it is recommended that initial contact with patients in home isolation be made by a trained health professional. abbreviation covid-19: coronavirus; pcr: polymerase chain reaction; ct: computed tomography; sars-cov: severe acute respiratory syndrome; who: the world health organization; cdc: centers for disease control and prevention; ace: angiotensin-converting enzyme; idsa: american association of infectious diseases declaration acknowledgment we would like to thank the family physicians at the şişli hamidiye etfal family health center for their contribution to the follow-up of isolation patients. we would like to thank all the participants of the survey. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing drsevgiduman@hotmail.com. authors’ contributions güzin zeren öztürk (gzö) and sevgi duman (sd) were the designers of the study, coordinating all aspects of the research and drafting and reviewing the article. zeynep unus yılmaz and gözde günindi hogan (zuy, ggh) contributed to the analysis and interpretation of the study and the article's writing. hacı mustafa özdemir (hmö) contributed to the study's concept, arrangement, and final approval. sevgi duman (sd) and elif karataş (ek) contributed to data collection. all authors have read and approved the final version of the manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the ethical protocol was approved by health sciences university şişli hamidiye etfal health application and research centre ethics committee with approval number 2759 on 5 may 2020, istanbul, turkey. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1family medicine department, şişli hamidiye etfal research and training hospital, i̇stanbul, turkey.2department of orthopedics and traumatology, şişli hamidiye etfal research and training hospital, i̇stanbul, turkey. article info received: 28 january 2021 accepted: 10 april 2021 published: 10 may 2021 yılmaz, zu, et al., journal of ideas in health (2021); 4(1):357-364 363 references 1. gorbalenya ae, baker sc, baric rs, de groot rj, drosten c, gulyaeva aa, et al. the species severe acute respiratory syndrome-related coronavirus: classifying 2019-ncov and naming it sars-cov-2. nat microbiol. 2020;5(4):536–44. doi: 10.1038/s41564-020-0695-z 2. who, coronavirus disease (covid-19) situation reports 2020. available from: https://www.who.int/docs/defaultsource/coronaviruse/situation-reports/20200312-sitrep-52-covid19.pdf?sfvrsn=e2bfc9c0_4 [accessed on 12 may 2020]. 3. ali jadoo sa. was the world ready to face a crisis like covid19? journal of ideas in health 2020 ;3(1):123-4. https://doi.org/10.47108/jidhealth.vol3.iss1.45 4. who director-general's opening remarks at the media briefing on covid-19 11 march 2020. available from: https://www.who.int/director-general/speeches/detail/whodirector-general-s-opening-remarks-at-the-media-briefing-oncovid-19---11-march-2020 [accessed on 12 may 2020]. 5. demirtaş t, tekiner h. filiation: a historical term the covid-19 outbreak recalled in turkey. erciyes med j. 2020; 42(3): 354–8. https://doi.org/10.14744/etd.2020.54782 6. the republic of turkey, ministry of health, general directorate for public health, covid-19 (sars-cov-2 infection) guide, study of scientific board; april 14th, 2020. available from: https://hsgm.saglik.gov.tr/depo/birimler/goc_sagligi/covid19/rehb er/covid-19_rehberi20200414_eng_v4_002_14.05.2020.pdf [accessed on 12 may 2020]. 7. bilimsel danışma kurulu çalışması. covid-19 (sars-cov-2 enfeksiyonu) temaslı takibi, salgın yönetimi, evde hasta izlemi ve filyasyon. 2020; available from: https://covid19.saglik.gov.tr/eklenti/40043/0/covid19rehberitemaslitakibievdehastaizlemivefilyasyonpdf.pdf 8. stokes ek, zambrano ld, anderson kn, marder ep, raz km, el burai felix s, et al. coronavirus disease 2019 case surveillance — united states, january 22–may 30, 2020. mmwr morb mortal wkly rep. 2020;69(24):759–65. http://dx.doi.org/10.15585/mmwr.mm6924e2external icon 9. yang j, zheng y, gou x, pu k, chen z, guo q, et al. prevalence of comorbidities and its effects in patients infected with sarscov-2: a systematic review and meta-analysis. int j infect dis. 2020 may;94:91-95. doi: 10.1016/j.ijid.2020.03.017. 10. cai h. sex difference and smoking predisposition in patients with covid-19. lancet respir med. 2020 apr;8(4):e20. doi: 10.1016/s2213-2600(20)30117-x. 11. gagliardi mc, tieri p, ortona e, ruggieri a. ace2 expression and sex disparity in covid-19. cell death discov. 2020;6(1):1– 2. 12. ali jadoo sa, alhusseiny a, yaseen s, al-samarrai m, al-rawi r, al-delaimy a, abed m, hassooni h. knowledge, attitude, and practice toward covid-19 among iraqi people: a web-based cross-sectional study. journal of ideas in health 2020; 3(special2):258-65. https://doi.org/10.47108/jidhealth.vol3.issspecial%202.59 13. ali jadoo sa, dastan i, al-samarrai m, yaseen s, abbasi a, alkhdar h, al saad m, danfour o. knowledge, attitude, and practice towards covid-19 among syrian people resident in turkey. journal of ideas in health 2020; 3(special2):278-85. https://doi.org/10.47108/jidhealth.vol3.issspecial2.61 14. ali jadoo sa, danfour o, zerzah m, abujazia m, torun p, alsamarrai m, yaseen s. knowledge, attitude, and practice towards covid-19 among libyan peoplea web-based cross-sectional study. journal of ideas in health 2021;4(special1):348-56. https://doi.org/10.47108/jidhealth.vol4.issspecial1.97 15. covid-19 coronavirus pandemic, https://www.worldometers.info/coronavirus/ [accessed on 6 july 2020]. 16. republic of turkey ministry of health, current situation in turkey, https://covid19.saglik.gov.tr/[accessed on 6 july 2020]. 17. zhou f, yu t, du r, fan g, liu y, liu z, et al. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. lancet. 2020 mar 28;395(10229):1054-1062. doi: 10.1016/s0140-6736(20)30566-3. 18. wang b, li r, lu z, huang y. does comorbidity increase the risk of patients with covid-19: evidence from meta-analysis. aging (albany ny). 2020 apr 8;12(7):6049-6057. doi: 10.18632/aging.103000. 19. kearney pm, whelton m, reynolds k, muntner p, whelton pk, he j. global burden of hypertension: analysis of worldwide data. lancet. 2005 jan 15-21;365(9455):217-23. doi: 10.1016/s01406736(05)17741-1. 20. schiffrin el, flack jm, ito s, muntner p, webb rc. hypertension and covid-19. am j hypertens. 2020 apr 29;33(5):373-374. doi: 10.1093/ajh/hpaa057. 21. lippi g, wong j, henry bm. hypertension in patients with coronavirus disease 2019 (covid-19): a pooled analysis. pol arch intern med. 2020 apr 30;130(4):304-309. doi: 10.20452/pamw.15272. 22. who global report on trends in prevalence of tobacco smoking 2000–2025, second edition. geneva: world health organization. available from: https://www.who.int/publications/i/item/whoglobal-report-on-trends-in-prevalence-of-tobacco-use-2000-2025third-edition [accessed on 12 march 2021] 23. zhang jj, dong x, cao yy, yuan yd, yang yb, yan yq, et al. clinical characteristics of 140 patients infected with sars-cov-2 in wuhan, china. allergy. 2020 jul;75(7):1730-1741. doi: 10.1111/all.14238. 24. china center for disease control and prevention 2015 china adult tobacco survey report. beijing, 2015. available from: http://www.tcrc.org.cn/uploadfiles/201603/318/201603231215175500.pdf [accessed on 12 march 2021] 25. zhao q, meng m, kumar r, wu y, huang j, lian n, et al. the impact of copd and smoking history on the severity of covid19: a systemic review and meta-analysis. j med virol. 2020 oct;92(10):1915-1921. doi: 10.1002/jmv.25889 26. vardavas ci, nikitara k. covid-19 and smoking: a systematic review of the evidence. tob induc dis. 2020 mar 20;18:20. doi: 10.18332/tid/119324. 27. simons d, shahab l, brown j, perski o. the association of smoking status with sars-cov-2 infection, hospitalization and mortality from covid-19: a living rapid evidence review with bayesian meta-analyses (version 7). addiction. 2020 oct 2:10.1111/add.15276. doi: 10.1111/add.15276. 28. li q, guan x, wu p, wang x, zhou l, tong y, et al. early transmission dynamics in wuhan, china, of novel coronavirusinfected pneumonia. n engl j med. 2020;382(13):1199–207. doi: 10.1056/nejmoa2001316. 29. mizumoto k, kagaya k, zarebski a, chowell g. estimating the asymptomatic proportion of coronavirus disease 2019 (covid19) cases on board the diamond princess cruise ship, yokohama, yılmaz, zu, et al., journal of ideas in health (2021); 4(1):357-364 364 japan, 2020. euro surveill. 2020 mar;25(10):2000180. doi: 10.2807/1560-7917. 30. guan w, ni z, hu y, liang w, ou c, he j, et al. clinical characteristics of coronavirus disease 2019 in china. n engl j med. 2020;382(18):1708–20. doi: 10.1056/nejmoa2002032 31. hanson ke, caliendo am, arias ca, hayden mk, englund ja, lee mj, et al. the infectious diseases society of america guidelines on the diagnosis of covid-19: molecular diagnostic testing. clin infect dis. 2021 jan 22:ciab048. doi: 10.1093/cid/ciab048. 32. ai t, yang z, hou h, zhan c, chen c, lv w, et al. correlation of chest ct and rt-pcr testing for coronavirus disease 2019 (covid-19) in china: a report of 1014 cases. radiology. 2020 aug;296(2): e32-e40. doi: 10.1148/radiol.2020200642. 33. yang y, yang m, yuan j, wang f, wang z, li j, et al. laboratory diagnosis and monitoring the viral shedding of sars-cov-2 infection. the innovation2020;1(3):1-6. doi:https://doi.org/10.1016/j.xinn.2020.100061 34. fang y, zhang h, xie j, lin m, ying l, pang p, ji w. sensitivity of chest ct for covid-19: comparison to rt-pcr. radiology. 2020 aug;296(2): e115-e117. doi: 10.1148/radiol.2020200432. 35. lee th, junhao lin r, lin rtp, barkham t, rao p, leo ys, chien lye d, young b; national centre for infectious diseases covid-19 outbreak research team. testing for sars-cov-2: can we stop at 2? clin infect dis. 2020 nov 19;71(16):22462248. doi: 10.1093/cid/ciaa459. 36. long dr, gombar s, hogan ca, greninger al, o'reilly-shah v, bryson-cahn c, et al. occurrence and timing of subsequent severe acute respiratory syndrome coronavirus 2 reverse-transcription polymerase chain reaction positivity among initially negative patients, clinical infectious diseases 2021;72, (2):323–326, https://doi.org/10.1093/cid/ciaa722 37. bernheim a, mei xm, huang m, yang y, fayad za, zhang n, et al. chest ct findings in coronavirus disease-19 (covid-19): relationship to duration of infection. vol. 19. 2020. https://doi.org/10.1148/radiol.2020200463 38. xie x, zhong z, zhao w, zheng c, wang f, liu j. chest ct for typical coronavirus disease 2019 (covid-19) pneumonia: relationship to negative rt-pcr testing. radiology. 2020 aug;296(2): e41-e45. doi: 10.1148/radiol.2020200343. 39. republic of turkey ministry of health, covid-19 adult treatment algorithm, https://covid19bilgi.saglik.gov.tr/depo/algoritmalar/covid19plkacilhastayonetimi.pdf [accessed on 02 july 2020]. 40. kinney gl, black-shinn jl, wan es, make b, regan e, lutz s, et al. pulmonary function reduction in diabetes with and without chronic obstructive pulmonary disease. diabetes care. 2014 feb;37(2):389-95. doi: 10.2337/dc13-1435. 41. donath my, dinarello ca, mandrup-poulsen t. targeting innate immune mediators in type 1 and type 2 diabetes. nat rev immunol. 2019;19(12):734–46. https://doi.org/10.1038/s41577019-0213-9 42. newcomb pa, carbone pp. the health consequences of smoking. cancer. med clin north am. 1992 mar;76(2):305-31. doi: 10.1016/s0025-7125(16)30355-8. 43. world health organization. (2020). advice on the use of masks in the context of covid-19: interim guidance, 6 april 2020. world health organization. https://apps.who.int/iris/handle/10665/331693. 44. world health organization. (2020). home care for patients with covid-19 presenting with mild symptoms and management of their contacts: interim guidance, 17 march 2020. world health organization. https://apps.who.int/iris/handle/10665/331473. https://doi.org/10.47108/jidhealth.vol6.iss1.274 ally aa, journal of ideas in health (2023); 6(1):820-827 © the author(s). 2023 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access seroprevalence of leptospirosis among hospitalized febrile patients in unguja island ally abdullah ally1, athumani msalale lupindu1, robert machang’u2, abdul selemani katakweba3,4 abstract background: leptospirosis is one of the neglected causes of febrile illness and death in developing countries, including tanzania. the study aims to determine the seroprevalence of leptospirosis among hospitalized febrile patients in unguja island. methods: a cross-sectional study was carried out in the three selected hospitals in unguja island between january and march 2022. a total of 402 participants with febrile illness were enrolled in the study, and blood samples were collected for sera preparation. microscopic agglutination test (mat) was used to detect antibodies against five leptospira serovars, including sokoine, lora, pomona, grippotyphosa, and hebdomadis. all sera samples reacted with mat titers≥1:160 were counted as positive, mat titers ranging from 1:20 to 1:80 were counted as exposed to leptospira bacteria while the absence of agglutination was regarded as negative. the data was analyzed using spss version 26, 2019. descriptive and logistic regression was performed, and p≤0.05 was considered statistically significant. results: the mean age of study participants was 29.62 ±16.34, with a range of 0 days to 80 years. most of them were females (64.2%) and unemployed (67.9%). the overall seroprevalence of leptospirosis was 7.7% (95% ci: 5.3-10.8). females were 1.016 times higher likelihood to have leptospirosis (aor = 1.016, 95% ci: 0.47-2.185, p = 0.968). participants aged 18-35 were 2.093 times more likely to be infected with leptospirosis (aor= 2.093, 95% ci: 0.8355.250, p = 0.115). participants who were unemployed (aor = 1.169, 95% ci: 0.522-2.615, p = 0.704) revealed a significantly higher likelihood of being infected with leptospirosis. the predominant leptospira serovars circulating among febrile patients were sokoine 44 (10.9%), lora 25 (6.2%), grippotyphosa 20 (5.0%), pomona 10 (2.5%), and hebdomadis 9 (2.2%). conclusion: leptospirosis is a public health threat among febrile patients in unguja island; therefore, it’s important to be considered in the differential diagnosis of non-malaria febrile patients for early prevention and control strategies. keywords: seroprevalence, leptospirosis, febrile patients, malaria, unguja island, tanzania background leptospirosis is a neglected tropical zoonotic disease of public health importance caused by pathogenic spirochete bacteria that belong to the genus leptospira [1-3]. the disease is distributed worldwide, particularly in tropical and subtropical regions, with over 1,000,000 cases reported annually and close to 60,000 deaths [4]. rodents are considered the most important disease reservoirs in humans due to their existence in various environments [5]. animals such as pigs, goats, cattle, and dogs act as carriers and can transmit leptospira infection to humans throughout their entire lifetime if left untreated [6-8]. humans may be infected by leptospira bacteria through either direct contact with the urine of infected animals or indirectly through polluted environments such as water and soil. the bacteria can penetrate the human body via open wounds and abrasions in the skin or through mucous membranes such as the mouth, nose, and eyes [5,9,10,11]. furthermore, the disease is one of the neglected causes of febrile illness and deaths in most african countries because of inadequate knowledge of the disease among healthcare workers and citizens and a lack of diagnostic resources [12,13]. infected patients with this disease can ___________________________________________________ ally.abdullah.ally@gmail.com 1department of veterinary medicine and public health, sokoine university of agriculture, p. o. box 3015, chuo kikuu, morogoro, tanzania full list of author information is available at the end of the article 10.47108/jidhealth.vol6.iss1.274 http://www.jidhealth.com/ ally aa, journal of ideas in health (2023); 6(1):820-827 821 develop acute, subacute, or chronic conditions. in acute and subacute stages, infected humans develop a range of symptoms such as fever, severe headache, chills, muscle, and joint pains, nausea, vomiting, diarrhea, and jaundice that are undifferentiated from other febrile illnesses such as malaria, brucellosis, yellow and dengue fevers [1,9,14]. in chronic conditions, the patients are associated with health complications, such as kidney dysfunctions, liver impairment, and hemorrhagic pulmonary syndrome [15]. the incubation period of leptospirosis usually ranges from 5–14 days but has also been reported to be up to 30 days [9,16]. in july 2022, tanzania experienced re-emerging leptospirosis in the southern part (lindi). twenty confirmed cases and three deaths associated with symptoms of nasal bleeds, fever, headaches, and fatigue were reported [17]. lack of diagnostic equipment and knowledge among healthcare workers on leptospirosis has led to misdiagnosis in favor of malaria due to the similarities in clinical symptoms [12,18]. malaria prevalence has been maintained below 1% in zanzibar for many years since 2013, but a clear understanding of the origin of fever among non-malaria febrile patients remains a big challenge [18,19]. even though malaria and leptospirosis have common clinical symptoms and leptospira bacteria being reported as a public health concern among non-malaria febrile patients [18], understanding the prevalence of leptospirosis and circulation serovars among febrile patients is important as far as the epidemiology of leptospirosis in concerned. hence, the present study aimed to determine the leptospira serovars circulating among febrile patients in unguja island, seroprevalence, leptospirosis, febrile patients, malaria, unguja island, tanzania. methods study area the study was conducted on unguja island, the main island of zanzibar, an archipelago situated off the eastern coast of tanzania mainland (6° 08′ 26.00" s, 39° 20′ 11.57" e). unguja island comprises three regions: mjini magharibi, kaskazini unguja, and kusini unguja. the health system of zanzibar is classified into primary, secondary, and tertiary levels for providing healthcare services to the communities and ensuring that communities access good health services at the primary level within or less than 5 km of the nearest public health facility [20]. hence, three purposively selected public hospitals at the tertiary level were involved in the study, including mnazi mmoja referral hospital located at mjini magharibi, kivunge district hospital situated at kaskazini unguja, and makunduchi district hospital located at kusini unguja (figure 1). these hospitals were selected because they are the only public hospitals available in unguja with advanced diagnostic facilities. study design and sample size determination a cross-sectional study was conducted from january to march 2022, involving patients of all ages with febrile illness. the estimated population size of people living on unguja island was 1,346,332 and was projected to equal 71.2% of the total population of the zanzibar islands [21]. therefore, the sample size of participants who enrolled in the study was estimated using a formula for the known population described by [22]: n = n/ (1+ne2) with a 95% confidence level, where n = estimated sample size, n = known population size and e= level of precision (0.05). therefore, the estimated sample size of the study participants was 399.8 people, almost 400 participants, and each hospital involved 134 study participants. figure 1. map of unguja island indicating the study location of hospitals sources: qgis version 3.24 “tisler” retrieved on august 22, 2022 inclusion and exclusion criteria the study involved patients of all ages with a fever who attended or were admitted to selected hospitals. the participants were orally informed that their blood could be tested for leptospirosis using an informed consent form as an agreement form. for all participants who could not give informed consent, such as those younger than 18 and those with learning disabilities, permission was granted by their family members on behalf of the participants. participants who did not agree or family members who did not agree on behalf of participants to consent were excluded from the study. participants were not interviewed to determine whether they had a history of symptoms related to leptospirosis because the symptoms of the disease are associated with other febrile illnesses, such as malaria. serum sample collection blood samples were collected from participants with fever who attended or were admitted to selected hospitals for various diseases. the participants were orally informed that their blood would be tested for leptospirosis after being used in a former hospital-recommended diagnostic test using an informed consent form. participants' demographic information, such as sex, age, and occupation, was documented. the blood was collected by the hospital laboratory scientists and/or laboratory technicians using 2ml and/or 5ml sterile syringes and needles. the blood was immediately transferred into plain vacutainer tubes and allowed to clot for serum separation at room temperature for at least 30 minutes. also, the un-separated blood was centrifuged for 10-15 min at 2000 rpm to acquire clear serum. the serum was transferred into labeled cryogenic tubes and/or eppendorf tubes and stored frozen at -20℃ in selected hospitals before transportation to the institute of pest ally aa, journal of ideas in health (2023); 6(1):820-827 822 management research laboratory at the sokoine university of agriculture morogoro, tanzania, for laboratory testing using the microscopic agglutination test (mat) [6,8,14]. laboratory procedures human leptospira antibodies in the sera samples were tested against live leptospira serovars antigens using the microscopic agglutination test (mat) as a gold standard [23]. five live reference leptospira serovars frequently reported among humans in tanzania were used, including l. kirschner serogroup ictero-haemorrhagiae serovars sokoine, l. kirschneri serogroup grippotyphosa serovar grippotyphosa, l. interrogans serogroup australis serovar lora, l. interrogans serovars hebdomadis, and l. interrogans serogroup pomona serovar pomona [8,14,24]. the ellinghausen mccullough mediumjohnson and harris (emjh) was used to subculture a stock of pure selected live serovars and incubated at 30℃ for at least 5 to 7 days with frequent screening to confirm the growth density, purity, and absence of bacterial contaminations using dark field microscope. a well-cultured live leptospires serovar with a density of approximately 3x108 cells /ml on the macfarland scale was used for mat. a 50µl volume of phosphate-buffered saline (pbs) with a ph of 7.2 was filled in every one of the 96 wells of a microtiter plate except the wells of row 2 that were filled with 90µl of phosphate-buffered saline (pbs). a 10μl of sera samples were mixed with 90μl of phosphate-buffered saline (pbs) from row 2 in the microtiter plate to obtain initial dilutions of 1:10, 1:20, 1:40, and 1:80. each dilution was thoroughly mixed and pipetting 50µl from the wells of row 2 to the following rows was done. finally, 50µl remained after the last well was discarded. a 50μl volume of well-grown live leptospires antigen was added to all microtitration wells to obtain the last double dilutions of 1:20, 1:40, 1:80, and 1:160, then mixed carefully. the serum–antigen mixture in microtiter plates was incubated at 30oc for at least 2 hours, as recommended for screening. the serum–antigen mixtures were examined under a dark field microscope for observation by taking a drop of the mixture from wells, using a loop to attach it to a microscopic slide, and examining it under the microscope. all samples' titers that give 50% of the leptospira agglutination, leaving 50% of cells free compared with the negative control of a mixture of pbs with live culture serovars without serum, were counted as either positive or prior exposure to leptospira bacteria. samples with mat titers≥1:160 were counted as positive for the disease, and samples with mat titers ranging from 1:20 to 1:80 were counted as exposed to leptospira bacteria. in contrast, missing agglutination was counted as negative. all positive samples that reacted at a titer≥1:160 as a cut-off point were diluted again to final dilution to determine the end titration of significance. the agglutinating sera were retested at dilutions of 1:20, 1:40, 1:80, 1:160, 1:320, 1:640, 1:1,280, 1:2,560, 1:5,120, and 1:10,240. the end titer of significance was 1:2,560 [8,9,24,25]. statistical analysis the data were entered, cleaned, and coded in microsoft excel 2010, and the data were imported into statistical product for service solution (spss) version 26, 2019 (ibm spss statistics). descriptive analyses, including frequency, proportion, and mean, were performed. logistic regression was performed to measure the association between the seroprevalence of leptospirosis and sex and age groups. odds ratios and a confidence interval of 95% were calculated, and p≤0.05 was considered statistically significant. results socio-demographic characteristics of study participants of 402 participants, 144 (35.8%) were males, and 258 (64.2%) were females. the mean (sd) age of the study participants was 29.62 (±16.34) years, with a range of 0 days to 80 years. the age group 18-35 contributed the highest proportion (51.7%). regarding occupation, a higher proportion of participants was unemployed (67.9%), as shown in table 1. table 1: socio-demographic characteristics of study participants (n=402) demographic characteristics categories number (%) sex males 144 (35.8) females 258 (64.2) age group (years) less than 18 86 (21.4) 18−35 208 (51.7) 36−59 83 (20.6) ≥ 60 25 (6.2) occupation category employed 129 (32.1) unemployed 273 (67.9) seroprevalence of leptospira antibodies in febrile patients in unguja hospitals out of 402 tested sera samples, 31 (7.7%) (95% ci: 5.3-10.8), were positive for leptospirosis. of the 31 positive, 13 (3.2%) were from kivunge district hospital, 10 (2.5%) from mnazi mmoja hospital, and 8 (2.0%) from makunduchi district hospital. regarding sex, leptospirosis rates in males were 11 (2.7%) and 20 (5.0%) in females. study participants aged 18-35 years had a higher positive rate of disease with a seroprevalence of 2.7%, followed by participants under 18 years with a seroprevalence of 2.2%. the highest seroprevalence of leptospirosis based on occupation category was found among unemployed participants (5.5%), as shown in table 2. table 2: seroprevalence of leptospirosis in relation to sociodemographics information of the study participants (n=402) variables total tested (n=402) leptospirosis positive (%) mat tit𝑒𝑟 ≥1:160 human participants 402 31 (7.7) sex category males 144 11(2.7) females 258 20(5.0) age group (years) less than 18 86 9 (2.2) 18−35 208 11 (2.7) 36−59 83 7 (1.7) ≥ 60 25 4 (1.0) occupation category employed 129 9(2.2) unemployed 273 22(5.5) hospital category kivunge district hospital 134 13(3.2) mnazi mmoja referral hospital 134 10(2.5) makunduchi district hospital 134 8(2.0) ally aa, journal of ideas in health (2023); 6(1):820-827 823 number of study participants with past exposure to leptospira bacteria out of 402 participants whose sera samples were tested for leptospira antibodies, 65 (16.2%) participants were observed to have past exposure to leptospira bacteria due to the mat titer range from 1:20 to 1:80, of whom 26 (6.5%) were from mnazi mmoja hospital, 21 (5.2%) were from kivunge district hospital, and 18 (4.5%) were from makunduchi district hospital. based on the sex category, 39 (9.7%) were females and 26 (6.5%) were males. the age groups 18-35 years had greater exposure to leptospira bacteria 30 (7.5%), followed by age groups less than 18 years 17 (4.2%), as shown in table 3. table 3: number of study participants with past exposure to leptospira bacteria in relation to socio-demographic information of the study participants (n=402). variables total tested mat titre (1:20 to 1:80) human participants 402 65(16.2) sex category males 144 26(6.5) females 258 39(9.7) age group (years) less than 18 86 17(4.2) 18−35 208 30(7.5) 36−59 83 11(2.7) ≥ 60 25 7(1.7) occupation category employed 129 20(5.0) unemployed 273 45(11.2) hospital category mnazi mmoja referral hospital 134 26(6.5) kivunge district hospital 134 21(5.2) makunduchi district hospital 134 18(4.5) comparison of seroprevalence of leptospirosis in different variables the seroprevalence of disease among participants in different variables such as sex, age, and occupation groups were compared to determine whether certain groups were at greater risk of disease than others using logistic regression. the seroprevalence of leptospirosis in female participants was 1.016 times higher than in males, which was not statistically significant (aor = 1.016, 95% ci: 0.47-2.185, p = 0.968). concerning age groups, participants aged 18-35 were 2.093 times more likely to be infected with leptospirosis (aor= 2.093, 95% ci: 0.835-5.250, p = 0.115) r, which was not statistically significant. participants who were unemployed (aor = 1.169, 95% ci: 0.522-2.615, p = 0.704) revealed a significantly higher likelihood of being infected with leptospirosis (table 4). discussion human leptospirosis is little known in unguja island. the present study aimed to address the gap in human leptospirosis by examining the seroprevalence of leptospirosis among hospitalized febrile patients. the findings of this study revealed that the overall seroprevalence of human leptospirosis was 7.7%, which was in line with the previous studies in different parts of the world, including northern tanzania, with a prevalence of 8.8% [16,26] and northeastern malaysia, with a seroprevalence of 8.4% [27]. however, this study's seroprevalence was higher than the findings reported from nepal (4.8%) [28], mozambique (1.3%) [29], and uganda 4.7% [30]. in contrast, the study prevalence was lower compared to a prevalence of 13% reported in kilosa district, tanzania [31], 14.7 % in ecuador [32], 21% in nepal [33], 11.2% in northern peru [34], and 46.3% reported in japan [35]. the difference in disease seroprevalence among febrile patients is probably due to different serovars and methodological and geographical differences [27]. furthermore, the frequent use of the recommended antibiotics among non-malaria febrile patients could help clear the infection early. therefore, previous exposure to recommended antibiotics among non-malaria febrile patients could probably lead to low seroprevalence of disease in the studies [25,30]. in terms of sex variables, the findings of this study showed that female participants have a higher seroprevalence of leptospirosis than males. this study's finding was comparable with the study of [33], which concluded that females have a higher prevalence of disease than males due to the high number of females attending hospitals for other treatments compared to males [33]. however, this finding was in contrast with previous studies conducted in different areas of the world that explain that males have a higher seroprevalence of leptospirosis than females because of greater involvement in economic activities that have high exposure to the leptospira bacteria [4,36]. regarding age groups, this study finding indicated that the participants in the middle age groups ranging from 18-35 years and 36-59 years were highly seropositive to leptospirosis and suggesting that they are the most risk groups. this result was equivalent to the studies of [33,37], which concluded the occurrence of higher seropositivity to leptospirosis among middle-aged 21 to 40 years due to their occupational and recreational exposure. in contrast, age groups above 60 years showed lower seropositivity to leptospirosis, probably due to less exposure to environmental contaminants or animals’ reservoirs [38]. furthermore, the prevalence of leptospirosis in this study is 7.7% higher than that of malaria, which is below 1% by 2013 in zanzibar [19]; this gives the impression that the contribution of malaria among febrile patients is relatively small. hence, proper diagnosis is essential before prescribing antimalarial drugs to non-malaria patients. otherwise, mistreatment may lead to prolonged illness and death or drug resistance. in addition, the seroprevalence of disease in this study is higher than that reported by [18], which was below 1% in 2015. this difference in prevalence may be due to methodology differences, the number of sampling areas, and the range of time (years) from the former to the present study. this gives the concept that the prevalence of leptospira infections in unguja island is increasing with time due to the changes in the human-socioeconomic activities of the study population. in this study, serovar sokoine was most prevalent (10.9%) compared to other serovars; this indicated that serovar sokoine is the common serovar circulating among febrile patients in unguja island and widespread in different regions of tanzania, including kilosa district [31], morogoro [39], bahi district [14], kagera [15] and mwanza [40]. ally aa, journal of ideas in health (2023); 6(1):820-827 824 table 4: comparison of differences in seroprevalence between variables variables leptospirosis positive (%) aor (95% cl) p-value sex category males 11(2.7) *** *** females 20(5.0) 1.016 0.472−2.185 0.968 age group (years) less than 18*** 9 (2.2) *** *** 18−35 11 (2.7) 2.093 0.835−5.250 0.115 36−59 7 (1.7) 1.269 0.450−3.581 0.653 ≥ 60 4 (1.0) 0.614 0.172−2.191 0.452 occupation category employed 9(2.2) *** *** unemployed 22(5.5) 1.169 0.522−2.615 0.704 ***reference age group aor= adjusted odds ratio cl=confidence interval on the other hand, the findings of this study showed the presence of some participants prior to exposure to leptospira bacteria due to their antibodies reacting to mat titers, which ranged from 1:20 to 1:80, below the cut-off point of significance. this result agreed with the study of [30], which concluded the presence numbers of participants’ prior exposure to leptospira infection. these conditions occur probably due to the routine practice of healthcare workers in primary and secondary levels of treatment to suggest the frequency of uses of recommended antibiotics among non-malarial febrile patients that may be un-diagnosed. leptospira bacteria become highly susceptible to recommended antibiotics, and the history of leptospira infections remains for a long time in humans due to the presence of the igg antibody [30]. the present study had certain limitations. first, participants with fever who attended or were admitted to selected hospitals were enrolled in this study without being interviewed to determine whether they had a history of symptoms related to leptospirosis because the symptoms of the disease are associated with other febrile illnesses, such as malaria. secondly, the estimation of seroprevalence of leptospirosis was limited due to the use of a single serum sample per participant. thus, at least two serum samples were recommended to be collected from each participant. conclusion in conclusion, this study revealed that leptospirosis is a public health threat among febrile patients in unguja island, with a seroprevalence of 7.7%. these results call for the inclusion of leptospirosis in the differential diagnosis of acute non-malaria febrile illnesses to reduce misdiagnosis and inappropriate uses of drugs, particularly in primary and secondary treatment. finally, we recommend that public awareness of the causes and transmission of leptospirosis among healthcare workers and the general population is needed as an essential strategy for preventing and controlling the disease. developing a rapid diagnostic test to diagnose leptospirosis disease among nonmalaria patients in primary healthcare facilities is needed. this test is reliable, affordable, and simple to apply. the ministry of health in zanzibar needs to initiate integrated disease surveillance, which involves arboviral and zoonotic diseases of public health concern, such as leptospirosis. further studies of human leptospirosis are needed, including the epidemiology and burden of the disease and coverage of pemba island... table 5: circulating leptospira serovars and its agglutination titers l. serovars titers total (%) 1:20* 1:40* 1:80* 1:160 1:320 1:640 1:2,560 l. kirschneri serovars sokoine 0 12 19 7 5 0 1 44 (10.9) l. interrogans serovar lora 0 4 9 10 1 1 0 25 (6.2) l. kirschneri serovar grippotyphosa 0 5 11 4 0 0 0 20 (5.0) l. interrogans serovar pomona 0 2 5 3 0 0 0 10 (2.5) l. interrogans serovars hebdomadis 1 3 3 2 0 0 0 9 (2.2) total (%) 1 26 47 26 6 1 1 108 (26.8) *the titers ranged from 1:20 to 1:80, indicating the participants were previously exposed to leptospira bacteria, and titers≥1:160 indicate the positive for leptospirosis. abbreviation ace: african centre of excellence; btd: biosensor technology development; emjh: ellinghausen mccullough medium-johnson and harris; ibm: international business machines; irpm: innovative rodent pest management; mat: microscopic agglutination test; pbs: phosphate buffered saline; who: world health organization; zahrec: zanzibar health research ethical committee. declaration acknowledgment the authors would like to acknowledge the laboratory staff from mnazi mmoja referral hospital, kivunge district hospital, and makunduchi district hospital under the ministry of health zanzibar for their cooperation during the study period. we are thankful to the study participants who were willing to participate. we honestly acknowledge mr. ginethon g. mhamphi from the institute of pest management at the sokoine ally aa, journal of ideas in health (2023); 6(1):820-827 825 university of agriculture (sua) for laboratory assistance. in advance, i dedicate this work to my late supervisors, dr. georgies f. mgode and prof. l.s. mulungu, who passed away while i was undertaking this research, for their guidance and contribution. we sincerely acknowledge the african centre of excellence for innovative rodent pest management and biosensor technology development (ace ii irpm and btd) at the institute of pest management of the sokoine university of agriculture (sua) for their financial support of this research. funding this research was funded by the african centre of excellence for innovative rodent pest management and biosensor technology development (ace ii irpm & btd) at the institute of pest management of the sokoine university of agriculture (sua). availability of data and materials data will be available by emailing ally.abdullah.ally@gmail.com authors’ contributions ally abdullah ally (aaa) is the principal investigator (pi) who contributed to the conceptualization, data collection, analysis, and writing of the original draft of the manuscript. athumani msalale lupindu (aml) and robert machang’u (rm) are the core supervisors, and abdul selemani katakweba (aask) is the main supervisor. aml, rm, and aask contributed to the manuscript's supervision, review, editing, and re-writing. all authors have read and accepted the manuscript to the final version for submission. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the ethical clearance for conducting this study was granted by the research ethics committee at sokoine university of agriculture (ref no. sua/adm/r.1/8/767 on january 10, 2022). the permission to conduct research in zanzibar was obtained from the research committee of the office of the second vice president and the office of the chief government statistician (ocgs), ref no. 61b6f85e745b7 on december 13, 2021). research protocols were revised and approved by the zanzibar health research ethics committee, ref no zahrec/04/st/nov/2021/94, on november 30, 2021) under the zanzibar ministry of health. furthermore, the participants were orally informed that their blood could be tested for leptospirosis using an informed consent form as an agreement form. consent for publication not applicable competing interest the authors declare that they have no competing interest. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of veterinary medicine and public health, sokoine university of agriculture, p. o. box 3015, chuo kikuu, morogoro, tanzania. 2st francis university college of health and allied sciences, p.o. box 175, ifakara-morogoro, tanzania. 3african centre of excellence for innovative rodent pest management and biosensor technology development (ace ii irpm & btd) at the sokoine university of agriculture, morogoro, tanzania. 4institute of pest management, sokoine university of agriculture, p.o. box 3110, chuo kikuu, morogoro, tanzania. article info received: 08 february 2023 accepted: 11 march 2023 published: 27 march 2023 references 1. bharti ar, nally je, ricaldi jn, matthias ma, diaz mm, lovett ma. peru united states leptospirosis consortium. leptospirosis: a zoonotic disease of global importance. lancet infect dis. 2003 dec; 3(12): 757 – 71. doi: 10.1016/s1473-3099(03)00830-2. 2. soo zmp, khan na, siddiqui r. leptospirosis: increasing importance in developing countries. acta trop. 2020 jan; 201:105183. doi: 10.1016/j.actatropica.2019.105183. 3. samrot av, sean tc, bhavya ks, sahithya cs, chandrasekaran s, palanisamy r, et al. leptospiral infection, pathogenesis and its diagnosis–a review. pathogens. 2021 feb 1;10(2): 145. doi 10.3390/pathogens10020145. 4. costa f, hagan je, calcagno j, kane m, torgerson p, martinez-silveira ms, et al. global morbidity and mortality of leptospirosis: a systematic review. plos negl trop dis. 2015 sep 17;9(9): 1 – 19. doi: 10.1371/journal.pntd.0003898. 5. mwachui ma, crump l, hartskeerl r, zinsstag j, hattendorf j. environmental and behavioural determinants of leptospirosis transmission: a systematic review. plos negl trop dis. 2015 sep 17;9(9): 1 – 15. doi: 10.1371/journal.pntd.0003843. 6. rahman mhaa, hairon sm, hamat ra, jamaluddin tzmt, shafei mn, idris n, et al. seroprevalence and distribution of leptospirosis serovars among wet market workers in northeastern, malaysia: a cross sectional study. bmc infect dis. 2018 nov 14;18(1): 1 – 5. doi 10.1186/s12879-018-3470-5. 7. allan kj, halliday je, moseley m, carter rw, ahmed a, goris mg, et al. assessment of animal hosts of pathogenic leptospira in northern tanzania. plos negl trop dis. 2018 jun 7;12(6): 1 – 19. doi: 10.1371/journal.pntd.0006444. 8. mgode gf, mhamphi gg, massawe aw, machang’u rs. leptospira seropositivity in humans, livestock and wild animals in a semi-arid area of tanzania. pathogens. ally aa, journal of ideas in health (2023); 6(1):820-827 826 2021 jun 3;10(6): 1 – 12. doi: 10.3390/pathogens10060696. 9. who. human leptospirosis: guidance for diagnosis, surveillance and control. world health organization, geneva; 2003. 10. guernier v, goarant c, benschop j, lau cl. a systematic review of human and animal leptospirosis in the pacific islands reveals pathogen and reservoir diversity. plos negl trop dis. 2018 may 14;12(5): 1 – 32. doi: 10.1371/journal.pntd.0006503. 11. galan di, roess aa, pereira svc, schneider mc. epidemiology of human leptospirosis in urban and rural areas of brazil, 2000–2015. plos one. 2021 mar 4; 16(3): 1 – 20. doi 10.1371/journal.pone.0247763. 12. mgode gf, mhamphi gg, katakweba as, mboera le, machang rs. leptospirosis in tanzania: a neglected cause of febrile illness that needs attention of the health system. national institute for medical research, dar es salaam, tanzania. 2017. 8pp. 13. maze mj, cash-goldwasser s, rubach mp, biggs hm, galloway rl, sharples k j, et al. risk factors for human acute leptospirosis in northern tanzania. plos negl trop dis. 2018 jun 7; 12(6): 1 – 22. doi: 10.1371/journal.pntd.0006372. 14. mgode gf, japhary mm, mhamphi gg, kiwelu i, athaide i, machang’u rs. leptospirosis in sugarcane plantation and fishing communities in kagera northwestern tanzania. plos negl trop dis. 2019 may 31;13(5): 1 – 12. doi: 10.1371/journal.pntd.0007225. 15. motto sk, shirima gm, de clare bronsvoort bm, cook eaj. epidemiology of leptospirosis in tanzania: a review of the current status, serogroup diversity and reservoirs. plos negl trop dis. 2021 nov 16;15(11): 1 – 17. 10.1371/journal.pntd.0009918. 16. crump ja, morrissey ab, nicholson wl, massung rf, stoddard ra, galloway, rl, et al. etiology of severe nonmalaria febrile illness in northern tanzania: a prospective cohort study. plos negl trop dis. 2013 jul 18;7(7): 1 – 8. doi: 10.1371/journal.pntd.0002324. 17. masunga ds, rai a, abbass m, uwishema o, wellington j, uweis l, et al. leptospirosis outbreak in tanzania: an alarming situation. ann med surg (lond). 2022 aug 6;80(104347): 1 – 5. doi: 10.1016/j.amsu.2022.104347. 18. ali ma, james oc, mohamed aa, mubi m, omodior o. etiologic agents of fever of unknown origin among patients attending mnazi mmoja hospital, zanzibar. j community health. 2020 oct; 45(5): 1073 – 1080. doi 10.1007/s10900-020-00832-w. 19. monroe a, msaky d, kiware s, tarimo bb, moore s, haji k., et al. patterns of human exposure to malaria vectors in zanzibar and implications for malaria elimination efforts. malar j. 2020 jun 22;19(1): 1 – 14. doi: 10.1186/s12936-020-03266-w. 20. smz. zanzibar health sector strategic plan iii 2013/142018/19. ministry of health zanzibar, zanzibar; 2013. 21. urt. national population and house census of tanzania. national bureau of statistics, dar es salaam, tanzania; 2022. 22. tejada jj, punzalan jrb. on the misuse of slovin’s formula. the philippine statistician. 2012; 61(1): 129 – 136. 23. goris mg, leeflang mm, loden m, wagenaar jf, klatser pr, hartskeerl ra, et al. prospective evaluation of three rapid diagnostic tests for diagnosis of human leptospirosis. plos negl trop dis. 2013 jul 11;7(7): 1 – 11. doi: 10.1371/journal.pntd.0002290. 24. assenga ja, matemba le, muller sk, mhamphi gg, kazwala rr. predominant leptospiral serogroups circulating among humans, livestock and wildlife in katavi-rukwa ecosystem, tanzania. plos negl trop dis. 2015 mar 25;9(3): 1 – 14. doi: 10.1371/journal.pntd.0003607. 25. muller sk, assenga ja, matemba le, misinzo g, kazwala rr. human leptospirosis in tanzania: sequencing and phylogenetic analysis confirm that pathogenic leptospira species circulate among agropastoralists living in the katavi-rukwa ecosystem. bmc infect dis. 2016 jun 10;16(1): 1 – 9. doi: 10.1186/s12879016-1588-x. 26. biggs hm, bui dm, galloway rl, stoddard ra, shadomy sv, morrissey ab, et al. leptospirosis among hospitalized febrile patients in northern tanzania. am j trop med and hyg. 2011 aug; 85(2): 275 – 81. doi: 10.4269/ajtmh.2011.11-0176. 27. rafizah an, aziah bd, azwany yn, imran mk, rusli am, nazri sm, et al. a hospital-based study on seroprevalence of leptospirosis among febrile cases in northeastern malaysia. int j infect dis. 2013 jun;17(6): 394 – 397. doi: 10.1016/j.ijid.2012.12.012. 28. nepal hp, acharya a, gautam r, shrestha s, ansari s, paudel r, et al. serological study of leptospirosis in central nepal. international journal of biomedical and advance research. 2013; 4(7): 455 – 459. 29. ribeiro p, bhatt n, ali s, monteiro v, da silva e, balassiano it, et al. seroepidemiology of leptospirosis among febrile patients in a rapidly growing suburban slum and a flood-vulnerable rural district in mozambique 2012– 2014: implications for the management of fever. int j infect dis. 2017 nov; 64:50 – 57. doi: 10.1016/j.ijid.2017.08.018. 30. wambi r, worodria w, muleme j, aggrey s, mugisha l. prevalence of leptospirosis among patients attending renal and general outpatient clinics in mulago hospital, kampala, uganda. sci rep. 2022 may 19;12(1): 1 – 7. doi: 10.1038/s41598-022-12544-3. 31. chipwaza b, mhamphi gg, ngatunga sd, selemani m, amuri m, mugasa jp. prevalence of bacterial febrile illnesses in children in kilosa district, tanzania. plos negl trop dis. 2015 may 8;9(5):1 – 18. doi: 10.1371/journal.pntd.0003750. 32. barragan v, chiriboga j, miller e, olivas s, birdsell d, hepp c, et al. high leptospira diversity in animals and humans complicates the search for common reservoirs of human disease in rural ecuador. plos negl trop dis. 2016 sep 13;10(9): 1 – 14. doi: 10.1371/journal.pntd.0004990. 33. regmi l, pandey k, malla m, khanal s, pandey bd. sero-epidemiology study of leptospirosis in febrile patients ally aa, journal of ideas in health (2023); 6(1):820-827 827 from terai region of nepal. bmc infect dis. 2017 sep 18;17(1): 1 – 6. doi: 10.1186/s12879-017-2733-x. 34. del valle-mendoza j, palomares-reyes c, carrillo-ng h, tarazona-castro y, kym s, aguilar-luis ma, et al. leptospirosis in febrile patients with suspected diagnosis of dengue fever. bmc res notes. 2021 may 29;14(1): 1 – 6. doi: 10.1186/s13104-021-05627-3. 35. kakita t, okano s, kyan h, miyahira m, taira k, kitashoji e. laboratory diagnostic, epidemiological, and clinical characteristics of human leptospirosis in okinawa prefecture, japan, 2003–2020. plos negl trop dis. 2021 dec 14;15(12): 1 – 15. doi: 10.1371/journal.pntd.0009993. 36. ricardo t, bergero lc, bulgarella ep, previtali ma. knowledge, attitudes and practices (kap) regarding leptospirosis among residents of riverside settlements of santa fe, argentina. plos negl trop dis. 2018 may 7;12(5): 1 – 19. doi: 10.1371/journal.pntd.0006470. 37. hagan je, moraga p, costa f, capian n, ribeiro gs, wunder jea, et al. spatiotemporal determinants of urban leptospirosis transmission: four-year prospective cohort study of slum residents in brazil. plos negl trop dis. 2016 jan 15;10(1): 1 – 16. doi: 10.1371/journal.pntd.0004275. 38. narkkul u, thaipadungpanit j, srisawat n, rudge jw, thongdee m, pawarana r, et al. human, animal, water source interactions and leptospirosis in thailand. sci rep. 2021 feb 5;11(1): 1 – 13. doi: 10.1038/s41598-02182290-5. 39. mgode gf, machang’u rs, mhamphi gg, katakweba a, mulungu ls, durnez l, et al. leptospira serovars for diagnosis of leptospirosis in humans and animals in africa: common leptospira isolates and reservoir hosts. plos negl trop dis. 2015 dec 1; 9(12): 1 – 19. doi: 10.1371/journal.pntd.0004251. 40. mirambo mm, silago v, msemwa b, nyawale h, mgomi mg, madeu jm, et al. seropositivity of leptospira spp. antibodies among febrile patients attending outpatient clinics in mwanza, tanzania: should it be included in routine diagnosis? trop med infect dis. 2022 aug 9;7(8): 1 8. doi: 10.3390/tropicalmed7080173. https://doi.org/10.47108/jidhealth.vol5.iss4.264 odisho sk & mohammad fk., journal of ideas in health 2022;5(4):786-793 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access blood cholinesterase activities and oxidative stress status among farmworkers using pesticides in duhok, krg, iraq simona khamo odisho1, fouad k. mohammad2* abstract background: the use of pesticides by farmworkers poses considerable health risks. this study was undertaken to examine plasma and erythrocyte cholinesterase activities, plasma oxidative biomarkers malondialdehyde (mda), and total antioxidant status (tas) among farmworkers using different pesticide products in duhok, northern of iraq. methods: this is a case-control study conducted between november 2021 to july 2022 on 92 male farmworkers who were exposed to pesticides in comparison with 44 non-exposed male subjects (control). the availability and uses of pesticides were obtained from 19 agrochemical shops and the farmworkers exposed to pesticides. demographic data of pesticide-exposed farmworkers and their practice of pesticide applications were recorded. plasma and erythrocyte cholinesterase activities and plasma mda and tas levels were determined in both groups. results: the farmworkers had a significant 10.0% increase in plasma mda level, with no significant changes in blood cholinesterase activities or the tas level. odds and risk ratios of reduced plasma cholinesterase activity (20.0%) suggested an association of health risks in pesticide-exposed farmworkers. most of the pesticide products (278) in use were insecticides (47.0%), which comprised mainly 26.0% pyrethroids and 3.0-7.0% anticholinesterase insecticides, among others. the majority of the farmworkers (51%) were merely aware of the general target use of the pesticide, and 75% had an exposure history of > 5 years. pesticide application was mostly (50.0%) manual, and 54.0% used insufficient personal protection equipment; 32.0% ate and drank at work, 48.0% practiced disposal of empty pesticide containers by burning and/or burying them, whereas 25.0% dumped the containers indiscriminately, and 25% disposed them at garbage sites openly. conclusion: the farmworkers, with only a marginal increase in oxidative stress biomarker mda, did not suffer from significant reductions in blood cholinesterase activities, although odds and risk ratios of reduced plasma cholinesterase activity suggested a health risk. implementation of a national program is needed to measure pre-exposure blood cholinesterase activities in farmworkers. keywords: farmers, insecticides, oxidative biomarker, plasma cholinesterase, iraq background pesticides are chemical substances used to control harmful organisms in agriculture, public health, and veterinary clinical practice [1-5]. they are generally classified as insecticides, herbicides, fungicides, biocides, rodenticides, molluscicides, nematicides, pediculicides, and plant growth regulators [1,2,4,5]. pesticides are increasingly used worldwide to protect crops from infestations with pests and increase crop productivity that eventually poses health risks to the environment and users such as farmworkers [1,3,5-9]. exposure of farmworkers to pesticides which gain entry to the body and systemic circulation usually occurs through dermal, oral, and respiratory routes as well as through the eyes and ears if proper protective measures are not taken [1,2,8-10]. this usually occurs during planting, spraying, harvesting, and packing activities in agriculture as well as through other activities related to direct or indirect pesticide applications [1,9,10]. the pesticide marketplace is undergoing a global expansion, especially in developing countries [3,7,11]. pesticide products can be obtained easily by farmers, as they are sold as over-thecounter formulations in many countries, including iraq [11-14], with the possibility of misuse and mishandling of the products [12]. based on the wide usage of pesticides, studies universally ___________________________________________________ fouadmohammad@yahoo.com 2department of physiology, biochemistry and pharmacology, college of veterinary medicine, university of mosul, mosul, iraq a full list of author information is available at the end of the article 10.47108/jidhealth.vol5.iss4.264 http://www.jidhealth.com/ odisho sk & mohammad fk., journal of ideas in health (2022); 5(4):786-793 787 indicated their environmental hazards and health risks in man and animals [2-5,8,15]. the availability of pesticide products in the local iraqi market is not fully controlled or known. one study reported the types of pesticides used in greenhouses in sulaimani, iraq [14]. they were mainly insecticides and herbicides [14]. studies have been conducted in iraq for biomonitoring exposure of agricultural workers, farmers, and veterinarians to pesticides, and they reported variably low blood cholinesterase (che) activities but with limited information on the types of pesticides used, their frequency of application, and the extent of exposure [16-20]. a study conducted in mosul found 21.0%-30.0% decreases in plasma (pche) or erythrocytes (eche) che activities in agriculture workers and veterinarians [17]. however, in another study performed in erbil, pche in agriculture workers and veterinarians exposed to pesticides for up to 19 years was below control levels by only 11.0% and 10.0%, respectively [18]. subsequently, in a similar study in kirkuk, the whole blood che activity of agriculture workers after six years of exposure was 22.0% below control values [16]. a single study conducted in duhok found 14.0% and 4.0% reductions in pche and eche activities, respectively, in pesticide-exposed farmworkers in comparison to unexposed ones [20]. pesticide exposure of agricultural workers and those involved in handling and dispensing pesticides can be monitored biologically by examining pche or eche activities [8,20-22], monitoring oxidative status such as plasma malondialdehyde (mda) [8,23], as well as by analysis of concentrations of pesticides or their metabolites in human biological samples [24]. the studies which have been conducted in iraq [16-18,20] suggested a marginal blood che inhibition, though important from a risk assessment point of view. this enzyme inhibition, however, is difficult to assess or interpret in the absence of pre-exposure blood che activities of the workers [5,25-28]. the aim of study was to examine blood che activities and the levels of the oxidative biomarkers plasma mda and total antioxidant status in farmworkers in duhok, krg, northern of iraq. the study also included surveying the availability and proper use of pesticides by farmworkers. methods study design and population the present study was a case-control study conducted in duhok, iraq, between november 2021 to july 2022, where pesticideexposed farmworkers (case) were compared with non-exposed control subjects. the study recruited 98 pesticide-exposed male agricultural workers identified as farmworkers who were previously exposed to different types of pesticides during their handling of pesticides and routine work in farms of the duhok province that included zakho (11), sumel (18), mangesh (48), shikhan (12) and baadra (9). of these, a total of 92 pesticideexposed subjects were finally eligible for the study and data analysis. the control group comprised 44 age-matched male subjects who were not exposed previously to pesticides. sample size the samples size of the study was within the acceptable range for clinical research studies, as shown by the online tool (https://www.benchmarksixsigma.com/calculators/sample-sizecalculator-for-2-sample-t-test/), taking into consideration 95.0% confidence level, 80.0% power of the test, with 20.0% difference expected in blood che activities between the pesticide-exposed and control groups. inclusion and exclusion criteria inclusion criteria in the pesticide-exposed subjects of the study were any prior pesticide exposure, age > 15 years, and no recent major surgical procedures. exclusion criteria included nonexposed workers, last exposure to pesticides was >10 years ago, or the presence of chronic diseases such as cancer, liver diseases, and advanced diabetes mellitus. the inclusion and exclusion criteria of the control subjects were the same as the case group, with the exception of the pesticide exposure status. data collection pesticide products in use to examine the types of pesticides in use by farmworkers, a survey was conducted on 19 agrochemical shops in seven marketplace locations of the duhok region, which included duhok, sumel, zakho, qedsh, sarsing, akre, and shikhan. farmers usually purchase their agrochemicals, including the pesticides needed, from these shops. types of pesticides available in these agrochemical shops were identified according to the chemical nature of the active ingredient(s) and usage target [1,6], and whenever possible, they were classified as per who criteria [10]. the pesticide products were also tabulated according to their formulation as a single active ingredient or a combination of two or more pesticides in the product. data were collected by visiting each agrochemical shop in person to record the types of pesticide products available for the farmers or agriculture workers to buy. the purpose of the study was clearly explained to every shop owner and/or attendant. demographic information a structured questionnaire was designed to obtain the demographic information of the study subjects, which included age, gender, marital status, educational level, economic status, as well as any pesticide exposure information such as the type of pesticide used, years of working in farms, age of first exposure at the farm, home exposure if any and the practice of using personal protective equipment (ppe). laboratory investigations blood samples about five-ml heparinized venous blood samples were obtained from all study subjects by a qualified assistant. the plasma was separated from the erythrocyte by centrifugation at 3000 rpm for 15 min. and kept in deep freeze at –20 ºc pending analysis within one month. determination of blood che activity a modified electrometric method was used to determine pche and eche activities using 0.2 ml of plasma or erythrocytes aliquots, respectively [20,29,30]. the enzyme reaction mixture contained, in addition to the blood sample, 3 ml distilled water and 3 ml of ph 8.1 buffer consisting of 1.237 g sodium barbital, 0.163 g potassium dihydrogen phosphate, and 35.07 g sodium chloride/l of distilled water. the ph1 of the mixture was measured with the glass electrode of a ph meter (ph700, eutech instruments, singapore) before the addition of 0.1 ml of 7.1% acetylcholine iodide substrate. after incubation in a water odisho sk & mohammad fk., journal of ideas in health (2022); 5(4):786-793 788 bath at 37 ºc for 20 min, the ph2 of the mixture was measured. blood che activities of all the subjects were estimated [20,29,30] as follows: pche or eche activity ( ph/20 min) = (ph1 – ph2) –  ph of blank (no blood sample). calculation of odds and risk ratios observed and expected cases of 20% reduction in pche activity [28] among pesticide-exposed farmworkers and the control group were used to calculate odds and risk ratios of the association of having such a low pche activity with applying pesticides in pesticide-exposed farmworkers. we derived the expected case numbers using a pche activity (δ ph/20 min) ≤ 0.9. accordingly, a table of odds ratios of pesticide-exposed farmworkers and their control counterparts was constructed [31]. determination of plasma mda level a spectrophotometric method [32] was used to determine plasma mda level as follows: in a dry test tube containing 0.25 ml of plasma aliquot, 2 ml of tba reagent (0.375% w/v thiobarbituric acid, with 20% w/v trichloroacetic acid dissolved in 0.25n hcl) were added and mixed well. the test tubes with glass marbles on top were placed in a boiling water bath for 15 min. after cooling, the mixtures were centrifuged at 4000 rpm for 10 min. the absorbance of the supernatant solution was read by a spectrophotometer (apel, pd-307, japan) at 535 nm against the blank. plasma mda level (μmol/l) was estimated as follows: mda (μmol/l) = (absorbance of test – absorbance of blank) *106 / 156000 the calculation of plasma mda level was also verified using an online tool (https://www.omnicalculator.com/chemistry/beerlambert-law). determination of plasma tas the plasma tas was determined using a colorimetric assay kit (elabscience biotechnology inc., usa) and a microplate reader (elx800, biotek, usa) at 660 nm. statistical analysis all data were statistically analyzed using the statistical software programpast4.09: (https://www.nhm.uio.no/english/research/resources/past/). categorical variables were expressed as frequencies and percentages. unpaired student's -t-test was applied for comparison between the means of the two groups. odds ratios and risk ratios were estimated for cases of observed and expected low pche activity. whenever applicable, the chisquared test was applied to the frequencies, and the z score was calculated for two population proportions via the statistical tool at https://www.socscistatistics.com/tests/ztest/default.aspx. the level of statistical significance was p < 0.05. results descriptive and general characteristics of related factors the mean (± sd) ages of pesticide-exposed farmworkers and their control counterparts were very close to each other (43 ± 13.5 vs. 43.7 ± 13.8 years). primary school was the major education level of the farmworkers (40.0%), whereas 41.0% of them did not have any formal education level (table 1). other demographic data of the participants (education level, cigarette smoking, alcohol consumption, marital status) are also shown in table 1. table 1: demographic data of male farmworkers and control subjects who participated in the study from different regions of duhok, krg, northern of iraq variables not exposed to pesticides n= 44 exposed to pesticides n= 92 age (mean ± sd years) 43.7 ± 13.8 43 ± 13.5 education level primary school 21 (47.7%) 37 (40.2%) high school 10 (22.7%) 8 (8.7%) college 11 (25.0%) 9 (9.8%) none 2 (4.6%) 38 (41.3%) smoking habit 27 (61.4%) 39 (42.4%) non-smoking habit 17 (38.6%) 53 (57.6%) alcohol consumption 17 (38.6%) 16 (17.4%) non-alcohol consumption 27(61.4%) 76(82.6%) married 36 (81.2%) 82 (89.1%) unmarried 8 (18.8%) 10 (10.9) according to the survey, which included 19 agricultural shops in the duhok region, it was found that the total number of pesticide products for agricultural use by farmers was 278, of which 26.0% were pyrethroids, followed by 19.0% miscellaneous pesticides, 12.0% two or more pesticides in combination, 9.0% neonicotinoids, 7.0% glyphosate, 6.0% organophosphates, 6.0% avermectins and milbemycin, 5.0% phenoxy-propionates, 4.0% benzimidazoles 3.0% triazoles, and 3.0% carbamates (table 2). of the 278 types of pesticide products, insecticides comprised 47.0% of the pesticides in use, followed by fungicides 19.0%, herbicides 16.0%, combinations 14.0%, acaricides 3.0%, and miscellaneous 1.0% (figure 1). table 2: classification of commercial pesticides based on their chemical natures with corresponding percentages, which are available in the duhok (krg, iraq) marketplace pesticides type number of products % pyrethroids 72 26 miscellaneous* 53 19 combination** 34 12 neonicotinoids 26 9 organophosphate-like compounds (glyphosate) 20 7 organophosphates 16 6 avermectins, milbemycin 16 6 aryloxy phenoxypropionates 15 5 benzimidazole (group 1) 11 4 triazoles 8 3 carbamates 7 3 total 278 100 *miscellaneous (each < 2%). **various products contain 2 or more mixtures of pesticides. odisho sk & mohammad fk., journal of ideas in health (2022); 5(4):786-793 789 figure 1: percentages of classification and commercial types of pesticide products (total 278) available in the market place of duhok (krg, iraq) for agricultural use by farmworkers. *various products containing 2 or more mixtures of pesticides [(insecticide, acaricide and miticide), (insecticide, acaricide, nematicide, metabolite, veterinary substance), (insecticide, acaricide), (insecticide, veterinary substance; insect growth regulator), (fungicide, bactericide), (fungicide, insecticide), (fungicide, nematicide)]. **miscellaneous (< 1 %) consisted of molluscicides and nematicide. upon meeting the farmers, they were all aware of the possible adverse effects of the pesticides; however, they did not know what to expect after the pesticide exposure, nor did they recognize the potential toxicity of such an exposure. this was reflected by their ignorance (49.0%) of the type (or the use) of pesticides they are dealing with (table 3). the rest of them (51.0%) were merely aware of the general target use (e.g., insecticide or herbicide) of the pesticide. most of the farmworkers (75.0%) had an exposure history of > 5 years, and 64.0% were exposed to pesticides within a year (table 3). pesticide application was mostly (50.0%) done manually or even openly (41.0%) using a tractor (table 3). the use of proper ppe was also assessed, and only 54.0% of the farmworkers used some sort of protection, such as gloves, masks, and head covers, but still not a complete one (table 3). the attitude and behavior of the farmworkers in the field reflected that 32% of them eat and drink at the work area; only 48% practiced the disposal of empty pesticide containers by burning and/or burying them in the field, and strangely enough, 25% of them dumped the containers indiscriminately and unattended in the field, whereas 25% disposed them at open garbage collection sites (table 3). comparison of pche and eche activities, as well as plasma tas levels between the pesticide-exposed farmworkers and the control group, did not reveal significant statistical differences (tables 4 and 5). however, the plasma mda level of the pesticide-exposed farmworkers significantly increased by 10% (p= 0.022) in comparison with the control value (table 5). table 3: the availability of information on the use of pesticides by farmworkers (n= 92) exposed to pesticide products in a different region of duhok, krg, northern of iraq variable no. of farmworkers (%) types of pesticides used unknown 45 (48.9) known (general target use) 47 (51.1) years of exposure 1-5 23 (25.0) > 5 69 (75.0) last exposure < 1 month 30 (32.6) within a year 59 (64.1) > 1 year 3 (3.3%) type of pesticide application manual backpack sprayer 46 (50.0) automatic backpack sprayer 8 (8.7) using a tractor (open) 38 (41.3) use of personal protection equipment none 42 (45.7) some sort of protection 50 (54.3) eat and drink in the field yes 29 (31.5) no 63 (68.5) disposal of empty containers by farmworkers buried/ burned 44 (47.8) dumped indiscriminately 23 (25.0) garbage collection sites (open air) 23 (25.0) did not know 2 (2.2) table 4: comparison of plasma and erythrocyte cholinesterase (che) activities (δ ph/20 min) of pesticide-exposed and agematched unexposed (control) male subjects group n plasma che % inhibition erythrocyte che % inhibition control 44 1.10 ± 0.195 1.38 ± 0.141 exposed 92 1.07 ± 0.192 3 1.39 ± 0.101 0 values are mean ± sd table 5: comparison of plasma malondialdehyde (mda) level and total plasma antioxidant status (tas) level in pesticideexposed male subjects and age-matched unexposed-controls subjects n† plasma mda (μmol/l) p-value tas (mmol trolox equiv/l) p-value control 44 2.79 ± 0.540 1.34 ± 0.354 exposed 92 3.07 ± 0.677* < 0.022 1.34 ± 0.326 0.94 values are mean ± sd. †one outlier value from each group was omitted from the statistical analysis. *significantly different from the corresponding control value, p < 0.05. 47 19 16 14 3 1 % pesticides insecticides fungicides herbicides combination* acaricides miscellaneous** odisho sk & mohammad fk., journal of ideas in health (2022); 5(4):786-793 790 it was noticed that farmworkers who did not use any sort of ppe had significantly lower eche activity by 6% in comparison to the control group (table 6). the activity of pche was not significantly different between the two groups (table 6). when a reduction of 20% in pche activity (≤ 0.9 δ ph/20 min) was taken into consideration (cases) to construct the table of the odds ratio of farmworkers (table 7), it was found that values of the odds ratio and the risk ratio of occurrence of such reduced pche activities were 1.33 and 1.26, respectively (table 8). these values indicated an association between having cases of low pche activities with applying pesticides in pesticideexposed farmworkers (table 8). table 6: comparison of plasma (pche) and erythrocyte (eche) cholinesterase activities (δ ph/20 min) between farmworkers using a method for personal protection (ppe) compared to those not using any protection use of ppe n (%) pche eche use ppe 50 (54.3%) 1.10 ± 0.189 1.43 ± 0.083 none 42 (45.7%) 1.05 ± 0.194 1.35 ± 0.099* values are mean ± sd *significantly different from those with no protection, p < 0.05. table 7: odds ratio table of the frequency of occurrence of plasma cholinesterase activity (pche) ≤ 0.9 δ ph/20 min* in pesticide-exposed and non-exposed control subjects groups ≤ 0.9 δ ph/20 min > 0.9 δ ph/20 min total exposed 21 (22.8%) 71 (77.2%) 92 control 8 (18.2%) 36 (81.8%) 44 *a reduction of 20% in pche activity was taken into consideration, according to wilson et al. [28]. table 8: results of odds and risk ratios of 20% reduction in plasma cholinesterase (pche) activity in pesticide-exposed and non-exposed control subjects. parameters results odds ratio 1.33 95% confidence interval 0.537, 3.299 p (ratio =1) 0.54 risk ratio 1.26 95% confidence interval 0.605, 2.607 p (ratio =1) 0.54 discussion the present study reflects the diversity of pesticides available in the marketplace of the duhok region (iraq) for agricultural use by farmworkers. these pesticides, according to their target use, were mostly insecticides (47.0%). all pesticide products, including insecticides, were available on an over-the-counter basis without the supervision of health authorities or extension services. this condition predisposes users to the potential toxicity of pesticides [2,7,12,33]. the majority of the farmworkers (41.0%) had no formal education, whereas 40.0% had only a primary school education. this low level of formal education (or none at all) precludes the farmworkers from gaining proper information on pesticide precautions, usage, and application, as well as disposal of pesticide containers [33]. taking all these factors together, namely, uncontrolled purchase and use of pesticides, disposal practice of containers, and the low educational level, there would be a threat to human health, farm animals, and the environment [2,12,34,35]. being within the middle age group (43 ± 13.5 years), it is strongly recommended to enroll farmworkers of the duhok region in extension educational programs on the proper use and disposal of pesticides [36]. we noticed that 46% of farmworkers did not use ppe, and the rest did not use ppe properly. furthermore, the method of pesticide application was manual (50.0%) or even applied openly via a tractor (41.0%). all these practices, together with improper disposal of pesticide containers and the habit of drinking and eating on the farm, unequivocally increase the risk of pesticide exposure through dermal contamination, inhalation, and ingestion of pesticides during the preparation, handling, and application of pesticide products [34,37,38]. it was speculated that the improper use of ppe may be associated with illiteracy or low education level and lack of training [39]. in support of the present notion about using ppe, we found that farmworkers who did not use any sort of ppe had lower eche activity (6.0%) in comparison to the control group (table 6). however, the adoption of precautionary measures in dealing with pesticide applications and proper disposal practices would reduce the potential health and environmental risks associated with pesticide use by farmworkers [34,38]. in the present study, pche and eche activities of pesticideexposed farmworkers were not significantly different from those of the control group (table 4). many studies have reported reduced blood che activity in farmers handling pesticides, especially the organophosphates [2,8,1517,20,22,23,25,31,37,39]. the reason for this discrepancy could be related to the fact that pre-exposure pche and eche values of farmworkers of the present study were not known, as measuring pre-exposure che activity of farmworkers is not practiced in our region. a significant marginal decrease in pche (14.0%), but no eche activity was reported in duhok region farmers [20]. however, in the present study, as in the previous one [20], the types of the che-inhibiting pesticides used (other than calling them insecticides) could not be verified. within this context, the present study reported that theinhibiting insecticides organophosphates and carbamates comprised only 7.0% and 3.0% of the pesticides used, respectively (table 2). usually, reduced blood che activity is attributed to organophosphates since, contrary to carbamates, they are non-reversible che inhibitors [5,25-28]. furthermore, in accordance with previous studies in iraq [16-18,20], acupesticide intoxication of farmworkers was not reported in the present study. therefore, we can deduct from these reports and ours that exposure of farmworkers to pesticides was limited in intensity and/or toxic doses involved. according to the current situation involving the present interpretation of blood che activities, we strongly recommend establishing an iraqi national plan such as that of california to assess the health status of farmworkers and prevent their overexposure to insecticides by recording their pre-exposure blood che activities for future post-exposure definitions and comparisons [28,37,40,41]. in support of such a national plan, the marginal reduction of eche activity (6.0%) in farmworkers odisho sk & mohammad fk., journal of ideas in health (2022); 5(4):786-793 791 not using any ppe in the present study could have been subjected to a different interpretation if the pre-exposure che activity (baseline) were available. additional support was introduced by the finding of the present study that the assessment of odds and the risk ratios of occurrence of reduced pche activity (20.0%) were 1.33 and 1.26, respectively, suggesting, in spite of the wide 95.0% ci, an association of having low pche activity with pesticide application in pesticide-exposed farmworkers. a similar finding was reported when an association between blood che activity and organophosphate pesticide residues was examined in thailand (adjusted or = 2.09, 95%ci: 0.63-6.99) [42]. furthermore, a study conducted in ethiopia on women farmers exposed to pesticides did not find significant changes in blood che activities in comparison to the non-exposed group [43]. also, one study reported in a farm that active pesticide sprayers (4 out of 47), but not other pesticide handlers, had low pche activity [44]. however, a cut point of 20% reduction in blood che activity was challenged by others, and it was found that a 15% reduction could be a better indicator for the expected significant change [45]. nonetheless, according to the washington state department of labor and industries, the 20% reduction in an individual's blood che activity from baseline value suffices to initiate inquiries addressing the worker and workplace conditions [37]. a comparison of plasma mda and tas levels between the pesticide-exposed farmworkers and the control group revealed a significant increase in the mda level (10%) with no changes in the tas level (table 5). these results corresponded to the nonsignificant changes we noticed in the pche and eche activities of the same farmworkers. however, farmworkers exposed to pesticides with reduced blood che activities were reported to show concomitantly oxidative stress, which was revealed as increases in oxidative stress biomarkers in the blood such as plasma mda level, tas, and total antioxidant capacity [8,23,46,47]. it is worth mentioning that nonsignificant changes in oxidative stress biomarkers could be expected concomitantly with no che inhibition [43]. according to the findings of the present study with regards to oxidative biomarkers, which showed a marginal increase in the plasma mda level, it is recommended to further include other blood chemical and biochemical tests to evaluate the health status of farmworkers more properly. indeed, we attempted this approach in our exposed subjects and found changes in serum creatinine and some electrolyte levels (msc thesis of the present 1st author, unpublished data). because of the potential occupational health risks of pesticides, several studies have also reported changes in biochemical blood variables other than che activity and oxidative stress biomarkers [48-50]. the present study suggests that regular monitoring of blood biochemical parameters and che activity as health risk assessments could be effective measures to control the exposure of farmworkers to pesticides. last, we were unable to perform 30-day and long-term followup, which should be aimed at further studies. conclusion various types of pesticides are available for use by farmworkers, who do not abide completely by protection rules, and the most commonly used pesticides were pyrethroids, and che-inhibiting insecticides were of lower use and application. the farmworkers, with only a marginal increase in the oxidative stress biomarker mda, did not suffer from significant reductions in blood che activities, although odds and risk ratios of reduced pche activity suggested a health risk in pesticideexposed ones. we strongly recommend the implementation of a national program to measure pre-exposure blood che activities and possibly other blood biochemical variables in farmworkers engaged in pesticide application and/or handling. abbreviation che: cholinesterase; eche: erythrocyte cholinesterase; mda: malondialdehyde; pche: plasma cholinesterase; sd: standard deviation; tas: total antioxidant status. declaration acknowledgment the authors greatly acknowledge the cooperation of all study subjects involved in donating blood samples for the present research project. the authors thank the college of pharmacy for the support and for providing facilities to conduct this research. this report represents a portion of a thesis to be submitted by the first author to the university of duhok, krg, northern of iraq, in partial fulfillment of the requirements for an msc degree in toxicology. funding the study was supported by the university of duhok, duhok, krg, iraq. availability of data and materials data will be available by emailing semona.91@gmail.com. authors’ contributions simona khamo odisho (sko) executed the survey and laboratory assays, acquired the data, conducted literature search and statistical analyses, and shared in drafting the manuscript. fouad k. mohammad (fkm) conceptualized and supervised the study, shared in literature search and statistical analyses, and drafted the manuscript. both authors have read and approved the final version of the manuscript. all authors read and approved the final version of the manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the protocol of the study was approved by the research ethics committee, duhok directorate general of health, ministry of health, krg, iraq (no. 10112021-11-2 on november 10, 2021) as well as by the committee of post graduate studies in the college of pharmacy, university of duhok, krg, iraq (no. 535, october 28, 2021) with the approval of the university of duhok (no. 8813, october 31, 2021). written consent consented from individuals participate who d in the study. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication odisho sk & mohammad fk., journal of ideas in health (2022); 5(4):786-793 792 waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of pharmacology, college of pharmacy, university of duhok, krg, iraq. 2department of physiology, biochemistry and pharmacology, college of veterinary medicine, university of mosul, mosul, iraq. article info received: 21 november 2022 accepted: 27 december 2022 published: 29 december 2022 references 1. pandya iy. pesticides and their applications in agriculture. asian j appl sci technol. 2018;2(2):894-900. 2. rashid s, rashid w, tulcan rxs, huang h. use, exposure, and environmental impacts of pesticides in pakistan: a critical review. environ sci pollut res int. 2022;29(29):43675-43689. doi: 10.1007/s11356-022-20164-7. 3. tudi m, daniel ruan h, wang l, lyu j, sadler r, connell d, chu c, phung dt. agriculture development, pesticide application and its impact on the environment. int j environ res public health. 2021;18(3):1112. doi: 10.3390/ijerph18031112. 4. baynes re. ectoparasiticides. in: riviere je, papich mg (eds). veterinary pharmacology and therapeutics. 10th edition. hoboken, nj, usa: wiley blackwell & son, inc. 2018; 1166-1187. 5. wilson bw. cholinesterase inhibition. in: wexler p (ed). encyclopedia of toxicology. 3rd ed. amesterdam: elsevier 2014; 942-951. 6. who. who recommended classification of pesticides by hazard and guidelines to classification, 2019 edition. geneva: world health organization; 2020. 7. who. global situation of pesticide management in agriculture and public health. geneva: world health organization and food and agriculture organization of the united nations; 2019. 8. samareh a, asadikaram g, mojtabaabbasi-jorjandi, abdollahdokht d, abolhassani m, khanjani n, nematollahi mh. occupational exposure to pesticides in farmworkers and the oxidative markers. toxicol ind health. 2022;38(8):455-469. doi: 10.1177/07482337221106754. 9. rajmohan ks, chandrasekaran r, varjani s. a review on occurrence of pesticides in environment and current technologies for their remediation and management. indian j microbiol. 2020;60(2):125-138. doi: 10.1007/s12088-019-00841-x. 10. saravi sss, shokrzadeh m. role of pesticides in human life in the modern age: a review. in: stoytcheva m, editor. pesticides in the modern world risks and benefits rijeka, croatia: in tech; 2011. 11. ecobichon dj. pesticide use in developing countries. toxicology. 2001;160(1-3):27-33. doi: 10.1016/s0300-483x(00)00452-2. 12. ben khadda z, fagroud m, el karmoudi y, ezrari s, berni i, de broe m, behl t, bungau sg, sqalli houssaini t. farmers' knowledge, attitudes, and perceptions regarding carcinogenic pesticides in fez meknes region (morocco). int j environ res pub health. 2021;18(20):10879. doi: 10.3390/ijerph182010879. 13. jongerden j, wolters w, dijkxhoorn y. explorative study agricultural development in iraq and the federal kurdistan autonomous region; 2018. https://www.government.nl/documents/reports/2018/11/09/explor ative-study-agricultural-development-in-iraq-and-the-federalkurdistan-autonomous-region (accessed 7.8.2021). 14. ahmed zfg, majeed bk. a survey study of pesticide application pattern in selected plastic houses in sulaimani governorate/iraq. j z sulaimani. (university of sulaimani). 2020;2: 63-76. 15. lopes-ferreira m, maleski ala, balan-lima l, bernardo jtg, hipolito lm, seni-silva ac, batista-filho j, falcao map, lima c. impact of pesticides on human health in the last six years in brazil. int j environ res pub health. 2022;19(6):3198. doi: 10.3390/ijerph19063198. 16. ahmed as. evaluation of acetylcholine esterase activity in the blood of workers exposed to organophosphate and carbamate insecticides by an electrometric method. kirkuk j sci stud. (university of kirkuk). 2013;3(3): 26-33. 17. ahmed oah, mohammad fk. electrometric determination of blood cholinesterase activities in workers exposed to insecticides in mosul, iraq. r j env. toxicol. 2007;1: 144-148. https://dx.doi.org/10.3923/rjet.2007.144.148 18. al-haseni ana, yahya bm. measurement of plasma cholinesterase activity in field workers. iraqi j pharm. 2012;12(1):41-47. 19. othman ba, kakey es. environmental pesticides residues and health biomarkers among farmers from greenhouses of erbil cucumber crops. iraqi j agric sci. 2020;51(5):1357-1366. 20. mohammed aa, mohammad fk. monitoring blood cholinesterase activity of farmworkers: in vitro inhibition by diphenhydramine and carbaryl. malaysian appl biol. 2022;51:2332. 21. cotton j, edwards j, rahman ma, brumby s. cholinesterase research outreach project (crop): point of care cholinesterase measurement in an australian agricultural community. environ health. 2018;17(1):31. doi: 10.1186/s12940-018-0374-1. 22. assis crd, linhares ag, cabrera mp, oliveira vm, silva kcc, marcuschi m, maciel carvalho evm, bezerra rs, carvalho lb jr. erythrocyte acetylcholinesterase as biomarker of pesticide exposure: new and forgotten insights. environ sci pollut res int. 2018;25(19):18364-18376. doi: 10.1007/s11356-018-2303-9. 23. abbasi-jorjandi m, asadikaram g, abolhassani m, fallah h, abdollahdokht d, salimi f, faramarz s, pournamdari m. pesticide exposure and related health problems among family members of farmworkers in southeast iran. a case-control study. environ pollut. 2020; 267:115424. doi: 10.1016/j.envpol.2020.115424. 24. kapka-skrzypczak l, cyranka m, skrzypczak m, kruszewski m. biomonitoring and biomarkers of organophosphate pesticides exposure state of the art. ann agric environ med. 2011;18(2):294-303. pmid: 22216802. 25. jaga k. dharmani c. sources of exposure to and public health implications of organophosphate pesticides. revista panamericana de salud publica. (pan am j pub health). 2002;14(3):171-185. 26. vale a, lotti m. organophosphorus and carbamate insecticide poisoning. handb clin neurol. 2015;131:149-68. doi: 10.1016/b978-0-444-62627-1.00010-x. 27. wilson, bw. cholinesterase inhibition. in: wexler p (ed). encyclopedia of toxicology. 3rd ed, amesterdam: elsevier; 2014. pp. 942-951. 28. wilson bw, arrieta de, henderson jd. monitoring cholinesterases to detect pesticide exposure. chemico-biol interac. 2005 dec;157-158:253-256. doi: 10.1016/j.cbi.2005.10.043. pmid: 16298353. 29. mohammad fk, alias as, ahmed oa. electrometric measurement of plasma, erythrocyte, and whole blood cholinesterase activities in healthy human volunteers. j med toxicol. 2007;3(1):25-30. doi: 10.1007/bf03161035. 30. mohammad fk. clarifying an electrometric method for determining blood cholinesterase activity: a scientific letter. asia pac j med toxicol. 2022;11(1):30-32. doi: 10.22038/apjmt.2022.19924 31. ciesielski s, loomis dp, mims sr, auer a. pesticide exposures, cholinesterase depression, and symptoms among north carolina migrant farmworkers. am j public health. 1994;84(3):446-51. doi: 10.2105/ajph.84.3.446. 32. buege ja, aust sd. microsomal lipid peroxidation. methods enzymol. 1978; 52:302-10. doi: 10.1016/s0076-6879(78)52032-6. 33. doi: 10.2105/ajph.84.3.446. pmid: 8129063; pmcid: pmc1614838. 34. imoro za, larbi j, duwiejuah ab. pesticide availability and usage by farmers in the northern region of ghana. j health pollut. 2019 aug 6;9(23):190906. doi: 10.5696/2156-96149.23.190906. 35. buczyńska a, szadkowska-stańczyk i. identification of health hazards to rural population living near pesticide dump sites in odisho sk & mohammad fk., journal of ideas in health (2022); 5(4):786-793 793 poland. int j occup med environ health. 2005;18(4):331-9. pmid: 16617849. 36. atreya k, sitaula bk, bajracharya rm. pesticide use in agriculture: the philosophy, complexities and opportunities. sci res essays. 2012;7(25):2168–73. 37. remoundou k, brennan m, hart a, frewer lj. pesticide risk perceptions, knowledge, and attitudes of operators, workers, and residents: a review of the literature. hum ecol risk assess. 2014;20(4):1113–38. doi: 10.1080/10807039.2013.799405. 38. environmental protection agency. pesticides: health and safety. national assessment of the worker protection workshop #3. washington dc, usa: epa; 2007. 39. sharma n, singhvi r. effects of chemical fertilizers and pesticides on human health and environment: a review. int j agric environ biotechnol. 2017;10(6):675–9. 40. neupane d, jørs e, brandt l. pesticide use, erythrocyte acetylcholinesterase level and self-reported acute intoxication symptoms among vegetable farmers in nepal: a cross-sectional study. environ health. 2014; 13:98. doi: 10.1186/1476-069x-1398. 41. lessenger je. fifteen years of experience in cholinesterase monitoring of insecticide applicators. j agromedicine. 2005;10(3):49-56. doi: 10.1300/j096v10n03_06. 42. lessenger je, reese be. rational use of cholinesterase activity testing in pesticide poisoning. j am board fam pract. 1999;12(4):307-14. doi: 10.3122/jabfm.12.4.307. 43. nganchamung t, robson mg, siriwong w. association between blood cholinesterase activity, organophosphate pesticide residues on hands, and health effects among chili farmers in ubon ratchathani province, northeastern thailand. rocz panstw zakl hig. 2017;68(2):175-183. pmid: 28646835. 44. martin-reina j, casanova ag, dahiri b, fernández i, fernándezpalacín a, bautista j, morales ai, moreno i. adverse health effects in women farmers indirectly exposed to pesticides. int j environ res public health. 2021; 18(11):5909. https://doi.org/10.3390/ijerph18115909 45. mekonnen y, ejigu d. plasma cholinesterase level of ethiopian farm workers exposed to chemical pesticide. occup med (lond). 2005;55(6):504-5. doi: 10.1093/occmed/kqi088. 46. quandt sa, chen h, grzywacz jg, vallejos qm, galvan l, arcury ta. cholinesterase depression and its association with pesticide exposure across the agricultural season among latino farmworkers in north carolina. environ health perspect. 2010;118(5):635-9. doi: 10.1289/ehp.0901492. 47. abdollahdokht d, asadikaram g, abolhassani m, pourghadamyari h, abbasi-jorjandi m, faramarz s, nematollahi mh. pesticide exposure and related health problems among farmworkers' children: a case-control study in southeast iran. environ sci pollut res int. 2021;28(40):57216-57231. doi: 10.1007/s11356-021-14319-1. 48. curl cl, spivak m, phinney r, montrose l. synthetic pesticides and health in vulnerable populations: agricultural workers. curr environ health rep. 2020;7(1):13-29. doi: 10.1007/s40572-02000266-5. 49. dereumeaux c, mercier f, soulard p, hulin m, oleko a, pecheux m, fillol c, denys s, quenel p. identification of pesticides exposure biomarkers for residents living close to vineyards in france. environ int. 2022; 159:107013. doi: 10.1016/j.envint.2021.107013. 50. soulard p, dereumeaux c, mercier f. determination of biomarkers of exposure to boscalid, captan, folpel, mancozeb, and tebuconazole in urine and hair samples. methodsx. 2022; 9:101671. doi: 10.1016/j.mex.2022.101671. 51. hayat k, afzal m, aqueel ma, ali s, saeed mf, qureshi ak, ullah mi, khan qm, naseem mt, ashfaq u, damalas ca. insecticide toxic effects and blood biochemical alterations in occupationally exposed individuals in punjab, pakistan. sci total environ. 2019; 655:102-111. doi: 10.1016/j.scitotenv.2018.11.175. https://doi.org/10.47108/jidhealth.vol5.iss3.245 kareem qn, et al., journal of ideas in health 2022;5(3):739-747 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author (s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access human cytomegalovirus and relationship with abortion among iraqi females: a systematic review qabas naser kareem1, areej atiyah hussein1, shahad khudhair khalaf 1* abstract background: human cytomegalovirus (hcmv) seroprevalence is a significant health problem, especially among pregnant women in lower socioeconomic societies. this study aims to explore the prevalence of hcmv infections among women in iraq. methods: a systematic review was designed to collect and summarize articles concerning the relationship between hcmv infection and abortion in iraq. we identified the titles and abstracts of the publications from 2008 to 2022. a predefined keyword was recruited to recognize the publications and filter the articles to eliminate duplication and remove irrelevant articles. in the reviewed studies, the hcmv was detected using diagnostic methods such as enzyme-linked immunosorbent assay and immunochromatography (rapid test) or molecular methods such as polymerase chain reaction. results: twenty-four eligible articles have been included in this review sourced data from about 5442 patients covering 15 of 18 provinces in iraq. the prevalence of hcmv igg and igm was (0%-100%) and (0%-93%), respectively. many factors influenced the varied results, including the design of the study and sociodemographic and clinical aspects. conclusion: the high prevalence of hcmv infection indicates a causative relationship with repeated abortion among iraqi females. keywords: human cytomegalovirus, prevalence rate, congenital infections, abortion, female, iraqi background human cytomegalovirus (hcmv) is a widespread herpes virus. according to the centers for disease control and prevention (cdcs) and the world health organization (who), human cytomegalovirus infects people of all ages, and approximately one-third of children by the age of five in the united states are infected [1]. the prevalence of hcmv is about 100 % in africa and asia and 80% in europe and north america [2]. germany recorded an infection rate of 56.7%, with a higher seroprevalence in women (62.3%) than in men (51.0%) [3]. human cytomegalovirus is endemic in many countries, and the seropositivity of hcmv varies from 30-100%, depending on the region [4]. human cytomegalovirus infection goes undiagnosed in healthy children and adults. however, some high-risk categories, such as immunocompromised organ transplant recipients, hematopoietic stem cell transplant recipients, and hiv-positive individuals, are in danger of developing life-threatening and vision-threatening hcmv diseases [5]. in lowand middleincome countries, the prevalence of prenatal hcmv infection is estimated to range between 0.7% and 5% of all neonates [6]. roughly 5-30 % of children aged 5-6 years in high-income countries are human cytomegalovirus seropositive, compared to 85-95 % in lowand middle-income countries, which renders it a national health threat to the latter countries [7]. the hcmv, commonly known as human herpesvirus 5 (hhv-5), is a member of the herpes viral family's beta herpes virus subgroup [8]. the transmission of the virus is mainly by vertical transmission from a mother to her fetus or infant [9], then by infected persons' breast milk, saliva, and urine [10]. however, transmitted through sexual activity in pregnant women and teenagers [11]. congenital hcmv transmission rates are as high as 50.0% in women who get the hcmv ___________________________________________________ shahadkhudaier@gmail.com 1department of medical microbiology, college of medicine, university of diyala, diyala, iraq a full list of authors information is available at the end of the article. https://doi.org/10.47108/jidhealth.vol5.iss3.245 http://www.jidhealth.com/ kareem qn, et al., journal of ideas in health (2022); 5(3):739-747 740 infection during pregnancy and fewer than 2.0% in women who do not get primary hcmv infection [12]. even though there are numerous causes of abortion, more than 50.0% of cases are still idiopathic. most miscarriages occur in the first trimester of pregnancy, accounting for roughly 80.0% of unplanned fetal deaths, resulting from signs like bleeding and discomfort that increase maternal worry [13]. several studies showed that viruses such as human cytomegalovirus; enterovirus, human herpes simplex virus (type 1 and type 2), human parvovirus b19, varicella-zoster virus, and adenovirus are causative agents of spontaneous abortion [1416]. human cytomegalovirus can infect and act in the cytoplasm and nucleus of infected cells, creating inclusions. it also can elude the immune system [8]. hcmv is the most common cause of intrauterine infection-induced congenital disabilities in humans. the hcmv infection can lead to abortion or stillbirth. ventricular encephalitis and microglial nodular encephalitis are two distinct symptoms of hcmv infection [17]. human cytomegalovirus can be pathogenic by direct organ damage that can make human cytomegalovirus dangerous by lowering host defenses against other microbes and/or increasing the body's inflammatory response, as in acute respiratory distress syndrome [18]. a glandular fever (mononucleosis) condition marked by flulike symptoms, or a prolonged fever, are clinical symptoms of primary infection. elevated lymphocyte counts and liver transaminase levels may be detected in laboratory tests [19]. the infection might be asymptomatic or produce severe problems at delivery in pregnant women. 10-15% will have intrauterine growth retardation, microcephaly, retinitis, jaundice, and hepatosplenomegaly, and 20-30% will die, causing irreversible harm. mental retardation, deafness, and blindness account for 50-80% of the cases [20, 21]. in approximately 10% of infected neonates, signs involve unilateral or bilateral deafness, loss of vision, optic atrophy, strabismus, chorioretinitis, hydrocephalus, enlargement of the liver and spleen, decrease in platelet number, and jaundice [22]. about 15% of asymptomatic infected newborns develop neurological sequelae before five years of age [23]. the method of diagnosis depends on the presence of igm, and low igg avidity in the urine and saliva is used to diagnose acute maternal hcmv infection. fetal infection is often confirmed using polymerase chain reaction (pcr) of the amniotic fluid and viral culture of the urine and saliva [24]. the polymerase chain reaction has been recognized as the gold standard for identifying systemic hcmv infections by blood samples, with a sensitivity of 80.1% and specificity of 93.0% [25]. the treatment of the virus by using valganciclovir to start treatment in aids patients with hcmv retinitis [26]. the nucleoside analogs valganciclovir and ganciclovir (gcv) block the viral dna polymerase. cidofovir and foscarnet, both second-choice medicines, block the viral polymerase over the polymerases of the cells [27]. letermovir (prevymis) is a new antiviral against human cytomegalovirus that targets the hcmv terminase complexes [28]. maribavir is another favorable antihcmv drug, which is taken orally and targets the viral kinase [29], which has a vital role in the formation of the viral structure, assembly complex, and viral release [30]. in the profile of iraq, human cytomegalovirus infection was under the eyes of iraqi researchers over the last three decades. various studies have been conducted depending on the study objective and the population involved [31-54]. lazim and kadhim [55] reviewed 46 cmv-related articles published in iraq between 2007-2015. most of the reviewed articles discussed the relation of cmv to abortion among pregnant women. in this study, we systematically reviewed the hcmv-related articles to identify the seropositive anti-hcmv igg and igm rates among iraqi women. methods design and protocol this systematic review was conducted according to prisma (the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration) guidelines and guidance [56]. however, the current review has no prepublished protocol and is not registered in any systematic review registers. criteria for inclusion and exclusion all research (original research, case report, systematic and meta-analysis) designed to estimate the prevalence of hcmv infection among iraqi females who suffered from repeat abortion were considered for inclusion. articles should be published in peer-reviewed english journals. all studies articles not written in english designed to estimate other causes of abortion with hcmv infection as co-infection; the studies conducted in females younger than 18 years and hcmv seronegative were excluded. search methods for eligible literature the highly-indexed electronic databases (pubmed, elsevier, science direct, google scholar, and academic scientific iraqi journals website) have been searched for literature on women suffering from abortion in iraq. the database search was restricted to english to make it easier for all authors who took part in the literature search to understand. the last date of the database search was july 31, 2022. the keywords used for the search are described here: ‘aborted women’, ' women with abortion', ' prevalence of hcmv, ' hcmv with abortion', ' infectious agent caused abortion', and ' abortion in iraqi women'. eligible literature was also selected from the reference list of articles that met the inclusion criteria. article screening and selection we used the databases mentioned above and the search mentioned above criteria to find articles. for the study, we used a four-stage technique (figure 1). step 1: a total of 97 articles were retrieved for the identification of articles using mentioned search criteria. step 2: after reading the titles and abstracts in accordance with the goals of the study to identify possibly pertinent papers, 33 articles were excluded due to duplication. step 3: we evaluated the complete texts using the eligibility and inclusion standards. due to mismatched content, 22 articles were omitted. step 4: when the predetermined exclusion criteria were applied, 18 articles were disqualified. as a result, we included 24 articles in the comprehensive final review. kareem qn, et al., journal of ideas in health (2022); 5(3):739-747 741 authors’ role the review authors carefully searched the literature and evaluated the pertinent material for inclusion and eligibility. as sessment bias has decreased due to group discussions that led to decisions. in other situations, a second party's opinion was required. figure 1 prisma 2009 diagram results scope of this review the database search showed ninety-seven citations. duplication was detected in twenty -three articles. further, thirty articles were excluded due to non-matching and ineligibility criteria. figure 1 presents the steps used in the selection process. in this systematic review, we included twenty-four matching the inclusion and exclusion criteria and were conducted from 2008 to 2022. these articles sourced data from 5442 aborted or repeatedly aborted iraqi females covering 15 of 18 iraqi provinces. the reviewed articles reported information about the design of the study, population, when and where the study was conducted, and the prevalence of hcmv ig and igm among the aborted females (table1). maternal hcmv seroprevalences in iraqi women with abortion the current review was designed to determine the prevalence rate of hcmv among aborted women in our population. basically, the reported hcmv igg and igm among the studied sample in each study were considered the base to indicate the prevalence rate of hcmv infection. in our review, some studies reported low hcmv infection rates, and others reported high hcmv infection rates among aborted women based on the immunological methods. the immunological techniques included latex agglutination test, immune chromatography (rapid test), enzyme-linked immunosorbent assay (elisa), or molecular methods such as pcr and rt-pcr. depending on the study design, population, sociodemographic and clinical characteristics, the rates of igg and igm in the reviewed studies vary between 0%-100% and 0%-93%, respectively. compared to a review study by lazim and kadhim [55], the number of articles discussing the hcmv seroprevalences and their relationship with abortion among iraqi women significantly increased. the hcmv has attracted the interest of iraqi researchers. many articles have been published after 2007 referring to improvement in research activity in iraq. al-jurani [31] conducted a serological test among 92 pregnant women attending primary healthcare centers in baquba city, diyala province. the author did not find any positive cases for antihcmv igm. a descriptive correlational study conducted by ghailani and mohammed [32] among 100 women with records identified through database searching (n=97) records screened (n=64) r full-text articles assessed for eligibility (n=42) articles were involved in the study (n=24) duplicates and unrelated theme (n=33) exclusion due to exclusion criteria (n=18) exclusion due to unmatched content (n=22) id e n ti fi c a ti o n s c r e e n in g e li g ib il it y in c lu d e d additional records identified through other sources (n=0) studies included in qualitative analysis. (n = 0) kareem qn, et al., journal of ideas in health (2022); 5(3):739-747 742 pregnancy loss at the general kirkuk hospital, azadi teaching hospital, and al-nasr hospital in kirkuk city reported 37.0% for igg and 1.0% for igm, respectively. a brief report published by hussein and balatay [33] in the north of iraq reported a seroprevalence rate of 2.27% (29 out of 1275 aborted women) for anti-hcmv igm antibodies among 1275 women with early pregnancy loss. the authors recruited an elisa test to examine 575 women from duhok province, 189 women from suliamania province, 201 women from zakho city, 150 women from akra city, and 160 samples from amedi city, respectively. another study by yasir et al. [34] reported a 60.63% (97/160) prevalence rate of hcmv among pregnant women using an enzyme immunoassay and pcr amplification test in the alnajaf public health laboratory. the authors reported positive igg antibodies among 59.38%, indicating the presence of chronic hcmv infection, compared to two cases (1.25%) with positive igm antibodies referring to acute hcmv infection. an interesting study was conducted by al-mishhadani and abbas [35] among women who attended al-gailani medical laboratory (private laboratory) in al-anbar governorate (west of iraq). the authors found that "seropositivity rates of anticmv igg (90.4%) and igm (6.1%)" were higher among the aborted women than in the normal control group (82.7% and 3.6%), respectively. moreover, the authors reported that the prevalence rate of cmv infection increased with the increasing age of aborted women and the number of abortions. khudhair et al. [36] found that the anti-hcmv igm antibody seroprevalence was 6.92% among 180 aborted women who attended al-battol teaching hospital for maternity and children, the outpatient clinic in baquba teaching hospital. ali ks [37] conducted a case-control study of women with abnormal pregnancies who attended the emergency unit of maternity teaching in erbil city. the author found that the seroprevalence of hcmvigm, and igg was 8.0% and 100%, respectively. the author also detected an association between the history of abortion and cmvspecific igm seroprevalence. aljumaili et al. [38] conducted an interesting case-control study among women with bad obstetric history (boh) and their counterparts. the authors reported that pregnancy and sociodemographic factors (age, residence, and education) were significantly associated with acute cmv infection. the authors found that women with a bad obstetric history presented 8.3% for hcmv igm and 98.3% for hcmv igg. al-azzawi [39] screened pre-marital women for the presence of igg and igm antibodies against cmv by elisa test. among one hundred and sixty-one examined serums, the igg and igm antibodies were identified at 36% and 9.9%, respectively. the author also found that young women (30-35) years and urban residents were statistically associated with a rising in seropositivity of hcmv. al-baiati et al. [40] examined 152 aborted women to discover the prevalence of hcmv infection at the kamal al-sammaraee hospital and alyarmouk teaching hospital for infertility. the authors found that the percentages of igg and igm were 85%, and 10%, respectively. al-dorri [41] examined 128 aborted women who attended tikrit teaching hospital in salah al-deen province. the author found that 21 out of 128 (16.40%) aborted women presented with seropositive hcmv. furthermore, among the 21 seropositive cases, 15(71.42%) for igg ab and 6 (28.57%) for igm ab 6 (28.57%). al-saeed et al. [42] examined 44 sera of females who attended the hospital of children and maternity and general teaching hospital in al-hilla city from november 2006 until april 2007. the authors found that 35(79.5%) and 8(18.8%) were positive for anti-cmv igg and igm antibodies, respectively. ali et al. [43] screened pregnantly and miscarriage women for hsv and cmv in baghdad. the authors found that among the 420 examined sera of pregnant women, 81(19.3%) were positive for hcmv. jihad and rehab [44] reported in their case-control study among fifty sera women who had repeated miscarriages due to hcmv at the infertility clinic of kamal al –sammaraee hospital, baghdad. the authors found higher seropositive anti-hcmv igg and igm in 40% and 25% of miscarriage women than in the control group of infertile women, where the seropositive anti-hcmv igg and igm were 20%, and 15%, respectively. raisin and al-amara [45] conducted an interesting study to detect the relationship between heat shock protein 70 (hsp70) concentration and cmv infection in a sample of 160 aborted women suffering from repeated embryo predictions in basrah province, south of iraq. the authors found that the level of anti-hcmv igm antibody was statistically higher among the age group (26-30 years) than other age groups at a rate of 26.7%. in contrast, the level of anti-hcmv igg was higher among the age group (3135 years) and (36-40 years) at a rate of 100 % using the elisa test. a case control conducted by khudhair and al-azzawi [46] reported a 32.8% prevalence rate of anti-hcmv igg among 122 pregnant women admitted to al-elwiya maternity hospital in baghdad; however, the prevalence of anti-hcmv igm was 14.7%. recently, naame et al. [47] conducted a case-control study among 120 aborted women attending the public health center in ibn -ghazwan and basra hospital in basra city. the authors reported a 30.8% prevalence rate of anti-hcmv igg and 2.5% of anti-hcmv igm, respectively. a cross-sectional study conducted by al-ouqaili and al-karboli [48] to identify the possible role of anti-cytomegalovirus igm and igg antibodies in diagnosing cmv infection in women with recurrent fetal loss in ramadi city, west of iraq. the authors found that during the first trimester, the seropositive antihcmv igm and igg antibodies were 33.3%, and 28.5% among 87 asymptomatic pregnant women, respectively. the authors also concluded the increased liability of hcmv transmission of infection in the uterus to the fetus. saad et al. [49] reported that the seropositive anti-hcmv igm was 35.38 among 130 women with bad obstetric history (boh) included in the case-control study conducted in kerbala province. in diyala province, baquba city, hussein et al. [50] collected conceptus tissues of 50 pregnant females with spontaneous abortion admitted to albatool teaching hospital for maternity and children. the author found the prevalence of the hcmv rate was 36.0%, and the highest rate was among the age group 26-35 years. a study conducted at al-karama hospital and al-zahra hospital of wasit province reported 43.9% of hcmv igm among 750 aborted and pregnant women [50]. al-shammary [51] examined the sera of 750 pregnant women in al-karama hospital and alzahra hospital of wasit province to identify the congenital anomalies in embryos among aborted and pregnant women. the author found that the seropositive anti-hcmv igm was 43.9%. moreover, the author reported that the prevalence of hcmv infection significantly increased with the age of pregnant women and embryos at (22-26) weeks of pregnancy. recently, saeed et al. [52] collected sera of one hundred and fifty kareem qn, et al., journal of ideas in health (2022); 5(3):739-747 743 pregnant women knowing with bad obstetric history (group i), and group ii including one hundred and fifty primigravida pregnant women knowing with a history of aborted during (first, second, and third trimesters of pregnancy). the authors found that the seropositive anti-hcmv igm was (53.0% in group i compared to 32.6% in group ii. at the same time, the seropositive anti-hcmv igg was 74% in group i compared to 61.3% in group ii. al-mousawi and al-hajjar [53] reported that among seventy aborted women included in the study at a consultant clinic for infertile women in babylon province, the seropositive anti-hcmv igg was 93.0%, compared to 0.07% for the seropositive anti-hcmv igm. in al-najaf city, hamoud et al. [54] compared one hundred samples of recurrent pregnancy loss (rpl) with one hundred samples having no history of miscarriage. the findings showed no significant difference between the two groups; the seropositive anti-hcmv igg was 98.0% among the rpl and 96.0% among the other group. table1: the seropositive anti-hcmv igg and igm among iraqi women hcmv prevalence groups rate of positive igg rate of positive igm governorate of study no. of cases in the study study design references low prevalence group (igm) (0%-11%) 0% 0% diyala 92 pregnant women cross-sectional study al-jurani 2014 [31] 37% 1% kirkuk 100 women descriptive correlational study ghailan and mohammed 2020 [32] 2.27% kurdistan (duhok, suliamania, zakho, akra, and amedi) 1275 women (575 from duhok, 189 from suliamania, 201 from zakho, 150 from akra, and 160 from amedi ) cross-sectional study hussein and balatay 2019 [33] 60.63% 1.25% alnajaf 160 women case-control study yasir et al.2020 [34] 6.10% al-anbar 230 women cross-sectional study al-mishhadani andaljanabi 2008 [35] 6.92% diyala 180 women cross-sectional study khudhair et al. 2017 [36] 8% erbil 75 women case-control study ali 2020 [37] 8.30% kirkuk 245 women descriptive casecontrol study aljumaili et al. 2014 [38] 36.0% 9.90% baghdad 152 women cross-sectional study al-azzawi 2012 [39] 85% 10.0% baghdad 152 women cross-sectional study al-baiati et al. 2014 [40] moderate prevalence group (igm) (12%-30%) 16.40% salah al-deen 128 women cross-sectional study al-dorri 2018 [41] 18.8% al-hilla 120 women case-control study al-saeed et al. 2008 [42] 19.3% baghdad 420 women comparative study ali et al. 2019 [43] 40% 25% baghdad 100 women case-control study jihad 2015 [44] 100 % 26.7% basrah 160 women cross-sectional study raisan and al-amara 2020 [45] 32.78% 14.7% baghdad 122 women case-control study khudhair and al-azzawi 2018 [46] high prevalence group (igm) 31%-100% 30.8% basrah 120 women case-control study naame et al. 2021 [47] 28.50% 33.3% ramadi 87 women cross-sectional study al-ouqaili, and alkarboli 2010 [48] 35.38% kerbala 130 women case-control study saad et al. 2013 [49] 36% diyala 50 women cross-sectional study hussein et al. 2017 [50] 43.9% wasit 750 women cross-sectional study al-shammary 2014 [51] 53% baghdad 300 women cross-sectional study saeed et al. 2022 [52] 89% 93% babylon 90 women comparative study al-mousawi, and alhajjar 2020 [53] 95.09% 0% al-najaf 204 women case-control study hamoud et al. 2021 [54] kareem qn, et al., journal of ideas in health (2022); 5(3):739-747 744 discussion generally, the differences in the prevalence of hcmv infections in the above studies may be related to the difference in the geographical region, the sample, and the study's design. the age of women included in each study had a possible role in the distribution of infection. jerman et al. [57] studied the characteristics of abortion women (2008-2014) in the united the states of america. the authors reported that the most spontaneous and first abortions occur in women in the age group 20-24 years, and the lowest cases of miscarriage occur in women above 30 years. cannon [58] reported that the acquisition of hcmv in a population is characterized by an age-dependent rise in seroprevalence, closely related to socioeconomic status and race. another factor is the type of hcmv infection in another ward; acute infections are more frequently transferred to the fetus and more likely to cause fatal harm than recurrent infections [59]. due to latency after the first infection and reactivation of viral infection causing recurrent symptoms, hcmv transmission in the womb [60]. living in developed countries had an influential title role in delivering hcmv rates. zhang et al. [61] showed that the seropositivity of hcmv in adults varies from 55% in developed countries to more than 90% in developing countries. regarding financial status, the recurrence of human cytomegalovirus is the most common cause of a severe disease which is higher in the developed countries among lower financial strata [62]. a variety of factors can bring on fetal injury, including a woman's immune system, deficiencies in "trophoblast progenitor stem cell differentiation" and function, extravillous trophoblast invasiveness, dysregulation of "wnt signaling pathways” in cytotrophoblasts, tumor necrosis factormediated trophoblast apoptosis, hcmv-induced cytokine changes in the placenta, and inhibition of indoleamine 2,3dioxygenase [63,64]. the virus was detected by serological tests, which are very accurate and sensitive, and even though antibodies may decrease with aging and chronic immunosuppressive, igg seroprevalence is frequently lifelong. the ability to detect the virus is constantly improving, and nucleic acid assays like the polymerase chain reaction are now available at developed centers [65]. the variances in the sensitivity and specificity of the serologic markers utilized in various studies of iraq could be the cause of these inconsistencies. the high seroprevalence in women between the ages of 26 and 35 years is consistent with earlier research that linked it to these women's exposure to school-age children, particularly as their children started going to school [66], for the need for routine screening in antenatal clinics. regional differences necessitate local adaptation of national hcmv infection prevention and management policy. therefore, the widespread practice of breastfeeding throughout infancy in iraq may also be responsible for the high seroprevalence because breastfeeding is one of the main routes of transmission of infection [67]. on the other hand, the study that reported the low rate of infection due to maternal igm test findings that are positive is used to confirm the diagnosis of acute hcmv infection in pregnancy [40]. additionally, samples taken too early during the primary infection may not have detectable levels of igm, and it may emerge after cmv reactivation. thus, a negative igm result does not always rule out the initial infection with cmv [68]. the hsv family of viruses includes hcmv, which has a strong affinity for humans. the first phase of viral replication and shedding with body fluids, such as saliva, breast milk, urine, and vaginal secretions, follows primary infection with the virus. a viremia and, in some instances, an infectious mononucleosis phase follow this. after that, the infection enters a latent phase. while an effective vaccine is being developed, the ongoing relationship between inferior socioeconomic situations, such as overcrowding, breast milk transfer, and high hcmv seroprevalence, presents an opportunity to address this issue [69]. conclusion out of seventy-nine studies published in iraq between 2008 to 2022, twenty-four articles have undergone systematic review. about 5442 iraqi women were included in these studies. the reviewed articles covered 15 provinces out of 18 in iraq, indicating the generalization of the study findings. the prevalence of hcmv igg and igm was (0%-100%) and (0%93%), respectively. several articles found a significant relationship between the hcmv infection and frequent abortion among iraq females. many challenges in our country, such as a lack of management and diagnostic policies on hcmv, contributed to the high prevalence of hcmv infection. several factors such as lack of optimal/structured antenatal and postnatal care, a lack of adequate equipment and funding for laboratory facilities, socioeconomic factors such as poverty, low awareness, literacy, sexually transmitted diseases, and teenager pregnancies, are intolerably predisposing to unwanted consequences health problems among iraqi women. therefore, many countries, including iraq, demand more knowledge and international recommendations on managing hcmv. abbreviation hcmv: human cytomegalovirus; cdcs: centers for disease control and prevention; who: world health organization; pcr: polymerase chain reaction; elisa: enzyme-linked immune sorbent assay; hsp70: heat shock protein 70; gcv: ganciclovir; hhv-5: herpesvirus 5 declaration acknowledgment none. funding the author received no financial support for this article's research, authorship, and/or publication. availability of data and materials data will be available by emailing shahadkhudaier@gmail.com. authors’ contributions all authors equally participated in conceiving, designing, collecting data, drafting, and writing the manuscript. all authors have read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, review articles need no ethics committee approval. kareem qn, et al., journal of ideas in health (2022); 5(3):739-747 745 consent for publication not applicable competing interest the author declares that he has no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author (s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of medical microbiology, college of medicine, university of diyala, diyala, iraq article info received: 09 august 2022 accepted: 02 september 2022 published: 08 september 2022 references 1. al mana h, yassine hm, younes nn, al-mohannadi a, alsadeq dw, alhababi d, et al. the current status of cytomegalovirus (cmv) prevalence in the mena region: a systematic review. pathogens. 2019;8 (4):213-236. https://doi.org/10.3390/pathogens8040213 2. cannon mj, schmid ds, hyde tb. review of cytomegalovirus seroprevalence and demographic characteristics associated with infection. rev med virol. 2010;20(4):202–213. https://doi.org/10.1002/rmv.655 3. lachmann r, loenenbach a, waterboer t, brenner n, pawlita m, michel a. cytomegalovirus (cmv) seroprevalence in the adult population of germany. plos one. 2018;13 (7):e0200267. https://doi.org/10.1371/journal.pone.0200267 4. crough t, khanna r. immunobiology of human cytomegalovirus: from bench to bedside. clin microbiol rev. 2009;22(1):76–98. doi: https://doi.org/10.1128/cmr.00034-08 5. buxmann h, hamprecht k, meyer-wittkopf m, friese k. primary human cytomegalovirus (hcmv) infection in pregnancy. dtsch arztebl int. 2017;114(4):45-52. doi: 10.3238/arztebl.2017.0045. 6. manicklal s, emery vc, lazzarotto t, boppana sb, gupta rk. the “silent” global burden of congenital cytomegalovirus. clin microbiol rev. 2013;26: 86–102. doi: 10.1128/cmr.00062-12 [pmc free article] [pubmed] [google scholar] 7. prendergast aj, goga ae, waitt c, gessain a, taylor gp, rollins n. transmission of cmv, htlv-1, and hiv through breastmilk. lancet child adolesc heal. 2019;3(4):264–273. https://doi.org/10.1016/s2352-4642(19)30024-0 8. r schleiss m. congenital cytomegalovirus infection: molecular mechanisms mediating viral pathogenesis. infect disord targets (formerly curr drug targets-infectious disord. 2011;11(5):449– 465. doi: https://doi.org/10.2174/187152611797636721 9. boppana sb, ross sa, fowler kb. congenital cytomegalovirus infection: clinical outcome. clin infect dis. 2013;57(suppl_4): s178–181. https://doi.org/10.1093/cid/cit629 10. ho m. cytomegalovirus: biology and infection. springer science & business media; 2013. 11. zuhair m, smit gsa, wallis g, jabbar f, smith c, devleesschauwer b. estimation of the worldwide seroprevalence of cytomegalovirus: a systematic review and meta‐analysis. rev med virol. 2019;29(3):e2034. https://doi.org/10.1002/rmv.2034 12. kagan ko, hamprecht k. cytomegalovirus infection in pregnancy. arch gynecol obstet. 2017;296(1):15–26. https://doi.org/10.1002/bdra.23601 13. atik rb, hepworth-jones be dp. early pregnancy, chapter2, risk factors for miscarriage. cambridge university press,2010: 918. 14. chow ssw, craig me, jacques cfh, hall b, catteau j, munro sc. correlates of placental infection with cytomegalovirus, parvovirus b19 or human herpesvirus 7. j med virol. 2006;78(6):747–756. https://doi.org/10.1002/jmv.20618 15. kim id, chang hs, hwang kj. herpes simplex virus 2 infection rate and necessity of screening during pregnancy: a clinical and seroepidemiologic study. yonsei med j. 2012;53(2):401–407. doi: https://doi.org/10.3349/ymj.2012.53.2.401 16. zhou y, bian g, zhou q, gao z, liao p, liu y. detection of cytomegalovirus, human parvovirus b19, and herpes simplex virus‐1/2 in women with first‐trimester spontaneous abortions. j med virol. 2015;87(10):1749–1753. https://doi.org/10.1002/jmv.24218 17. fowler kb, pass rf. sexually transmitted diseases in mothers of neonates with congenital cytomegalovirus infection. j infect dis. 1991;164(2):259–264. https://doi.org/10.1093/infdis/164.2.259 18. kawasaki h, kosugi i, meguro s, iwashita t. pathogenesis of developmental anomalies of the central nervous system induced by congenital cytomegalovirus infection. pathol int. 2017;67(2):72–82. https://doi.org/10.1111/pin.12502 19. papazian l, hraiech s, lehingue s, roch a, chiche l, wiramus s. cytomegalovirus reactivation in icu patients. intensive care med. 2016;42(1):28–37. https://doi.org/10.1007/s00134-01540669. 20. nigro g, anceschi mm, cosmi e v, group tccdc. clinical manifestations and abnormal laboratory findings in pregnant women with primary cytomegalovirus infection. bjog an int j obstet gynaecol. 2003;110(6):572–577. https://doi.org/10.1016/s1470-0328(03)01902-5 21. collinet p, subtil d, houfflin-debarge v, kacet n, dewilde a, puech f. routine cmv screening during pregnancy. eur j obstet gynecol reprod biol. 2004;114(1):3–11. https://doi.org/10.1016/j.ejogrb.2003.09.016 22. zaker bostanabad s, rahimi mk, mahdavi z, pourazar sh. evaluation of cytomegalovirus (cmv) in abortion compared with embryos vaginal delivery by using pcr. sarem j reprod med. 2017;2(1):43–48. http://saremjrm.com/article-1-28-en.html 23. dollard sc, grosse sd, ross ds. new estimates of the prevalence of neurological and sensory sequelae and mortality associated with congenital cytomegalovirus infection. rev med virol. 2007;17(5):355–363. https://doi.org/10.1002/rmv.544 24. dahl h-hm, ching tyc, hutchison w, hou s, seeto m, sjahalam-king j. etiology and audiological outcomes at 3 years for 364 children in australia. plos one. 2013;8(3):e59624. https://doi.org/10.1371/journal.pone.0059624 25. ross s, novak z, pati s, boppana s. overview of the diagnosis of cytomegalovirus infection. infect disord targets (formerly curr drug targets-infectious disord. 2011;11(5):466–474. doi: https://doi.org/10.2174/187152611797636703 26. tan bh. cytomegalovirus treatment. curr treat options infect dis. 2014;6(3):256–270. doi 10.1007/s40506-014-0021-5 27. lischka p, zimmermann h. antiviral strategies to combat cytomegalovirus infections in transplant recipients. curr opin kareem qn, et al., journal of ideas in health (2022); 5(3):739-747 746 pharmacol.2008;8(5):541–548. https://doi.org/10.1016/j.coph.2008.07.002 28. ligat g, cazal r, hantz s, alain s. the human cytomegalovirus terminase complex as an antiviral target: a close-up view. fems microbiol rev. 2018;42(2):137–145. https://doi.org/10.1093/femsre/fuy004 29. biron kk, harvey rj, chamberlain sc, good ss, smith iii aa, davis mg. potent and selective inhibition of human cytomegalovirus replication by 1263w94, a benzimidazole lriboside with a unique mode of action. antimicrob agents chemother. 2002;46(8):2365–2372. doi: https://doi.org/10.1128/aac.46.8.2365-2372.2002 30. goldberg md, honigman a, weinstein j, chou s, taraboulos a, rouvinski a. human cytomegalovirus ul97 kinase and nonkinase functions mediate viral cytoplasmic secondary envelopment. j virol. 2011;85(7):3375–3384. doi: https://doi.org/10.1128/jvi.01952-10 31. al-jurani ahh. seroprevalence of anti-cytomegalovirus igm, igg antibodies among pregnant women in diyala province. djps. 2014;10(2-part 2):116–122. https://www.iasj.net/iasj/download/e3feba324fc007b3 32. ghailan sh, mohammed ss. assessing the risk factors for cytomegalovirus and prediction the relationship between abortion and virus in kirkuk city hospitals. mosul j nurs. 2020;8(2):127– 141. https://mjn.mosuljournals.com/article_166078.html 33. hussein n, balatay aa. the seroprevalence of toxoplasma, cytomegalovirus and rubella infections in women with abortion in kurdistan region of iraq: a brief report. int j infect. 2019;6(1): e86734. doi: 10.5812/iji.86734. 34. yasir sj, al-khafaji ya-r, al-kelaby kka. cytomegalovirus ul83 gene as diagnostic marker for preliminary infection in pregnant women in al-najaf city. syst rev pharm. 2020;11(5):123–129. doi: 10.31838/srp.2020.5.20 35. al-mishhadani ji, al-janabi au. toxoplasmosis and cytomegalovirus infection among aborted women in al-anbar governorate. ajvs. 2008;6(1): 88-97 https://www.iasj.net/iasj?aid=15678&func=fulltext 36. khudhair mk, mohammed mr, jassim n-as. the serologicalrates of cytomegalovirus among women in diyala province, with a study of some the immunological markers. djps. 2017;13(3-part 3): 232-241 https://www.iasj.net/iasj/article/128777 37. ali ks. the sero-prevalence of cytomegalovirus infection among women with abortion and intrauterine death in erbil city kurdistan region, iraq. djm. 2020;18(1):77–90. https://www.djm.uodiyala.edu.iq/index.php/djm/article/view/535 38. aljumaili zkm, alsamarai am, najem ws. cytomegalovirus seroprevalence in women with bad obstetric history in kirkuk, iraq. j infect public health. 2014;7(4):277–288. https://doi.org/10.1016/j.jiph.2013.08.006 39. al-azzawi rhm. seroprevalence of cytomegalovirus infection in pre-marital women in some baghdad hospitals. iraqi j sci. 2012; 53:40–45. https://www.iasj.net/iasj/download/b324df73e8ae0f31 40. al-baiati amh, muhsin ma, jabbar rn. seroprevalence of human cytomegalovirus (hcmv) in aborted women in baghdad. international j. curr. microb. appl. sci.2014;3(2):97-102. 41. al-dorri azr. estimation of some immunological biomarkers in aborted women infected with human cytomegalovirus (hcmv) in salah al-deen province. mjotu. 2018;24(2):12–24. doi: http://dx.doi.org/10.25130/mjotu.24.02.02 42. al-saeed ms, muhsin ma, al-juburi gj. study the role of toxoplasma gondii, cytomegalovirus, and anti-phospholipids antibodies in cases of abortion among women in hilla city. qmj. 2008;4(6):27–34. 43. ali mk, shia js, and al-marsome hd. detection of hsv and cmv in pregnant and miscarriage women by elisa and real time pcr assay. res j pharm technol, 2019. 12(9), 4090-4094. doi: 10.5958/0974-360x.2019.00704.2 44. jihad sa. molecular detection of cytomegalovirus (cmv) isolated from repeated miscarriage women and its relation to tlr2 and ilt2 receptors. ms.c thesis submitted to the counsel of college of science/al-nahrain, supervised by dr. rehab subhi ramadhan 2015. 45. raisan sj, al-amara ssm. determine anti-human cytomegalovirus antibodies (igm, igg) and heat shock protein 70 in aborted women. eurasian j biosci. 2020;14(1):265–268. https://www.proquest.com/openview/d871ae13f38f758cdbd44deb bccbe84c/1?pqorigsite=gschola r&cbl=2042720 46. khudhair sa, al-azzawi rh. estimation of anti-cmv antibodies in iraqi pregnant women infected with chronic cytomegalovirus. j glob pharma technol. 2018;10(11):52–56. 47. naame, zk, thuwaini, mm, mahdi, ds. seroprevalence of toxoplasma gondii, cmv, rubella and hsv-1&2) in aborted women in basra, southern of iraq, ann. trop. med. public health. 2021; 24(5): 295-301. doi: http://doi.org/10.36295/asro.2021.24543 48. al-ouqaili mt, al-karboli ay. immunological study of cytomegalovirus infection in women with recurrent fetal loss in ramadi city, west of iraq. amj. 2010;8(1):74-78 49. saad a, rahi sj, hussein bw. serological study for torch infections by elisa method in women with bad obstetric history in kerbala city. kjm. 2013;6(2): 1621-1624 50. hussein aa, salman st, khashman bm. frequency of human cytomegalovirus and human herpesvirus-1 antigens in product of conceptus tissues of pregnant women with spontaneous abortion. iraqi j med sci. 2017;15(1):94-102 51. al-shammary rn. prevalence of cytomegalovirus among pregnant women relation to congenital abnormalities in embryos and children in wasit province, j ku. 2014;12(1):86-91 https://www.iasj.net/iasj/download/8f1d01530e853d1b 52. saeed nahaa, ibraheem lj, mahmood si. immune antibodies diagnosis of pregnant women in iraq infected with herpes simplex virus and human cytomegalo virus. wbph, 2022,12, 35-42. https://scholarexpress.net/index.php/wbph/article/view/1126 53. al-mousawi, ht, and al-hajjar, qn. immunogenic diagnosis of human cytomegalovirus infection in aborted and pregnant women in babylon governorate. journal of the college of basic education, 2020, proceedings of the second international scientific conference academics syndicate iraqi:215-227 https://www.iasj.net/iasj/download/0ea7cec68284aa4d 54. hamoud, hr, al-kashwan, taj, tarish, hr. cytomegalovirus seropositivity among iraqi women suffering from recurrent pregnancy loss. al-kufa university journal for biology, 2021 13(1): 34-26 https://www.iasj.net/iasj/download/dbd3e8826ba4edb2 55. lazim hh, kadhim hs. review of sero-prevalence of human cytomegalovirus in iraq. j microbiol exp. 2018;6(2):50-55. doi: 10.15406/jmen.2018.06.00188. 56. liberati a, altman dg, tetzlaff j, mulrow c, gøtzsche pc, et al. (2009) the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. plos med 6(7): e1000100. doi: 10.1371/journal.pmed.1000100. 57. jerman j, jones rk, onda t. characteristics of us abortion patients in 2014 and changes since 2008, a report. 2016:1-26 58. cannon mj. congenital cytomegalovirus (cmv) epidemiology and awareness. j clin virol. 2009;46:s6–10. https://doi.org/10.1016/j.jcv.2009.09.002 kareem qn, et al., journal of ideas in health (2022); 5(3):739-747 747 59. fowler kb, stagno s, pass rf, britt wj, boll tj, alford ca. the outcome of congenital cytomegalovirus infection to maternal antibody status. n engl j med. 1992;326(10):663–667. doi: 10.1056/nejm199203053261003 60. ahlfors k, ivarsson s-a, harris s, svanberg l, holmqvist r, lernmark b. congenital cytomegalovirus infection and disease in sweden and the relative importance of primary and secondary maternal infections: preliminary findings from a prospective study. scand j infect dis. 1984;16(2):129–137. https://doi.org/10.3109/00365548409087131 61. zhang s, zhou y-h, li l, hu y. monitoring human cytomegalovirus infection with nested pcr: comparison of positive rates in plasma and leukocytes and with quantitative pcr. virol j. 2010;7(1):1–7. https://doi.org/10.1186/1743-422x-7-73 62. schoenfisch al, dollard sc, amin m, gardner li, klein rs, mayer k. cytomegalovirus (cmv) shedding is highly correlated with markers of immunosuppression in cmv-seropositive women. j med microbiol. 2011;60(6):768–774. https://doi.org/10.1099/jmm.0.027771-0 63. tilburgs t, strominger jl. cd 8+ effector t cells at the fetal– maternal interface, balancing fetal tolerance and antiviral immunity. am j reprod immunol. 2013;69(4):395–407. https://doi.org/10.1111/aji.12094 64. hamid km, onoja ab, tofa ua, garba kn. seroprevalence of cytomegalovirus among pregnant women attending murtala mohammed specialist hospital kano, nigeria. afr health sci. 2014;14(1):125–130. https://doi: 10.4314/ahs. v14i1.19 65. rawlinson w, scott g. cytomegalovirus: a common virus causing serious disease. aust fam physician. 2003;32(10): 789-793 66. hameed my, aziz ih. detection of cytomegalovirus in iraqi recurrent miscarriage women. j. pharm. pharm. sci. 2015;5(1):79-89. 67. al-samarrai mam, al-rawi ra, yaseen sm, ali jadoo sa. knowledge, attitude, and practice of mothers about complementary feeding for infants aged 6-12 months in anbar province, iraq. journal of ideas in health 2020 may 09;3(1):1259. doi: 10.47108/jidhealth.vol3.iss1.17. 68. ogbaini-emovon e, oduyebo oo, lofor pv, onakewhor ju, elikwu cj. seroprevalence and risk factors for cytomegalovirus infection among pregnant women in southern nigeria. j. microb. infect. dis.2013 ;3(03):123-127 https://doi.org/10.5799/ahinjs.02.2013.03.0094 69. pembrey l, raynor p, griffiths p, chaytor s, wright j, hall aj. seroprevalence of cytomegalovirus, epstein barr virus and varicella zoster virus among pregnant women in bradford: a cohort study. plos one.2013; 8(11): e81881https://doi.org/10.1371/journal.pone.008188 figure 1 prisma 2009 diagram records identified through database searching (n=97) records screened ( n=54) r full-text articles assessed for eligibility (n = 42) articles were involved in the study (n=24) duplicates and unrelated theme (n=23) exclusion due to exclusion criteria (n=18) exclusion due to unmatched conten (n=12) id e n ti fi c a ti o n s c re e n in g e li g ib il it y in c lu d e d additional records identified through other source (n=0) studies included in qualitative synthesi (n = 0) https://doi.org/10.47108/jidhealth.vol6.iss2.278 chalo sl, et al., journal of ideas in health (2023); 6(2):836-846 © the author(s). 2023 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access the community knowledge, awareness, and practices influencing transmission of toxoplasmosis in mbeya district, tanzania stela lucas chalo*1, eliakunda michael mafie2, abdul selemani katakweba3, ernatus martin mkupasi1 abstract background: toxoplasmosis caused by toxoplasma gondii is an important but neglected zoonotic disease of global distribution. the study aimed at evaluating community knowledge, awareness, and practices linked to transmission and control of the disease among the residents of urban and peri-urban areas of mbeya district, tanzania. methods: a cross-section study was conducted from january 2022 to march 2022 in the mbeya district. a semistructured questionnaire was self-administered to gather information on social demographic characteristics, knowledge, and risk behaviors related to toxoplasma infection, chi squire was employed to test the difference where pvalue < 0.05 was considered statistically significant. results: a total of 100 respondents were recruited. the majority (38.0%) of the respondents were aged 26 35 years and (49.0%) had attained primary education. the average mean age was 35.6 (+ 11.5 sd), 57% were male while 43.0% were female. only 22 percent of the respondents were aware of toxoplasmosis and among them, 10 percent were aware of the clinical manifestations of the disease and 20 percent knew the mode of the disease transmission. identified risk practices include lack of deworming in cats (81.0%), outdoor cats management (60.0%), disposal of cats' faces in gardens (36.0%), use of cats in controlling rodents (41.0%), and not wearing gloves during gardening (77.0%). children are noted to be at the highest risk of contracting the disease as they are greatly involved in caring for cats. (49.0%). the knowledge of the disease was found to be associated with sex (males) p value= of 0.041, occupation (medical employees) p-value =0.002, and high level of education of the respondents' p value =0.000.\. conclusion: the study revealed a low level of knowledge of the participants and practiced risky behaviors for disease transmission. thus, we recommend to relevant authorities to offer education to the community concerning toxoplasmosis. keywords: protozoan, rodents, cats, neglected diseases, mbeya, tanzania background toxoplasmosis is a zoonotic protozoan disease caused by a parasite called toxoplasma gondii. the parasite infects all warm-blooded animals affecting one-third of the global population [1, 2]. the disease is transmitted to humans via either vertical or horizontal pathways. the horizontal pathway involves the ingestion of oocysts in contaminated water, soil, or food with the feces of a definitive feline host. also, ingestion of intracellular cysts in undercooked meat of an intermediate host such as rodents [3, 4]. on the other hand, the vertical pathway is observed in an infected pregnant mother who transfers the pathogen to her fetus through the placenta which may consequently result in miscarriage, fetal death, and neurological and/or ocular disorders to the fetus [5, 6]. furthermore, t. gondii infection could also occur as a result of a blood transfusion or an organ donation from an infected donor [7]. toxoplasmosis may cause retinochoroiditis and central nervous system lesions [8] that are presented as encephalitis [9]. the clinical manifestations are more pronounced in immunocompromised individuals [10, 11, 12]. ___________________________________________________ chalostell71@gmail.com 1department of veterinary medicine and public health, sokoine university of agriculture, p. o. box 3021, morogoro, tanzania a full list of author information is available at the end of the article 10.47108/jidhealth.vol6.iss2.278 http://www.jidhealth.com/ chalo sl, et al., journal of ideas in health (2023); 6(2):836-846 837 the global spatial orientation of this disease reveals it to be more prevalent in tropical countries with warm, humid climates compared to arid or colder countries. local variation of the prevalence of this disease is influenced by variations in social practices such as eating habits, sanitation, keeping petty animals, and hygiene practices as well as variations in host immune status among individuals in a particular population [10, 13]. human toxoplasmosis in particular is most prevalent in western and eastern parts of the african continent while the southern part of the continents has the lowest prevalence. the status of the disease in humans in tanzania has been reported to range from 4 to 60.0% in the past 30 years [14, 15, 16]. the disease caused 188 deaths in the country during ten years (2006-2015), the figure might be a gross underestimation of the burden as many cases might have gone undiagnosed. the highest case mortality rate per 100 000 population was noted in the southern part of the country [17]. despite that, the disease does not receive due attention due to limited epidemiological information. the community risk factors influencing the acquisition and transmission of the disease remained unknown in the country's southern part despite the reported higher case mortality rates. this phenomenon demands the assessment of community knowledge, awareness, and practices that are likely to influence the disease dynamics in the area. this study therefore aimed to assess community knowledge, awareness, and practices to establish the risk factors which may influence the epidemiology of the disease in the study community. the findings will be useful in planning and designing proper disease prevention, and control strategies in the country. methods study area the study was conducted in urban and peri-urban areas of mbeya district from january 2022 to march 2022. the district is located in the southwest highlands of tanzania and it lies along the crossings of latitude and longitude of 8054' south of equator, 330 27'east of greenwich meridian respectively. the district is bordered by mbarali, ileje, rungwe, and mbozi districts on the northern, southern, eastern, and western sides, respectively [18]. mbeya district's population is approximately 385279 people [19]. the district is administratively divided into 36 wards. the major economic activities in the district include business, agriculture, and livestock keeping as well as small and largescale industrial production [19]. the climate is generally mildwarm and temperate. the annual average temperature is 7°c to 22 °c while the average rainfall is around 2068 mm per year [20]. four periurban wards (igawilo, mwansekwa, itende, and iziwa) and four urban wards (ruanda, iyela, mabatini, and maendeleo) were selected to make a total of 8 surveyed wards in the district (fig 1). study design and setting a cross-sectional study was conducted to assess sociodemographic characteristics, knowledge, awareness, and practices influencing the epidemiology of toxoplasmosis. the study was conducted in the mbeya district from january 2022 to march 2022. figure 1: map of mbeya district showing surveyed wards source: gis 3.28.0 “firenze” visited on (10/11/2022) inclusion and exclusion criteria three inclusion criteria were observed in the selection of the study population. the first criterion was age, where all participants had to be 18 years old and above. the second was the location, where all study participants had to be permanent residents in urban and peri-urban wards of the study area. the last criterion was affiliation to a household or storage facility that was recruited in the trapping of the rodents and cats to achieve a complementary objective of the study. on the other hand, exclusion criteria were age below 18 years old, not being a permanent resident of the study area, and unwillingness to participate in the study. sample size the formula n= [z2 p (1-p)]/ d 2 was used to calculate the sample size for the survey based on the previously known prevalence of the disease [16]. where, n = sample size; z = statistic for the degree of confidence (1.96 at the confidence level of 95.0%); p = expected prevalence (13.0%) [16]; d = precision (5.0%). the computation results in: n=1.96x1.96x0.13 (1-0.13)/0.05x0.05=173. a total of 173 respondents from the eight selected wards were required to participate in the questionnaire data survey. however, the study recruited 100 participants due to inclusion criteria and exclusion. study tool a semi-structured questionnaire in the swahili language translated from the english version was administered to the respondents. each question was read to respondents who were unable to read the questions on their own then their responses were recorded. the questionnaire consisted of 30 questions, 25 of these questions were closed-ended while the remaining five were open-ended. the questionnaire had four major parts; demographic characteristics 5 questions, basic knowledge of toxoplasmosis 3 questions, awareness towards toxoplasmosis 2 questions, and practices 20 questions influencing the prevalence of disease in the sampled community participants. the bulk of the questions were designed to assess practices reflecting the chalo sl, et al., journal of ideas in health (2023); 6(2):836-846 838 0 50 periurban urban c o u n t location have you ever heard of a disease called toxoplasmosis? no yes role of the definitive host(cats), intermediate host (rodents), respondents' behaviors, and their influence on the acquisition and transmission of this disease in the study community. dependent and independent variables independent variables were education level, sex, marital status, occupation, age, and location while the dependent variables were knowledge, awareness, and practices influencing transmission of the disease. emphasis was given to the role of the intermediate and definitive hosts in spreading the disease in a household setting. the mean percentage of scores in relation to the knowledge and awareness of toxoplasmosis in the community was interpreted where knowledge and awareness of the respondents in relation to toxoplasmosis was considered either low or high if the mean score was less or more than 50%, respectively. statistical analysis the survey data were coded and entered in microsoft excel spreadsheets and descriptive and analytic statistics were computed using statistical package for social science (spss) software version 25, ibm corporation, armonk, ny, usa [22]. the variables in the frequency tables and their proportions were summarized and described using descriptive statistics. the chi-square test was employed to determine statistically significant variations in awareness of the disease among categorical demographic variables. knowledge and awareness of the respondents in relation to the disease were considered either low or high if the mean score was less or more than 50% respectively. results socio-demographic characteristics of study participants a total of 100 participants were recruited in the study, 52.0% of these were from urban while 48.0% were peri-urban residents. the majority (38.0%) of the respondents were aged 26-35 years. males formed a slightly bigger portion (57.0%) of the total respondents in the study population. about half (49.0%) attended primary educational level. in addition, farming appeared to be the main source of income for the respondents (table 1). respondents' knowledge and awareness of toxoplasmosis the results revealed that a relatively small percentage (22.0%) of the respondents were aware of the existence of the disease while most (78.0%) of them were unaware of its existence (figure 2). figure 2: the distribution of responses reflecting respondents' awareness of the existence of toxoplasmosis furthermore, an analysis was made of respondents who were aware of the existence of the disease to reveal the sources of that information. the results show that a substantial amount of these respondents appeared to have obtained the information from higher learning institutions, health facilities, social networks, and radio while a noticeably small portion of them obtained the information from newspapers and television (figure 3). figure 3: source of information on toxoplasmosis knowledge the respondent's awareness in relation to transmission of this disease was relatively low, where 80.0% of the respondents were uncertain of the mode of transmission. 20.0% was distributed to 15.0%, 4.0%, and 1.0% of the respondents who respectively thought that the disease was transmitted through consuming raw meat, contaminated food, and cat excretions. furthermore, the awareness of respondents on other communicable diseases spread by cats or rodents was assessed where 81.0% claimed to be unaware of any communicable disease spread by these animals. on the other hand, the remaining 19.0% was distributed to 10.0%, 3.0%, 3.0%, and 3.0% of the respondents who respectively mentioned plague, leptospirosis, rabies, and worms as communicable diseases transmitted from rodents and cats while none mentioned toxoplasmosis. in relation to respondent's knowledge of clinical manifestations of this disease, only 10% of the respondents mentioned relevant clinical manifestations while the majority (90.0%) of them were unaware (table 2). the mean scores of 17.0% reflected that the majority of the respondents in the mbeya district had low knowledge and awareness of toxoplasmosis (table 3). practices influencing the definitive host (cats) in the transmission of toxoplasmosis the practices influencing the risk of toxoplasmosis transmission from the definitive hosts (cats) were assessed by seven questions. the results show that more than 80.0% of respondents did not deworm their cats regularly. the results also revealed a great diversity in cat feeding practices where 39.0% and 30.0% of the respondents fed their cats with milk and homemade feeds respectively. on the other hand, a relatively smaller proportion of the respondents claimed to employ other cat-feeding practices where 15.0% fed products unfit for human consumption from slaughterhouses and slabs while the remaining 17.0% claimed not to feed them at all. factors reflecting domestic cat management were also assessed where results showed that the majority (60.0%) of the respondents didn't manage to keep their cats indoors while the remaining 37.0% and 3.0% respectively kept their cats indoors or didn't own one (table 4). 1 1 4 4 5 7 0 2 4 6 8 television (4.5%) newspaper (4.5%) radio (18.2%) health workers (18.2%) social network (22.8%) university (31.8%) source of information on toxoplazmosis knowledge chalo sl, et al., journal of ideas in health (2023); 6(2):836-846 839 table 1: socio-demographic characteristics of study participants in urban and periurban areas of mbeya district. periurban wards urban wards variable categories igawilo mwansekwa iziwa itende maendeleo mabatini ruanda iyela total education level none _ 6(35%) 4(23.5%) 3(17.6%) 2(11.8%) 1(5.9%) 1(5.9%) _ 17 primary education 5(10.2%) 2(4.1%) 4(4.1%) 8(16.3%) 7(14.3%) 7(14.3%) 10(20.4%) 6(12.2%) 49 secondary education 1(8.3%) 3(25%) 2(16.7%) 2(16.7%) 1(8.3%) 3(25%) 12 advanced education 2(40%) 1(20%) _ 2(40%) 5 post-secondary education 6(35.3%) 1(5.9%) 1(5.9%) 2(11.8%) 2(11.8%) 1(5.9%) 2(11.8%) 17 sex male 8(66.7%) 4(33.3%) 9(75%) 10(83.3%) 6(46.2%) 7(53.8%) 5(38.5%) 8(61.5%) 57 female 4(33.3%) 8(66.7%) 3(25%) 2(16.7%) 7(53.8%) 6(46.2%) 8(61.5%) 5(38.5%) 43 marital status single 4(12.9%) 4(12.9%) 4(12.9%) 4(12.9%) 5(16.1%) 5(16.1%) 2(6.5%) 3(9.7%) 31 married 7(13%) 6(11.1%) 6(11.1%) 7(13%) 4(7.4%) 6(11.1%) 8(14.8%) 10(18.5%) 54 cohabiting 1(100%) _ _ _ _ _ _ _ 1 separated/divorced _ 1(16.7%) 2(33.3%) 1(16.7%) 1(16.7%) _ 1(16.7%) _ 6 widow _ 1(12.5%) _ _ 3(37.5%) 2(25%) 2(25%) _ 8 occupation peasant 2(5.3%) 7(18.4%) 8(21.1%) 6(15.8%) 5(13.2%) 1(2.6%) 3(7.9%) 6(15.8%) 38 formally employed 1(33.3%) _ 1(33.3%) _ _ _ 1(33.3%) _ 3 self employed 4(13.8%) 1(3.4%) 2(6.9%) 4(13.8%) 5(13.8%) 5(17.2%) 6(20.7%) 2(10.3%) 29 business 4(16%) 3(12%) 1(4%) 2(8%) 3(12%) 5(20%) 3(12%) 4(16%) 25 student 1(50%) 1(50%) _ _ _ _ _ _ 2 unemployed 1(33.3%) 2(66.7%) 3 age 18-25 2(11.1%) 2(11.1%) 2(11.1%) 4(22.2%) 2(11.1%) 1(5.6%) 2(11.1%) 3(16.7%) 18 26-35 3(7.9%) 7(18.2%) 3(7.9%) 5(13.2%) 4(10.5%) 8(21.1%) 2(5.3%) 6(15.8%) 38 36-45 5(20%) 1(4%) 6(24%) 1(4%) 5(20%) 1(4%) 5(20%) 1(4%) 25 46-55 2(16.7%) 1(8.3%) 2(6.7%) 1(8.3%) 1(8.3%) 2(6.7%) 3(25%) 12 56 and above 1(14.3%) 1(14.3%) 1(14.3%) 2(28.6%) 2(28.6%) _ 7 chalo sl, et al., journal of ideas in health (2023); 6(2):836-846 840 table 2: awareness of clinical signs and transmission of toxoplasmosis periurban wards urban wards igawilo iziwa itende mwansekwa maendeleo mabatini ruanda iyela total do you know the clinical manifestation of the disease? yes 2(14.3%) 1(7.1%) 3(21.4%) _ 5(35.7%) _ 1(7.1%) 2(14.3%) 14 no 10(11.6%) 11(12.8%) 9(10.5%) 12(14%) 8(9.3%) 13(15.1%) 12(14%) 11(12.8%) 86 if yes mention abortion 1(12.5%) 1(12.5%) 3(37.5%) _ 2(12.5%) _ _ 1(12.5%) 8 eye infection 1(50%) _ _ _ 1(50%) _ _ _ 2 i don’t know 10(11.1%) 11(12.2%) 9(10%) 12(13.3%) 10(11.1%) 13(14.4%) 13(14.4%) 12(13.3%) 90 how is toxoplasmosis transmitted food contamination 1(25%) 1(25%0 _ _ 1(25%) _ 1(25%) _ 4 consumption of raw meat 4(26.7%) 1(6.7%) _ 2(13.3%) 4(26.7%) 3(20%) _ 1(6.7%) 15 cat excreta _ _ 1(50%) _ _ 1(50%) _ _ 1 i don’t know 9(11.3%) 11(13.8%) 12(15%) 11(13.8%) 7(8.8%) 8(10%) 11(13.8%) 11(13.8%) 80 mention other rodent or cat -borne diseases plague 2(20%) 1(10%) 1(10%) 1(10%) 2(20%) 1(10%) 1(10%) 1(10%) 10 leptospirosis 3(100%) _ _ _ _ _ _ _ 3 rabies 2(66.7%) _ _ _ 1(33.3%) _ _ _ 3 worms 1(33.3%) _ _ _ 2(66.7%) _ 3 i don’t know 5(6.2%) 11(13.6%) 11(13.6%) 11(13.6%) 10(12.3%) 11(13.6%) 11(13.3%) 11(13.3%) 81 chalo sl, et al., journal of ideas in health (2023); 6(2):836-846 841 table 3: mean score assessment of the respondents toward toxoplasmosis knowledge aspect under assessment question number desired response percentage awareness of toxoplasmosis existence 6 yes 22 awareness of clinical manifestation of disease 8 yes 14 ability to mention a clinical manifestation 8 relevant clinical sign 10 mode of disease transmission 9 relevant mode of transmission 20 awareness of any other rodent/cat-borne disease 10 common rodent/cat-borne disease 19 total 85 mean 17 human sanitation and hygiene the questionnaire also assessed factors revealing human sanitation and hygiene practices influencing transmission of the disease from definitive hosts. in relation to this, the results showed that the majority (91.0%) of the respondents didn't clean their hands after physical contact with a cat. furthermore, children appeared to be at the highest risk of contracting the disease as the greatest percentage of respondents mentioned them to be the group that was involved in cat kennel /box cleaning as well as playing with them. in addition to this, the results also revealed a great diversity in methods employed to dispose of cat litter material where the majority (36.0%) of the respondents disposed of cat litter materials in their gardens while 21.0% and 15.0% of the respondents' mentioned farms and in designed boxes as respective disposal destination (table 4). table 4: practices influencing the risk of toxoplasmosis from definitive host cats statements n % do you deworm cats regularly? no 81.0 81.0 yes 19.0 19.0 what do you feed your cat? homemade feedstuff 30.0 30.0 milk 39.0 39.0 leftovers/condemned parts from slaughter slab 15.0 15.0 do nothing 17.0 16.0 do you keep your cat indoors or outdoors? indoor 37.0 37.0 outdoor 60.0 60.0 i don't have a cat 3.0 3.0 how do you dispose of cat litter material? boxes 15.0 15.0 garden 36.0 36.0 farm 21.0 21.0 pity 6.0 6.0 garbage dump 10.0 10.0 do nothing 12.0 12.0 who cleans cat kennels/cat litter boxes? children 49.0 49.0 youth 30.0 30.0 adult 21.0 21.0 seniors 0.0 0.0 do you wash your hands after physical contact with cats or their feces? no 91.0 91.0 yes 9.0 9.0 practices assessing the role of the intermediate host (rodent) in the transmission of toxoplasmosis practices influencing the risk of toxoplasmosis transmission from the intermediate host (rodents) in a home setting were assessed by four questions. in relation to this assessment, the results revealed that the majority (80.0%) of the respondents claimed not to consume rodents as a source of food. however, most (41.0%) of the respondents claimed to use cats to control rodents in their homes. the questionnaire also assessed methods employed in the disposal of dead rodents where results showed that the majority (55.0%) of the respondents disposed of dead rodents in land pits, followed by 19.0% and 12.0% of the respondents who respectively claimed to burn and feed dead rodents to cats. the remaining 14.0% included those who disposed of dead rodents either by consumption, throwing them in farm fields, or left unattended (table 5). table 5: practices influencing toxoplasmosis transmission from the intermediate host (rodent) n % do you consume rodents for food? no 80.0 80.0 yes 20.0 20.0 do you control rodents in your house? no 27.0 27.0 yes 73.0 73.0 if yes, specify the method rodenticides 19.0 19.0 cats 41.0 41.0 traps 13.0 13.0 nothing 27.0 27.0 how do you dispose of dead rodents? pity 55.0 55.0 feeding the cats 12.0 12.0 eating as meat 1.0 1.0 burning 19.0 19.0 farm 3.0 3.0 do nothing 10.0 10.0 practices influencing transmission of toxoplasmosis with the exclusion of intermediate and definitive host involvement the results revealed that the majority (65.0%) of the respondents consumed boiled water. furthermore, the results show that 77.0%, 61.0%, and 84.0% of the respondents didn't consume raw meat, vegetables, and milk respectively. questions linked to human hygiene in relation to the disease were also assessed where 88.0%, 96.0%, and 77.0% of the respondents, claimed to wash vegetables before consumption, wash their hands before eating, and do not wear gloves/protective gear while conducting gardening activities respectively (table 6). chalo sl, et al., journal of ideas in health (2023); 6(2):836-846 842 table 6: respondents' behaviors that may influence the risk of toxoplasmosis transmission statements n % does your household utilize boiled water for drinking? no 35.0 35.0 yes 65.0 65.0 do you directly consume raw animal meat? no 77.0 77.0 yes 23.0 23.0 do you directly consume raw vegetables for food? no 61.0 61.0 yes 39.0 39.0 do you consume unboiled milk? no 84.0 84.0 yes 16.0 16.0 do you wash vegetables before cooking them? no 12.0 12.0 yes 88.0 88.0 do you protect your hands during gardening activities? no 77.0 77.0 yes 23.0 23.0 do you clean your hand before meals? no 4.0 4.0 yes 96.0 96.0 statistically inference of variations in awareness of the disease within categorical demographic variables the results showed a statistically significant variation in awareness of the existence of the disease within three of the socio-demographic variables assessed. the variables that showed a statistically significant variation in the awareness of the existence of this disease include education level, sex, and occupation of respondents (table 7). discussion this study reports the level of community awareness, knowledge, and practices related to toxoplasma transmission and prevention in the mbeya district. the study indicates a low level of knowledge about the disease. only 17.0% were aware implying that the majority of the study respondents were not aware of toxoplasmosis. as with other neglected diseases, the disease is not given priority in health education programs. this increases the risk of disease transmission in the community. a similar observation was also made by [16] in dar es salaam who found that less than 36% of study participants knew the existence of the disease. furthermore, [23,22] respectively reported a similarly low level of awareness of the disease in morocco (41.2%) and kuwait (15.6%). the unawareness of the existence of this disease observed in our study is probably due to fewer regular toxoplasmosis screening programs in tanzania compared to other common diseases like malaria, typhoid, and hiv aids. this hypothesis is in line with that provided by [24, 16] who respectively claimed that the low level of awareness of the disease is attributed to the lack of a screening program in morocco and tanzania. for effective prevention of the disease awareness campaign is important. this low level of knowledge and awareness (17.0%) about toxoplasmosis among study participants furthermore, relates to their low level of education as the majority had only primary education as similarly observed in iraq [25]. in addition, the low case mortality rate and the chronic nature of the disease have left it neglected and made it less common as evidenced by the lack of a local vernacular term to address it hence negatively affecting its popularity. in relation to this, [16,26] similarly, reported unawareness of this disease and emphasized on negative effects of the absence of a local vernacular term on its popularity. the limited awareness of the existence of this disease among community members could also be attributed to the low/lack of continuous mass health education (education campaigns) by members of the health sector towards toxoplasmosis as among zoonotic diseases [27]. the results further revealed highlearning institutions to be the main source from which most of the respondents (32.0%) got informed of the disease through attending university education. similarly, a scenario observed by [28]in iran showed that the majority (55.8%) of study participants got informed of the disease in the pursuit of medical training in higher learning institutions during parasitological curriculum courses. furthermore, similar to this study done in dar es salaam by [29], found that social networks, radio, and health centers were significant sources of knowledge. this emphasizes the need for more government effort in health education awareness campaigns towards the disease through different media. the results also exposed the risk of toxoplasmosis transmission from infected definitive hosts (cats) who play a major role in local transmission of the disease with an ability to shed numerous oocysts in the environment [30]. the results revealed poor veterinary management of domesticated cats highlighted by a high percentage of respondents who never dewormed their cats but simultaneously use them for rodent control in their homes hence increasing their potential to contract and transmit the disease to humans. outdoor management of domesticated cats and their feeding behaviors including access to rodents as intermediate hosts, in this study majority of the participants (60.0%) practiced outdoor management of the cats this can attribute the diseases transmission and hence leading to an increase in toxoplasmosis prevalence in both human and animals in the study area similarly observed by [31]. there is a great possibility of cat feeding behaviors influence their risk of contracting the disease as reflected by the diversity of cat feeding practices such as feeding raw milk, as well as un edible offal observed in this study population. a similar finding has been reported in britain by [32]. local transmission of the disease in the study community could also be influenced by poor cat litter disposal and sanitary management practices employed by the majority of the community members. such an observation occurs in line with that provided by [33] in kenya and [34] in thika region kenya who reported that disposal of cat litter waste in gardens could increase the risk of acquiring toxoplasmosis infections, particularly to farmers. children are the ones who play, feed, and clean cat litter boxes or kennels this can risk them acquiring toxoplasmosis and other companion zoonosis such as parasitic diseases [35, 36]. there is a great possibility of cat feeding behaviors influencing their risk of contracting the disease as reflected by the diversity of cat feeding practices such as feeding raw milk, as well as un edible offal observed in this study population. chalo sl, et al., journal of ideas in health (2023); 6(2):836-846 843 table 7: association between social demographic characteristics and knowledge of toxoplasmosis variable have you heard of a disease called toxoplasmosis no yes total x2 p-value education level none 17(100%) 0(0.0%) 17 23 0.000* primary education 9(81.6%) 40(18.4%) 49 secondary education 2(83.3%) 10(16.7%) 12 advance education 2(60.0%) 3(40%) 5 post-secondary education (college, university) 6(35.3%) 11(64.7%) 17 sex male 39(68.4%) 18(31.6) 57 4.174 0.041* female 37(86.0%) 6(14.0%) 43 marital status single 21(67.7%) 10(32.3%) 31 3.95 0.413 married 41(75.9%) 13(24.1%) 54 cohabiting 1(100%) 0(0.0%) 1 separated/divorced 6(100%) 0(0.0%) 6 widow 7(87.5%) 1(12.5%) 8 occupation peasant 36(94.7%) 2(5.3%) 38 17.551 0.002* formally employed 1(33.3%) 2(66.7%) 3 self employed 16(55.2%) 13(44.8) 29 business 19(76.0%) 6(24.0%) 25 unemployed 3(100%) 0(0.0%) 3 student 1(50.0%) 1(50.0%) 2 age 18-25 15(83.3%) 3(16.7) 18 4.368a 0.358 26-35 25(65.8%) 13(34.2%) 38 36-45 21(84%) 4(16%) 25 46-55 10(83.3%) 2(16.7%) 12 56above 6(85%) 1(14.3%) 7 location periurban 39(81.2%) 9(18.8%) 48 0.941 0.332 urban 38(73.1%) 14(26.9%) 52 chalo sl, et al., journal of ideas in health (2023); 6(2):836-846 844 a similar finding has been reported in britain by [32]. local transmission of the disease in the study community could also be influenced by poor cat litter disposal and sanitary management practices employed by the majority of the community members. such an observation occurs in line with that provided by [33] in kenya and [34] in thika region kenya who reported that disposal of cat litter waste in gardens could increase the risk of acquiring toxoplasmosis infections, particularly to farmers. children are the ones who play, feed, and clean cat litter boxes or kennels this can risk them acquiring toxoplasmosis and other companion zoonosis such as parasitic diseases [35, 36]. the study further revealed community members practicing good hygienic behaviors hence lowering the risk of acquiring the disease. the majority of the community members reported consuming boiled water and milk as well as cooked meat and vegetables and avoided consuming rodent meat. this observation is contrary to those obtained in previous studies by [33,37], in kenya and mvomero respectively who found that the majority of community members were practicing risky eating habits in relation to the acquisition of the disease. however, one practice appeared to raise the risk of acquiring toxoplasmosis where 77% claimed that they don't wear gloves while conducting gardening practices as similarly observed in al-najaf [38]. the results revealed a statistically significant relationship between knowledge of the disease among sex, occupations, and education such an observation was similarly made in studies conducted by [39, 24] in ethiopia and morocco respectively. in this study, participants with higher levels of education (post-secondary education), were more knowledgeable about toxoplasmosis compared to those with lower levels. on the other hand, respondents who are formally employed especially in medical-related employment were more knowledgeable about toxoplasmosis than other occupation categories. this might be escalated by the educational background linked to their professions this is in line with reports from dodoma by [26] and [40] in nigeria. nevertheless, the sex of the respondent had a significant association with knowledge of the disease. males were more knowledgeable than females. however, [40] in nigeria contrarily found insignificant variations in awareness of the same disease between sexes. the variation of these findings could be attributed to the difference in representative sample within the study populations as well as the occupation of the respondents and educational background. conclusion the study revealed low community awareness and knowledge of the existence of toxoplasmosis in the study area. the study also revealed some of the practices that are considered as the risk factors in local transmission of the disease from definitive, intermediate, and human hosts of the pathogen such as lack of regular deworming of cats, outdoor management of cats, poor disposal of cat's litter materials in gardens, use of cats in controlling of rodents and not wearing gloves during gardening. we recommend more efforts to educate the mass community in both rural and urban on aspects related to transmission, clinical signs, treatment, and control of the disease harnessing the one health approach. furthermore, we recommend regular animal and human screening of the disease to reveal its epidemiological patterns. also, we recommend similar studies be done targeting health providers. abbreviation ny: new york; usa: united states of america; sua: sokoine university of agriculture; hiv: human immunodeficiency virus; aids: acquired immunodeficiency syndrome. declaration acknowledgment the authors gratefully acknowledge the mbeya regional council for the provision of permission in conducting research in the study area, and the african center of excellence for innovative rodent pest management and biosensor technology development project (ace ii-irpm&btd) 5799/tz for financing the study support. last but not least we wish to express our gratitude to all study participants. funding this research was funded by the african center of excellence for innovative rodent pest management and biosensor technology development project (ace ii-irpm&btd) 5799/tz. . availability of data and materials data will be available by emailing chalostell71@gmail.com authors’ contributions stela. chalo (slc) is a primary investigator involved in data collection, analysis, interpretation, and article writing. ernatus.m. mkupasi (emm), a.s.katakweba (ask), and eliakunda.m. mafie (emm) are supervisors, both supervisors were responsible for drafting and reviewing the article. ethics approval and consent to participate the study was conducted in accordance with the ethical principles of the declaration of helsinki (2013). ethical clearance was obtained from the institutional review board of the sokoine university of agriculture with reference number (sua/dprtc/r/186/20) issued on 1/12/2021. furthermore, permission was also obtained from the mbeya district administrative authorities to allow the conduct of research activity in all respective study sites (wards) prior to commencing the study (mcc/r.50/1/vol.xxv/207) issued on 27/01/2022. the purpose of the study was explained to participants whose verbal consent was requested and confidentiality guaranteed before data collection. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) chalo sl, et al., journal of ideas in health (2023); 6(2):836-846 845 and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of veterinary medicine and public health, sokoine university of agriculture, p. o. box 3021, morogoro, tanzania. 2department of microbiology, parasitology and biotechnology, sokoine university of agriculture, p.o. box 3019, morogoro, tanzania. 3institute of pest management, sokoine university of agriculture, p. o. box 3110, morogoro, tanzania. article info received: 02 march 2023 accepted: 09 may 2023 published: 19 may 2023 references 1. alzaheb ra. seroprevalence of toxoplasma gondii and its associated risk factors among women of reproductive age in saudi arabia: a systematic review and meta-analysis. international journal of women's health. 2018 sep 21:53744. doi: 10.2147/ijwh.s173640 2. calero-bernal r, gennari sm. clinical toxoplasmosis in dogs and cats: an update. frontiers in veterinary science. 2019 feb 26; 6:54. doi: 10.3389/fvets.2019.00054 3. gontijo da silva m, clare vinaud m, de castro am. prevalence of toxoplasmosis in pregnant women and vertical transmission of toxoplasma gondii in patients from basic units of health from gurupi, tocantins, brazil, from 2012 to 2014. plos one. 2015 nov 11;10(11):e0141700. doi: 10.1371/journal.pone.0141700 4. stelzer s, basso w, silván jb, ortega-mora lm, maksimov p, gethmann j, conraths fj, schares g. toxoplasma gondii infection and toxoplasmosis in farm animals: risk factors and economic impact. food and waterborne parasitology. 2019 jun 1; 15: e00037. doi: 10.1016/j.fawpar.2019.e00037 5. mcauley jb. congenital toxoplasmosis. journal of the pediatric infectious diseases society. 2014 sep 1; 3(suppl_1):s30-5.doi: 10.1093/jpids/piu077 6. hampton mm. congenital toxoplasmosis: a review. neonatal network. 2015 jan 1; 34(5):274-8. doi: 10.1891/0730-0832.34.5.274 7. khurana s, batra n. toxoplasmosis in organ transplant recipients: evaluation, implication, and prevention. tropical parasitology. 2016 jul; 6(2):123. doi: 10.4103/2229-5070.190814 8. strang ag, ferrari rg, do rosário dk, nishi l, evangelista ff, santana pl, de souza ah, mantelo fm, guilherme al. the congenital toxoplasmosis burden in brazil: systematic review and meta-analysis. actatropica.2020 nov 1; 211:105608.doi: 10.1016/j.actatropica.2020.105608 9. smith nc, goulart c, hayward ja, kupz a, miller cm, van dooren gg. control of human toxoplasmosis. international journal for parasitology. 2021 feb 1; 51(23):95-121.doi: 10.1016/j.ijpara.2020.11.001 10. furtado jm, smith jr, belfort jr r, gattey d, winthrop kl. toxoplasmosis: a global threat. journal of global infectious diseases. 2011 jul;3(3):281. doi: 10.4103/0974777x.83536 11. wang zd, liu hh, ma zx, ma hy, li zy, yang zb, zhu xq, xu b, wei f, liu q. toxoplasma gondii infection in immunocompromised patients: a systematic review and meta-analysis. frontiers in microbiology. 2017 mar 9; 8:389. doi: 10.3389/fmicb.2017.00389 12. dupont d, fricker-hidalgo h, brenier-pinchart mp, garnaud c, wallon m, pelloux h. serology for toxoplasma in immunocompromised patients: still useful? trends in parasitology. 2021 mar 1; 37(3):205-13. doi: 10.1016/j.pt.2020.09.006 13. retmanasari a, widartono bs, wijayanti ma, artama wt. prevalence and risk factors for toxoplasmosis in middle java, indonesia. ecohealth. 2017 mar; 14:162-70. doi: 10.1007/s10393-016-1198-5 14. schoonman lb, wilsmore t, swai es. seroepidemiological investigation of bovine toxoplasmosis in traditional and smallholder cattle production systems of tanga region, tanzania. tropical animal health and production. 2010 apr; 42:579-87. doi: 10.1007/s11250009-9460-2 15. mose jm, kagira jm, kamau dm, maina nw, ngotho m, karanja sm. a review on the present advances on studies of toxoplasmosis in eastern africa. biomed research international. 2020 jul 6; 2020. doi: 10.1155/2020/7135268 16. onduru og, rumisha sf, munyeme m, phiri am. evaluation of the level of awareness of congenital toxoplasmosis and associated practices among pregnant women and health workers in tanzania’s temeke district in dar es salaam. african health sciences. 2019; 19(4):3027-37. doi: 10.4314/ahs.v19i4.24 17. mboera le, kishamawe c, kimario e, rumisha sf. mortality patterns of toxoplasmosis and its comorbidities in tanzania: a 10-year retrospective hospital-based survey. frontiers in public health. 2019 feb 19; 7:25. doi: 10.3389/fpubh.2019.00025 18. urt (united republic of tanzania) mbeya region socioeconomic profile. the planning commission dar-essalaam and regional commissioner's office mbeya. 1997. http://www.mbeya.go.tz/uploads/mbeya_region_social_e conimic_profile_2000.pdf (visited on 10/ june/ 2022) 19. national bureau of statistics (nbs) ‘data visualization: basic demographic and social economic indicators, population size, growth and distribution. institute for health metrics and evaluation2012. http://www.healthdata.org/tanzania] site visited on 12/10/2022 20. tanzania metrological authority: https://www.meteo.go.tz visited on 10/6/2021 21. kothari cr. research methodology: methods and techniques. new age international; 2004. 22. iqbal j, khadadah n, mohammed a. knowledge, attitude and preventive behavior towards toxoplasmosis among chalo sl, et al., journal of ideas in health (2023); 6(2):836-846 846 kuwaiti women with/without pregnancy experience: a cross sectional study 2021, 23. ait hamou s, laboudi m. an analytical study on the awareness and practice relating toxoplasmosis among pregnant women in casablanca, morocco. bmc public health. 2021 dec; 21(1):1-9. doi: 10.1186/s12889-02110474-9 24. ait hamou s, lamhamdi b, hayah i, belbacha i, sadak a, laboudi m. the level of knowledge about toxoplasmosis among university students in rabat in morocco. journal of parasitology research. 2021 jul 26; 2021. doi: 10.1155/2021/5553977 25. al-hellaly em, chyad rt. knowledge of iraqi pregnant woman about toxoplasmosis and their practice towards its prevention. journal of university of babylon for pure and applied sciences. 2019 sep 22;27(3):308-15. 26. lema gb. toxoplasma gondii infection among outpatients attending dodoma regional referral hospital in central tanzania: prevalence and associated risk factors in central tanzania (doctoral dissertation, sokoine university of agriculture) 2020. 27. efunshile am, elikwu cj, jokelainen p. toxoplasmosis– awareness and knowledge among medical doctors in nigeria. plos one. 2017 dec 19; 12(12): e0189709. doi: 10.1371/journal.pone.0189709 28. ebrahimi m, ahmadi a, yaghfoori s, rassouli m, azizzadeh m. evaluating the prior knowledge of toxoplasmosis among students of ferdowsi university of mashhad. medical journal of the islamic republic of iran. 2015; 29:163. 29. lushina m, mushi v, tarimo d, babafemi eo. seroprevalence of toxoplasma gondii and associated risk factors among pregnant women attending antenatal care in ilala municipality, dar es salaam, tanzania. 30. alrashada n, al-gharrash z, alshehri f, al-khamees l, alshqaqeeq a. toxoplasmosis among saudi female students in al-ahssa, kingdom of saudi arabia: awareness and risk factors. open journal of preventive medicine. 2016 aug 26; 6(8):187-95. 31. kijlstra a, meerburg bg, mul mf. animal-friendly production systems may cause re-emergence of toxoplasma gondii. njas: wageningen journal of life sciences. 2004 sep 1;52(2):119-32. 32. davies rh, lawes jr, wales ad. raw diets for dogs and cats: a review, with particular reference to microbiological hazards. journal of small animal practice. 2019 jun;60(6):329-39. doi: 10.1111/jsap.13000 33. ogendi e, maina n, kagira j, karanja s, ngotho m, mbugua g. questionnaire survey on the occurrence of risk factors for toxoplasma gondii infection amongst farmers in thika district, kenya. journal of the south african veterinary association. 2013 jan 1; 84(1):1-6. doi: 10.4102/jsava.v84i1.191 34. nyambura njuguna a, kagira jm, muturi karanja s, ngotho m, mutharia l, wangari maina n. prevalence of toxoplasma gondii and other gastrointestinal parasites in domestic cats from households in thika region, kenya. biomed research international. 2017 oct; 2017. doi: 10.1155/2017/7615810 35. robertson id, irwin pj, lymbery aj, thompson rc. the role of companion animals in the emergence of parasitic zoonoses. international journal for parasitology. 2000 nov 1; 30(12-13):1369-77. doi: 10.1016/s00207519(00)00134-x 36. purewal r, christley r, kordas k, joinson c, meints k, gee n, westgarth c. companion animals and child/adolescent development: a systematic review of the evidence. international journal of environmental research and public health. 2017 mar; 14(3):234. doi: 10.3390/ijerph14030234 37. sheppa sp. seroprevalence of toxoplasma infection in goats and sheep and associated risk factors in mvomero district, tanzania (doctoral dissertation, sokoine university of agriculture).2016. 38. hussein za. nurses knowledge of toxoplasmosis in alnajaf province/iraq. al-kufa university journal for biology. 2017 jun 5. 39. fesseha h, abebe f. assessment of community knowledge, attitude, and practice on common zoonotic diseases in jinka town, southern ethiopia. journal of gaz medical science. 2020; 1:18-29. 40. ode sa, jubril aj, emikpe bo. awareness and habits of nigerians towards toxoplasmosis and risk factors. pamjone health. 2021 apr 20; 4(15). alim-marvasti, journal of ideas in health 2020;3(1):135-137 © the author(s). 2020 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access non-invasive thrombectomy: magnetized antibodies in reperfusion of thromboses ali alim-marvasti 1-4 abstract background: five multi-center randomized controlled trials have shown superior outcomes for mechanical thrombectomy to standard intravenous thrombolysis for acute anterior ischaemic stroke. this idea-paper aims to provoke multi-disciplinary expertise to develop a less invasive and more rapid thrombectomy technology. the hypothesis is that by adapting existing technology to magnetize in vivo blood clots, we should be able to dislodge clots from major vessels magnetically and achieve minimally invasive reperfusion. methods: first, magnetized antibodies against specific epitopes in blood clots must be developed (such as the previously used fibrin beta-chain specific antibody, 59d8) and an external portable magnetic device with superlens magnetic-field focusing would be used to dislodge and guide the clot proximally to establish reperfusion; subsequently, the clot will be removed. a distal magnet, statically held at the original location of the dislodged clot, would prevent microemboli from occluding distal vessels during dislodgement and removal of the clot. conclusion: developing specific antibodies against in vivo blood clots (immunology) with attached superparamagnetic nanoparticles (nanoscience) and an external portable magnetic device with a focused magnetic flux (applied medical physics) will significantly improve time to revascularization in acute ischaemic stroke, minimize risks of intervention, and thus improve outcomes further. keywords: stroke, thrombosis, thrombectomy, clot retrieval, magnetized antibodies, portable magnetic device background ischaemic stroke is a leading cause of mortality and morbidity in the world, and constitute 85.0% of all strokes, costing the uk national health service (nhs) over £3billion a year [1]. in vivo, acute blood clots may be visualized on computedtomography (ct) scans as hyperdense and radio-opaque to xrays. intrinsically, the blood clot has chemically altered blood components which arise as a result of the coagulation cascade and platelet adhesion and aggregation. intravenous or intra-arterial thrombolysis with recombinant tissue-plasminogen activators (e.g., alteplase) have remained the gold-standard hyperacute treatment of ischaemic stroke, and previously were the standard of treatment for st-elevation myocardial infarctions prior to primary percutaneous coronary intervention. several studies have shown a modest benefit of thrombectomy interventions. in meta-analyses and subgroup analysis, invasive neuro-radiologically performed thrombectomies are of most benefit the earlier they are performed and in patients with more severe strokes as quantified on the national institutes of health stroke scale (nihss) scores [2]. five multi-center, randomized controlled trials have shown mechanical thrombectomy devices to be superior (outcomes on the modified rankin scale at 90 days) to standard treatment with intravenous thrombolysis alone (in anterior circulation ischemic stroke caused by a proximal large artery occlusion) [3-7]. the procedures themselves carry risk and benefit is limited due to dependence on expertise, speed of transfer to a centre capable of vascular intervention as well as time required for the preparations for intervention. therefore, developing a noninvasive technique that can dislodge and remove clots would improve time to thrombectomy, enhancing benefits, and reduce risks associated with mechanical thrombectomy. methods overview what is proposed here is to develop antibodies specifically against an epitope restricted to in vivo blood clots. the fragment crystallizable (fc) region of the antibody would be pre-attached to superparamagnetic nanoparticles. ___________________________________________________ a.alim-marvasti@ucl.ac.uk 1department of clinical and experimental epilepsy, ucl queen square institute of neurology, london wc1n 3bg, uk full list of author information is available at the end of the article http://www.jidhealth.com/ alim-marvasti, journal of ideas in health (2020);3(1):135-137 136 after intravenous or intra-arterial administration of this magnetized antibody, a non-invasive transcutaneous external magnet would be applied to the region of the clot, for example, for carotid occlusions. the externally applied magnetic field would be varied in order to dislodge the clot from the vessel, with the option of using ultrasound to assist the mechanical dislodging. a second bolus of magnetized antibody would then be injected to coat the clot further as more epitopes are revealed during dislodgement. the magnetic field can then guide the clot against arterial blood flow towards a more proximal superficial artery, thus establishing reperfusion while a more distal magnet remains to catch any microemboli dislodged from the clot. an arterial puncture can then be performed to remove the clot entirely (in later iterations, instead of arterial puncture, intra-arterial thrombolysis and/or ultrasound could conceivably be used to break the clot in situ). 1. antibodies 1a. super-paramagnetic-nanoparticles (mnp) these have already been used for magnetized drug delivery. although high loadings (>100 μg/ml) of mnps cause cytotoxicity, toxicity studies on magnetic nanoparticles show that these particles can be biocompatible [8]. 1b. in vivo blood clot specific epitope (fibrin) in studies performed in the late 1980s, fibrin beta chainspecific antibody 59 d8 – which provided the highest level of binding to clot – binds fourteen-fold better to blood clots than the control (antidigoxin antibody) [9]. fibrin would thus be the most likely candidate for a specific epitope. other blood clot epitopes could be considered if anti-fibrin antibodies are deemed insufficiently specific for blood clots after testing. 2. transcutaneous portable magnetic device (tpmd) recently the food and drug administration (fda) in the usa issued a substantial equivalence approval for a portable magnetic resonance imaging scanner (mri). this low magnetic field scanner can provide images of the brain [10]. a similar bespoke device would be required for this purpose, a portable high-field machine, to be applied via the transcutaneous route after the clot is magnetized. alternatively, a device integrated into an mri scanner to automate the process and localize the clot, akin to radiotherapy preparation. 2a. magnetic flux focusing and portability in order to increase the magnetic force on the clot with increased chances of dislodgement and reperfusion, besides an advanced integrated version within mri-stroke specific scanners, the portable external magnet can utilize the following design concepts: i) solenoid: increased magnetic flux within the solenoid. it would be difficult to access the clot from the carotid. thus, a superlens design is preferable (see below). ii) by focusing on a magnetic field, the size of the tpmd could be reduced, and a smaller electric power source would be required than would be feasible with the magnetic field of an unfocused magnet [11]. this allows for miniaturization and a portable tpmd, which may be used even in the emergency department itself – thus substantially reducing the preparation time required for mechanical thrombectomy in an angiography suite. iii) superlens metamaterials with magnetic permeability of ¬-1 can focus the near fields of magnetic flux and improve efficiency, allowing for a smaller, more portable tpmd [12]. 2b. dynamic magnetic field to dislodge the clot (prior to the second injection of magnetized antibody) there will be a need for mechanical, magnetic, ultrasonic, or combined mechanisms to help dislodge the clot. this may be achieved by: i) altering the strength of the tpmd magnetic-field focused on the magnetized clot ii) moving the portable external magnet to alter the distance between it and the magnetized clot. this can be an automated mechanical process occurring in the hand-held device. while the portable device is held constant, the external magnet within it moves. iii) an electrically controlled alternating magnetic field, similar to that used in mri. these field-altering methods may not be sufficient to dislodge the clot. a mechanical or ultrasonic component may be required. 3. magnetic microemboli filter (mmf) the mmf would be a straightforward permanent magnet which occupies the original location of the clot. after the tpmd has dislodged the clot and is guiding it proximally, the mmf would prevent arterial blood flow from throwing microemboli off the retrieved clot more distally. the mmf would magnetically prevent distal micro-embolization during dislodgement and removal of the clot by the tpmd. discussion the key to better outcomes in strokes is rapid thrombectomy or thrombolysis, with the former showing improved outcomes, especially when clots are retrieved without delay. within a few minutes of hypoxia or lack of blood flow, nervous tissue begins to die. current thrombectomy procedures puncture the skin and artery, whether in the leg (femoral) or arm (radial), and a clot retrieval device is advanced up towards the heart and then into the blocked artery. risks include pulmonary embolism, embolic strokes, infection, and damage to the blood vessel at the site of the clot. the combined methodology outlined above has the potential to not only expedite interventions but also minimize risks due to no clot retrieval device being advanced into the arterial system. this is achieved by a hand-held tpmd that can be used immediately after magnetized antibody injection, reducing the duration of the ischaemic brain. further work based on the specifics of the antibody and tpmd capability will be required in the form of a theoretical calculation of required magnetic field strength of the tpmd using fluid mechanics. it will be necessary and may be possible, using the data below, to determine the theoretically required tpmd field-strength in order to magnetically hold on to the clot and steer it against blood flow: i) antibody specificity to blood clots. ii) mnp strength. iii) arterial blood flow dynamics, e.g., in carotid arteries alim-marvasti, journal of ideas in health (2020);3(1):135-137 137 iv) vessel and blood clot distance from the external magnetic device (ultrasound estimation of soft tissue thickness between skin and vessel). furthermore, a calculation is required using the above data to ensure there are no major shearing forces on other organs (e.g., endothelial cells of intact patent vessels) to minimize side effects from less specifically bound mnp around the body. for example, using fibrin beta-chain specific antibodies, we would need to ensure that these are sufficiently specific to prevent significant binding of the magnetized antibodies to other tissues. conclusion the outlined innovative method has the potential to improve ischaemic and embolic stroke outcomes. abbreviations nhs: national health service; ct: computed-tomography; nihss: national institutes of health stroke scale; fc: fragment crystallizable mnp: magnetic nanoparticles; fda: food and drug administration; mri: magnetic resonance image; tpmd: transcutaneous portable magnetic device; mmf: magnetic microemboli filter declarations acknowledgement none funding the author (s) received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing a.alim-marvasti@ucl.ac.uk authors’ contributions ali alim-marvasti (aa-m) is the principal investigator of this manuscript (viewpoint). aa-m is responsible for the study concept, design, writing, reviewing, editing, and approving the manuscript in its final form. aa-m read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki; however, viewpoint article need no ethic committee approval. consent for publication not applicable competing interest the author declare that he has no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated author details 1department of clinical and experimental epilepsy, ucl queen square institute of neurology, london wc1n 3bg, uk. 2department of medical physics and biomedical engineering, ucl.3wellcome / epsrc centre for interventional and surgical sciences (weiss). 4 national hospital for neurology and neurosurgery, london, uk article info received: 02 may 2020 accepted: 11 may 2020 published: 17 may 2020 references 1. clinical commissioning policy: mechanical thrombectomy for acute ischaemic stroke (all ages) nhs england; 2018. available from: https://www.england.nhs.uk/wpcontent/uploads/2019/05/mechanical-thrombectomy-for-acuteischaemic-stroke-errata-29-05-19.pdf [accessed 1 may 2020]. 2. broderick jp, palesch yy, demchuk am, yeatts sd, khatri p, hill md, et al. endovascular therapy after intravenous t-pa versus t-pa alone for stroke. n engl j med. 2013;368(10):893-903. 3. berkhemer oa, fransen ps, beumer d, van den berg la, lingsma hf, yoo aj, et al. a randomized trial of ıntraarterial treatment for acute ıschemic stroke. n engl j med 2015; 372:1120. 4. goyal m, demchuk am, menon bk, eesa m, rempel jm, thornton j, et al. randomized assessment of rapid endovascular treatment of ischemic stroke. n engl j med 2015; 372:1019-1030. 5. saver jl, goyal m, bonafe a, diener h-c, levy ei, pereira vm, et al. stent-retriever thrombectomy after intravenous t-pa vs. t-pa alone in stroke. n engl j med 2015; 372:2285-2295. 6. campbell bc, mitchell pj, kleinig tj, dewey hm, churilov l, yassi n, et al. endovascular therapy for ischemic stroke with perfusion-imaging selection. n engl j med 2015; 372:1009-1018. 7. jovin tg, chamorro a, cobo e, de miquel ma, molina ca, rovira a, et al. thrombectomy within 8 hours after symptom onset in ischemic stroke. n engl j med 2015; 372:2296-2306. 8. bucak s, yavuztürk b, sezer ad. magnetic nanoparticles synthesis surface modifications and application in drug delivery. in: sezer ad, editor. recent advances in novel drug carrier systems. croatia: intech; 2010. p. 165–200. 9. liau cs, haber e, matsueda gr. evaluation of monoclonal antifibrin antibodies by their binding to human blood clots. thromb haemost1987; 57(1):49–54. 10. united states food and drug administration, u.s.-fda 510 (k) approval. available from: https://www.accessdata.fda.gov/cdrh_docs/pdf19/k192002.pdf. [accessed 1 may 2020]. 11. boyd b. bushman. "apparatus and method for amplifying a magnetic beam"; expired us patent 5929732 a. 12. lipworth g, ensworth j, seetharam k, huang d, lee js, schmalenberg p, et al. magnetic metamaterial superlens for increased range wireless power transfer. sci rep2014; 4, 3642. https://doi.org/10.47108/jidhealth.vol6.iss2.287 mlowe gd, et al., journal of ideas in health (2023); 6(2):878-886 © the author(s). 2023 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access seropositivity of leptospira in rodents, shrews, and domestic animals in unguja, tanzania gerald dickson mlowe1*, isaac makundi2, abdul suleman katakweba 3,4, robert machang’u5 abstract background: leptospirosis is one of the most commonly neglected zoonoses in developing nations including tanzania. this study aims to find out the seroprevalence of leptospirosis in rodents, shrews, and domestic animals in different regions in unguja island, tanzania. methods: a cross-sectional study was carried out from january to april 2022. the blood samples were collected from rodents and shrews (n=248), cattle (n=247), goats (n=130), sheep (n=32), and dogs (n=80). the blood samples were allowed to clot in a slanted position and serum samples were harvested. a microscopic agglutination test (mat) was performed on the sera to check for leptospiral antibodies using five leptospira serovars as antigens (sokoine, lora, pomona, grippotyphosa and hebdomadis). results: the overall seropositivity of leptospiral antibodies was 9.68% in rodents and shrews, 14.57% in cattle, 10.01% in goats, 31.25% in sheep, and 26.25% in dogs. the seropositivity of leptospira varied significantly with animal species (or=1.9, 95 % ci:1.1-3.3, p=0.03). the most frequently detected serovar was sokoine (27.89%), followed by pomona (19.47%), lora (18.26%), grippotyphosa (17.98%), and hebdomadis (8.16%), respectively. conclusion: our study suggests that further research should be conducted to find out factors of high seropositivity of leptospiral in unguja. vaccination of domestic animals with vaccines against local leptospira strains should be encouraged, and rodent control and public awareness should be emphasized. keywords: leptospirosis, animals, microscopic agglutination test (mat), unguja, tanzania background leptospirosis is a zoonotic infectious disease caused by a spirochete of the genus leptospira [1]. rodents are the major reservoir host of leptospira worldwide [1]. so, humans and other animals can become ill upon contact with contaminated water or soil with urine or other materials from infected animals leptospirosis is a public health concern, especially in tropical and subtropical countries where the environment is ideal for the survival of pathogenic leptospira [2]. it is a life-threatening disease that causes 1.03 million severe cases report and 60, 000 death each year globally [3]. in africa, leptospirosis poses a huge disease burden to society as it impacts livestock productivity and human health [4]. in tanzania, the annual incidence of human leptospirosis is estimated to be 75 to 102 cases per 100,000 population [5]. tanzania is the second-largest livestock producer in africa, after ethiopia, with 87.7 million chickens, 3.2 million pigs, 3.2 million goats, 8.5 million sheep, and 33.9 million cattle. zanzibar has 270 998 cattle, 111 623 goats, 934 sheep, 2209 pigs, and 3.8 million chickens [6]. furthermore, it is estimated that zanzibar has 8095 dogs, found in kaskazini 'a' (1810), kaskazini 'b' (476), kusini (1080), kati (1865), magharibi 'a' (229), magharibi 'b' (341), micheweni (346), wete (736), chakechake (260) and mkoani (952) [7]. findings from previous studies from tanzania have shown that leptospiral infection is very common in domesticated and wild animals, rats, shrews, and people in several regions of the country [2,8–11]. moreover, serovars circulating in tanzania reported in rodents, shrews, and domestic animals were identified as sokoine, lora, kenya, grippotyphosa, hebdomadis, pomona, and canicola [2]. in zanzibar, studies on the seroprevalence of leptospirosis have been reported to be 7.7% in humans [12] and less than 1.0% in patients at mnazi mmoja hospital [13]. thus, the disease is underreported or goes unnoticed. so, this is the first study conducted on the island, to find out the prevalence of leptospiral ___________________________________________________ geraldmlowe@gmail.com 1department of veterinary medicine and public health, sokoine university of agriculture, p. o. box 3021, morogoro, tanzania a full list of author information is available at the end of the article 10.47108/jidhealth.vol6.iss2.287 http://www.jidhealth.com/ mlowe gd, et al., journal of ideas in health (2023); 6(2):878-886 879 infection in rodents, shrews, ruminant animals, and dogs. it is necessary to understand the prevalence of circulating leptospira species in these hosts to obtain baseline information on the disease for effective zoonotic disease management for public health welfare in zanzibar, specifically on unguja island. methods study locations the research was done in unguja, zanzibar (figure 1), an island in the indian ocean. it is located between latitudes 04°50' and 06°30's and longitudes 39°10' and 39°50'e. unguja and pemba are zanzibar's two largest islands. unguja has a total area of 1 554 km2, while pemba has a total area of 990 km2. the total population of zanzibar is about 1.9 million [14]. according to [15], zanzibar's economy is based significantly on agriculture, which generates 31% of the country's gdp. the sampling sites (farms, domestic, peridomestic, forest, and grazing habitats) were selected randomly with assistance from the department of livestock development. sites were located across the entire island including kaskazini b, kati, kaskazini a, kusini, magharibi a, mjini, and magharibi b districts to ensure a representative sample population. moreover, a total of 31 shehia (ward) and 155 households were purposely selected based on the animal population while domestic animals were selected randomly. the following shehia were selected in each district: kaskazini a (kinyasini, donge muwanda, kibokwa, kikobweni, kisongoni, and pwanimchangani), kaskazini b (kilombero, mahonda, mangapwani, mkadini, zingwezingwe, kiwengwa, and kitope), mjini (maruhubi, darajani, and mwemberadu), magharibi a (kizimbani, dole, kianga, mwera, bubwisudi and mkwajuni), kati (dunga, bambi, kiboje and mpapa), and kusini (unguja-ukuu, pungume, and kizimkazi) and magharibi b (kisakasaka). figure 1: the distribution of seven different districts, shehia, and habitat types in unguja island; sources: qgis: v.3.24'tisler'. coordinate reference system (crs): wgs 84 epsg:4326” retrieved on september 16, 2022 inclusion and exclusion criteria the study included live rodents and shrews ranging from adult, sub-adult, and juvenile, and all dead rodents and shrews were not included. while on the other hand, the research included adult and juvenile livestock older than one year (>1 year). young animals (<1 year) and animals in 3rd trimester of pregnancy were excluded. likewise, household owners who were not ready to be involved were excluded. in dogs, the finding included only individuals one or more years of age and excluded aggressive animals and those with poor health conditions. data collection and blood sample this study utilized a cross-sectional design to collect samples and related information from january to april 2022. sherman live traps (7.5 x 9.0 x 23.0 cm) were used to catch rodents and shrews (n = 248) in domestic, peridomestic, and farm (cultivated, fallow lands), woodland, and grazing areas habitats. a total of one hundred sherman live traps were set per site in ten lines each with ten trapping stations, positioned ten meters apart in each station and line for four consecutive nights. traps were daily baited using a mixture of peanut butter and maize brans [16]. the traps were inspected early in the morning (06:00 and 07:00h) and late in the evening (18:00h). the traps were then washed with water to remove any old feces, food, and smell that may discourage other species from entering such as shrews, the bait was replaced to new one after each trap's inspection for four consecutive night per month, because of inactive of rodents at day and active at night time. all captured individuals were shipped in ventilated plastic buckets to the department of livestock and development laboratory and anesthetized using diethyl ether. basic descriptive characteristics (gender, age, and species) and morphometric data were recorded [17]. blood (1 to 2 ml) was aseptically collected from the retro-orbital sinus and through heart puncture for both rodents and shows using sterile syringes and needles. blood samples from livestock (cattle, sheep, goats, and dogs) were collected by manually restraining the animal and retrieving 4 to 10 ml from the jugular vein while in dogs blood sampling was performed from the cephalic vein. collected samples were immediately transferred into plain vacutainer tubes and allowed to clot for separation of serum, before completing the serum separation by centrifugation at 4000rpm for 5 minutes. the sera obtained were subsequently transferred into appropriately labeled eppendorf tubes and stored at-20oc until subjected to serology analysis [18]. serological detection of leptospiral antibodies microscopic agglutination test (mat) which is the gold standard for serological analysis was used to detect antibodies against leptospira in rodents and shrews [19]. five leptospiral serovars belonging to two pathogenic leptospira species commonly circulating in our locality namely l. interrogans (serovar lora, pomona, and hebdomadis) and l. kirschineri (serovars sokoine and grippotyphosa) were used in the test. thereafter, they were divided into five serogroups, including hebdomadis (serovar hebdomadis), pomona (serovar pomona), australis (serovar lora), grippotyphosa (l. kirschineri serovar grippotyphosa) and icterohaemorrhagiae (serovar sokoine) [20]. leptospira stock cultures of serovars "pomona, sokoine, hebdomadis, lora and grippotyphosa" were purified by subculturing into ellinghausen–mccullough–johnson–harris (emjh) medium. pure leptospira cultures were subcultured and incubated for five to seven days at 30ᵒc. the purity of the leptospira serovars was observed by a dark field microscope. the recommended maximum leptospira density for mat is 3 x 108 cells/ml on the macfarland scale (goris et al., 2013). mat was conducted on a microtitre plate. all wells of a microtiter plate were filled with 50µl of phosphate-buffered saline (pbs), ph 7.2, except the wells of row 2 which contained 90µl of pbs. ten microlitres of mlowe gd, et al., journal of ideas in health (2023); 6(2):878-886 880 serum were added to the wells of row 2 (dilution was 1:10). then serially double diluted with pbs to obtain dilution of 1:10, 1:20, 1:40, and 1:80 by pipetting 50 µl from the wells of row 2 to the next rows. finally, the remaining 50 µl were discarded. then after, volumes of 50 µl of leptospira antigen were added to all wells of the microtitre plate for initial screening. the antigen– serum mixtures were examined under a dark field microscope, by taking a drop of antigen pbs mixture to a microscopic slide. positive samples titer was noted by detecting 50% leptospira agglutination [19]. statistical analysis data entry, storage, descriptive statistics, and graph creation were all done using microsoft office excel 2007. epi-info version 7.2.5.0 epi-info version 7.2.5.0 (cdc atlanta, usa) was used to calculate the seroprevalence of leptospiral antibodies. categorical data were presented as frequencies and percentages, and numerical variables were reported as means and standard deviations (sd). logistic regression analyses (lr) were conducted to compute the correlation been explanatory variable (age, breed, gender, sites, and species) and the presence of the seroprevalence (leptospiral seropositive), odds ratios, and a confidence interval of 95% were calculated and chi-square test (χ2) was used calculate the statistical significance of the difference between proportions of seroprevalence of antibodies against leptospira and associations were considered statistically significant at p-values ≤ 0.05. results rodents and shrews captured a total of 248 rodents and shrews were sampled from farm, forest, domestic, grazing, and peridomestic settings as shown in table 1. out of the rodents and shrews sampled, 133 were males, and 115 females. in urban and peri-urban regions, rattus rattus was the most frequent species in domestic habitats, r. norvegicus the most frequent in peridomestic habitats, and m. natalensis in farms. table 1: prevalence of leptospiral antibodies in different species of rodents and shrews in unguja island, tanzania. type species number male female habitat proportion tested positive (%) pvalue chisquare (χ2) rodents cricetomys gambianus 10 4 6 peridomestic/ domestic 4.03 10 1 (0.40) 0.04 0.54 rattus rattus 69 37 32 domestic/ grazing 27.82 69 7 (2.82) mus spp. 39 24 15 domestic 15.73 39 4 (1.61) rattus norvegicus 62 32 30 peridomestic 25 62 6 (2.42) mastomys natalensis 56 29 27 farm 22.58 56 5 (2.02) shrews crocidura spp 12 7 5 forest 4.84 12 1 (0.40) total 248 133 115 5 100 248 24 (9.67) prevalence of leptospiral antibodies the overall prevalence of leptospiral antibodies in cattle, goats, sheep, dogs, rodents, and shrews were 14.57%, 10.01%, 31.25%, 26.25%, and 9.68% respectively. five leptospiral serovars used to test leptospiral antibodies of the different hosts in this study were; serovar sokoine, serovar lora, serovar pomona, serovar grippotyphosa and serovar hebdomadis. all hosts had positive leptospiral serovar tests. except for sheep, which were not tested for serovar hebdomadis. serovar sokoine showed the highest seropositivity of leptospiral antibodies, followed by pomona, lora, grippotyphosa, and hebdomadis (table 2). titres were highest in cattle followed by rodents and shrews and dogs as indicated in table 3. however, the highest titre of 1:80 was common. on the other hand, 1:160 titer was not tested in sheep. it may be considered that the different antibody titre observed may be caused by different immune response among species. serovar sokoine showed high titers and high frequencies for all the titres shown in table 4. while 1:80 titer was more abundant compared to other titers, 1:20 titer was not observed in serovar “pomona, grippotyphosa and hebdomadis.” (table 4). a high prevalence of leptospiral antibodies (4.03%) of rodents and shrews (n=10/248) was observed in kaskazini a district, followed by magharibi a district (2.02% or 5/248) and kaskazini b district (1.61%) as shown in figure 2. in cattle, sheep, and dogs, the high prevalence was observed in the kaskazini a district (5.67%), 18.75%, and 10% respectively); while goats' high prevalence was observed in the kati district (3.85%). table 2: several leptospira serovars' seroprevalence in tested animal species leptospiral serovars rodents and shrews cattle goats sheep dogs total χ2 pvalue sokoine 9(3.63%) 11(4.45%) 3(2.31%) 4(12.5%) 4(5.00%) 31(27.89%) 22.83 0.0004 lora 7(2.82%) 5(2.02%) 2(1.54%) 3(9.38%) 2(2.50%) 19(18.26%) pomona 5(2.02%) 7(2.83%) 6(4.62%) 2(6.25%) 3(3.75%) 23(19.47%) grippotyphosa 1(0.40%) 6(2.43%) 1(0.77%) 1(3.13%) 9(11.25%) 18(17.98%) hebdomadis 2(0.81%) 7(2.83%) 1(0.77%) 0(0.00%) 3(3.75%) 13(8.16%) total 24(9.68%) 36(14.57%) 13(10.01%) 10(31.25%) 21(26.25%) 104(91.76%) mlowe gd, et al., journal of ideas in health (2023); 6(2):878-886 881 table 3: different host species' composition and proportion of leptospiral antibody titers host 1:20 1:40 1:80 1:160 total positive rodents and shrew 2(0.80%) 10 (4.04%) 11(4.43%) 1(0.40%) 24(9.68%) cattle 3(1.21%) 11(4.45%) 17(6.88%) 10(4.05%) 41(16.60%) sheep 1 (3.13%) 6(18.75%) 4(12.5%) 0(0.00%) 11(34.38%) goats 3(2.30%) 5(3.85%) 7(5.38%) 2(1.54%) 17(13.08%) dogs 2(2.50%) 5(6.25%) 6(7.5%) 11(13.75%) 24(30.00%) total 11(9.94%) 37(37.34%) 45(36.69%) 24(19.74%) 117(103.71%) table 4: titres of the tested serovars titers sokoine lora pomona grippotyphosa hebdomadis total 1:20 9 2 0 0 0 11 1:40 12 8 9 4 4 37 1:80 13 7 13 7 5 45 1:160 7 3 3 7 4 24 total 41 20 25 18 13 117 figure 2: distribution of leptospiral antibodies in different host species in different sites comparison of seroprevalence of leptospiral antibodies in different variables seroprevalence of leptospiral antibodies (dependent variable) among dogs, cattle, sheep, goats, rodents, and shrews in different predictor variables such as age, sex, breed, species, and serovars was compared to determine whether certain groups were at great risk of contracting disease than others by using logistic regression. the study demonstrated that adult age was 0.7 times more likely to be infected with the disease than juvenile (or=0.7,95% ci:0.5-1.2, 0.27). the seroprevalence of leptospiral antibody in male animals was 0.9 times higher than in females, which was not statistically significant (or=0.9,95% ci:0.6-1.3, p=0.45). in domestic animal breeds, local breeds were 0.8 times more likely to be infected with leptospirosis compared to improved breeds (or=0.8,95% ci:0.5-1.4, p=0.54). all animals were 0.6 times more likely to be infected by serovar sokoine compared to other serovars, which was not statistically significant (or=0.6,95% ci:0.3-1.4, p=0.25). in contrast, animal species revealed a significantly higher likelihood to be infected with the disease (or=1.9,95% ci:1.1-1.3, p=0.03), although, sheep was 1.9 times significantly more likely to be infected with leptospirosis compared to other animals (table 5). in addition, the results showed that samples from three sheep, five cattle’s and one dog reacted to more than one leptospiral serotype (coinfection). discussion to the best of our knowledge, this is the first study to document the seropositivity of leptospira spp. among rodents, shrews, cattle, goats, sheep, and dogs in unguja, tanzania. the previous reports in the same settings documented leptospira seropositivity among hospitalized febrile patients [12,13]. the current study aimed to address that gap of animal leptospirosis by examining the seroprevalence of leptospirosis among rodents, shrews, cattle, goats, sheep, and dogs. the overall prevalence in rodents and shrews was 9.68%. this may be explained by the fact that for this study the high-risk factors and climate conditions include high temperature and tropical climate that favors infection and allow leptospira to multiply in the environment resemble with the study by mgode et al. [20] in morogoro, tanzania, which seropositivity was 10.8% are also almost similar with this study. 0 2 4 6 8 10 12 14 16 18 20 kaskazini a kaskazini b magharibi a magharibi b kati mjini kusini host species s tu d y s it e s dogs goats sheep cattle rodents&shrews mlowe gd, et al., journal of ideas in health (2023); 6(2):878-886 882 table 5: logistic regression analyses (lr) associated with leptospira seropositivity in unguja. variable categories or 95% c. i p-value age adult 0.7 0.5-1.2 0.27 juvenile sex male 0.9 0.6-1.3 0.45 female breed local improved 0.8 0.5-1.4 0.54 species dogs cattle rodents and shrews sheep 1.9 1.1-3.3 0.03 serovars hebdomadis grippotyphosa lora pomona sokoine 0.6 0.3-1.4 0.25 however, the findings are in agreement with the report by mirambo et al. [21] in mwanza, tanzania, in which seropositivity was 10.0% is also almost similar to this study. this may be attributed to the fact that for this study the associated-risk factors and climate conditions resemble those of the study conducted by mgode et al. [20] in morogoro, tanzania. in domestic animals, the overall prevalence was 16.36%, with the highest seroprevalence being observed in sheep (31.25%) followed by dogs (26.25%), cattle (14.57%), and goats (10.01%). a high number of sheep originated from tanzania's mainland. the present study revealed that farmers rarely vaccinate their animals against leptospira. thus, resulted in a high prevalence of leptospiral antibodies positive. these findings resemble the report by yupiana et al. [22], from new zealand. in cattle and goats which mainly originated from unguja. the observed prevalence may probably be due to the grazing system (zero grazing and tethering) which are commonly practiced. as in this grazing system animals are kept within a fenced homestead and feeds and water are brought to them. rodents easily share feed with domesticated animals, and there is a high human–animal interaction, thus increasing the risk of this zoonotic disease to humans [12,18]. in comparison with the observation made in a previous study which reported a prevalence of 38.0% in sheep in morogoro, tanzania [20], probably due to a small number of sheep in the morogoro study areas, most of these animals are imported from the outside the island and are used as a source of meat consumption. in dogs, the results showed that 26.25% were seropositive leptospira antibodies, the results are in agreement with the study by msemwa et al. [11] in mwanza, tanzania in which the seropositivity was 16.1%. this could be justified by the fact that this study included a cluster (farmers and livestock keepers) of a higher risk for leptospira than those enrolled in the previous study. moreover, the study previously conducted by assenga et al. [9], in katavi-rukwa ecosystem, tanzania. reported seropositivity of 29.9%. this difference could be explained by the fact that only a small number of serovars were explored in the present study compared to the previous one. cattle may act as maintenance hosts of leptospira [23] and the overall prevalence for cattle in this study was 14.57%. a study done in tanga by karimuribo et al. [24], in east usambara mountains, tanzania, reported, a prevalence of 21.3% in cattle, which is slightly higher than what is reported in this study, which implies that animals may serve as a host for leptospira maintenance and a potential source of leptospirosis in humans [25]. rodents are likely the carriers of several leptospiral serovars, as evidenced by the discovery of antibodies to various leptospiral serovars in six different species of rodents captured in various unguja environments, thus playing a pivotal role in humans and domestic animals' leptospirosis transmission. in this study, serovar leptospira sokoine had the highest seroprevalence (3.63%), followed by serovar leptospira lora (2.82%), leptospira pomona (2.02%), leptospira hebdomadis (0.81%) and leptospira grippotyphosa (0.41%), in the tested rodent and shrew samples, this indicated that serovar sokoine is the common serovar circulating among rodents and shrews in unguja island. the present finding was similar to three studies conducted in morogoro, which revealed the existence of leptospiral antibodies in domestic animals, wildlife, rodents, and pet animals in tanzania [20,26,27]. although in this study, serovar kenya was not investigated. the interactions between rodents, shrews, domestic animals, and humans occurred regularly, as rats share the same habitats with people and domesticated animals, hence providing a suitable environment for leptospira transmission across species. furthermore, other studies in tanzania reported that serovar sokoine was most prevalent and widespread in different regions, including kagera [2] and mwanza [21]. among the five serovars identified in rodents, shrews, cattle, and sheep in the present study, l. kirschneri, serovar sokoine of the serogroup icterohaemorrhagiae, was the most frequent. with the serogroup icterohaemorrhagiae, rodents are recognized to be the natural reservoir, and the high prevalence of serovar sokoine in these hosts would be evidence of frequent contacts between the cattle, rodents, shrews, and sheep in the study site. this finding agrees with the study reported by mgode et al. [20] and assenga et al. [9]. for rodents and shrews, these results are in agreement with the research findings by mgode et al. [18] in bahi district, dodoma, tanzania. also, serovar sokoine has been mostly reported in rodents [28], in contrast with the study by allan, and bvm [29], in kilimanjaro, northern tanzania. it was notable that rattus norvegicus was absent from this site. furthermore, the seropositivity of serogroup icterohaemorrhagie (serovar sokoine) can be influenced by the abundance of commensal rats in urban and peri-urban locations. these small mammals could mlowe gd, et al., journal of ideas in health (2023); 6(2):878-886 883 be the natural carriers of these serogroups. consequently, these species could potentially be the cause of leptospirosis in both humans and animals. serovar grippotyphosa was the most prevalent in dogs and cattle. this finding is consistent with the study by okewole, and ayoola [30] in southwestern, nigeria. however, these differ from those reported by assenga et al. [9] in katavi-rukwa, tanzania, which found grippotyphosa as the most prevalent in goats. the high prevalence of these serovars would imply that there is likely close interaction between dogs and cattle kept in peri-urban settings in our study areas. serovar pomona showed a high prevalence in goats, as well as in rodents, shrews, cattle, dogs, and sheep. these animals could be important maintenance hosts of this serovar, probably due to the close contact of commensal rodents with domestic animals in the study sites. this is similar to the study by haji hajikolaei et al. [31] in ahvaz, iran, which found that serovar pomona was predominant in sheep and goats, implying that small ruminants potentially play a role in the epidemiology of the disease in animals and humans due to close interactions. in this finding, a higher seroprevalence of leptospiral infection was observed in peri-urban areas than urban ones, probably due to associated occupational risk in peri-urban sites [2,18,20], including farming, sewage cleaning, and livestock keeping. a high prevalence of rodents and shrews was observed in kaskazini a district at (4.03% (10/248), followed by magharibi a district (2.02% (5/248)) and kaskazini b district (1.61% (4/248)). this agrees with a previous study reported by motto et al. [10] from kilimanjaro, tanzania, which observed a high prevalence of the disease in rural rice field rats. in the study area, most livestock feeds were not stored properly and served as rodent nesting sites because feed was plentiful for rodents and domestic animals frequently come into contact with the rodents. as a result, the feeds became contaminated with rodent urine and feces, thus posing the risk of animals and humans contracting leptospirosis. a similar finding was reported by national report [6], tanzania, which showed that the main reason is that in zanzibar, 180,220 (51.8%) were involved in agricultural activities including crops production (64.2%), crops and livestock farming (34.6%) and 1.2% in livestock only. moreover, on the island during the rainy season, floods in trenches, ponds, and water streams, pose the chance of disease outbreaks. floods have a significant role in the spread of leptospirosis in this area because runoff and soil polluted with rodents and shrew pee end up in water sources. this finding revealed that the seropositivity of leptospirosis in roof rats was (2.82%) and the brown rat was (2.42%). these rats were important reservoirs of leptospira in domestic, peridomestic, and farms proximal to the human settlements. the comparison of the serovars found in rodents and shrews showed no statistically significant difference because they share habitats and also probably due to the relatively large sample size of commensal rodents collected compared to shrews in the study area. this finding is similar to those other researchers by haake, and levett [32] from los angeles, usa and mgode et al. [2] from kagera, tanzania, who recorded that the rattus norvegicus and rattus rattus, were plentiful in urban environments and are potentially the major sources of leptospira infection. in rodents and shrews, the seropositivity for the five leptospira serovars was characterized by high antibody titers except for serovar hebdomadis, but also two animals demonstrated a relatively lower titre (1:20). according to goris et al. [19] from amsterdam, netherlands, cut-off point adopted should be below 1:160. in contrast to the study by mgode et al. [25] from morogoro, tanzania. the majority of leptospira serovars were characterized by low antibody titre. the difference is due to variations in hosts and environmental, serovars, and methodology used in this study. high titres were found in periurban districts and were associated with human occupational activities which require water to be achieved [2]. also, this study has stated the possibility of contracting the disease without including the livestock, but pet animals such as dogs and cats [26]. the study has shown the urban prevalence of leptospirosis was slightly lower than in peri-urban, probably due to a lack of enough habitats such as grazing and agricultural activities as well as forest habitats. also, risk factors such as sewage systems, and the presence of the rodent and shrews were found in domestic habitats as well as in peridomestic habitats providing a broader environment for the commensal animals to multiply. additionally, on the island, pet animals were allowed kept in urban homes which may act as a source of leptospirosis transmission to people through their urine and fluids, but also through contaminated feeds. high titres (double fold rise) were observed in dogs and cattle, suggesting that acute leptospirosis infection had high levels of igg but also non-specific of the host. on the other hand, the lower titre may suggest chronic leptospirosis infection with lower levels of igg, that are host specific which can be below the detection threshold of mat test, [25]. the low prevalence of the serovar sokoine, pomona, lora, hebdomadis, and grippotyphosa in rodents, shrews, and goats and the absence of serovar hebdomadis in sheep, may suggest host specificity. but also, the variation of antibody titre observed may be caused by different immune responses among species. this is in agreement with the study by machang'u et al. [27] from morogoro, tanzania, in which the serovar kenya was common in cricetomys spp. in morogoro. no significant difference (p>0.05) in seroprevalence by age, breed, and sex, suggesting that all groups may face an equal risk of being infected by leptospira. seropositivity varied significantly with animal species (or=1.9,95% ci:1.1-1.3, p=0.03). this implies that animal species were more likely to be infected with the disease. although the results showed that sheep had a 1.9 times significantly higher likelihood of contracting leptospirosis than other animals, this may be because sheep imported from tanzania's mainland were not routinely immunized and were kept inside a fenced homestead, which increases human-animal interaction and increased the likelihood of this zoonotic disease spreading to the population in unguja. antibodies against pathogenic leptospira spp. were detected in livestock, wild animals, and companion dogs in both settings, this imply that there is high close interaction between commensal rodents with companion dogs, livestock, and human, which poses the risk of disease transmission to human. the frequent rodents contact with reservoir hosts (dogs, cattle, sheep, and goats) was observed in the peri-urban and urban locations. this finding is similar to the studies by ally et al. [12] and, mlowe et al. [16] from unguja. zanzibar, tanzania. the present study observed serum agglutination in more than one serovar in sheep, cattle, and dogs. this may imply two or more frequent serological cross-reactions in past infections. therefore, a previously infected host by one serovar may, later on, become infected by another serovar. the current serovars may cross-react with the previous one by mlowe gd, et al., journal of ideas in health (2023); 6(2):878-886 884 activating the memory response [9]. higher antibody titers were evident in the serological cross-reactivity antibody titer attributable to past infection. the current study had some methodological limitations including, the absence of previous research studies on the seroprevalence of animal leptospirosis in the study areas, the scarcity of sufficient grazing and agricultural activities, and the fact that only pet animals like dogs and cats were permitted in towns while livestock keeping was not. as a result, some data and the connection between livestock and dogs were missed. in addition, due to a small population and insufficient data on some animals such as sheep in the study sites resulted to opt for purposive sampling. a minimum of two serum samples were advised to be collected because the estimation of seroprevalence of leptospirosis was constrained by the use of a single serum sample per species. conclusion in conclusion, the present study showed high leptospira prevalence in domestic animals, rodents, and shrews, suggesting that leptospirosis could be a major animal and public health threat. the study areas, characterized by high interactions of commensal rodents with domestic animals, have a high risk of leptospirosis transmission. therefore, preventive measures, including rodent 'control such as reducing rodents' contact with reservoir hosts (dogs and ruminant animals), environmental sources of leptospira (water sources), and vaccination of domestic animals with vaccines against local leptospira strains, should be emphasized in both urban and rural settings to reduce the spread of pathogenic leptospira spp. to people. additionally, this study's findings show that common leptospira serovars are present in rodents, shrews, domestic ruminants, and dogs, which will help in the planning of interventions to reduce the effects of infection on both domestic animals and people. thus, we recommend that further research should be conducted to find out factors of high seropositivity of leptospiral in unguja island. abbreviation mat: microscopic agglutination test; rdts: rapid diagnostic tests: emjh; ellinghausen mccullough medium-johnson and harris; ocgs: office of the chief government statistician; zaliri: zanzibar livestock research institute; pbs: phosphate buffered saline; gdp: growth domestic product; urt: united republic of tanzania; nbs: national bureau of statistics; ace: african centre of excellence; btd: biosensor technology development; irpm: innovative rodent pest management; pbs: phosphate buffered saline; cdc: centre for disease control and prevention; phc: population and housing census. declaration acknowledgment the authors would like to acknowledge the african centre of excellence for innovative rodent pest management and biosensor technology development. appreciations should go to the revolutionary government of zanzibar through the second vice president's office, in collaboration with the office of the chief government statistician, zanzibar (ocgs), ministry of agriculture, natural resources, irrigation, and livestock through zanzibar livestock research institute (zaliri) and department of livestock development in zanzibar who gave the permit to conduct my research as well as district livestock field officers for guidance and technical support without forgetting farmers and livestock keeper who gave up their time and allowed us to use their animals as part of the study. funding this research was funded by the african centre of excellence for innovative rodent pest management and biosensor technology development (ace ii irpm & btd) at the institute of pest management of the sokoine university of agriculture (sua). availability of data and materials data will be available by emailing geraldmlowe@gmail.com authors’ contributions gerald dickson mlowe (gdm) is the principal investigator (pi) who contributed to the conceptualization, data curation, formal analysis, and writing of the original draft of the manuscript. isaac makundi (im) and robert machang’u (rm) are the core supervisors and abdul selemani katakweba (aask) is the main supervisor. im, rm, and aask contributed to the methodology, supervision, review, editing, and re-writing of the manuscript. all authors have read and accepted to be published final version of the manuscript. ethics approval and consent to participate the ethical clearance for conducting this study was granted by the research ethics committee at sokoine university of agriculture (ref no. sua/adm/r.1/8/779 on january 10, 2022). research protocols were revised and approved by the zanzibar livestock research institute (zaliri) and permission to conduct research in zanzibar was obtained from the research committee of the office of the second vice president and the office of the chief government statistician (ocgs), ref no. ompr/m.95/ c.6/2/vol.xviii/187 on january 20, 2022). consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of veterinary medicine and public health, sokoine university of agriculture, p. o. box 3015, chuo kikuu, morogoro, tanzania. 2department of microbiology, parasitology and biotechnology, sokoine university of agriculture, p. o. box 3019, morogoro, tanzania. 3institute of pest management, sokoine university of agriculture, p.o. box 3110, chuo kikuu, morogoro, tanzania. 4african centre of mlowe gd, et al., journal of ideas in health (2023); 6(2):878-886 885 excellence for innovative rodent pest management and biosensor technology development (ace ii irpm & btd) at the sokoine university of agriculture, morogoro, tanzania. 5st francis university college of health and allied sciences, p.o. box 175, ifakara-morogoro, tanzania. article info received: 02 may 2023 accepted: 12 june 2023 published: 14 june 2023 references 1. motto sk, shirima gm, de clare bronsvoort bm, cook eaj. epidemiology of leptospirosis in tanzania: a review of the current status, serogroup diversity and reservoirs. plos negl trop dis. 2021 nov 16;15(11):e0009918. doi: 10.1371/journal.pntd.0009918 2. mgode gf, japhary mm, mhamphi gg, kiwelu i, athaide i, machang'u rs. leptospirosis in sugarcane plantation and fishing communities in kagera northwestern tanzania. plos negl trop dis. 2019 may 31;13(5):e0007225. doi: 10.1371/journal.pntd.0007225 3. torgerson pr, hagan je, costa f, calcagno j, kane m, martinez-silveira ms, goris mg, stein c, ko ai, abelaridder b. global burden of leptospirosis: estimated in terms of disability adjusted life years. plos negl trop dis. 2015 oct 2;9(10):e0004122. doi: 10.1371/journal.pntd.0004122 4. allan kj, biggs hm, halliday je, kazwala rr, maro vp, cleaveland s, crump ja. epidemiology of leptospirosis in africa: a systematic review of a neglected zoonosis and a paradigm for 'one health' in africa. plos negl trop dis. 2015 sep 14;9(9):e0003899. doi: 10.1371/journal.pntd.0003899. erratum in: plos negl trop dis. 2016 mar;10(3):e0004552. 5. biggs hm, hertz jt, munishi om, galloway rl, marks f, saganda w, maro vp, crump ja. estimating leptospirosis incidence using hospital-based surveillance and a population-based health care utilization survey in tanzania. plos negl trop dis. 2013 dec 5;7(12):e2589. doi: 10.1371/journal.pntd.0002589. 6. nbs. national sample census of agriculture 2019/20, key findings report for crops and livestock sectors and fish farming.dar es salaam. tanzania: national bureau of statistics. 2021 aug 01. pg. 7(40). [https//www.nbs.go.tz › tak › agric ›pdf). 2021]. 7. zls. annual report, department of livestock development zanzibar, tanzania. zanzibar livestock survey 2021 dec 01. pg 95(181). https://www.ocgs.go.tz › php › reportocgs › pdf.2021]. 8. machang’u rs, mgode g, mpanduji d. leptospirosis in animals and humans in selected areas of tanzania. belgian journal of zoology. 1997;127 suppl (january):97–104. 9. assenga ja, matemba le, muller sk, mhamphi gg, kazwala rr. predominant leptospiral serogroups circulating among humans, livestock and wildlife in katavirukwa ecosystem, tanzania. plos negl trop dis. 2015 mar 25;9(3):e0003607. doi: 10.1371/journal.pntd. 0003607. 10. motto sk, shirima gm, de clare bronsvoort bm, cook eaj. epidemiology of leptospirosis in tanzania: a review of the current status, serogroup diversity and reservoirs. plos negl trop dis. 2021 nov 16;15(11):e0009918. doi: 10.1371/journal.pntd.0009918. 11. msemwa b, mirambo mm, silago v, samson jm, majid ks, mhamphi g, genchwere j, mwakabumbe ss, mngumi eb, mgode g, mshana se. existence of similar leptospira serovars among dog keepers and their respective dogs in mwanza, tanzania, the need for a one health approach to control measures. pathogens. 2021 may 16;10(5):609. doi: 10.3390/pathogens10050609. 12. ally aa, lupindu am, machang r, katakweba as. seroprevalence of leptospirosis among hospitalized febrile patients in unguja island. 2023 march 27; 6(1):820–82. https://doi.org/10.47108/jidhealth.vol6.iss1.274 13. ali ma, james oc, mohamed aa, joachim a, mubi m, omodior o. etiologic agents of fever of unknown origin among patients attending mnazi mmoja hospital, zanzibar. j community health 2020 may 12;45(5):1073– 80. https://doi.org/10.1007/s10900-020-00832-w. 14. the united republic of tanzania (urt). ministry of finance and planning, tanzania national bureau of statistics and president’s office finance and planning, office of the chief government statistician, zanzibar. the population and housing census: administrative units population distribution report; tanzania, 2022 dec 01. vol1a: 1-290. [https://www.nbs.go.tz › takwimu › census2022. pdf]. 15. the united republic of tanzania (urt). ministry of finance and planning, tanzania national bureau of statistics and president’s office finance and planning, office of the chief government statistician, zanzibar. national sample census of agriculture 2019/20 atlas.2021, aug 01. pg 1-40. ttps://www.nbs.go.tz › takwimu›agriculture.pdf 16. mlowe gd, katakweba as, makundi i, sabuni c. assessment of rodent diversity and abundance in different habitats of unguja, zanzibar, tanzania. sustain biodivers conserv 2023 feb 12:2(1) 29–55: https://doi.org/10.5281/zenodo.7643678 17. mulungu ls, makundi rh, massawe aw, machang’u rs, mbije ne. diversity and distribution of rodent and shrew species associated with variations in altitude on mount kilimanjaro, tanzania. in: mammalia. 2008 oct 01. 72:(3); 178–85. https://doi.org/10.1515/mamm.2008.021 18. mgode gf, mhamphi gg, massawe aw, machang'u rs. leptospira seropositivity in humans, livestock and wild animals in a semi-arid area of tanzania. pathogens. 2021 jun 3;10(6):696. doi: 10.3390/pathogens10060696. 19. goris mg, leeflang mm, loden m, wagenaar jf, klatser pr, hartskeerl ra, boer kr. prospective evaluation of three rapid diagnostic tests for diagnosis of human leptospirosis. plos negl trop dis. 2013 jul 11;7(7):e2290. doi: 10.1371/journal.pntd.0002290. 20. mgode gf, machang'u rs, mhamphi gg, katakweba a, mulungu ls, durnez l, leirs h, hartskeerl ra, belmain sr. leptospira serovars for diagnosis of leptospirosis in humans and animals in africa: common leptospira isolates and reservoir hosts. plos negl trop dis. 2015 dec 1;9(12):e0004251. doi: 10.1371/journal.pntd.0004251. mlowe gd, et al., journal of ideas in health (2023); 6(2):878-886 886 21. mirambo mm, mgode gf, malima zo, john m, mngumi eb, mhamphi gg, mshana se. seropositivity of brucella spp. and leptospira spp. antibodies among abattoir workers and meat vendors in the city of mwanza, tanzania: a call for one health approach control strategies. plos negl trop dis. 2018 jun 25;12(6):e0006600. doi: 10.1371/journal.pntd.0006600. 22. yupiana y, vallée e, wilson p, weston jf, benschop j, collins-emerson j, heuer c. on-farm risk factors associated with leptospira shedding in new zealand dairy cattle. epidemiol infect. 2020 may 18;148:e219. doi: 10.1017/s095026882000103x 23. swai es, schoonman l. a survey of zoonotic diseases in trade cattle slaughtered at tanga city abattoir: a cause of public health concern. asian pac j trop biomed. 2012 jan;2(1):55-60. doi: 10.1016/s2221-1691(11)60190-1 24. karimuribo ed, swai es, kyakaisho pk. investigation of a syndrome characterised by passage of red urine in smallholder dairy cattle in east usambara mountains, tanzania. j s afr vet assoc. 2008 jun;79(2):89-94. doi: 10.4102/jsava.v79i2.250. 25. mgode gf, katakweba as, mhamphi gg, fwalo f, bahari m, mdangi m, kilonzo bs, mulungu ls. prevalence of leptospirosis and toxoplasmosis: a study of rodents and shrews in cultivated and fallow land, morogoro rural district, tanzania. tanzan j health res. 2014 jul;16(3):2505. doi: 10.4314/thrb.v16i3.11. 26. katakweba a. small mammals in fenced houses as source of leptospirosis to livestock pets animals and humans in morogoro municipality, tanzania. tanzania veterinary association proceedings [internet]. 2018;36(2018). available from: https://www.ajol.info/index.php/tvj/article/view/194951%0 ahttps://tvj1.sua.ac.tz/index.php/tvj/article/view/83 27. machang'u rs, mgode gf, assenga j, mhamphi g, weetjens b, cox c, verhagen r, sondij s, goris mg, hartskeerl ra. serological and molecular characterization of leptospira serovar kenya from captive african giant pouched rats (cricetomys gambianus) from morogoro tanzania. fems immunol med microbiol. 2004 jun 1;41(2):117-21. doi: 10.1016/j.femsim.2004.02.002. 28. ahmed n, devi sm, valverde mde l, vijayachari p, machang'u rs, ellis wa, hartskeerl ra. multilocus sequence typing method for identification and genotypic classification of pathogenic leptospira species. ann clin microbiol antimicrob. 2006 nov 23;5:28. doi: 10.1186/1476-0711-5-28. 29. allan kj, bvm h. leptospirosis in northern tanzania : investigating the role of rodents and ruminant livestock in a neglected public health problem. phd thesis. university of glasgow. 2016 june 01. pg. 1-299. http://theses.gla.ac.uk/7565/ 30. okewole ea, ayoola mo. seroprevalence of leptospiral serovars other than canicola and icterohaemorrhagiae in dogs in the southwestern nigeria. veterinarski arhiv. 2009 feb 24;79(1):87-96. 31. haji hajikolaei mr, rezaei s, ghadrdan mashhadi ar, ghorbanpoor m. the role of small ruminants in the epidemiology of leptospirosis. sci rep. 2022 feb 9;12(1):2148. doi: 10.1038/s41598-022-05767-x. 32. haake da, levett pn. leptospirosis in humans. leptospira and leptospirosis. curr top microbiol immunol, 2015 nov 12:65-97. https://doi.org/10.47108/jidhealth.vol6.iss3.292 bhuyan n, rabha a, journal of ideas in health 2023;6(3):895-898 © the author(s). 2023 open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. journal of ideas in health e issn: 2645-9248 journal homepage: www.jidhealth.com open access case report article intersecting paths: a rare case report of malignant melanoma in a patient with body dysmorphic disorder geet bhuyan1, anjumoni rabha2 abstract background: body dysmorphic disorder (bdd) characterized by excessive and persistent preoccupation with perceived defects or flaws in appearance and has a prevalence of 1.7-2.9%. it is a disorder with a relatively unclear etiology. case presentation: a 36-year-old unmarried female presented to the surgery department with a self-inflicted lesion on her right ankle. the patient underwent fine needle aspiration cytology, and later, a wide local excision of the lesion was done. the final histological diagnosis of malignant melanoma was established. on careful psychiatric evaluation, the patient had an excessive and persistent preoccupation with her appearance, which caused severe psychological and social morbidity and drove her to her actions. thus, the final diagnosis of body dysmorphic disorder (dsm v) was established. the patient was put on fluoxetine and cognitive behavioral therapy. conclusion: given the significantly reduced functionality and quality of life, bdd should be recognized and accurately diagnosed. keywords: body dysmorphic disorder, melanoma, fine needle aspiration, cognitive behaviour therapy, india background body dysmorphic disorder (bdd) characterized by excessive and persistent preoccupation with perceived defects or flaws in appearance and has a prevalence of 1.7-2.9% [1-2]. enrico morselli, an italian doctor who coined the term "dysmorphophobia" for this condition, provided this moving explanation in 1891: “the dysmorphophobic patient is miserable; in the middle of his daily routines, conversations, reading and meals, in fact everywhere and at any time, is overcome by the fear of deformity... which may reach a very; painful intensity, even to the point of weeping and desperation" [3]. recently, it has been included in the spectrum of obsessive-compulsive and related disorders under the diagnostic and statistical manual of mental disorders (dsmv) [4]. bdd is associated with various other psychiatric disorders, including stress, anxiety, mood disorders, and depression [5]. patients with common skin diseases, including acne, atopic dermatitis, psoriasis, and bullous diseases, also had an 11-fold higher chance of having bdd symptoms than the normal population [6]. moreover, bdd is also associated with the body image disturbance in cases of various cancers, including breast cancer, skin cancer, etc. such patients suffered from negative body image arising from both the lesion itself and the consequences of the surgery on their image [6, 7]. here we present a case of a 36-year-old lady with body dysmorphic disorder and malignant melanoma over her right ankle. case presentation a 36-year-old unmarried female and a hairdresser by profession presented to the surgery department of jorhat medical college and hospital, assam, india with a self-inflicted lesion on her right ankle in october 2022. on examination, the lesion was 3 x 0.5 cm in size and had a firm consistency. the main complaint was the patient had noticed the painless lesion for the last 3 months. the lesion was gradually increasing in size and a blackish discoloration. fine needle aspiration cytology (fnac) was done. the smears were cellular, with the presence of round-tospindle cells with moderate cytoplasm and round-to-oval nuclei with prominent nucleoli. occasional cells with highly pleomorphic nuclei were also noted (figure 1). a differential ___________________________________________________ *correspondence: arabha818@gmail.com 1department of psychiatry, lakhimpur medical college and hospital, india. a full list of author information is available at the end of the article. 10.47108/jidhealth.vol6.iss3.292 http://www.jidhealth.com/ bhuyan n, rabha a, journal of ideas in health (2023); 6(3):895-898 896 diagnosis of either a malignant spindle cell neoplasm or a malignant melanoma was suggested. figure 1: cellular cluster with round to oval cells. occasional cells show highly pleomorphic nuclei (black arrow) (mgg, 10x) the patient underwent wide local excision of the lesion with a margin of 1 cm as a malignant lesion was suspected on fnac and since malignant melanoma was a differential diagnosis in the case. the biopsy was sent to the department of pathology at our institute. on gross examination, the lesion was skin-covered and nodular, measuring 2.5 x 1 cm, with areas of blackish pigmentation. on microscopic examination, the epidermis and upper dermis showed the presence of tumor cells present in sheets with pleomorphic nuclei and prominent nucleoli. tumor thickness was estimated at 1 mm. melanin pigment deposition is present. no areas of ulceration were noted and all the resected margins were free of tumor. (figure 2). no lymph nodes were sent in this case. thus, a final diagnosis of malignant melanoma was given. a pathological stage of pt1b was given based on the histological findings. on radiological and clinical evaluation, no significant lymphadenopathy was noted. figure 2: tumour cells present in sheets with pleomorphic nuclei and prominent nucleoli. melanin pigment deposition is present. (h&e, 10x) the patient was advised to undergo follow-up with complete clinical surveillance every 6 months to rule out any recurrence or metastasis in the department of surgery and medical oncology of our institute. no additional therapy was advised as the patient belonged to pathological grade 1b [8]. the patient was later referred to the psychiatry department of jorhat medical college and hospital, assam, india for further evaluation due to the nature of the injury. the patient was guarded during the initial psychiatric evaluation. however, the patient later reported her preoccupation with her physical appearance, particularly her facial skin color, since the age of 17. she acknowledged spending at least 6 to 8 hours each day checking her facial skin color, considering her appearance. she would also spend the majority of her day worrying about her appearance; she would engage in habitual skin excoriation to remove any minor perceived skin flaws, and she would frequently visit her dermatologist or search the internet for treatment to improve her skin. even after repeated assurances regarding her skin color and appearance from her doctor and family members, she would say that she remained preoccupied with her appearance. the patient also recalls being frequently absent or late for work due to her appearance. but, in the last two months, she's noticed a black spot on her right ankle. initially, she attempted to excoriate the spot as she would in her face, but the lesion grew in size. she would remain distressed due to the spot over her ankle and would often try to conceal the lesion by putting on makeup, wearing socks, or wearing long clothing. she would remain preoccupied with the thoughts of people who noticed the lesion. after failing to pluck the lesion, she attempted to cut it with a knife on her own. when the wound did not heal, she went to the surgery department for treatment. the patient belonged to the lower socio-economic strata and attended school up to class 6. the patient did not have a history of any other psychiatric illness, any significant drug history, or any similar illness in the family. thus, a final diagnosis of body dysmorphic disorder (dsm v) was established, and the patient was started on fluoxetine at 20 mg/day initially, which was later increased to 40 mg/day. along with pharmacological treatment, she was also started on cognitive behavioral therapy (cbt) and sessions were started in outpatient settings. discussion due to the intensely sensitive and individualized nature of its symptoms, bdd frequently goes undetected or is incorrectly identified as another disorder, resulting in inadequate care and psychiatric therapy [9, 10]. in our case, the patient had come to seek psychiatric help for the first time despite suffering from the illness for a long time. cancer survivors experiencing body image issues represent a vulnerable group and are prone to various psychological disorders, including depression, body dysmorphic disorder, sexual dysfunction, etc. [11]. according to virginia et al, patients who had breast cancer surgery were more likely to experience psychological distress and possibly have poorer post-surgical adjustment [12]. similar problems were faced by cancer survivors who were suffering from chemotherapyinduced alopecia [13]. in our peculiar case, the patient attempted to excise the lesion she discovered in her ankle. on careful psychiatric evaluation, the patient had an excessive and persistent preoccupation with her appearance, which caused severe psychological and social morbidity and drove her to her actions. in the present case, the lesion was later diagnosed as bhuyan n, rabha a, journal of ideas in health (2023); 6(3):895-898 897 malignant melanoma, which may offer serious diagnostic challenges. it is a malignant tumor of melanocytes, which is an aggressive neoplasm with high motility [14]. the tumor commonly presents as a flat or elevated lesion, or sometimes it can present as a nodular lesion with variable pigmentation of the overlying skin [15]. in the literature, bdd is related to several skin disorders, including various skin cancers [6]. the relationship between the effects of malignant melanoma lesions leading to bdd is not completely studied. however, lesions of the skin can trigger psychological stress and anxiety, leading to bdd and depression [6, 16]. the patient is currently on fluoxetine 40 mg/day along with regular cbt sessions and is responding well to her treatment. after six months of surgery, she has not reported any recurrences or the appearance of new lesions in her body. on radiological evaluation, she is free from any metastatic deposit of malignant melanoma at any other site and has been advised to make regular visits to our medical facility for surveillance. conclusion bdd is still underdiagnosed in clinical settings despite its frequency and severity. bdd must be acknowledged and properly diagnosed given the notably poor functioning and quality of life, as well as the high rates of suicidality, among these patients. abbreviation bdd: body dysmorphic disorder; dsm-v: diagnostic and statistical manual of mental disorders; fnac: fine needle aspiration cytology; cbt: cognitive behavioral therapy. declaration the authors declared that the pictures (histological smears) used in the article belong to the present case itself which we received in our department. the citation has been given in the case presentation section in the representative places. furthermore, we do not have a picture of the lesion (the selfinflicted lesion on the patient's right ankle) at this time, as the case initially presented in the department of surgery, which had already been surgically treated before it came to the department of pathology. acknowledgment none. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing arabha818@gmail.com. authors’ contributions geet bhuyan (gb) was the principal investigator of this manuscript and approved the final manuscript. anjumoni rabha (ar) was responsible for the design, reviewing, and editing of the manuscript in its final form. all authors read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. ethical permission was granted by the institutional ethics committee, jorhat medical college and hospital, assam, india [october 2022]. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1jorhat medical college and hospital, assam, india. 2department of psychiatry, lakhimpur medical college and hospital, india. article info received: 13 june 2023 accepted: 08 august 2023 published: 24 august 2023 references 1. american psychiatric association. diagnostic and statistical manual of mental disorders. 5th ed va: arlington american psychiatric publishing 2013. 2. prevalence of bdd. available at: https://bdd.iocdf.org/professionals/prevalence/ (accessed: february 22, 2023). 3. morselli e. sulla dismorfofobia e sulla tafefobia. bolletinno della r accademia di genova. 1891; 6: 110– 119. 4. first mb, gaebel w, maj m, stein dj, kogan cs, saunders jb, poznyak vb, gureje o, lewis-fernández r, maercker a, brewin cr, cloitre m, claudino a, pike km, baird g, skuse d, krueger rb, briken p, burke jd, lochman je, reed gm. an organizationand categorylevel comparison of diagnostic requirements for mental disorders in icd-11 and dsm-5. world psychiatry: official journal of the world psychiatric associatio. 2021; 20(1): 34–51. https://doi.org/10.1002/wps.20825. 5. hakim rf, alrahmani da, ahmed dm, alharthi na, fida ar, al-raddadi rm. association of body dysmorphic disorder with anxiety, depression, and stress among university students. j taibah univ med sci. 2021;16(5):689-694. published 2021 jun 12. doi: 10.1016/j.jtumed.2021.05.008. 6. schut c, dalgard fj, bewley a, evers awm, gieler u, lien l, et al. body dysmorphia in common skin diseases: results of an observational, cross-sectional multicentre study among dermatological outpatients in 17 european countries. br j dermatol. 2022;187(1):115-125. doi:10.1111/bjd.21021. 7. bahrami m, mohamadirizi m, mohamadirizi s, hosseini sa. evaluation of body image in cancer patients and its association with clinical variables. j educ health promot. 2017 oct 4; 6:81. doi: 10.4103/jehp.jehp_4_15. bhuyan n, rabha a, journal of ideas in health (2023); 6(3):895-898 898 8. michielin o, van akkooi acj, ascierto pa, dummer r, keilholz u; esmo guidelines committee. electronic address: clinicalguidelines@esmo.org. cutaneous melanoma: esmo clinical practice guidelines for diagnosis, treatment and follow-up†. ann oncol. 2019;30(12):1884-1901. doi:10.1093/annonc/mdz41. 9. buhlmann u, glaesmer h, mewes r, et al. updates on the prevalence of body dysmorphic disorder: a populationbased survey. psychiatry res. 2010;178(1):171-175. doi: 10.1016/j.psychres.2009.05.002. 10. phillips ka. body dysmorphic disorder: recognizing and treating imagined ugliness. world psychiatry. 2004 feb;3(1):12-7. 11. boquiren vm, esplen mj, wong j, toner b, warner e, malik n. sexual functioning in breast cancer survivors experiencing body image disturbance. psychooncology. 2016;25(1):66-76. https://doi.org/10.1002/pon.3819. 12. lemieux j, maunsell e, provencher l. chemotherapyinduced alopecia and effects on quality of life among women with breast cancer: a literature review. psychooncology.2008;17(4):317-328. doi:10.1002/pon.1245. 13. shellenberger r, nabhan m, kakaraparthi s. melanoma screening: a plan for improving early detection. ann med. 2016;48(3):142-148. doi:10.3109/07853890.2016.1145795. 14. keung ez, gershenwald je. clinicopathological features, staging, and current approaches to treatment in highrisk resectable melanoma. j natl cancer inst. 2020;112(9):875-885. doi:10.1093/jnci/djaa012. 15. castle dj, phillips ka, dufresne rg jr. body dysmorphic disorder and cosmetic dermatology: more than skin deep. j cosmet dermatol. 2004;3(2):99-103. doi:10.1111/j.14732130.2004. 00105.x https://doi.org/10.47108/jidhealth.vol6.iss2.283 opoku sy, et al., journal of ideas in health (2023); 6(2):864-873 © the author(s). 2023 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access how organizational climate of silence affects job performance: the role of work engagement and supervisor support among frontline nurses samuel yaw opoku1*, sabina ampon-wireko1, susan yaa aframah arka2, abraham donkor2 abstract background: the growing body of evidence demonstrates both the desirable and undesirable consequences of organizational silence. this study aims to explore the influence of the organizational climate of silence on job performance through the mediating effects of work engagement (we). further, the degree to which supervisor support (ss) and work engagement moderate job performance are examined. methods: a quantitative cross-sectional design was used for the study. survey data from 14 hospitals and 15 health centers and community-based health planning services (chps) compounds in the western region of ghana. we used the variable-to-sample ratio to determine an appropriate and sufficient sample size of 565 respondents. the hierarchical regression technique was employed in estimating the relationship between the variables. results: in selecting an adequate and appropriate sample size for this current study, we relied on the variable-tosample ratio. results from the study showed that top management's attitude to silence and the supervisor's attitude to silence had a significant adverse effect on task performance (β=-.090, p< 0.05) and (β=-.110, p< 0.01). work engagement had no role in mediating top managers' and supervisors' attitudes toward silence, communication opportunities, and task performance. supervisor support acted as a moderating factor in the relationship between job engagement and task performance. in contrast, despite the direct positive relationship between supervisor support and contextual performance, it failed to moderate the relationship between work engagement and contextual performance. conclusion: the study's findings demonstrate the need for health managers and supervisors to become more conscious of silence. the results offer diverse recommendations for encouraging the sharing of relevant ideas, facts, and opinions within the health sector. keywords: organizational climate, job performance, work engagement, supervisor support, frontline nurses, ghana background organizational silence is a communication and management issue in health care, as it is essential for high performance. it is common for health professionals to remain silent about workplace issues due to fear of confrontation, alienation, being labeled as a complainer, fear of damaging relationships, or misinterpretation by direct managers [1,2]. the growing body of evidence demonstrates both the desirable and undesirable consequences of organizational silence, with some scholars suggesting that it can have a beneficial effect on an individual or an organization [3]. however, others have argued that it can be more damaging than being outspoken. the impact of organizational silence on employee engagement (ee) is critical for organizations to achieve their goals, as we are a positive, fulfilling work mindset characterized by vitality, devotion, and absorption [1, 4, 5]. there is a need for further investigation, especially among frontline nurses, who are vital components of the quality of healthcare services in ghana. pirzada et al. [6] investigated the effects of employee silence on job engagement and discovered a significant negative correlation. this research aims to develop a more comprehensive understanding that will assist health managers in enhancing communication. from this perspective, the objective of the study shown in figure 1 is to examine the three components of an organismal climate of silence on the job between the organizational climate of silence and job performance through work engagement. supervisor ___________________________________________________ syopoku58@gmail.com 1school of public health and allied sciences, catholic university of ghana, fiapre sunyani, ghana a full list of author information is available at the end of the article 10.47108/jidhealth.vol6.iss2.283 http://www.jidhealth.com/ opoku sy, et al., journal of ideas in health (2023); 6(2):864-873 865 support is considered to moderate the relationship between the types of organizational climate of silence and job performance, of which little research has been reported in the literature. we also segregated performance into contextual and tasks following borman and motowidlo (1993) [7] to systematically compare and evaluate the impact of organizational climate, work engagement, and supervisor support. the research examines frontline nurses' perceptions of their supervisor's attitude toward job engagement and its effect on their contextual and task performance. literature review motowidlo [8] described job performance (jp) as the forecasted benefit from an employee's actions over a given timeframe. numerous researchers [9-12] have examined the direct effects of organizational silence on job performance among nurses and concluded that staying silent affected the job satisfaction and performance of nurses in turkey. the organizational climate of silence (ocs) and performance is an undesirable occurrence within an organization. vakola and bouradas [13] classified organizational silence into attitudes toward silence and communication opportunities held by top management and supervisors. it is believed that investigating jp among nurses using established theory could guide decision-makers and researchers to augment communication, work engagement, and performance in ghana. the social exchange theory by blau [14] suggests that when one party indulges in beneficial activities aimed at another party, the first person creates an implicit obligation that can affect employees' empowerment, performance, and job satisfaction. supervisors are more likely to reciprocate by providing additional resources and emotional support, which promotes the development of positive working relationships with subordinates. communication opportunities (co) influence performance, and employee voice is associated with contextual performance. vakola and bouradas's [13] findings show that when leaders communicate well with employees and listen, they are encouraged to perform well in their jobs. h1: organizational climate of silence is significantly related to job performance. h1a: there is a significantly negative relationship between top management's attitude to silence and task performance. h1b: there is a significantly negative relationship between a supervisor's attitude to silence and task performance. h1c: there is a significantly positive relationship between communication opportunity and task performance. h1d. there is a significant negative relationship between top management's attitude to silence and contextual performance. h1e: there is a significantly negative relationship between a supervisor's attitude to silence and contextual performance. h1f: communication opportunities will positively and significantly influence contextual performance. silence and work engagement (we) rees et al. [15] found that organizational silence is associated with work engagement, but relatively little attention has been paid to the relationship between voice and engagement [16]. work engagement is widely known as critical to organizational success and a driver of novelty and competitiveness, but few studies have been conducted on communication and engagement [17] truss and hall [18] found that having opportunities to communicate upward is one of the top factors influencing engagement, while purcell and hall [19] posit that speaking up and being heard is a critical antecedent to work engagement. beugré [20] noted that the "deaf-ear" syndrome may discourage communication, resulting in employee disengagement. it is hypothesized that employees' engagement at work decreases when they suspect their superiors are going through the motions of discussion without genuinely attaching seriousness. h2: organizational climate of silence is related to work engagement. h2a: top management's attitude to silence will negatively and significantly affect work engagement. h2b: supervisor attitude to silence negatively and significantly influences work engagement. h2c: communication opportunity positively and significantly affects we. work engagement as a mediator between organizational climate of silence and job performance work engagement creates an environment of self-identity where employees feel excited and show greater job satisfaction [21, 22]. this study believes that work engagement will help explain the influence of the organizational climate of silence on job performance. frontline nurses who can communicate freely and take seriously are inherently motivated and engaged in their work, but nurses whose views are not taken seriously are less likely to become committed and engaged, leading to poor performance [23, 24]. the above debates led to the following hypothesis: h2a: top management's attitude to silence will negatively and significantly affect work engagement. h2b: supervisor attitude to silence negatively and significantly influences work engagement h2c: communication opportunity positively and significantly affects we h3: we will significantly relate to job performance: from the above-reviewed literature, it is therefore hypothesized that h2: organizational climate of silence is related to work engagement. h3a: work engagement will significantly mediate the relationship between tmas and task performance. h3b: work engagement will significantly mediate the relationship between sas and task performance. h3c: work engagement will significantly mediate the relationship between co and task performance. h3d: we will significantly mediate the relationship between tmas and contextual performance. h3e: we will significantly mediate the relationship between sas and contextual performance. h3f: we will significantly mediate the relationship between co and contextual performance. supervisor support as a moderator between we and jp supervisor support is defined as assistance received from superiors at the workplace [25]. according to meral et al. [26] social exchange theory, makes employees feel more connected and affiliated with the organization, and they reciprocate by assisting supervisors in achieving organizational goals. babin and boles [27] established that supervisors exert significant opoku sy, et al., journal of ideas in health (2023); 6(2):864-873 866 influence over employees, and employees may provide supervisor support by improving performance to return [28]. despite evidence in the literature demonstrating supportive supervisors as a buffering factor, there is a limited number of studies demonstrating supervisor support as a vital buffering factor contributing to job engagement and performance [26, 29. 30.31,32]. in this present study, supervisor support is expected to moderate the relationship between work engagement and performance (task and contextual). communication opportunities are usually related to contextual performance because affiliate behavior is designed to maintain or improve relationships. vakola and bouradas's (2005) [13] findings show that when leaders communicate well with employees and listen, they are encouraged to perform well in their jobs. given the above research findings concerning the association between silence and performance, it is hypothesized that: h4: supervisor support will significantly moderate the relationship between we and performance. h4a: supervisor support will significantly moderate the relationship between we and task performance. h4b: supervisor support will significantly moderate the relationship between we and contextual performance. figure1: conceptual framework: (author’s construction 2023) methods study design and data analysis a quantitative cross-section design was used for the study. the survey was data collected from 14 hospitals and 15 health centers and community-based health planning services (chps) compounds in the western region of ghana between 21st april and november 20th, 2021. the data were collected in four waves, with a two-month gap between each wave. the informed consent form also described the main constructs, such as job performance. the average age of the respondents was 43, and they had an average of nine years of professional experience. we used stata and statistical package for the social sciences (spss) software for data analysis. the unrotated principal component factor analysis revealed five factors with eigenvalues greater than one on all measurement elements. inclusion and exclusion criteria frontline workers who were on leave and had not worked for more than at least six months at the health facility were exempted from the study. the study however focused on frontline workers who had patient care experience for more than six months. the eligibility requirements included answering yes to two questions: do you experience organizational silence at the moment, and will you be able to participate in four data collection waves performed at nearly 8-month time intervals? frontline health workers who qualifiers and responded yes to the questions were targeted for the study and those who responded no were exempted. sample size we used the variable-to-sample ratio to determine an appropriate and sufficient sample size for this study [33]. according to sprent and smeeton [33], the variable-to-sample ratio suggests that the choice of sample size should be made based on the proportion of respondents to items. as n: p, the ratio is written. the p stands for the number of items, while the n stands for the number of respondents. variable-to-item ratio examples include 3:1, 6:1, 15:1, and even 20:1. in contrast, we used a 10:1 ratio for this research project. according to this ratio, ten respondents were used for each item, as recommended by cattell [34], among other earlier studies. we could have settled on 370 respondents based on the total of thirty-five items used in assessing the study's variables. the current study, on the other hand, gathered 565 valid responses from frontline healthcare professionals. the 549 valid responses outnumber the 370 respondents; thus, the data from this current study is more than adequate for further analysis. in addition, we selected respondents using the purposive sampling technique. it is strong enough to allow a researcher to collect data from a convenient and accessible segment of a population. opoku sy, et al., journal of ideas in health (2023); 6(2):864-873 867 survey instruments the questionnaire employed in the study contained items evaluating top management's attitude to silence, the supervisor's attitude to silence, communication opportunities, work engagement, supervisor support, task performance, and contextual performance. organizational climate of silence the organizational climate of silence was categorized into three subscales: top manager's and supervisor's attitude to silence and communication opportunity. top management attitude to silence (tmas) this study assessed tmas, the unwillingness of top managers to share their errors or seek assistance from others, using five items from vakola and bouradas [13]. sample items were modified to suit the context of the current study, such as "if you express your disagreements about company issues, you may suffer negative consequences from top management." the cronbach's α coefficient was 0.84, and the cronbach alpha was 0.949 indicating high internal consistency. sample items were assessed on a 7-point likert scale with 1 = strongly disagree to 7= strongly agree. supervisor attitude to silence (sas) this study assessed the sas construct by using five items from vakola & bouradas [13]. these items have been proven to have high reliability and were rated on a seven-point likert scale from one (strongly disagree) to seven (strongly agree). the cronbach alpha for sas was 0.89. communication opportunity (co) communication opportunities in the current study are related to mutual trust and openness and a perceived sense of having a say and being recognized. the communication opportunity was evaluated with five items from vakola & bouradas [13]. these items had high reliability in previous studies with cronbach alpha 0.79. sample items comprise “communications with coworkers from other departments are satisfactory,” “in this hospital, there is a structured and systematic exchange of experience and knowledge among employees.” items for co were rated on a seven-point likert scale from one (strongly disagree) to seven (strongly agree). task performance (task) task performance is described as an employee essential job description. we measured task with seven items that were adapted from (kahya 2009) [35] sample items include “job knowledge” and “problem-solving” these items have been proven to have high internal consistency in previous studies. for instance, kahya [35] recorded a reliability coefficient of 0.89 for the task construct. in this current study, the cronbach alpha coefficient for oc is 0.949. all items on the scale were assessed on a 7-point likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). contextual performance (cont) individual actions unrelated to their primary task structure shape the organizational, social, and psychological context that serves as a future value for task practices and functions. this is described as contextual performance [36]. we measured cont with eight items following the work of koopmans et al. [37]. the cronbach alpha value for the job performance scale is 0.905, which is even better than in previous studies. items for jp were rated on a 7-point likert scale ranging from 1 (extremely low) to 7 (extremely high). work engagement (we) the current study defines we as an employee's high job-related psychological state, followed by total commitment and resilience. four items adapted from schaufeli et al [38] were used to assess the work engagement construct. the cronbach alpha for we was 0.88. items were rated on a seven-point likert scale from one (strongly disagree) to seven (strongly agree). supervisor support (ss) we measured supervisor support (ss) with three items adapted from the work. cronbach's alpha value for the job performance scale was 0.913, higher than in previous studies. items for jp were rated on a 7-point likert scale ranging from 1 (extremely low) to 7 (extremely high). control variables the variables such as gender, age, education, and marriage were employed as controls during the hierarchical regression analysis. the variables were chosen because they have been identified by al‐ahmadi (2009) [39] to influence performance among nurses. results socio-demographic characteristics of study participants the data analysis included 565 valid responses from 169 male and 397 female nurses, with a net response rate of 68.9%. the first element explained 14.68% of the total variance, less than the 50.0% cut-off criteria suggested by hu and bentler [40], while all elements explained 77.25% of the variance. the findings of this study provide evidence that the data was not affected by common method bias. correlations, mean, and standard deviation analysis from table 1 below, the inter-factor correlation factor, mean, and standard deviation analysis of all elements showed that the supervisor's attitude to silence correlated with task and contextual performance and work engagement. to check the discriminant validity of the scales, we assessed the latent variable correlations and the square root of the aves. the results showed that discriminant validity has been achieved, indicating that the variables are distinct from each other. measurement model, construct validity, and reliability the data was subjected to validity and reliability testing with spss version 23 software as shown in table 2 below. an exploratory factor analysis (efa) was performed to see if the items for the survey could load onto their predicted variables. the spss was also used to check the reliability of the scales, which had cronbach alpha (α) coefficient values above the proposed 0.70 thresholds. a validity test with critical interests in standardized factor loadings, fit indices, average variance extracted (ave), composite reliability (cr), and discriminant validity showed that the scales had good convergent validity. opoku sy, et al., journal of ideas in health (2023); 6(2):864-873 868 table 1: correlation analysis, discriminant validity, means, and standard deviations (n=565) 1 2 3 4 5 6 7 8 9 10 mean std. dev 1. gender 1.27 0.442 2. age 0.053 3.09 0.931 3. educa -.188** 0.01 2.03 0.917 4. marriage .196** 0.016 -.261** 1.35 0.476 5. tmas -0.016 0.046 0.014 .093* 0.867 3.12 1.32 6. sas 0.018 -0.016 0.02 -.077 -.489** 0.890 2.92 1.357 7. cont -0.021 -0.074 0.022 0.006 -.171** .175** 0.742 2.3 0.743 8. task -0.069 -0.036 -0.033 -0.024 .172** .181** .178** 0.867 2.85 1.216 9. we -0.032 -.167** 0.023 -.097* -.246** .201** .561** .155** 0.932 2.11 0.816 10. co -0.017 -.159** .101* -0.029 -.084* 0.078 .234** .180** .236** 0.851 4.2874 0.8004 11.ss 0.014 -0.026 -0.034 -0.011 -.230** .180** .491** .151** .572** .173** 0.780 11.ss 0.014 abbreviation: tmas, top management attitude to silence; sas, supervisor attitude to silence; cont, contextual performance; task, task performance; we, work engagement; co, communication opportunity and ss, supervisor support. table 2: result of the confirmatory factor analysis and reliability testing variables loadings cronbach alpha composite reliability ave task6 .903 0.949 0.955 0.752 task7 .892 task5 .889 task4 .875 task2 .874 task3 .873 task1 .755 cont1 .864 0.905 0.907 0.550 cont4 .787 cont7 .744 cont3 .742 cont6 .740 cont5 .730 cont8 .672 cont2 .633 sas3 .898 0.958 0.949 0.789 sas4 .894 sas2 .891 sas1 .882 sas5 .877 tmas1 .921 0.947 0.938 0.753 tmas5 .871 tmas2 .867 tmas3 .855 tmas4 .823 co1 .884 0.913 0.929 0.724 co3 .878 co4 .870 co5 .818 co2 .801 we2 .837 0.925 0.884 0.657 we3 .829 we4 .793 we1 .781 ss3 .799 0.840 0.823 0.608 ss2 .792 ss1 .747 abbreviation: tmas, top management attitude to silence; sas, supervisor attitude to silence; cont, contextual performance; task, task performance; we, work engagement; co, communication opportunity and ss, supervisor support. opoku sy, et al., journal of ideas in health (2023); 6(2):864-873 869 hypotheses testing assessing the main effect and mediating effect of work engagement the study employed the hierarchical regression procedure to estimate the various hypothesized associations illustrated in the conceptual framework (figure 1). first, we examined the main effect model (table 3), which involves the effect of the controls and organizational climate variables on task performance. the results of model 2, as represented in table 3, showed that top management attitude to silence and supervisor attitude to silence had a significant adverse effect on task performance (β=-.090, p< 0.05) and (β=-.110, p< 0.01). however, communication opportunities showed a significant positive relationship with task performance. thus, hypotheses h1a, h1b, and h1c, h1d, h1e, and h1f were supported. employing work engagement as a dependent variable in model 3, top management and supervisor attitude to silence negatively impacted we. at the same time, communication opportunities positively and significantly predicted work engagement. the result, therefore, supported h2a and h2b. employing we as an exogenous variable and task performance as the endogenous variable, the findings from model 4 showed a significant positive relationship with task performance. the outcome of the study, however, supports h2c. table 3: hierarchical regression results of the mediating effects of we in the relationship between tmas, sas, oc, and task performance. variables task task w task task model 1 𝛽 (𝑡) model 2 𝛽 (𝑡) model 3 𝛽 (𝑡) model 4 𝛽 (𝑡) model 5 𝛽 (𝑡) constant 3.447 (11.262) 2.955*** (6.662) 2.394*** (8.299) 2.816*** (11.262) 2.651*** (5.655) gender -.200 (-1.674) -.226 (-1.957) -.030 (-.394) -.198 (-1.674) -.224 (-1.941) age -.041 (-7. .002 (.043) -.110*** (-3.123) -.008 (-.153) .015 (.268) educational -.069 -.088 (-1.550) -.014 (-.383) -.068 (-1.184) -.088 (-1.553) marriage -.058 -.005 (-.042) -.116 (-1.622) -.022 (-.195) .005 (042) tmas -.090* (-2.080) -.106*** (-3.760) -.055 (-1.452) sas -.110*** (-2.637) -.058* (-2.113) -.114* ** (-2.768) co .254 *** (4.020) .197*** (4.799) .232*** (3.605) we .226*** (3.576) .118 (1.826) r square 0.675 0.077 0.037 0.031 0.913 f .726 6.640 12.363 5.097 6.061 abbreviation: tmas, top management attitude to silence; sas, supervisor attitude to silence; co, communication opportunity; task, task performance; and we, work engagement the study regressed the control variables, tmas, sas, and co, on task performance and found that only sas and co had a significant relationship with task performance. supervisors' attitude to silence had a significant negative coefficient, whereas communication opportunities showed a positive relationship. table 3, model 2, showed that top management and supervisor attitude to silence similarly had a negative impact on work engagement. work engagement as a dependent variable showed that both tmas and sas had a significant adverse effect on contextual performance, while communication opportunities had a positive and significant impact contextual performance. h3a, h3b, and h3c were not supported. the results of model 5 showed that both tmas and sas had an insignificant effect on contextual performance. work engagement partially mediated the relationship between communication opportunities and contextual performance, partially supporting h3d, h3e, and h3f. the structural model for model fitness with chi-square = 98.143, standardized root mean square residual (srmr)= 0.026, root mean square error (rmsea)= 0.103, and comparative fit indexes (cfi), p=0.935, showed that our data had an acceptable model fit. model 4 showed a significant positive relationship with task performance. table 4: hierarchical regression results of the mediating effects of we in the relationship between tmas, sas, oc, and cont performance. variables cont 𝜷 (𝒕) cont 𝜷 (𝒕) we 𝜷 (𝒕) cont 𝜷 (𝒕) cont 𝜷 (𝒕) model 1 model 2 model 3 model 4 model 5 constant 2.439*** (13.020) 1.931*** (7.168) 2.394*** (8.299) .990*** (5.510) .771*** (3.157) gender -.027 (-.373) -.044 (-.623) -.030 (-.394) -.023 (-.375) -.029 (-.489) age -.059 (-1.752) -.027 (-.814) -.110*** (-3.123) .016 (.574) .026 (.934) educational .020 (0.551) .004 (.120) -.014 (-.383) .020 (.685) .011 (.373) marriage .027 (0.386) .059 (.879) -.116 (-1.622) .110 (1.924) .115 * (2.007) tmas -.057* (-2.163) -.106*** (-3.760) -.006 (-.246) sas -.061* (-2.403) -.058* (-2.113) -.033 (-1.521) co .197*** (5.132) .197*** (4.799) .101*** (3.026) we .519*** (16.023 .484*** (14.308) r square 0.90 0.037 0.31 0.335 f 7.854 12.363 52.413 34.97 abbreviation: tmas, top management attitude to silence; sas, supervisor attitude to silence; co, communication opportunity; cont, contextual performance; and we, work engagement. opoku sy, et al., journal of ideas in health (2023); 6(2):864-873 870 assessing the moderating role of supervisor support the study employed hierarchical regression analysis, meancentered work engagement, and contextual performance variables to determine the moderating effect of supervisor support. the results presented in table 5 model 2, show the moderating effect of ss on task performance. in table 5, model 2, the results showed that the impact of we and supervisor support on tasks was statistically insignificant. finally, the results presented in model 3 revealed that the interaction between we and ss was positive and statistically significant, hence supporting h4b. the results show a partial moderating influence of the interactive term between we and task performance. the graphical presentation of the moderating impact of we on the association between ss and tasks performance is presented in figure 2. the results show that we still exerted a significant positive effect on contextual performance, which provides additional support for h2. supervisor support also had a significant positive relationship with contextual performance. the interaction between work engagement and supervisor support was positive and statistically insignificant. the findings suggest that supervisor support could not moderate the relationship between work and engagement and contextual performance. hence, h4a was not supported. the graphical presentation of the moderating impact of we on the association between ss and contextual performance is presented in figure 3. table 5: hierarchical regression results of the moderating effects of ss in the relationship between we and performance. variables task 𝜷 (𝒕) task 𝜷 (𝒕) task 𝜷 (𝒕) cont 𝜷 (𝒕) cont 𝜷 (𝒕) cont 𝜷 (𝒕) model 1 model 2 model 3 model 1 model 2 model 3 constant 3.447*** (11.262) 2.428*** (5.966) 4.372**(6.375) 2.439*** (13.020) .361 (1.783) .730* (2.118) gender -.200 (-1.674) -.202 (-1.712) -.189 (-1.620) -.027 (-.373) -.029 (-.496) -.027 (-.456) age -.041 (-.749) -.017 (-.313) .008 (.143) -.059 (-1.752) .002 (.067) .007 (239) educational -.069 (-1.176) -.064 (-1.105) -.061 (-1.064) .020 (0.551) .028 (.967) .028 (.987) marriage -.058 (-.517) -.030 -.026 (-.238) .027 (0.386) .098 (1.753) .098 (1.766) we .143 (-.266) .971*** (-2.969) .384*** (9.973) .172 (1.048) ss .139 (1.863) .349* (-2.212) .226*** (6.069) .133 (1.680) we* ss .254*** (3.503) .048 (1.322) r square 0.82 0.37 0.57 0.82 .361 0.363 f 3.53 4.84 52.616 45.41 abbreviation: we, work engagement; co, communication opportunity and ss, supervisor support; we* ss, interaction between work engagement and supervisor support. discussion in this current study, a conceptualized model is proposed to investigate the influence of the organizational climate of silence (ocs) on job performance, directly and indirectly, using work engagement as a mediator. in addition, the study tested the moderating role of supervisor support in the relationship between work engagement (we) and job performance (jp) among frontline nurses. findings from the hierarchical regression analysis confirmed most of the hypotheses proposed. figure 2. the moderating influence of work engagement in the relationship between the organizational climate of silence and task performance the influence of ocs on job performance the study found that communication opportunities had the highest predictive capacity on task and contextual performance, followed by supervisor attitude to silence (β=-0.110, p<0.05) and top management attitude to silence. the positive relationship between communication opportunities and contextual performance corroborates the findings of ruck et al [17]. effective communication can foster collaboration and the ability of nurses to work cooperatively toward a common goal. however, top management and supervisor attitudes toward silence had significant and negative effects on work engagement and performance. silence among nurses could slow organizational development and decrease employee engagement. this study found that organizational silence is detrimental to the health sector, especially hospital success and that ocs variables are statistically significant and influence work engagement. communication opportunities showed a strong predictive effect on contextual and task performance, while top managers and supervisors' attitudes toward silence had a significant negative impact on performance. this is possible because top managers' and supervisors' attitudes toward silence cause nurses to perceive themselves as having fewer opportunities to effectively communicate their concerns, eliciting fewer positive attitudes and demonstrating lower levels of engagement. this study is in line with welch [41] which identified the linkage between silence and work engagement and encouraged women to take communication seriously. opoku sy, et al., journal of ideas in health (2023); 6(2):864-873 871 the mediating effect of work engagement work engagement had no mediatory role between tmas, sas, co, and task performance, but partially mediated the relationship between communication opportunities and contextual performance. this study contributes to the literature in the health industry, articulating human resource and healthcare management perspectives. it provides empirical evidence that senior manager and supervisor attitudes towards silence can influence work engagement, which predicts nurses' level of contextual performance. sequentially, work engagement predicts a nurse's level of contextual performance [42, 43, 44]. moderating effects of supervisor support on work engagement and contextual performance the most important details are that supervisor support could not moderate the relationship between work engagement and contextual performance, quansah et al [45] indicated that it would not be wrong to interpret the main effects in the case of statistically insignificant interactions among exogenous variables, and the influence of work engagement and supervisor support on task performance was positive and statistically significant. the results suggest that support from supervisors should be taken seriously at the hospital as their powerful influence can enhance work engagement and task performance among nurses. this study contributes to human resource and healthcare management perspectives but has limitations that should be considered in future research. the initial data collection method was a two-month time lag, which may be limited in terms of causal impact. future studies should collect data at longer time intervals and use larger samples and multiple hospitals in ghana and elsewhere. figure 3. the moderating influence of work engagement in the relationship between the organizational climate of silence and contextual performance theoretical implications the current research assesses top managers' and supervisors' attitudes to silence and communication opportunities on performance among frontline nurses through the mediatory role of work engagement. to comprehensively compare and evaluate the impact of the organizational climate of silence on performance, the study disaggregated performance into contextual and task following borman and motowidlo [7]. additionally, the moderating effects of supervisor support on the association between work engagement and job performance are examined. this study breaks new ground in the health management literature by introducing a systematic model with a crucial emphasis on the relationship between the climate of silence and job performance. it also contributes to the literature and the expectancy theory by investigating the mediating role. practical implications this study makes several recommendations for improving nurse performance. top managers and supervisors must create an environment where employees can express their opinions and contribute thoughts about a pending issue. to avoid silence, managers must create opportunities for communication and formalize the exchange of information and ideas. milliken et al [45] found that employees who have suggestions but are unsure how and where to approach their superiors can submit them to an authorized officer. additionally, managers must consider organizational silence as a critical factor when examining the organizational climate to improve organizational performance. finally, supervisors must strengthen their support for frontline nurses to increase their engagement in work-related activities and performance in the health sector. violations of this policy can undermine work engagement and negatively impact performance. conclusion this study examined the effects of organizational silence on contextual and task performance among frontline nurses. results showed that work engagement played no role in mediating top managers' and supervisors' attitudes toward silence and task performance. however, work engagement served as a full mediator between top managers' and supervisors' attitudes. supervisor support acted as a moderating factor in the relationship between job engagement and task performance but failed to moderate the relationship between work engagement and contextual performance. the study provides theoretical and practical contributions based on the findings. abbreviation we: work engagement; ss: supervisor support; ee: employee engagement; jp: job performance; ocs: organizational climate of silence; co: communication opportunity; tmas: top management attitude to silence; sas: supervisor attitude to silence; spss: statistical package for the social science declaration acknowledgment the authors are very grateful to the wireko family for their assistance in the data collection. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing amponwirekosabina@gmail.com opoku sy, et al., journal of ideas in health (2023); 6(2):864-873 872 authors’ contributions syo and sa-w developed the concept of the study and contributed to the design of the research article, data collecting, and analysis. sya and ad were also involved in data analyses and drafted the manuscript. all authors were involved in the revision of the manuscript. we can also confirm that the coauthors have approved the final version of the manuscript. ethics approval and consent to participate the study was conducted in accordance with the ethical principles of the declaration of helsinki (2013). ethical approval was guaranteed by the corresponding institution. moreover, permission to collect the data from the fourteen hospitals and fifteen health centers, and community-based health planning services (chps) in the western region of ghana was guaranteed. a cover letter suggesting confidentiality and anonymity was maintained. the participants were informed that participation was entirely voluntary and could withdraw from the study at any time without any disadvantage to the respondents. participants were further assured that their personal information was protected, including protecting their privacy in line with the dictates of the ethical clearance obtained. all respondents willingly partook in the study. the participants provided written informed consent. informed consent was obtained from all the participants of the study. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1school of public health and allied sciences, catholic university of ghana, fiapre sunyani, ghana 2. graduate school of business management philippine christian university article info received: 11 april 2023 accepted: 21 may 2023 published: 02 june 2023 references 1. çaylak e, & altuntas s. organizational silence among nurses: the impact on organizational cynicism and intention to leave work. journal of nursing research, 2017;25(2): 90-98. doi: 10.1097/jnr.0000000000000139. 2. eroğlu a, adıgüzel o, öztürk u. dilemma of silence vortex and commitment: relationship between employee silence and organizational commitment. the journal of faculty of economics and administrative sciences 2011; 16(2), 97-124. 3. world health organization. world health report: working together for health. geneva: 2016 (http://www.who.int/ whr/2016/whr06. 4. yurdakul m, beşen ma. erdoğan s. the organizational silence of midwives and nurses: reasons and results. journal of nursing management. 2016; 24 (5), 686-694. doi: 10.1111/jonm.12374 5. robinson em, lee sm, zollfrank a, jurchak m, frost d & grace p. enhancing moral agency: clinical ethics residency for nurses. hastings center report. 2014; 44(5): 12-20. https://doi.org/10.1002/hast.353 6. pirzada za, mirani sh, phulpoto nh, dogar h, & mahar sa. study of employee silence, organizational justice and work engagement: mediation analysis. 2020; ijcsns, 20 (1):10. 7. borman wc and motowidlo sj. expanding the criterion domain to include elements of contextual performance. personnel selection in organizations san francisco: jossey-bass, 1993:71-98. 8. motowidlo sj. job performance. handbook of psychology: industrial and organizational psychology, 2003; 12: 39-53. 9. di muzio m. diella g., di simone e, novelli l, alfonsi v, scarpelli s, giannin am. nurses and night shifts: poor sleep quality exacerbates psychomotor performance. frontiers in neuroscience. 2020; 14: 1050. doi: 10.3389/fnins.2020.579938 10. haresaku s, uchida s, aoki h, akinaga k, yoshida r, kubota k, & naito t. factors associated with nurses’ performance of oral assessments and dental referrals for hospital inpatients. bmc oral health. 2020; 20(1): 1-10. doi.org/10.1186/s12903-020-1058-0 11. dafchahi zn, gilani mhn. the effect of psychological capital on nurses' performance with regard to the mediating role of burnout and job satisfaction. research in medical education. 2021; 35-45. 12. kılıç sp, aybar dö, sevinç s. effect of organizational silence on the job satisfaction and performance levels of nurses. perspectives in psychiatric care. effect of organizational silence on the job satisfaction and performance levels of nurses. perspective of psychiatric care. 2021; 57 (4):1888-96. 13. vakola m, bouradas d. antecedents and consequences of organisational silence: an empirical investigation. employee relations. 2005; 27(5):441-58. 14. blau pm. social exchange and power in social life. 2017; eedition in: new york: wiley. 15. rees c, alfes k, gatenby m. employee voice and engagement: connections and consequences, international journal of human resource management. 2013; 24(14): 2780-98. 16. gruman ja, saks am. being psychologically present when speaking up: employee voice engagement. handbook of research on employee voice: elgar original reference, 2014: 455. 17. ruck k, welch m, menara b. employee voice: an antecedent to organizational engagement. public relations review. 2017; 43(5): 904-14. 18. truss c, soane e, edwards c, wisdom k, croll a, burnett j. working life: employee attitudes and engagement 2007: chartered inst. of personnel and development. 19. purcell j, hall m. voice and participation in the modern workplace: challenges and prospects. acas future of opoku sy, et al., journal of ideas in health (2023); 6(2):864-873 873 workplace relations discussion paper series, london: 2012; acas. 20. beugre cd. organizational conditions fostering employee engagement: the role of “voice”. in sl albrecht (ed.), handbook of employee engagement: perspectives, issues, research and practice. 2010: 174–181. northampton, ma. edward elgar publishing. 21. fairchild aj, mackinnon d p. a general model for testing mediation and moderation effects. prevention science. 2009;10(2): 87-99. 22. hayes af. introduction to mediation, moderation, and conditional process analysis: a regression-based approach. 2017; guilford publications. 23. côté k, lauzier m, stinglhamber f. the relationship between presenteeism and job satisfaction: a mediated moderation model using work engagement and perceived organizational support. european management journal. 2021; 39(2): 270-78. 24. edwards-dandridge ym. work engagement, job satisfaction, and nurse turnover intention. 2019; doctoral dissertation, submitted to college of management and technology at walden university. 25. yoon j, lim jc. organizational support in the workplace: the case of korean hospital employees. human relations. 1999;.52(7): 923-45. 26. meral e, yildiz b, karabay me. how burnout affects turnover intention? the conditional effects of subjective vitality and supervisor support. international journal of organizational leadership 2018; 7(1): 47. 27. babin bj, boles js. the effects of perceived co-worker involvement and supervisor support on service provider role stress, performance and job satisfaction. journal of retailing. 1996; 72(1): 57-75. 28. shanock lr, eisenberger r. when supervisors feel supported: relationships with subordinates' perceived supervisor support, perceived organizational support, and performance. journal of applied psychology. 2006; 91(3): 689. 29. kickul j, posig m. supervisory emotional support and burnout: an explanation of reverse buffering effects. journal of managerial issues 2001:328-44. 30. o'driscoll mp, poelmans s, spector pe, kalliath t, allen t d, cooper cl, sanchez ji. family-responsive interventions, perceived organizational and supervisor support, work-family conflict, and psychological strain. international journal of stress management. 2003; 10(4): 326. 31. russo ja, waters le. workaholic worker type differences in work‐family conflict: the moderating role of supervisor support and flexible work scheduling. 2006; career development international. 32. weigl m, stab n, herms i, angerer p, hacker w, glaser j. the associations of supervisor support and work overload with burnout and depression: a cross‐sectional study in two nursing settings. journal of advanced nursing. 2016;.72(8): 1774-88. 33. sprent p, smeeton nc. (2016). applied nonparametric statistical methods. crc press. 34. cattell rb, johnson rc. functional psychological testing. new york: brunner mazel; 1986. 35. kahya e. the effects of job performance on effectiveness. international journal of industrial ergonomics. 2009; 39(1): 96-104. 36. werner jm. implications of ocb and contextual performance for human resource management. human resource management review. 2000; 10(1): 3-24. 37. koopmans l, coffeng jk, bernaards cm, boot cr, hildebrandt vh, de vet hc, van der beek aj. responsiveness of the individual work performance questionnaire. bmc public health. 2014; 14(1): 1-11. 38. schaufeli wb, bakker ab & salanova m. the measurement of work engagement with a short questionnaire: a cross-national study. educational and psychological measurement. 2006; 66(4):701-16. 39. al‐ahmadi h. factors affecting performance of hospital nurses in riyadh region, saudi arabia. int j health care qual assur. 2009;22(1):40-54 40. hu l, bentler pm. cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. structural equation modeling: a multidisciplinary journal. 1999; 6(1):1-55. 41. welch m. the evolution of the employee engagement concept: communication implications. corporate communications: an international journal. 2011; 16(4): 328-46. 42. bayona ja, caballer a & peiró jm. the relationship between knowledge characteristics’ fit and job satisfaction and job performance: the mediating role of work engagement. sustainability. 2020; 12(6): 2336. 43. bizri r, wahbi m, al jardali h. the impact of csr best practices on job performance: the mediating roles of affective commitment and work engagement. j of org effectiveness: people and performance. 2021; 8(1):129-48. doi:10.1108/joepp-01-2020-0015. 44. lai fy, tang hc, lu sc, lee, yc, lin cc. transformational leadership and job performance: the mediating role of work engagement. sage open. 2020; 10(1): 2158244019899085. 45. quansah pe, zhu y, obeng af. assessment of the effects of supervisor behaviour, safety motivation and perceived job insecurity on underground miner’s safety citizenship behaviour. chinese management studies. 2021;16(2), 356–81. https://doi.org/10.1108/cms-08-2020-0361. https://doi.org/10.47108/jidhealth.vol3.issspecial1.55 bhandari s et al., journal of ideas in health 2020;3(special 1):188-189 © the author(s). 2020 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access curbing covid-19: the quest continues in time sudhir bhandari1, ajit singh1, jitendra gupta2, shivankan kakkar3*, amitabh dube2 abstract the menace of coronavirus disease-19 (covid-19) has made life more and more challenging throughout the world. amidst these difficult times, doctors have proved their exceptional worth. they have performed their duties with notable dedication, diligence, resilience, and compassion. here we share our experiences from the state of rajasthan in northern india. we were benefitted by very early lockdown by the government, preventive strategies of containment, and the most effective contact tracing program. the creation of hundreds of surveillance teams and rapid response teams (rrt) was instrumental for the containment program. this was coupled with outstanding medical care exemplified by sawai man singh medical college hospital (smsmch) at jaipur, the capital city of rajasthan. the mortality rate-limiting to 1.98% in rajasthan has been an outcome of the amalgamation of brisk administrative action, government support, and visionary action and the best of health care facilities. our covid-19 management program strategy was based on the advanced treatment guidelines from the indian council of medical research, new delhi, india, and the ministry of health and family welfare, government of india. keywords: containment strategies, covid-19, treatment guidelines, india. background the specter of coronavirus disease-19 (covid-19) defying and flouting all time and geographic locale precepts have bemused humanity across the globe. an onerous challenge that specialists in medical science took spearheading the mission with evident dedication, diligence, resilience, and compassion to break into the esoteric code of severe acute respiratory syndrome coronavirus 2 (sars-cov-2). it would be worthwhile to add that the state of rajasthan in northern india was very ably supported by timely and meticulous government preventive containment strategies of early lockdown with timely effective contract tracing program inclusive of the genesis of adequate surveillance rapid response teams (rrt) along with exemplary medical care, an essential feature of policy-making the edifice of which was drafted by sawai man singh medical college hospitals (smsmch) at jaipur, a premier tertiary care medical institute of asia. to achieve the best results in treatment outcome, it is prudent to address the disease process in its infancy with the premise to nip through a proactive investigative armamentarium with customized management protocol to be initiated in the prescient early stage of the disease. an aggressive protocol was designed for mild to the moderately severe disease process of covid-19, wherein the reported axes of the disease were assessed namely, coagulopathy through d-dimers and fibrinogen degradation products (fdps) levels in serum, cytokine storm, and inflammatory overdrive through varied markers of neutrophilic/lymphocytic ratio (n/l ratio), c-reactive protein (crp), interleukin-6 (il-6), tumor necrosis factor (tnf) and interleukin-1 (il-1) assay, the cardiac evaluation was done through color doppler, and the lungs were assessed through hrcct, pulmonary ct angiography and point of care ultrasonography (pocus) in those patients who could not be mobilized to high-resolution chest computed tomography (hrcct) [1]. a need-based utility management approach was strategized in the initial stages of the disease that included sars-cov-2 portal of entry blocker namely hydroxychloroquine (hcq), anti-viral drugs of lopinavir, ritonavir and remdesivir, steroids in acute respiratory distress syndrome (ards), low-molecular-weight heparin in pulmonary thromboembolic phenomenon and tocilizumab in the documented picture of cytokine storm along with administration of convalescent plasma when endogenous antibody response to the virus is still in nascence in the widespectral covid-19. ___________________________________________________ drshivankan@gmail.com 3department of pharmacology, sawai man singh medical college hospital, jaipur, rajasthan, india. full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol3.issspecial1.55 http://www.jidhealth.com/ bhandari s et al., journal of ideas in health (2020); 3(special 1):188-189 189 such a proactive, aggressive clinical approach was instrumental in keeping the case and case fatality rates low along with decreased chances of mortality in patients with existing comorbid conditions. the stratagem so conscripted acted as a fountainhead for the state with the creation of dedicated covid-19 center of 300 bedded icu and thousand bedded ipd along with separate covid-19 opd and observation ward for suspected patients. for critically ill patients, infectious diseases hospital (idh) was fully equipped with highbred icu facilities. during the pandemic's peak, average 500 plus patients were admitted to the institute from asymptomatic category to severe category. the extraordinary cure rate of 73.27% and mortality rate-limiting to 1.98% in rajasthan was an outcome of the amalgamation of brisk administrative action, outstanding government support, and advanced visionary action with state-of-art medical facilities [2]. the covid-19 management program was developed on extensive logistic deliberations based on evolving treatment guidelines from indian council of medical research, new delhi, india and ministry of health and family welfare, government of india [3] inclusive of early proactive work up with aggressive treatment at sawai man singh medical college hospitals (smsmch), jaipur. the covid-19 management protocol was designed according to the severity scale, managing aggressively mild to moderate disease, and addressing cytokine storm in covid-19 patients that gave appreciable outcomes. smsmch is one of the pioneers in covid-19 plasma therapy and is part of the who solidarity trial, [4, 5] with an emphasis on bringing down the mortality rate and increasing recovery rate as part of various measures to contain covid-19. conclusion the measures inclusive of government, societal and medical, so outlined, were able to curtail the covid-19 pandemic to some extent in our state. there are ongoing efforts to address knowledge gaps and accelerate the development of new therapeutics. abbreviation ards: acute respiratory distress syndrome; covid-19: coronavirus disease-19; crp: c-reactive protein; fdps: fibrinogen degradation products; hcq: hydroxychloroquine; hrcct: high-resolution chest computed tomography; icmr: indian council of medical research, new delhi, india; idh: infectious diseases hospital; il-1: interleukin1; il-6: interleukin-6; n/l ratio: neutrophilic/lymphocytic ratio; pocus: point of care ultrasonography; rrt: rapid response teams; sars-cov-2: severe acute respiratory syndrome coronavirus 2; smsmch: sawai man singh medical college hospitals, jaipur, india; tnf: tumor necrosis factor declarations acknowledgement the contributors acknowledge the invaluable support of departments of medical education, medical & health, government of rajasthan, india, and indian council of medical research (icmr), new delhi, india. funding the author received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing drshivankan@gmail.com authors’ contributions all authors contributed equally to the writing and editing of the manuscript (commentary). the authors approved the final draft of the manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, viewpoint articles need no ethics committee approval. consent for publication not applicable competing interest the author declares that he has no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of medicine, sawai man singh medical college hospital, jaipur, rajasthan, india. 2department of physiology, sawai man singh medical college hospital, jaipur, rajasthan, india. 3department of pharmacology, sawai man singh medical college hospital, jaipur, rajasthan, india. article info received: 29 july 2020 accepted: 11 august 2020 published: 21 september 2020 references 1. gao y, li t, han m, li x, wu d, xu y, et al. diagnostic utility of clinical laboratory data determinations for patients with the severe covid-19. j med virol. 2020;92(7):791-796. https://doi.org/10.1002/jmv.25770. 2. covid-19 data for rajasthan, india. available from: https://www.covid19india.org/state/rj. [accessed on 17 july 2020]. 3. clinical management protocol: covid-19. version 5, 03/07/20. available from: http://www.rajswasthya.nic.in/pdf/covid%2019/for%20hospitals/03.07.2020.pdf. [accessed on 17 july 2020] 4. brown bl, mccullough j. treatment for emerging viruses: convalescent plasma and covid-19. transfus apher sci. 2020;59(3):102790. https://doi.org/10.1016/j.transci.2020.102790. 5. bhatnagar t, murhekar mv, soneja m, gupta n, giri s, wig n, et al. lopinavir/ritonavir combination therapy amongst symptomatic coronavirus disease 2019 patients in india: protocol for restricted public health emergency use. indian j med res. 2020;151(2 & 3):184-189. https://doi.org/10.4103/ijmr.ijmr_502_20. https://doi.org/10.47108/jidhealth.vol5.iss4.258 utami fp and nurfita d., journal of ideas in health 2022;5(4):766-775 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access postpartum blues reviewed by the risk factors in indonesia fitriana putri utami1*, desi nurfita1 abstract background: postpartum blues are known as postpartum sadness that could initiate a more serious mental disorder. it causes a decrease in the mother's interest in her baby, failure to breastfeed, to acts of hurting the baby and themself. knowing the determinant factors of postpartum blues as a prevention effort is necessary. therefore, this review aims to assess the factors contributing to postpartum blues, especially in indonesian mothers. methods: a review of all peer-reviewed journal-published studies on postpartum blues and its risk factors among indonesian mothers from 2012 2022. the following databases were searched; google scholars; springerlink; and science direct on september 2022 using the keywords "postpartum blues", "maternal blues", "baby blues", "risk factors”, and “indonesia”. results: fifteen studies were included in this review. risk factors that contribute to the occurrence of postpartum blues are age, salary, education, employment, breastfeeding process, health education after labor, type of labor, labor induction and labor complications, parity, pregnancy status, mother readiness, labor readiness, marriage satisfaction, husband support, and social support. conclusion: women with low socioeconomic status (ses) and primiparous births have a greater risk of suffering from postpartum blues. therefore, it is necessary to provide psychological assistance to health workers to the mother after giving birth. keywords: postpartum blues, maternal blues, postpartum depression, risk factors, indonesia background postpartum mothers need adjustments after giving birth, both physically and mentally. some mothers may feel frustrated because they feel incompetent and unable to control the situation [1]. the unsuccessful adjustment made by women to physical, physiological, and psychological changes, including changes in the role of a mother with a newborn, will tend to lead women to have emotional problems [2]. postpartum blues or baby blues, or maternity blues are known as postpartum sadness that occurs 14 days after delivery, initiating a more severe mental disorder, namely postpartum depression, if not handled properly [3]. mood lability in the first 14 days of the puerperium is associated with psychiatric symptoms and is the strongest predictor of subsequent psychopathology [4]. the incidence of baby blues or postpartum blues varies between 30% 75%, usually occurring on the third or fourth day after birth. postpartum psychosis, the most serious condition, usually appears 48-72 hours after birth and lasts up to two weeks. postpartum blues that are not handled properly can cause postpartum depression, experienced by 13% of women who give birth. in general, postpartum depression appears in the first four weeks after delivery and can last up to six months [5]. postpartum blues has a fairly high incidence worldwide. according to who, the prevalence reaches 26-85% of births [6]. the incidence of postpartum blues in indonesia ranges from 50-70% of all postpartum mothers, while the prevalence of postpartum depression is 2.32% (440/18,937), and the majority occurs in urban women [7]. mothers who experience deep postdelivery sadness experience reduced interest in their babies, are less able to recognize the baby's needs, and may even continue to refuse to breastfeed their babies to the point of hurting them and themselves [8]. postpartum blues also contribute to the failure of exclusive breastfeeding, especially for women with low socioeconomic status [9]. based on the explanation above, it is necessary to know the factors that can contribute to the emergence of postpartum blues to prevent and improve ___________________________________________________ fitriana.utami@ikm.uad.ac.id 1public health faculty, universitas ahmad dahlan, indonesia full list of author information is available at the end of the article 10.47108/jidhealth.vol5.iss4.258 http://www.jidhealth.com/ utami fp and nurfita d., journal of ideas in health (2022); 5(4):766-775 767 maternal and child health status. the study aimed to review the risk factors for postpartum blues in indonesia. methods study design a cross-sectional web-based study was conducted between a comprehensive review of the peer-reviewed published literature was conducted through several search engines: google scholar; springerlink; and sciencedirect in september 2022 with the keywords "postpartum blues", "maternal blues", "baby blues", “risk factors”, and “indonesia”. inclusion and exclusion criteria the inclusion criteria in the selection of articles were the articles published from 2012 through 2022; original studies about postpartum blues published in peer-reviewed journals; focus on prevalence and/ or risk factors for postpartum blues; and published in english and bahasa indonesia. the scoring at least five on the methodological assessment criteria based on hierarchies of evidence and critical appraisal checklist by [10], which has been developed by [11-12]. the criteria points assessed are as follows: i.) clear study aims; ii.) adequate sample size or justification; iii.) representative sample (with justification); iv.) clear inclusion and exclusion criteria; v.) validity measurement of mental health; vi.) the rate reported and losses response; vii.) clear data description, viii.) appropriate statistical analysis, ix.) appropriate informed consent. the cut of point 5 refers to the previous study [13]. this assessment is mentioned below in table 1. the exclusion criteria included the bachelor and/or magister and/or doctoral thesis and books; studies about treatment methods or interventions; studies about biological and genetic risk factors; studies about postpartum depression prevalence and/or risk factors; review studies; qualitative design study; and descriptive study. the literature search process to review risk factors for postpartum blues in indonesia can be seen in figure 1. figure 1. literature search process results the total number of studies that fulfill the criteria for review in this article was 15 studies described in table 1. the longest published time of the articles reviewed was 2015, while the most recent was published in 2022. there are three articles published in 2022 in this study. of these, most of the studies were conducted on java island, and only three were conducted outside the island of java, namely sumatra island, precisely in the provinces of riau and bengkulu. moreover, 9 out of 15 studies used the public health center (phc) to recruit informants, only one study chose to recruit mothers from the general and maternal clinic, and the rest used the hospital as a setting, both general hospital, and maternal child hospital. the article was identified by the search engine (google scholar, springerlink, and sciencedirect) using the term: postpartum blues / maternal blues/baby blues and indonesia postpartum blues / maternal blues/baby blues and risk factors and indonesia n = 77 52 articles were excluded by their title: 32 about postpartum depression 17 literature review two were published in the non-reviewed journal one thesis n=25 nine articles were excluded by reading the abstract: three intervention study one instrument development three descriptive quantitative study two qualitative study n=16 n=15 1 article scored four on the methodological assessment criteria utami fp and nurfita d., journal of ideas in health (2022); 5(4):766-775 768 table 1. the methodological assessment criteria (1 = yes, 0 = no) study and year title (in english) clear study aims adequate sample size representative sample clear inclusion and exclusion criteria validity measurement the rate reported and losses response clear data description appropriate statistical analysis appropriate informed consent total score suparwati, et al (2018) [14] relationship between successful exportation of breastfeeding with the case of postpartum blues in the trucuk public health center coverage area, klaten city 1 1 1 1 1 0 1 1 0 7 fitrah, et al (2017) [15] relationship between husband's support with the case of postpartum blues in the payung sekaki public health center coverage area of pekanbaru city 2017 1 1 1 0 0 0 1 1 0 5 fatmawati (2015) [16] risk factors that influence postpartum blues cases 1 1 1 0 1 0 1 1 0 6 oktaputrining, et al (2017) [17] post-partum blues: the importance of social support and marital satisfaction in primiparous mothers 1 1 1 1 1 0 1 1 0 7 harianis et al. (2022) [18] analysis of affecting factors of postpartum blues 1 1 1 0 1 0 1 1 0 6 kurniawati, et al (2022) [19] determinants of postpartum blues in indonesia 1 1 1 1 1 0 1 1 1 8 qonita, et al (2021) [6] analysis of the risk factors of the postpartum blues in the wijaya kusuma 1 1 1 0 0 0 1 1 0 5 susanti, et al. (2017) [20] analysis of causes factors of baby blues syndrome on postpartum mother 1 1 1 0 1 0 1 1 0 6 purnamaningru m, et al (2018) [21] young age pregnancy and postpartum blues incidences 1 1 1 1 1 0 1 1 0 7 marwiyah, et al (2022) [22] determinant factors of postpartum blues in postnatal mother 1 1 1 0 1 0 1 1 0 6 pramudianti (2018) [23] relationship between age of postnatal women with postpartum blues 1 1 1 1 1 0 1 1 0 7 susilawati, et al (2020) [24] factors influencing the post-partum blues incidence at gadjah mada university academic hospital 1 1 1 1 1 0 1 1 0 7 rosalinna, et al (2022)[25] impact of delivery complications on prellactal feeding, postpartum blues, and postpartum depression 1 1 1 1 1 0 1 1 1 8 sari, et al (2020)[26] analysis risk factors incidence of postpartum blues in public health center of rejang lebong district 1 1 1 0 1 0 1 1 0 6 vidayati, et al (2021)[27] determinant factors associated with incidence of postpartum blues in one of primary general and maternity clinics in east java, indonesia 1 1 1 1 0 0 1 1 0 6 utami fp and nurfita d., journal of ideas in health (2022); 5(4):766-775 769 the variation in the number of participants involved in the study showed that 14 studies had a sample of fewer than 100 respondents, and only one study had a sample of 330 respondents [19]. the number of respondents in each study is described in table 2. the sampling technique used was dominated by non-probability sampling, namely purposive sampling, used mainly through 5 studies [14,18,19,21,23], followed by consecutive sampling by two studies [15,22], and accidental also by two studies [6,16]. lastly, saturated sampling by 1 study is the same as total sampling also by 1 study [17,26]. the probability sampling technique was only used by four studies, namely simple random sampling by two studies [24,27] and cluster random sampling by two studies [20,25]. the number of non-probability sampling techniques and the small sampling size hindered the generalization of the result. the study design approach that was widely used was crosssectional; only one study was known to use a prospective cohort [25]. the majority of the study observed the prevalence of postpartum blues only during the postnatal period (not more than 40 days postpartum); one study [25] with a prospective cohort design observed it three times, namely, during delivery, a few hours after delivery, and 40 days postnatally, while the other two studies namely [16,23] did not report the time of investigation carried out (only mention on the postpartum period). the enforcement of postpartum blues cases using edinburgh postnatal depression scale (epds) tools was carried out by 11 out of 15 studies; the rest did not report the tools used [6,14,15,27]. lastly, two studies did not show the postpartum blues prevalence [16,22], four studies reported cases of postpartum blues occurring in more than 50% of the respondents [20,24,26,27], and nine studies found the prevalence of postpartum blues to be less than 50% namely [6,14-19,21,23,25]. this information can be seen in table 2. table 2. summary of the included studies study and year city, province no. of participants recruitment setting study design tools used time of investigation prevalence [95% ci] suparwati, et al (2018) [14] klaten, central java 48 trucuk ii public health center crosssectional 3-10 days postpartum 44.2% fitrah, et al (2017) [15] pekanbaru, riau 45 sekaki public health center coverage area cross sectional 40 days postpartum 26,7% fatmawati (2015) [16] yogyakarta, special region of yogyakarta 80 all public health centers in yogyakarta city crosssectional epds 46% oktaputrining, et al (2017) [17] madiun, east java 35 3 public health centers & 1 maternal hospital crosssectional epds 3-14 days of postpartum harianis, et al. (2022) [18] inhil, riau 73 tembilahan hulu and gajah mada public health center crosssectional epds 1-7 days of postpartum 24.7% kurniawati, et al (2022) [19] jember, east java 330 balung hospital crosssectional epds 0-6 months postpartum 42.7% qonita, et al (2021) [6] serang, banten 97 dr. dradjat prawiranegara hospital cross sectional 0-6 months postpartum 24.7% susanti, et al. (2017) [20] boyolali, central java 72 maternal and child hospital umia barokah crosssectional epds two days – 3 wk postpartum 91.7% purnamaningrum, et al (2018) [21] gunungkidul, special region of yogyakarta 90 wonosari general hospital crosssectional epds 6-14 days postpartum 44.1% marwiyah, et al (2022) [22] pandeglang, west java 68 jiput public health center crosssectional epds 4-14 days postpartum pramudianti (2018) [23] klaten, central java 48 kalikotes public health center crosssectional epds 50% susilawati, et al (2020) [24] sleman, special region of yogyakarta 31 ugm academic hospital crosssectional epds 0-41 days of postpartum 67.7% rosalinna, et al (2022) [25] klaten, central java 57 basic emergency neonatal obstetric services public health center prospective cohort epds during delivery, 72 hours, 7-14 days, four weeks of postpartum 31.6% sari, et al. (2020) [26] rejang lebong, bengkulu 43 perumnas public health center working area crosssectional epds 0-40 days postpartum 67.4% vidayati, et al (2021) [27] east java 36 primary general and maternity clinic crosssectional 1-14 days of postpartum 58.3% utami fp and nurfita d., journal of ideas in health (2022); 5(4):766-775 770 risk factors of postpartum blues risk factors of postpartum blues are classified into four categories: sociodemographic factors, labor and breastfeeding, parity and pregnancy, and marriage and support. risk factors of postpartum blues are present in table 3. sociodemographic status factors age was the most studied sociodemographic factor, as seen in>50% of articles. many articles make teenage pregnancy (<20 years) the cut point in the age assessment. one article categorizes it based on women's reproductive age, 20-35 years. in this age assessment, it is known that giving birth at the age of <20 years is more at risk for postpartum blues than those with age> 20 years [21,27,28]. it is known that postpartum blues are riskier in pregnancies that occur outside the reproductive age of women [26]. other sociodemographic factors that are also known to be at risk for postpartum blues are low family income and women's low level of education [19,22,26]. unemployed women are also known to be a risk factor for postpartum blues [19,24]. labor and breastfeeding factors the childbirth factors studied were the type of labor, the induction given during labor, and complications that occurred during labor. normal labor with doctor's interventions (induction, vacuum, or forceps) and cesarean delivery are more at risk of causing postpartum blues with multiple regression test results t=2.637 than naturally normal labor without doctor’s interventions [20]. caesarean section labor has a risk of causing postpartum blues 5.1 times greater than spontaneous labor [21]. the same magnitude (5.1 times higher) also occurs in the type of normal labor with induction compared to natural labor without induction [21]. postpartum blues are also known to be at higher risk for complicated labor [25]. in addition to the birthing process, the breastfeeding process that is not smooth at the beginning of birth is also a risk factor for postpartum blues [14]. it is known that health education efforts given after giving birth can reduce the occurrence of postpartum blues, with the possibility of postpartum blues occurring 12.750 times in mothers who do not receive health education [18]. parity and pregnancy factors five studies examined the correlation of parity with the incidence of postpartum blues. four of these studies distinguished parity with the categories of primiparous and multiparous; one study divided it into three categories: primiparous, multiparous, and grande multiparous. primiparous parity is a risk factor for postpartum blues, with a 6.686 times greater chance than multiparous [6]. in addition to parity, pregnancy status (planned or unplanned), women's readiness to become mothers (prepared vs. unprepared), and delivery readiness also correlated with the occurrence of postpartum blues [19,20,22]. marriage and support factors support plays an important role in the occurrence of postpartum blues. the support studied consisted of husband and social support and family support. seven studies assessed husband support that correlated with the occurrence of postpartum blues. husband's support is a risk factor for postpartum blues, as shown by a study which states that husbands who don't really support their wives have a 2.44 times greater risk of causing postpartum blues than husbands who fully support their wives [16]. a greater influence is obtained by a study which states that a lack of husband's support can cause postpartum blues 29.777 times greater than a good husband's support [6]. similar to the husband's support, social support also contributes as a risk factor in the occurrence of postpartum blues [22]. in addition to the support provided by the husband and social, family involvement in taking care of the baby is also a risk factor for the occurrence of postpartum blues, with 8.114 times the possibility to occur in mothers with families who are not involved in taking care of the baby [18]. in addition to the assessment of support, a study on marital satisfaction, which is composed of several aspects: aspects of intimacy, harmony, sexual life, conflict resolution, and religiosity perceived by primiparous mothers, shows that satisfaction is correlated with postpartum blues [17]. discussion this review involves 15 articles that study the postpartum blues in indonesia, 12 of which are located on the island of java as a study setting. java island is the center of economic activity, education, and health, with indonesia's largest and most developed population [29]. in this review, the risk factors of postpartum blues are classified into several sub-topics: sociodemography, labor and breastfeeding, parity and pregnancy, marriage, and support. sociodemographic status factors one of the most studied sociodemographic factors is age. in this review, it is known that teenage pregnancy is also a risk factor for postpartum blues. teenage pregnancy is a global phenomenon with well-known causes, seriously affecting physical and mental health and socioeconomic consequences for individuals, families, and communities [30]. it is imminent that adolescent girls are unable to make a healthy and safe transition into adulthood. these developmental changes place especially for adolescent mothers at increased risk of developing depression [31-32]. such findings are strengthened by the sentimental situation of parents is known to correlate with teenage pregnancy [33]. thus, making them more vulnerable group to suffering postnatal stress than adult mothers [32]. this raises the need for intervention in pregnant women at a young age by involving health stakeholders to provide postpartum counseling and infant care [21]. being part of the sociodemographic factor, low socioeconomic status (ses) factors are also a risk factor for the incidence of postpartum blues. low ses has been reported to be associated with increased depressive symptoms in late pregnancy and 2–3 months postpartum. along with other low sociodemographic factors, namely: low monthly income; low level of education; unmarried; and unemployed, were 11 times more likely than women without the ses risk factor to have an elevated depression score at three months postpartum [34]. the maternal aspect of low ses, which consists of educational level, unemployment, and income, is correlated with postpartum anxiety and depression [35]. furthermore, low ses increased the adverse effects of prior negative life events. utami fp and nurfita d., journal of ideas in health (2022); 5(4):766-775 771 table 3. risk factors of postpartum blues variables study associated factors analysis test results sociodemographic factors age fatmawati (2015) [16] ≤ 20 years vs > 20 years chi-square test p=0.000 or 3.41, 95% ci [2.129 – 5.469] kurniawati, et al (2022) [19] chi-square test p=0.002 purnamaningrum, et al (2018) [21] ≤ 20 years vs > 20 years logistic regression test p=0.042 pr 4.0 95% ci [1.0 – 15.2] marwiyah, et al (2022) [22] multiple regression test t= -1.940 pramudianti (2018) [23] chi-square test p=0.001 or 5.75, 95% ci [1/53 – 21.64] susilawati, et al (2020) [24] chi-square test p=0.03 sari, et al. (2020) [26] < 20 years, 20-35 years, > 35 years chi-square test p=0.038 vidayati, et al (2021) [27] ≤ 20 years vs > 20 years chi-square test p=0.026 salary kurniawati, et al (2022) [19] <idr 2.000.000 vs >idr 2.000.000 chi-square test p=0.032 marwiyah, et al (2022) [22] multiple regression test t= -0.987 education kurniawati, et al (2022) [19] chi-square test p=0.001 sari, et al. (2020) [26] chi-square test p=0.000 employment kurniawati, et al (2022) [19] chi-square test p=0.042 susilawati, et al (2020) [24] chi-square test p=0.03 labor and breastfeeding breastfeeding process suparwati, et al (2018) [14] smooth vs. not smooth chi-square test p=0.001 health education after delivery harianis, et al. (2022) [18] get an education vs. not getting an education chi-square test p=0.001 or 12.750, 95% ci [3.225 – 50.40] type of labor kurniawati, et al (2022) [19] sectio secarea vs normal chi-square test p=0.0001 susanti, et al. (2017) [20] normal naturally vs. normal with doctor action (induction, vacuum, forceps) vs. sectio cesarea multiple regression test p=0.010 t = 2.637 purnamaningrum, et al (2018) [21] sectio secarea vs. spontaneous chi-square test p=0.003 or 5.1, 95% ci [ 1.7 – 15.3] marwiyah, et al (2022) [22] sectio secarea vs normal multiple regression test t= -0.427 labor induction purnamaningrum, et al (2018) [21] chi-square test p=0.004 or 5.1, 95% ci [1.6 – 15.7] labor complication rosalinna, et al (2022) [25] chi-square test p=0.01 parity and pregnancy parity fatmawati (2015) [16] primiparous vs multiparous chi-square test p=0.007 or 1.94 95% ci [1.162 – 3.242] qonita, et al (2021) [6] primiparous vs multiparous chi-square test or 3.844, 95% ci [1.644 – 27.184] susilawati, et al (2020) [24] primiparous vs multiparous chi-square test p=0.02 sari, et al (2020) [26] primiparous vs multiparous chi-square test p=0.021 vidayati, et al (2021) [27] primiparous vs multiparous vs grande multiparous chi-square test p=0.037 pregnancy status kurniawati, et al (2022) planned vs. unplanned chi-square test utami fp and nurfita d., journal of ideas in health (2022); 5(4):766-775 772 [19] p=0.009 mother readiness susanti, et al. (2017) [20] ready vs. unready multiple regression test p=0.036 t = 2.142 labor readiness marwiyah, et al (2022) [22] multiple regression test t = -0.283 marriage and supports marriage satisfaction oktaputrining, et al (2017) [17] multiple regression test t=-2,755 partial correlation= -0,438 p=0,010 (p<0,05) husband support fitrah, et al. (2017) [15] good vs. not good chi-square test p=0.000 fatmawati (2015) [16] medium vs. high chi-square test p=0.000 or 2.44, 95% ci [ 1.564 – 3.818] kurniawati, et al (2022) [19] good vs bad chi-square test p=0.003 qonita, et al. (2021) [6] less vs. good chi-square test or 29.777, 95% ci [2.679 – 330.941] susanti, et al. (2017) [20] less vs. good multiple regression test t = 3.491 p=0.001 sari, et al. (2020) [26] support vs. not support chi-square test p=0.013 vidayati, et al (2021) [27] support vs not support chi-square test p=0.049 social support marwiyah, et al (2022) [22] multiple regression test t= 1.072 p<0.05 family involvement in taking care of the baby harianis, et al. (2022) [18] engaged vs. uninvolved chi-square test p=0.003 or 8.114, 95% ci [2.020 – 32.59] in terms of employment, it is known that it may be a protective factor for postpartum depression symptomatology in mothers who work part-time and full-time [36]. since 12 of the 15 articles in this review conducted their research on the island of java, which is the economic center of indonesia, so the estimated economic burden for mothers who are classified as having low ses in this study can be different from mothers who live outside java island. this condition is a limitation of this study. compared to women with ses advantages, mothers with low ses experienced poorer mental and overall health. however, statistically, mothers with advantages of ses and low ses found no difference in the need for physical and mental health care, help with household chores, and breastfeeding support. the difference that is not surprising is that there is a greater need for mothers with low ses for financial assistance. acceptance of public health offers at-home visits is twice as much accepted by mothers with low ses [37]. labor and breastfeeding factors several studies have reported that cesarean section labor is more at risk for postpartum blues than vaginal labor [21,38,39]. this is in accordance with the findings in this review that cesarean delivery and induced vaginal delivery are more at risk for postpartum blues than natural vaginal births. this risk is related to the mother's birth satisfaction. where birth satisfaction is significantly lower seen in the group of mothers who gave birth with surgical delivery compared to mothers with vaginal delivery. the presence of medical interventions, cesarean sections, and various other surgical interventions during childbirth is a predictor of low birth satisfaction [38]. induction during childbirth is also a risk factor for postpartum blues because induction has been shown to increase the pain felt by the mother. experiencing pain causes anxiety and fear in the mother about the success of the intervention. maternal anxiety and possible complications in both the baby and the mother contribute to the postpartum blues [40]. some mothers show symptoms of postpartum blues because they are triggered by a cesarean delivery for medical reasons. this is because of the consequences of unthinkable financial burdens, negative views from others because they can't give birth normally, feelings of not being a full mother, and surgical incisions that hinder daily activities [41]. in this review, it is known that the breastfeeding process that does not run smoothly in early birth is a risk for postpartum blues. the same thing was conveyed by the findings that exclusive breastfeeding at six months postpartum had a lower risk of depression than those who adopted other feeding patterns, regardless of feeding pattern or duration, mothers who maintained eye contact and talked to their infants while breastfeeding had a lower risk of postpartum depression than mothers who engaged in other activities [42]. the association between breastfeeding and depression may also be the other way. around 37% of babies with late initiation breastfeeding (libf) were born to depress pregnant women, while those born to non-depressed pregnant women were only 8.4% [43]. therefore, postpartum partner social support and strong breastfeeding intention were positively related to breastfeeding self-efficacy (bse) [44]. this bse is very important, considering that breastfeeding promotes hormonal processes that can protect the mother from postpartum depression by weakening the cortisol response to stress. it also reduces mother anxiety by helping to regulate sleep and wake patterns for utami fp and nurfita d., journal of ideas in health (2022); 5(4):766-775 773 mother and baby and also increases the emotional bond between mother and baby [45]. parity and pregnancy factors in this review, it was found that primiparous parity is a risk factor for postpartum blues. mothers with only one child were rated as less experienced in infant care and role transition changes compared to mothers with two or three children [46]. the low adaptability in primiparous women causes them to be overwhelmed, while the situation requires her to adapt quickly because there is a baby to take care of. not infrequently, this situation causes the mother to experience physical exhaustion, which causes her to be reluctant to take care of her baby [47]. primiparous women differ from multiparous women in breastfeeding, insecurity, and anxiety. primiparous were twice as likely as multiparous to experience anxiety and depression during the first week and six weeks after delivery [48]. in addition, the possibility of complications such as hypertension, intrauterine growth retardation, premature labor, fetal distress, and oligohydramnios is also higher primiparous [49]. therefore, grand multiparous parity is a protective factor against the risk of postpartum depression [50]. pregnancy status is also a risk for postpartum blues. unplanned pregnancies have long-term effects on women's mental health in the perinatal period [51]. the prevalence of postpartum blues was found to be higher in women with unplanned pregnancies, where factors causing unwanted pregnancies such as young age; non-white race; unmarried, and anxiety during pregnancy were also associated with postpartum blues [52]. when viewed from their ses, postpartum mothers with unplanned pregnancies who experience postpartum depression are more common in low and lower-middle-income countries and minority groups who experience disadvantaged ses compared to those who enjoy better ses conditions [53]. postpartum stress experienced by unplanned pregnancies increased significantly at nine months postpartum. thus, women with unplanned pregnancies, although currently in stable partnerships, receive many benefits from postnatal care by health professionals, especially those with limited support [54]. marriage and supports factors the support received by postpartum mothers also contributes to the occurrence of postpartum blues. the support can come from social, family, and husband. the study from [55] showed that mothers who gave birth at a young age and received social support did not experience postpartum blues. social support has an effect on minimizing the occurrence of postpartum blues and reducing it. social support given to mothers can be in the form of attention, communication, and warm emotional relationships. the encouragement that has been given by friends who have given birth also reduces the postpartum pain felt by the mother. however, social and family support that is too high can put pressure on postpartum mothers. excessive attention from the family, especially the baby's grandmother, makes postpartum mothers uncomfortable taking care of their babies, so they feel less involved in caring for their own babies [17]. the excessive family expansion also makes postpartum mothers think about building their own household with their husbands and children in the house they live alone (separated from their parents) [41]. among the support given by others, the support that is most expected by mothers, especially primiparas, is the support that comes from their husbands. husband's support is correlated with marriage satisfaction felt by postpartum mothers. marriage is shown in the behavior of the husband, who often helps his wife in caring for the baby in the breastfeeding process, and helps create a positive atmosphere when the wife feels the tiring days at the beginning of the birth. this support gives its own strength, especially at the birth of the first child [17]. the mother feels that her duties and responsibilities in baby care are absolute, so she does not want to complain to others so that the husband's special treatment as a breastfeeding father and caring for the baby can prevent the mother from postpartum blues [41,56]. conclusion in conclusion, published articles on postpartum blues in indonesia found several risk factors for postpartum blues, including ses factors consisting of age, salary, education, and employment. labor and breastfeeding factors consist of: the breastfeeding process, health education after labor, type of labor, labor induction, and labor complications. parity and pregnancy factors consist of parity, pregnancy status, mother readiness, and labor readiness. marriage and support factors consist of: marriage satisfaction, husband support, and social support. psychological assistance from health workers is needed for mothers who have just given birth, especially in primiparous births. abbreviation ad: after christ; hiv: human immunodeficiency virus; bse: breastfeeding self-efficacy; epds: edinburgh postnatal depression scale; libf: late initiation breastfeeding; or: odds ratio; phc: public health center; ses: socio-economic status declaration acknowledgment none. funding the author would like to thank the universitas ahmad dahlan for the research funding due to a number of contracts pd-199/sp3/lppmuad/vii/2022. availability of data and materials data will be available by emailing fitriana.utami@ikm.uad.ac.id. authors’ contributions fitriana putri utami (fpu) contributed in the study concept and design, formal analysis, writing-original draft preparation, writing-review, and editing. desi nurfita (dn) contributed in the study concept and design, writing-review and editing. all authors approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the protocol was approved by the ethics committee of universitas ahmad dahlan with a reference number of 012207100 on september 06, 2022. consent for publication not applicable competing interest the authors declare that they have no competing interest. utami fp and nurfita d., journal of ideas in health (2022); 5(4):766-775 774 open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1public health faculty, universitas ahmad dahlan, indonesia. article info received: 16 october 2022 accepted: 23 november 2022 published: 15 december 2022 references 1. sari ra. literature review: depresi postpartum. j kesehat. 2020 may 27;11(1):167. https://doi.org/10.26630/jk.v11i1.1586 2. restarina d. gambaran tingkat depresi ibu postpartum di wilayah kerja puskesmas ciputat timur kota tangerang selatan tahun 2017. universitas islam negeri syarif hidayatullah; 2017. https://repository.uinjkt.ac.id/dspace/bitstream/123456789/37290/ 1/dwi restarina-fkik.pdf 3. tarisa n, octarianingsih f, ladyani f, pramesti w. distribusi frekuensi kejadian postpartum blues pada ibu pascamelahirkan. j ilm kesehat sandi husada. 2020;12(2):1057–62. https://doi.org/10.35816/jiskh.v12i2.430 4. hapgood cc, elkind gs, wright jj. maternity blues: phenomena and relationship to later post partum depression. aust n z j psychiatry. 1988; 22:299–306. https://doi.org/10.3109/00048678809161211 5. varney h, kriebs jm, gegor cl. varney’s midwifery. jones and bartlett publishers. massachusetts; 2004. 1433 p. https://eprints.triatmamulya.ac.id/1336/1/%28midwifery%20and %20maternity%20care%29%20helen%20varney%2c%20jan% 20m.%20kriebs%2c%20carolyn%20l.%20gegor%20%20varney%e2%80%99s%20midwiferyjones%20_%20bartlett%20learning%20%282003%29.pdf 6. muhida v, qonita, umalilhayati. analisis faktor risiko terjadinya postpartum blues di ruang wijaya kusuma. j appl heal res dev. 2021;3(1):1–16. https://jurnal.poltekkesaisyiyahbanten.ac.id/index.php/path/article/view/95/56 7. idaiani s, basuki b. postpartum depression in indonesia women: a national study. heal sci j indones. 2012;3(1):3–8. https://media.neliti.com/media/publications-test/56266postpartum-depression-in-indonesia-women-8da1fa92.pdf 8. tolongan c, korompis ge., hutauruk m. dukungan suami dengan kejadian depresi pasca melahirkan. j keperawatan. 2019;7(2). https://doi.org/10.35790/jkp.v7i2.24453 9. silva cs, lima mc, sequeira-de-andrade las, oliveira js, monteiro js, lima nms, et al. association between postpartum depression and the practice of exclusive breastfeeding in the first three months of life. j pediatr (rio j). 2017;93(4):356–64. https://doi.org/10.1016/j.jped.2016.08.005 10. greenhalgh t. how to read a paper, the basics of evidence based medicine. second edi. bmj books. london: bmj publishing group; 2001. 222 p. https://www.ebcp.com.br/simple/upfiles/livros/001htrp.pdf 11. mirza i, jenkins r. disorders in pakistan: systematic review. br med j. 2004;328(april):1–5. https://doi.org/10.1136/bmj.328.7443.794 12. fisher j, de mello mc, patel v, rahman a, tran t, holton s, et al. prevalence and determinants of common perinatal mental disorders in women in low-and lower-middle-income countries: a systematic review. bull world health organ. 2012;90(2):139–49. https://doi.org/10.2471/blt.11.091850 13. ayoub k, shaheen a, hajat s. postpartum depression in the arab region: a systematic literature review. clin pract epidemiol ment heal. 2020;16(1):142–55. https://doi.org/10.2174/1745017902016010142 14. suparwati i, murwati m, suwanti e. hubungan antara kelancaran pengeluaran asi dengan kejadian postpartum blues di wilayah puskesmas trucuk ii 8 klaten. j kebidanan dan kesehat tradis. 2018;3(1):8–13. https://doi.org/10.37341/jkkt.v3i1.58 15. fitrah ak, helina s. hubungan dukungan suami terhadap kejadian postpartum blues di wilayah kerja puskesmas payung sekaki kota pekanbaru tahun 2017. j ibu dan anak. 2017;33(december):17–25. https://media.neliti.com/media/publications/432788-none68cb234d.pdf 16. fatmawati da. faktor risiko yang berpengaruh terhadap kejadian postpartum blues. j eduhealth. 2015;5(2). https://doi.org/10.15294/ujph.v5i4.11372 17. oktaputrining d, c. s, suroso s. post partum blues: pentingnya dukungan sosial dan kepuasan pernikahan pada ibu primipara. psikodimensia. 2018;16(2):151. https://doi.org/10.24167/psiko.v16i2.1217 18. harianis s, sari ni. analisis faktor yang mempengaruhi kejadian post partum blues. jomis (journal midwifery sci. 2022;6(1):85–94. https://doi.org/10.36341/jomis.v6i1.2141 19. kurniawati d, septiyono ea. determinants of postpartum blues in indonesia. pediomaternal nurs j. 2022;8(1):1–8. https://doi.org/10.20473/pmnj.v8i1.27649 20. susanti lw, sulistiyanti a. analisis faktor-faktor penyebab terjadinya baby blues syndrom pada ibu nifas. j ilm rekam medis dan inform kesehat. 2017;7(2):12–20. https://www.apikescm.ac.id/ejurnalinfokes/index.php/infokes/artic le/view/178/158 21. yuni kusmiyati, herlina tri nugraheni, waryana yep. young age pregnancy and postpartum blues incidences. int j sci res educ. 2018;6(2):7812–9. https://doi.org/10.18535/ijsre/v6i2.02 22. marwiyah n, suwardiman d, kurnia mutia h, ayu alkarimah n, rahayu r, uzzakiyyah i. faktor determinan yang mempengaruhi terjadinya postpartum blues pada ibu nifas. faletehan heal j. 2022;9(1):89–99. https://doi.org/10.33746/fhj.v9i01.298 23. pramudianti dn. hubungan antara usia ibu nifas dengan kejadian postpartum. j midwifery reprod. 2018;2(1):13–8. https://doi.org/10.35747/jmr.v2i1.320 24. susilawati b, dewayani er, oktaviani w, subekti ar. faktorfaktor yang mempengaruhi kejadian post partum blues di rs akademik universitas gadjah mada. j nurs care biomol. 2020;5(1):77–86. https://doi.org/10.32700/jnc.v5i1 25. rosalinna, siswiyanti. impact of delivery complications on prellactal feeding , postpartum blues and postpartum depression. j matern child heal sci. 2022;2(1):139–46. https://doi.org/10.36086/maternalandchild.v2i1.1286 26. sari rp, densy a, keraman b. analisis faktor risiko kejadian postpartum blues di puskesmas perumnas kabupaten rejang lebong. j midwifery. 2020;8(1):29–36. https://doi.org/10.37676/jm.v8i1.1031 27. vidayati la, zainiyah h. determinant factors that has associated with incidence of postpartum blues in the one of primary general and maternity clinic in east java, indonesia. j int dent med res. 2021;14(2):845–8. http://www.jidmr.com/journal/wp utami fp and nurfita d., journal of ideas in health (2022); 5(4):766-775 775 content/uploads/2021/07/66m21_1468_lelly_aprilia_vidayati_indonesia-1.pdf 28. fatmawati a, wahyuni rj, imansari b. pengaruh psikoedukasi terhadap penurunan tingkat postpartum blues: literature review. j ilmu keperawatan dan kebidanan. 2022;13(1):35. https://doi.org/10.26751/jikk.v13i1.1180 29. pitoyo aj, triwahyudi h. dinamika perkembangan etnis di indonesia dalam konteks persatuan negara. populasi. 2018;25(1):64. https://doi.org/10.22146/jp.32416 30. goldstein ma. adolescent pregnancy. massgeneral hosp child adolesc med handb. 2011;111–3. https://doi.org/10.1007/978-14419-6845-6_15 31. unfpa. fact sheet : teenage pregnancy. united nations popul funds. 2016;1–4. https://tanzania.unfpa.org/sites/default/files/pubpdf/factsheet_teenage%20pregnancy_unfpa_14oct.pdf 32. ladores s, corcoran j. investigating postpartum depression in the adolescent mother using 3 potential qualitative approaches. clin med insights pediatr. 2019;13:117955651988404. https://doi.org/10.1177/1179556519884042 33. castañeda j, santacruz h. factores de riesgo asociados al embarazo en adolescentes. enfermería glob. 2021;20(2):109–28. https://doi.org/10.6018/eglobal.438711 34. goyal d. prenatal and postpartum depressive symptoms in first time. women heal issues. 2010;20(2):96–104. https://doi.org/10.1016/j.whi.2009.11.003 35. verbeek t, bockting clh, beijers c, meijer jl, van pampus mg, burger h. low socioeconomic status increases effects of negative life events on antenatal anxiety and depression. women and birth. 2019;32(1):e138–43. https://doi.org/10.1016/j.wombi.2018.05.005 36. lewis ba, billing l, schuver k, gjerdingen d, avery m, marcus bh. the relationship between employment status and depression symptomatology among women at risk for postpartum depression. women’s heal. 2017;13(1):3–9. https://doi.org/10.1177/1745505717708475 37. kurtz landy c, sword w, ciliska d. urban women’s socioeconomic status, health service needs and utilization in the four weeks after postpartum hospital discharge: findings of a canadian cross-sectional survey. bmc health serv res. 2008;8:1–9. https://doi.org/10.1186/1472-6963-8-203 38. urbanová e, škodová z, bašková m. the association between birth satisfaction and the risk of postpartum depression. int j environ res public health. 2021;18(19). https://doi.org/10.3390/ijerph181910458 39. pamogsa daniyar, riski d, rofi’ah s. systematic review: factors affecting postpartum blues. mikia mimb ilm kesehat ibu dan anak (maternal neonatal heal journal). 2020;0825:29–39. https://doi.org/10.36696/mikia.v5i2.78 40. handerson c, jones. buku ajar konsep kebidanan. jakarta: egc: penerbit buku kedokteran; 2006. https://www.poltekkesbdg.info/perpustakaan/opac/index.php?p=s how_detail&id=30446 41. andarini a, ulya z. coping strategy in mother with post partum blues experience in kediri : a case report. j psychiatry psychol behav res. 2022;3(1):16–9. https://doi.org/10.21776/ub.jppbr.2022.003.01.5 42. shimao m, matsumura k, tsuchida a, kasamatsu h, hamazaki k, inadera h, et al. influence of infants’ feeding patterns and duration on mothers’ postpartum depression: a nationwide birth cohort ―the japan environment and children’s study (jecs). j affect disord. 2021;285(september 2020):152–9. https://doi.org/10.1016/j.jad.2021.02.011 43. beyene gm, azale t, gelaye ka, ayele ta. effect of antenatal depression on the initiation of breastfeeding in south gondar zone, northwest ethiopia: a population-based prospective cohort study. heliyon. 2022;8(1):e08759. https://doi.org/10.1016/j.heliyon.2022.e08759 44. ahmad zadeh beheshti m, alimoradi z, bahrami n, allen ka, lissack k. predictors of breastfeeding self-efficacy during the covid-19 pandemic. j neonatal nurs. 2021;(july). https://doi.org/10.21203/rs.3.rs-246918/v1 45. figueiredo b, dias cc, brandão s, canário c, nunes-costa r. breastfeeding and postpartum depression: state of the art review. j pediatr (rio j). 2013;89(4):332–8. https://doi.org/10.1016/j.jped.2012.12.002 46. ambarwati er, listiyani r. parity early stage of marriage with incidence of postpartum depression. int j public heal sci. 2014;3(3):158. https://doi.org/10.11591/ijphs.v3i3.4687 47. anggasari y. the event of maternity blues been reviewed from paritas ibu nifas in bpm nanik cholid sidoarjo. in: proceeding of surabaya international health conference. 2017. p. 490–6. http://repository.unusa.ac.id/6600/3/the%20event%20of%20mat ernity%20blues%20been%20reviewed%20from%20parity%20 of%20postpartum%20mothers%20in%20bpm%20nanik%20ch olid%20sidoarjo.pdf 48. lindblad v, melgaard d, jensen kl, eidhammer a, westmark s, kragholm kh, et al. primiparous women differ from multiparous women after early discharge regarding breastfeeding, anxiety, and insecurity: a prospective cohort study. eur j midwifery. 2022;6(march):1–11. https://doi.org/10.18332/ejm/146897 49. kaur j, kaur k. obstetric complications: primiparity vs. multiparity. eur j exp biol. 2012;2(5):1462–8. https://www.primescholars.com/articles/obstetric-complicationsprimiparity-vs-multiparity-91604.html 50. smithson s, mirocha j, kilpatrick s, horgan r, graebe r, massaro r, et al. 1225: grand multiparity is protective against risk for postpartum depression. am j obstet gynecol. 2020;222(1):s753. https://doi.org/10.1016/j.ajog.2019.11.1236 51. muskens l, boekhorst mgbm, kop wj, van den heuvel mi, pop vjm, beerthuizen a. the association of unplanned pregnancy with perinatal depression: a longitudinal cohort study. arch womens ment health. 2022;25(3):611–20. https://doi.org/10.1007/s00737-022-01225-9 52. abbasi s, chuang ch, dagher r, zhu j, kjerulff k. unintended pregnancy and postpartum depression among first-time mothers. j women’s heal. 2013;22(5):412–6. https://doi.org/10.1089/jwh.2012.3926 53. salsabilla da, prasetya h, murti b. the effect of unplanned pregnancy on postpartum depression: a meta-analysis. j matern child heal. 2020;5(5):500–13. https://doi.org/10.26911/thejmch.2020.05.05.05. 54. barton k, redshaw m, quigley ma, carson c. unplanned pregnancy and subsequent psychological distress in partnered women: a cross-sectional study of the role of relationship quality and wider social support. bmc pregnancy childbirth. 2017;17(1):1–9. https://doi.org/10.1186/s12884-017-1223-x 55. rahayu cd, mulyani s. pengaruh dukungan sosial orang terdekat dalam meminimalisir peristiwa dan dampak postpartum pada ibu usia muda. j ilm kesehat. 2020;19(mei):33–42. https://ojs.unsiq.ac.id/index.php/jik/article/view/1314 56. dinarum, rosyidah h. literatur review : pengaruh dukungan suami terhadap kejadian postpartum blues. call pap semin nas kebidanan. 2020;2(2):90–5. http://jurnal.unw.ac.id/index.php/semnasbidan/article/view/825/59 0. https://doi.org/10.47108/jidhealth.vol5.iss3.240 gamage m, et al., journal of ideas in health 2022;5(3):730-738 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access impact of covid-19 lockdown on meat or equivalent consumption behavior among sri lankan adults: a cross-sectional study manoja gamage1, piumika sooriyaarachchi2,3, tormalli francis4, ranil jayawardena5,6 abstract background: the covid-19 lockdown severely affected dietary behaviors, particularly meat or equivalent consumption. this study aimed to understand the impact of covid-19 confinement on meat or equivalent consumption pattern among sri lankans. methods: a cross-sectional study was conducted from 27th may to 2nd june 2021 as a national-level online survey in sri lanka using a self-administered questionnaire developed as google forms. the questionnaire consisted of questions related to socio-demographics and dietary behaviors. descriptive, univariate, and multinomial logistic regression was performed. the statistical significance is considered at less than 0.05. results: a total of 3600 respondents were included, with the majority being women (60.1%). a higher proportion of the participants increased their consumption of eggs (53.7%), dhal (47.0%), and dry fish and sprats (36.3%). a big trend was observed in cutting down the fish (41.1%) and other seafood (52.0%) consumption. nearly half of the respondents did not change their consumption of meat other than chicken (54.5%), pulses (52.6%), soya meat (52.1%), dry fish and sprats (48.9%), canned fish (47.6%), sausages and meatballs (45.1%), and chicken (43.7%). the males (odds ratio (or) 0.852; 95% ci: 0.738 to 0.984, p = 0.029) and tamil (or = 1.605, 95% ci: 1.150 to 2.239, p = 0.005) showed a significant likelihood to increase egg consumption. respondents with a lower income <25,000 lkr (or 2.220; 95% ci 1.672-2.947, p = 0.000) were more than twice likely to report increased dhal consumption. the same income group (< 25,000 lkr) (or = 2.752; 95% ci: 2.024-3.741, p = 0.000) reported more than twice reduction in fish consumption. respondents in municipal area (or = 1.523; 95% ci: 1.186 to 3.292, p = 0.009) showed a significantly higher likelihood to reduction in other seafood consumption. conclusion: an overall change in meat or equivalent consumption behavior among sri lankan adults was evidenced. furthermore, nutrition recommendations should be revised to avoid future long-term consequences. fish and other seafood intake declined, while consumption of eggs, dhal, dry fish, and sprats increased. keywords: meat consumption, covid-19, fish consumption, seafood consumption, dietary behaviour, sri lanka background meat and equivalents are considered essential food groups for being a major source of protein, vitamins, and minerals in the human diet. they play important roles in many metabolic and physiological processes [1], particularly due to bioavailable iron, zinc, vitamins a, d, b1, b12, and niacin [2-5]. an adequate intake of zinc, iron, vitamins a, b12, b6, c, and e is essential to strengthen the immune system and maintain immune function [6]. due to its ability to build and maintain a robust human immune system against viruses, the title role of meat and its substitutes in the human diet is the subject of intense research today. one recommended nutritional strategy to fight coronavirus disease in 2019 (covid-19) is to include meat or equivalent in two to three portions per day in the diet [5]. however, the succession waves of the global pandemic (covid-19) have seriously threatened millions of people worldwide [7,8]. in response to the covid-19 pandemic emergency, many governments implemented social confinement strategies, such as self-isolation, lockdown, or social distancing. these restrictions have severely affected dietary behaviors, particularly meat and fish consumption in individual and global contexts [9]. according to a recent population-based italian survey, 37.3% of respondents have changed their eating habits and lifestyle as a direct impact of the covid-19 lockout, including reduced processed meat intake ___________________________________________________ ranil@physiol.cmb.ac.lk 5department of physiology, faculty of medicine, university of colombo, colombo, sri lanka.6institute of health and biomedical innovation, queensland university of technology, brisbane, queensland, australia. a full list of author information is available at the end of the article 10.47108/jidhealth.vol5.iss3.240 http://www.jidhealth.com/ gamage m, et al., journal of ideas in health (2022); 5(3):730-738 731 and higher consumption of eggs [10]. they further claimed that more than half of the population experienced changes in appetite and satiety levels during the covid-19 lockdown. interestingly, it was documented that there was a significant increase in consumption of pulses, dhal, and legumes among adults in the jain community in mumbai city as a result of the covid-19 lockdown [11]. furthermore, rahman et al. [12] found that the meat consumption pattern was altered during the lockdown period among non-vegetarian indians. undoubtedly, the covid-19 epidemic has modified the high-quality proteinrich meat and seafood consumption behavior worldwide [9]. the third pandemic wave of the covid-19 infection in sri lanka prompted the government to implement extremely rigid lockdown restrictions, which included limitations on crossing district borders. however, the immediate impact of covid-19 restrictions on dietary behavior, especially in terms of meat or equivalent, has not yet been well understood. therefore, this online survey aimed to determine how the covid-19 pandemic affected meat consumption or its equivalent during the covid19 containment in sri lanka. methods study population and sample this study was conducted in sri lanka as a part of a nationallevel cross-sectional online survey that aimed to investigate the immediate impact of the covid-19 pandemic on lifestylerelated behaviors. a detailed description of the study population, methods, and the impact on other lifestyle patterns have been published elsewhere [13-15]. data were collected through a self-administered questionnaire accessible through the google forms web survey platform. the survey was active from 27th may to 2nd june 2021, when island-wide confinement for the third covid-19 wave was imposed. participants did not receive monetary or any form of compensation for their participation. the participants were invited to take part in the survey by sharing the google form’s link mainly through the social networks of the research team. social media platforms: facebook, instagram, twitter, and whatsapp were used for this purpose. the study's purpose and confidentiality declaration were briefly described before taking part in the survey. then informed consent was obtained from all participants for voluntary participation in the study and inclusion in the research. then consenting participants were subjected to interview through a self-administered questionnaire. inclusion and exclusion criteria the respondents should be; a) age ≥ 16 years, b) living in sri lanka c) of sri lankan nationality to be included in the study. respondents excluded from the study who have; a) illnesses or other conditions that change the regular dietary pattern, including pregnancy, b) incomplete questionnaire. sample size the online raosoft sample size calculator was used to calculate the sample size. the assumptions made in the sample size calculation were; a) sri lankan population size is 14.4 million, b) 50% response rate c) 20% incomplete forms since this was an online survey. the calculated sample size was 385 at a 95% confidence level, and 5% margin of error, and the final minimal required sample size was 482 with assumed dropouts. however, a total of 3714 responses were received. after removing duplicates and incomplete data, 3600 respondents who satisfied the inclusion criteria were included in the analysis. study instrument the data collection was carried out through a structured digital self-administered questionnaire. it was available in tamil, sinhala, and english and was predicted to take 5 to 10 minutes. questions with multiple choices and direct answers were included in the questionnaire. the validity and reliability of the questionnaire were assessed by pilot testing. the questionnaire was comprised of two sections: personal and diet-related. a total of eleven key questions were included in the first section to collect socio-demographic data, including the year of birth, district of residence, nature of the residential area, gender, ethnicity, education level, current employment status, and monthly family income. the presiding district was reported from a drop-down list of all the 25 districts in sri lanka. the selections for the nature of residential area were municipal council, city council, and rural. the resided districts of the participant were grouped as colombo, gampaha, kandy, and other districts based on the descending order of the frequency. the gender was recorded under three categories: male, female, and prefer not to say. the categories included for ethnicity were sinhalese, sri lankan tamil, indian tamil, sri lankan moors, and others. however, the ethnic groups were further summarized into “sinhala, tamil, moors, and others”. the categories to depict the education level were no schooling, primary education, secondary education, tertiary education, degree or above, and preferred not to say. eight categories were used to categorize each respondent's employment status: employed, self-employed, unemployed, engaged in home duties, retired from employment, full-time student/pupil, other, and prefer not to say. the income level was recorded under five categories, ranging from less than 10,000 lkr (50 usd as of 27th may 2021) to higher than 200,000 lkr (1000 usd as 27th may 2021). however, the monthly family income of participants was further summarized to be <25,000 (125 usd as at 27th may 2021), 25,000-49,999 (125-249.99 usd as at 27th may 2021), 50,000-99,999 (250 – 499.99 usd as at 27th may 2021),100,000-199,999, (500-999.99 usd as at 27th may 2021) >200,000 (1000 usd as at 27th may 2021) by combining income groups: <10,000 lkr (50 usd as at 27th may 2021) and 10,000-24,999 lkr (50-124.99 usd as at 27th may 2021). the second section of the questionnaire was based on dietary behavior-related questions to assess the key objective of the study: the impact on diet habits due to covid-19. the participants were asked to report whether they increased, decreased, or not changed the consumption of eleven meat and equivalent food types: fish, other seafood (prawns, cuttlefish), chicken, other meat, eggs, dry fish and sprats, canned fish, sausages and meatballs, soya meat, dhal and other pulses (chickpea, green gram). the successfully filled questionnaire was sent to the google platform, where the database was downloaded. dependent and independent variables dependent variables were recorded under three strata; increased, decreased, and not change the consumption of eleven gamage m, et al., journal of ideas in health (2022); 5(3):730-738 732 meat and equivalent food types: fish, other seafood (prawns, cuttlefish), chicken, other meat, eggs, dry fish and sprats, canned fish, sausages and meatballs, soya meat, dhal and other pulses (chickpea, green gram). independent variables were year of birth, residing district, nature of the residential area, gender, ethnicity, education level, current employment status, and monthly family income. statistical analysis all variables were analyzed and expressed as numbers (n) and percentages (%). descriptive statistics were employed to describe the changes in meat or equivalent consumption behavior. results were presented as frequency and percentage in parentheses (%) for socio-demographic variables. bivariate analysis using the chi-square test was performed to determine the associated socio-demographic variables with dependent variables. multinomial linear regression analyses were recruited to examine the direction of association between dependent variables and socio-demographic variables. a p-value less than 0.05 was considered statistically significant. all data were cross-checked for consistency and analyzed using spss ver. 23.0 (ibm, chicago, il, usa). results descriptive and general characteristics of related factors the study sample comprised 3600 respondents after removing incomplete and duplicate results. the socio-demographic characteristics of the participants are presented in table 1. the majority were women (2163, 60.1%), while the mean (sd) age of the participants was 33.05 (± 9.74). ages 26 to 30 account for nearly one-fourth of the population, and 82.1% of the respondents were sinhalese. however, all other minor ethnic groups were also represented by the sample. respondents symbolized the entire country, whereas a higher proportion (61.1%) were found in colombo, gampaha, and kandy districts. although 32.5% of respondents resided in municipal council regions, most lived in rural areas (40.3%). approximately 70% of the survey population had a degree or higher educational level education, and 26% had a tertiary educational level. a higher fraction (86.0%, 2506) of participants were either workers or students, while 365 (10.1%) were unemployed, and 54 (1.5%) were retired. almost half of the respondents (49.0%; 1766) had a monthly family income beyond 100000 sri lankan rupee (lkr) equivalent to 500 us dollar (usd). table 1: demographic characteristics of the study population (n=3600) variables male n (%) female n (%) total n (%) n % n % n % observation 1437 39.9 2163 60.1 3600 100 age 18-25 years 218 6.1 567 15.8 785 21.8 26-30 years 314 8.7 577 16.0 891 24.8 31-35 years 306 8.5 441 12.3 747 20.7 36-40 years 211 5.9 277 7.7 488 13.6 >40 years 388 10.8 301 8.4 689 19.1 district colombo 561 15.6 808 22.4 1369 38.0 gampaha 193 5.4 297 8.3 490 13.6 kandy 108 3.0 233 6.5 341 9.5 other 575 16.0 825 22.9 1400 38.9 area of residence municipal council area 504 14.0 664 18.4 1168 32.5 city council area 376 10.4 603 16.8 979 27.2 rural area 558 15.5 895 24.9 1453 40.3 ethnicity sinhala 1113 30.9 1844 51.2 2957 82.1 tamil 166 4.6 185 5.1 351 9.8 moors and others 158 4.4 134 3.7 292 8.1 education level secondary education or below 47 1.3 91 2.5 138 3.8 tertiary education 338 9.4 594 16.5 932 25.9 degree or above 1052 29.2 1478 41.1 2530 70.3 employment status employed 1146 31.8 1360 37.8 2506 69.6 unemployed 86 2.4 279 7.8 365 10.1 retired 29 0.8 25 0.7 54 1.5 full-time student or pupil 136 3.8 456 12.7 592 16.4 other 40 1.1 43 1.2 83 2.3 monthly family income (in lkr) < 25,000 96 2.7 214 5.9 310 8.6 25,000-49,999 183 5.1 406 11.3 589 16.4 50,000-99,999 363 10.1 572 15.9 935 26.0 100,000-199,999 387 10.8 482 13.4 869 24.1 >200000 408 11.3 489 13.6 897 24.9 gamage m, et al., journal of ideas in health (2022); 5(3):730-738 733 changed behavior of meat or equivalents consumption the changes in meat or equivalents consumption of the study population during the covid-19 lockdown are depicted in figure 1. participants were more likely to increase their consumption of eggs (53.7%), dhal (47.0%), dry fish, and sprats (36.3%) during the covid-19 lockdown period. it was further observed a big trend in cutting down the consumption of fish (41.1%) and other seafood (52.0%) consumption during the covid-19 restricted period. relatively, higher proportions of the population kept their intake pattern the same in terms of their consumption of meat other than chicken (54.5%), other pulses (52.6%), soya meat (52.1%), dry fish and sprats (48.9%), canned fish (47.6%), chicken (43.7%), sausages and meatballs (45.1%). however, nearly one-fourth of respondents had increased intake levels with other pulses (28.4%), chicken (26.8%), and soya meat (25.8%). figure 1. changes in meat or equivalent consumption during covid-19 lockdown association between meat or equivalents consumption and socio-demographic factors the cross-tabulation was performed to investigate the association of socio-demographic factors with observed meat or equivalents intake patterns, and the results are presented in table 2. the cross-tabulation indicated that gender (chi-square test (χ2 (2) = 26.985, p = 0.000), age group (χ2 (8) = 18.035, p = 0.021), nature of residence area (χ2 (4) = 17.185, p = 0.002), and ethnicity (χ2 (4) = 28.811, p = 0.000), and monthly family income level (χ2 (8) = 67.464, p = 0.000) were significantly associated with decreased fish consumption. however, the reduction in other seafood consumption was significantly associated with gender (χ2 (2) = 21.544, p = 0.000), nature of residence area (χ2 (4) = 48.354, p= 0.000), ethnicity (χ2 (4) = 45.007, p = 0.002), employment status (χ2 (8) = 20.945, p = 0.007), and monthly family income level (χ2 (8) = 78.283, p = 0.000). as implied by the crosstabs analysis, gender (χ2 (2) = 22.300, p = 0.000), residing district (χ2 (6) = 60.904, p = 0.000), nature of residence area (χ2 (4) = 66.199, p = 0.000), ethnicity (χ2 (4) = 59.893, p = 0.000), employment status (χ2 (8) = 25.159, p = 0.001), and monthly family income level (χ2 (8) = 132.273, p = 0.000) were significantly associated with reduced chicken intake during covid-19 confinement. the declined intake of other meat items was significantly related to gender (χ2 (2) = 20.950, p = 0.000), age group (χ2 (8)= 16.735, p = 0.033), residing district (χ2 (6) = 42.210, p = 0.000), nature of residence area (χ2 (4) = 70.671, p = 0.000), ethnicity (χ2 (4) = 88.775, p = 0.000), an education level (χ2 (8) = 31.581, p = 0.000), employment status (χ2 (8) = 36.284, p = 0.000), and monthly family income level (χ2 (8) = 168.724, p = 0.000). moreover, increased egg consumption of respondents was significantly associated with gender (χ2 (2) = 7.021, p = 0.030), residing district (χ2 (6) = 15.790, p = 0.015), nature of residence area (χ2 (4) = 11.117, p = 0.025), an education level (χ2 (8) = 12.949, p = 0.012), and monthly family income level (χ2 (8) = 44.867, p = 0.000). apart from that, observed growth in dry fish intake behavior was significantly associated with gender (χ2 (2) = 9.443, p = 0.009), residing district (χ2 (6) = 14.955, p = 0.021), nature of residence area (χ2 (4) = 19.086, p = 0.001), ethnicity (χ2 (4) = 52.693, p = 0.000), and monthly family income level (χ2 (8) = 26.262, p = 0.001). nevertheless, the flattened trend of canned fish consumption was significantly associated with ethnicity (χ2 (4) = 17.399, p = 0.002), education level (χ2 (8) = 20.015, p = 0.000), employment status (χ2 (8) = 34.972, p = 0.000), and monthly family income level (χ2 (8) = 66.151, p = 0.000) only. as explained by the cross-tabulation, age group (χ2 (8)= 32.738, p = 0.000), residing district (χ2 (6) = 62.501, p = 0.000), nature of residence area (χ2 (4) = 59.267, p = 0.000), ethnicity (χ2 (4) = 10.696, p = 0.000), an education level (χ2 (8) = 45.182, p = 0.000), employment status (χ2 (8) = 61.669, p = 0.000), and monthly family income level (χ2 (8) = 119.844, p = 0.000) were significantly associated with constant consumption in sausages and meatballs during covid-19 lockdown in sri lanka. however, unchanged behavior of soya meat consumption was significantly associated with age group (χ2 (8) = 26.676, p = 0.001), ethnicity (χ2 (4) = 16.179, p = 0.003), education level (χ2 (8) = 11.397, p = 0.022), employment status (χ2 (8) = 19.170, p = 0.014), and monthly family income level (χ2 (8) = 47.530, p = 0.000) only. interestingly, increased dhal consumption was significantly associated with gender (χ2 (2) = 6.714, p = 0.035), residing district (χ2 (6) = 14.885, p = 0.021), ethnicity (χ2 (4) = 25.688, p = 0.000), and monthly family income level (χ2 (8) = 68.568, p = 0.000) whereas the unmoved behavior of other pulses intake was significantly associated with age group (χ2 (8)= 19.448, p = 0.013), ethnicity (χ2 (4) = 21.116, p = 0.000), education level (χ2 (8) = 11.323, p = 0.023), and monthly family income level (χ2 (8) = 56.175, p = 0.000). gamage m, et al., journal of ideas in health (2022); 5(3):730-738 734 table 2: statistical data of crosstab and chi-square analysis (p≤0.05 is significant at a 95% confidence interval) meat or equivalent food χ2, p-value gender age group district nature of residence area ethnicity education level employment status monthly family income level fish χ2 value 26.985 18.035 11.162 17.185 28.811 3.110 8.338 67.464 p-value 0.000 0.021 0.083 0.002 0.000 0.540 0.401 0.000 other seafood χ2 value 21.544 9.239 9.003 48.354 45.007 6.285 20.945 78.283 p-value 0.000 0.323 0.173 0.000 0.000 0.179 0.007 0.000 chicken χ2 value 22.300 11.020 60.904 66.199 59.893 7.501 25.159 132.273 p-value 0.000 0.201 0.000 0.000 0.000 0.112 0.001 0.000 other meat χ2 value 20.950 16.735 42.210 70.671 88.775 31.581 36.284 168.724 p-value 0.000 0.033 0.000 0.000 0.000 0.000 0.000 0.000 eggs χ2 value 7.021 11.327 15.790 11.117 8.819 12.949 15.238 44.867 p-value 0.030 0.184 0.015 0.025 0.066 0.012 0.055 0.000 dry fish and sprats χ2 value 9.443 10.568 14.955 19.086 52.693 2.419 5.100 26.262 p-value 0.009 0.227 0.021 0.001 0.000 0.659 0.747 0.001 canned fish χ2 value 4.682 4.320 10.255 7.761 17.399 20.015 34.972 66.151 p-value 0.096 0.827 0.114 0.101 0.002 0.000 0.000 0.000 sausages and χ2 value 3.609 32.738 62.501 59.267 10.696 45.182 61.669 119.844 meatballs p-value 0.165 0.000 0.000 0.000 0.030 0.000 0.000 0.000 soya meat χ2 value 0.016 26.676 3.285 6.184 16.179 11.397 19.170 47.530 p-value 0.992 0.001 0.772 0.186 0.003 0.022 0.014 0.000 dhal χ2 value 6.714 5.643 14.885 5.356 25.688 1.691 8.767 68.568 p-value 0.035 0.687 0.021 0.253 0.000 0.792 0.362 0.000 other pulses χ2 value 2.394 19.448 7.709 7.373 21.116 11.323 7.364 56.175 p-value 0.302 0.013 0.260 0.117 0.000 0.023 0.498 0.000 socio-demographic factors associated with changed behavior of meat or equivalent consumption in multinomial logistic regression the final model of the multinomial logistic regression is presented in table 3. the males (odds ratio (or) 0.852; 95% ci: 0.738 to 0.984, p = 0.029) and tamil (or = 1.605, 95% ci: 1.150 to 2.239, p = 0.005) were significantly likely to report increased egg consumption compared to females and moors and other ethnic groups respectively. in comparison to the rural participants, respondents living in municipal area (or = 1.105; 95% ci: 0.928 to 1.315, p = 0.263) and city area (or = 1.149; 95% ci: 0.963 to 1.372, p = 0.123) were more likely to increase their egg consumption. respondents in the lowest monthly family income group, less than 25,000 lkr (125 lkr) (or = 1.310; 95% ci: 0.975 to 1.759, p = 0.073) were more likely to consume eggs at increased levels compared to the highest monthly family income group more than 200,000 lkr (1000 usd). in terms of increased dhal intake, tamils (or = 1.571; 95% ci: 1.131 to 2.183, p = 0.007) showed significantly higher odds than moors and other ethnicities. moreover, the respondents with monthly income levels of less than 200,000 lkr (1000 usd) were significantly more likely to report increased consumption of dhal. among them, the lowest monthly family income group; <25,000 lkr (125 lkr) (or 2.220; 95% ci 1.672-2.947, p = 0.000), were more than twice likely to report increased dhal consumption compared to respondents with the highest monthly family income levels (>200,000 lkr/1000 usd). furthermore, respondents in middle monthly family income groups; 25,00049,999 lkr (125.00-249.99 usd) (or = 1.981; 95% ci: 1.583 to 2.478, p = 0.000), 50,000-99,999 lkr (250.00-499.99 usd) (or = 1.507; 95% ci: 1.242 to 1.828, p = 0.000), and 100,000199,999 lkr (500.00-999.99 usd) (or = 1.254; 95% ci: 1.034 to 1.522, p = 0.021), had significantly higher likelihood for the elevated dhal consumption behavior. however, in the final multinomial logistic regression model, respondents living in municipal areas (or 0.828; 95% ci: 0.691 to 0.993, p = 0.042) were significantly less likely to report increased dry fish consumption and sprats in comparison to rural participants. nevertheless, tamils (or 1.519; 95% ci 1.057-2.181, p = 0.024) reached the significantly increased levels in consumption of dry fish and sprats compared to moors and others ethnic group whereas both the lowest monthly family income group; < 25,000 lkr (125 usd) (or = 1.687; 95% ci: 1.253-2.271, p = 0.001) and 25,000-49,999 lkr (125.00249.99 usd) (or = 1.356; 95% ci: 1.070-1.718, p = 0.012) were also showed significantly higher odds in increased levels of dry fish and sprats consumption compared to respondents with >200,000 lkr (1000 usd) monthly family income level. gamage m, et al., journal of ideas in health (2022); 5(3):730-738 735 table 3. odds ratios (or) for the likelihood of increased consumption of meat or equivalents by socio-demographic variables variables eggs dhal dry fish and sprats or (95% ci) p-value or (95% ci) p-value or (95% ci) p-value gender male 0.852 0.738-0.984 0.029 1.058 0.920-1.218 0.427 0.865 0.745-1.005 0.058 female (reference) 1 1 1 nature of living area municipal 1.105 0.928-1.315 0.263 0.994 0.839-1.178 0.945 0.828 0.691-0.993 0.042 city 1.149 0.963-1.372 0.123 0.998 0.840-1.184 0.977 0.934 0.779-1.120 0.461 rural (reference) 1 1 1 ethnicity sinhala 1.252 0.968-1.620 0.086 1.216 0.937-1.578 0.141 1.116 0.839-1.485 0.451 tamil 1.605 1.150-2.239 0.005 1.571 1.131-2.183 0.007 1.519 1.057-2.181 0.024 moors and other (reference) 1 1 1 monthly family income level (lkr) < 25,000 1.310 0.975-1.759 0.073 2.220 1.672-2.947 0.000 1.687 1.253-2.271 0.001 25,000-49,999 0.985 0.784-1.238 0.900 1.981 1.583-2.478 0.000 1.356 1.070-1.718 0.012 50,000-99,999 1.173 0.963-1.428 0.114 1.507 1.242-1.828 0.000 1.177 0.957-1.447 0.124 100,000-199,999 1.044 0.858-1.270 0.669 1.254 1.034-1.522 0.021 1.136 0.923-1.398 0.228 >200,000 (reference) 1 1 1 multinomial logistic regression model as per the final multinomial logistic regression model, the socio-demographic factors associated with decreased fish and other seafood consumption are demonstrated in table 4. interestingly, all income groups were significantly more likely to report decreased fish consumption than their counterparts with the highest monthly family income level (>200,000 lkr/1000 usd). moreover, the lowest monthly family income group; < 25,000 lkr (125 usd) (or = 2.752; 95% ci: 2.0243.741, p = 0.000) reported more than twice reduction in fish consumption whereas other middle income groups; 25,00049,999 lkr (125.00-249.99 usd) (or = 1.860; 95% ci: 1.460-2.370, p = 0.000) 50,000-99,999 lkr (250.00-499.99 usd) (or = 1.535; 95% ci: 1.246 to 1.890, p = 0.000), and 100,000-199,999 lkr (500.00-999.99 usd) (or = 1.341; 95% ci: 1.089 to 1.652, p = 0.006), had significantly higher likelihood for the reduced fish consumption behavior compared respondents with highest monthly family income level more than 200,000 lkr (1000 usd). additionally, males (or = 1.301; 95% ci: 1.006 to 1.681, p = 0.011) were significantly more likely to report decreased levels of other seafood (prawns, cuttlefish) consumption compared to their female counterparts. compared to the rural participants, respondents living in the municipal area (or = 1.523; 95% ci: 1.186 to 3.292, p = 0.009) showed a significantly higher likelihood of reduction in other seafood (prawns, cuttlefish) consumption. similarly, tamils (or = 1.976, 95% ci: 1.186 to 3.292, p = 0.009) were significantly likely to report decreased intake levels of other seafood (prawns, cuttlefish) compared to moors and other ethnic groups. in addition, the monthly family income groups; 25,000-49,999 lkr (125.00-249.99 usd) (or = 0.596; 95% ci: 0.379-0.937, p = 0.025), and 100,000-199,999 lkr (500.00-999.99 usd) (or = 0.627; 95% ci: 0.443 to 0.888, p = 0.008), had significantly less likelihood for the reduced seafood consumption behavior compared highest monthly family income level more than 200,000 lkr (1000 usd) group. table 4. odds ratios (or) for the likelihood of decreased fish consumption of meat or equivalents by socio-demographic variables variables fish other seafood or (95% ci) p-value or (95% ci) p-value gender male 0.873 0.750-1.015 0.078 1.301 1.006-1.681 0.045 female (reference) 1 1 nature of living area municipal 0.903 0.753-1.084 0.273 1.523 1.102-2.105 0.011 city 0.986 0.820-1.186 0.883 1.237 0.876-1.747 0.227 rural (reference) 1 1 ethnicity sinhala 1.072 0.813-1.414 0.622 0.688 0.447-1.059 0.089 tamil 1.089 0.760-1.560 0.643 1.976 1.186-3.292 0.009 moors and other (reference) 1 1 monthly family income level (lkr) < 25,000 2.752 2.024-3.741 0.000 0.955 0.554-1.646 0.867 25,000-49,999 1.860 1.460-2.370 0.000 0.596 0.379-0.937 0.025 50,000-99,999 1.535 1.246-1.890 0.000 0.873 0.623-1.223 0.430 100,000-199,999 1.341 1.089-1.652 0.006 0.627 0.443-0.888 0.008 >200,000 (reference) 1 1 gamage m, et al., journal of ideas in health (2022); 5(3):730-738 736 discussion to our knowledge, the current study was among a few surveys designed to investigate the immediate consequence of the covid-19 lockdown on meat or equivalent intake among sri lankans. social distancing was the strategy adopted by many countries to reduce the spread of covid-19 [15-21]. among the imposed social confinements, lockdown measures resulted in a positive effect of flattening the epidemic curve [16,21]. consequences of covid-19 restrictions consist of substantial distress for numerous aspects of human lives, including dietary habits [22]. results of our study indicated that meat or alternative intake patterns were impacted during the early period of covid-19 restrictions in sri lanka. during the blockade, more than onefourth of the sri lankans were more likely to consume eggs, dhal and other pulses, dry fish and sprats, soya meat, and chicken. contrarily, over one-fourth of the population has reduced their intake of fish and other seafood, chicken and other meat, sausages and meatballs, and canned fish. nearly half of the sri lankans have not changed their dhal and other pulses intake, dry fish and sprats, canned fish, soya meat, and other meat. mandal et al. [23] assessed the impact of covid-19 on fish consumption and household food security in bangladesh, and a reduced behavior in the frequency of fish consumption per week was observed across all income groups. in turkish adults, haskaraca et al. [24] have found that only 13.0%, 11.0%, and 31.0% of the participants have reduced their red meat, poultry meat, and fish consumption, respectively, due to the impacts of the covid-19 pandemic. yu et al. [21] conducted a study in china to evaluate the impact of lockdown on dietary patterns. the authors indicated a significant increase in fish (7.5%), and egg (10.3%) consumption, whereas more participants stopped or reduced their intake of meat (8.4%) and poultry (9.5%). the dynamics of meat or equivalent intake during covid-19 have been discussed extensively in the literature. the sudden imposition of a countrywide lockdown affected all kinds of transport, shutting down markets and resulting in the scarcity of meat and alternatives. as per other investigations, the primary reason behind the change in meat or equivalent consumption was the non-availability of products due to barriers to transportation from other geographical areas [23]. a recent survey in india reported that the quantity of meat purchased had been reduced. most consumers could not obtain sufficient meat and meat products during the lockdown period [12]. reduced ability to purchase food, greater availability of stockpiled products and more time spent at home contributed to increased egg, dhal, dry fish, and “sprats” intake during the covid-19 pandemic [25]. moreover, food prices have surged, leading to the respondents' inability to buy certain foods [23]. there was a general decline in the consumption of fresh foods among people in denmark, germany, and slovenia, but an increase in the consumption of food with a longer shelf life [19]. primarily this could be the reason for reduced intake of chicken and other meats, fish, and other seafood such as prawns and cuttlefish. a decrease in chicken and other meat, as well as value-added meat products, also might be due to the closure of fast-food restaurants. since many purchases were processed online, the public hesitated to purchase perishables as some delay might occur in delivery, and it might negatively impact on reduction in fish, chicken, and other meat consumption during the lockdown period [24]. apart from economic reasons and inability to reach it, reduced meat or equivalents consumption behavior might be due to being concerned with them as a source of covid-19 origin [12]. the fact that eggs can be stored in the open air while meat and fish need special storage conditions and greater attention to food safety may be the reason for the growing consumption of eggs over meat and fish [23]. the lower meat consumption could be further related to the lack of stock in some supermarkets and grocery stores [11]. apart from these consequences, the fear of covid-19 infection and death and the restrictions on individual freedom have worsened the stress load and altered habitual behaviors. a recent review underlines that balanced nutrition, which can help maintain immunity, is essential for preventing and managing viral infections [5]. considering that covid-19 has no effective preventive and pharmacological therapies, healthy eating habits are crucial, and elective micronutrient supplementations (e.g., vitamins, trace elements, nutraceuticals, and probiotics) may be beneficial [5]. generally, the mean daily intake of meat and fish portions among sri lankans is well below the minimum recommendations of the world health organization [26]. in a previous survey, daily consumption of meat or alternatives was 1.75 portions, and the sum of meat and pulses was 2.78 portions per day [27]. as reported in a recent review, two to three portions of meat or equivalent should be included daily to satisfy nutritional needs and maintain robust immune function to withstand any assault by the virus [5]. the present study's findings conveyed favorable and critical changes in meat and alternative consumption among sri lankans. the observed changes occurred in a short period, raising concerns about worsening the trends once the covid19 restrictions are prolonged. the long-term consequences are difficult to predict in terms of dietary behaviors. in aggregated terms, results indicated that consumers reacted initially to the covid-19 lockdown by changing their meat or equivalent consumption pattern. nutrition insecurity may increase the vulnerability to infection with covid-19, and its more severe consequences may last longer [28]. further, it can be expected to adversely affect the prevalence of diet-related non-communicable diseases such as obesity, type 2 diabetes, and cardiovascular diseases. understanding the impact of the covid-19 pandemic on meat and fish consumption is important to overcome the future implications of the nutritional burden on the sri lankan health system. a significant limitation of the present study was that most of the participants were middle-aged youngers who resided in colombo city, and the respondents were predominately female. given the variations in contextual factors within sri lanka, it is uncertain how much our results may be applied to other geographical areas. at the time of data collection, supermarkets, groceries, retail markets, restaurants, cafes, cinemas, and playgrounds were closed, public and in-home gatherings were banned, schools were closed, and people were encouraged to work from home. the government announced financial aid for those who were struggling financially as a result of the covid19 lockdown. the covid-19 restrictions substantially disrupted sri lankans' regular lifestyle routines. the current gamage m, et al., journal of ideas in health (2022); 5(3):730-738 737 study did not record price fluctuations for food items and the changes in online shopping frequency. however, this type of investigation facilitated us to perform a nationwide survey during the pandemic constraints prolonging the opportunity to meet a relatively larger sample. furthermore, our study disclosed the limited capacity of current dietary guidelines to endure during a global public health pandemic. these findings further suggest the prerequisite of revision for the existing nutritional programs and guidelines to support healthy eating across sri lanka, a low and middle-income country. conclusion for the first time, data on changes in meat and its equivalent consumption among sri lankans during the covid-19 lockdown were provided in this study. the dietary intake of meat and equivalents among sri lankan adults was changed due to the covid-19 lockdown. while fish and other seafood intake decreased, consumption of eggs, dhal, dry fish, and sprats increased. however, as the covid-19 pandemic is still ongoing worldwide, more research is required to determine its impact on dietary behavior locally and globally. abbreviation covid-19: coronavirus; lkr: sri lankan rupee; usd: us dollar; or: odds ratios declaration acknowledgment none. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing ranil@physiol.cmb.ac.lk. authors’ contributions ranil jayawardena (rj) contributed to conceptualization, project administration, and validation. rj, ps, and tf contributed to data curation, formal analysis, investigation, supervision, and methodology. mg contributed to writing-original the draft, while mg, rj, ps and tf contributed to writing-review and editing. all authors have read and approved the final manuscript. ethics approval and consent to participate the research was performed in accordance with the principles of the declaration of helsinki. the authors declared that the protocol of this article was part of a previously published [12-14] large initiative in sri lanka (2021-2022). moreover, web-based informed consent was obtained from each participant after explaining the study objectives and the guarantee of secrecy. consent for publication not applicable competing interest open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1diabetes research unit, faculty of medicine, university of colombo, colombo, sri lanka. 2health and wellness unit, faculty of medicine, university of colombo, colombo, sri lanka. 3queensland university of technology, school of exercise & nutrition sciences, brisbane, queensland, australia. 4health and wellness unit, faculty of medicine, university of colombo, colombo, sri lanka. 5department of physiology, faculty of medicine, university of colombo, colombo, sri lanka. 6institute of health and biomedical innovation, queensland university of technology, brisbane, queensland, australia. article info received: 15 july 2022 accepted: 19 august 2022 published: 29 august 2022 references 1. sharma s, sheehy t, kolonel ln. contribution of meat to vitamin b (1)(2), iron and zinc intakes in five ethnic groups in the usa: implications for developing food-based dietary guidelines. journal of human nutrition and dietetics: the official journal of the british dietetic association. 2013;26(2):156-68. doi: 10.1111/jhn.12035. 2. laskowski w, gorska-warsewicz h, kulykovets o. meat, meat products, and seafood as sources of energy and nutrients in the average polish diet. nutrients. 2018;10(10). doi: 10.3390/nu10101412. 3. battaglia richi e, baumer b, conrad b, darioli r, schmid a, keller u. health risks associated with meat consumption: a review of epidemiological studies. international journal for vitamin and nutrition research internationale zeitschrift fur vitaminund ernahrungsforschung journal international de vitaminologie et de nutrition. 2015;85(1-2):70-8. doi: 10.1024/0300-9831/a000224. 4. walker p, rhubart-berg p, mckenzie s, kelling k, lawrence rs. public health implications of meat production and consumption. public health nutrition. 2005;8(4):348-56. doi: 10.1079/phn2005727. 5. jayawardena r, sooriyaarachchi p, chourdakis m, jeewandara c, ranasinghe p. enhancing immunity in viral infections, with special emphasis on covid-19: a review. diabetes & metabolic syndrome. 2020;14(4):367-82. doi: 10.1016/j.dsx.2020.04.015. 6. aman f, masood s. how nutrition can help to fight against covid-19 pandemic. pak j med sci. 2020 may;36 (covid19s4): s121-s123. doi: 10.12669/pjms.36.covid19-s4.2776. 7. ali jadoo sa. the second wave of covid-19 is knocking at the doors: have we learned the lesson? journal of ideas in health. 2020 oct. 8;3(special1):183-4. doi: 10.47108/jidhealth.vol3.issspecial1.72 8. elsahoryi n, al-sayyed h, odeh m, mcgrattan a, hammad f. effect of covid-19 on food security: a cross-sectional survey. clinical nutrition espen. 2020; 40:171-8. doi: 10.1016/j.clnesp.2020.09.026. 9. jayawardena r, misra a. balanced diet is a major casualty in covid-19. diabetes metab syndr. 2020;14(5):1085-6. epub 2020/07/12. doi: 10.1016/j.dsx.2020.07.001. 10. di renzo l, gualtieri p, pivari f, soldati l, attina a, cinelli g, et al. eating habits and lifestyle changes during covid-19 lockdown: an italian survey. journal of translational medicine. 2020;18(1):229. doi: 10.1186/s12967-020-02399-5. 11. jain r sr. effect of lockdown on protein intake and sleep patterns in adults aged 40-60 years in jain community. international journal of creative research thoughts. 2021;9(6):871-88. 12. rahman ckf, sharun k, chand s, bardhan d, dhama k, kumar rr. impact of covid-19 pandemic and lockdown on the meat consumption pattern in india: a preliminary analysis. journal of gamage m, et al., journal of ideas in health (2022); 5(3):730-738 738 experimental biology and agricultural sciences. 2021;9(2):17282. doi: 10.18006/2021.9(2).172.182. 13. francis tv, sooriyaarachchi p, jayawardena r. usage of nutritional supplements to improve immunity during the covid19 pandemic: an online survey. clinical nutrition open science. 2022; 43:6-19. doi: 10.1016/j.nutos.2022.04.003. 14. sooriyaarachchi p, francis tv, jayawardena r. fruit and vegetable consumption during the covid-19 lockdown in sri lanka: an online survey. nutrire. 2022;47(2). doi: 10.1186/s41110-022-00161-z. 15. sooriyaarachchi p, francis tv, king n, jayawardena r. increased physical inactivity and weight gain during the covid-19 pandemic in sri lanka: an online cross-sectional survey. diabetes metab syndr. 2021 jul-aug;15(4):102185. doi: 10.1016/j.dsx.2021.06.022. 16. srivastav ak, sharma n, samuel aj. impact of coronavirus disease-19 (covid-19) lockdown on physical activity and energy expenditure among physiotherapy professionals and students using web-based open e-survey sent through whatsapp, facebook and instagram messengers. clinical epidemiology and global health. 2021; 9:78-84. doi: 10.1016/j.cegh.2020.07.003. 17. gornicka m, drywien me, zielinska ma, hamulka j. dietary and lifestyle changes during covid-19 and the subsequent lockdowns among polish adults: a cross-sectional online survey plifecovid-19 study. nutrients. 2020;12(8). doi: 10.3390/nu12082324. 18. galali y. the impact of covid-19 confinement on the eating habits and lifestyle changes: a cross sectional study. food science & nutrition. 2021. doi: 10.1002/fsn3.2179. 19. janssen m, chang bpi, hristov h, pravst i, profeta a, millard j. changes in food consumption during the covid-19 pandemic: analysis of consumer survey data from the first lockdown period in denmark, germany, and slovenia. frontiers in nutrition. 2021; 8:635859. doi: 10.3389/fnut.2021.635859. 20. prete m, luzzetti a, augustin lsa, porciello g, montagnese c, calabrese i, et al. changes in lifestyle and dietary habits during covid-19 lockdown in italy: results of an online survey. nutrients. 2021;13(6). doi: 10.3390/nu13061923. 21. yu b, zhang d, yu w, luo m, yang s, jia p. impacts of lockdown on dietary patterns among youths in china: the covid19 impact on lifestyle change survey. public health nutrition. 2021;24(11):3221-32. doi: 10.1017/s1368980020005170. 22. alamri es. effects of covid-19 home confinement on eating behaviour: a review. journal of public health research. 2021;10: 2088. https://doi.org/10.4081/jphr.2021.2088. 23. mandal sc, boidya p, haque mi-m, hossain a, shams z, mamun a-a. the impact of the covid-19 pandemic on fish consumption and household food security in dhaka city, bangladesh. global food security. 2021;29. doi: 10.1016/j.gfs.2021.100526. 24. haskaraca g, bostanci e, arslan y. effects of the covid-19 pandemic on eating and meat consumption habits of turkish adults. turkish journal of agriculture food science and technology. 2021;9(1):63-9. doi: 10.24925/turjaf. v9i1.6369.3704. 25. boleslawska i, blaszczyk-bebenek e, jagielski p, jagielska a, przyslawski j. nutritional behaviors of women and men in poland during confinement related to the sars-cov-2 epidemic. scientific reports. 2021;11(1):19984. doi: 10.1038/s41598-02199561-w. 26. abeywickrama hm, wimalasiri kms, koyama y, uchiyama m, shimizu u, chandrajith r, nanayakkara n. assessment of nutritional status and dietary pattern of a rural adult population in dry zone, sri lanka. int j environ res public health. 2019 dec 24;17(1):150. doi: 10.3390/ijerph17010150. 27. jayawardena r, byrne nm, soares mj, katulanda p, hills ap. food consumption of sri lankan adults: an appraisal of serving characteristics. public health nutr. 2013;16(4):653-8. epub 2012/07/13. doi: 10.1017/s1368980012003011. 28. ammar a, brach m, trabelsi k, chtourou h, boukhris o, masmoudi l, et al. effects of covid-19 home confinement on eating behaviour and physical activity: results of the eclb-covid19 international online survey. nutrients. 2020 may 28;12(6):1583. doi: 10.3390/nu12061583. https://doi.org/10.47108/jidhealth.vol5.iss3.231 lazar am, journal of ideas in health 2022;5(3):716-724 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access monkeypox in the covid-19 era angela madalina lazar 1* abstract currently, in addition to the covid-19 waves, the world is confronting an additional threat: the global monkeypox infection outbreak, already regarded as a “public health emergency of international concern” by the world health organization. according to the most recently published reports, more than 21000 monkeypox infection cases have been confirmed in 78 countries, with 5 african deaths and more than three deaths outside endemic africa while the numbers are still increasing. too little is currently known about the monkeypox virus, although it does not appear as a recently emerged pathogen, being probably as ancient as the smallpox virus. the major fear in regards to the current international monkeypox infection spread has multiple causes: monkeypox's similarity to smallpox, the deadliest pathogen in the history of humanity; lack of knowledge of the virus's natural occurrence, animal reservoir, mechanisms of transmission, pathogenicity, host immune response; lack of effective specific treatment and vaccine; unusually rapid geographic spread and atypical clinical presentation; increase in the mutation rate outside the standard, mathematically anticipated rates; putative complications and sequelae of the infection; potential use as a biological weapon. actually, with such characteristics, the monkeypox virus has the potential to occupy/replicate the place of the much-feared smallpox virus. in the near future, due to the high registry of viral mutagenesis, limitations in the preventive strategies, and lack of an efficient vaccine, several viruses, including sars-cov-2 and monkeypox, could continue their worldwide spread and generate flu-like subsequent infective bursts. therefore, dedicated research and detailed knowledge of the viral pathogenic mechanisms and transmission routes are required to design efficient therapies and limit/stop future pandemics: until the emergence of a new virus. keywords: monkeypox, smallpox, variola virus, poxvirus, vaccine, sars-cov-2, covid-19, outbreak, epidemics, pandemics, romania background currently, along with the subsequent covid-19 waves, the world is confronting a new threat: monkeypox infections, already declared a “public health emergency of international concern” by the world health organization (who) [1]. an apparently ancient zoonotic pathogen that is nowadays changing its biology, monkeypox is the isolated causative agent in more than 16000 new cases of infections worldwide in 2022, in 75 countries/areas (in the two americas, europe, north africa, middle east, asia, oceania, australia) (even 21000 cases in 78 countries as reported by the bno (breakingnewson) on july 29, 2022) [1,2]. therefore, the world is facing a monkeypox epidemic, with the potential of becoming a pandemic, as reported by the who [1]. it is already regarded as a global health problem, as it exhibits an unusual fast geographic spread, has the potential to occupy/replicate the ancient eradicated deadly smallpox place through evolutionary mutations, and there is no current efficient specific antiviral treatment, nor an ideal approved vaccine [3-6]. it is considered a high consequence of infectious disease (hcid) in the uk and is treated in specially designated centers [7]. the monkeypox pathogen is a large (250 nm long and 200 nm wide), brickor oval-shaped, lipoprotein-enveloped virus of approximately 200000 base pairs, consisting of a double-strand dna, from the orthopox genus, poxviridae family, chordopoxvirinae subfamily, with intra-cytoplasmic replication [3, 4, 6, 8]. along with the monkeypox virus, the poxviridae family includes multiple life-threatening viruses that can affect a broad array of organisms, humans or animals, such as human smallpox, that has been eradicated until 1980 (considered to ___________________________________________________ angelalazar.2008@yahoo.com 1department of functional sciences, university of medicine and pharmacy “carol davila” bucharest, romania. a full list of author information is available at the end of the article. https://doi.org/10.47108/jidhealth.vol5.iss3.231 http://www.jidhealth.com/ lazar am, journal of ideas in health (2022); 5(3):716-724 717 have historically killed more than 300 million people), molluscum contagiosum virus, cowpox, rabbitpox, camelpox, mousepox (ectromelia virus), vaccinia and pox viruses affecting goats, cervids, rabbits, but even birds, reptiles such as crocodiles and insects [9-15]. there is a large degree of genetic similarity between the pox viruses, with highly conserved genes for virus replication and more variability in concern with the genes that dictate the host range, immune response, and pathogenicity [4, 10]. the most acknowledged and feared virus of the poxviridae family is the smallpox virus, the deadliest human-specific virus ever described in the history of humanity. in fact, it is due to the historical smallpox epidemics that the vaccine and vaccination were invented and implemented for the first time by edward jenner due to the cowpox/vaccinia virus similarity to the smallpox virus [5, 15, 16]. the current preoccupation with the monkeypox virus: reasons for concern in fact, the current fear in regards to monkeypox infections is determined by: its important similarity to the feared eradicated smallpox virus; significant lethality rates of up to 11%; potential use as a biological weapon; recent changing biology with the more frequent human-to-human transmission; rapid unexplainable geographic spread; atypical clinical presentation of the cases; unknown pathogenesis mechanisms; as well as due to the lack of an efficient and specific antiviral treatment for such a disease [6, 14, 17, 18, 19]. too many unknowns are related to the monkeypox infection: the mechanisms of the natural occurrence of the virus; the routes of transmission are insufficiently studied and understood; the mechanism of human infectivity; the response of the human immune system to the virus; the histological changes within the human organs as a consequence of the infection; the short and long-term sequelae of the monkeypox infection [5, 6, 17, 18]. detailed genetic knowledge of the monkeypox virus is also lacking, as the isolation and characterization of pathogens like smallpox and even monkeypox from ancient probes via molecular paleoepidemiology (ancient bones) has many limitations: difficulty in dna isolation, purification, possible contamination of the genetic material from other sources (environmental or laboratory), a mixture of various dna sources, partial damage of the dna with time [20, 21]. however, in the absence of basic knowledge on the monkeypox virus, efficient prevention of transmission and treatment of the disease is not possible in modern medicine. the current lack of knowledge and treatment of the monkeypox infection can be explained by the relatively delayed isolation and description of the monkeypox virus, although it is probably a persistent ancient pathogen, along with the smallpox virus. actually, smallpox virus recordings date back from 1350 bc, with historical descriptions from the egyptians and hittites and periodical rebursts worldwide until its eradication [22]. however, the genetic and clinical similarity between the two viruses [17, 23, 24], the late discovery of the monkeypox virus, and the efficacy of the smallpox ring vaccination against monkeypox as well has probably led to a prolonged confusion between the two viruses, with historical monkeypox infections misdiagnosed as smallpox cases, the monkeypox virus not being known at that time. only after the smallpox eradication (due to the large-scale worldwide ring vaccination program), as officially declared in 1980 and after the cessation of the vaccination campaign, has the monkeypox virus existence become obvious to the medical community [5, 15, 18, 22, 25, 26]. first isolation and history (transmission routes) the monkeypox virus was first described only in 1958 by the danish virologist preben christian alexander von magnus, being isolated from a group of monkeys that had been shipped from singapore to denmark to be used for polio vaccine [3, 5, 20, 27-30]. at that time, it had been considered as affecting only animals, with a reservoir in the central and western african rain forests. the first case of monkeypox infection in humans was recorded in 1970 in a 9-year child from zaire, the current democratic republic of congo, who was first suspected of smallpox infection but tested positive only for monkeypox virus [4, 12, 20, 23, 28, 31]. the recognition of the monkeypox infection is most probably due to the smallpox eradication and cessation of the vaccination program [32] and not to the monkeypox infection emergence at that time. however, monkeypox has been long regarded as a zoonotic infection, with a persistent african animal reservoir and only rare animal to human transmission. in fact, the exact african animal reservoir is still largely unknown [6, 10, 18, 24]. although the infection bears the name "monkeypox", it is nowadays acknowledged that it is not the monkeys that are the common natural reservoir for such a viral transmission and that monkeys are only an incidental host, along with many others and humans [4, 5, 20, 25]. in fact, repeated infective studies using various species of monkeys and rodents have shown that some species can even be immune to the infection (do not develop the disease or show an atypical, subclinical course of the infection). however, rhesus macaques appear to be susceptible to it, with lethality rates of up to 80% after intravenous injection of high doses of monkeypox virus, although the natural transmission route is not intravenous [10, 14, 17, 33]. that is the argument that led to the recent proposal of renaming the virus, with the exclusion of the term “monkey” [34]. instead, the natural reservoir for the monkeypox virus is considered to be several african rodents, such as giant pouched rats, dormice, rope squirrels, and tree squirrels, although precise data on this matter are currently lacking [4, 12, 20, 29, 32]. in the central and west african rain forests, where monkeypox infection is endemic, an important transmission route of the virus appears to be from animal to human due to the direct contact with live animals or carcasses, scratches, bites, skin lesions caused by rodents to humans, contact with animal saliva, respiratory droplets or skin lesions, frequently occasioned by hunting and animal skinning and even consumption of inadequately cooked bush meat [4-6, 12, 15, 24, 28, 29]. however, an additional transmission route has also appeared obvious: human-to-human transmission, mainly among household members or in hospital settings [7, 12]; such a transmission route requires direct, intimate contact, in contrast to the much more infective sars-cov-2 virus [35-37]. although monkeypox infection is regarded as endemic in africa, viral outbreaks outside the african continent have been rare. for example, in 2003, there was a monkeypox outbreak in humans in the united states, linked to the adoption of prairie dogs that got infected by exotic african gambian giant rats and other rodents imported from ghana. at that time, 72 human lazar am, journal of ideas in health (2022); 5(3):716-724 718 cases of monkeypox infection were recorded [29], all linked to contact with the infected exotic rodents shipped from ghana to the united states [3, 6, 12, 25, 29]. since then, the number of non-african monkeypox infection cases has increased worldwide, initially with occasional reports in the uk, israel, the us, and singapore, mostly linked to travel to the african continent and household interactions [7, 8, 18, 23, 25, 30]. however, from its first human description until now, probably due to the wane in the immunity conferred by the smallpox vaccine, especially in the young, non-vaccinated individuals, there has been a gradual increase in the number of monkeypox infections as reported by the african countries [4, 6, 11, 12, 16, 23, 25, 29, 38]. current out-african monkeypox outbreak nowadays, however, starting with the end of april and the beginning of may 2022, we are facing an unusual, unexpected out-african outbreak of monkeypox infections worldwide, with mysterious/undocumented and difficult to understand links for such a large geographic spread. in the current outbreak, no apparent links between most of the cases of monkeypox infection could be found [38]. actually, a recent theory for the current extended geographic spread of the monkeypox virus suggests that the medical attention and resources focused on covid-19 could have led to poorer monkeypox surveillance, diagnosis, and prevention [4]. some reports link the current monkeypox infection outbreaks to lgbt/msm (men having sex with men) prides, various festivals, and events that gather many people, such as the recent gay pride maspalomas from gran canaria island, as the majority of the infected cases were declared to be msm (men having sex with men) individuals [6, 8, 28]. according to the who report, as of july 25, 2022, 16016 cases of infection and five deaths (in africa) were confirmed in 75 countries/areas worldwide [1]. about 98% of the cases that reported their sexual orientation were gay or bisexual, and more than 41% of the documented cases were hiv-positive [1, 28]. according to the european centre for disease prevention and control update, as of august 08, 2022, there were 13912 confirmed cases of monkeypox infection in 29 eu/eea countries [39]. according to the bno (breaking news) news, on july 29, more than 21000 cases in 78 countries worldwide have been reported [2]. five deaths in africa have been recorded [40]. up to now, the countries with the largest number of monkeypox infection cases are: spain, the us, germany, the uk, france, netherlands, portugal, italy, belgium, and austria, but the situation can change rapidly [1, 6, 25, 38]. also, 37 countries have recently reported a weekly increase in the number of monkeypox infection cases, according to the who report published on july 25, 2022 [1]. in fact, belgium is the first country to introduce a 21-days mandatory quarantine for monkeypox infection cases [6, 28]. more than three deaths outside of africa (from spain and brazil) have already been recorded [41, 42]. actually, it can be speculated that a monkeypox infection outbreak in non-endemic areas could lead to more severe consequences, as there is no pre-existing anti-poxvirus immunity in the countries outside endemic africa [15]. along with the smallpox vaccine waning immunity, vaccination cessation, and covid-19 attention-shift, other putative mechanisms to explain the current monkeypox worldwide spread are: the extension of urbanization, deforestation and climate changes with the alteration of the wildlife habitat, increasing animal-to-human interactions; extensive hunting with bush meat consumption and worldwide exotic animal trade; increase in the percent of the immunocompromised population (hiv-positive individuals) and increase in the number of lgbt parades [4, 18, 23, 28]. human-to-human monkeypox virus transmission mechanisms in africa, two major viral clades are the western and the central clade (from the congo basin). the geographic region between the cross and the sanaga rivers has probably acted as a barrier to viral propagation, leading two the occurrence of two different viral clades [28, 32]. the central clade of monkeypox virus is characterized by a higher aggressiveness and infectivity than the western clade, being responsible for a fatality rate of up to 1011%, while the west clade associates lower fatality rates of 13% [3, 4, 7, 12, 18, 28]. fortunately, the current worldwide outbreak appears to be a western clade monkeypox transmission [7, 25]), with 0% fatality [28] or a low rate of fatality as reported until now by the who and the european centre for disease prevention and control [1, 39-42]. it is clear now that human-to-human transmission requires close/prolonged contact between individuals, such as interactions between household members, sexual contact, or healthcare professionals' interaction with monkeypox-infected patients. currently, the studies are insufficient, and debates persist on the human-to-human transmission mechanisms. however, it appears that the human-to-human transmission is possible via close (and usually prolonged) contact with body fluids and skin lesions such as: by large respiratory droplets while sneezing and coughing; direct contact with the monkeypox skin lesions of an infected individual, or indirect contact with skin lesions material via bed linen, towels, contaminated clothes, various surfaces touched by an infected case and contaminated; putative contact with infected blood/urine/other body fluids, even feces [3, 4, 11, 25, 29, 32, 38]. another transmission route can be via the placenta [6, 32]. a controversial spread of the infection is the sexual transmission route, either by the intimate contact with the skin lesions of the partner/ respiratory droplets and/or even by the seminal/sexual fluids, where the monkeypox virus has been isolated in large titers, comparable to those of the nasal/throat swab titers [8, 28, 32, 38]. however, the sexual transmission route via seminal fluids remains much disputed [6]. some authors, even if acknowledging that the monkeypox virus, along with other sexually transmitted viruses, is present in the semen, doubt the viral transmission via such a route. they consider that the monkeypox virus high titers in semen are only secondary, via the systemic viral spread during the infection, especially in immunocompromised individuals, due to the permeability of the blood-testis barrier and the viral immune escape at that level, the testis being considered an immunologic “sanctuary site” [8, 28]. however, more than 50% of the cases of the current worldwide outbreak were among msm, with past or current history of other sexually transmitted infections as well (hiv, hepatitis b or c, syphilis, herpetic, chlamydia infections) lazar am, journal of ideas in health (2022); 5(3):716-724 719 having an atypical presentation with primary genital/perianal lesions and inguinal lymphadenopathy a short time after nonprotected sexual contacts; another unusual presentation of such cases was with genital lesions only [6, 8, 25, 28, 38]. such a fact clearly suggests that the sexual route is a major transmission route for the monkeypox infection and that the genitals could represent a monkeypox virus reservoir [7]. additionally, to the mentioned transmission mechanisms, if we consider the monkeypox similarity to the smallpox virus, other putative feared transmission routes can be taken into consideration, such as long-distance aerosol convection dissemination, as reported for the variola virus [43]. such a transmission route could explain the current rapid geographic spread of monkeypox infections worldwide, with no apparent links between many of the cases. the highest risk of monkeypox infection is among the individuals that have not been vaccinated against smallpox, with immune vulnerability: children, young individuals, pregnant, elderly individuals; immunocompromised individuals, hiv patients, patients with other sexually transmitted infections that may act synergically; certain professional categories, such as healthcare providers and animal trade professionals [4, 7, 8, 12, 24-26]. in fact, it was reported that adult laboratory animals such as mus musculus with a healthy immune system remain resistant when challenged to monkeypox virus [5], while a deficient immune response favors the infection [14]. another category of individuals at risk are obviously those that undertake risky sexual behavior, with non-protected sexual intercourse, multiple, frequently anonymous partners, especially among the msm, and those with other sexually transmitted diseases, that are also frequently vulnerable to infection due to their immunocompromised status [38]. instead, older people that have been vaccinated against smallpox do not develop the disease or present only with mild forms of monkeypox infection, the smallpox vaccine being considered protective in 85% of the cases, even after more than 25 years from the vaccination [4, 12, 16, 25]. clinical presentation of the monkeypox infection the incubation of the monkeypox virus ranges from 5 to 14 days and even up to 21 days post-exposure [25, 32]. although detailed medical data on the pathogenesis of the infection and host immune response are currently lacking, the clinical presentation of the monkeypox infection has the following stages: a prodromal, flu-like manifestation characteristic of the invasion period lasting up to 5 days, with fever, chills, headache, backache, myalgia, fatigue, asthenia, sore throat, arthralgia, when the systemic viral spread takes place; the virus is most likely taken up by lymphocytes/immune cells to the lymph nodes and other immune organs (spleen or even bone marrow), a phase that is characterized by lymphadenopathy, especially inguinal and cervical and less frequently axillary lymphadenopathy; 1-3 days after the prodromal stage with lymphadenopathy or sometimes even concomitant with the characteristic monkeypox infection rash appears [4, 6, 12, 28, 29, 32]. typically, there is a monomorphic centrifugal skin eruption, with the progression of skin lesions from macules to papules, then pustules, umbilicated pustules, ulcerations, crusts, and scars over approximately 2-4 weeks. usually, the skin eruption is located on the face (in 95% of the infected individuals), extremities (palms of the hands, soles of the feet, arms, legs), but also affects the mucous membranes (starting with the oropharynx, nose), conjunctivae, genital organs [3, 6, 28, 29, 32]. the skin lesions are firm, well-circumscribed, deep, 2-10 mm in size, and can be present in small numbers or up to thousands, usually in crops [3, 12, 25]. the infection is usually mild and lasts 2 to 4 weeks. the healing is natural, spontaneous, and without additional medical intervention (self-limited infection) [25, 32]. the individuals are usually considered infective until the crusts fall off (the desquamation lasts between 7 to 14 days) [3]. however, reports on monkeypox virus isolate in upper respiratory tract swabs/other body fluids even after skin lesions resolution can suggest a longer contagious period [7]. it is not known for how long the contaminated materials/crusts could contain viable viruses in the environment and the precise duration of the infectivity period [7]; however, it was reported that the variola virus could remain viable and be isolated up to 13 years in the skin crusts kept at room temperature [43]. also, there are reports of recurring diseases [7]. however, rarely, depending on the viral clade, infective dose, host immune system, and comorbidities, there can also be complications and sequelae, such as pneumonia, encephalitis, secondary bacterial infections, sepsis, sight-threatening lesions, vision loss, azoospermia, miscarriage (pregnant patients), permanent pitted skin scars (the most frequent sequelae), skin hyperor hypopigmentation, skin bacterial superinfections, and death (1% to 11% mortality rates) [3, 7, 9, 12, 23-25, 28, 44].]. monkeypox infection case definitions there are two recent monkeypox case definitions in the current literature: the portuguese directorate-general of health definition of a suspected, probable, and confirmed case; and the bunge et al. definition of a monkeypox case [23, 28]. other definitions were proposed and used across time as well, such as that of the drc (democratic republic of congo) ministry of health in endemic areas [24], but an update on the definition of monkeypox cases is much needed [23, 28]. according to the portuguese definition, starting with march 15, 2022, a suspected case is an individual that presents with localized or generalized skin eruption (rash) at any stage/anogenital lesions and one or more of the prodromal symptoms (high fever, more than 38 celsius degrees; headache; backache; myalgia; asthenia; lymphadenopathy), after excluding other sexually transmitted diseases and other differential diagnoses. a probable case has been added to the suspected case contact with a monkeypox case within 21 days from the first symptoms, either by direct contact, sexual contact, hospitalization, or travel to monkeypox-endemic areas. a confirmed case means a laboratory-proven infection [28, 38]. the laboratory diagnostic of the monkeypox infection can be done by pcr (polymerase chain reaction), western blot, positivity for igm antibodies (elisa), virus isolation and culture, immunohistochemistry, using material/fluid from the skin lesions, blood, and other body fluids of an individual [4, 6, 7, 12]. the differential diagnosis for monkeypox infection due to the skin rash that is associated with monkeypox infection, several differential diagnoses can be considered, including multiple sexually transmitted infections: smallpox lazar am, journal of ideas in health (2022); 5(3):716-724 720 (historically); hiv-associated dermatitis; syphilis; herpetic lesions; varicella, scabies, rickettsia pox, generalized vaccinia, bacterial infections, and even drug-associated skin lesions [3, 11, 12, 28]. the lymphadenopathy is the key finding that differentiates the monkeypox infection from smallpox, as otherwise, the clinical presentation of the two is indistinguishable [9, 11, 16, 24]. however, the current 2022 outbreak is characterized by an atypical presentation, most likely linked to the sexual transmission of the virus, with anogenital, even lower abdomen lesions; primary skin eruption on the thigh; pleomorphic erosions (simultaneous occurrence of various development stages of skin lesions, such as maculopapules, pustules, crusts, and scabs); inguinal lymphadenopathy; and change in the onset from childhood to a mean age of thirties [7, 23, 28, 45]. the atypical presentation of the monkeypox infection appears to be determined by the recent mutations of the virus. historically the monkeypox virus, like other dna viruses, has been relatively well conserved genetically but with potential for evolutionary mutations via subsequent selections [20]. however, lately, some authors have described an atypical, mathematically unanticipated number of mutations (10 times more than the usual mutation rate) that appear to be responsible for a more effective human-to-human transmission, increase in the monkeypox infection incidence, atypical clinical presentation, modified course of the disease and host immune modulation/escape [4, 6, 11, 18, 20]. lack of sufficient current knowledge on the two similar viruses: smallpox and monkeypox smallpox was the most deadly virus in the history of humanity. however, as it was officially declared eradicated in 1980 when there were no modern virological, immunological, or histological techniques, our medical knowledge of it is reduced to the clinical and dermatological descriptions of those times. a more detailed description of the pathogenesis of the virus would have helped us with the understanding of the monkeypox virus infectivity, as the two viruses share many similarities [5, 12, 15]. unfortunately, knowledge of the monkeypox virus is also scarce, and most of the data come from recent animal models of macaques or rodents infected with monkeypox or vaccinia virus to study smallpox. the smallpox virus has been eradicated, but due to a fear of a biological threat, there are still two variola virus stocks kept in maximum containment facilities: cdc (that is, us centers for disease control and prevention) in atlanta and vektor, located in russia, novosibirsk, under the surveillance of the who biosafety experts [16, 22]. that is, most of the monkeypox studies have been conducted until the current outbreak due to a persistent preoccupation with a potential bioterrorist threat with the smallpox virus [46, 47] and are not necessarily directly linked to the monkeypox virus per se [16, 29, 33, 48]. however, smallpox studies on humans are impossible due to ethical issues and putative severe health consequences for the subjects. therefore, most of the studies were smallpox surrogates using animal models of monkeypox virus infection [4, 19, 48]. still, the current worldwide monkeypox infection outbreak clearly highlights the paucity of data on monkeypox transmission routes, pathogenesis, host immune response to the virus, and lack of specific treatment for it. despite the clinical description, there are no specific studies to describe the detailed biochemical, molecular, histologic, and immunologic changes that occur during and after the infection, nor post-mortem descriptions. also, information on the monkeypox virus's natural occurrence and transmission routes is insufficient, even in endemic areas [4]. the paucity of data on the biochemical, pathologic, and immunologic changes that occur during monkeypox infection despite the loud clinical presentation, the only biochemical changes reported by a few authors are inconsistent, such as lymphopenia, hypoalbuminemia, increases in the c-reactive protein and alanine transaminase (alt) levels, and only rarely increased bun (blood urea nitrogen), creatinine levels, anemia or thrombocytopenia; also, limited reports on cytokine level changes in macaques models of monkeypox infection, such as increases in the ifn-γ, il-6, il-8 il-1ra [7,9, 45, 48]. other blood parameters, including ferritin or other inflammatory/immune markers as measured in the case of covid-19 [49], have not been analyzed yet in monkeypox patients. also, the mechanisms of immune response to the monkeypox virus remain elusive. however, the monkeypox virus appears to ensure its spread to the lymphatic organs and blood and afterward to multiple organs such as the skin, respiratory system, digestive tract, testis, and less frequently to the liver, kidney, and bone marrow, via the lymphocytes that take up the pathogen. afterward, the virus has multiple cytopathic effects, leading to inflammation, promoting cell apoptosis or necrosis and ulceration, as described in animal models of monkeypox infection [48]. most of the more detailed tissue and organ lesions are known due to the animal models used to study the infection. the effects seen in the superficial skin are cell ballooning, necrosis of the keratinocytes, ulcerations, and hyperplasia; in the derma: inflammation with an initial lymphocytic infiltrate, followed by neutrophilic, eosinophilic, macrophage, and multinucleated giant cells infiltrate; vasculitis; in the lymph nodes: hyperplasia with lymphadenopathy; spleen and tonsil lesions; in the digestive tract: vesicles, pustules, ulcerations leading to dysphagia, nausea/emesis and even diarrhea leading to dehydration; respiratory tract: ulcerations, with pharyngitis, laryngitis, bronchitis, pneumonitis; conjunctivitis and sightthreatening lesions; potential to cause orchiepididimitis with fibrotic and azoospermia sequelae, similar to the smallpox infection; rarely, it can cause even hepatitis or nephritis, heart and brain lesions [8, 10, 12, 25, 33, 48]. such advanced cytopathic effects with putative sequelae can be partly explained by the central clade viral ability to block and evade the immune system mechanisms, such as the complement system, t-cells, and nk lymphocytes, inhibition of inflammatory cytokine generation, decreased nk cell chemokine receptor expression, migration capacity, and killing function, loss of cytokine secretion and immune cell degranulation functions. in this context, multiple immunomodulatory mechanisms have been described for central clade monkeypox virus: complement system inhibition via complement control protein homologs; acquisition of host immune system evasion genes; interference with the t cell receptor-mediated t–cell activation by the central monkeypox lazar am, journal of ideas in health (2022); 5(3):716-724 721 clade; suppression of the t-cell functions; inhibition of the complement enzymes; prevention of the transcription of the host immune system genes and even expression of an antibodydependent enhancement of infection [4, 6, 12, 17, 50], as in covid-19 [36, 51]. for variola virus and other poxviruses, a homologous il-18 (interleukin 18) binding protein neutralizing human il-18, important in the evasion from the host immune response, has been described [46] and remains to be investigated in monkeypox virus as well. prevention and treatment although the smallpox vaccine could be reintroduced, the interruption in its routine administration was due not only to the smallpox eradication but also to the important adverse effects of the vaccine, especially of the live variants, with cases of significant skin scars, post-vaccinal encephalitis, variolization/generalized vaccinia, myopericarditis, cardiac arrhythmias, sepsis and even death [16, 19, 24, 29]. however, fortunately, there are no smallpox alive, fully replicative vaccines in use for monkeypox prevention/treatment [4, 12]. nowadays, among the various smallpox vaccines, there are two types regarded as safer (although none of them is ideal) available in the us that could be offered to monkeypox contacts and healthcare providers for preventive reasons or to ease and shorten the course of the disease: jynneous and acam 2000 (imvanex and imvamune) which are live, attenuated, nonreplicating vaccinia virus ankara strain, which require two doses. jynneos vaccine is considered safe even in immunocompromised individuals and cases of atopy [3, 4, 12, 25, 26, 38]. for prophylactic reasons, the vaccine must be delivered ideally within four days post-exposure and maximally (but not proven effective) within 14 or even 21 days after the exposure to the virus [3, 7, 29). however, none of them is considered ideal, nor has it been designed specifically for monkeypox. there are also two antiviral treatments: brincidofovir, designed for cytomegalovirus retinitis in hiv patients, which is an antireplicative drug; st-246, later known as tecoviramat, designed for smallpox treatment (as an anticowpox virus replication drug), blocks the release of the virions from the infected cells [4, 12, 25]. tecoviramat has already been approved for monkeypox infections but is not available worldwide [32]. another option is the prophylactic intravenous administration of vaccinia immune globulin, but its usefulness has not been sufficiently explored yet [25]. currently, it becomes obvious that there is a significant registry of information on sars-cov-2, which is a recently described virus, while the comparatively ancient monkeypox virus is insufficiently studied. such a contrast is due to the distinct historical timing of the emergence of the two viruses, with totally different medical research availabilities. however, even for the much-studied sars-cov-2, the pathogenic mechanisms and mechanisms of propagation across species are insufficiently understood [36, 52, 53]. nonetheless, the preoccupation with the monkeypox virus will gain place due to its fast geographic spread and already reported deaths outside of africa, but also because a lot of attention is paid to the exterior aspect, such as skin scars. as nowadays monkeypox infection is a recognized global health problem, with potential to become a pandemic, while the world is still vulnerable due to the covid19 repeated waves, multiple preventive strategies are to be considered: avoiding contact with infected patients or suspected cases that present with fever and rash; isolation/quarantine of the confirmed cases and of the contacts, ideally in negative-pressure rooms; manipulation of the personal objects (linen, towels) of the infected patients with gloves and careful disinfection of the laundry; vaccination and/or antiviral drugs; vaccination and professional protective equipment for the healthcare providers including n95 mask, protective eyeglasses/eye protection, gloves, gown; good hand hygiene; educational programs for the general population (reeducation of the population towards an adequate hygiene), as the level of knowledge on monkeypox disease is still low; specific education for the individuals that have high-risk sexual behavior; restriction of exotic animal trade; immediate quarantine of the animals suspected to be infected; prevention of unprocessed meet consumption in endemic countries; adequate epidemiological control with the identification of clusters and gathering of information from festival/event’s organizers [3, 25, 30, 32, 38, 54]. conclusions however, with the covid-19 pandemics, it has become obvious that no virus can be contained, and sole isolation/quarantine [53, 55-57] can bring only disastrous economic and social effects. also, a ring vaccination, as in the case of smallpox, is no longer possible because people cannot be forced to be vaccinated, due to the lack of an ideal efficient vaccine, especially for patients with vulnerable immunity (children, pregnant, elderly, immunocompromised), the impossibility of geographically tracing all contacts with the progress of fast transportation means across the globe and the persistence of the animal reservoir. in the near future, due to the high registry of viral mutagenesis, we can expect that viruses such as monkeypox and sars-cov-2 will continue their worldwide spread and generate flu-like subsequent infective bursts. only detailed knowledge of the viral pathogenesis will make possible a decisive cure and cessation of such epidemics /pandemics: until the emergence/reemergence/discovery of a new virus. therefore, all efforts should be conducted towards specific, dedicated studies to understand the pathogenic mechanisms of such viruses that are essential to design an effective treatment if we want to survive the next wave. abbreviation who: world health organization; bno: breakingnewson; msm: men having sex with men; hiv: human immunodeficiency virus; the drc: the democratic republic of congo; sars-cov-2: severe acute respiratory syndrome coronavirus 2; covid-19: the coronavirus disease 19; dna: deoxy nucleic acid; pcr: polymerase chain reaction; elisa: enzyme-linked immunosorbent assay; cdc: us centers for disease control and prevention; alt: alanine transaminase; bun: blood urea nitrogen; il: interleukin; il6: interleukin 6; il-8: interleukin 8; il-18: interleukin 18; ifngamma: interferon-gamma; hcid: high consequence of infectious disease. declaration acknowledgment none. lazar am, journal of ideas in health (2022); 5(3):716-724 722 funding the author received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing angelalazar.2008@yahoo.com. authors’ contributions angela madalina lazar (aml) is the principal investigator of this manuscript (review article). aml is the author responsible for the study concept, design, writing, reviewing, editing, and approving of the manuscript in its final form. aml has read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, review articles need no ethics committee approval. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of functional sciences, university of medicine and pharmacy “carol davila” bucharest, romania. 2colentina clinical hospital, bucharest, romania article info received: 31 may 2022 accepted: 12 august 2022 published: 17 august 2022 references 1. world health organization (who). multi-country outbreak of monkeypox external situation report 2, published july 25 2022. [cited 2022 july 30]. available from: https://www.who.int/publications/m/item/multicountry-outbreak-of-monkeypox--external-situationreport--2---25-july-2022. 2. spain and brazil report first monkeypox deaths bno news. published on july 29, 2022, by bno news. [cited 2022 july 31]. available from: https://bnonews.com/index.php/2022/07/spain-andbrazil-report-first-monkeypox-deaths/. 3. moore mj, rathish b, zahra f. monkeypox. [updated 2022 july 16]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2022 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk574519/. 4. alakunle e, moens u, nchinda g, okeke mi. monkeypox virus in nigeria: infection biology, epidemiology, and evolution. viruses 2020; 12:1257. doi: 10.3390/v12111257. 5. reynolds mg, doty jb, mccollum am, olson va, nakazawa y. monkeypox re-emrgence in africa: a call to expand the concept and practice of one health. expert rev anti infect ther 2019; 17(2): 129-139. 6. kumar n, acharya a, gendelman he, byrareddy sn. the 2022 outbreak and the pathobiology of the monkeypox virus. journal of autoimmunity 2022; https://doi.org/10.1016/j.jaut.2022.102855. 7. adler h, gould s, snell lb, wong w, houlihan cf, osborne jc, et al. clinical features and management of human monkeypox: a retrospective observational study in the uk. lancet infect dis 2022; 22:11531162.https://doi.org/10.1016/s1473-3099(22)002286. 8. bragazzi nl, kong jd, wu j. is monkeypox a new, emerging sexually transmitted disease? a rapid review of the literature. researchgate preprint june 2022. [cited 2022 july 31]. available from: https://www.researchgate.net/publication/361372229_ is_monkeypox_a_new_emerging_sexually_transmitte d_disease_a_rapid_review_of_the_literature. 9. benites-zapata v, ulloque-badarocco jr, alarconbraga ea, hernandez-bustamante ea, mosquerarojas md, bonilla-aldana dk, rodriguez-morales aj. clinical features, hospitalization and deaths associated with monkeypox: a systematic review and meta-anlysis. researchsquare preprints 2022 (july 05 2022); preprint (version 1) available at research square [https://doi.org/10.21203/rs.3.rs-1789976/v1]. 10. earl pl, americo jl, cotter ca, moss b. comparative live bioluminescence imaging of monkeypox virus dissemination in a wild-derived inbred mouse (mus musculus castaneus) and outbred african dormouse (graphiurus kelleni). virology 2015; 475: 150-158. 11. sklenovska n, van ranst m. emergence of monkeypox as the most important orthopoxvirus infection in humans. frontiers in public health 2018; 6:241. 12. mccollum am, damon ik. human monkeypox. clin infect dis 2014; 58 (2): 260-267. 13. smithson c, purdy a, verster aj, upton c. prediction of steps in the evolution of variola virus host range. plos one 2014; 9(3): e91520. 14. mucker em, wollen-roberts se, kimmel a, shemblin j, sampey d, hooper jw. intranasal monkeypox marmoset model: prophylactic antibody treatment provides benefit against severe monkeypox lazar am, journal of ideas in health (2022); 5(3):716-724 723 virus disease. plos neglected tropical disease 2018; 12(6): e0006581. 15. weaver jr, isaacs sn. monkeypox virus and insights into its immunomodulatory proteins. immunol rev 2008; 225:96-113. 16. breman jg. smallpox. jid 2021; 224 (s 4): s379s386. https://doi.org/10.1093/infdis/jiaa588. 17. song h, josleyn n, janoska k, skinner j, reeves rk, cohen m, jett c, johnson r, blaney je, bollinger l, jennings g, jahrling pb. monkeypox virus infection of rhesus macaques induces massive expansion of natural killer cells but supresses natural killer cell functions. plos one 2013; 8(10): e77804. 18. petersen e, abubakar i, thekweazu c, heymann d, ntoumi f, blumberg l, et al. monkeypoxenhancing public health preparedness for an emrging lethal zoonotic epidemic threat in the wake of the smallpox eradication era. international journal of infectious diseases 2019; 78:78-84. 19. nigam p, earl pl, americo jl, sharma s, wyatt ls, edghill-spano y, et al. dna/mva hiv-1/aids vaccine elicits long-lived vaccinia virus-specific immunity and confers pretection against a lethal monkeypox challenge. virology 2007; 366(1): 7383. 20. douglass nj, richardson m, dumbell kr. evidence for recent genetic variation in monkeypox viruses. journal of general virology 1994; 75: 1303-1309. 21. malyarchuk ab, andreeva tv, kuznetsova il, kunizheva ss, protasova ms, uralsky li, tyazhelova tv, gusev fe, manakhov ad, rogaev ei. genomics of ancient pathogens: first advances and prospects. biokhimiya (moscow) 2022; 87(3): 242-258.doi: 10.1134/s0006297922030051. 22. wahl-jenssen v, cann ja, rubins kh, huggins jw, fisher rw, johnson aj, de kok-mercado f, larsen t, raymond jl, hensley le jahrling pb. progression of pathogenic events in cynomolgus macaques infected with variola virus. plos one 2011; 6(10): e24832. 23. bunge em, hoet b, chen l, lienert f, weidenthaler h, baer lr, steffen r. the challenging epidemiology of human monkeypoxa potential threat? a systematic review. plos negl trp dis 2022; 16(2):e0010141. doi: 10.1371/journal.pntd.0010141. 24. beer em, rao vb. a systematic review of the epidemiology of human monkeypox outbreaks and implications for outbreak strategy. plos negl trop dis. 2019;13(10):e0007791. doi: 10.1371/journal.pntd.0007791. 25. guarner j, del rio c, malani pm. monkeypox in 2022-what clinicians need to know. jama 2022; 328 (2): 139-140. 26. petersen bw, kamamba j, mccollum am, lushima rs, wemakoy eo, tamfum jjm, et al. vaccinating against monkeypox in the democratic republic of the congo. antiviral res 2019; 162:171-177. 27. von magnus p, andersen ek, petersen kb, birchandersen a. a pox-like disease in cynomegalus monkeys. acta pathologica microbiologica scandinavica 1959; 46:156-176. https://doi.org/10.1111/j.1699-0463.1959.tb00328.x. 28. bragazzi nl, kong jd, mahroum n, tsigalou c, khamisy-farah r, conerti m, wu j. epidemiological trends and clinical features of the ongoing monkeypox epidemic: a preliminary pooled data analysis and literature review. j med virol. 2022; 1-8. doi:10.1002/jmv.27931. 29. ligon bl. monkeypox: a review of the hostory and emergence in the western hemisphere. semin pediatr infect dis 2004; 15:280-287. 30. harapan h, setiawan am, yufka a, anwar s, wahyuni s, asrizal fw, et al. knowledge of human monkeypox viral infection among general practioners: a cross-sectional study in indonesia. pathogens and global health 2020; 114(2): 68-75. 31. guagliardo sa, reynolds mg, kabamba j, nguette b, lushima rs, wemakoy oe, mccollum am. sounding the alarm: defining thresholds to trigger a public health response to monkeypox. plos neglected tropical disease 2018;12(12): e0007034. https://doi.org/10.1371/journal.pntd.0007034. 32. world health organization (who). monkeypox (who.int), 19 may 2022. [cited 2022 july 31]. available from: https://www.who.int/news-room/factsheets/detail/monkeypox. 33. cann ja, jahrling pb, hensley le, wahl-jensen v. comparative pathology of smallpox and monkeypox in man and macaques. j comp pathol 2013; 148(1):6-21. 34. taylor l. monkeypox: who to rename disease to prevent stigma bmj 2022; 377:o1489 doi:10.1136/bmj.o1489. 35. jiang s, du l, shi z. (2020). an emerging coronavirus causing pneumonia outbreak in wuhan, china: calling for developing therapeutic and prophylactic strategies. emerging microbes & infections 9, 275-277. 36. lazar am. understanding sars-cov-2 features of infectivity, aggressiveness, and transmissibility: an insect-vector theory for sars-cov-2 dissemination. journal of ideas in health 2021; 4 (special 1): 343347; https://doi.org/10.47108/jidhealth.vol4.issspecial1.10 9. 37. south am, tomlinson l, edmonston d, hiremath s, sparks ma. (2020). controversies of reninangiotensin system inhibition during the covid-19 pandemic. nature reviews. nephrology; https://doi.org/10.1038/s41581-020-0279-4. 38. sah r, abdelaal a, reda a, katamesh be, manirambona e, abdelmonem h, et al. monkeypox and its possible sexual transmission: where are we now with its evidence? preprints 2022, 2022070314. [cited 2022 july 31]. doi: 10.20944/preprints202207. 0314.v1. 39. monkeypox situation update, as of 8 august 2022 (europa.eu). european centre for disease prevention and control. [cited 2022 august 11]. available from: https://www.ecdc.europa.eu/en/monkeypox-multi lazar am, journal of ideas in health (2022); 5(3):716-724 724 country-outbreak/situation-update-eueea-westernbalkans-turkey. 40. who: 14,000 monkeypox cases worldwide, 5 deaths | cidrap (umn.edu). [cited 2022 july 30]. available from: https://www.cidrap.umn.edu/newsperspective/2022/07/who-14000-monkeypox-casesworldwide-5-deaths 41. bisset v. first monkeypox deaths reported in brazil and spain the washington post, 2022. [cited 2022 july 30]. available from: https://www.washingtonpost.com/world/2022/07/30/ monkeypox-deaths-brazil-spain/. 42. al jazeera. spain reports second monkeypox death | health news | al jazeera. 2022. [cited 2022 july 31]. available from: https://www.aljazeera.com/news/2022/7/30/spainreports-second-monkeypox-death. 43. macintyre cr, das a, chen x, de silva c, doolan c. evidence of long-distance aerial convection of variola virus and implications for disease control. viruses 2020; 12:33. doi: 10.3390/v12010033. 44. reynolds mg, mccollum am, nguette b, shongo lushima r, petersen bw. improving the care and treatment of monkeypox patients in low-resource settings: applying evidence from contemporary biomedical and smallpox biodefense research. viruses. 2017;9(12):380. doi: 10.3390/v9120380. 45. bragazzi nl, kong jd, wu j. monkeypox and laboratory medicine: more data are urgenty needed. researchgate preprint 2022; june 2022; [cited 2022 july 31]. available from: https://www.researchgate.net/publication/361411982_ monkeypox_and_laboratory_medicine_more_data_ar e_urgently_needed. 46. meng x, leman m, xiang y. variola virus il-18 binding protein interacts with three human il-18 residues that are part of a binding site for human il-18 receptor alpha subunit. virology 2007; 358(1):211-220. 47. su hp, garman sc, allison tj, fogg c, moss b, barboczi dn. the 1.51-a structure of the poxvirus l1 protein, a target of potent neutralizing antibodies. pnas 2005; 102(12): 4240-4245. 48. tree ja, hall g, rayner e, graham va, steeds k, bewley kr, hatch gj, dennis m, taylor i, roberts ad, funnell sgp, vipond j. sequence of pathogenic events in cynomolgus infected with aerosolized monekypox virus. journal of virology 2015; 89(9): 4335-4342. 49. lazar am. hyperferritinemia: the link between covid-19, inflammation, and patient comorbidities. journal of ideas in health 2021; 4(special4):615-22. doi: https://doi.org/10.47108/jidhealth.vol4.iss4.193. 50. hudson pn, self j, weiss s, braden z, xiao y, girgis nm, et al. elucidating the role of the complement control protein in monkeypox pathogenicity. plos one 2012; 7(4):e35086. 51. wan y, shang j, sun s, tai w, chen j, geng q, he l, chen y, wu j, shi z, et al. (2020). molecular mechanism for antibody-dependent enhancement of coronavirus entry. journal of virology 94(5), e02015-19. 52. lazar am. renin-angiotensin-aldosterone system inhibitors – a realm of confusion in covid-19. journal of ideas in health 2021; 4 (special2): 389394. https://doi.org/10.47108/jidhealth.vol4.issspecial2.12 5. 53. lazar am. ace2 enzymatic role in the sars-cov-2 activation: a perspective through the evolutionary promiscuy and substrate diversity of enzymes. journal of ideas in health 2021; 4(4): 581-587. https://doi.org/10.47108/jidhealth.vol4iss4.169. 54. who. statement: vaccines alone won't end the monkeypox outbreak – at-risk individuals will have to take action, too (who.int). [cited 2022 july 31]. available from: https://www.who.int/europe/news/item/26-07-2022statement--vaccines-alone-won-t-end-themonkeypox-outbreak---at-risk-individuals-will-haveto-take-action-too. 55. ali jadoo sa. the second wave of covid-19 is knocking at the doors: have we learned the lesson? journal of ideas in health 2020; 3 (special 1):183184; https://doi.org/10.47108/jidhealth.vol3.issspecial1.7. 56. ali jadoo sa, dastan i, al-samarrai mam, yaseen sm, abbasi a, alkhdar h, al saad m, danfour om. knowledge, attitude, and practice towards covid-19 among syrian people resident in turkey. journal of ideas in health 2020; 3(special2):278-85. https://doi.org/10.47108/jidhealth.vol3.issspecial2.6. 57. ali jadoo sa. covid -19 pandemic is a worldwide typical biopsychosocial crisis. journal of ideas in health 2020; 3 (2):152-54. https://doi.org/10.47108/jidhealth.vol3.iss2.58. https://doi.org/10.47108/jidhealth.vol5.iss2.213 karpay s, et al., journal of ideas in health 2022;5(2):664-668 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access evaluation of biochemical parameters in acute myocardial infarction and angina patients soujanya karpay1, c.v. sarada2*, deepthi kondu3, pratyusha pavuluri4, ramesh gadepalli5, bandaru naresh6 abstract background: early and accurate detection of acute myocardial infarction (ami) is an important unmet clinical requirement. the present study sought to evaluate the levels of n-terminal pro-brain natriuretic peptide (ntprobnp), cardiac troponin i (ctni), fasting lipid profile, random blood sugar, and serum creatinine in ami patients compared to angina patients. methods: in a single-center, hospital-based, cross-sectional, observational, prospective study conducted at gandhi medical college, secunderabad, from october-2018 to september-2019. a total of 150 patients aged above 40 years with acute chest pain (within 2-6 hours) and who were clinically susceptive of ami and angina were investigated. the patients were divided into group i (50 ami patients) and group ii (100 angina patients). levels of all biochemical parameters of blood were assessed. the statistical analyses were performed using the spss statistical software, version 15. a student t-test was used to compare the continuous variables between the two groups. results: out of 150 patients, higher male prevalence was found in both the groups (60% and 63%, respectively). group i had higher levels of ntprobnp (2909±273pg/ml vs. 110±20.74pg/ml, p<0.01), ctni (2.06±1.3ng/ml vs. 0.006±0.002ng/ml, p<0.01), and fasting lipid profile (total cholesterol:216±41.2mg/dl vs.201±32.5mg/dl, p<0.05, triglycerides:217.7±63.6 mg/dl vs. 175.3±48.8 mg/dl, p<0.01, low-density lipoprotein:141.7mg/dl±41.5 vs. 127.1±30.24 mg/dl, p<0.05, very low-density lipoprotein:43.4±12.8mg/dl vs. 35.1±9.8mg/dl, p<0.01) than group ii, except low levels of high-density lipoprotein (31.2±3.83mg/dl vs. 38.9±4.32 mg/dl, p<0.01). conclusion: assessment of ntprobnp, ctni, and fasting lipid profile may aid in the early diagnosis of ami and its management. keywords: biomarkers, diagnosis, myocardial infarction; stable angina, india background acute myocardial infarction (ami) is the leading cause of death and morbidity worldwide. recently, india has had the highest disease burden of ami, with 6-9% in-hospital mortality rates [1,2]. ami is characterized by reduced coronary artery reperfusion attributed to stenosis or distal embolization of the thrombus and abrupt total obstruction of a coronary artery caused by thrombosis. the main clinical manifestations of ami include acute chest discomfort and prolonged st-segment elevation on an electrocardiogram (ecg). though, a small percentage of patients have no symptoms or changes in their ecg [3]. as ecg has limited sensitivity and specificity for the diagnosis of ami, the european society of cardiology (esc) and the american college of cardiology (acc) established ami criteria. to be diagnosed with ami, a patient must exhibit at least two of the following traits: a) characteristic elevation in cardiac markers (such as creatinine kinase-mb (ck-mb) isoenzymes), particularly serum cardiac troponins i or t (ctni or ctnt), and b) ecg changes with st elevations and abnormal q waves [4-6]. though ami causes significant morbidity and mortality, measuring a variety of cardiac biomarkers is of paramount importance for early diagnosis, risk classification, and tailoring appropriate treatment in the management of these high-risk patients. the optimal ___________________________________________________ cvsarada2@gmail.com 2cdepartment of biochemistry, gandhi medical college, secunderabad, telangana-500003, india. full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol5.iss2.213 http://www.jidhealth.com/ karpay s, et al., journal of ideas in health (2022); 5(2):664-668 665 biomarkers for identifying myocardial injury are exhibited at significantly higher levels inside cardiac tissue, have good clinical sensitivity and specificity, and can be detected in the bloodstream early following the commencement of clinical manifestations such as chest pain [3]. against this background, the present study was done to assess the levels of n-terminal prohormone of brain natriuretic peptide (ntprobnp), ctni, fasting lipid profile, serum creatinine, and random blood sugar (rbs) in ami patients as compared to angina patients. methods study design a single-center, hospital-based, cross-sectional, observational, prospective study was conducted from october-2018 to september-2019 at gandhi medical college, secunderabad. a total of 150 patients aged above 40 years with acute chest pain (within 2-6 hours) and who were clinically susceptive of ami and angina were included in the study. patients with known cases of heart failure and chronic kidney disease were excluded. two-dimensional echocardiography was performed at admission to exclude cases of heart failure. the patients were segregated into group i (50 patients with ami) and group ii (100 patients with angina). the levels of ntprobnp, ctni, fasting lipid profile, rbs, and serum creatinine were compared between both groups. sample collection after obtaining informed consent, 5ml of venous blood sample was collected within 6 hours of chest pain for ntprobnp, ctni, rbs, and serum creatinine assays. another 5ml of blood sample was collected after 10-12 hours of fasting to assay the fasting lipid profile by venipuncture into plain red-color vacutainer tubes under aseptic conditions. the collected blood sample was sent for analysis. then, the blood was allowed to stand for about 30 minutes at room temperature. it was centrifuged at a rate of 3000 rpm, and serum was separated and analyzed for the following parameters: ntprobnp, ctni, fasting lipid profile [total cholesterol, triglycerides, high-density lipoprotein (hdl), low-density lipoprotein (ldl), and verylow-density lipoprotein (vldl)], rbs, and serum creatinine. ntprobnp was assayed by immunosandwich method with final detection by enzyme-linked fluorescent assay and analyzed in biomerieuxvidas autoanalyzer. ctni was assayed by immunometric immunoassay and analyzed in vitros 5600 autoanalyzer. total cholesterol was assayed by the cholesterol oxidase peroxidase method and analyzed in beckman coulter au 5800 analyzer. triglycerides were assayed by the glycerol3-phosphate oxidase method and analyzed in beckman coulter au 5800. hdl was analyzed by beckman coulter au 5800. ldl was assayed by the inbuilt calculated method by friedewald equation and analyzed in beckman coulter au 5800. rbs was assayed by the hexokinase method and analyzed in beckman coulter au 5800. serum creatinine was assayed by the modified jaffe method and analyzed in beckman coulter au 5800. statistical analysis continuous variables are described as mean and standard deviation. categorical variables are represented as numbers and percentages. comparison of age and biochemical parameters among the two groups were performed using the student t-test. a p-value of <0.05 was considered statistically significant. the statistical analyses were performed using the spss statistical software, version 15 (statistical package for the social sciences, inc., chicago, illinois, usa). results out of 150 patients, 50 ami patients were allocated to the group i, and 100 angina patients were assigned to group ii. a higher male prevalence was found in both groups (60% and 63%, respectively). the majority of the patients in both groups were in the sixth decade of life (figure 1). duration of diabetes was 5-10 years in most patients of group i, while <10 years in group ii (figure 2). non-diabetic patients were more prevalent in group ii (15%) than in group i (4%). figure 1: distribution of patients by age between the two groups figure 2: distribution of patients by diabetes duration between the two groups table 1 represents the demographic characteristics of study groups. there was no significant difference found between the mean age of the study population (group i: 55.06 ± 5.01 vs. group ii: 54.9 ± 4.24 years, p=0.9084). group i had significantly higher levels of serum ntprobnp (2909 ± 273 pg/ml vs. 110 ± 20.74 pg/ml, p=0.0001), serum ctni (2.06 ± 1.3 ng/ml vs.0.006 ± 0.002 ng/ml, p=0.0001), and fasting lipid profile (total cholesterol: 216 ± 41.2 mg/dl vs. 201 ± 32.5 mg/dl, p=0.0162, triglycerides: 217.7 ± 63.6 mg/dl vs. 175.3 ± 48.8 mg/dl, p=0.0001,ldl: 141.7 mg/dl ± 41.5 vs. 127.1 ± 30.24 mg/dl, p=0.0001, and vldl: 43.4 ± 12.8 mg/dl vs. 35.1 ± 9.8 mg/dl, p=0.0001) than group ii, except low levels of hdl (31.2 ± 3.83 mg/dl vs. 38.9 ± 4.32 mg/dl, p=0.0001). karpay s, et al., journal of ideas in health (2022); 5(2):664-668 666 table 1: demographic characteristics of study groups characteristics group i: ami patients (n=50) group ii: angina patients (n=100) p value age, years 55.06 ± 5.01 54.9 ± 4.24 0.9084 serum ntprobnp, pg/ml 2909 ± 273 110 ± 20.74 0.0001 serum troponin i, ng/ml 2.06 ± 1.3 0.006 ± 0.002 0.0001 fasting lipid profile total cholesterol, mg/dl 216 ± 41.2 201 ± 32.5 0.0162 high-density lipoprotein, mg/dl 31.2 ± 3.83 38.9 ± 4.32 0.0001 triglycerides, mg/dl 217.7 ± 63.6 175.3 ± 48.8 0.0001 low-density lipoprotein, mg/dl 141.7 ± 41.5 127.1 ± 30.24 0.0001 very low-density lipoprotein, mg/dl 43.4 ± 12.8 35.1 ± 9.8 0.0001 random blood sugar, mg/dl 202.2 ± 61.3 187.9 ± 39.3 0.0836 serum creatinine, mg/dl 0.880 ± 0.191 0.892 ± 0.2 0.7212 ǂ data are presented as mean ± s.d. ntprobnp: n-terminal prohormone of brain natriuretic peptide table 2: comparison of ntprobnp levels of the present study with previous studies studies study patients serum ntprobnp, pg/ml present study ami vs. angina 2909 ± 273 vs. 110 ± 20.74 ezekowitz et al.(2006) [9] ami patients with duration of symptoms<2 hours, 2-4 hours,>4hours 113 (50-245), 246 (83-711) and 464 (158 2174) kasap et al. (2007) [10] ami vs. healthy 1432.17 ± 140.64 vs. 93.23 ± 3.25 khan et al. (2008) [11] ami (survivors vs. dead) 700.2(0.3–11485.3) vs.5781.3 (1.4–10835.9) haaf et al. (2011) [12] ami patients vs. other final diagnoses 886 vs.135 drewniak et al. (2015) [13] ami patients 4773 ± 8807 discussion the quantitative data collected in this research has shown that the present study scrutinized the diagnostic value of ntprobnp, ctni, fasting lipid profile, rbs, and serum creatinine in ami patients compared to angina patients and reported the significance of ntprobnp, ctni, and fasting lipid profile with the potential to improve early diagnosis in ami patients. significance of ntprobnp in ami patients the release of ntprobnp into the bloodstream is triggered by increased wall stretching due to ventricular wall stress. this is directly related to the diameter of the chamber and the transmural pressure but inversely related to the thickness of the wall. the increase in chamber diameter and transmural pressure in ami patients contributes to the elevation of natriuretic peptides. the level of ntprobnp rises soon after infarction and peaks after 24 hours, thereby relating to the extent of the infarct [7]. furthermore, its level increases after five days in ami patients with complications such as cardiac failure. after 24 hours of symptom onset, ntprobnp remains a prognostic factor in addition to cardiac troponin when assessed upon admission [8]. the present study reported significantly higher values of ntprobnp in ami patients than in angina patients (2909 ± 273 pg/ml vs. 110 ± 20.74 pg/ml, p=0.0001). this result is satisfactory when compared to past studies. the comparison of values of ntprobnp among these studies is shown in table 2 [9-13]. all these studies also substantiated the significance of higher levels of ntprobnp as a marker of poor cardiac function in ami patients. significance of cardiac troponin i in ami patients the cardiac troponin increases at 3-8 hours, peaks at 12-24 hours, and remains elevated for about ten days. though the use of troponin for diagnosing ami and risk stratification to facilitate decision-making has transformed the treatment of patients with chest pain, the 12-hour delay for the levels to peak remains a problem for this biomarker [14]. the test approach employed in the present investigation was exceptionally sensitive troponin i with an ami cutoff of 0.012 ng/ml. statistical analysis of the acquired findings revealed that serum troponin i readings are significantly higher in acute ami patients (2.06 ± 1.3 ng/ml) than in angina patients (0.006 ± 0.002 ng/ml). keller et al. [15] reported that troponin i is a more sensitive assay that improves early identification of ami and risk stratification, consistent with the present study's findings. the present study also supports the results of reichlin et al. [16] and daubert et al. [17]. they stated that troponin i is a highly sensitive marker of myocardial necrosis that is requisite for identifying mi in a clinical situation where ischemia is present. significance of fasting lipid profile in ami patients current prospective cohort studies have propounded that lipid abnormality is linked to an increased risk of cardiovascular events, and ldl, hdl, and triglycerides are all critical determinants of cardiovascular disease [18, 19]. however, there is a paucity of evidence of the significance of serum lipid assessments in ami patients. thus, in the present study, we have found a significant increase in total cholesterol (216 ± 41.2 mg/dl vs. 201± 32.5 mg/dl), triglycerides (217.7±63.6 mg/dl vs. 175.3 ± 48.8 mg/dl), ldl (141.7 mg/dl ± 41.5 vs. 127.1 ± karpay s, et al., journal of ideas in health (2022); 5(2):664-668 667 30.24 mg/dl), and vldl (43.4 ± 12.8 mg/dl vs. 35.1 ± 9.8 mg/dl), whilst there was a significant decrease in hdl (31.2 ± 3.83 mg/dl vs. 38.9 ± 4.32 mg/dl) in ami patients than angina patients. this finding is concordant with those of other studies investigating fasting lipid profiles in an ami population that found a direct association between total cholesterol, triglycerides, ldl, and vldl and an inverse relationship between hdl and ami disease, as delineated in table 3 [18, 20, 21]. the present study's findings are expected to weigh in on the discussion about the management of ami patients. there are several limitations to the study that need to be acknowledged. first and foremost, because this was a single-center study with small sample size, it is not representative of the general population. furthermore, the conclusion of this study was constrained by an inadequate history and a shorter study period. further large, well-designed studies, especially in different ethnic populations, are warranted. table 3: comparison of fasting lipid profile of the present study with previous studies studies present study narayana et al. (2011) [18] shirafkan et al. (2012) [20] kumar et al. (2019) [21] study patients ami vs. angina ami vs. stable angina ami vs. normal controls ami (within 24 hours and after 48 hours) total cholesterol, mg/dl 216 ± 41.2 vs. 201 ± 32.5 224.02 ± 14.92 vs.202.39 ± 15.72 201.86 ± 44.24 vs. 181.37 ±1 5.32 207.5 ± 30.5 vs. 192.4 ± 49.3 high-density lipoprotein, mg/dl 31.2 ± 3.83 vs. 38.9 ± 4.32 31.82 ± 4.49 vs. 44.03 ± 5.37 40.62 ± 5.18 vs. 61.57 ± 11.59 46.6 ± 9.9 vs. 40.7 ± 11.8 triglycerides, mg/dl 217.7 ± 63.6 vs. 175.3 ± 48.8 165.03 ± 20.09 vs. 125.09 ± 20.02 168.69 ± 17.34 vs. 123.69 ± 31.71 153.8 ± 10.2 vs. 183.8 ± 14.8 low-density lipoprotein, mg/dl 141.7 ± 41.5 vs. 127.1 ± 30.24 160.08 ± 18.27 vs. 137.02 ± 20.75 117.03 ± 22.67 vs. 87.57 ± 20.78 149.0 ± 41.2 vs. 133.4 ± 54.0 very low-density lipoprotein, mg/dl 43.4 ± 12.8 vs. 35.1 ± 9.8 32.89 ± 4.12 vs. 24.83 ± 4.03 33.73 ± 3.46 vs. 24.73 ± 6.34 conclusion higher levels of nt-probnp, ctni, and fasting lipid profile (total cholesterol, triglycerides, ldl, and vldl), as well as lower levels of hdl, were found in ami patients. thus, measurement of ntprobnp, ctni, and fasting lipid profile may provide crucial prognostic information in the evaluation of ami patients. abbreviation acc: american college of cardiology; ami: acute myocardial infarction; ck-mb: creatinine kinase-mb; ctni or ctnt: cardiac troponins i or t; ecg: electrocardiogram; esc: european society of cardiology; hdl: high-density lipoprotein; ldl: low-density lipoprotein; ntprobnp: nterminal prohormone of brain natriuretic peptide; rbs: random blood sugar; vldl: very-low-density lipoprotein declaration acknowledgment we would like to thank all the participants for their responses and insight during the covid-19 pandemic. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing cvsarada2@gmail.com authors’ contributions all authors equally contributed to the concept, design, literature search, data analysis and data acquisition, manuscript writing, editing, and reviewing. all authors have read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. ethical permission was granted by the institutional ethics committee of gandhi medical college, secunderabad (ref no. iec/gmc/2019/03/14) on 01st august 2019. all patients gave written informed consent. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of biochemistry, r.v.m medical college, laxmakkapally, telangana-502279, india. 2*department of biochemistry, gandhi medical college, secunderabad, telangana-500003, india. 3department of biochemistry, r.v.m medical college, laxmakkapally, telangana-502279, india.4department of biochemistry, r.v.m medical college, laxmakkapally, telangana-502279, india. 5department of cardiology, yashoda hospitals, secunderabad, telangana karpay s, et al., journal of ideas in health (2022); 5(2):664-668 668 500003, india. 6department of cardiology, yashoda hospitals, secunderabad, telangana-500003, india. article info received: 15 march 2022 accepted: 15 april 2022 published: 14 may 2021 references 1. kumar as, sinha n. cardiovascular disease in india: a 360degree overview. med j armed forces india. 2020;76(1):1. https://doi.org/10.1016/j.mjafi.2019.12.005 2. guha s, sethi r, ray s, bahl vk, shanmugasundaram s, et al. cardiological society of india: position statement for the management of st elevation myocardial infarction in india. indian heart j. 2017;69(suppl 1): s63–s97. https://doi.org/10.1016/j.ihj.2017.03.006. 3. wang x-y, zhang f, zhang c, zheng l-r, yang j. the biomarkers for acute myocardial infarction and heart failure. biomed res int. 2020; 2020:2018035. https://doi.org/10.1155/2020/2018035. 4. nagurney jt, huang c, heredia o, sane s, lewis sc, et al. the new and old definitions of acute myocardial infarction: a data-based comparison. am j emerg med. 2008;26(5):523-531. https://doi.org/10.1016/j.ajem.2007.08.001. 5. thygesen k, alpert js, jaffe as, chaitman br, bax jj, et al. fourth universal definition of myocardial infarction (2018). eur heart j. 2019;40(3):237-269. https://doi.org/10.1161/cir.0000000000000617. 6. aydin s, ugur k, aydin s, sahin i̇, yardim m. biomarkers in acute myocardial infarction: current perspectives. vasc health risk manag. 2019; 15:1–10. https://doi.org/10.2147/vhrm.s166157. 7. morita e, yasue h, yoshimura m, ogawa h, jougasaki m, et al. increased plasma levels of brain natriuretic peptide in patients with acute myocardial infarction. circulation. 1993;88(1):82-91. https://doi.org/10.1161/01.cir.88.1.82. 8. james sk, lindahl b, siegbahn a, stridsberg m, venge p, et al. n-terminal pro–brain natriuretic peptide and other risk markers for the separate prediction of mortality and subsequent myocardial infarction in patients with unstable coronary artery disease: a global utilization of strategies to open occluded arteries (gusto)-iv substudy. circulation. 2003;108(3):275-281. https://doi.org/10.1161/01.cir.0000079170.10579.dc. 9. ezekowitz ja, théroux p, chang w, mahaffey kw, granger cb, et al. n-terminal pro-brain natriuretic peptide and the timing, extent and mortality in st elevation myocardial infarction. can j cardiol. 2006;22(5):393-397. https://doi.org/10.1016/s0828-282x(06)70924-2. 10. kasap s, gönenç a, şener de, hisar i̇. serum cardiac markers in patients with acute myocardial infarction: oxidative stress, c-reactive protein and n-terminal probrain natriuretic peptide. j clin biochem nutr. 2007;41(1):50-57. https://doi.org/10.3164/jcbn.2007007. 11. khan sq, quinn p, davies je, ng ll. n-terminal pro-btype natriuretic peptide is better than timi risk score at predicting death after acute myocardial infarction. heart. 2008;94(1):40-43. https://doi.org/10.1136/hrt.2006.108985. 12. haaf p, balmelli c, reichlin t, twerenbold r, reiter m, et al. n-terminal pro b-type natriuretic peptide in the early evaluation of suspected acute myocardial infarction. am j med. 2011;124(8):731-739. https://doi.org/10.1016/j.amjmed.2011.02.035. 13. drewniak w, szybka w, bielecki d, malinowski m, kotlarska j, et al. prognostic significance of nt-probnp levels in patients over 65 presenting acute myocardial infarction treated invasively or conservatively. biomed res int. 2015; 2015:782026. https://doi.org/10.1155/2015/782026. 14. chan d, ng ll. biomarkers in acute myocardial infarction. bmc med. 2010;8(1):1-11. https://doi.org/10.1186/1741-7015-8-34. 15. keller t, zeller t, peetz d, tzikas s, roth a, et al. sensitive troponin i assay in early diagnosis of acute myocardial infarction. n engl j med. 2009;361(9):868877. https://doi.org/10.1056/nejmoa0903515. 16. reichlin t, hochholzer w, bassetti s, steuer s, stelzig c, et al. early diagnosis of myocardial infarction with sensitive cardiac troponin assays. n engl j med. 2009;361(9):858-867. https://doi.org/10.1056/nejmoa0900428. 17. daubert ma, jeremias a. the utility of troponin measurement to detect myocardial infarction: review of the current findings. vasc health risk manag. 2010; 6:691– 699. https://doi.org/10.2147/vhrm.s5306. 18. narayana ks, koora s, shaker ia, basha ss, babu ks. comprehensive levels of serum enzymes and lipid profile testing in mi and stable angina subjects. indian j basic and applied medical research. 2011;1(1):13-21. 19. roberts r, gowda k, ludbrook pa, sobel be. specificity of elevated serum mb creatine phosphokinase activity in the diagnosis of acute myocardial infarction. am j cardiol. 1975;36(4):433-437. https://doi.org/10.1016/00029149(75)90890-5. 20. shirafkan a, marjani a, zaker f. serum lipid profiles in acute myocardial infarction patients in gorgan. biomedical research. 2012;23(1):119-124. 21. kumar n, kumar s, kumar a, shakoor t, rizwan a. lipid profile of patients with acute myocardial infarction (ami). cureus. 2019;11(3). https://doi.org/10.7759/cureus.4265. choudhari ok, et al., journal of ideas in health 2020;3(special 1):196-197 © the author(s). 2020 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access cotrimoxazole as adjuvant therapy in critical ill covid-19 patients omkar kalidasrao choudhari1*, sonam spalgis2, umesh chandra ojha3 dear editor, the ongoing pandemic of covid-19 has forced us to consider using available drugs in the shortfall of vaccines and established treatment. cotrimoxazole is one of the oldest drugs presently used in the prevention and treatment of opportunistic infections in the human immune deficiency virus (hiv) etc. it is a combination of two drugs trimethoprim and sulfamethoxazole. cotrimoxazole is a potent broad-spectrum antibiotic with antifungal, antiprotozoal, activity. the rationale behind the use of cotrimoxazole is its anti-inflammatory and immunomodulatory action. the mortality among the covid19 patients is mainly due to the acute respiratory distress syndrome or pulmonary embolism and respiratory failure mediated by cytokine storm due to unopposed multiplication of cascade of inflammatory mediators [1]. the immunomodulatory and anti-inflammatory activity of the cotrimoxazole is seen in many studies [2.3]. the arrow trial showed lower concentrations of plasma pro-inflammatory markers like c reactive protein (crp), interleukin 6 in continuous cotrimoxazole prophylaxis, suggesting its role as antiinflammatory and immunomodulation [3]. the role of interleukin 6 (il6) and tumour necrosis factor-alpha (tnf α) in the pathogenesis of covid-19 mortality is well documented [4]. the role of cotrimoxazole in the suppression of tnf α is also well documented [5]. lymphopenia is associated with adverse outcomes in covid-19. cotrimoxazole has shown an increase in lymphocyte count in a short and long therapy duration, but these study findings are not consistent with few other studies; however, no significant impact of cotrimoxazole was seen on immune activation of cd8 t cells [6-8]. hence it should be reserved only for critically ill patients. oxidative stress has an important aspect of the cytokine storm, which is also reduced by cotrimoxazole [9]. various side effects are mentioned in the literature. this cost-effective old drug is well tolerated among the population with the concomitant use of folic acid; moreover, it also looks after the secondary infections [7]. to conclude, cotrimoxazole can be used as critically ill covid-19 patients. abbreviations covid-19: coronavirus disease-19; hiv: human immune deficiency virus; crp: c reactive protein; tnf: tumour necrosis factor; tnf α: tumour necrosis factor-alpha; il6: interleukin 6 declarations acknowledgment none funding the author received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing omkarchoudhari@yahoo.com authors’ contributions omkar kalidasrao choudhari (okc) is the principal investigator of this manuscript (letter). okc, ss and uco are equally participated in the the study concept, design, writing, reviewing, editing, and approving the manuscript in its final form. all authors read and approved the final manuscript. ethics approval and consent to participate i conducted the research following the declaration of helsinki; however, letter article needs no ethics committee approval. consent for publication not applicable competing interest the author declare that he has no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1post graduate resident, department of clinical biochemistry vardhman mahavir medical college (vmmc) & safdarjung hospital new delhi. 2department of respiratory medicine, vallabhbhai patel ___________________________________________________ omkarchoudhari@yahoo.com 1post graduate resident, department of clinical biochemistry vardhman mahavir medical college (vmmc) & safdarjung hospital new delhi keywords: cotrimoxazole, pandemic, covid 19 http://www.jidhealth.com/ choudhari ok, et al., journal of ideas in health 2020;3(special1):196-197 197 chest institute, new delhi. 3institute of occupational health and environmental research, basaidarapur, new delhi & department of respiratory medicine, esic pgimsr, new delhi. article info received: 13 august 2020 accepted: 27 august 2020 published: 25 september 2020 references 1. ruan q, yang k, wang w, jiang l, song j. clinical predictors of mortality due to covid-19 based on an analysis of data of 150 patients from wuhan, china. intensive care med. 2020;46(5): 846–48. https://doi.org/10.1007/s00134-020-05991-x 2. rozin a, schapira d, braun-moscovici y, nahir am. cotrimoxazole treatment for rheumatoid arthritis. semin arthritis rheum. 2001;31(2):133-41. 3. bourke cd, gough ek, pimundu g, shonhai a, berejena c, terry l, et al. cotrimoxazole reduces systemic inflammation in hiv infection by altering the gut microbiome and immune activation. sci transl med. 2019;11(486): eaav0537. https://doi.org/10.1126/scitranslmed. aav0537 4. liu b, li m, zhou z, guan x, xiang y. can we use interleukin-6 (il-6) blockade for coronavirus disease 2019 (covid-19)induced cytokine release syndrome (crs)? j autoimmun. 2020; 111:102452. https://doi.org/10.1016/j.jaut.2020.102452 5. vickers ie, smikle mf. the immunomodulatory effect of antibiotics on the secretion of tumour necrosis factor alpha by peripheral blood mononuclear cells in response to stenotrophomonas maltophilia stimulation. west indian med j. 2006;55(3):138-41. https://doi.org/10.1590/s004331442006000300002 6. onyebuagu pc, kiridi k, pughikumo dt. effects of septrin administration on blood cells parameters in humans. int. j. basic appl. innov. res, 2014;3(1): 14 -8. https://www.ajol.info/index.php/ijbair/article/view/104688 7. ho jmw, juurlink dn. considerations when prescribing trimethoprim– sulfamethoxazole. cmaj. 2011; 183(16):1851-8. https://doi.org/10.1503/cmaj.111152 8. mahan cs, walusimbi m, johnson df, lancioni c, charlebois e, baseke j, et al. tuberculosis treatment in hiv infected ugandans with cd4 counts .350 cells/mm3 reduces immune activation with no effect on hiv load or cd4 count. plos one.2010;5(2): e9138. https://doi.org/10.1371/journal.pone.0009138 9. varney va, smith b, quirke g, parnell h, ratnatheepan s, bansal as, et al. p49 the effects of oral cotrimoxazole upon neutrophil and monocyte activation in patients with pulmonary fibrosis and healthy controls; does this relate to its action in idiopathic pulmonary fibrosis. thorax. 2017;72: a109. http://dx.doi.org/10.1136/thoraxjnl-2017-210983.191 https://doi.org/10.47108/jidhealth.vol3.iss2.57 katib aa, journal of ideas in health 2020;3(2):173-175 © the author(s). 2020 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access emphysematous epididymo-orchitis with involvement of the prostate, seminal vesicles, and the scrotum: a case report atif abdulhamid katib1* abstract emphysematous epididymo-orchitis is a rare clinical entity. up until july 2020, only 9 cases have been reported in pubmed and scopus platforms, one of which also had scrotal involvement. therefore, we are reporting the second case with prostate, seminal vesicle, and scrotal involvement. the condition represents an aggressive form of infection caused by gas-forming microbes. the radiological detection of air within the organs involved in the characteristic diagnostic sign. the case we are reporting is a 47 years old diabetic, chronic renal failure patient on regular hemodialysis who had a fulminant emphysematous infection in the left testis, epididymis, spermatic cord, the prostate, seminal vesicles, and the scrotum. emergency orchiectomy has been carried out. the most significant part of the case is the pictures showing ballooning scrotum and gas bubbles in abnormal anatomical locations. keywords: epididymo-orchitis, emphysematous infection, gas-forming organisms, orchiectomy background emphysematous infection of the male genitalia is exceedingly rare. only six cases have been reported, one of which also had seminal vesicles involvement. we are reporting the second case in the literature that has seminal vesicles involvement. this type of infection is caused by gas-forming microbes such as e. coli, klebsiella, pseudomonas, or fungi. the characteristic gas bubbles are found in and around the affected organs. the gas consists of nitrogen, hydrogen, oxygen, and carbon dioxide. the pathogenesis of emphysematous infection is poorly understood. it commonly occurs in diabetics, elderly, transplant recipients, patients with neurogenic bladder, and those with urinary tract obstruction. clinically, emphysematous infections are serious infections that fulminate rapidly and require urgent surgical intervention. case report a 47-year-old man presented to the emergency department complaining of scrotal pain, scrotal wall maceration with crepitation, and high fever (38.4 c) for two days. upon presentation, he was in septic shock with leukocytosis, anemia, and high blood sugar. his anamnesis showed poor background. he has had a chronic renal failure (crf) on regular hemodialysis, diabetes mellitus (dm) type 2 on insulin for 20 years, three amputated toes, and obesity. soon after admission, his condition turned sharply to become life-threatening that necessitates urgent investigations and surgery. ultrasonic examination (u/s) has shown ballooned left scrotum (fig.1). computer tomography scan (ct), too, has revealed gas in the scrotum (fig.2), and within the confinements of the testis, spermatic cord (fig.3), seminal vesicles (fig.4), and the prostate (fig.5). operatively, no tissue putrefaction or necrotizing fasciitis found. when we opened the tunica albuginea, we found no much of recognized testicular tissues, as they have been eaten up by the aggressive infection. based on the best of our experience and intuition, we decided to excise the testis from the highest possible level near the internal ring and to spare the scrotum. we believed that removing the prostate and seminal vesicles would do more harm than good, and they could be treated conservatively. nevertheless, exploration of the contra-lateral hemiscrotum has shown otherwise normal testis. on close follow up, the scrotum caught up and survived. histopathology revealed acute inflammation of the testis, epididymis, and cord with areas of necrosis and thrombosis of veins. astonishingly, the blood culture came negative. the patient did well on the empirical combination of tazocin (piperacillin/ tazobactam) plus clindamycin antibiotics. he had a smooth postoperative course and discharged after recovery. a follow-up ct in a month showed the disappearance of the gas bubbles from the scrotum, seminal vesicle, and prostate. ___________________________________________________ atifkatib@gmail.com 1department of urology/andrology, king abdul-aziz hospital, makkah, saudi arabia full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol3.iss2.57 http://www.jidhealth.com/ katib aa, journal of ideas in health (2020); 3(2):173-175 174 figure 1: ultrasound image showing the scrotum filled with air figure 2: ct scan, cross-sectional view, showing a massive amount of air ballooning the lt. hemiscrotum figure 3: ct scan, sagittal view, showing air within the scrotum and the spermatic cord figure 4: ct cross-sectional view, showing air in the seminal vesicles figure 5: ct cross-sectional view, showing air in the prostate gland discussion emphysematous infection of the testis is extremely rare [1]. one of the reported cases had seminal vesicle involvement due to a fistula developed secondary to sigmoid diverticulitis [2]. however, the infection in the case we are reporting had spread in no time, probably due to poor body immunity. although the scrotum looks similar to fournier`s gangrene case series, we have reported [3,4], pneumoscrotum is substantially different in this case. it doesn`t smell bad, with no spread to surrounding structures such as perineum, penis, or the right hemiscrotum. the rarity of the case is ascribed to its infrequent occurrence. the ambiguity lies in explaining the involvement of various organs supplied by different arteries. that is to say, the blood supply of testes from the aorta; and the prostate and seminal vesicles from internal iliac arteries, whereas the scrotal wall receives blood supply from the internal and external pudendal branches of the external iliac artery. the direct spread of infection could explain the transmission of infection among adjacent organs, especially weak body defense. there is no much information, let alone guidelines, over the best way to treat such an intricate condition. follow-up ct has revealed no more gas bubbles. the scrotal condition has improved gradually. confidently, the differential diagnosis of acute scrotum could be zoomed down to emphysematous infection of the testis by the colossal amount of air that appeared on ultrasonography and ct. on ultrasonic examination, air appears as a bright, highly reflective tissue interface of the testis. ct is considered the diagnostic modality of choice, as it demonstrates air within and around the testis, cord, prostate, and seminal vesicles. on ct, air appears as hypodense foci or patchy areas of very low hounsfield unit (-1000 hu). the controversies surrounding requesting magnetic resonance image (mri) in this setting, we have the intuition that mri does confirm the presence of air in the testis substance but doesn`t add up further information. therefore, we believe that mri, in this case, is not recommended as it, unnecessarily, consumes time, and delays the emergency operation. conclusion emphysematous acute epididymo-orchitis is a rare clinical entity. it should be thought of in frail men with significant comorbidity presented to the casualty with a febrile cute scrotal condition. radiologic evidence of air in the affected tissues is unmistakable. life-saving medical and surgical management is required. katib aa, journal of ideas in health (2020); 3(2):173-175 175 abbreviations crf: chronic renal failure; dm: diabetes mellitus; ct: computer tomography scan; us: ultrasonic examination (u/s); hu: hounsfield unit; mri: magnetic resonance image declarations acknowledgment none funding the author received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing atifkatib@gmail.com authors’ contribution atif abdulhamid katib (aak) is the principal investigator of this manuscript (case report). aak is the responsible author for the study concept, design, writing, reviewing, editing, and approving the manuscript in its final form. aak has read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, case report articles need no ethics committee approval. consent for publication not applicable competing interest the author declares that he has no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of urology/andrology, king abdul-aziz hospital, makkah, saudi arabia article info received: 10 august 2020 accepted: 16 august 2020 published: 21 august 2020 references 1. mathur a, manish a, maletha m, luthra nb. emphysematous epididymo-orchitis: a rare entity. indian j urol. 2011;27(3):399400. doi: 10.4103/0970-1591.85447. 2. coulier b, ramboux a, maldague p. emphysematous epididymitis as presentation of unusual seminal vesicle fistula secondary to sigmoid diverticulitis: case report. abdom imaging 2004;30: 113–116. https://doi.org/10.1007/s00261-004-0216-1 3. katib a, al-adawi m, dakkak b, bakhsh a. a three-year review of the management of fournier's gangrene presented in a single saudi arabian institute. cent european j urol. 2013;66(3):331334. doi:10.5173/ceju.2013.03. art22 4. balani a, hegde r, dey a. intratesticular and scrotal wall air: emphysematous epididymo-orchitis or fournier's gangrene: a dilemma. indian j radiol imaging 2015 ;25(1):74 katib et al., journal of ideas in health 2020;3(3):226-227 © the author(s). 2020 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access serratia fonticola microbe presented as a community-acquired urinary tract infection (uti): a case report atif abdulhamid katib1, omar shaikhomar 2*, mazen dajam 2, laila alqurashi 2 abstract background: the case we are presenting is about one of the rare pathogens, serratia fonticola (sf) that may cause urinary tract infection. case presentation: a 58 years-old female presented with dysuria, suprapubic pain, frequency of micturition, and change in urine color. the patient was afebrile on physical examination; however, the urine culture was positive to sf as the sole isolate. the patient received levofloxacin tables (750 mg) once a day for 5 days along with supportive instructions to improve hygiene. on follow-up, she was free of symptoms and the repeated urine culture was negative. conclusion: this case can be considered globally the third that diagnosed in the urine culture of the asymptomatic patient. keywords: serratia fonticola, urinary tract infection, female, case report, community, saudi arabia background among the most prevalent bacterial infections are urinary tract infection (utis). during micturition, bacteria that colonize the urethra and the bladder are flushed out. females have a shorter urethra than males, which makes bacterial infection more likely [1]. classically, the diagnosis of uti is made by its symptoms and a positive urinalysis and culture [2]. different microbial agents cause utis, yet most commonly, escherichia coli. the case we are presenting is about one of the rare pathogens, serratia fonticola (sf). sf is a member of the large family of enterobacteriaceae that seldom causes an infection on its own. in “1979, sf was introduced as a new pathogen of serratia species” [3]. case report we proffer a 58-year-old female who presented with dysuria, suprapubic pain, frequency of micturition, change in urine color, and constipation for a week. initially symptoms were associated with constipation. of note, she is a polymyalgia rheumatic (pmr) patient on daily prednisolone 30mg and ondemand ibuprofen. the patient had no prior hospitalization. she is a housewife, non-smoker, and a mother of 5 grown children. she was well and fit for her age and condition. physical examination revealed no fever but mild suprapubic tenderness. urine analysis showed 25 wbc/hpf, 15 rbc/hpf, and a trace of urate crystals. urine culture was positive for sf as the sole isolate. the microbe was sensitive to tigecycline, oral ciprofloxacin, levofloxacin, and trimethoprimsulfamethoxazole. intermediate sensitivity was noted for gentamicin (table 1). ultrasonic examination of the urinary tract revealed mild diffuse bladder wall thickness measuring 4 mm, suggesting mild cystitis. moreover, a 3-cm simple left kidney cyst was found. the lady has been put on levofloxacin 750 mg once a day for five days, along with supportive instructions to improve hygiene and relieve constipation. on follow-up, she was symptomless and growth-free on repeated urine culture. table 1 culture and sensitivity of serratia fonticola (sf) no. sensitivity agent 1 sensitive ciprofloxacin 2 insensitive gentamicin 3 sensitive levofloxacin 4 sensitive tigecycline 5 sensitive trimethoprim/sulfamethoxazole discussion usually, sf pathogens are present in nature, and their appearance in laboratory tests of human fluids and tissues is considered a rare case. aljorayid et al. [4] indicated that when sf is discovered with other organisms, often work as a bystander, with no clinical and virulent impact. on the contrary, ___________________________________________________ omarmohammednoor@gmail.com 2* king saud bin abdulaziz university for health sciences, jeddah, saudi arabia full list of author information is available at the end of the article http://www.jidhealth.com/ katib et al., journal of ideas in health (2020); 3(3):226-227 227 when sf is found alone, which is rare, the likelihood of acting as a human pathogen increases. sf was isolated from freshwater and soil [3]. müller he [5] was able to isolate the bacteria from wild bird droppings, whereas garcia et al. [6] found the sf in a crocodile skin lesion. bollet et al. [7] recorded the first case of sf transmission to humans due to a traffic accident. in the mideighties of the twentieth century, the efforts made by farmer and his colleagues resulted in the isolation of thirteen species of sf, eleven found in the wound cultures, and two in the respiratory system [8]. in 2003, stock and his team succussed to recover two sf species from urine and bloodstream [9]. gorret et al. [10] isolated the sf from the soft-tissue. hai et al. [11] find out the "first case of biliary tract infection due to multidrug-resistant sf". aljorayid et al. [4] recovered the sf from the urinary tract. the authors presented a case of a 67year-old male patient who had developed urosepsis due to sf. blood and urine cultures tested positive for sf and providencia stuartii during hospitalization. moreover, aljorayid et al. [4] reviewed seventeen patients presented with clinical cultures positive for sf from 1999 to 2015. the urine culture was positive with sf in eleven cases. three cultures grew sf alone. the authors reported five cultures for patients presented with clinical signs and symptoms related to utis. two of the five symptomatic patients with utis had sf alone. conclusion along with the two cases that had sf alone in an asymptomatic patient's urine cultures, our case is globally considered the third. our case harmonizes with the case series mentioned earlier that believes that sf caused mild manifestations. the risk factors that our patient had are age, gender, and prednisolone administration. abbreviation sf: serratia fonticola; uti: urinary tract infection; pmr: polymyalgia rheumatic; wbc: white blood cell; rbc: red blood cell declaration acknowledgment none funding the authors received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing omarmohammednoor@gmail.com authors’ contributions all authors participated equally in fulfilling this paper. all have read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, the institutional review board at the corresponding author’s institution approved the case series. consent for publication not applicable competing interest the author declares that he has no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of urology/andrology, king abdul-aziz hospital, makkah, saudi arabia. 2king saud bin abdulaziz university for health sciences, jeddah article info received: 02 september 2020 accepted: 09 september 2020 published: 27 october 2020 references 1. geerlings se. clinical presentations and epidemiology of urinary tract infections. microbiol. spectr. 4, 2016. https://doi.org/10.1128/9781555817404.ch2 2. flores-mireles al, walker jn, caparon m, hultgren sj. urinary tract infections: epidemiology, mechanisms of infection and treatment options. nat rev microbiol. 2015 may;13(5):269-84. https://doi.org/10.1038/nrmicro3432 3. gavini f, ferragut c, izard d, trinel pa, leclerc h, lefebvre b, mossel da. serratia fonticola, a new species from water. international journal of systematic and evolutionary microbiology. 1979;29(2):92-101. https://doi.org/10.1099/00207713-29-2-92 4. aljorayid a, viau r, castellino l, jump rl. serratia fonticola, pathogen or bystander? a case series and review of the literature. idcases. 2016 may 24; 5:6-8. https://doi.org/10.1016/j.idcr.2016.05.003 5. müller he. isolation of serratia fonticola from birds. zentralblatt bakteriol mikrobiol und hyg abt 1 orig a 1986; 261:212–8. https://doi.org/10.1016/s0176-6724(86)80038-4 6. garcia me, lanzarot p, costas e, lopez rodas v, marín m, blanco jl. isolation of serratia fonticola from skin lesions in a nile crocodile (crocodylus niloticus) with an associated septicaemia. vet j. 2008 may;176(2):254-6. https://doi.org/10.1016/j.tvjl.2007.02.025. 7. bollet c, gainnier m, sainty jm, orhesser p, de micco p. serratia fonticola isolated from a leg abscess. j clin microbiol 1991; 29:834–5. https://doi.org/10.1128/jcm.29.4.834-835.1991 8. farmer jj 3rd, davis br, hickman-brenner fw, mcwhorter a, huntley-carter gp, asbury ma, riddle c, wathen-grady hg, elias c, fanning gr, et al. biochemical identification of new species and biogroups of enterobacteriaceae isolated from clinical specimens. j clin microbiol. 1985 jan;21(1):46-76. https://doi.org/10.1128/jcm.21.1.46-76.1985 9. stock i, burak s, sherwood kj, gruger t, wiedemann b. natural antimicrobial susceptibilities of strains of 'unusual' serratia species: s. ficaria, s. fonticola, s. odorifera, s. plymuthica and s. rubidaea. j antimicrob chemother. 2003;51(4):865-85. https://doi.org/10.1093/jac/dkg156. 10. gorret j, chevalier j, gaschet a, fraisse b, violas p, chapuis m, anne jg. childhood delayed septic arthritis of the knee caused by serratia fonticola. knee 2009; 16 (6):512–4. https://doi.org/10.1016/j.knee.2009.02.008 11. hai pd, hoa ltv, tot nh, phuong ll, quang vv, thuyet bt, son pn. first report of biliary tract infection caused by multidrugresistant serratia fonticola. new microbes new infect. 2020; 36:100692. https://doi.org/10.1016/j.nmni.2020.100692 https://doi.org/10.47108/jidhealth.vol6.iss3.291 yahyaa bt, al-samarrai mam., journal of ideas in health (2023); 6(3):887-894 © the author(s). 2023 open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. journal of ideas in health e issn: 2645-9248 journal homepage: www.jidhealth.com open access original article knowledge and practice regarding prevention of osteoporosis among iraqi women badea'a thamir yahyaa1*, mustafa ali mustafa al-samarrai1 abstract background: osteoporosis is known to cause long-acting disability. this study aimed to explore the knowledge, and preventive practice among women attending the primary health centers (phc) in al ramadi city, west of iraq. methods: a cross-sectional study was conducted between january and march 2022. a simple random sampling technique was recruited to collect samples using face-to-face interviews of women during the routine visit to phcs. univariate and bivariate were used to analyze the data. the statistical package for the social sciences was used for data analysis. results: two hundred and fifty women were interviewed with a mean age of 37.9 ±11.3 years. the majority of them were married (87.0%), and unemployed or housewives (66.0%). although, most of the participants heard about osteoporosis (238, 95.2%), and the possibility to cause pain before the occurrence of fracture (67.6%), the average knowledge score on osteoporosis was 55.75 ± 18.87. furthermore, the surveyed women reported that practices of sunlight exposure (p=0.000), calcium-rich foods (p=0.003), and vitamin d supplementation (p=0.022) are significantly related to reducing the risk of osteoporosis. healthcare providers played a significant role to support women with osteoporosis-related knowledge. conclusion: although most women heard about the disease, their level of knowledge was modest, which might affect the measures necessary to prevent the disease. keywords: osteoporosis, knowledge, practice, prevention, healthcare workers, iraq background osteoporosis stands as a concealed ailment, a multifaceted condition characterized by diminished bone density and heightened susceptibility to fractures [1]. while it primarily afflicts mature females, there exists a subset of young males and females with elevated vulnerability. nonetheless, the gender disparity is pronounced, with women facing an eightfold higher likelihood of falling prey to osteoporosis compared to their male counterparts. this discrepancy stems from the cessation of estrogen's safeguarding influence, which is operative during reproductive years but wanes post-menopause, leading to a deterioration in bone density [2]. osteoporosis is influenced by a spectrum of factors, some within our control and others beyond our influence. among those we can regulate are factors such as inadequate physical activity, a familial predisposition to osteoporosis, a lower body mass index (bmi), sedentary living, tobacco and alcohol usage, as well as dietary imbalances. conversely, certain elements are beyond our sway, encompassing gender, genetic inheritance, ethnic and racial background, advancing age, the postmenopausal state, and bodily dimensions [3,4]. the propensity for osteoporosis escalates when confronted with irregular menstruation and the absence of menstruation altogether, known as amenorrhea. hence, it becomes imperative for young women to familiarize themselves with the potential risk factors associated with menopause. esteemed health organizations advocate that to avert the onset of osteoporosis, women should be motivated to uphold their bone mineral density through conscientious dietary choices, incorporate vitamin d and calcium supplementation, and engage in a ___________________________________________________ *correspondence: med.badeaa.thamir@uoanbar.edu.iq 1department of family and community medicine, faculty of medicine, anbar university, anbar, iraq a full list of author information is available at the end of the article 10.47108/jidhealth.vol6.iss3.291 http://www.jidhealth.com/ yahyaa bt, al-samarrai mam., journal of ideas in health (2023); 6(3):887-894 888 consistent regimen of physical exercises [5,6]. the peak of bone mass density is achieved by the age of 30, beyond which there is a gradual decline in bone density. as individuals age, there's a tendency for diminished natural synthesis of vitamin d [14]. across numerous european countries, a notable incidence of plasma 25-hydroxyvitamin d levels hovering near or beneath the standard range has been documented among the elderly populace, particularly within the "oldest-old" age group and those residing in environments with limited sun exposure, such as institutions [7,8]. furthermore, it's worth noting that the pervasive covid-19 pandemic has played a substantial role in exacerbating the prevalence of vitamin d deficiency among populations [9]. the disruption caused by the pandemic has led to lifestyle modifications, including reduced outdoor activities and limited sun exposure, which in turn has had a tangible impact on vitamin d levels in individuals. as a consequence, a higher number of people are finding themselves deficient in this essential nutrient. this situation underscores the intricate interplay between global health crises and nutritional status, shedding light on the multifaceted nature of public health challenges in the face of unprecedented events [10,11]. bone fractures stand as the defining indicator of osteoporosis, and imparting knowledge to patients constitutes a vital aspect of effectively addressing this complication [3, 5]. in the absence of awareness, these individuals are likely to remain unaware of their susceptibility to developing osteoporosis. they might not consider requesting diagnostic examinations, adopting preventive measures against the onset of the disease, or recognizing that osteoporosis can commence well before the onset of menopause [12]. consequently, they could mistakenly believe that preventive actions only become relevant after menopause. this underscores the urgent requirement to heighten awareness regarding osteoporosis and to instill accurate beliefs among both mature and younger women [13]. numerous intervention-based investigations have demonstrated that improved understanding motivates individuals to actively seek out further insights concerning osteoporosis, ultimately leading to the adoption of lifestyle changes [14,15]. this study aims to explore the knowledge and practice regarding the prevention of osteoporosis among a sample of iraqi women. methods study design and setting a cross-sectional study was carried out at primary health care (phc) centers in al-anbar city, iraqi between 15th february and 15th march 2022. a convenient sampling technique was recruited to collect female patients during their routine visits to four phcs (alsubaihat center, al-quds center, al-andalus center, and al-habbaniyah cente). a well-trained independent eight investigators were recruited to collect the data. all women were briefly informed of the background, aims, and expected outcomes of the study, before acquiring verbal consent for participation in the study. data was collected through direct interviews with patients, documented on paper records, manually entered into a specifically-designed google form, and imported as a spreadsheet into the statistical analysis software. best practices for the protection of patient confidentiality were followed throughout the study process, and all data analysis was done anonymously. inclusion and exclusion criteria all premenopausal women, aged 18-49 years old, and willing to participate. we excluded the pre or postmenopausal women who had already been diagnosed with osteoporosis, young age women (< 18 years old), the care provider's women, and those unwilling to participate in the study. sample size we assumed the response rate will be 50.0% at a significance level of 6.0 and a power of 95.0% to calculate a sample size of 264 participants. a 10.0% was allowed to compensate for possible dropout. the required sample size was 290 (264+26) participants. study tool the questionnaire is composed of four sections. the first section had the socio-economic features, reproductive health data, and source of osteoporosis information. the second section was a semi-structured questionnaire devised to measure the level of women's knowledge regarding different aspects of osteoporosis and its prevention. the osteoporosis knowledge assessment tool (okat) [16] was the main source of 33 questions designed to explore the respondents' knowledge (knowledge and awareness) about osteoporosis. the response to knowledge questions was either "true," "false," or "do not know" options. the incorrect answer and "do not know" answer were given "zero code", while the correct answer was given "one code" resulting in a total potential score of thirty three. then we equally subdivided the total score into three categories: a knowledge score below 11 was regarded as low knowledge, 11-22) as medium knowledge, and above 22 was regarded as a high level of knowledge. the third section had eight questions about the women's practice (behavior and habits). the total potential score of practice was 8, estimated by one point to the most proper answer for each question. practice scores ranged (from 1-3) regarded as low practice, (4-6) medium practice, and (7-9) high practice. statistical analysis analysis of data was carried out using the statistical package for the social sciences (spss<inc., chicago, iii, version 23). data was presented in simple measures of frequencies, percentages, ranges, means, and standard deviations, and collated into appropriate tables. charts were used to illustrate important differences and associations when applicable. the significance of differences in percentages (qualitative data) was tested using pearson's chi-square test with the application of fisher's exact test whenever applicable. statistical significance was considered whenever the p value was equal to or less than 0.05. results socio-demographic characteristics of study participants the mean age of patients was 37.9 ±11.3 years (range 18-65 years). the mean bmi of the study sample was 26.4 ± 6.7. two hundred and seventeen women (87.0%) were married, and 164 women (66%) were unemployed (housewives). the sample was classified according to their educational level into low (n= 103; 41.0%), middle (n= 58; 23.0%), and high (n= 89; 36.0%) educational levels. table 1 summarizes the sociodemographic characteristics of the study sample. yahyaa bt, al-samarrai mam., journal of ideas in health (2023); 6(3):887-894 889 table 1: sociodemographic characteristics of the study sample (n=250) characteristic categories n. % age group (years) < 20 27 10.8 20-29 66 26.4 30-39 55 22.0 40-49 43 17.2 50-59 41 16.4 > 60 18 7.2 weight classification underweight (bmi <18.5) 11 4.4 normal (bmi 18.5-25) 87 34.8 overweight ( (bmi 25-30) 86 34.4 obese class i (bmi 30-35) 42 16.8 obese class ii (bmi 35-40) 17 6.8 obese class iii (bmi >40) 7 2.8 level of education low illiterate 25 10.0 reads/writes 29 11.6 primary school 49 19.6 middle middle school 32 12.8 high school 26 10.4 high undergraduate 72 28.8 postgraduate 17 6.8 marital status married 217 86.8 divorced 11 4.4 widow 22 8.8 occupation housewife 164 65.6 employed 86 34.4 smoking yes 47 18.8 no 203 81.2 alcohol consumption yes 0 0.0 no 250 100.0 most of the surveyed women have regular menstruation (202, 80.8%). the mean age of menarche of the study sample was 13.32 ± 1.79, and 180 women (72%) of the study sample had not yet had menopause at the time of the study. the mean number of pregnancies was 3.95 ± 3.04, while the mean number of abortions was 0.52 ± 0.95. a full summary of the reproductive health data of the study sample can be seen in table 2. table 2: reproductive health data of the study sample (n=250) characteristic categories n. % age of menarche (years) 11 and below 8 3.2 12-14 185 74.0 15-17 56 22.4 18 and above 1 0.4 regular menstruation yes 202 80.8 no 48 19.2 number of pregnancies none 24 9.6 g 1-2 69 27.6 g 3-4 69 27.6 more than 4 88 35.2 number of living children 0 32 12.8 1 35 14.0 2 40 16.0 3 40 16.0 4 29 11.6 5+ 74 29.6 number of abortions 0 170 68.0 1 48 19.2 2 23 9.2 3+ 9 3.6 time of menopause yet to occur 180 72.0 before 45 11 4.4 after 45 59 23.6 yahyaa bt, al-samarrai mam., journal of ideas in health (2023); 6(3):887-894 890 the participants' average knowledge score on osteoporosis was 55.75 ± 18.87 (20-100). table 3 shows that most women heard about osteoporosis (238, 95.2%), and it will cause pain before the occurrence of fracture (67.6%). more than half knew that excessive consumption of beverages such as tea and coffee, and alcohol might contribute to the stimulation of osteoporosis (54.0%, and 57.7%) respectively. in contrast, a high percentage of women expressed good knowledge about the importance of physical activity and a balanced diet. table 3: women's responses to the knowledge questionnaire of the study (n=250) no. questions true false don’t know n % % 5 n % 1 i’ve heard of osteoporosis 238 95.2 12 4.8 0 0.0 2 smoking contributes to osteoporosis 135 54.0 94 37.6 21 8.4 3 stimulant beverages (coffee, tea) contribute to osteoporosis 144 57.6 80 32.0 26 10.4 4 alcohol consumption contributes to osteoporosis 139 55.6 111 44.4 0 0.0 5 i’ve had osteoporosis 52 20.8 198 79.2 0 0.0 6 i’ve had a fractured bone 62 24.8 188 75.2 0 0.0 7 i have a family history of osteoporosis 77 30.8 173 69.2 0 0.0 8 positive family history strongly increases the risk of osteoporosis 114 45.6 136 54.4 0 0.0 9 osteoporosis causes symptoms (e.g., pain) before fractures occur 169 67.6 81 32.4 0 0.0 10 i know about the risk factors of osteoporosis 101 40.4 149 59.6 0 0.0 11 i know about the physical changes that occur with osteoporosis 105 42.0 64 25.6 81 32.4 12 i know about the gender deposition of osteoporosis 137 54.8 35 14.0 78 31.2 13 osteoporosis means reduced bone density 166 66.4 84 33.6 0 0.0 14 osteoporosis is a dangerous disease 168 67.2 82 32.8 0 0.0 15 i am worried about osteoporosis 191 76.4 59 23.6 0 0.0 16 osteoporosis increases the risk of bone fractures 211 84.4 39 15.6 0 0.0 17 it is easy to know if you are at risk of osteoporosis through clinical signs and symptoms (e.g., pain) 135 54.0 115 46.0 0 0.0 18 there is some minor gradual loss of bone density in the 10 years following menopause 86 34.4 164 65.6 0 0.0 19 sedentary lifestyle increases the risk of osteoporosis 149 59.6 101 40.4 0 0.0 20 extremely thin or small people are at higher risk of osteoporosis 122 48.8 128 51.2 0 0.0 21 thin women are more likely to have osteoporosis compared to other women 124 49.6 126 50.4 0 0.0 22 having an imbalanced diet increases the risk of osteoporosis 180 72.0 70 28.0 0 0.0 23 long-term use of corticosteroids increases the risk of osteoporosis 114 45.6 136 54.4 0 0.0 24 starting at age 50, most women should expect at least 1 bone fracture during their lifetime 136 54.4 114 45.6 0 0.0 25 by age 80, most women suffer from osteoporosis 159 63.6 91 36.4 0 0.0. 26 excessive salt intake is a risk factor for osteoporosis 101 40.4 149 59.6 0 0.0 27 short stature after age 65 is a sign of osteoporosis 90 36.0 160 64.0 0 0.0 28 women with early menopause have a higher risk of osteoporosis 113 45.2 137 54.8 0 0.0 29 hormonal therapy prevents further bone loss at any age following menopause 81 32.4 169 67.6 0 0.0 30 long-term nursing (lactation) affects bone density 186 74.4 64 25.6 0 0.0 31 you can get enough calcium by drinking 2 cups of milk a day 230 92.0 20 8.0 0 0.0 32 sardines and spinach are good sources of calcium for those unable to consume dairy products 203 81.2 47 18.8 0 0.0 33 calcium supplementation alone can prevent bone loss 182 72.8 68 27.2 0 0.0 chi-square and fisher's exact tests were used to test the difference in women's knowledge of each questionnaire item between different levels of education for statistical significance. only the items "smoking contributes to osteoporosis (p=0.021), stimulant beverages (coffee, tea) contribute to osteoporosis (p=0.002), alcohol consumption contributes to osteoporosis (p=0.000), i’ve had a fractured bone (0.031), osteoporosis means reduced bone density (p=0.000), osteoporosis increases the risk of bone fractures (p=0.000), it is easy to know if you are at risk of osteoporosis through clinical signs and symptoms (e.g., pain) (p=0.000), and having an imbalanced diet increases the risk of osteoporosis(p=0.017)”, were statistically different between women of different levels of education. (table 4). yahyaa bt, al-samarrai mam., journal of ideas in health (2023); 6(3):887-894 891 table 4: the difference in knowledge of the questionnaire items about osteoporosis between women of different educational levels in the study (n=250). no. questionnaire item (“yes” response by level of education) low middle high p value n. % n. % n. % 1 i’ve heard of osteoporosis 94 91.3 57 98.3 87 97.8 0.056 2 smoking contributes to osteoporosis 45 43.7 33 56.9 57 64.0 0.021* 3 stimulant beverages (coffee, tea) contribute to osteoporosis 45 43.7 34 58.6 65 73.0 0.002* 4 alcohol consumption contributes to osteoporosis 44 42.7 31 53.4 64 71.9 0.000* 5 i’ve had osteoporosis 26 25.2 12 20.7 14 15.7 0.257 6 i’ve had a fractured bone 33 32.0 15 25.9 14 15.7 0.031* 7 i have a family history of osteoporosis 33 32.0 16 27.6 28 31.5 0.852 8 positive family history strongly increases the risk of osteoporosis 42 40.8 27 46.6 45 50.6 0.402 9 osteoporosis causes symptoms (e.g., pain) before fractures occur 63 61.2 38 65.5 68 76.4 0.073 10 i know about the risk factors of osteoporosis 35 34.0 23 39.7 43 48.3 0.123 11 i know about the physical changes that occur with osteoporosis 41 39.8 20 34.5 44 49.4 0.465 12 i know about the gender deposition of osteoporosis 50 48.5 29 50.0 58 65.2 0.088 13 osteoporosis means reduced bone density 51 49.5 41 70.7 74 83.1 0.000* 14 osteoporosis is a dangerous disease 61 59.2 40 69.0 67 75.3 0.060 15 i am worried about osteoporosis 71 68.9 48 82.8 72 80.9 0.071 16 osteoporosis increases the risk of bone fractures 71 68.9 55 94.8 85 95.5 0.000* 17 it is easy to know if you are at risk of osteoporosis through clinical signs and symptoms (e.g., pain) 42 40.8 30 51.7 63 70.8 0.000* 18 there is some minor gradual loss of bone density in the 10 years following menopause 33 32.0 20 34.5 33 37.1 0.762 19 sedentary lifestyle increases the risk of osteoporosis 56 54.4 35 60.3 58 65.2 0.310 20 extremely thin or small people are at higher risk of osteoporosis 48 46.6 27 46.6 47 52.8 0.654 21 thin women are more likely to have osteoporosis compared to other women 50 48.5 29 50.0 45 50.6 0.960 22 having an imbalanced diet increases the risk of osteoporosis 64 62.1 46 79.3 70 78.7 0.017* 23 long-term use of corticosteroids increases the risk of osteoporosis 38 36.9 29 50.0 47 52.8 0.063 24 starting at age 50, most women should expect at least 1 bone fracture during their lifetime 53 51.5 32 55.2 51 57.3 0.708 25 by age 80, most women suffer from osteoporosis 63 61.2 39 67.2 57 64.0 0.733 26 excessive salt intake is a risk factor for osteoporosis 41 39.8 19 32.8 41 46.1 0.293 27 short stature after age 65 is a sign of osteoporosis 30 29.1 23 39.7 37 41.6 0.158 28 women with early menopause have a higher risk of osteoporosis 39 37.9 26 44.8 48 53.9 0.079 29 hormonal therapy prevents further bone loss at any age following menopause 37 35.9 16 27.6 28 31.5 0.552 30 long-term nursing (lactation) affects bone density 73 70.9 46 79.3 67 75.3 0.496 31 you can get enough calcium by drinking 2 cups of milk a day 91 88.3 54 93.1 85 95.5 0.186 32 sardines and spinach are good sources of calcium for those unable to consume dairy products 78 75.7 48 82.8 77 86.5 0.169 33 calcium supplementation alone can prevent bone loss 72 69.9 44 75.9 66 74.2 0.685 knowledge of the study sample regarding preventative practices that reduce the risk of osteoporosis (is shown in table 5. of note, "calcium-rich food" was the most known practice by the study sample (92.4%), while "regular exercise" was the least known practice (71.2%). table 6 shows the level of knowledge of preventative practices among women of different levels of education, testing for statistical significance using chi-square and fisher’s exact tests. only “sunlight exposure (p=0.000), calcium-rich foods (p=0.003), and vitamin d supplementation (p=0.022)”, were equally recognized by women of all levels of education to be important preventative practices for osteoporosis. table 5: knowledge of preventative practices among the study sample (n=250) no. questionnaire item yes no n. % n. % 1 sunlight exposure 230 92.0 20 8.0 2 physical activity 180 72.0 70 28.0 3 calcium-rich food 231 92.4 19 7.6 4 calcium supplementation 222 88.8 28 11.2 5 vitamin d supplementation 218 87.2 32 12.8 6 regular exercise 178 71.2 72 28.8 7 regular light exercise (e.g., walking) 188 75.2 62 24.8 8 general healthy awareness 188 75.2 62 24.8 yahyaa bt, al-samarrai mam., journal of ideas in health (2023); 6(3):887-894 892 table 6: difference in knowledge of preventative practices for osteoporosis among women of different levels of education (n=250) no. questionnaire items (“yes” response by level of education) low medium high 0-value n. % n. % n. % 1 sunlight exposure 91 88.3 55 94.8 84 94.4 0.000* 2 physical activity 59 57.3 45 77.6 76 85.4 0.073 3 calcium-rich food 90 87.4 56 96.6 85 95.5 0.003* 4 calcium supplementation 86 83.5 51 87.9 85 95.5 0.065 5 vitamin d supplementation 80 77.7 51 87.9 87 97.8 0.022* 6 regular exercise 58 56.3 45 77.6 75 84.3 0.151 7 regular light exercise (e.g., walking) 64 62.1 47 81.0 77 86.5 0.204 8 general healthy awareness 59 57.3 46 79.3 83 93.3 0.072 the sources of women’s knowledge regarding osteoporosis are listed in table 7. “doctors & healthcare workers” was the most common source of information for the women in the study sample (73.2%), while “books & magazines” was the least common source of information (35.6%). table 7: sources of knowledge regarding osteoporosis among the study sample (n=250). source of information n. % friends 115 46.0 social media 128 51.2 doctors & healthcare workers 183 73.2 family & relatives 179 71.6 books & magazines 89 35.6 discussion in our research, we conducted an in-depth examination of the levels of knowledge and practical awareness regarding osteoporosis among women residents in the west of iraq. the findings of our study revealed that a substantial majority of iraqi women (approximately 95.2%) had encountered information or possessed some familiarity with this medical condition. it is noteworthy that these women exhibited a commendable average score of 55.75 ± 18.87 on our knowledge assessment scale, reflecting a satisfactory grasp of the subject. a similar finding was reported by alhouri et al. [17]. delving into the nuances of their understanding, the surveyed women displayed a noteworthy comprehension of osteoporosis and its associated risk factors. a significant aspect of their awareness was centered around recognizing the factors that contribute to the development of osteoporosis [18]. additionally, it is worth highlighting that more than half of the participants demonstrated a recognition that the process of aging linked to menopause can indeed be a substantial risk factor for osteoporosis [19]. turning to the parameters of the number of pregnancies and incidences of abortion, the present investigation revealed that slightly less than half of the women examined had a gravidity count exceeding four pregnancies, and less than three-quarters of the cohort did not have a history of abortion (as illustrated in table 2). this correspondence in findings could be attributed to the fact that elevated levels of sex hormones during pregnancy stimulate an enhanced absorption of calcium from the gastrointestinal tract and increased uptake by the skeletal system. it is noteworthy to underscore that such hormonal changes during pregnancy have been identified as potential risk factors for the development of osteoporosis. consequently, it becomes imperative to provide pregnant women with supplemental calcium and vitamin d to counterbalance the potential loss of these essential nutrients [20,21]. our investigation brought to light a compelling insight into the exercise habits of the population under scrutiny, revealing that over 70% of individuals were actively participating in exercise regimens of the recommended type. among the various forms of exercise, walking emerged as the most prevalent, with a significant majority—75%—of participants engaging in this activity. notably, this differs from a study conducted among women in new zealand, where walking also held the distinction of being the most popular exercise choice, albeit with a lower participation rate of 42.0% within the age groups ranging from 20 to 29 years. this intriguing contrast underscores how exercise preferences can differ across populations and age groups, even when a particular activity maintains its popularity [22]. in the context of osteoporosis prevention, maintaining adequate calcium intake is of paramount importance. the guidance surrounding this matter emphasizes the significance of ensuring a sufficiently balanced diet rich in calcium, as this serves as one of the key preventive strategies against the onset of osteoporosis. however, our study revealed that a notable majority of the participants exhibited limited awareness regarding the association between smoking and osteoporosis risk. surprisingly, only 1.2% of respondents correctly recognized smoking as a potential contributor to the disease. this finding echoes another research endeavor conducted among pakistani women, where a significant 42.76% of participants lacked awareness about the detrimental impact of smoking on osteoporosis. this shared gap in knowledge, both within a specific demographic (like medical school entrants) and across the broader population, underscores the need for more comprehensive education efforts on this critical aspect of bone health [23]. interestingly, when it came to the sources of information that the iraqi women relied upon to gather knowledge about osteoporosis, there were distinct trends [24]. the most prevalent channels for acquiring information were identified as medical professionals including doctors and healthcare workers, along with insights gained from the women's immediate social circle, which included family members and relatives. this suggests that both formal medical advice and informal discussions within their networks played pivotal roles in shaping their understanding of osteoporosis [25]. in summary, our study sheds light on the awareness landscape among iraqi women regarding osteoporosis. their considerable familiarity with the condition, coupled with a decent knowledge level, underscores the importance of continuing education yahyaa bt, al-samarrai mam., journal of ideas in health (2023); 6(3):887-894 893 efforts in the realm of bone health. recognizing the significant roles that healthcare practitioners and close family connections play in disseminating information about osteoporosis could inform future strategies for enhancing awareness and prevention among this population. beyond the utilization of a crosssectional design, our study was accompanied by several additional limitations that warrant consideration. foremost among these limitations was the specific nature of our sample, which was constrained to women who were actively seeking healthcare services at primary health care (phc) centers. it is important to acknowledge that these women might possess a heightened sensitivity towards their health concerns compared to individuals who are not engaged with such healthcare facilities. this particular demographic bias could influence the overall perceptions and insights garnered from our research. moreover, the integrity of the data collection process was occasionally disrupted by interruptions experienced by participants while responding to the questionnaire. such disruptions might have introduced variability or inconsistencies in their answers, potentially affecting the accuracy of the data collected. a significant aspect of our study pertains to the questionnaire itself, where a majority of the questions posed were subjective rather than grounded in objective criteria. this subjectivity introduces the possibility of misinterpretation or misjudgment among respondents. additionally, there is a concern that these subjective questions could inadvertently prompt participants towards certain responses, potentially introducing a bias in their answers due to the suggestive nature of the questions. to address these limitations and enhance the robustness of future studies, careful consideration should be given to the selection of a more diverse and representative sample that extends beyond healthcare-seeking individuals. implementing measures to minimize interruptions during data collection and incorporating a mix of objective and subjective questions in the questionnaire could also contribute to a more comprehensive and accurate assessment of the research subject. conclusion the study conducted in western iraq revealed satisfactory levels of osteoporosis knowledge among adult females. enhancing awareness through effective health education campaigns could prove instrumental in promoting an understanding of osteoporosis and its associated risk factors, thereby encouraging the adoption of healthy practices that can mitigate bone loss. notably, approximately 30.0% of the women surveyed had a positive family history of osteoporosis. a significant proportion of them exhibited behaviors such as not taking vitamin d supplements and having a high consumption of coffee, tea, carbonated beverages, and red meat throughout the week. encouraging lifestyle changes becomes imperative for this group to proactively prevent osteoporosis. maintaining optimal dietary habits is a pivotal factor in sustaining bone density, mass, and strength, particularly in women aiming to conceive. given that women often spend a substantial portion of their time indoors or at work, their limited exposure to sunlight and reduced physical activity compared to men contributes to their heightened vulnerability to osteoporosis. to address this concern, educational initiatives should encompass the installation of informative posters in public spaces, city gathering areas, and healthcare centers. these resources should emphasize risk factors and preventive measures relevant to women aged 18 to 45 years. furthermore, the implementation of early screening programs targeting women in the 18 to 45 age group is crucial to proactively identify and manage osteoporosis, minimizing potential complications and adverse outcomes. public media platforms, particularly television, and radio, offer valuable avenues for disseminating information about adopting a health-conscious lifestyle. by harnessing the power of media, comprehensive awareness campaigns can effectively reach and empower a wider audience to make informed choices for their bone health. abbreviation phc: primary health centers. declaration acknowledgment none. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing med.badeaa.thamir@uoanbar.edu.iq authors’ contributions all authors badea'a thamir yahyaa (bty) and, mustafa ali mustafa al-samarrai (mama) are equally participated in the concept, design, literature search, data analysis, data acquisition, manuscript writing, editing, and reviewing. ebc has read and approved the final manuscript. all authors have read the final manuscript. ethics approval and consent to participate the study was conducted in accordance with the ethical principles of the declaration of helsinki (2013). the protocol was approved by the ethics committee of the scientific issues and postgraduate studies unit (psu), college of medicine, university of anbar (ref: sr/207 at 21jaunary-2019). moreover, written informed consent obtained from each participant after explanation of the study objectives and the guarantee of secrecy. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. yahyaa bt, al-samarrai mam., journal of ideas in health (2023); 6(3):887-894 894 author details 1department of family and community medicine, faculty of medicine, anbar university, anbar, iraq article info received: 03 june 2023 accepted: 27 july 2023 published: 19 august 2023 references 1. pouresmaeili f, kamalidehghan b, kamarehei m, goh ym. a comprehensive overview of osteoporosis and its risk factors. ther clin risk manag. 2018 nov 6;14:2029-2049. doi 10.2147/tcrm.s138000. 2. alswat ka. gender disparities in osteoporosis. j clin med res. 2017 may;9(5):382-387. doi 10.14740/jocmr2970w. 3. borer kt. physical activity in the prevention and amelioration of osteoporosis in women: interaction of mechanical, hormonal and dietary factors. sports med. 2005;35(9):779-830. doi:10.2165/00007256-200535090-00004 4. carter mi, hinton ps. physical activity and bone health. mo med. 2014 jan-feb;111(1):59-64. 5. sözen t, özışık l, başaran nç. an overview and management of osteoporosis. eur j rheumatol. 2017 mar;4(1):46-56. doi 10.5152/eurjrheum.2016.048. 6. parker se, troisi r, wise la, palmer jr, titus-ernstoff l, strohsnitter wc, hatch ee. menarche, menopause, years of menstruation, and the incidence of osteoporosis: the influence of prenatal exposure to diethylstilbestrol. j clin endocrinol metab. 2014 feb;99(2):594-601. doi 10.1210/jc.2013-2954. 7. laird e, ward m, mcsorley e, strain jj, wallace j. vitamin d and bone health: potential mechanisms. nutrients. 2010 jul;2(7):693-724. doi: 10.3390/nu2070693. 8. augustine lf, nair km, kulkarni b. sun exposure as a strategy for acquiring vitamin d in developing countries of tropical region: challenges & way forward. indian j med res. 2021 mar;154(3):423-432. doi: 10.4103/ijmr.ijmr_1244_18. 9. sooriyaarachchi p, jeyakumar dt, king n, jayawardena r. impact of vitamin d deficiency on covid-19. clin nutr espen. 2021 aug;44:372-378. doi: 10.1016/j.clnesp.2021.05.011. 10. saha s. impact of missingness on clinical trials on the effectiveness of antenatal vitamin d supplementation in gestational diabetes mellitus patients. jidhealth [internet]. 2020 may 21 [cited 2023 aug. 15];3(1):138-9. doi: 10.47108/jidhealth.vol3.iss1.47. 11. ilesanmi os, oguntoye aa, afolabi aa. the new norm in the management of covid-19 positives: home-based care. jidhealth [internet]. 2020 nov. 24 [cited 2023 aug. 15];3(4):252-3. doi: 10.47108/jidhealth.vol3.iss4.78. 12. senthilraja m, cherian ke, jebasingh fk, kapoor n, paul tv, asha hs. osteoporosis knowledge and beliefs among postmenopausal women: a cross-sectional study from a teaching hospital in southern india. j family med prim care. 2019 apr;8(4):1374-1378. doi: 10.4103/jfmpc.jfmpc_95_19. 13. tella sh, gallagher jc. prevention and treatment of postmenopausal osteoporosis. j steroid biochem mol biol. 2014 jul;142:155-70. doi: 10.1016/j.jsbmb.2013.09.008. 14. beaudart c, boonen a, li n, bours s, goemaere s, reginster jy, roux c, mcgowan b, diez-perez a, rizzoli r, cooper c, hiligsmann m. patient preferences for lifestyle behaviours in osteoporotic fracture prevention: a cross-european discrete choice experiment. osteoporos int. 2022 jun;33(6):1335-1346. doi: 10.1007/s00198-022-06310-4. 15. ali jadoo sa, alhusseiny ah, yaseen sm, al-samarrai mam, mahmood as. evaluation of health system in iraq from people’s point of view: a comparative study of two different eras. jidhealth [internet]. 2021 may 20 [cited 2023 aug. 15];4(2):380-8. doi 10.47108/jidhealth.vol4.iss2.100. 16. winzenberg tm, oldenburg b, frendin s, jones g. the design of a valid and reliable questionnaire to measure osteoporosis knowledge in women: the osteoporosis knowledge assessment tool (okat). bmc musculoskelet disord 2003; 4:17. 17. alhouri a, zahrawi h, alasaad s, alhayek sm, al houri hn, jomaa s, torbey a, swed s, alamash d, zawda a, alhasan sa, khalayli n, kudsi m. assessing the knowledge and attitude towards osteoporosis among syrian women: a cross-sectional study. int j rheumatol. 2022 nov 8;2022:6431151. doi 10.1155/2022/6431151. 18. yahyaa bt, al-rawi ra, taha my, sarhan yt, abdul fatah bnaf, al-delaimy ak, al-samarrai mam, mukhlif or, altaha ma. impact of family structure and sociodemographic characteristics on parents headed families in ramadi city, iraq . jidhealth [internet]. 2022 dec. 29;5(4). doi: 10.47108/jidhealth.vol5.iss4.266 19. gemalmaz a, oge a. knowledge and awareness about osteoporosis and its related factors among rural turkish women. clin rheumatol. 2008;27(6):723-728. doi:10.1007/s10067-0070777-9. 20. mahadevan s, kumaravel v, bharath r. calcium and bone disorders in pregnancy. indian j endocrinol metab. 2012 may;16(3):358-63. doi: 10.4103/2230-8210.95665. 21. soma-pillay p, nelson-piercy c, tolppanen h, mebazaa a. physiological changes in pregnancy. cardiovasc j afr. 2016 marapr;27(2):89-94. doi: 10.5830/cvja-2016-021. 22. von hurst pr, wham ca. attitudes and knowledge about osteoporosis risk prevention: a survey of new zealand women. public health nutrition. cambridge university press; 2007;10(7):747–53. doi: https://doi.org/10.1017/s1368980007441477. 23. shakeel s, naveed s, iffat w, nazeer f, yousuf v (2015) pakistani women knowledge, beliefs and attitudes towards osteoporosis. j bioequiv availab 7: 270-273. doi:10.4172/jbb.1000252. 24. mahdi, z. awareness and knowledge of osteoporosis among iraqi women. kirkuk journal of medical sciences, 2023; (): -. doi: 10.32894/kjms.2023.139437.1058. 25. ali jadoo sa, yaseen sm, al-samarrai mam, mahmood as. patient satisfaction in outpatient medical care: the case of iraq. jidhealth [internet]. 2020 aug. 26 [cited 2023 aug. 16];3(2):176-82. doi 10.47108/jidhealth.vol3.iss2.44. ilesanmi and afolabi, journal of ideas in health 2020;3(special 1):198-200 © the author(s). 2020 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access six months of covid-19 response in nigeria: lessons, challenges, and way forward olayinka s. ilesanmi1,2*, aanuoluwapo a. afolabi1 abstract background: the declaration of covid-19 as a public health emergency by the world health organization necessitated countries across the globe to implement response and mitigation measures. we aimed to assess the nigerian government's response following six months of detection of covid-19 in nigeria. methods: a narrative review of existing literature on the topic was done. the authors' opinion as experts supporting the covid-19 pandemic response was included. the review and opinion were summarized, covering six months of the outbreak response in nigeria. results: contact tracing commenced after identifying the index case of covid-19 in nigeria but has been faced with challenges such as inadequate equipment and shortage of funds. school closure was implemented barely three weeks after detecting the index case, but the resumption of terminal classes has been announced recently. the nigerian government implemented restrictions on gatherings involving up to 11 people after three weeks following the detection of the index case of covid-19. the lack of enforcement and supervision of gatherings and public events made many individuals disregard the restriction measures. lockdowns on religious gatherings and public events have been recently eased nationwide, and regulatory measures have been put in place. the nigerian government implemented bans on international travel from all countries, especially high-risk countries. however, the existence of porous borders limited success, which could have been obtained from the travel ban. conclusion: covid-19 mitigation measures should be implemented and reinforced as required nationwide and get provided the needed support. keywords: coronavirus disease, covid-19 mitigation, lockdown, response, nigeria background the emergence of novel coronavirus disease (covid-19) since late fall in 2019 introduced a global health crisis that has revealed the present-day health system's limits globally [1]. presently, nearly 24 million confirmed cases and 820,000 fatalities had been recorded globally, out of which 5% is accrued to the african continent [2]. as of 26th august 2020, nigeria had recorded 52800 cases and 1007 deaths [2]. the declaration of covid-19 as a public health emergency by the world health organization (who) on march 11, 2020, necessitated countries across the globe to implement response and mitigation measures [1]. the nigerian government immediately set up an emergency response team, and an emergency response was activated at the highest level [3]. public health campaigns and awareness were initiated early alongside the issuance of advisory against travel to and from high-risk countries [4]. in this study, we aimed to assess the nigerian government's response following six months of detection of covid-19 in nigeria. testing/contact tracing prior to detecting the index case of covid-19 in nigeria, the african centre for disease control (acdc) had set up a task force to enable the timely detection of covid-19 cases in nigeria. similarly, the presidential task force was set up by the nigerian government shortly after detecting the index case [5]. because covid-19 did not previously exist in nigeria, testing activities were primarily focused on travelers or internationals who could contact infected persons. the intensification of the testing activity enabled the prompt identification of the index case of covid-19, an italian traveler. contact tracing commenced after the identification of the index case of covid-19. since no case was detected earlier than february ___________________________________________________ ileolasteve@yahoo.co.uk 1department of community medicine, college of medicine, university of ibadan, oyo state, nigeria full list of author information is available at the end of the article http://www.jidhealth.com/ ilesanmi and afolabi, journal of ideas in health (2020); 3(special 1):198-200 199 27, there was no need for contact tracing. although testing and contact tracing were faced with some challenges such as inadequate equipment, shortage of funds, and inadequate expertise, the decentralization of testing facilities and commencement of community-wide testing and contact tracing have helped reduce the risk of exposure of non-infected persons too ill persons [6,7]. the deployment of more personnel such as doctors, nurses, and community health workers are required to enable an improved response in events of future outbreaks [6]. a transition from a vertical to a horizontal approach in the covid-19 response could yield satisfactory results in the covid-19 response [8]. school closure identification of educational institutions as possible transmission sites for covid-19 necessitated its closure [9]. school closure was implemented barely three weeks after the detection of the index case. the closure was initially commenced at some levels only. shortly after, all educational institutions in the country were temporarily closed [9]. although different reactions met this activity, it was a laudable mitigation measure that commenced early enough. school closure was especially needed for children in the junior category who would not adhere to standard precautions such as social distancing, regular handwashing, and use of face shields. similarly, it was required in higher institutions to enable both local and international students to return to their homes and home country, respectively. recently, terminal classes in primary and secondary schools were declared open nationwide examinations [10]. the declaration of these exit classes' resumption by the nigerian government emanated from a desire to keep these no further at home. the commencement of online schooling has helped reduce the brunt of school closure to a minimal level, and institutions who could afford it are unbothered since regular classes continue, for whom examinations are scheduled [11]. although online schooling as an alternative may not be affordable to an average family, it sure is a strategy to check delays in academic activities in the absence of which individuals are prone to engage in risky behavior [11]. in the events of future outbreaks, be it local or global, it is expected that the capacities of institutions, especially those run by the government, get enlarged in proceeding with online schooling. this would reduce the inequity associated with schooling in public schools compared to self-owned schools, as previously obtained in the nigerian educational setting. restriction of gatherings/cancellation of public events the nigerian government implemented restrictions on gatherings involving up to 11 people after three weeks following the detection of the index case of covid-19 [12]. the cancellation of public events also became recommended at this period [12]. these measures were conceived because of the likelihood that crowded spaces could increasingly place individuals at risk for onward transmission of covid-19. the lack of enforcement and supervision of gatherings and public events, especially at the community level, made many individuals disregard the restriction measures [13]. this gave room to indifference in the attitude of many regarding the supposed existence of covid-19. physical religious gatherings became suspended, and religious activities' online scheduling became the new routine for five months following the initial declaration [14]. although the federal government earlier announced the resumption of religious activities, state governors rejected the decision because the states were incapable of managing the aftermath of a surge in covid-19 infection rates [14]. lockdowns on religious gatherings and public events have been recently eased nationwide [15]. regulatory measures have been put in place to ensure compliance with temperature checking, use of face masks, and handwashing [15]. also, religious gatherings have been admonished to ensure a maximum of a quarter-full capacity in their respective worship centers [16]. however, this might not be obtainable in mosques where throngs of persons gather on fridays for the jumat service. besides, enforcement of face masks in religious gatherings lacks as it is evident that many individuals shy away from its use. therefore, coordinated health teams are required to make regular checks to places of worship and event centers to ensure adherence to precautionary measures to forestall increased rates of covid-19 infection. international travel controls the nigerian government implemented bans on international travel from all countries, especially high-risk countries such as china, korea, and germany [4]. travel bans were commenced early, but not immediately after detecting the first case [4]. it was expected that the nigerian government would declare a total ban on international travels; however, this activity was poorly coordinated and badly implemented. also, the existence of porous borders that lacked supervision and monitoring of security personnel limited the success, which could have been obtained from the travel ban [17]. although many in-bound travelers were isolated for two weeks following their arrival, some individuals were missed in the isolation exercise. this amplifies the existing laxity in the nigerian security system. to nip future pandemics in their buds, it is highly required that the nigerian borders be closed to entry during such periods except for emergencies. also, responsible security personnel are mounted at all land borders that presently exist in the country. conclusion on the overall, the nigerian government has not entirely performed poorly regarding the covid-19 response. there are, however, opportunities to translate the successes and learn from the failures in ensuring an appropriate covid-19 response. it is required that response activities such as testing, and contact tracing are commenced early enough and sustained throughout the outbreak to prevent further transmission. also, mitigation measures should be implemented as required nationwide and get provided the needed support, contributing to a break in the epidemic chain of covid-19 and subsequent diseases. abbreviation covid-19: coronavirus disease-19; who: world health organization; acdc: african centre for disease control acknowledgment none funding ilesanmi and afolabi, journal of ideas in health (2020); 3(special 1):198-200 200 the authors received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing ileolasteve@yahoo.co.uk authors’ contributions olayinka s. ilesanmi (ois), and aanuoluwapo a. afolabi (aaa) are the principal and responsible investigators of the study. ois and aaa participated equally in the writing and editing of the manuscript. ois and aaa approved the final draft of the manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, commentary articles need no ethics committee approval. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of community medicine, college of medicine, university of ibadan, oyo state, nigeria. 2department of community medicine, university college hospital, ibadan, oyo state, nigeria article info received: 29 august 2020 accepted: 09 september 2020 published: 27 september 2020 references 1. world health organization. covid-19 public health emergency of international concern (pheic) global research and innovation forum, 2020 february 12. in: who 2020. available from: https://www.who.int/publications/m/item/covid-19-public-healthemergency-of-international-concern-(pheic)-global-research-andinnovation-forum [accessed on 26 august 2020].] 2. european centre for disease prevention and control. covid-19 situation updates worldwide, as of 26 august 2020. in: ecdc 2020. available from: https://www.ecdc.europa.eu/en/geographical-distribution-2019ncov-cases [ accessed on 26 august 2020].] 3. nigeria centre for disease control. covid-19 outbreak in nigeria situation report. abuja. in: ncdc. 2020 contract no.: s/n: 001. available from: https://covid19.ncdc.gov.ng/ [accessed on 26 august 2020]. 4. ogundele k. updated: fg places travel ban on china, italy, us, uk, nine others. punch newspapers, 2020 mar 18. available from: https://punchng.com/breaking-fg-places-travel-ban-onchina-italy-us-uk-others/ [ accessed on 26 august 2020] 5. presidential task force on covid-19. available from: https://statehouse.gov.ng/covid19/ [accessed on 26 august 2020]. 6. okunola a. 5 challenges facing health care workers in nigeria as they tackle covid-19. on 9 june 2020. in: global citizen. available from: https://www.globalcitizen.org/en/content/challenges-for-healthcare-workers-nigeria-covid/ [accessed on 26 august 2020]. 7. sessou e. covid-19: why we provided testing kits in kano adf. 2020 may 8. in: vanguard. available from: https://www.vanguardngr.com/2020/05/covid-19-why-weprovided-testing-kits-in-kano-adf/ [accessed on 26 august 2020]. 8. ilesanmi os, afolabi aa. time to move from vertical to horizontal approach in our covid-19 response in nigeria. scimed j. 2020; 2:28-29. https://doi.org/10.28991/scimedj-202002-s1-3. 9. olisa c. covid-19: fg orders immediate shut down of all schools. 2020 march 20. in: naira metrics [internet]. available at: https://nairametrics.com/2020/03/20/covid-19-fg-ordersimmediate-shut-down-of-all-schools/ [accessed on 26 august 2020]. 10. adejayan g. covid-19: lagos decontaminates schools for partial resumption. on 1 august 2020 [cited 26 august 2020]. in: within nigeria. available from: https://www.withinnigeria.com/2020/08/01/covid-19-lagosdecontaminates-public-schools-for-partial-resumption/ [accessed on 26 august 2020]. 11. oyetimi k, adewakun a. e-learning: how covid-19 is reshaping education in nigeria. on 10 april 2020. publish in: msn. available at: https://www.msn.com/en-za/news/other/elearning-how-covid-19-is-reshaping-education-in-nigeria/arbb12pmed [accessed on 26 august 2020]. 12. hale t, webster s, petherick a, phillips t, kira b. oxford covid-19 government response tracker, blavatnik school of government. 2020 march 21. in: our world in data. oxford covid-19 government response tracker. available from: https://ourworldindata.org/grapher/public-gathering-rulescovid?year=2020-08-26&time=2020-01-01.2020-0804&region=africa [accessed on 26 august 2020]. 13. vanguard. lagos police command enforces ban on social gatherings to prevent spread of coronavirus. on 22 march 2020. in vanguard. available from: https://www.vanguardngr.com/2020/03/lagos-police-commandenforces-ban-on-social-gatherings-to-prevent-spread-ofcoronavirus/ [accessed on 26 august 2020]. 14. donohue jm, miller e. covid-19 and school closures. jama. 2020;324(9):845-847. https://doi.org/10.1001/jama.2020.13092 15. sahara reporters. nigerian government lifts ban on religious gatherings, reduces curfew hours. on 1 june 2020. in: sahara reporters. available from: http://saharareporters.com/2020/06/01/nigerian-government-liftsban-religious-gatherings-reduces-curfew-hours [accessed on 26 august 2020]. 16. vanguard. covid-19: lagos reels out guidelines for reopening of mosques, churches. on 6 august 2020. in: vanguard. available from: https://www.vanguardngr.com/2020/08/covid-19-lagosreels-out-guidelines-for-reopening-of-mosques-churches/ [accessed on 26 august 2020]. 17. vanguard. porous borders, cause of rise in covid-19 cases — fg. on 3 april 2020. in: vanguard [internet]. available from: https://www.vanguardngr.com/2020/04/porous-borders-cause-ofrise-in-covid-19-cases-fg/ [accessed on 26 august 2020]. ilesanmi os, et al., journal of ideas in health 2020;3(4):252-253 © the author(s). 2020 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access the new norm in the management of covid-19 positives: homebased care olayinka stephen ilesanmi1,2*, abolanle adesile oguntoye2, aanuoluwapo adeyimika afolabi1 abstract background: the coronavirus disease (covid-19) has disrupted health systems globally and locally. the increasing number of covid-19 positives has overwhelmed healthcare facilities and health workers. home-based care (hbc) is a new norm in the management of covid-19 positives. we aimed to give insight into the hbc of covid-19 positives in nigeria. methods: we conducted a descriptive review of the existing literature and summarized the authors' opinions regarding hbc in nigeria. results: hbc has increasingly gained recognition for the management of covid-19 positives. the hbc of covid-19 positives provides the opportunity for patient management under an atmosphere of emotional, physical, and spiritual fulfillment as required for quick recovery. guidelines have been developed for hbc of covid-19 positives; however, negligence to these measures has been noted. conclusion: to ensure compliance and harness hbc's benefits, community leaders, religious organizations, civilbased organizations, and opinion leaders should be actively involved in hbc activities. also, enforcement authorities such as the civil defence corps could help to improve adherence to hbc restrictions. keywords: covid-19; home-based care, covid-19 positives, management of covid-19 positives, nigeria. background the coronavirus disease outbreak 2019 (covid-19) has signaled a disruption in health systems across the globe [1,2]. the increasing number of covid-19-infected persons have placed great pressure on the health system with resulting exhaustion of available health facilities, non-admittance of new covid-19 positives, and increased workload for health workers (hw) [1,3]. therefore, it becomes necessary to explore other options that assure adequate patient management and reduce the burden placed on the health system. this, therefore, justifies the evolution of home-based care (hbc) of positives during the covid-19 pandemic. the hbc has been defined as any form of care provided to ill individuals in their homes while drawing on the sound and evidence-based recommendations and support from hw [4,5]. contrary to the management at isolation centers, hbc of covid-19 positives provides the opportunity for patient management under an atmosphere of emotional, physical, and spiritual fulfillment as required for quick recovery [3]. as of 1st november 2020, covid-19 cases have risen to 46,156,540 globally, with nigeria accounting for 62,853 [6]. the preexisting weakness of nigeria’s health system provides substantial evidence to prove that the country's existing health facilities are insufficient to serve these ones [1]. therefore, in line with the world health organization recommendations, the nigeria center for disease control (ncdc) has issued an advisory for the management of severe covid-19 positives in treatment centers [5,7]. on the other hand, mildly symptomatic or asymptomatic covid-19 positives are to be placed on hbc. the hbc of covid-19 positives is not a venture which could be haphazardly coordinated or poorly implemented [7]. for this cause, hbc guidelines are required to be developed by each of the 36 states in nigeria as well as the federal capital territory. the development of these local guidelines considers the peculiarities of each state and the adaptability of hbc in each setting, a feat that may not be possible on a general platform. the decision on home isolation and care of covid-19 positives critically depends on the results obtained from the assessment of the following factors, namely; the clinical condition of each covid-19 positive, the availability of hbc personnel to monitor the clinical progression of the covid-19 positive in his/her home, and an assessment of the feasibility of ___________________________________________________ ileolasteve@yahoo.co.uk 1,2department of community medicine, university college hospital, ibadan, oyo state, nigeria full list of author information is available at the end of the article http://www.jidhealth.com/ ilesanmi os, et al., journal of ideas in health (2020);3(4):252-253 253 home care in the proposed home setting where the covid-19 positive is to be managed. after that, subsequent visits are made by hws, including community hws, to these sites to ascertain the compliance of covid-19 positives and relatives to homecare restrictions [7,8]. these include the isolation of patients into single ventilated rooms where possible or a portion of a room with a minimum of two meters from other persons. infection prevention and control (ipc) materials such as face masks and hand gloves are used and discarded after each use. wastes generated by the covid-19 patients should be handled as contaminated materials, which should be properly disposed of. in addition, visitors are not expected to enter such rooms, and patients are not expected to be seen in public places as a strategy to forestall onward transmission of covid-19 [7]. despite restrictive measures that have been put in place to reduce the risk for onward familial transmission of covid-19, anecdotal evidence has reported non-adherence to these directives among covid-19 patients on hbc. such disregard of recommended guidelines compromises the hbc's effectiveness in breaking the epidemic chain of covid-19 [7]. conclusion the hbc strategy offers a promising approach to the effective management of covid-19 positives from the home settings. to maximize the potential benefits presented by the hbc strategy for covid-19 positives, the services of enforcement authorities such as the civil defence corps could help improve adherence to hbc restrictions. also, community leaders, religious organizations, civil based organizations, and opinion leaders could both serve as authorities for maintaining covid19 guidelines and as focal persons in case of non-adherence. besides, the roles of community hws should clearly include strategies to ensure accurate reporting of hbc activities to present a true reflection of the covid-19 infection in communities. furthermore, the development of hbc guidelines should be hastened in states that are lacking to assess the hbc strategy's effectiveness on a national level. abbreviation covid-19: coronavirus disease; hw: health workers; hbc: home-based care; ncdc: nigeria centre for disease control; ipc: infection prevention and control declaration acknowledgment none funding the authors received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by ileolasteve@yahoo.co.uk authors’ contributions olayinka s. ilesanmi (osi), abolanle a. oguntoye (aao), and aanuoluwapo a. afolabi (aaa) are the principal investigators of this manuscript. all authors have equally participated in the study concept, design, writing, reviewing, editing, and approving the manuscript in its final form. all authors have read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, commentary articles need no ethics committee approval. consent for publication not applicable competing interest the author declares that he has no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of community medicine, lecturer 1, university of ibadan, ibadan, oyo state, nigeria; department of community medicine, honorary consultant, university college hospital, ibadan, oyo state, nigeria. 2department of community medicine, resident doctor, university college hospital, ibadan, oyo state, nigeria. 3department of community medicine, post-graduate student, university of ibadan, ibadan, oyo state, nigeria. article info received: 10 october 2020 accepted: 03 november 2020 published: 24 november 2020 references 1. ilesanmi os, afolabi aa. time to move from vertical to horizontal approach in or covid-19 response in nigeria. scimed. 2020; 2(special issue "covid-19"):28-29. 2. ilesanmi os, afolabi aa. ilesanmi o, afolabi a. perception and practices during the covid-19 pandemic in an urban community in nigeria: a cross-sectional study. peer journal. 2020; 8: e10038. https://doi.org/10.7717/peerj.10038. 3. ilesanmi os, afolabi aa. six months of covid-19 response in nigeria: lessons, challenges, and way forward. journal of ideas in health. 2020;3(special 1):198-200. https://doi.org/10.47108/jidhealth.vol3.issspecial1.63 4. world health organization. home care for patients with covid19 presenting with mild symptoms and management of their contacts. available from: https://www.who.int/publicationsdetail/home-care-for-patients-with-suspected-novel-coronavirus(ncov)-infection-presenting-with-mild-symptoms-andmanagement-of-contacts. [accessed on 5 october 2020]. 5. ilesanmi os, afolabi aa. a scope review on home-based care practices for covid-19: what nigeria can learn from other countries. ibom med j. 2021;14(1). 6. european center for disease prevention and control. covid-19 situation update worldwide, as of 1 november 2020. available from: https://www.ecdc.europa.eu/en/geographical-distribution2019-ncov-cases. [accessed on 1 november 2020]. 7. 7.nigeria center for disease control, 2020. interim guidelines for home care of confirmed covid-19 cases. available from: https://covid19.ncdc.gov.ng/media/files/homecareinterimguide.p df. [accessed on 5 october 2020]. 8. ilesanmi os, afolabi aa. in search of the true prevalence of covid-19 in africa: time to involve more stakeholders. ijhls. 2020; in press: e108105. https://doi.org/10.5812/ijhls.108105. https://doi.org/10.47108/jidhealth.vol5.iss1.209 katib aa, et al. journal of ideas in health 2022;5(1):649-654 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access what textual copying does not count as plagiarism? elaborate examples and problem-solving atif abdulhamid katib1*, bakr bakr kalo2, nadir hamza motair3 abstract scientists are motivated to publish original and high-quality articles. the only right way to accomplish that is through a long and daunting academic career. sometimes illegal shortcuts and tortuous methods are attempted by some people. bolstered with elaborate examples and problem-solving, this treatise explains the legal ways of textual copying and proper referencing techniques. moreover, it teaches how to steer away from copyright violations. in addition, it warns off all forms of literary theft and the catastrophic consequences of research misconduct. keywords: plagiarism, common knowledge, paraphrasing, creative commons, public domain, saudi arabia background authoring a research article is a great experience, though it has obligations. the author and his associates are held accountable for the content and formality of the work they produce [fig. 1][1]. the content should not only be correct; it has to be original as well. copyright code is all about originality and intellectual ownership protection. in the age of cyber media, taking part in a research article has become more compelling than it once was. the global momentum of publication among scientists might push unwary writers to cross red lines infringing the copyright code. the demand for publication is on the rise. students are encouraged to partake in research; postgrad fellows are obliged to bolster their resumes by publications to get decent posts or scholarships. competition in academic careers is very hectic. academics thrive on publications. they often deal with deadlines and are compelled to publish the best of their work in time to be promoted or at least to keep the current position. many biomedical scientists report exerting enormous pressure on them by the hiring agencies to produce numerous research publications, partly because the number of papers published is the main metric in most academic promotion systems [2]. in some cases, this pressure gives way in the form of ethical lapses, such as plagiarism, ghost, gift, guest authorship, or failure to report competing interests [1]. the increased number of published studies may or may not increase useful knowledge [3]. furthermore, this might limit exposure to potentially impactful work. novice searchers might stumble across a large pool of substandard studies and subsequently cite low-evidence studies because high-quality research is hard to find [4]. some researchers publish modest-quality papers that have never been cited just to fulfill a promotion requirement. moreover, others tend to eclectically cite their publications to over credit their earlier works [5]. many researchers commit literary theft, unaware that it is theft. they might think that sharing others` opinions is a form of admiration that justifies copying their work verbatim without permission or proper referencing. failing to abide by the rules and standards of academic writing is understandable when it comes to junior writers. however, it is not tenable when experienced writers commit research misconduct, though they might be lazy, slobby, or believe that the odds of being caught are very slim. research misconduct repercussions could be career-ending or scandalous at best. no one could think about that happening to him until it did. it is undeniable that the authorship profession is long and arduous, a matter that must be lucid to new researchers from the outset. the article's main goal is to increase the writers’ awareness and knowledge in the field of copyrights and research publication ethics. illegal textual copying it is unethical to borrow others` published texts without referring to the origin. violation of copyright code is unacceptable in any form as it undermines the integrity of research and the reputation ___________________________________________________ atifkatib@gmail.com 1senior urology consultant, clinical research associateking abdul-aziz hospital, makkah, saudi arabia full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol5.iss1.209 http://www.jidhealth.com/ katib aa, et al. journal of ideas in health (2022); 5(1):649-654 650 of researchers. however, the following are common forms of literary theft. figure. 1: the authorship equation [1] plagiarism it is the act of passing off others` words, works, and any kind of creative production and intellectual property as your own; without referring to the source. according to merriam webster dictionary, plagiarism is defined as the act of using another person's words or ideas without giving credit to that person: the act of plagiarizing something [6]. plagiarism is, perhaps, the most common form of research misconduct. if researchers quote another person's spoken or written words or paraphrase someone else’s conclusions, ideas, concepts, summaries, thoughts, arguments, or judgments, they are legally required to cite the source. likewise, statistics, designs, and graphic materials should be cited when using others' published works. common types of plagiarism there are different types of plagiarism. they are all serious violations of academic honesty. their common ground is copying words or sentences from the source verbatim with no attribution or using quotation marks. direct plagiarism is the classical transcription of a section or part of someone else's work. this violation varies from borrowing a section to copying the entire passage. it represents the most flagrant form of plagiarism. self-plagiarism is a form of redundant publication. it involves (recycling) or reusing content from previously published work without citation. this practice is widespread and could be unintentional. at a lower level, it applies to school or college students submitting a section of their assignments in different classes without obtaining permission from instructors. mosaic plagiarism is composing a text by assembling patches from different articles while maintaining the same template of the original. the final draft would look patchy and read incoherent. accidental plagiarism is considered when copying and pasting occur unintentionally. proving the wrongdoer oblivious does not absolve the full responsibility for plagiarism, yet, he is probably entitled to a reduced penalty [7]. what also counts as plagiarism is translating an article or part of it to a different language without attribution to its author [8]. most cases of plagiarism can be detected by using plagiarism checkers and avoided by making proper referencing. referring to a data source depends wholly on the publishing journal's citation style that is readily available at the authors` corner or by using the (live chat) service. borrowing images, videos, or music is beyond the scope of this article. falsification it is the manipulation or omission of research data to support the researchers' claims or hypotheses. falsification can include rounding up or down primary figures to multiply fractions to whole numbers after processing several calculations. it also involves manipulating images, graphics, or tables to distort the true data. falsification could extend to tampering with research instrumentation, materials, or processes. a professional, though a malign way of falsification on experimenting is by choosing the inappropriate controls; or not considering the proper reference population for statistical analysis in intent to over or underestimate the prevalence of a disease. such a deceiving study design generates misleading conclusions. likewise, in qualitative research, picking a non-representative sample to interview is premeditated dishonesty to produce wishful outcomes. fabrication it is also known as (dry-labbing). fabrication is probably the most heinous form of research misconduct. it is a blatant way of research data forgery, where perpetrators depend entirely on their wits to manufacture data and report conclusions. as falsification involves fiddling with existing data, fabrication, in turn, is creating new data out of nothing. fabrication could be in the form of making up data, faking scenarios, observations, or characterizations that never occurred in real life. although fabricated data are fictional, they are made plausible. perpetrators typically avoid outliers and surprising outcomes. the reported conclusions are carefully guesstimated or copied from other works in many instances. some forms of unintentional academic incompetence and malpractice can be difficult to distinguish from intentional fabrication. examples of this include the failure to account for measurement error or the failure to control experiments for any parameters being measured adequately. deep inspection of the researcher's background, his mentor's history, and the institution's reputation could help judge the case. consequences of research misconduct the consequences of research misconduct are serious and potentially disastrous [9]. in modern science, infringing copyrights is an offense that should be treated sternly. penalties for plagiarism vary considerably among universities and institutions around the world. from ithenticate.com: “most cases of plagiarism are considered misdemeanors, punishable by fines of anywhere between $100 and $50,000 — and up to one year in jail. plagiarism can also be considered a felony under certain state and federal laws. for example, if a plagiarist copies and earns more than $2,500 from copyrighted material, he or she may face up to $250,000 in fines and up to ten years in jail” (robert creutz, 2010) [10]. when undergrad students plagiarize, falsify, or fabricate a laboratory or homework assignment, it is considered cheating and usually handled within the institution. cheating is a mild term that describes students` misdemeanor. penalties are naturally lighter than court sentences [11]. research misconduct can haunt a scientist’s reputation, even ten years later. moreover, he could be dishonorably discharged from service and typically face the end of his career. however, depending on the type and severity of the allegation, the issue will be handled. it is also exceedingly important for postgrad fellows to understand that the katib aa, et al. journal of ideas in health (2022); 5(1):649-654 651 aftermath of engaging in plagiarism affects a wide range of bodies. misconduct can irreparably erode trust among colleagues. its deleterious effect might extend to the public, who might lose confidence in the ability and integrity of researchers. the fault of illegal text copying could cast a negative shadow on overall levels of affiliation and might go far beyond the wildest imaginations. it could stigmatize the school, college, or university. a vicious chain of events might follow. ruining the university's reputation could lower its national and international rankings. repercussions might extend further to impact the city or state economy. it can undermine trust between researchers and funding agencies, making it harder for colleagues at the same institution to receive grants. from a different perspective, research misconduct of any kind devalues the degree held by students and discounts alumni; therefore, they might be paid less for their degree or not employed at all. the value of research, journals, and scientific materials released by the institute under question would be worthless. students` enrolment at the degreeproviding institute would decrease, and tuition fees would drop. the entire academic industry could fall apart [12]. salami publishing salami publishing (sp) is an independent, unethical publication practice. in other words, it has nothing to do with textual copying. it is, in fact, the practice of slicing research into several independent paragraphs known as the least publishable units or "publon" and publishing them in multiple papers. in other words, it is a publication of numerous articles derived from a single study. in academic publishing, the publon is the smallest piece of information that can stand on its own in a peer-review process [13]. authors turn to this practice, often to get more recognition, increase their number of publications, and receive more funding. sp is unethical as a single study might count double or multiple in systematic review and meta-analysis, therefore, giving a deleterious impact on clinical practice. the intricate part of sp is that no algorithm or software application could objectively detect it, as there is no clear text similarity among the first and subsequent publications. that poses a serious threat to publication ethics. however, honesty in confirming the originality of the work submitted to a journal is the major touchstone [14]. cunning malpractice that could lead to sp is using the same primary datasheet or control group in more than one study. these publications could be simultaneous or years later, in the same language or translated to different languages. failure to cite prior publications and make proper crossreferencing is unethical. publishing a work more than once could artificially inflate the author's and journal's citation records and the scientific literature at large. it might displace the work of others waste the time and resources of editors and reviewers by going through the bogus quantity of research. it also could add clutter exaggerate the significance of findings. moreover, sp could interfere with the statistical methods used to generate evidence-based recommendations. in addition, it could distort the academic reward systems [15]. premature public statement for unwary speakers, making a statement in public about research results before peer-review and legal publication is not uncommon in the scientific community. it entails presenting research results in whole or in part in teaching venues, social gatherings, or closed circles. this practice subjects the research idea, protocol, or results to theft, especially if the legal publication was denied or deferred for unexpected reasons. researchers have to exercise self-control in public to avoid slipups that might spoil the research project before it is legally tied to them. recommended steps to protect your intellectual rights before publication are listed in [tab. 1]. the main issue of the preprint version of a manuscript is that it is not attributed to an author yet, and did not underwent to peer-review making them invalid for citation and liable to foul plays. tab. 1: tips on protecting your unpublished manuscript? • never share your work or talk about it or give hints in public. • register your work at a copy-right protection authority. • keep a dated physical record especially the first draft in a secure place. • email a copy of your work to yourself. • send it to a journal chief editor as a short communication (brief correspondence) for publication. • save a true copy at a solicitor or deposit it in a bank safe. • always mark your work with the© symbol followed by your name and date. legal textual copying quoting it is a common experience for academic writers to feel the need to include others’ wordings into their writing. it happened when the original author wrote something unique worth highlighting word for word and litter for litter; or when quoting from the holy book, or providing a precise definition of a phenomenon, quoting someone's testimony, definition, opinion view, insult, or threat. furthermore, a quoted text could be a piece of evidence to prove someone's claims false. in addition, you might quote to focus on a dialect or a language for educational and teaching purposes. in-text citation of a quote depends largely on the journal's citation style. whatever style you use, you must avoid plagiarism by correctly citing the true author, typing the original text precisely, and enclosing the quoted text in quotation marks. quoting a short text, fewer than 40 words, should be in quotation marks followed by the author's name and year in parenthesis [16]. for example, "better three hours too soon than a minute too late” (william shakespeare, 1603); and “yes, we can” (barack obama, 2008). a block quote is used in the case of longer texts. block quoting is formatted in a separate block text set after an indented line. for example: "bottom line is, i did not return to apple to make a fortune. i have been very lucky in my life and already have one. when i was 25, my net worth was $100 million or so. i decided then that i was not going to let it ruin my life. there is no way you could ever spend it all, and i do not view wealth as something that validates my intelligence" (steve jobs, 1997). [17] despite there being no official limits to quotation frequency or length, conventionally, a percentage ranging from 0 to 5 is considered acceptable by many institutions. academics argue that any type of work must include some words that are similar to different sources. therefore, a (similarity report) called also (originality score) with less than 15% matching text can represent plagiarism-free work [18]. quoting could support your view by verses of the holy book or famous poem or song or words said or written by eminent figures in the field. on the other hand, excessive quoting reflects the writer's inability to digest the katib aa, et al. journal of ideas in health (2022); 5(1):649-654 652 subject at hand. paraphrasing, in other respects, demonstrates a better comprehension of the subject and personalizes your work. paraphrasing paraphrasing means formulating someone else's ideas in your own words. to paraphrase a source, you have to rewrite a passage without changing the original text's meaning [19]. for paraphrasing to be legal, the paraphrased sentence must be cited. in other words, paraphrasing without a citation is plagiarism [20]. paraphrasing is encouraged in the scientific context when data are abstracted from different sources in different styles. paraphrasing in this situation helps streamline the flow of knowledge seamlessly. for the writer to keep his voice prevailing throughout the paper, he or she has to paraphrase. the following is an example of effective paraphrasing. the original passage: "if you want to try a new career, come on and hand in your papers as the displayed openings differ from your current work area" (atif katib, 2021). the paraphrased version is: "the job opportunities we are offering do not exactly match your field of specialization. if you are looking for a change, step forward and submit your documents". on close looking, the techniques used to paraphrase the original passage encompassed breaking the original sentence down into two phrases and getting into the speech from a different point of the original sentence. using formal vocabularies such as “field of specialization” instead of “area of work”; and “step forward” instead of “come on”. changing the sentence voice from passive to active such as “displayed openings” changed to “the job opportunities we are offering”. replacing phrasal verbs with regular verbs “hand in” changed to “submit". using synonyms is probably the simplest way to paraphrase a given sentence, like "openings" and "job opportunities", “papers” and “documents”. common knowledge virtually, not all textual copying is an offense; and therefore, counts as plagiarism. common knowledge (ck) is information that many or most people know [21]. publishing commonly known information does not require referencing. examples of ck are electrons that revolve around the nucleus; no one has yet discovered a cure to cancer; water boils at 100 degrees celsius, and innumerable other examples. some information that is believed to be true within specific circles of scientists or artists is similarly considered ck. examples of common knowledge in the scientific community, taking the audience background into account, everyone knows that testosterone is the hormone of masculinity, and the testes release it. to narrow the circle further, it is undisputable amongst urologists that escherichia coli is the commonest bacterium that causes urinary tract infection; and that prostate-specific antigen is the most reliable tumor marker for detecting prostate cancers. when verifying a given statement across multiple sources yields the same information, it is probably ck. whenever experts question a statement, comprehend it in different ways, or they might have to look deeper for its accuracy, it is not ck information is deemed ck when it is undisputed. however, whenever you are in doubt, provide a citation. general knowledge general knowledge (gk) is defined as the knowledge available to anyone [22]. gk is the information that has been accumulated over time through various media and sources like the radio, television, newspapers, encyclopedias, and the internet. it does not include diploma-based information or acquired from formal teaching. examples of gk are that global warming might lead to the extinction of polar bears; the tallest building on earth is burj khalifa in dubai; viagra helps men get a harder erection and uncountable more examples. fair use and transformative use of protected copyrights the above-mentioned concept grants a legal ruse for writers to use a small portion of protected copyrights in specific situations. examples of contexts that fair use might apply are teaching, criticism, comments, news reporting, and non-commercial purposes. considering such activities, fair use is a court judgment. in other words, there is no statute or solid criteria that determine a percentage or number of words, pages, or images to be used without permission. therefore, specialized courts judge fair use claims case-by-case [23]. an example of fair use is when authors make the abstract or a certain number of pages of their protected articles free to copy. a kind of fair use is transformative use which is legitimate likewise. the latter does not replace the original work, but it transforms it by adding new expression or meaning to create new information, aesthetics, insights, or different understanding. for instance, making the mona liza painting frowning or adding a mustache to it for sarcastic or symbolic purposes. harnessing fair and transformative uses should be low-key and non-profit. however, respect the creator's rights and use your material [24]. public domain the public domain (pd) refers to intellectual properties not protected by a copyright term. pd includes works produced before january 1923, works intentionally placed by the creator in the pd known as dedication, or when copyright law does not protect this particular type of work and works that have never been protected. some materials had once held the copyright, but that has expired; therefore, they are no longer protected and are in the public domain. in some cases, the copyright owner fails to follow copyright renewal rules, rendering his work to land in the pd [25]. public domain materials are free to use without permission, but no one can ever own them. moreover, you can mix, add on, adapt, and alter the original work legitimately. for example, shakespeare’s (romeo and juliet) may be in the public domain, but a new version with annotations or illustrations may have copyright protection in these new parts of the work. for this reason, authors should be aware that materials not protected by copyright could be covered by other legal protections such as patent or trademark laws. examples of what trademark laws cover are logos, pseudonyms, and trade dress [26]. rights depend on registrations and therefore vary by country and jurisdiction. that explains, in part, why claims are handled case by case, taking bylaws into account. in some countries, works enter the public domain 50 or 70 years after the creator's death, whereas in others, copyright protection lasts the whole author's life plus 95 years (mickey mouse law). to detail further, the walt disney entertainment company enjoys several layers of legal protection for major characters like mickey mouse. it owns the copyright to the original character. moreover, it owns the copyrights to subsequent versions of the character, which tend to be better known to modern katib aa, et al. journal of ideas in health (2022); 5(1):649-654 653 audiences. in addition, it owns trademark rights. the copyright for the original version of mickey mouse is scheduled to expire on january 1, 2024, whereas the other rights associated with mickey mouse will remain in place for longer [27]. creative commons creative commons (cc) is intellectual property licensure under which a given work would be liable for free usage without permission under a few conditions. marking your work as cc implies grating others the right to reuse, edit, and distribute your work for free. cc provides several core licenses, each of which allows anyone to use the material differently. while there are different cc licenses, all cc licenses include certain obligations. the conventional obligations are to attribute the work to its creator, use it precisely as it is, and not use it for commercial purposes or monetary gain. cc users must understand that any new work produced out of this material must be permissible under the same license as the original work. in addition, whenever you make changes to the work, you must acknowledge the original work and indicate that changes have been made [28]. reasonable applications of cc license embody educational purposes, as teachers and students are allowed to copy and edit an entire work, keeping an eye on exceptions if there are. for example, ted talks materials, which are videos created from presentations on any topic at the domain ted (technology, entertainment, design); are allowed to be shared under creative commons license (cc by–nc–nd 4.0 international), which means you have to include an attribution to ted as the owner of the ted talk and include a link to the talk. furthermore, you can use ted talks for personal use only, away from any profitable or commercial context. in addition, no derivative works are permitted, so you cannot edit, remix, create, modify or alter the form of the ted talks in any way [29]. attempting to use material out of the cc scope of usage mandates legal permission. example problems query 1: a scientist develops data while working at the arabian gulf college. he then moves to al-andalus university, where he publishes an article in the journal of new data, using the original data. who owns the data? answer: the arabian gulf academy. according to guidelines established by harvard university in 1988 and subsequently adopted by other institutions, data developed by employees of academic institutions are owned by the institutions [26]. query 2: george and shari are classmates attending the final semester in medical physics. while studying in a group, george is appalled to discover that the dissertation he had purchased from an academic services shop near the university campus is eerily similar to shari's. on closer look, he finds the two papers are carefully paraphrased except for the conclusion section, which is an identical word for word. in a hunch, he copies and pasts a conclusion paragraph from a previous paper he wrote. after submitting the dissertations to the instructor, she reports on them for suspicion of foul play, as the two papers share the exact graphics and reference lists. investigations reveal that the students and the shop manager are guilty. the latter has been selling ready-made treatises for a decade long; therefore, he has been sentenced to 5-year in prison and is punishable by fines of $20,000. the students violate the student conduct code and have been sentenced to a two-quarter delay in the conferral of the degree and 40 hours of community service. what are the violations committed? answer: the shop owner is criminally cheating on the community and deserves the harsh penalty under civil law. shari is a scammer, committing more than plagiarism. she did not only submit what she did not write, but she also paid money for that, rebutting the premise that the act was unintentional. george is a master scammer and twice plagiarist, as he committed direct and self-plagiarism. the unlawful payment he made is an aggravated offense. the students should receive heavier penalties. conclusion textual copying, when duly quoted or properly referenced, is legal. creative commons, general and common knowledge, fair use, public domain are legislations that legalize textual copying under certain conditions. abbreviation sp: salami publishing; ck: common knowledge; gk: general knowledge; pd: public domain; cc: creative commons; ted: technology, entertainment, design; declaration acknowledgment none funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing atifkatib@gmail.com authors’ contributions all authors contributed equally in the designing and writing the manuscript. all authors approved the final version of the manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, commentary articles need no ethics committee approval. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. consent for publication not applicable competing interest the author declares that he has no competing interests. katib aa, et al. journal of ideas in health (2022); 5(1):649-654 654 author details 1senior urology consultant, clinical research associateking abdulaziz hospital, makkah, saudi arabia. 2senior family medicine consultantdirectorate of makkah health affairs, saudi arabia. 3disaster medicine specialistdirectorate of makkah health affairs, saudi arabia. article info received: 02 march 2022 accepted: 17 march 2022 published: 23 march 2022 references 1. katib aa. clinical research authorships: ethics and problemsolving. can. j. bioeth. 2020; 3:118-23. https://doi.org/10.7202/1073787ar. 2. tijdink jk, vergouwen ac, smulders ym. publication pressure and burn out among dutch medical professors: a nationwide survey. plos one. 2013 sep 4;8(9): e73381. doi: 10.1371/journal.pone.0073381. 3. lefaivre ka, shadgan b, o'brien pj. 100 most cited articles in orthopaedic surgery. clin orthop relat res. 2011 may;469(5):1487-97. doi: 10.1007/s11999-010-1604-1. 4. ranasinghe i, shojaee a, bikdeli b, gupta a, chen r, ross js, et al. poorly cited articles in peer-reviewed cardiovascular journals from 1997 to 2007: analysis of 5-year citation rates. circulation. 2015 may 19;131(20):1755-62. doi: 10.1161/circulationaha.114.015080. 5. bardeesi am, jamjoom aa, algahtani a, jamjoom a. the impact of country self-citation rate among medical specialties in saudi arabia. cureus. 2021 jan 4;13(1):e12487. doi: 10.7759/cureus.12487. 6. merriam-webster.com/dictionary. (n.d.). full definition of plagiarism. merriam-webster.com/dictionary/plagiarism. retrieved february 9, 2022, from https://www.merriamwebster.com/dictionary/plagiarism. 7. enago academy. (2021, november 26). 8 most common types of plagiarism to stay away from! https://www.enago.com/. retrieved february 9, 2022, from https://www.enago.com/academy/fraud-research-many-typesplagiarism/. 8. george t. (2022, january 14). how to avoid plagiarism, common mistakes & tips. https://www.scribbr.com. retrieved february 9, 2022, from https://www.scribbr.com/plagiarism/how-to-avoidplagiarism/ 9. georgia institute of technology. (n.d.). responsible conduct of research. georgia tech. retrieved february 9, 2022, from https://rcr.gatech.edu/researchmisconduct#:~:text=the%20consequences%20that%20research% 20misconduct,same%20institution%20to%20receive%20grants. 10. creutz r. (2010, june 23). plagiarism punishment. ithenticate.com. retrieved february 9, 2022, from https://www.ithenticate.com/plagiarism-detectionblog/bid/52974/plagiarism-punishment. 11. shapiro mf. data audit by a regulatory agency: its effect and implication for others. account res. 1992;2(3):219-29. doi: 10.1080/08989629208573818. pmid: 11653981. 12. consequences of plagiarism. (n.d.). scanmyessay.com. retrieved february 9, 2022, from https://www.scanmyessay.com/plagiarism/consequences-ofplagiarism.php. 13. broad wj. the publishing game: getting more for less. science. 1981 mar 13;211(4487):1137-9. doi: 10.1126/science.7008199. pmid: 7008199. 14. broad w, wade n. (1983), betrayers of the truth: fraud and deceit in the halls of science, london: century publishing, pp. 53–55, isbn 0-7126-0243-7. 15. hennessey kk, williams ar, afshar k, macneily ae. duplicate publications: a sample of redundancy in the journal of urology. can urol assoc j. 2012 jun;6(3):177-80. doi: 10.5489/cuaj.11265. 16. mccombes s. (2021, september 20). how to quote | citation examples in apa, mla & chicago. scribbr.com. retrieved february 9, 2022, from https://www.scribbr.com/citingsources/how-to-quote/. 17. qwm. (2021, november 24). 50+ famous steve jobs quotes on life, work, an leadership. quoteswishesmsg.com. retrieved february 9, 2022, from https://www.quoteswishesmsg.com/stevejobs-quotes.html 18. smart j. (2020b, may 7). acceptable turnitin percentage: interpret originality report. essaylot.com. retrieved february 10, 2022, from https://essaylot.com/acceptable-turnitinpercentage/#:~:text=the%20acceptable%20turnitin%20percentag e%20is,when%20well%2dcited%20and%20referenced. 19. gahan c. (2018, april 18). how to paraphrase in 5 easy steps | tips and examples. scribbr.com. retrieved february 14, 2022, from https://www.scribbr.com/citing-sources/how-to-paraphrase/ 20. check for plagiarism. (n.d.). what is plagiarism? checkforplagiarism.net. retrieved february 14, 2022, from https://www.checkforplagiarism.net/research/what-is-plagiarism. 21. merriam-webster, incorporated. (n.d.). definition of common knowledge. merriam-webster.com. retrieved february 10, 2022, from https://www.merriamwebster.com/dictionary/common%20knowledge 22. farlex, inc. (n.d.). general knowledge. thefreedictionary.com. retrieved february 10, 2022, from https://www.thefreedictionary.com/general+knowledge 23. us copyright office. (2021, may). more information on fair use. copyright.gov. retrieved february 10, 2022, from https://www.copyright.gov/fair-use/more-info.html 24. justia. (2021, october). transformative use and copyright infringement. justia.com. retrieved february 10, 2022, from https://www.justia.com/intellectual-property/copyright/fairuse/transformative-use/ 25. boyle j. (2008). the public domain, enclosing the commons of the mind [press release]. https://thepublicdomain.org/thepublicdomain1.pdf 26. king l. (2012). intellectual property quiz [press release]. https://www.amamanualofstyle.com/fileasset/files/quizzes/2012_1 2-answers_intellectualproperty.pdf 27. lee t. (2019, january 1). mickey mouse will be public domain soon—here’s what that means [press release]. https://arstechnica.com/tech-policy/2019/01/a-whole-years-worthof-works-just-fell-into-the-public-domain/ 28. smartcopying. (n.d.). what is creative commons? smartcopying.edu.au. retrieved february 14, 2022, from https://smartcopying.edu.au/what-is-creative-commons/# 29. ted. ideas worth spreading. (n.d.). ted talks usage policy. ted.com. retrieved february 14, 2022, from https://www.ted.com/about/our-organization/our-policiesterms/ted-talks-usage-policy https://doi.org/10.47108/jidhealth.vol3.issspecial2.87 bennaoum mn, et al., journal of ideas in health 2020;3(special 2):276-277 © the author(s). 2020 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access infectious serology, how to test large series without pooling samples mohammed nazim bennaoum1,2*, affaf adda1,2, mohamed chekkal1,2, fatima seghier1,3 abstract: pooling samples for serological testing was used first during the second world war. it was described later as a costeffective technique permitting large screening of populations, especially for new infectious diseases. however, the dilution effect is responsible for decreasing sensitivity, limiting its use in practice, especially blood banking. in this paper, we describe a modification of the classic enzyme-linked immunosorbent assay (elisa) procedure, which permits the test of indefinite samples using just one well. specimens are tested pure one by one without any dilution, so sensitivity remains unchanged. this new procedure is time-consuming but can be considered as a revolution in qualitative elisa testing. keywords: elisa, pooling sera, infectious serology, algeria background elisa testing was developed in the 1960s as a safety method to replace radioimmunologic assays. in the 80s, elisa was generalized in all laboratories with the discovery of the human immunodeficiency virus. however, in the first times, the cost was high and couldn't be supported in low-income countries. pooling sera for testing was considered a solution to reduce the cost of screening large populations; six to ten sera were mixed and tested. the negative result excluded the infection in all samples, while the positive reaction requires analyzing them one by one [1, 2]. unfortunately, mixing sera shows to reduce the test's sensitivity, especially when diluting some low positive samples. in this case, the reactivity will be lower than the cutoff of detection [3, 4]. thereby, novack found a diminution of the sensitivity of detecting antigen s of b hepatitis from 99% to 93% when pooling and an extension of the serological windows for five days [5]. in another study, novack also found a reduction of the sensitivity by 3% to detect antibodies of c hepatitis when using a pool of 6 samples [6]. in addition to the effect of dilution, there is a risk of neutralization of antigens such as antigen s of b hepatitis when mixed with sera containing antibodies against antigen s [5]. for these reasons, pooling was prohibited in blood banking, even in developing countries [7]. we presented a modification of the procedure of qualitative elisa permitting testing theoretically an infinite number of samples using just one well. presentation of the hypothesis in elisa testing, wells are coated with an antibody (or antigen for sandwich elisa), forming a solid phase [8]. in the first step, the sample is added, and the eventual antigen (or antibody) presents in sera will set to the solid phase. after washing, this reaction will be completed by the addition of a conjugate containing an antibody (or antigen) associated with a specific enzyme such as alkaline phosphatase (ec 3.1.3.1) or glucose oxidase (ec 1.1.3.4). this enzyme catalysis a colorimetric reaction, which means a positive reaction. the proposed idea consists of the incubation in one well of samples one after one before washing and adding conjugate. in the first step, a sample is incubated, and in the second step, the first sample is eliminated from the well, and a second sera is added for incubation. these operations can be repeated many times (eliminating sera and incubation of a new one in the same well). if one of the multiple samples tested contains the specific antibody (or antigen), it will be irreversibly fixed in the solid phase even if all other samples are negatives. the procedure is completed without modifications with washing, the addition of conjugate followed by colorimetric revelation. ___________________________________________________ benazim@ymail.com 1department of hemobiology, ehu "1er novembre 1954", oran, algeria. faculty of medicine, university of oran 1 ahmed ben bella, algeria. full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol3.issspecial2.87 http://www.jidhealth.com/ bennaoum mn, et al., journal of ideas in health (2020); 3(special 2):275-277 277 a positive reaction means that at least one of the samples is reactive and impose analyzing them one by one or by smaller groups. evaluation of the procedure to be validated, this method must present the same sensitivity as classical elisa testing. for evaluating this procedure, positive control, or a known positive sample (confirmed containing antibodies or antigens of an infectious disease) should be tested first and followed by a series of known negatives sera in the same well as described above. in the end, the reaction must be positive. the sensitivity of this new procedure can also be evaluated and compared to classical methods. for this, the positive sample should be diluted half to half (1⁄2, 1⁄4, 1/8, 1/16, 1/32…). each dilution is tested in duplicate with classical elisa and with the proposed procedure. the last dilutions giving a positive reaction with the two methods are compared and must be the same. consequences of the idea the main disadvantage of pooling sera is the dilution effect as described above. the proposed procedure permits to test of pure samples, so the sensitivity remains unchanged and avoids antigens' neutralization. successive incubations of samples are time-consuming, but the financial benefit is significant. this hypothesis's benefit is also important, for example, during the first times of a pandemic, especially with new emerging infectious diseases. in these situations, the need for screening tests exceeds their production rate. this has been observed in the 80s with the apparition of the acquired immunodeficiency disease syndrome and, more recently, with the severe acute respiratory syndrome coronavirus 2 (sarscov-2) [9]. the other benefit is economic; this hypothesis's application permits a drastic reduction in screening populations' cost, particularly in low-income countries. conclusion incubating samples one by one in elisa testing, as described in this paper, seems to be a real alternative to pooling sera without any disadvantage. abbreviation elisa: enzyme-linked immunosorbent assay; sars-cov-2: severe acute respiratory syndrome coronavirus 2 declaration acknowledgment none funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing benazim@ymail.com authors’ contributions mohammed nazim bennaoum (mnb) is the principal investigator of this manuscript (viewpoint). mnb proposed the idea, and ad, and mc have contributed to the writing, reviewing, editing, and approving the manuscript in its final form. all authors have read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, viewpoint articles need no ethics committee approval. consent for publication not applicable competing interest the author declares that he has no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of hemobiology, ehu "1er novembre 1954", oran, algeria. 2faculty of medicine, university of oran 1 ahmed ben bella, algeria. 3department of hemobiology chu oran, algeria article info received: 07 november 2020 accepted: 19 december 2020 published: 24 december 2020 references 1. behets f, bertozzi s, kasali m, kashamuka m, atikala l, brown c et al. successful use of pooled sera to determine hiv-1 seroprevalence in zaire with development of cost-efficiency models. aids 1990; 4(8):737-742. https://doi.org/10.1097/00002030-199008000-00004 2. cahoon-young b, chandler a, livermore t, gaudino j, benjamin. sensitivity and specificity of pooled versus individual sera in a human immunodeficiency virus antibody prevalence study. journal of clinical microbiology 1989; 27(8):1893-1895. https://jcm.asm.org/content/27/8/1893.short 3. shipitsyna e, shalepo k, savicheva a, unemo m, domeika m. pooling samples: the key to sensitive, specific and cost-effective genetic diagnosis of chlamydia trachomatis in low-resource countries. acta dermato-venereologica 2007; 87(2):140-143. https://doi.org/10.2340/00015555-0196 4. mcmahan cs, tebbs jm, bilder cr. informative dorfman screening. biometrics 2012; 68(1): 287-296. https://doi.org/10.1111/j.1541-0420.2011.01644.x 5. novack l, sarov b, goldman-levi r, yahalom v, safi j, soliman h et al. impact of pooling on accuracy of hepatitis b virus surface antigen screening of blood donations. transactions of the royal society of tropical medicine and hygiene 2008; 102(8):787-792. https://doi.org/10.1016/j.trstmh.2008.04.005 6. novack l, shinar e, safi j, soliman h, yaari a, galai n et al. evaluation of pooled screening for anti hcv in two blood services set‐ups. tropical medicine & international health 2007; 12(3): 415-421. https://doi.org/10.1111/j.1365-3156.2006.01810.x 7. schmunis ga, zicker f, pinheiro f, brandling-bennett d. risk for transfusion-transmitted infectious diseases in central and south america. emerging infectious diseases 1998; 4(1):5. https://doi.org/10.3201/eid0401.980102 8. voller a, bidwell d, bartlett a. enzyme immunoassays in diagnostic medicine: theory and practice. bulletin of the world health organization 1976; 53(1): 55. https://pubmed.ncbi.nlm.nih.gov/1085667/ 9. ali jadoo sa. was the world ready to face a crisis like covid19? journal of ideas in health 2020; 3(1):123-124. https://doi.org/10.47108/jidhealth.vol3.iss1.45 https://doi.org/10.47108/jidhealth.vol4.iss4.196 visuddho v, et al., journal of ideas in health 2021;4(special 4):623-629 © the author(s). 2021 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access predictive accuracy of blood inflammatory markers on covid-19 mortality visuddho visuddho1, agus subagjo2, retno asih setyoningrum3*, alfian nur rosyid4 abstract background: the impact of covid-19 may be more severe in developing countries. our study aims to analyze the accuracy of several inflammatory biomarkers in predicting covid-19 mortality, providing information about the most suitable markers for developing countries. methods: a retrospective cohort study was conducted at dr. soetomo general hospital, indonesia, from march to june 2020. white blood cells (wbc) count, neutrophil-lymphocyte ratio (nlr), procalcitonin (pct), d-dimer, and c-reactive protein (crp) have been collected from the electronic medical records. we performed survival analysis to provide the hazard ratio and receiver operating characteristic (roc) curve analysis to test for accuracy for each parameter. results: a total of 423 patients who met the criteria for participating had a median age of 54 (iqr 45-61) years. patients in the death group are characterized by older age and shorter length of hospitalization. the wbc, nlr, pct, d-dimer, and crp are found significantly higher in the death group (p=0.000). the wbc, nlr, pct, d-dimer, and crp have an area under the curve (auc) of 0.709, 0.773, 0.738, 0.721, and 0.769, respectively moderate accuracy in predicting covid-19 patient mortality. we found that nlr is significantly more accurate than the age parameter (z=3.527; p=0.000) but has equal accuracy with other laboratory parameters. conclusion: since nlr obtained the highest accuracy, we still recommend routine complete blood count tests as prognostic biomarkers with the highest feasibility to be performed in developing countries. keywords: covid-19, infectious disease, laboratory, inflammatory, marker, predictive, indonesia background coronavirus disease 2019 (covid-19) has been one of the most significant global pandemics. recently, on july 27th, 2021, indonesia contributed the third-highest number of new covid-19 cases in the world [1]. the exponential increase of covid-19 patients is also found in indonesia, with 3,532,567 cases and 100,636 deaths as of august 4th, 2021 [2]. therefore, indonesia, and other developing countries, must increase awareness and develop the most well-suited guidelines for covid-19 management. the early identification can provide necessary information for managing covid-19 patients [3,4]. a previous study showed an association between several biomarkers to the severity and mortality of covid-19 patients [5–7]. early laboratory examinations are necessary to predict worsened outcomes and prepare the most advisable management for patients [5,8]. however, few studies from a large developing country like indonesia reported early laboratory examination on predicting survival and mortality. the white blood cell count (wbc) and neutrophil-lymphocyte ratio (nlr) have been recognized as routine hematological markers that have been used widely in clinical settings [9,10]. the wbc and nlr have good predictive accuracy in predicting poor clinical outcomes [11,12]. however, previous studies show that only the newer inflammatory biomarker, procalcitonin (pct), has high accuracy in predicting covid-19 poor outcomes in critical conditions [13]. the findings were also supported by one meta-analysis, showing the accuracy of pct was 90.5%, while other markers (wbc, nlr, and creactive protein (crp)) have accuracy below 85% [14]. the newer inflammatory marker seems promising but has a higher cost and difficulty implementing primary or secondary medical care in developing countries. therefore, there is a need for information on the difference in accuracy between the newer inflammatory marker and the routine, low-cost, complete blood count test. our study aims to analyze the accuracy of wbc, nlr, pct, d-dimer, and crp in predicting covid-19 mortality. these findings may support the decision of clinical management protocols in developing countries. ___________________________________________________ retno-a-s@fk.unair.ac.id 3*department of pediatrics, faculty of medicine, universitas airlangga jl. mayjen prof. dr. moestopo 47, surabaya, east java 60132, indonesia. a full list of author information is available at the end of the article. https://doi.org/10.47108/jidhealth.vol4.iss4.196 http://www.jidhealth.com/ visuddho v, et al., journal of ideas in health (2021); 4(special 4):623-629 624 methods study design and participants this study was a retrospective cohort study of hospitalized patients with covid-19 enrolled at dr. soetomo general hospital (surabaya city, east java province, indonesia). all confirmed covid-19 patients were screened, and those who had definite outcomes (death or discharged) between march 1st, 2020, and june 30th, 2020, were listed. from the total of 423 patients, then 28 pregnant patients, 8 patients with no realtime polymerase chain reaction (rt-pcr) test record, and 46 patients with no early laboratory tests were excluded, leaving 341 patients included in this study. not all the patients received all parameters tests because of physicians' feasibility and clinical decision. data collection the age, length of hospitalization, and early laboratory test (wbc, neutrophil percentage, lymphocyte percentage, procalcitonin, d-dimer, and crp) were collected from secondary data from electronic medical records using a standardized data collection form. all data were checked twice to ensure the data retrieve correctly before being entered into a computerized database. . definitions the diagnosis of covid-19 was defined according to the indonesian ministry of health covid-19 prevention and control guidelines (version 5.0) [15]. detection of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection is done using real-time rt-pcr methods from nasopharyngeal swab specimens. the confirmative examination was conducted by the diagnostic center of dr. seotomo general hospital, surabaya. the criteria for discharge were complete isolation for ten days from the date of onset with a minimum of 3 days after an absence of fever and respiratory problems (for mild and moderate patients) or has obtained a negative one-time rt-pcr follow-up examination plus a minimum of 3 days after an absence of fever and respiratory problems (for severe and critical patients). the laboratory examination was conducted based on dr. soetomo general hospital clinical practice guidance. neutrophil-lymphocyte ratio (nlr) was calculated by dividing the neutrophil percentage by the lymphocyte percentage. statistical analysis the age, length of hospitalization, and laboratory data were presented as the median and interquartile range (iqr), while sex variables were presented as count (n) and percentage (%). the mann-whitney u test and chi-square test compared differences between the discharge and death groups. survival analysis was performed using the kaplan-meier survival curve to measure survival probability during hospitalization, showing the log rank p-value. we use the cox proportional hazard regression model to determine the hazard ratio (hr) during hospitalization. receiver operating characteristic (roc) curves were conducted to measure the area under the curve (auc) value, sensitivity, and specificity of a predictivevariable. all statistic was performed individually for each variable. since the difference in the sample size of each laboratory data, we can not perform multivariable analysis to show the most influencing variables. we do z-test between nlr to other laboratory parameters to compare the accuracy. statistically significant was considered using two-sided α less than 0.05. statistical analysis was done using the ibm spss software (version 13). results patients characteristic and comparative test the patient's baseline characteristics, early laboratory test, and comparative test results are presented in table 1. a total of 423 patients who met the criteria for participating had a median age of 54 (iqr 45-61) years. patients in the discharge group have lower age (51.00 vs. 55.00; p =0.000) and higher length of hospitalization (15.00 vs. 5.00; p =0.000) than patients in the death group. there is no significant difference in mortality between male and female patients (p =0.514). the discharge group has significantly lower value than death group for wbc (7.71 vs 10.80; p =0.000), nlr (4.43 vs 9.32; p=0.000), pct (0.13 vs 0.39; p =0.000), d-dimer (1010.00 vs 2560.00; p =0.000) and crp (6.00 vs 15.00; p =0.000) parameters. table 1. baseline characteristic and early laboratory test of the study cohort variables total (n=341) discharge (n=193) death (n=148) p-value age (year) 54.00 (45.00-61.00) 51.00 (40.50-59.00) 55.00 (47.25-65.00) 0.000** sex 0.514 male 189 (55%) 104 (54%) 85 (57%) female 152 (45%) 89 (46%) 63 (43%) length of hospitalization (days) 11.00 (5.00-17.00) 15.00 (11.00-20.00) 5.00 (2.00-9.00) 0.000** white blood cell count (103/ul) (n=325 patients) 8.73 (6.42-12.06) 7.71 (5.86-9.77) 10.80 (7.88-15.02) 0.000** neutrophil lymphocyte ratio (n=325 patients) 6.02 (3.48-10.64) 4.43 (2.79-6-95) 9.32 (5.81-15.12) 0.000** procalcitonin (ng/ml) (n=249 patients) 0.19 (0.09-0.69) 0.13 (0.08-0.26) 0.39 (0.16-1.71) 0.000** d-dimer (ng/ml) (n=184 patients) 1390.00 (712.50-5537.50) 1010.00 (520.00-2400.00) 2560.00 (1185.00-11395.00) 0.000** c-reactive protein (mg/dl) (n=111 patients) 9.70 (3.80-15.90) 6.00 (1.50-11.90) 15.00 (9.78-19.45) 0.000** **p-value<0.001 visuddho v, et al., journal of ideas in health (2021); 4(special 4):623-629 625 survival analysis as seen in figure 1, by using old age criteria and prespecified cut-off (obtained from the diagnostic tools) for laboratory parameters, we compare the survival probability between discharge and death group using kaplan-meier survival curve. patients with older age (>59 years), higher wbc (>10.000/ul), nlr(>5), pct (>0.5 ng/ml), d-dimer (>440 ng/ml), and crp (>1 mg/dl) seem more vulnerable with lower survival during hospitalization. patients older than 59 years have a significantly lower survival than patients younger than 59 years. table 2 shows that all laboratory parameters predict patient mortality during hospitalization. each addition of one year's age would increase 1.027 (95% ci: 1.013-1.040; p=0.000) times of mortality risk. the hr of other laboratory parameters are 1.041 (95% ci: 1.025-1.057; p =0.000) for wbc, 1.020 (95% ci: 1.010-1.030; p =0.000) for nlr, 1.047 (95% ci: 1.024-1.070; p =0.000) for pct, 1.000 (95% ci: 1.000-1.000; p =0.012) for d-dimer, and 1.004 (95% ci: 0.998-1.009; p =0.209). table 2. cox regression analysis of predictive variables variables hr (95% ci) p-value age (year) 1.027 (1.013-1.040) 0.000** white blood cell count (103/ul) (n= 325 patients) 1.041 (1.025-1.057) 0.000** neutrophil lymphocyte ratio (n= 325 patients) 1.020 (1.010-1.030) 0.000** procalcitonin (ng/ml) (n= 249 patients) 1.047 (1.024-1.070) 0.000** d-dimer (ng/ml) (n= 184 patients) 1.000 (1.000-1.000) 0.012* c-reactive protein (mg/dl) (n= 111 patients) 1.004 (0.998-1.009) 0.209 hr = hazard ratio; *p-value<0.05; ** p-value<0.01 roc analysis and comparison of auc value the auc value of all variables is shown in figure 2. age has an auc value of 0.633, a low accuracy category (0.6-0.7). the early laboratory parameter, wbc, nlr, procalcitonin, d-dimer, and crp, have moderate accuracy (0.7-0.8). nlr accuracy is significantly greater than age in predicting patient mortality with a z-test score of 3.527 (p=0.000). as shown in table 3, we found a more excellent auc value on nlr but no significant z-test in other comparisons. as a result, nlr was comparable to other laboratory parameters in predicting covid-19 patient mortality. table 3. comparison of area under the curve of neutrophil-lymphocyte ratio to other parameters variables auc of nlr auc of comparator z-test p-value nlr vs age 0.773 (0.722-0.824) 0.633 (0.574-0.692) 3.527 0.000** nlr vs. wbc 0.709 (0.652-0.767) 1.643 0.100 nlr vs pct 0.738 (0.674-0.802) 0.833 0.405 nlr vs d-dimer 0.721 (0.649-0.794) 1.150 0.250 nlr vs crp 0.769 (0.679-0.858) 0.076 0.939 auc = area under the curve; crp = c-reactive protein; nlr = neutrophil-lymphocyte ratio; pct = procalcitonin; wbc = white blood cells; **p-value<0.001 discussion the increasing demand for managing covid-19 cases has burdened medical healthcare systems. implementing good triage by early identification of a patient's prognosis is essential to improve covid-19 patient management. in this study, the high mortality percentage (43.4%) might be caused by higher severe cases in dr. soetomo general hospital due to its function as a national referral hospital. we found that all the variables involved in the patients' survival can be a predictor with low-moderate accuracy. we also found that nlr was comparable to other laboratory parameters in predicting covid-19 patient mortality. previous studies have reported the association between older age and covid-19 mortality [16– 18]. we confirmed that patients with older age have lower survival during hospitalization. the decrease of immunity function due to immunosenescence may be involved in a patient's condition [19]. in addition, the elderly appears to develop sub-clinical chronic inflammation conditions, called inflame-aging, after viral or other pathogens infections [20]. the consequence of inflame-aging is deleterious effet to organ leading to a higher risk of mortality [21]. consistent with other studies, our findings reported that patients with higher wbc count, nlr, pct, d-dimer, and crp had higher odds of covid-19 mortality [5,22,23]. although several studies declare no significant result on the association of higher wbc with the severity, higher wbc may impact higher neutrophils cells which have a role in inflammation [23,24]. the higher nlr reflects the increase in pro-inflammatory cells and decreased lymphocytes and regulatory t cells, which have a role in controlling inflammation [22,25]. the use of pct and crp in covid-19 patients may be based on their capability in detecting sepsis conditions [26,27]. the pct showed high accuracy, while the crp showed moderate accuracy in predicting sepsis [28]. interestingly, these are also similar to the accuracy of both parameters in predicting covid-19 severity, with the high accuracy for pct and moderate accuracy for crp [13]. d-dimer is also one of the standard parameters tested in covid-19 patients. the significant association may be based on the potency of d-dimer to detect coagulopathy, the risk for venous thromboembolism, and excessive inflammation in covid-19 infection [29]. the survival analysis shows the significance of all variables in determining the patient's mortality risk. visuddho v, et al., journal of ideas in health (2021); 4(special 4):623-629 626 a. b. c. d. e. f. figure 1. kaplan-meier survival curve of (a) age (b) white blood cell count (c) neutrophil-lymphocyte ratio (d) procalcitonin (e) d-dimer (f) c-reactive protein for covid-19 patients survival this can be explained since all the variables are associated with inflammation [30]. inflammation is responsible for the progression of tissue damage and organ injury, from mild to severe organ dysfunction leading to poor outcomes [31,32]. sepsis and other organ dysfunction appear as complication and mortality cause in covid-19 patients [33,34]. roc curve analysis reveals low accuracy of age and moderate accuracy of all laboratory markers on predicting mortality of covid-19 patients. the nlr has the highest accuracy with auc 0.734 (95%ci 0.675-0.793). this result is quite different from other studies reporting higher accuracy of pct than other parameters [13], even though all the markers still show a significant accuracy to predict covid-19 patient mortality. z-test also showed no significant difference in accuracy between all laboratory markers, interpreted as all these markers have the same moderate accuracy in predicting covid1-9 mortality. hence, our study still recommends using conventional parameters, like wbc and nlr, for predicting the mortality of covid-19, with better accessibility, feasibility, and affordable price, especially in developing countries. until now, there are still few studies focused on analysis survival and predictive factors for covid-19 mortality from developing countries in southeast asia. our strength is to show the survival and predictive value of the conventional and "advanced" laboratory parameters. therefore, our result can be used as a reference, especially for the developing countries which needed effective parameters with relatively low-cost expenditure. log-rank p = 0.028 log-rank p = 0.000 log-rank p = 0.000 log-rank p = 0.004 log-rank p = 0.017 log-rank p = 0.000 visuddho v, et al., journal of ideas in health (2021); 4(special 4):623-629 627 limitation of study several limitations exist in our study. first, due to the limited sample tested by the "advanced" laboratory parameters, our accuracy comparison only can be conducted indirectly using the z-test. second, we cannot do the multivariate analysis due to the unequal sample size of each parameter. finally, the investigators could not include other variables that may influence the result due to limited data on electronic medical records. conclusion in conclusion, our study found a significant association between age and all laboratory markers (wbc, nlr, pct, d-dimer, and crp) and covid-19 patient mortality. all laboratory markers showed moderate accuracy as early predictors. however, our study still suggests routine complete blood count tests as prognostic biomarkers with moderate accuracy and the highest feasibility to be performed in developing countries. further research may look into comparing all these parameters with radiological markers or specific clinical conditions to improve the management of covid-19, especially in developing countries. abbreviation covid-19: coronavirus disease 2019; wbc: white blood cells; nlr: neutrophil-lymphocyte ratio; pct: procalcitonin; crp: c-reactive protein; auc: area under the curve; rtpcr: real-time polymerase chain reaction; sars-cov-2: severe acute respiratory syndrome coronavirus 2; iqr: interquartile range; hr: hazard ratio a. b. c. d. e. f. figure 2. receiver operating characteristic curve of (a) age (b) white blood cell count (wbc) (c) neutrophil-lymphocyte ratio (nlr) (d) procalcitonin (pct) (e) d-dimer (f) c-reactive protein (crp) for prediction of covid-19 mortality age auc 0.633; p =0.000 wbc auc 0.709; p =0.000 nlr auc 0.773; p =0.000 pct auc 0.738; p =0.000 d-dimer auc 0.721; p =0.000 crp auc 0.769; p =0.000 visuddho v, et al., journal of ideas in health (2021); 4(special 4):623-629 628 declaration acknowledgment none. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing visuddho2018@fk.unair.ac.id authors’ contributions visuddho visuddho (vsd), agus subagjo (ags), and retno asih setyoningrum (ras) are responsible for the study concept, design, data acquisition, and writing the original draft. vsd also performed the data analysis. alfian nur rosyid (anr) is responsible for editing and reviewing the manuscript. the approval of the final manuscript is done by all authors. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the ethical protocol was approved by the research ethics commission of dr. soetomo general hospital (ref. no: 0257/loe/301.4.2/xii/2020). consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1medical programme, faculty of medicine, universitas airlangga, surabaya, indonesia. 2department of cardiology and vascular medicine, faculty of medicine, universitas airlangga, surabaya, indonesia. 3department of pediatrics, faculty of medicine, universitas airlangga, surabaya, indonesia. 4department of pulmonology and respiratory medicine, faculty of medicine, universitas airlangga, surabaya, indonesia. article info received: 13 december 2021 accepted: 29 december 2021 published: 31 december 2021 references 1. world health organization. covid-19 weekly epidemiological update july 27th, 2021 [internet]. world health organization. 2021. https://www.who.int/docs/defaultsource/coronaviruse/situationreports/weekly_epidemiological_update_22.pdf 2. world health organization. coronavirus disease 2019 (covid-19) situation report 66 [internet]. 2021. https://cdn.who.int/media/docs/defaultsource/searo/indonesia/covid19/external_situation_report_ 66_4_august_2021_final.pdf?sfvrsn=ad645ea_5 3. liang w, liang h, ou l, chen b, chen a, li c, et al. development and validation of a clinical risk score to predict the occurrence of critical illness in hospitalized patients with covid-19. jama intern med. 2020;180(8):1081–9. https://doi.org/10.1001/jamainternmed.2020.2033 4. hu h, du h, li j, wang y, wu x, wang c, et al. early prediction and identification for severe patients during the pandemic of covid-19: a severe covid-19 risk model constructed by multivariate logistic regression analysis. j glob health. 2020;10(2):1–12. https://doi.org/10.7189/jogh.10.020510 5. henry bm, de oliveira mhs, benoit s, plebania m, lippi g. hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (covid-19): a meta-analysis. clin chem lab med. 2020;58(7):1021–1028. 6. ji p, zhu j, zhong z, li h, pang j, li b, et al. association of elevated inflammatory markers and severe covid-19: a meta-analysis. medicine (baltimore). 2020;99(47):e23315. https://doi.org/10.1097/md.0000000000023315 7. pourbagheri-sigaroodi a, bashasha d, fatehb f, abolghasemi h. laboratory findings in covid-19 diagnosis and prognosis. clin chim acta. 2020;510(2020):475–482. https://doi.org/10.1016/j.cca.2020.08.019 8. ponti g, maccaferri m, ruini c, tomasi a, ozben t. biomarkers associated with covid-19 disease progression. crit rev clin lab sci. 2020;0(0):389–99. https://doi.org/10.1080/10408363.2020.1770685 9. anurag a, jha pk, kumar a. differential white blood cell count in the covid-19: a cross-sectional study of 148 patients. diabetes metab syndr clin res rev. 2020;14(january):2099–102. https://doi.org/10.1016/j.dsx.2020.10.029 10. seyit m, avci e, nar r, senol h, yilmaz a, ozen m, et al. neutrophil to lymphocyte ratio, lymphocyte to monocyte ratio and platelet to lymphocyte ratio to predict the severity of covid19. am j emerg med. 2020;40(2021):110–114. https://doi.org/10.1016/j.ajem.2020.11.058 11. elshazli rm, toraih ea, elgaml a, el-mowafy m, elmesery m, amin mn, et al. diagnostic and prognostic value of hematological and immunological markers in covid-19 infection: a meta-analysis of 6320 patients. plos one. 2020;15(8):e0238160. http://dx.doi.org/10.1371/journal.pone.0238160 12. yang a, liu j, tao w, li h. the diagnostic and predictive role of nlr, d-nlr and plr in covid-19 patients. int immunopharmacol. 2020;84. https://doi.org/10.1016/j.intimp.2020.106504 visuddho v, et al., journal of ideas in health (2021); 4(special 4):623-629 629 13. zare me, wang y, kansestani an, almasi a, zhang j. procalcitonin has good accuracy for prognosis of critical condition and mortality in covid-19: a diagnostic test accuracy systematic review and meta-analysis. iran j allergy, asthma immunol. 2020;19(6):557–69. https://doi.org/10.18502/ijaai.v19i6.4926 14. sayah w, berkane i, guermache i, sabri m, lakhal fz, yasmine rahali s, et al. interleukin-6, procalcitonin and neutrophil-to-lymphocyte ratio: potential immuneinflammatory parameters to identify severe and fatal forms of covid-19. cytokine. 2021;141(2021):155428 contents. https://doi.org/10.1016/j.cyto.2021.155428 15. keputusan menteri kesehatan republik indonesia. keputusan menteri kesehatan republik indonesia nomor hk.01.07/menkes/413/2020 tentang pedoman pencegahan dan pengendalian corona virus disease 2019 (covid-19). menkes/413/2020. 2020;2019:207. 16. atkins jl, masoli jah, delgado j, pilling lc, kuo cl, kuchel ga, et al. preexisting comorbidities predicting covid-19 and mortality in the uk biobank community cohort. journals gerontol ser a biol sci med sci. 2020;75(11):2224–30. https://doi.org/10.1093/gerona/glaa183 17. chen y, klein sl, garibaldi bt, li h, wu c, osevala nm, et al. aging in covid-19: vulnerability, immunity and intervention. ageing res rev. 2021;65:101205. https://doi.org/10.1016/j.arr.2020.101205 18. perrotta f, corbi g, mazzeo g, boccia m, aronne l, d’agnano v, et al. covid-19 and the elderly: insights into pathogenesis and clinical decision-making. aging clin exp res. 2020;32(8):1599–608. https://doi.org/10.1007/s40520-020-01631-y 19. kadambari s, klenerman p, pollard aj. why the elderly appear to be more severely affected by covid-19: the potential role of immunosenescence and cmv. rev med virol. 2020;30(5):1–5. https://doi.org/10.1002/rmv.2144 20. pietrobon aj, teixeira fme, sato mn. i mmunosenescence and inflammaging: risk factors of severe covid-19 in older people. front immunol. 2020;11:1–18. https://doi.org/10.3389/fimmu.2020.579220 21. omarjee l, perrot f, meilhac o, mahe g, bousquet g, janin a. immunometabolism at the cornerstone of inflammaging, immunosenescence, and autoimmunity in covid-19. aging (albany ny). 2020;12(24):26263–78. https://doi.org/10.18632/aging.202422 22. liu y, du x, chen j, jin y, peng l, wang hhx, et al. neutrophil-to-lymphocyte ratio as an independent risk factor for mortality in hospitalized patients with covid19. j infect. 2020;81(1):e6–12. https://doi.org/10.1016/j.jinf.2020.04.002 23. moradi ev, teimouri a, rezaee r, morovatdar n, foroughiana m, layegh p, et al. increased age, neutrophilto-lymphocyte ratio (nlr) and white blood cells count are associated with higher covid-19 mortality. am j emerg med. 2020;40(2021):11–14. https://doi.org/10.1016/j.ajem.2020.12.003 24. marik pe, stephenson e. the ability of procalcitonin, lactate, white blood cell count and neutrophil-lymphocyte count ratio to predict blood stream infection. analysis of a large database. j crit care. 2020;60:135–9. https://doi.org/10.1016/j.jcrc.2020.07.026 25. qin c, zhou l, hu z, zhang s, yang s, tao y, et al. dysregulation of immune response in patients with covid-19 in wuhan, china. ssrn electron j. 2020; https://doi.org/10.2139/ssrn.3541136 26. cui n, zhang h, chen z, yu z. prognostic significance of pct and crp evaluation for adult icu patients with sepsis and septic shock: retrospective analysis of 59 cases. j int med res. 2019;47(4):1573–9. https://doi.org/10.1177/0300060518822404 27. mierzchała-pasierb m, lipinska-gediga m. sepsis diagnosis and monitoring procalcitonin as standard, but what next? anaesthesiol intensive ther. 2019;51(4):299– 305. https://doi.org/10.5114/ait.2019.88104 28. tan m, lu y, jiang h, zhang l. the diagnostic accuracy of procalcitonin and c-reactive protein for sepsis: a systematic review and meta-analysis. j cell biochem. 2019;120(4):5852–9. https://doi.org/10.1002/jcb.27870 29. rostami m, mansouritorghabeh h. d-dimer level in covid-19 infection: a systematic review. expert rev hematol. 2020;13(11):1265–75. https://doi.org/10.1080/17474086.2020.1831383 30. zeng f, huang y, guoa y, yina m, chena x, xiao l, et al. association of inflammatory markers with the severity of covid-19: a meta-analysis. int j infect dis. 2020;96(2020):467–474. https://doi.org/10.1016/j.ijid.2020.05.055 31. mortaz e, alipoor sd, adcock im, mumby s, koenderman l. update on neutrophil function in severe inflammation. front immunol. 2018;9:1–14. https://doi.org/10.3389/fimmu.2018.02171 32. sauaia a, moore f, moore e. postinjury inflammation and organ dysfunction. crit care clin. 2017;33(1):167–91. https://doi.org/10.1016/j.ccc.2016.08.006 33. devaux c, rolain j, raoult d. ace2 receptor polymorphism: susceptibility to sars-cov-2, hypertension, multi-organ failure, and covid-19 disease outcome. j microbiol immunol infect. 2020;53(3):425–35. https://doi.org/10.1016/j.jmii.2020.04.015 34. zhou f, yu t, du r, fan g, liu y, liu z, et al. clinical course and risk factors for mortality of adult in patients with covid-19 in wuhan, china: a retrospective cohort study. lancet. 2020;395:1054–62. https://doi.org/10.24966/msr-5657/100015. https://doi.org/10.47108/jidhealth.vol5.iss2.219 hamad sm, journal of ideas in health 2022;5(2):669-672 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access detection of stem cells in human endometrium: immune-histochemical study sameeah mejbel hamad 1* abstract in this work, we recruited cd105 and cd90 markers to identify the endometrial stem cells (enscs) in the human uterine endometrium. fifty endometrial specimens have been extracted from twenty-five deceased women. all specimens have been embedded in paraffin block and prepared for immune-histochemical processing. the expression of cd105 and cd90 was counted per high power field (hpf). paired sample t-test was used to compare the means between groups and age variables. the statistical analysis was conducted using “spss16 software" the statistical significance was considered at less than 0.05. results of paired sample t-test showed that the expression count (ec) at the basalis layer (with cd105) was 5.26 points higher than the functionalis layer (95% ci [3.43, 7.09]) and the correlation was strongly and positively related (r = 0.829, p < 0.001). the ec at basalis layer (with cd90) was 4.96 points higher than functionalis layer (95% ci [3.02, 6.89]) and the correlation was strongly and positively related (r = 0.746, p= < 0.001). the ec at functionalis layer (with cd105) was 0.9 points higher than the stroma layer (95% ci [2.27, 4.11]); however, the correlation was weak and positively related (r = 0.429, p = 0.032). the ec at functionalis layer (with cd90) was 1.4 points higher than the stroma layer (95% ci [2.1, 4.2]), but the correlation was moderately and positively related r = 0.547, p = 0.005). findings of an independent-sample t-test showed that the ec of stem cells at the functionalis, basalis, and stroma layers (with cd105 and cd90 markers) was more among patients of reproductive age (<50 years) than patients who were at non-reproductive age (50 years and above), a statistically significant difference [(m = 9.6, 95% ci (5.3, 14.6), t (19.630) = 4.413, p  < 0.001)], [(m = 10.2, 95% ci (5.2, 15.2), t (20.714) = 4.202, p  < 0.001)] and [(m = 8.4, 95% ci (3.5, 13.4), t (12.313) = 3.523, p  = 0.002)], respectively. in conclusion, the ec of the stem cells in the endometrium decreases with age. keywords: stem cell, immunohistochemistry, uterine endometrium, cd90, cd105, iraq background multipotent stem cells are infrequent in the adult stage that has been specified in different adult tissues such as the intestine [1], skin [2], muscle [3], blood [4], and nervous system [5], and endometrium [6]. in general terms, stem cells or somatic stem cells (sscs) are specialized cells that can self-renew and give rise to differentiated cells [7]. stem cells were reported in many previous studies. the endometrium physiologically undergoes cyclical changes such as self-renewal, reproduction, differentiation, and shedding during each woman's menstrual cycle. [8,9]. furthermore, endometrial renewal occurs after all endometrial incisions and pregnancy [10,11]. these features of the endometrium have indicated the being of a low number of endometrial-derived stem cell (ensc) populations that appear to be accountable for its noteworthy restoration potency [12]. stem cells are specialized cells having the capability to selfrenewal and have the ability to produce two new identical daughter stem cells for the maintenance of a pool of stem cells in the tissue [13]. the gradually occurring physiological changes in females, especially those bearing children, make them more vulnerable to emotional exhaustion [14]. the human uterus undergoes two remarkable changes. the first is during regular cyclic change of the menstrual cycle, and the second is during pregnancy. the stem cells are essential in replacing and maintaining uterine endometrial structure [15]. recently published work about the biology of stem cells proved that the renewal of the damaged tissue is made by progenitor or stem cells [16]. this study aimed to identify the endometrial stem cells (enscs) and the likelihood of variations in different layers of human uterine endometrium using the cd105 and cd90 markers, respectively. ___________________________________________________ samieaalgenabi@gmail.com 1department of anatomy, college of medicine, anbar university, anbar, iraq. a full list of author information is available at the end of the article. https://doi.org/10.47108/jidhealth.vol5.iss2.219 http://www.jidhealth.com/ hamad sm, journal of ideas in health (2022); 5(2):664-668 670 methods study design prospective immunohistochemistry research was designed to collect convenient “uterine samples” of recently deceased women in iraq from april 2018 to june 2019. based on immunohistochemistry (ihc) handbook [17], “cd90” and “cd105 markers” were recruited to detect stem cells in the endometrium. inclusion and exclusion criteria all iraqi women, regardless of age and marital status, whose deaths were recorded in forensic medicine due to natural causes, considering the absence of diseases or damage to the uterine tissue, have been included. however, we excluded the known samples with uterine problems during childbirth, such as severe bleeding or severe damage to uterine tissue due to accidents or chronic space-occupying lesions or diseases. procedure of study in this study, we performed an immunohistochemical analysis of paraffin-embedded sections, ihc(p). the clinical and research laboratories use the standard technique known as paraffin embedding to create a formalin-fixed, paraffinembedded tissue block (ffpe). to reduce the appearance of a back floor on the tissues, both "pathnsitu’s highly sensitive" and "specific polyexcel two-step detection system" has been adopted. the first step is the deparaffinization of tissue pieces in 3 xylene shifts considering hydrating slides to water in a series of alcohol gradations. the specimen should be incubated with 0.5% h2o2 for 5–10 minutes at room temperature to quench the endogenous peroxidase activity. then coupling the specimen with the appropriate diluted mouse or rabbit primary antibody, followed by incubation with the polyexcel target binder for 10 minutes, then another 10 minutes of incubation by a polymer labeled polyexcel hrp. the next step was the staining procedure. the general technique was to incubate the specimen with 3,3'diaminobenzidine (dab) chromogenic substrate for 5–10 minutes, giving a brown-colored precipitate at the antigen site. to prepare the working solutions, add "1 drop of stunn dab chromogen in a1ml of stunn dab buffer, mix well and store it at 2-8 co in the dark medium. the prepared solution is stable for a week; however, it should always be prepared fresh for smooth and crisp results". statistical analysis the immunostained cells per nucleated cell were counted directly in the cassette under a fluorescent microscope. the number of immunostained cells was observed and recorded per high power field (hpf). statistical analysis was conducted using spss16 software. the quantitative results were presented as means ± standard deviation. the difference in means was compared by paired sample t-test between groups pearson correlation test. an independent t-test was recruited to determine differences in the expression count of stem cells among the endometrial layers (functionalis, basalis, stroma) with sociodemographic factor (age). the statistically significant is considered at less than 0.05. results out sociodemographic factors twenty-five uterine samples have been extracted from deceased women. the mean age was 40.2 (sd 5.7). the age variable was further categorized (based on mean value) into the reproductive age group (<50 years old) and the non-reproductive age group (50 years and above). the ec of stem cells at the functionalis and basalis layers with cd105 markers the paired samples t-test was run to compare the expression count of stem cells at the functionalis and basalis layers of the uterine endometrium with cd105 markers. functionalis and basalis scores were strongly and positively correlated (r = 0.829, p < 0.001). there was a significant average difference between functionalis and basalis scores (t24 = 5.933, p < 0.001). basalis scores were 5.26 points higher than functionalis scores (95% ci [3.43, 7.09]). the ec of stem cells at the functionalis and basalis layers with cd90 markers the paired samples t-test was run to compare the expression count of stem cells at the functionalis and basalis layers of the uterine endometrium with cd90 markers. functionalis and basalis scores were strongly and positively correlated (r = 0.746, p < 0.001). there was a significant average difference between functionalis and basalis scores (t24 = 5.283, p < 0.001). basalis scores were 4.96 points higher than functionalis scores (95% ci [3.02, 6.89]). the ec of stem cells at the functionalis and stroma layers with cd105 markers the paired samples t-test was run to compare the expression count of stem cells at the functionalis and stroma layers of the uterine endometrium with cd105 markers. functionalis and stroma scores were weakly and positively correlated (r = 0.429, p = 0.032). there was no significant average difference between functionalis and stroma scores (t24 = 0.594, p =0.558). on average, stroma scores were 0.9 points higher than functionalis scores (95% ci [2.27, 4.11]). the ec of stem cells at the functionalis and stroma layers with cd90 markers the paired samples t-test was run to compare the expression count of stem cells at the functionalis and stroma layers of the uterine endometrium with cd90 markers. functionalis and stroma scores were moderately and positively correlated (r = 0.547, p = 0.005). there was no significant average difference between functionalis and stroma scores (t24 = 0.686, p < 0.499). on average, stroma scores were 1.4 points higher than functionalis scores (95% ci [2.1, 4.2]). an independent-sample t-test was run to determine if there were differences in the ec of stem cells at the functionalis, basalis, and stroma layers (with cd105 and cd90 markers) between patients aged less than fifty years (reproductive age) and patients aged fifty years and above (non-reproductive age). overall, the ec of stem cells at the functionalis (with cd105 and cd90 markers) was more among patients of reproductive age (<50 years) (m = 35.5, sd = 5.5) than patients who were of non-reproductive age (50 years and above) (m = 25.9, sd = 5.6), a statistically significant hamad sm, journal of ideas in health (2022); 5(2):664-668 671 difference (m = 9.6, 95% ci (5.3, 14.6), t (19.630) = 4.413, p < 0.001). overall, the ec of stem cells at the basalis (with cd105 and cd90 markers) was more among patients of reproductive age (<50 years) (m = 41.3, sd = 5.6) than patients who were of non-reproductive age (50 years and above) (m = 31.1, sd = 6.2), a statistically significant difference (m = 10.2, 95% ci (5.2, 15.2), t (20.714) = 4.202, p < 0.001). overall, the ec of stem cells at the stroma (with cd105 and cd90 markers) was more among patients of reproductive age (<50 years) (m = 35.9, sd = 7.8) than patients who were of nonreproductive age (50 years and above) (m = 27.5, sd = 4.1), a statistically significant difference (m = 8.4, 95% ci (3.5, 13.4), t (12.313) = 3.523, p = 0.002). table 1: paired sample t-test to compare the expression count of stem cells at the different endometrial layers (n=25) factors category mean (sd) *rvalue p-value mean difference (sd) t-test c.i.95% p-value cd105 basalis 35.2(7.7) 0.829 <0.001 5.3(4.4) 5.933 3.43-7.09 <0.001 functionalis 29.9(7.4) cd90 basalis 34.2(6.8) 0.746 <0.001 4.9(4.7) 5.283 3.02-6.89 <0.001 functionalis 29.3(6.3) cd105 stroma 30.8(7.1) 0.429 0.032 0.9(7.7) 0.594 2.27-4.11 0.558 functionalis 29.9(7.4) cd90 stroma 30.3(8.9) 0.547 0.005 1.4(7.6) 0.686 2.1-4.2 0.499 functionalis 29.2(6.3) discussion adult stem cells are uncommon undifferentiated cells existent in various adult tissues. stem cells play an important role in tissue homeostasis, altering cells to renew tissues lost by apoptosis or injury [18]. the role of stem cells is highly arranged to ensure a convenient balance in stem cell replacement and save sufficient differentiated mature cells for tissue and organ function [19]. the present work proved the existence of stem cells in the endometrium of the adult uterus. these findings agreed with prianiskiikov's study [20]. the author was the first to believe the extended endometrial adult stem cells in the deeper basalis layer, with their differentiation marked by functional changes in hormonal capability. moreover, tempest et al. [21] indicated that endometrium stem cells were necessary because the human endometrium is a highly regenerative organ, submit over 4000 cycles of shedding and regeneration over a woman's lifetime. our study showed a high expression with the cd105 and cd90 markers at the basalis layer compared to the functionalis. a similar finding has been reported by fayazi et al. [12]. the authors used a scoring system to record their results. they found that the core of expression with cd90 was more than the expression with cd105. their results are similar to the results obtained in the present work. our findings showed that the intensity of the two markers cd105 and cd90 was higher at the endometrial basalis, functionalis and stroma layers of patients aged less than forty years (reproductive age group) than patients aged forty and above (non-reproductive age). moreover, the intensity mentioned above significantly decreased with increasing age. similarly, schwab and gargett [22] have recorded that the stem cells of the endometrium are located in vessels in the perivascular cells. in another study, it has been proved that cd90 and cd105 are considered mesenchymal key markers to characterize mesenchymal stem cell localization. also, a similar result was obtained by schwab et al. [23] that cd90 and cd105 markers expression stained the two layers of endometrial functionalis and basalis. this study suffers from some limitations. some of the limitations are related to routine procedures in forensic medicine institutions, which caused the study time to be prolonged. some others are related to the difficulty of obtaining the consent of the deceased's relatives due to legal and social reasons. conclusion in conclusion, the expression count (ec) with cd105 and cd90 markers was 5.26 and 4.96 points higher in basalis than in functionalis. while the expression count (ec) with cd105 and cd90 markers was 0.9 and 1.4 points higher in functionalis than stroma, respectively. moreover, functionalis, basalis, and stroma layers of the patients in the reproductive age group showed high expression count (ec) with cd105 and cd90 markers compared to patients aged forty years old or above (non-reproductive age), respectively. abbreviation enscs: endometrial stem cells; hpf: high power field: ec: expression count; sscs: stem cells or somatic stem cells; ihc: immunohistochemistry; ffpe: paraffin-embedded tissue block; dab: diaminobenzidine declaration acknowledgment we would like to thank all the deceased women's relatives for their understanding, cooperation, and support of the study. also, our thanks to the directors and workers in the forensic centers for their unlimited support during the sample collection process. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing samieaalgenabi@gmail.com. authors’ contributions sameeah mejbel hamad (smh) is the corresponding and the responsible author of the concept, design, procedure, data analysis and data acquisition, manuscript writing, editing, and reviewing. the author (smh) has read and approved the final manuscript. hamad sm, journal of ideas in health (2022); 5(2):664-668 672 ethics approval and consent to participate the author conducted the research following the declaration of helsinki. the study protocol was approved by the ethics committee of the scientific issues and postgraduate studies unit (psu), college of medicine, university of anbar (ref: 3/7/451 at 07-march-2018). moreover, informed consent was obtained from each deceased’s relative after explaining the study objectives and the guarantee of secrecy. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of anatomy, college of medicine, anbar university, anbar, iraq. article info received: 12 april 2022 accepted: 13 may 2022 published: 14 may 2022 references 1. cervelló i, santamaría x, miyazaki k, maruyama t, simón c. cell therapy and tissue engineering from and toward the uterus. semin reprod med. 2015 sep;33(5):366-72. doi: 10.1055/s-00351559581. 2. alonso l, fuchs e. stem cells of the skin epithelium. proc natl acad sci u s a. 2003 sep 30;100 suppl 1(suppl 1):11830-5. doi: 10.1073/pnas.1734203100. 3. jankowski rj, prantil rl, fraser mo, chancellor mb, de groat wc, huard j, vorp da. development of an experimental system for the study of urethral biomechanical function. am j physiol renal physiol. 2004 feb;286(2): f225-32. doi: 10.1152/ajprenal.00126.2003. 4. eaves cj. hematopoietic stem cells: concepts, definitions, and the new reality. blood. 2015 apr 23;125(17):2605-13. doi: 10.1182/blood-2014-12-570200. 5. wang yz, plane jm, jiang p, zhou cj, deng w. concise review: quiescent and active states of endogenous adult neural stem cells: identification and characterization. stem cells. 2011 jun;29(6):907-12. doi: 10.1002/stem.644. 6. gargett be, chan rw. endometrial stem/progenitor cells and proliferative disorders of the endometrium. minerva ginecol. 2006 dec;58(6):511-26. 7. maruyama t. endometrial stem/progenitor cells. journal of obstetrics and gynaecology research. 2014 ;40(9):2015-22. 8. chan rw, schwab ke, gargett ce. clonogenicity of human endometrial epithelial and stromal cells. biol reprod. 2004 jun;70(6):1738-50. doi: 10.1095/biolreprod.103.024109. epub 2004 feb 6. 9. gargett ce. identification and characterisation of human endometrial stem/progenitor cells. aust n z j obstet gynaecol. 2006 jun;46(3):250-3. doi: 10.1111/j.1479-828x.2006.00582. x. 10. gargett ce, ye l. endometrial reconstruction from stem cells. fertil steril. 2012 jul;98(1):11-20. doi: 10.1016/j.fertnstert.2012.05.004. epub 2012 may 30. 11. gargett ce. uterine stem cells: what is the evidence. human reproduction update. 2007;13(1):87–101. https://doi.org/10.1093/humupd/dml045 12. fayazi m, salehnia m, ziaei s. characteristics of human endometrial stem cells in tissue and isolated cultured cells: an immunohistochemical aspect. iranian biomedical journal 2016; 20(2):109. 13. ramalho-santos m, willenbring h. on the origin of the term ʺstem cell˝. cell stem cell. 2007;1(1):35-38. 14. dastan i, al-samarraie m, ali jadoo sa. female doctors are more emotionally exhausted than their male counterparts in iraq. jidhealth [internet]. 29jun.2019 [cited 18sep.2021];2(1):75-9. doi: 10.47108/jidhealth.vol2.iss1.18 15. ohagwu cc, agwu kk, abu po. real time sonographic assessment of common uterine sizes, shapes and positions in nigerians. j expt clin anat 6.1 (2007);6(1) :41-6. 16. escalante nmm, pino jh. arrangement of muscle fibers in the myometrium of the human uterus: a mesoscopic study. moj anatomy & physiology.2017;4(2):131-135. 17. immunohistochemistry (ihc) handbook, novus biological. available from: https://images.novusbio.com/design/br_ihcguide_011017_web. pdf 18. li l, xie t. stem cell niche: structure and function. annu rev cell dev biol. 2005; 21:605-31. doi: 10.1146/annurev.cellbio.21.012704.131525. 19. moore ka and lemischka ir. stem cells and their niches. science,2006; 311,1880–1885. 20. prianishnikov va. on the concept of stem cell and a model of functionalmorphological structure of the endometrium. contraception,1978; 18,213–223. 21. tempest n, maclean a, hapangama dk. endometrial stem cell markers: current concepts and unresolved questions. int j mol sci. 2018 oct 19;19(10):3240. doi: 10.3390/ijms19103240. 22. schwab ke, gargett ce. co-expression of two perivascular cell markers isolates mesenchymal stem-like cells from human endometrium. hum reprod. 2007 nov;22(11):2903-11. doi: 10.1093/humrep/dem265. 23. schwab ke, hutchinson p, gargett ce. identification of surface markers for prospective isolation of human endometrial stromal colony-forming cells. hum reprod. 2008 apr;23(4):934-43. doi: 10.1093/humrep/den051. ilesanmi os, et al., journal of ideas in health 2020;3(3):213-216 © the author(s). 2020 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access infection prevention and control (ipc) at a lassa fever treatment center before and after the implementation of an intensive ipc program olayinka stephen ilesanmi1*, oladele olufemi ayodeji2, ayobami a. bakare3, nelson adedosu4, anthonia adeagbo5, adedamola odutayo6, felix olugbenga ayun6, ayomide e. bello7 abstract background: infection prevention and control (ipc) programs are important to control the lassa fever (lf) outbreak. we reported ipc's status at the federal medical centre, owo, southwest nigeria, before and after implementing the ipc program during a surge in the lf outbreak. methods: we conducted a longitudinal observational study among five health care professionals at the federal medical centre, owo, between february 2019 and may 2019 using the ipc assessment framework (ipcaf). the tool has eight core components with a score of 0-100 per component and provided a baseline assessment of the ipc program and evaluation after three months. we interviewed relevant unit heads and ipc committee members in the first phase. in the second phase, we designed and implemented the ipc program, and in the third phase, we conducted a repeat interview similar to the first phase. the program initiated included training healthcare workers and providing relevant ipc items according to identified gaps and available funding. results: we interviewed five health care professionals, two female nurses, and three male doctors responsible for organizing and implementing ipc activities at the federal medical centre, owo, with an in-depth understanding of ipc activities. the overall ipc level score increased from 318.5 at baseline to 545 at three months later. ipc improvements were reported in all the components, with ipc education and training [baseline (20), final (70)], ipc guidelines [baseline (50), final (92.5)] and monitoring/audits of ipc practices and feedback [baseline (40), final (82.5)] recording the highest improvements. healthcare-associated infection [baseline (10), final (25)], and built environment, materials, and equipment for ipc [baseline (43.5), final (55)] had the least improvement. poor motivation to adopt recommended changes among hospital staff were major issues preventing improvements. conclusion: promotion of ipc program and activities should be implemented at the federal medical centre, owo. keywords: infection prevention and control, lassa fever, control assessment framework, ipc programs, nigeria background lassa fever is a type of viral hemorrhagic fever caused by the lassa virus, an arenavirus family member. lassa fever is also known as lassa hemorrhagic fever (lhf) [1]. lhf was named after the lassa community in borno state nigeria, where it was first reported in the 1950s following two nurses' deaths from an unusual febrile illness [2,3]. since then, the disease has affected many countries, predominantly the west africa region, where it is considered endemic, particularly in benin, ghana, guinea, liberia, mali, sierra leone, togo, and nigeria [1,2]. lhf is considered an epidemic-prone disease in nigeria, which occurs mostly during the dry season. in recent years, the disease has been trending towards endemicity in the country, with repeated outbreaks and cases being recorded during the rainy season [4]. many lhf-infected persons are asymptomatic; however, they include headache, fever, muscle pains, backache, and vomiting during events of manifestation of symptoms. a few other periods, oral or gastrointestinal bleeding may occur. the likelihood of death occurs among one percent of lhfinfected persons and often occurs after two weeks of manifestation of the symptoms [1]. among lhf cases that survive, hearing loss occurs among a quarter of persons and eventually resolves among half of the individuals with a hearing impairment presentation [5]. the primary mode of transmission of lhf among humans is through contact with droppings (feces or urine) of an infected ___________________________________________________ ileolasteve@yahoo.co.uk 1department of community medicine, lecturer 1, university of ibadan, ibadan, oyo state, nigeria; department of community medicine, honorary consultant, university college hospital, ibadan, oyo state, nigeria full list of author information is available at the end of the article http://www.jidhealth.com/ ilesanmi os, et al., journal of ideas in health (2020); 3(3):213-216 214 multimammate rat. secondary transmission from person to person is also common—thus making it a potential nosocomial infection. in fact, there have been reports of cases, including deaths among health care workers. infection prevention and control (ipc) measures have been shown to limit spread in the hospital setting [6]. unfortunately, knowledge and adherence to ipc measures have been sub-optimal among health care workers.[7] in early 2018, there was an unusually intense outbreak in nigeria, which resulted in morbidity and mortality among health workers. implementation of infection prevention and control (ipc) programs is important in controlling the lhf outbreak. we reported ipc's status at a tertiary health facility in southwest nigeria before and after the implementation of the ipc program during a surge in the lhf outbreak. methods study area the study was conducted at the federal medical centre (fmc) located in owo, ondo state, nigeria. fmc owo is a tertiary health facility established to serve the specialized health needs of owo, akure, and their environs. the emergency operations centre (eoc) serves as the command center for all activities during an outbreak. the various pillars of the eoc form the foundation on which the eoc functions. in the 2019 outbreak, the national lassa fever eoc operates on six major pillars as activated by the nigeria centre for disease control: coordination, surveillance/epidemiology; case management; infection prevention, and control/safe burial; risk communication; logistics; and supplies and laboratory. response activities revolve around these pillars. study design thispre-post quasi-experimental study was conducted to evaluate the impact of ipc training for health care workers. study population five health care professionals responsible for organizing and implementing ipc activities at the federal medical centre, owo, who have an in-depth understanding and knowledge of ipc activities at the facility, were interviewed. the five team members used the infection prevention and control assessment framework (ipcaf) tool in joint evaluations. the five respondents were made up of two female nurses and three male doctors. the inclusion criterion was working in the health facility for at least five years. setting the study involved 3 phases: baseline assessment using the ipcaf, intervention phase, and evaluation phase. ipcaf is a close-formatted and structured questionnaire to which a scoring system has been assigned. the ipcaf has been structured in tandem with the world health organization (who) guidelines regarding the core components of ipc programs at the health facility. the ipcaf has eight divisions, which highlights the who ipc core components. eighty-one indicators have been developed to measure the outcome of the implemented framework. these indicators have been developed as questions and are intended to provide an objective assessment based on the overall performance recorded in all the eight sections. the fmc, owo, presently has assigned to her one of the four levels of ipc promotion and practice [8]. we interviewed relevant unit heads and ipc committee members. during the second phase, we designed and implemented ipc programs based on gaps identified from the baseline assessment (see box 1). the third phase included a repeat of the assessment conducted during phase one. box 1 summary of intervention delivered • facility dialogue • supportive supervision and mentorship vis a vis adherence to ipc guidelines and appropriate waste management, ppe use, workplace hygiene, including injection safety • training of health workers • provision of alcohol-based hand sanitizers, scrubs, and chlorinated water • sensitization on ipc, distribution of poster and handbills assessment tool and scoring the tool has eight core components: ipc program, ipc guidelines; ipc education and training; healthcare-associated infection (hai) surveillance, multimodal strategies for implementation of ipc interventions, monitors, and audits ipc practices and feedback; and is concerned with the workload, staffing, and bed occupancy. in addition, the ipcaf is responsible for the built environment as well as the materials and equipment for ipc at the facility level. points are allocated to individual questions depending on their importance in the context of the component being assessed. the overall score for all components is 800. the overall score obtained across the eight subsections is therefore used to assign the health facility to one of the four levels of ipc promotion and practice [8]: • inadequate (scores 0-200) implies that ipc core components implementation is deficient. significant improvement is required. • basic (scores 201-400) means that some aspects of the ipc core components are in place but not sufficiently implemented. further improvement is required. • intermediate (scores 401-600) elucidate the proper implementation of most aspects of the ipc core components. results in this category inform on the need for an improvement in the facility's scope and quality of implementation. it also focuses on developing long-term plans for the sustenance and promotion of the existing ipc program activities. • advanced (601-800) explains the full implementation of the ipc core components by a health facility in tandem with the who's recommendations. it also highlights that such ipc programs have been fully implemented to suit the health facility's specifications. results the mean age of the five health care professionals responsible for organizing and implementing ipc activities at the federal medical centre, owo, and who have in-depth understanding and knowledge of ipc activities was 50 ±9.6 years. the baseline score was 318.5, and the final score 545. there were varying levels of improvements post-intervention. during the baseline assessment, ipc education and training had the least score and recorded the highest improvement. the least improvement was recorded in component 8: built environment, materials, and equipment for ipc at the facility level. ilesanmi os, et al., journal of ideas in health (2020); 3(3):213-216 215 table 1 infection prevention and control assessment framework at the facility level core component and scores at the federal medical centre, owo section (core component) subtotal scores before intervention after intervention differences percentage improvement ipc program 40 75 35 87.5 ipc guidelines 50 92.5 42.5 85.0 ipc education and training 20 70 50 250.0 hai surveillance 10 25 15 150.0 multimodal strategies 65 80 15 23.1 monitoring/audits of ipc practices and feedback 40 82.5 42.5 106.3 workload, staffing, and bed occupancy 50 65 15 30.0 built environment, materials, and equipment for ipc at the facility level 43.5 55 11.5 87.5 final total score 318.5 basic 545 intermediate 226.5 discussion given that ipc training and education were one of the components with the least scores, this finding underscores the need for regular training of health care workers on ipc measures before and during epidemics. it is possible to make assumptions that health care workers are familiar with infection prevention measures; our finding, however, points out that such assumptions may be wrong. thus, health managers and relevant bodies need to consider ipc training for health workers as urgent steps during an epidemic response. also, it reveals the need to institute mechanisms for the monitoring and supportive supervision of ipc activities during outbreaks of infections. we found that surveillance on hai was sub-optimal before and after the intervention. this is not surprising, as the surveillance system requires a systemic approach with commitment and coordination from national and regional governments [9]. however, commitment and coordination are frequently suboptimal. a previous study on ipc found a similar finding whereby little improvement was observed in structures or domains that require government efforts [10]. in our survey, the respondent identified poor motivation and excess workload as barriers to effective ipc practice. these have previously been reported in another study on guidelines implementation in kenya [11]. heavy workload has similarly been identified as barriers to hand hygiene practice among health care workers in sub-saharan africa [12]. this is a critical area that has not gained much attention in service delivery in nigeria. however, another study conducted at health facilities reported a high disregard for physicians' ipc policies, contributing to increased hai [13]. therefore, the findings from this study highlight the need for a reduction of workload among health care workers to bearable limits to enhance adherence to ipc measures. study limitations the study was conducted over a short period in a single health facility, which could have limited the generalizability of the findings from this study. besides, this study did not assess longterm changes in ipc practice at the selected facility. despite these limitations, this study presented valid results regarding the differences in ipc practice at a lassa fever treatment center before and after implementing an intensive ipc program. conclusion adherence to ipc measures is required in the control of lhf infection. regular ipc training of healthcare workers is highly required in ensuring appropriate management of lhf infection. we hereby recommend the establishment of local teams to coordinate training and provide motivation for ipc adherence. we also recommend strengthening the surveillance system and coordinating mechanisms to ensure the coping capability of the health systems in dealing with the extra demand associated with epidemics. regarding policy implications, it is required that ipc planning be commenced at the early stage of infectious disease outbreaks to enable the successful implementation of ipc programs. abbreviation ipc: infection prevention and control; lf: lassa fever; ipcaf: infection prevention and control assessment framework; lhf: lassa hemorrhagic fever; fmc: federal medical centre; eoc: emergency operations centre; who: world health organization; hai: healthcare-associated infection acknowledgment we thank the management and staff of fmc owo for their cooperation and support during the conduct of this study. funding the authors received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by the corresponding author at ileolasteve@yahoo.co.uk. authors’ contributions olayinka stephen ilesanmi (osi) is the principal investigator of this manuscript. all authors are equally participated in the study concept, design, writing, reviewing, editing, and approving the manuscript in its final form. all authors have read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki, and the ethics committee approved the protocol of the federal medical ilesanmi os, et al., journal of ideas in health (2020); 3(3):213-216 216 centre, owo, ondo state, nigeria (ref: fmc/ow/380/vol. lxvii/187 fmc owo). consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of community medicine, lecturer 1, university of ibadan, ibadan, oyo state, nigeria; department of community medicine, honorary consultant, university college hospital, ibadan, oyo state, nigeria. 2department of community health, consultant, federal medical centre, owo, ondo state, nigeria. 3department of community medicine, resident, university college hospital, ibadan, oyo state, nigeria. 4department of microbiology, consultant, federal medical centre, owo, ondo state, nigeria. 5department of community health, assistant director of nursing services, federal medical centre, owo, ondo state, nigeria. 6department of community health, resident, federal medical centre, owo, ondo state, nigeria. 7department of pharmacy, intern, university college hospital, ibadan, oyo state, nigeria. article info received: 02 september 2020 accepted: 16 october 2020 published: 21 october 2020 references 1. world health organization, who. lassa fever. available from: https://www.who.int/health-topics/lassa-fever/#tab=tab_1. [accessed on 11 october 2020] 2. nigeria centre for disease control. lassa fever. available from: https://ncdc.gov.ng/diseases/factsheet/47. [accessed on 11 october 2020]. 3. world health organization, who. lassa fever. available from: https://www.who.int/news-room/fact-sheets/detail/lassa-fever. [accessed on 11 october 2020]. 4. ijarotimi it, ilesanmi os, aderinwale a, abiodun-adewusi o, okon im. knowledge of lassa fever and use of infection prevention and control facilities among health care workers during lassa fever outbreak in ondo state, nigeria. pan afr med j. 2018; 30:1-13. https://doi.org/10.11604/pamj.2018.30.56.13125 5. mateer ej, huang c, shehu ny, paessler s. lassa fever–induced sensorineural hearing loss: a neglected public health and social burden. plos negl trop dis. 2018;12(2):1-11. https://doi.org/10.1371/journal.pntd.0006187 6. ijarotimi i., oladejo j., nasidi a, jegede o. lassa fever in the state specialist hospital akure, nigeria: case report, contact tracing and outcome of hospital contacts. int j infect trop dis. 2016;3(1):20-28. https://doi.org/10.14194/ijitd.3.1.4 7. ireye f, ejiyere h, aigbiremolen ao, famiyesin oe, rowlandudoh ea, ogeyemhe co, okudo i, onimisi ab. knowledge, attitude and infection prevention and control practices regarding lassa fever among healthcare workers in edo state, nigeria. int j prev treat. 2019;8(1):21-27. https://doi.org/10.5923/j.ijpt.20190801.03 8. world health organization. infection prevention and control assessment framework at the facility level. 2018; 2016:1-15. available from: https://www.who.int/infectionprevention/tools/core-components/ipcaf-facility.pdf?ua=1 [accessed on 11 october 2020]. 9. world health organization, who. communicable disease surveillance and response systems guide to monitoring and evaluating. epidemic and pandemic alert and response. published online 2006:90. doi: rr5305a1 [pii] 10. ousman k, kabego l, talisuna a, diaz j, mbuyi j, houndjo b, et al. the impact of infection prevention and control (ipc) bundle implementation on ipc compliance during the ebola virus outbreak in mbandaka/democratic republic of the congo: a before and after design. bmj open. 2019;9(9):1-6. https://doi.org/10.1136/bmjopen-2019-029717 11. nzinga j, mbindyo p, mbaabu l, warira a, english m. documenting the experiences of health workers expected to implement guidelines during an intervention study in kenyan hospitals. implement sci. 2009;4(1):1-9. https://doi.org/10.1186/1748-5908-4-44. 12. ataiyero y, dyson j, graham m. barriers to hand hygiene practices among health care workers in sub-saharan african countries: a narrative review. am j infect control. 2019 may;47(5):565-573. https://doi.org/10.1016/j.ajic.2018.09.014. 13. gilbert gl, kerridge i. the politics and ethics of hospital infection prevention and control: a qualitative case study of senior clinicians’ perceptions of professional and cultural factors that influence doctors’ attitudes and practices in a large australian hospital. bmc health serv res. 2019; 19(212). https://doi.org/10.1186/s12913-019-4044-y. https://doi.org/10.47108/jidhealth.vol5.iss1.202 mohamed c, et al., journal of ideas in health 2022;5(1):637-642 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access microparticles and d-dimers improve prediction of chemotherapyassociated thrombosis in cancer patients chekkal mohamed1,2*, bennaoum mohamed nazim1,2, adda affaf 1,2, zmouli noujoum1,2, yafour nabil2,3, arabi abdessamad2,3, elhorri mohamed2, badsi dounia4, seghier fatima2,5 abstract background: the cancer is associated with a state of hypercoagulability, which may be the cause of venous thromboembolism (vte), representing an undeniable cause of morbidity and mortality. our study aimed to investigate the role of hypercoagulability markers (d-dimers, microparticles, and v leiden mutation) in predicting cancerassociated vte. methods: a prospective cohort study was conducted among cancer patients who will receive chemotherapy in the medical oncology and hematology departments of the ehu of oran, algeria from february 2013 to may 2015, followed by an observation period of two years. first, we evaluated the risk of cancer-related vte by hypercoagulability parameters (d-dimers, microparticles, v leiden mutation). in the second step, we tested the predictive value of the khorana risk score (krs) of cancer-related vte. then, we developed and tested the predictive value of an expanded score based on the addition of predictive biomarkers to the krs parameters. results: a total of 165 patients were included in our study whose median age was 62 years. more than half were males (52.7%). after an observation period of 2 years, ten patients (6.0%) developed a vte. among the criteria studied, only the d-dimers and the microparticles were predictive of vte in cancer. the positive predictive value (ppv) of the krs was 13.6%, and the negative predictive value (npv) was 97.9%. after adding two predictive biomarkers (d-dimers and microparticles), the expanded score had a better predictive value with a ppv of 23.5% and a vpn of 98.6%. conclusion: the addition of hypercoagulability biomarkers (microparticles and d-dimers) to the routine clinical and biological parameters of the krs enhances the predictive potential of vte risk in cancer. keywords: thrombosis, cancer, d-dimers, microparticles, khorana risk score, algeria background venous thromboembolism (vte) is strongly linked to cancer. the association between cancer and vte had been previously established in different settings and populations. nevertheless, the pathophysiology of thrombi formation has not yet been fully elucidated. many studies have shown increased mortality in the case of vte in cancer patients [1]. also, there was a considerable variation in the incidence of cancer-related vte between the different studies. this phenomenon is aggravated by the use of chemotherapy and many other factors related to the patients or the treatments they receive [2,3]. accurate population-based data are needed on the incidence of vte in patients with different cancers in order to inform guidelines on which hospitalized and ambulatory cancer patients should receive vte prophylaxis. several risk factors have been identified as contributing to vte, such as site and stage of cancer [4,5], age, comorbidities, obesity, acquired prothrombotic states, congenital prothrombotic states such as prothrombotic gene mutation factor v g1691a (factor v leiden), and prothrombin g20210a [6]. multivariable analyses showed that coagulation activation and fibrinolysis biomarkers predict the occurrence of vte in patients with cancer. elevated d-dimers, prothrombin fragment 1+2 (f 1+2), and microparticles were independently associated with an increased risk for occurrence of vte [7,8]. it has been suggested that the risk score of khorana et al. [9] can identify cancer patients at high risk for vte. this study aimed to investigate the role of hypercoagulability markers (d-dimers, microparticles, and v leiden mutation) in predicting cancer-associated vte. ___________________________________________________ chekkal.mohamed@univ-oran1.dz 1department of hemobiology and blood transfusion, faculty of medicine, oran university hospital establishment (ehuo), oran1 university, oran, algeria. a full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol5.iss1.202 http://www.jidhealth.com/ mohamed c, et al., journal of ideas in health (2022); 5(1):637-642 638 methods study design and sample selection this prospective cohort study was carried out in the hemobiology and blood transfusion department of the oran university hospital “ehu 1er novembre 1954” (west algeria). the universal sampling technique was recruited to collect data from all patients attending the medical oncology and hematology departments of the oran university hospital from february 2013 to may 2015, followed by an observation period of two years. the study protocol was approved by the ethical scientific committee of the oran faculty of medicine. written informed consent was obtained from all patients. inclusion and exclusion criteria all patients aged 16 years and older with newly diagnosed cancer or disease progression after complete remission, both gender and willing to participate are included in the study. discharge letters from participating patients with cancer who participated in the full study were collected. exclusion criteria for participation were overt venous or arterial thromboembolism within the last three months, continuous anticoagulation with vitamin k antagonists or low molecularweight heparin (lmwh), surgery or radiotherapy within the past two weeks, pregnancy and chemotherapy within the past three months. procedure of study at study inclusion, patients underwent a structured interview; data on the tumor site, histologic confirmation diagnosis, and stage were documented. patients received detailed information on symptoms of vte and were asked to report immediately to our department if symptoms developed. patients were observed for two years until vte occurrence, death, loss of follow-up, or withdrawal of consent, whichever came first. blood collection and laboratory analysis three tubes of venous blood (approximately 15 ml) were collected from our patients. one on a tube containing edta which was used to do a complete blood count (cbc) on an advia 2120i hematology system (siemens healthcare diagnotics®. usa) and for a dna extraction when two others were collected on tubes containing anticoagulant citrate complying with recommendations for hemostasis which were used for the assay of hypercoagulability biomarkers (d dimers, microparticles, and activated protein c) on a coagulation system (sta compact. stago®. france). thus, the d-dimers were dosed by immunoturbidimetric method (stalatest ddi. stago®) and the microparticles by the functional test based on the detection of procoagulant phospholipids (staprocoagppl. stago®). we measured in the presence of calcium; the clotting time after addition of activated clotting factor x (ctxa) of a platelet depleted plasma (obtained by double centrifugation 2500g for 15 minutes and intermediate decantation) where the addition of the substrate plasma depleted in procoagulant phospholipids makes the test dependent on the procoagulant phospholipids contained in the tested sample. the initiation of coagulation with a reagent containing fxa eliminates the interaction of all upstream factors. the v leiden mutation was detected by the apcr test (sta-staclot apc-r. stago®). the heterozygous or homozygous state of positive cases was looked for for fretpcr (fluorescence resonance energy transferpolymerase chain reaction). confirmation of the thrombosis diagnosis objective imaging methods were performed to confirm or exclude the diagnosis only when a patient developed symptoms of vte. duplex sonography was applied to diagnose deep vein thrombosis (dvt), and computed tomography was applied to diagnose pulmonary embolism (pe). accidentally detected thrombotic events were considered events when clinicians confirmed the diagnosis and proved the clinical significance of these events. definition of risk scores firstly, we used the khorana risk score for predicting chemotherapy-associated vte in ambulatory cancer patients using baseline clinical and laboratory variables: site of cancer (2 points for very high-risk site, 1 point for high-risk site), platelet count of 350 x 109/l or more, hemoglobin less than 10 g/dl (and/or use of erythropoiesis-stimulating agents), leukocyte count more than 11x109/l, and bmi of 35 kg/m2 or more (1 point each). a sum score of 0 points classifies patients as at low risk of vte, 1 or 2 points at intermediate risk, and those with three or more points at high risk. then we expanded the krs by assigning 1 point to each predictive hypercoagulability biomarker. a hypercoagulability biomarker was considered predictive when a significant statistical relationship was found with vte, and the hazard ratio with its confidence interval was strictly greater than 1. statistical analysis the patients were categorized into low-risk (0 points), intermediate-risk (1–2 points), and high-risk (≥ 3 points) groups when we used the krs, then into two groups when we used our expanded risk score based on a threshold value defined by a roc curve (receiver operating characteristic curve). the quantitative variables were described by the median and the interquartile range (iqr). in contrast, the qualitative variables were described by percentage. the chi-square test and fisher's exact test sought the statistical relationship between these variables. the probabilities of survival without vte were estimated via the kaplan-meier survival curve and the log-rank test was used to compare the survival distributions of groups. the cox proportional hazards model was fitted to estimate the effect of the analyzed factors on the outcome. in this model, the hazard ratio (hr) for each independent variable was determined with a 95% ci. a p-value < 0.05 was regarded as statistically significant. the sensitivity, specificity, negative predictive value, and positive predictive value of occurrence of vte for krs and extended krs were calculated after two years of observation from the date of recruitment of each patient. the statistical analyses were performed with spss statistics 17.0. results characteristics of the participants one hundred and sixty-eight patients were considered eligible. three women were excluded because of their pregnancies. our study population consisted of 165 patients whose basic characteristics clinical and therapeutic data are shown in table mohamed c, et al., journal of ideas in health (2022); 5(1):637-642 639 1. more than fifty percent (52.7%) of patients were males, with localized tumor (60.0%) in colorectal (21.2%), lung (20.0%) and breast (17.6%), respectively. all patients received chemotherapy, combined with radiotherapy or surgery in about 74.2% and 24.2%, respectively (table 1). ten patients (6.0 %) developed vte in a median follow-up period of 188.5 days (25th–75th percentile: 183–346.25) day (table 2). six of them were males, and five were having metastases mainly in the stomach and colorectal sites. all of them received chemotherapy combined with surgery in five and radiotherapy in four patients, respectively. table 1 baseline characteristics of the total study population (n=165 patients) characteristics of patients categories value median age at inclusion, (25th_75th percentile) 62 (53-73) sex, n (%) male 87 (52.7) female 78 (47.3) classification of the tumour at inclusion, n (%) localized 100 (60.6) metastasis 54 (32.7) unclassifiable 11 (6.7) cancer site, n (%) lung 33 (20.0) breast 29 (17.6) ovary 12 (7.3) cervix 7 (4.3) colorectal 35 (21.2) stomach 11 (6.7) pancreas 03 (1.8) undifferentiated nasopharyngeal cancer 08 (4.8) bladder 07 (4.3) prostate 06 (3.6) brain 04 (2.4) multiple myeloma 03 (1.8) lymphoma 04 (2.4) melanoma skin cancer 2 (1.2) larynx 1 (0.6) treatment during observation, n (%) chemotherapy 165 (100) surgery 40 (24.2) radiotherapy 78 (47.2) hormonotherapy 18 (11) median laboratory values (25th-75th percentile) platelet count, ×109/l 276 (229351) leukocyte count, ×109/l 7.9 (5.89.2) hemoglobin, g/l 127 (114143) d-dimers, μg/ml 0.72 (0.471.53) microparticles (ctxa), sec 41.1 (33.6 60.1) v leiden mutation, n (%) 5 (3.0) table 2: characteristics of the patients with vte (n =10) characteristics of patients catégories value median age at inclusion, (25th_75th percentile) 66 (58-73) sex, n (%) male 6 (60) female 4 (40) classification of the tumor at inclusion, n (%) localized 3 (30) metastasis 5 (50) unclassifiable 2 (20) cancer site, n (%) lung 1 (10) breast 1 (10) ovary 1 (10) cervix 0 (00) colorectal 2 (20) stomach 2 (20) pancreas 0 (00) undifferentiate d nasopharyngea l cancer 0 (00) bladder 0 (00) prostate 1 (10) brain 0 (00) multiple myeloma 2 (20) lymphoma 0 (00) melanoma skin cancer 0 (00) larynx 0 (00) treatment during observation, n (%) chemotherapy 10 (100) surgery 5 (50) radiotherapy 4 (40) hormonothera py 1 (10) median laboratory values (25th-75th percentile) platelet count, ×109/l 312 (235408) leukocyte count, ×109/l 7.4 (6.3-9.0) hemoglobin, g/l 123 (105136) d-dimers, μg/ml 1.52 (1.014.12) microparticles (ctxa), sec 36.2 (21.2 48.2) v leiden mutation, n (%) 1 (10) in kaplan meier analysis, the log rank test demonstrated a statistically significant difference between the groups defined by the khorana score (p = 0.025) (figure 1). in univariate cox regression analysis, the hazard ratio (hr) of vte was 3.514, 95% ci [1.133-10.900] between one group and another of higher risk. incidence of vte did not present a statistically significant difference between intermediate-risk and low-risk patients (p=0.447) with an hr of 2.539, 95% ci [0.23027.998]. after two years and at the cut-off point for the high-risk category (score ≥ 3), we calculated the sensitivity (probability of high risk in those patients experiencing vte), specificity (probability of high risk in those patients not experiencing vte), positive predictive value (ppv, probability of high risk in those patients identified to be at high risk) and negative mohamed c, et al., journal of ideas in health (2022); 5(1):637-642 640 predictive value (npv, probability of no vte in those patients identified to be at low risk) for vte development. the sensitivity was 50%, specificity was 88.0%, ppv was 13.6%, and npv was 97.9%. among the hypercoagulability markers, d-dimers were predictive of cancer-related vte when their level was more significant than 1.53 (75th percentile) with an hr of 4.449, 95% ci [1.194-16.573. an elevated microparticles count was also predictive of cancer-related vte with an hr of 5.678, 95% ci [1.52321.163]. microparticles elevation was defined as a shortening of clotting time after the addition of activated clotting factor x (ctxa) to values ≤ the 25th percentile. we did not find a statistical relationship between the heterozygous v leiden mutation and the vte when fisher’s exact test was applied (p=0.268). adding these two biomarkers (d dimers and microparticles) to the khorana score improved its predictive power. at the cut-off point for the high-risk category (score ≥ 4) and using the kaplan meier analysis, the log rank test demonstrated a statistically significant difference between the two groups defined by the expanded khorana score (p = 0.000) (figure 2). in univariate cox regression analysis, the hazard ratio (hr) of vte was 17.987, 95% ci [3.29198.294] between the low-risk group and the high-risk one. the sensitivity was 66.7%, specificity was 91.8%, ppv was 23.5%, and npv was 98.6%. figure1: kaplan meier estimates of risk of vte among patients with cancer according to the khorana score. there is a statistically significant difference between the groups defined by the khorana score (log rank=0.025) figure 2: kaplan meier estimates of risk of vte among patients with cancer according to the expanded khorana score. there is a statistically significant difference between the low risk (<4) group and the high risk one (>4) defined by the expanded khorana score (log rank=0.000) mohamed c, et al., journal of ideas in health (2022); 5(1):637-642 641 discussion this cohort study tested the khorana predictive model in patients from western algeria using five clinical and biological parameters before chemotherapy. the sensitivity and specificity of the khorana predictive model for vte were comparable between the original study and our own. however, the two studies differed in predicting vte using this score. the rate of vte was also higher in our study than the original one (6.0% vs. 2.1%). such finding is most likely due to the observation time of these two studies (2.5 months in the original study and 24 months in ours). moreover, while khorana's study only concerned patients on chemotherapy, ours was more heterogeneous with the addition of chemotherapy other treatments received during the observation period of 24 months, which may increase the risk of vte, such as radiation therapy and surgery. it has been reported that cancer patients undergoing a surgical procedure have twice the risk of postoperative vte, which remains a long time after surgery [10,11]. in similar krs validation studies, the incidence of thrombotic events ranged from 4 to 18% [12,13]. during our krs study, we found that patients considered to be at intermediate risk (score=1 or 2) had the same risk of vte as those considered to be at low risk (score=0). we thus concluded that for our population, only the cut-off value of a score ≥3 should be considered to determine the risk of vte. at the end of our study, we find that in addition to krs parameters, two other biomarkers have good predictive values: d-dimers and microparticles. in contrast, no statistical relationship was found between the v leiden mutation and cancer-related vte. such a result is most probably because 100% of the cases observed were heterozygous, knowing that there is a significant difference between the heterozygous and homozygous state of the mutation varying from 3.5 and 24 depending on the lite study (longitudinal investigation thromboembolism etiology) [14]. in their guidance for the prevention of cancer-related vte, khorana et al. [15] clarified that in addition to the biomarkers of their score (platelet count, leukocytes count, and hemoglobin rate), others are associated with mtev in cancer and cited d-dimers, prothrombin activation products, soluble p selectin, thrombin generation and microparticles [15]. visuddho v, et al. [16] found that elderly patients (>59 years) with ddimer of >440 ng/ml experienced lower survival during hospitalization. by integrating d-dimers and microparticles into the krs with the determination of the cut-off value by roc curve, we succeeded in increasing the positive predictive value from 13.6% using the original khorana score to 23.5% using the expanded score. we found that the risk of vte in the highrisk stratified group was much higher than that of surgery or prolonged hospitalization in which thromboprophylaxis was nevertheless well indicated with many benefits [17,18]. in the recommendations of the guidelines of the american society of clinical oncology and those of the european society of medical oncology on vte in cancer, it is clarified that prophylaxis in cancer patients receiving outpatient chemotherapy is not routinely recommended except for highrisk patients where it may be considered [19, 20]. conclusion in conclusion, the khorana score is a simple score, reproducible, and validated on our population of western algeria. its use will allow better stratification of patients according to the risk of vte for a better benefit-risk ratio of thromboprophylaxis in them. clinical trials should be encouraged in our population to demonstrate the efficacy and safety of thromboprophylaxis in high-risk patients defined by this score. abbreviation vte: venous thromboembolism; cbc: complete blood count; krs: khorana risk score; lmwh: low molecular-weight heparin; hr: hazard ratio; ppv: positive predictive value: npv: negative predictive value; roc curve: receiver operating characteristic curve; iqr: interquartile range declaration acknowledgment none funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing chekkal.mohamed@univoran1.dz authors’ contributions all authors equally contributed to the concept, design, literature search, data analysis, and data acquisition, manuscript writing, editing, and reviewing. all authors have read and approved the final version of the manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the ethical protocol was approved by the scientific council of the faculty of medicine of the university of oran1, algeria. certificate issued on november 11, 2012 under the reference/315/v.d.g.p.r.r.rxt/2012. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of hemobiology and blood transfusion. oran university hospital establishment (ehuo), oran, algeria. 2oran1 university. medicine faculty, oran, algeria. 3department of hematology and cellular therapy, oran university hospital establishment (ehuo), oran, algeria. 4department of vascular neurology, oran university hospital establishment (ehuo), oran, algeria. 5department of hemobiology and blood transfusion, oran university hospital center, algeria. mohamed c, et al., journal of ideas in health (2022); 5(1):637-642 642 article info received: 19 january 2022 accepted: 06 march 2022 published: 17 march 2022 references 1. khorana aa, francis cw, culakova e, kuderer nm, lyman gh. thromboembolism is a leading cause of death in cancer patients receiving outpatient chemotherapy. j thromb haemost. 2007 mar ;5(3):632-4. doi: 10.1111/j.1538-7836.2007.02374. x. 2. sousou t, khorana a. identifying cancer patients at risk for venous thromboembolism. hamostaseologie. 2009;29(1):121-4. 3. blom jw, doggen cj, osanto s, rosendaal fr. malignancies, prothrombotic mutations, and the risk of venous thrombosis. jama. 2005 feb 9;293(6):715-22. doi: 10.1001/jama.293.6.715. 4. sallah s, wan jy, nguyen np. venous thrombosis in patients with solid tumors: determination of frequency and characteristics. thromb haemost. 2002 apr;87(4):575-9. 5. chew hk, wun t, harvey d, zhou h, white rh. incidence of venous thromboembolism and its effect on survival among patients with common cancers. arch intern med. 2006 feb 27;166(4):458-64. doi: 10.1001/archinte.166.4.458. 6. mandalà m, curigliano g, bucciarelli p, ferretti g, mannucci pm, colleoni m, et al. factor v leiden and g20210a prothrombin mutation and the risk of subclavian vein thrombosis in patients with breast cancer and a central venous catheter. ann oncol. 2004 apr;15(4):590-3. doi: 10.1093/annonc/mdh146. 7. ay c, vormittag r, dunkler d, simanek r, chiriac al, drach j, et al. d-dimer and prothrombin fragment 1 + 2 predict venous thromboembolism in patients with cancer: results from the vienna cancer and thrombosis study. j clin oncol. 2009 sep 1;27(25):4124-9. doi: 10.1200/jco.2008.21.7752. 8. zwicker ji, liebman ha, neuberg d, lacroix r, bauer ka, furie bc, furie b. tumor-derived tissue factorbearing microparticles are associated with venous thromboembolic events in malignancy. clin cancer res. 2009 nov 15;15(22):6830-40. doi: 10.1158/10780432.ccr-09-0371. 9. khorana aa, kuderer nm, culakova e, lyman gh, francis cw. development and validation of a predictive model for chemotherapy-associated thrombosis. blood. 2008 may 15;111(10):4902-7. doi: 10.1182/blood-200710-116327. 10. kakkar ak, williamson rc. prevention of venous thromboembolism in cancer patients. semin thromb hemost. 1999;25(2):239-43. doi: 10.1055/s-2007-994925. 11. rasmussen ms, jørgensen ln, wille-jørgensen p. prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. cochrane database syst rev. 2009 jan 21;(1):cd004318. doi: 10.1002/14651858.cd004318.pub2. 12. mandala m, clerici m, corradino i, vitalini c, colombini s, torri v, et al. incidence, risk factors and clinical implications of venous thromboembolism in cancer patients treated within the context of phase i studies: the 'sendo experience'. ann oncol. 2012 jun;23(6):1416-21. doi: 10.1093/annonc/mdr524. 13. moore ra, adel n, riedel e, bhutani m, feldman dr, tabbara ne, et al. high incidence of thromboembolic events in patients treated with cisplatin-based chemotherapy: a large retrospective analysis. j clin oncol. 2011 sep 1;29(25):3466-73. doi: 10.1200/jco.2011.35.5669. 14. cushman m, tsai aw, white rh, heckbert sr, rosamond wd, enright p, folsom ar. deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology. am j med. 2004 jul 1;117(1):19-25. doi: 10.1016/j.amjmed.2004.01.018. 15. khorana aa, carrier m, garcia da, lee ay. guidance for the prevention and treatment of cancer-associated venous thromboembolism. j thromb thrombolysis. 2016 jan;41(1):81-91. doi: 10.1007/s11239-015-1313-4. 16. geerts wh, heit ja, clagett gp, pineo gf, colwell cw, anderson fa jr, wheeler hb. prevention of venous thromboembolism. chest. 2001 jan;119(1 suppl):132s175s. doi: 10.1378/chest.119.1_suppl.132s. 17. visuddho v, subagjo a, setyoningrum ra, rosyid an. predictive accuracy of blood inflammatory markers on covid-19 mortality. journal of ideas in health 2021 ;4(4):623-629. doi: 10.47108/jidhealth.vol4.iss4.196 18. zakai na, wright j, cushman m. risk factors for venous thrombosis in medical inpatients: validation of a thrombosis risk score. j thromb haemost. 2004 dec;2(12):2156-61. doi: 10.1111/j.1538-7836.2004.00991. x. 19. lyman gh, bohlke k, khorana aa, kuderer nm, lee ay, arcelus ji, balaban ep, clarke jm, flowers cr, francis cw, gates le, kakkar ak, key ns, levine mn, liebman ha, tempero ma, wong sl, somerfield mr, falanga a; american society of clinical oncology. venous thromboembolism prophylaxis and treatment in patients with cancer: american society of clinical oncology clinical practice guideline update 2014. j clin oncol. 2015 feb 20;33(6):654-6. doi: 10.1200/jco.2014.59.7351. 20. mandalà m, falanga a, roila f, and esmo guidelines working group management of venous thromboembolism (vte) in cancer patients: esmo clinical practice guidelines. ann oncol 2011; 22(suppl6):85– 92.doi:10.1093/annonc/mdr392. ali jadoo et al., journal of ideas in health 2018; 1(1):14-22 © the author(s). 2018 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. journal homepage: www.jidhealth.com open access impact of conflict related and workplace related violence on job satisfaction among physicians from iraq a descriptive cross-sectional multicentre study saad ahmed ali jadoo1*, perihan torun1, ilker dastan 2, mustafa ali mustafa al-samarrai 3 abstract background: during the last decade, the events of violence against healthcare providers have been escalated, especially in the areas of conflicts. this study aimed to test the impact of conflict-related and workplace-related violence on job satisfaction among iraqi physicians. methods: a cross-sectional study with a self-administered survey was conducted among medical doctors in iraq from january to june 2014. participants (n=535, 81.1% response rate) were selected at random from 20 large general and district hospitals using a multistage sampling technique. results: the mean (+sd) value on the total job satisfaction score was 42.26 (+14.63). the majority of respondents (67.3%) experienced unsafe medical practice; however, the conflictrelated violence showed no significant difference in job satisfaction scores. in backward regression analysis, two socio-demographic variables (age, gender), and three work-related variables (being a specialist, working less than 40 hours per week, working in both government and private sector) were positively related to job satisfaction, while the workplace violence variables were negatively related. it was found that increases in physical attack, verbal abuse, bullying, and racial harassment brought about decreases in job satisfaction scores of 6,087, 3.014, 9,107, and 4,242, respectively. conclusion: our results suggest that work-related variables and workplace violence do affect job satisfaction. specifically, when physicians have been physically attacked, verbally abused, bullied, and racially harassed, their job satisfaction decreases significantly. keywords: physicians, conflict, violence, job satisfaction, iraq background the issue of violence against doctors and medical personnel in iraq attracted local and international attention due to the severe increase in the number of doctors of both sexes subjected to various forms of attacks, verbal, social violence and physical violence, including intentional killings, in different parts of the country [1-4]. it is worth mentioning that many cases of abuse are still unregistered [5]. a high number of doctors and health care providers fail to report various types of attacks, especially verbal and social violence, which have become commonplace [5]. on the other hand, due to the laxity of the security services, there has been a failure to take strict measures against the aggressors, especially those with authority and power (e.g., relatives of vip and armed groups) [5,6]. consequently, the mental health of doctors and health staff is negatively affected, which might create a state of insecurity in workers. eventually, many decided to migrate to countries with stricter legal protection for doctors [1,4]. the factors as mentioned earlier are most likely to exacerbate the shortage of medical staff [7], and this will hinder reforming the health situation; thus, any policy or effort which ignores these facts is considered inefficient, and the opportunity to improve the health status of the community will be diminished [7-9]. the clinical work standards indicate that a decline in the number of doctor/patient ratios will inevitably lead to physical and psychological stress for doctors, further affecting the doctor-patient relationship (poor communication, leading to non-cooperative and eventually unsatisfied patients). technically, the quality of service is also affected by stress (errors in diagnosis and treatment), which may lead to delayed recovery or health complications, possibly permanent disability or even death. this applies to all patients, whether in hospitals, outpatient clinics, or even emergency ___________________________________________________ drsaadalezzi@gmail.com 2department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey full list of author information is available at the end of the article http://www.jidhealth.com/ ali jadoo et al., journal of ideas in health 2018; 1(1):14-22 15 rooms [10]. it is noteworthy that the violence against doctors has intensified in the period beginning with the internal conflicts that followed the occupation the provinces of central iraq in mid-2012 by armed groups, constituting until the liberalization of those areas, which took as long as three years. in this period, violent acts against healthcare providers and health organizations increased in the whole country, with high rates recorded in central and northern iraqi provinces [11]. this period also was associated with the internal displacement of more than two million people in those provinces [12] and created a situation of imbalance in the daily number of hospital patients with the number of doctors, which has far exceeded the absorptive capacity and created a vicious cycle [6,13]. inadequate health education, especially in a population of low social class or sparse learning, could also have been related. last but not least, mass media, when acting in an inflammatory way against some doctors, may create aggressive thoughts against the whole medical profession, increasing aggression against this vital class stratum. for all the reasons mentioned above, it was necessary for those involved or interested in medical affairs to study these events scientifically and objectively in order to identify real factors and create solutions aiming at preventing or at least minimize this crisis. this study can be considered one of the first attempts to produce and analyze and link them to their real causes. despite the importance of the subject, it received little interest from researchers in iraq and neighboring countries, but at the international level, many studies have been published. methods study design and subjects a cross-sectional survey was conducted to test the impact of the workplace and war-related violence on job satisfaction. the present study is part of a larger research initiative [4], in which we employed a multistage sampling technique to gather a random sample of 660 physicians from twenty major general hospitals and medical centers covering the main five geographical regions in iraq (north, west, south, central, and the capital city). design, sampling, and data collection have been reported in detail previously [4]. in the current analysis, responses were received from 535 physicians (response rate of 81.1%). all iraqi physicians in the selected hospitals received a copy of the self-administered questionnaire manually, with the contact number and email of the data collector. the exclusion criteria included the chief medical officers (cmo), hospital managers, and their deputies. outcome variable for this study, a dependent variable (job satisfaction) was measured with the 10-item warr-cook-wall (wcw) job satisfaction (seven-point likert-type) scale ranging from 1 = "very dissatisfied" to 7 = "very satisfied". the overall job satisfaction was measured by summing the scores of the ten items (in range of 10 to 70). independent variables the socio-demographic variables were collapsed and coded as follows: age (above/below 40 years old), gender (male or female), marital status (married or single), presence of children (yes or no), and residency (urban or rural). variables of conflicts or war-related violence were collapsed and coded as either (1) "yes" or (0) "no" in response to the following questions: "because of the conflict in iraq, have you lost a family member?"; "have you been threatened?"; "have you been displaced internally?"; "do you think that it is safe to practice medicine?" and "is the doctor-patient-relationship satisfactory?" individual work-related variables were categorized as follows: the current professional level (specialist or not); the working hours per week (more or less than 40 hours/week); the number of years spent in their current job or at the same facility (more or less than ten years); the type of employment (government only or government and private); opportunity for training and educational (yes or no); the effectiveness of the senior manager in staff relations (agreed or disagreed). variables of workplace-related violence were collapsed and coded as either (1) "yes" or (0) "no" in response to the following questions regarding the workplace, "have you been physically attacked?"; "have you been verbally abused?"; "have you been bullied/mobbed?"; "have you been racially harassed?" and "have you been sexually harassed?" statistical analysis statistical analysis was undertaken using spss 16.0 for windows (spss inc., chicago il, usa). frequency distribution and descriptive statistics of socio-demographic variables and work characteristics were obtained to provide the sample profile. an independent-sample t-test was run to determine any differences in overall job satisfaction between different variables. in the bivariate analysis (p-value <0.05), the significant factors were included in the multivariate model. multiple logistic regression analysis (backward technique) was performed to identify significant predictors of turnover intentions. in backward elimination, the insignificant variables in the models individually removed until a satisfactory model obtained. odds ratio (or) and 95% confidence interval (ci) were calculated. an alpha level of p < 0.05 is considered to be statistically significant. results descriptive analyses table 1 shows the descriptive characteristics of the sociodemographic variables. the mean age (±sd) was 40.2 years (±8.4), and those aged 40 years old or more were significantly associated with job satisfaction. more than half of the respondents (53.3%) were females, married (63.3%), living in an urban region (63.3%), and with children (51.4). there was a significant difference in job satisfaction between male and female participants, and it was higher in women than in men (44.2+13.8, p=0.001). ali jadoo et al., journal of ideas in health 2018; 1(1):14-22 16 table 1 socio-demographic variables on overall job satisfaction (n=535) job satisfaction the mean (+sd) value on the total job satisfaction score was 42.26 (sd = 14.63). the level of satisfaction on "overall job satisfaction, opportunities to use their abilities, remuneration, amount of responsibility, and variation in work". the lowest satisfaction score was reported for physical working conditions, recognition for good work, the freedom to choose your own method of working, your hours of work, and the cooperation with colleagues and fellow workers" (table 2). table 2 descriptive statistics of the ten items and overall job satisfaction scale no. job satisfaction statements (wcw) mean sd min. max. 1 physical working conditions 3.80 1.61 1 7 2 freedom to choose your own method of working 4.09 1.78 1 7 3 your colleagues and fellow workers 4.26 1.59 1 7 4 recognition you get for good work 3.87 1.60 1 7 5 amount of responsibility you are given 4.28 1.70 1 7 6 your remuneration, i.e., income 4.38 1.70 1 7 7 opportunity to use your abilities 4.51 1.67 1 7 8 your hours of work 4.20 1.74 1 7 9 amount of variety in your job 4.28 1.71 1 7 10 taking everything into consideration, how do you feel about your job? 4.59 1.78 1 7 11 overall scale job satisfaction 42.26 14.63 10 70 wcw, warr-cook-wall job satisfaction scale conflict or war-related variables in table 3, none of the conflict or war-related variables showed a significant difference in job satisfaction. as a consequence of war and conflict in iraq since 2003, the majority of surveyed doctors (67.3%) had experienced a lack of safety in medical practice, 26.9% had lost one or more close relative, 54.3% had threatened, and 39.3% had internally displaced at least once; however, the doctors-patients relationship reported as excellent by 71.0%. work-related variables table 4 presents the work-related variables. although sixty percent of respondents were not specialists, more than half (55.0%) were satisfied with the available training and education opportunities and endorsed managers handling of staff (58.9%). all variables showed a significant difference in job satisfaction (except for the training and educational opportunities). job satisfaction was higher for specialists, working 40 hours or fewer per week, spent more than ten years in the same job or facility, worked in the government and private sectors, or endorsed the managers' handling of staff. workplaceviolence variables table 5 presents workplace violence variables. only females (n=269, 94.4% response rate) responded to the question: "have you been sexually harassed in your workplace?". about 146 (54.3%) reported no sexual harassment in their workplace, compared to 123(45.7), who reported some harassment. all variables showed a significant difference in job satisfaction. the doctors who were not physically attacked, verbally abused, bullied, or racially harassed showed higher job satisfaction than their counterparts. multiple linear regression analysis table 6 shows the results of multiple linear regression analysis to identify the associated variables with job satisfaction. the job satisfaction was higher in physicians of 40 years old and more, females, specialist doctors, those working 40 or fewer hours per week, or those working in both government and private sectors. in contrast, multivariate regression showed that an increase in physical attacks, verbal abuse, bullying, or racial harassment would lead to decreases in job satisfaction scores of approximately 6,087, 3.014, 9,107 and 4,242 respectively, (figure 1). variable category n% mean+ sd t-test p-value 95% ci upperlower age > or = 40 years old 268(50.1) 47.3+12.7 8.563 0.000 7.8-12.4 < 40 years old 267(49.9) 37.1+14.6 gender female 285(53.3) 44.2+13.8 3.412 0.001 1.8-6.7 male 250(46.7) 39.9+15.2 marital status married 340(63.6) 42.3+14.5 0.209 0.835 -2.3-2.8 single 195(36.4) 42.0+14.8 presence of children no 260(48.6) 43.1+13.7 1.402 0.161 -0.7-4.2 yes 275(51.4) 41.4+15.3 residency urban 341(63.7) 43.0+13.8 1.710 0.088 -0.3-4.8 rural 194(36.3) 40.8+15.8 ali jadoo et al., journal of ideas in health 2018; 1(1):14-22 17 table 3 conflict-related variables on overall job satisfaction (n=535). table 4 work-related variables on overall job satisfaction (n=535) variable category n% mean+ sd t-test p-value 95%ci upper-lower loss of family member no 391(73.1) 42.5+14.0 0.744 0.457 -1.7-3.8 yes 144 (26.9) 41.4+16.1 exposure to threat or kidnapped yes 290(54.2) 42.8+13.9 0.985 0.325 -1.2-3.7 no 245(45.8) 41.5+15.3 internally displaced no 325(60.7) 43.0+14.2 1.514 0.131 -0.5-4.5 yes 210(39.3) 41.0+15.1 medical practice in iraq is safe. risky 360(67.3) 42.4+13.9 0.345 0.730 -2.1-3.1 safe 175(32.7) 41.9+15.9 the doctor-patient relationship is excellent. yes 380(71.0) 42.9+14.0 1.687 0.092 -0.3-5.0 no 155(29.0) 40.5+15.9 variable category n% mean+ sd t-test p-value 95%ci upper-lower current professional level specialist 211(39.4) 53.3+10.0 17.983 0.000 16.3-20.3 non-specialist 324(60.6) 35.0+12.4 way managers handle staff agreed(yes) 315(58.9) 46.3+12.7 8.254 0.000 7.6-12.3 disagreed(no) 220(41.1) 36.3+15.1 training and educational opportunities no 241(45.0) 42.6+13.8 0.540 0.590 -1.8-3.1 yes 294(55.0) 41.9+15.2 years of service >10 years 392(73.3) 44.3+13.2 5.495 0.000 4.9-10.3 < or = 10 years 143(26.7) 36.6+16.7 hours of work/week <or=40 h 290(54.2) 46.4+12.5 7.570 0.000 6.7-11.5 >40 h 245(45.8) 37.3+15.4 type of employment government and private 298(55.7) 44.2+14.8 3.535 0.000 1.9-6.9 government only 237(44.3) 39.7+13.9 ali jadoo et al., journal of ideas in health 2018; 1(1):14-22 18 table 5 workplace violence variables on overall job satisfaction (n=535) table 6 factors associated with job satisfaction in multiple linear regressions (n=535) variable category n% mean+ sd t-test p-value 95%ci upper-lower have you been physically attacked in your workplace? no 292(54.6) 51.2+10.5 21.272 0.000 18.0-21.7 yes 243(45.4) 31.4+11.3 have you been verbally abused in your workplace? no 251(46.9) 51.6+10.7 17.367 0.000 15.6-19.6 yes 284(53.1) 34.0+12.5 have you been bullied/mobbed in your workplace? no 339(63.4) 49.5+10.8 20.200 0.000 18.0-21.9 yes 196(36.6) 29.6+11.2 have you been racially harassed in your workplace? no 284(53.1) 51.0+11.5 19.136 0.000 16.7-20.6 yes 251(46.9) 32.3+11.0 variables b s.e beta t-test sig. 95% ci upper-lower tolerance vif constant 42.518 1.285 33.076 0.000 39.99-45.04 40 years old or more 5.867 0.767 0.201 7.647 0.000 4.36-7.37 0.879 1.138 less than 40 years old reference female 2.808 0.732 0.096 3.836 0.000 1.37-4.24 0.969 1.032 male reference specialist 5.039 1.129 0.168 4.463 0.000 2.82-7.25 0.425 2.354 non-specialist reference <40 hours/week 2.150 0.774 0.073 2.779 0.006 0.63-3.67 0.870 1.150 40 hours or more/week reference private and government work 4.277 0.803 0.145 5.328 0.000 2.70-5.85 0.813 1.230 government only reference physically attacked -6.087 1.217 -0.207 -5.000 0.000 -8.47-3.69 0.352 2.842 not reference verbally abused -3.104 1.080 -0.106 -2.874 0.004 -5.22-0.98 0.445 2.246 not reference bullied/mobbed -9.107 1.037 -0.300 -8.785 0.000 -11.14-7.07 0.518 1.930 not reference racially harassed -4.242 1.132 -0.145 -3.747 0.000 -6.46-2.01 0.405 2.469 not reference ali jadoo et al., journal of ideas in health 2018; 1(1):14-22 19 discussion for two decades, the iraqi human resources for health has been facing serious problems regarding the recruitment and retention of health care workers, particularly physicians. in a study of 576 doctors in 20 hospitals in iraq, more than half (55%) were actively seeking alternative employment [4]. there is evidence that this situation has worsened, and urgent measures are needed to reverse this trend. such measures should focus on the underlying causes of this problem. job dissatisfaction is one of the significant and consistent predictors of healthcare workers' intention to leave work or migrate [14,15]. it is crucial to raise employee satisfaction and motivation, as this determines higher productivity, efficiency, and patient satisfaction [16]. this dissatisfaction may be harmful not only for the physicians themselves, but it can also affect the quality of patient care [17,18]. dissatisfied, stressed, or burned out physicians were found to be more likely to prescribe drugs with a higher degree of side effects [19] and to be more responsible for more frequent medical errors [20,21]. it is therefore vital for policymakers and health professionals to have a better understanding of the causes of doctors' job dissatisfaction in order to prioritize the key issues and to develop effective retention strategies accordingly. in this study, the mean job satisfaction score among iraqi doctors was found to be 42.44 (range 10–70). therefore, doctors were, on average, neither satisfied nor dissatisfied with their jobs; this finding of neutrality is consistent with other international studies [22]. this study took into account various factors presumed to affect a doctor's job satisfaction. some socio-demographic variables (age, gender), work-related variables (being specialist, more than ten years of service, less than 40 hours of work per week, working in both government and private sector), and workplace violence variables (physically attacked, verbally abused, bullied, racially harassed) were related to job satisfaction in the bivariate analysis. ten of these factors (all except 'managers handle staff well') maintained in the stepwise regression analysis. job satisfaction is potentially multidetermined; therefore, any type of prevention or intervention will require multi-faceted approaches. concerning the demographic variables, the results of this study indicated that older respondents had more job satisfaction than younger respondents. this finding is compatible with most previous results [23-25]. some stated younger doctors [26], or middle-aged doctors were least satisfied [27], but a few documented that job satisfaction level reduces with age [28]. in our study, female doctors were more satisfied, while other studies showed mixed results. some showed that male doctors were more satisfied [29-30], and others less satisfied [31,32], while another group of studies reported that gender has no significant relation with job satisfaction [24,27]. further, similar to the results of this study, the literature review revealed no statistical impact of marital status or urban versus rural settings on job satisfaction [28,33]. none of the conflict and war-related variables showed a significant difference in job satisfaction in backward regression analysis in this study. regarding work-related variables, specialists were more satisfied than their non-specialist counterparts. similar results revealed in earlier studies [34]. moreover, we found that physicians working in both government and private sectors were more satisfied than those working only in the government sector. similarly, previous studies showed that private-sector physicians experience higher levels of job satisfaction, lower levels of psychological distress, and sleep problems compared to those in the public sector [23]. further, low income is a major complaint in the government sector. in iraq, the basic salary for the majority of public sector doctors has been kept low in order to ensure access to basic care for all, after the major collapse of the health care system [4]. government investment in health remains insufficient to better remunerate doctors. total health expenditure in iraq has remained around 3% of gross domestic product (gdp) in the last ten years, compared to 5% of gdp in the region, and more than 10% of gdp in most developed countries [35]. in 2015, public health expenditure was less than 1% of gdp in iraq and had dramatically decreased over the last five years. despite many initiatives, doctors' salaries remain low. thus, doctors may find other ways to supplement their income, such as working in both the public and private sectors. the results also revealed that a higher workload (more than 40 hours per week) led to a reduction in job satisfaction of iraqi doctors. studies from germany, new zealand, india, and other countries reported similar results regarding job satisfaction and workload [36-38]. it may not be possible to address all factors contributing to job dissatisfaction, particularly age and gender, by policy reforms, but reducing workload and increasing compensation can be effective methods. increasing government funding to increase doctors' salaries can help to attract and retain good doctors and increase satisfaction. increased health care fees that may be covered by governmental insurance schemes can be beneficially increasing hospital revenue and doctor compensations. appropriate actions must also be taken to address the imbalance between performance and reward. improving the working conditions of iraqi doctors should be an essential goal for their job satisfaction. since there are no effective gatekeeping systems in primary care, many patients apply directly to higher-level hospitals. this large proportion of patients in hospitals affects the quality of care and the doctorpatient relationship, and hence the job satisfaction of doctors. a comprehensive health care reform is needed to strengthen primary care intended to address the overutilization of hospitals. this may involve government hiring and training more staff [39]. additionally, effective human resources strategies are needed to support working conditions. it is also vital to consider socio-economic disparities in iraq. it is crucial to implement national strategies and local policies that consider local socioeconomic conditions. the most potent and novel finding of this study is the strong evidence of the impact of work-related violence on iraqi doctors' job satisfaction. the results revealed that doctors exposed to workplace violence were less satisfied with their job (figure 1). workplace violence has been recognized as a global concern for health care staff, particularly physicians. ali jadoo et al., journal of ideas in health 2018; 1(1):14-22 20 figure 1: factors affecting job satisfaction a literature search indicated that this issue had been studied in detail in developed countries, drawing attention to the magnitude of the problem and the potential adverse effects. for instance, 75% of physicians in the us [40], 59% of australian general practitioners [41], 56% of hospital and community physicians in israel [42], and more than 20% of physicians in finland [43] reported having encountered some form of workrelated violence during the previous 12 months. definitions and perceptions of violence may vary according to the country, the nature of culture, and the structure of health services. iraq has faced a catastrophic collapse in its health care system over three decades. it has its own specific cultural, socio-economic, and ethnic characteristics and may have different perceptions and behaviors regarding physician-patient relationships. to minimize this bias, we categorized work-related violence into two categories: verbal and physical. further, we subcategorized these into five distinct groups: verbal abuse, racial harassment, emotional abuse, bullying/mobbing, and physical abuse. in the past decade, hospital workplace violence in iraq has dramatically increased. the study results revealed that almost half of the survey respondents physically attacked, verbally abused, racially harassed, or emotionally abused (45.4%, 53.1%, 46.9%, respectively), and more than one third (36.6%) were bullied/mobbed in their workplaces. workplace violence can have many negative consequences for physicians on their work-related attitudes and behaviors. experiencing violence at the workplace may not only cause physical injuries, but it may also lead to psychological issues, such as anger, fear, depression, loss of confidence, burnout, anxiety, or insomnia [44,45]. both physical and psychological distress leads to a decrease in job satisfaction. the situation may further deteriorate if there is tolerance to violence from the public or spread of news on the internet, and media contributes to fear and insecurity. in this study, the factors had the greatest effect on job satisfaction related to workplace violence: bullying/mobbing (b= -9.11), physical abuse (b= -6.09), racial harassment (b= 4.24), verbal abuse (b= -3.10), (figure 1). these findings have consisted with the findings of previous studies that experiencing and witnessing workplace violence negatively affects doctors' job satisfaction. few studies assessed bullying/mobbing among healthcare professionals despite its well-known harmful effects on doctors and their institutions. doctors experiencing mobbing have a higher likelihood of showing behavioral disorders, such as feeling helpless and having fewer friends [46]. mobbing not only increases the risk of adverse events among mobbed doctors, which can lead to more medical errors but also awareness of mobbing threats may prevent witnesses from reporting unsafe practices. increasing the safety of the working environment is vital in preventing tensions and, ultimately, preventing mobbing. this can be achieved by discussing safetyrelated and other sensitive issues [47]. exposure to physical or psychological violence in the health care sector can have important consequences for the quality of patient care [48]. violent incidents can lead to interrupted or compromised care because doctors may either reduce the amount of time spent on the patient or even refuse to provide any care. workplace violence may also affect the employers, as low job satisfaction may lead to poor employee morale, and high turnover and exit rates [49]. the high levels of violence towards health care professionals in iraq suggest that reducing violence in this setting may help improve retention and recruitment. this is of critical importance in a context in which staffing shortfalls are exceptionally high, and most physicians have significant turnover intentions or intentions to leave the country [4]. measures to prevent violence in the workplace against doctors are needed to reduce risk and negative consequences. although healthcare organizations, in general, have made important progress in the development of violence prevention programs in iraq, there are still deficiencies in legislation prohibiting workplace violence, and it is essential to introduce a law to improve the medical environment and prevent workplace violence. in order to carry out these policies effectively, government and health care organizations must develop, implement, and encourage a strong safety and security environment. recommendations include tangible interventions, such as metal detectors, 24 hours security staff, security dog teams, cameras, incident-reporting mechanisms, and audits of violent incidents. additionally, doctors may be unaware of existing policies and programs or may be reluctant to use them. [50] physicians should be trained when and how to seek legal protection when violence occurs in the workplace. psychological support should also be available for affected health care workers. educational programs that help doctors to prevent and manage patient violence may also be useful. focusing on doctor-patient communication skills in the medical school curriculum can help improve this relationship and reduce workplace violence [51]. conclusion the findings of this paper revealed that although workload and pay were important areas of dissatisfaction, physical and psychological violence in the workplace were the most significant determinants of job satisfaction of iraqi doctors. the results of this study would, therefore, be of great interest to iraqi policymakers and health care managers seeking to improve doctors' job satisfaction levels. according to the results, the focus should not only be on the provision of financial incentives, but also special efforts must be made to create a safe and acceptable work environment. 5.867 5.039 4.277 2.808 2.15 -3.104 -4.242 -6.087 -9.107 1 2 3 4 5 6 7 8 9 f a c to rs r e la te d t o j o b s a ti sf a c ti o n job satisfaction scores ali jadoo et al., journal of ideas in health 2018; 1(1):14-22 21 abbreviations cmo: chief medical officers; wcw: warr-cook-wall; sd: standard deviation; ci: confidence interval; or: odds ratio; who: world health organization; gdp: gross domestic product declarations acknowledgment we render our special thanks to all directors of hospitals and medical centers we visited. we are also grateful to all the iraqi doctors and the paramedical staff for their working every day to serve their public in the face of violence and for their time and openness during the data collection. funding the author (s) received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing drsaadalezzi@gmail.com. authors’ contributions saaj is the principal investigator of the study who designed the study and coordinated all aspects of the research, including all steps of the manuscript preparation. he is responsible for the study concept, design, writing, reviewing, editing, and approving the manuscript in its final form. pt, ma, and id contributed to the study design, analysis and interpretation of data, drafting the work, writing the manuscript and reviewed and approved the manuscript. all authors read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki, and the ethical committee of the izmir university of economics approved the protocol (ref: b.30.2.ieu.0.05.05-020-014). confidentiality was assured with signed informed consent. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey. 2department of economics, izmir university of economics, izmir, turkey. 3department of public health, faculty of medicine, anbar university, anbar, iraq. article info received: 16 april 2018 accepted: 25 may 2018 published: 25 may 2018 references 1. al-kindi s. violence against doctors in iraq. lancet.2014; 384 (9947):954-5. 2. matt bradley. iraq’s doctors face threats of violence. the world street journal. 1 may 2017. available from: https://www.wsj.com/articles/iraqs-doctors-face-threats-of-violence1462145946 [accessed at: 14 november 2017]. 3. who, 2016 report on attacks on health care in emergencies. available from: http://www.who.int/hac/techguidance/attacksreport.pdf [accessed at: 14 november2017]. 4. ali jadoo sa, aljunid sm, dastan i, tawfeeq rs, mustafa ma, ganasegeran k, aldubai sa. job satisfaction and turnover intention among iraqi doctors--a descriptive cross-sectional multicenter study. hum resour health2015; 13: 21. 5. lafta m, pandya a. verbal and physical aggression against resident physicians in two general hospitals in baghdad. journal of muslim mental health 2006; 1 (2):137-144. 6. tarzi n. medical doctors in iraq: vilified, hunted and killed. global research, 15 december 2015. available from: https://www.globalresearch.ca/medical-doctors-in-iraq-vilified-huntedand-killed/5496148 [accessed at: 14 november 2017]. 7. cousins s. iraq: staff and medicine shortages are major challenges. lancet2014; 384(9947): 943-944. 8. al hilfi tk, lafta r, burnham g. health services in iraq. lancet 2013; 381: 939–948. 9. al-samarrai m, ali jadoo sa. impact of training on practical skills of iraqi health providers towards integrated management of neonatal and childhood illnessa multi-center cross sectional study. journal of ideas in health 2018; 1(1): 1-6. 10. ha jf, longnecker n. doctor-patient communication: a review. ochsner j. 2010; 10(1): 38–43. 11. human rights watch. iraq: government attacking fallujah hospital. barrel bombs hit residential areas. may 27, 2014. available from: http://www.hrw.org/news/2014/05/27/iraq-government-attackingfallujah-hospital [accessed at: 15 november 2017]. 12. reliefweb. iraq idp crisis situation report no. 1 (as of 4 july 2014). available from: https://reliefweb.int/report/iraq/iraq-idp-crisissituation-report-no-1-4-july-2014 [accessed 15 november 2017]. 13. webster pc. iraq’s growing health crisis. lancet2014; 384(9938):119–120. 14. steinmetz s, de vries dh, tijdens kg. should i stay or should i go? the impact of working time and wages on retention in the health workforce. hum resour health. 2014; 12:23. 15. samad s. the contribution of demographic variables: job characteristics and job satisfaction on turnover intentions. jims. 2006; 1(1):128–37. 16. mowday rt: strategies for adapting to high rate of employee turnover. hum resour manage 1984, 23(4):365-80. 17. soler jk, yaman h, esteva m, dobbs f, asenova rs, katic m, et al. burnout in european family doctors: the egprn study. fam pract2008; 25:245–265. 18. firth-cozens j, greenhalgh j. doctors’ perceptions of the links between stress and lowered clinical care. soc sci med1997; 44:1017– 1022. 19. melville a. job satisfaction in general practice: implications for prescribing. soc sci med med psychol med sociol1980; 14a: 495– 499. 20. klein j, frie kg, blum k, von dem knesebeck o. psychosocial stress at work and perceived quality of care among clinicians in surgery. bmc health serv res2011; 11:109. 21. shanafelt td, balch cm, bechamps g, russell t, dyrbye l, satele d, et al. burnout and medical errors among american surgeons. ann surg2010; 251:995–1000. 22. boafo im.the effects of workplace respect and violence on nurses’ job satisfaction in ghana: a cross-sectional survey. human resources for health2018; 16(1), 6. 23. heponiemi t, kuusio h, sinervo t, elovainio m. job attitudes and well-being among public vs. private physicians: organisational justice and job control as mediators. eur j public health 2011; 21(4):520–525. 24. rosta j, nylenna m, aasland og. job satisfaction among hospital doctors in norway and germany. a comparative study on national samples. scand j public health 2009, 37(5):503–508. ali jadoo et al., journal of ideas in health 2018; 1(1):14-22 22 25. wei yt, pang ys, huang jl, et al. a survey on job satisfaction of health care staff worked in township health center of guangdong province. chin j health stat 2005; 1:82–5. 26. aasland og, rosta j, nylenna m. healthcare reforms and job satisfaction among doctors in norway. scand j public health 2010; 38(3):253-258. 27. joyce cm, schurer s, scott a, humphreys j, kalb g. australian doctors’ satisfaction with their work: results from the mabel longitudinal survey of doctors. med j aust. 2011; 194(1):30-33. 28. iliopoulos e, priporas cv. the effect of internal marketing on job satisfaction in health services: a pilot study in public hospitals in northern greece. bmc health serv res. 2011; 11:261. 29. weng hc, hung cm, liu yt, cheng yj, yen cy, chang cc, et al. associations between emotional intelligence and doctor burnout, job satisfaction and patient satisfaction. med educ. 2011; 45(8):835-842. 30. zhang y, feng x. the relationship between job satisfaction, burnout, and turnover intention among physicians from urban stateowned medical institutions in hubei, china: a cross-sectional study. bmc health serv res 2011, 11:235. 31. liu ja, wang q, lu zx. job satisfaction and its modeling among township health center employees: a quantitative study in poor rural china. bmc health serv res. 2010; 10:115. 32. goetz k, musselmann b, szecsenyi j, joos s. the influence of workload and health behavior on job satisfaction of general practitioners. fam med 2013; 45(2):95–101. 33. atif k, khan hu, maqbool s. job satisfaction among doctors, a multi-faceted subject studied at a tertiary care hospital in lahore. pakistan journal of medical sciences 2015; 31(3): 610-614. 34. liu ww, wang yy. influence factors of health care staff satisfaction in tertiary hospital in domains of individual, working characteristics and organizational environment. chin hosp 2010; 14:47–50. 35. who global health expenditure database [internet]. geneva: world health organization; 2013. available from: http://www.who.int/health-accounts/ghed/en/ [accessed 5 april 2018]. 36. sehlen s, vordermark d, schäfer c, herschbach p, bayerl a, pigorsch s, et al. job stress and job satisfaction of physicians, radiographers, nurses and physicists working in radiotherapy: a multicenter analysis by the degro quality of life work group. radiat oncol 2009; 4:1–9. 37. kaur s, sharma r, talwar r, verma a, singh s. a study of job satisfaction and work environment perception among doctors in a tertiary hospital in delhi. indian j med sci. 2009; 63:139-144. 38. dowell ac, hamilton s, msleod dk. job satisfaction, psychological morbidity and job stress among new zealand general practitioners. n z med j. 2000; 113(1113):269-272. 39. dieleman m, harnmeijer jw. improving health worker performance: in search of promising practices. geneva: world health organization 2006; 5-34. 40. kowalenko t, walters bl, khare rk, compton s. workplace violence: a survey of emergency physicians in the state of michigan. ann emerg med 2005; 46:142–147. 41. magin pj, may j, mcelduff p, goode sm, adams j, cotter gl. occupational violence in general practice: a whole-of-practice problem. results of a cross-sectional study. aust health rev 2011; 35(1):75–80. 42. carmi-iluz t, peleg r, freud t, shvartzman p. verbal and physical violence towards hospitaland community-based physicians in the negev: an observational study. bmc health serv res 2005; 5:54. 43. kajantie m, vänskä. työpaikkaväkivalta kohdistuu nuoriin lääkäreihin [workplace violence focuses on young doctors]. finnish medical journal 2006; 10:1121–1125. 44. cooper cl, swanson n. workplace violence in the health sector. state of the art. geneva: organización internacional de trabajo, organización mundial de la salud, consejo internacional de enfermeras internacional de servicios públicos, 2002. available from: http://www.who.int/violence_injury_prevention/violence/activities/wor kplace/wvstateart.pdf 45. weifang z, yu z, xuehuan s. investigation on mental health status in emergency nurses after workplace violence. mod clin nurs.2009; 8:4–6. 46. trépanier sg, fernet c, austin s. a longitudinal investigation of workplace bullying, basic need satisfaction, and employee functioning. j. occup. health psychol.2015; 20 (1):105–116. 47. johnson sl. international perspectives on workplace bullying among nurses: a review. int. nurs. rev. 2009; 56 (1): 34–40. 48. arnetz je, & arnetz bb. violence towards health care staff and possible effects on the quality of patient care. social science & medicine 2001; 52: 417-427. 49. estryn-behar m, van der heijden b, camerino d, fry c, le nezet o, conway pm, et al. violence risks in nursing—results from the european ‘next’ study. occupational medicine (oxford england) 2008; 58(2):107-114. 50. fazzone pa, barloon lf, mcconnell sj, chitty ja. personal safety, violence, and home health. public health nursing 2000; 17(1): 43-52. 51. ong lm, de haes jc, hoos am, et al. doctor-patient communication: a review of the literature. soc sci med 1995; 40:903– 18. https://doi.org/10.47108/jidhealth.vol5.iss2.218 prado-galbarro f-j, et al., journal of ideas in health 2022;5(2):679-684 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access racial and ethnic disparities in covid-19 mortality in the united states francisco-javier prado-galbarro 1, ana-estela gamiño-arroyo 2, copytzy cruz-cruz 3, juan-manuel martínez-núñez 4, carlos sanchez-piedra 5* abstract background: among covid-19–associated deaths reported in the united states (u.s.), minority communities were disproportionately represented. the objective was to assess differences in mortality by race and ethnicity among patients with coronavirus disease 2019 (covid-19) in the u.s. methods: this is a retrospective case series study with information extracted from the u.s. centers for disease control and prevention between january 20 and december 29, 2020. clinical and sociodemographic data were analyzed by race and ethnicity from non-hospitalized and hospitalized patients with covid-19. binary logistic models were fitted to evaluate factors associated with covid-19-related mortality. results: a total of 434,076 patients with covid-19 were characterized; 284,574 cases were non-hispanic white, 10,468 cases were non-hispanic asian, and 949,022 cases were non-hispanic black, and 89,407 cases were hispanic/latino. for non-hospitalized patients, hispanic/latino with pneumonia (or 3.34, 95%ci: 1.70-6.58) and nonhispanic asian with comorbidities (or 3.88, 95%ci: 0.99-15.2) had the highest odds for mortality. for hospitalized patients, non-hispanic black with comorbidities (or 3.02, 95%ci: 2.24-4.08) and non-hispanic asian and nonhispanic black with pneumonia (or 2.98, 95%ci: 2.09-4.26; and or 2.97, 95%ci: 2.60-3.38, respectively) had the highest odds for mortality. conclusion: racial/ethnic disparities in mortality persist among patients with covid-19 in the u.s. these findings support the assertion that racial and ethnic minorities are disproportionately affected by covid-19 in the u.s. keywords: sars-cov 2, covid-19, race, ethnicity, health disparity, inequality background the novel coronavirus, known as severe acute respiratory syndrome coronavirus-2 (sars-cov2), was identified in wuhan, china, in december 2019 and was considered a pandemic by the world health organization on march 11, 2020 [1]. the coronavirus disease (covid-19) pandemic has had a devastating impact on public health and the global economy [2, 3]. actually, the united states (u.s.) has the highest number of confirmed sars-cov-2 cases globally, with 26.5 million affected people and more than 440,000 deaths in the country from january 20, 2020, to february 2, 2021 [4]. recent research has shown that low incomes and race are associated with the covid-19 incidence [5, 6]. the pandemic could increase poverty and inequities [7–10], and it is well documented that income is correlated with covid-19 severity [11, 12]. preexisting conditions could explain this situation. asian, black, and hispanic americans are more likely to be uninsured than non-hispanic white americans [13], resulting in more limited access to health. the combined effect of poverty and structural inequities among ethnic minorities makes them more exposed to the virus since these groups generally work in places where social distancing is impossible or live in crowded conditions [14, 15]. this study focused on four major groups: nonhispanics whites, non-hispanics asians, non-hispanics blacks, and hispanics/latinos. in this context, we evaluated racial and ethnic differences in mortality during the covid-19 pandemic in the u.s. ___________________________________________________ carlos.sanchez@isciii.es 5research unit, health technology assessment agency of carlos iii institute of health (aets), madrid, spain. full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol5.iss2.218 http://www.jidhealth.com/ prado-galbarro f-j, et al., journal of ideas in health (2022); 5(2):679-684 680 methods study design and data source a secondary analysis of covid-19 data collection and reporting in the u.s. was carried out. the centers for disease control and prevention (cdc) is the leading federal public health institute in the u.s. and releases daily updates on the number of total covid-19 cases, new cases, total deaths, new deaths, and tests [16]. the information was extracted from the covid-19 case surveillance restricted access dataset with 32 elements, including state and county of residence information from january 20 to december 29, 2020 (https://data.cdc.gov/case-surveillance/covid-19-casesurveillance-public-use-data/vbim-akqf/data ; accessed on december 31, 2020) [17]. we excluded people without information on the variables of interest and/or who did not belong to any of the aforementioned population groups (n=12,981,757). overall, 434,081 patients were included in the analysis (figure 1). figure 1: flowchart of patients selection variables the dependent variable was death in patients with covid-19. we considered as individual-level covariates: age categorized into six age groups, 0–29, 30–49, 50–59, 60–69, 70–79, and 80+ years, using the oldest age group as the reference category in the model specifications; sex that compared men (= 0) with women (= 1); comorbidities (no = 0 / yes = 1); hospitalization (no = 0 / yes = 1); pneumonia (no = 0 / yes = 1); and admission to the intensive care unit (icu) (no = 0 / yes = 1). we calculated weights to make statistics computed from the data more representative of the population. stratification was used to calculate weights so that the weighted case distribution was as close as possible to that of the target population. the information was extracted from the covid-19 case surveillance public-use data on may 8, 2021, and we stratified it by race, sex, age group, and if the patient had died. statistical analysis firstly, the variables of interest were presented as frequencies and percentages for the categorical variables stratified by race/ethnicity. secondly, we performed binary logistic regression models to test the effect of sex, age, and clinical factors on mortality. for each race/ethnicity, a model with sex, age group, comorbidities, hospitalization, pneumonia, and admission to the icu was fitted. models were then fitted for hospitalized and non-hospitalized patients. the results were expressed in terms of odds ratios (o.r.s) with 95% confidence intervals (c.i.s) for each model. statistical tests were two-tailed and considered significant under a 0.05 alpha. all analyses were conducted using the svy module for complex samples of the statistical software stata, version 14 (stata corp, stata statistical software, release 14, 2015). results table 1 summarizes the characteristics of 15,102 deceased patients with covid-19 by race/ethnicity. overall, nonhispanic white patients were the oldest, and hispanic/latino patients were the youngest (e.g., 80+ years: 54.23% nonhispanic white patients vs. 28.30% hispanic/latino patients). hispanic/latino patients had a higher proportion of young patients than other groups. non-hispanic black and nonhispanic white patients had a higher proportion of women patients (47.27% and 47.39%, respectively) than the other groups (non-hispanic asian: 42.55%; and hispanic/latino: 38.18%). non-hispanic black patients had a higher proportion of comorbidities (97.76% vs. range, 92.58%-95.63%). nonhispanic white patients had the lowest prevalence of hospitalization (74.13%), pneumonia (53.07%), and admission to the icu (40.20%). table 2 shows the factors associated with covid-19 mortality. non-hispanic white females (or 0.90, 95%ci: 0.86095) had a higher odd of mortality than non-hispanic black (or 0.77, 95%ci: 0.68-0.86) and hispanic/latino females (or 0.70, 95%ci: 0.61-–0.81). overall, the odds by age group were lower in non-hispanic white patients (e.g., 70-79 years: nonhispanic white patients: or 0.24, 95%ci: 0.22-0.26 vs. hispanic/latino patients: or 0.41, 95%ci: 0.31-0.54). hispanic/latino patients with hospitalization (or 8.72, 95%ci: 6.47-11.77) and icu (or 9.75, 95%ci: 8.29-11.48) had a higher risk of mortality compared with other groups (nonhispanic white patients: or hospitalization 3.37, 95%ci: 3.14-3.63, oricu 6.16, 95%ci: 5.70-6.65; non-hispanic asian patients: or hospitalization 7.42, 95%ci: 4.10-13.41, oricu 6.81, 95%ci: 4.76-9.75; and non-hispanic black patients: or hospitalization 5.03, 95%ci: 4.10-6.16, oricu 7.94, 95%ci: 7.00-9.01). finally, non-hispanic black patients with pneumonia (or 2.90, 95%ci: 2.54-3.30) had a higher risk of mortality compared with other groups (non-hispanic white patients: or 2.30, 95%ci: 2.15-2.46; non-hispanic asian patients: or 2.83, 95%ci: 1.95-4.10; and hispanic/latino: or 2.73, 95%ci: 2.293.25). figure 2. results of logistic regression model for non-hospitalized patients versus hospitalized patients considering pneumonia. odd ratio (or). 95% confidence interval (ci https://data.cdc.gov/case-surveillance/covid-19-case-surveillance-public-use-data/vbim-akqf/data https://data.cdc.gov/case-surveillance/covid-19-case-surveillance-public-use-data/vbim-akqf/data prado-galbarro f-j, et al., journal of ideas in health (2022); 5(2):679-684 681 figure 2 presents the association between pneumonia and mortality in hospitalized and non-hospitalized patients with covid-19. for non-hospitalized patients, hispanic/latino with pneumonia (or 5.89, 95%ci: 3.19-10.88) had a higher risk of mortality compared with other groups (non-hispanic white patients: or 4.50, 95%ci: 3.86-5.26; and non-hispanic black patients: or 2.96, 95%ci: 1.55-5.64-3.40). for hospitalized patients, non-hispanic asian and non-hispanic black with pneumonia (or 2.90, 95%ci: 2.00-4.21; and or 2.85, 95%ci: 2.50-3.24, respectively) had a higher risk of mortality compared with other groups (hispanic/latino patients: or 2.54, 95%ci: 2.15-2.99; and non-hispanic white patients: or 1.95, 95%ci: 1.83-2.08). associations of comorbidities and mortality in hospitalized and non-hospitalized patients with covid-19 are presented in figure 3. for non-hospitalized patients, nonhispanic asian with comorbidities (or 5.47, 95%ci: 1.1825.31) had a higher risk of mortality compared with other groups (non-hispanic white patients: or 2.48, 95%ci: 2.182.83; non-hispanic black patients: or 3.55, 95%ci: 1.93-6.53; and hispanic/latino patients: or 2.44, 95%ci: 1.45-4.10). for hospitalized patients, non-hispanic black with comorbidities (or 3.71, 95%ci: 2.70-4.08) had a higher risk of mortality compared with other groups (non-hispanic white patients: or 2.38, 95%ci: 2.11-2.69; non-hispanic asian patients: or 2.15, 95%ci: 1.29-3.57; and hispanic/latino patients: or 2.80, 95%ci: 2.27-3.45). figure 3. results of logistic regression model for non-hospitalized patients versus hospitalized patients considering comorbidities. odd ratio (or). 95% confidence interval (ci). table 1: covid-19 deaths by sociodemographic characteristics, comorbidities, and clinical outcomes variables categories non-hispanic white non-hispanic asian non-hispanic black hispanic/latino unweighted cases, n 284,574 10,953 49,147 89,407 weighted cases, n 7,706,610 510,112 1,709,849 4,578,528 unweighted deaths, n (%) 10,001 (3.51%) 485 (4.43%) 2,690 (5.47%) 1,931 (2.16%) weighted deaths, n (%) 222,176 (2.88%) 15,038 (2.95%) 51,526 (3.01%) 71,145 (1.55%) gender, % (95% ci) male 52.61 (51.62 53.59) 57.45 (52.6 62.17) 52.73 (50.82 54.63) 61.82 (59.41 64.17) female 47.39 (46.41 48.38) 42.55 (37.83 47.4) 47.27 (45.37 49.18) 38.18 (35.83 40.59) age groups, % (95% ci) 0 29 years 0.31 (0.24 0.39) 0.49 (0.17 1.46) 1.03 (0.71 1.5) 1.19 (0.87 1.64) 30 49 years 1.88 (1.67 2.12) 3.94 (2.58 5.96) 6.24 (5.42 7.17) 9.37 (8.35 10.51) 50 59 years 4.57 (4.22 4.95) 7.35 (5.61 9.57) 11.27 (10.19 12.45) 14.57 (13.25 15.99) 60 69 years 13.15 (12.53 13.8) 17.87 (14.89 21.31) 23.51 (21.97 25.13) 22.63 (20.83 24.54) 70 79 years 25.86 (25.01 26.73) 25.16 (21.58 29.1) 27.01 (25.37 28.71) 23.94 (21.94 26.06) 80+ years 54.23 (53.25 55.2) 45.19 (40.38 50.1) 30.94 (29.13 32.81) 28.30 (25.91 30.83) comorbidity, % (95% ci) no 6.50 (6.03 6.99) 4.37 (2.94 6.46) 2.24 (1.75 2.86) 7.42 (6.36 8.64) yes 93.5 (93.01 93.97) 95.63 (93.54 97.06) 97.76 (97.14 98.25) 92.58 (91.36 93.64) hospitalization, % (95% ci) no 25.87 (25.01 26.76) 5.15 (3.31 7.92) 6.75 (5.85 7.79) 5.63 (4.58 6.9) yes 74.13 (73.24 74.99) 94.85 (92.08 96.69) 93.25 (92.21 94.15) 94.37 (93.1 95.42) pneumonia, % (95% ci) no 46.93 (45.94 47.92) 20.59 (16.95 24.78) 26.77 (25.11 28.5) 21.12 (19.21 23.16) yes 53.07 (52.08 54.06) 79.41 (75.22 83.05) 73.23 (71.5 74.89) 78.88 (76.84 80.79) icu, % (95% ci) no 59.80 (58.83 60.76) 33.95 (29.46 38.75) 34.69 (32.89 36.54) 26.98 (24.85 29.22) yes 40.20 (39.24 41.17) 66.05 (61.25 70.54) 65.31 (63.46 67.11) 73.02 (70.78 75.15) all variables have significant values (p<0.05); icu: intensive care units. discussion in in this study, we observed racial and ethnic disparities associated with deaths related to covid-19 among a sample of patients in the u.s. between january 20 and december 29, 2020. we found overall mortality disparities by race/ethnicity: non-hispanic asian, non-hispanic black, and hispanic/latino populations were associated with higher mortality than the nonhispanic white population after controlling for comorbidities, sex, and age groups. furthermore, the black population presented the highest risk of dying from comorbidities, followed by non-hispanic white, hispanic-latino, and nonhispanic asian. our findings reinforce that racial and ethnic disparities are also of utmost importance for people at increased risk of severe illness from the virus that causes covid-19 [18,19]. disadvantaged social groups are at greater risk of becoming ill and dying since, due to the characteristics of their environment, they have greater exposure to risk factors while having fewer protective factors or resources to deal with diseases [18, 19]. the ogedegbe et al. [20] study found black populations are more likely to be uninsured and underinsured than white populations and thus more likely to die at home than in hospitals due to poorer access to care. covid-19–related mortality relative to their representation in the population affects disproportionately black and hispanic/latino people in major cities in the united states [15, 21]. prado-galbarro f-j, et al., journal of ideas in health (2022); 5(2):679-684 682 table 2: factors associated to covid-19 mortality according to race/ethnicity (results from logistic regression model) predictors non-hispanic white non-hispanic asian non-hispanic black hispanic/latino or 95% ci or 95% ci or 95% ci or 95% ci sex, female male 1 (ref.) 1 (ref.) 1 (ref.) 1 (ref.) female 0.903* 0.856 0.952 0.809 0.589 1.110 0.766* 0.684 0.858 0.702* 0.608 0.810 age groups, 80+ years 1 (ref.) 1 (ref.) 1 (ref.) 1 (ref.) 0 29 years 0.003* 0.002 0.004 0.001* 0.001 0.008 0.019* 0.012 0.028 0.018* 0.012 0.027 30 39 years 0.014* 0.013 0.016 0.035* 0.019 0.064 0.046* 0.037 0.057 0.051* 0.039 0.067 40 59 years 0.004* 0.036 0.0436 0.065* 0.039 0.108 0.082* 0.067 0.099 0.110* 0.085 0.143 60 69 years 0.100* 0.093 0.107 0.129* 0.081 0.206 0.166* 0.139 0.200 0.219* 0.168 0.286 70 79 years 0.240* 0.224 0.257 0.225* 0.139 0.365 0.333* 0.277 0.401 0.411* 0.311 0.543 comorbidities no 1 (ref.) 1 (ref.) 1 (ref.) 1 (ref.) yes 2.677* 2.446 2.929 2.575* 1.591 4.168 3.967* 2.991 5.261 2.894* 2.373 3.530 hospitalization no 1 (ref.) 1 (ref.) 1 (ref.) 1 (ref.) yes 3.374* 3.142 3.625 7.417* 4.102 13.410 5.029* 4.104 6.162 8.724* 6.467 11.770 pneumonia no 1 (ref.) 1 (ref.) 1 (ref.) 1 (ref.) yes 2.298* 2.145 2.461 2.830* 1.952 4.101 2.895* 2.541 3.298 2.730* 2.294 3.249 icu no 1 (ref.) 1 (ref.) 1 (ref.) 1 (ref.) yes 6.156* 5.697 6.653 6.810* 4.756 9.752 7.939* 7.000 9.005 9.754* 8.289 11.480 in a cross-sectional study in the united states, karmakar et al. [22] found that racial/ethnic minority status was significantly associated with covid-19 incidence and mortality. the highest likelihood of dying among black and hispanic patients found in this study is consistent with previous findings. the racial differences observed in the study population are probably the result of interactions among multiple factors. several studies found that where people live and work could increase disease risk because of difficulty engaging in social distancing [21, 23]. additional analysis by hospitalization led us to evaluate differences in covid-19 mortality among ethnic groups, considering hospitalized versus non-hospitalized patients. previous reports pointed out the existence of disparities in hospitalization rates due to covid-19 [24]. we found differences in the factors associated with covid-19 deaths according to hospitalization. black patients presented more risk of death associated with comorbidities in both groups (hospitalized and non-hospitalized patients). previous reports in the u.s. suggested the presence of more comorbidities in black patients. price et al. found disparities in comorbidities (obesity, diabetes, hypertension, and chronic kidney disease) among ethnic groups that could explain these findings [25]. another new york city community health survey analysis found similar results [26]. the apparition of pneumonia was associated with covid-19 fatality in hispanic/latino nonhospitalized patients. ogedegbe et al. [20] showed disparities in out-of-hospital deaths in black and hispanic communities. this study has strengths and limitations. the data analyzed were of a secondary nature, and the accuracy of the data, therefore, cannot be guaranteed. this study is based on complete information on the factors studied; thus, the proportion of severe and critical patients and fatality rate might be different for the whole infected population. finally, minority communities are more likely to experience living and working conditions that could predispose them to worse outcomes [19, 27, 28]. however, we do not have data on work occupation, household size, and the number and type of comorbidities. the strength of this study is the analysis of covid-19 epidemiologic data based on a large population of patients differentiated by race or ethnicity, adjusting by comorbidities, sex, and age groups. conclusion and policy implications health inequities are not new. covid-19 has emphasized disparities in disease outcomes by racial/ethnic status. in this sample of patients in the u.s., non-hispanic black and nonhispanic asian patients with comorbidities were more likely, and hispanic/latino patients less likely, than non-hispanic white patients to die after adjustment for sex, age, and the statelevel random effects. furthermore, non-hispanic black, hispanic/latino, and non-hispanic asian patients were more likely to die than non-hispanic white patients. these findings support the assertion that racial and ethnic minorities are disproportionately affected by covid-19 in the u.s., even though the underlying causes of ethnic disparities in covid-19 outcomes remain established. abbreviation cdc: centers for disease control and prevention; covid19: coronavirus disease 2019; u.s.: the united states; severe sars-cov2: acute respiratory syndrome coronavirus-2 declaration we would like to declare that the article has a pre-print version published in “the lancet” on 1st november 2021. available at ssrn: https://ssrn.com/abstract=3954100 or https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3954100. http://dx.doi.org/10.2139/ssrn.3954100 acknowledgment not applicable funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing carlos.sanchez@isciii.es prado-galbarro f-j, et al., journal of ideas in health (2022); 5(2):679-684 683 authors’ contributions csp and fjpg conceptualized the analysis. csp and fjpg accessed and verified the data, completed the formal analysis, and drafted the original manuscript. all authors had access to all data and contributed to study design, data collection, and manuscript editing. all authors had final responsibility for the decision to submit for publication. all authors have read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. this study was analysis of secondary data collected from: https://data.cdc.gov/case-surveillance/covid-19-casesurveillance-public-use-data/vbim-akqf/data. the approval of an institutional ethics committee was not required. there was no restriction to accessing the data. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1orphan drug laboratory, biologic system department metropolitan autonomous university, mexico city, mexico. 2epidemiology department. hospital infantil de méxico federico gómez. mexico city, mexico. 3orphan drug laboratory, biologic system department metropolitan autonomous university, mexico city, mexico. 4orphan drug laboratory, biologic system department metropolitan autonomous university, mexico city, mexico. 5research unit, health technology assessment agency of carlos iii institute of health (aets), madrid, spain. article info received: 06 april 2022 accepted: 06 may 2022 published: 18 may 2022 references 1. cucinotta d, vanelli m. who declares covid-19 a pandemic. acta biomedica. 2020;91(1):157-160. doi: 10.23750/abm. v91i1.9397. 2. nafsa: association of international educators. nafsa financial impact survey summary brief. 2020;12. available from: https://www.nafsa.org/sites/default/files/media/document/2 020-financial-impact-survey.pdf 3. nicola m, alsafi z, sohrabi c, kerwan a, al-jabir a, iosifidis c, et al. the socio-economic implications of the coronavirus pandemic (covid-19): a review. int j surg. 2020 jun; 78:185–93. doi: 10.1016/j.ijsu.2020.04.018. 4. johns hopkins university & medicine. covid-19 map [internet]. johns hopkins coronavirus resource center. 2020. available from: https://coronavirus.jhu.edu/map.html 5. chin-hong p, alexander km, haynes n, albert ma, cardiologists ta of b. pulling at the heart: covid-19, race/ethnicity and ongoing disparities. nat rev cardiol. 2020;17(9):533–5. doi.org/10.1038/s41569-020-0416-6 6. chen jt, krieger n. revealing the unequal burden of covid-19 by income, race/ethnicity, and household crowding: u.s. county versus zip code analyses. j public heal manag pract. 2021 jan/feb;27 suppl 1, covid-19 and public health: looking back, moving forward: s43-s56. doi: 10.1097/phh.0000000000001263. 7. furceri d, loungani p, ostry jd, pizzuto p. covid-19 will raise inequality if past pandemics are a guide. voxeu. 2020. 8. kikuchi s, kitao s, mikoshiba m. heterogeneous vulnerability to the covid-19 crisis and implications for inequality in japan. rieti discussion paper series. 2020. 9. lakner c, mahler dg, negre m, prydz eb. how much does reducing inequality matter for global poverty? how much does reducing inequality matter for global poverty? 2020. doi.org/10.1007/s10888-021-09510-w. 10. palomino jc, rodríguez jg, sebastian r. poverty and inequality surge across europe in the wake of covid-19. eur econ rev. 2020. 11. papageorge nw, zahn m v., belot m, van den broekaltenburg e, choi s, jamison jc, et al. sociodemographic factors associated with self-protecting behavior during the covid-19 pandemic. j popul econ. 2021. doi.org/10.1007/s00148-020-00818-x. 12. mcneely cl, schintler la, stabile b. social determinants and covid-19 disparities: differential pandemic effects and dynamics. world med heal policy. 2020. doi.org/10.1002/wmh3.370. 13. berchick e, barnett j, upton r. current population reports, p60-267(r.v.), health insurance coverage in the united states: 2018. u.s. gov print off washington, dc [internet]. 2019; available from: https://www.census.gov/content/dam/census/library/public ations/2019/demo/p60-267.pdf [accessed on february 14, 2021]. 14. burr ja, mutchler je, gerst k. patterns of residential crowding among hispanics in later life: immigration, assimilation, and housing market factors. journals gerontol ser b psychol sci soc sci. 2010. doi: 10.1093/geronb/gbq069. 15. cdc. covid-19 in racial and ethnic minority groups. 2020. available from: https://stacks.cdc.gov/view/cdc/89820/cdc_89820_ds1.pd f [accessed on february 18, 2021]. 16. madrigal a.c., meyer r. the atlantic; 2020. how could the cdc make that mistake? available from: https://www.theatlantic.com/health/archive/2020/05/cdc prado-galbarro f-j, et al., journal of ideas in health (2022); 5(2):679-684 684 and-states-are-misreporting-covid-19-test-datapennsylvania-georgia-texas/611935/ [accessed on february 25, 2021]. 17. centers for disease control and prevention. covid-19 case surveillance use data. available from: https://data.cdc.gov/case-surveillance/covid-19-casesurveillance-public-use-data/vbim-akqf/data [accessed on december 31, 2020]. 18. webb hooper m, nápoles am, pérez-stable ej. covid19 and racial/ethnic disparities. jama. 2020 jun 23;323(24):2466–7. doi.org/10.1001/jama.2020.8598. 19. tai dbg, shah a, doubeni ca, sia ig, wieland ml. the disproportionate impact of covid-19 on racial and ethnic minorities in the united states. clin infect dis. 2021 february 16;72(4):703-706. doi: 10.1093/cid/ciaa815. 20. ogedegbe g, ravenell j, adhikari s, butler m, cook t, francois f, et al. assessment of racial/ethnic disparities in hospitalization and mortality in patients with covid19 in new york city. jama netw open. 2020 dec 1;3(12):e2026881. doi: 10.1001/jamanetworkopen.2020.26881. 21. artiga s, garfield r, orgera k. communities of color at higher risk for health and economic challenges due to covid-19. kff [internet]. 2020; available from: https://www.kff.org/coronavirus-covid-19/issuebrief/communities-of-color-at-higher-risk-for-health-andeconomic-challenges-due-to-covid-19/ [accessed on february 19, 2021]. 22. karmakar m, lantz pm, tipirneni r. association of social and demographic factors with covid-19 incidence and death rates in the u.s. jama netw open. 2021 jan 4;4(1):e2036462. doi: 10.1001/jamanetworkopen.2020.36462. 23. madewell zj, yang y, longini jr im, halloran me, dean ne. household transmission of sars-cov-2: a systematic review and meta-analysis. jama netw open. 2020 dec 14;3(12):e2031756–e2031756. doi:10.1001/jamanetworkopen.2020.31756. 24. karaca-mandic p, georgiou a, sen s. assessment of covid-19 hospitalizations by race/ethnicity in 12 states. jama internal medicine. 2021. doi:10.1001/jamainternmed.2020.3857. 25. price-haywood eg, burton j, fort d, seoane l. hospitalization and mortality among black patients and white patients with covid-19. n engl j med. 2020. doi: 10.1056/nejmsa2011686. 26. arasteh k. prevalence of comorbidities and risks associated with covid-19 among black and hispanic populations in new york city: an examination of the 2018 new york city community health survey. j racial ethn health disparities. 2021 aug;8(4):863-869. doi: 10.1007/s40615-020-00844-1. 27. figueroa jf, wadhera rk, mehtsun wt, riley k, phelan j, jha ak. association of race, ethnicity, and communitylevel factors with covid-19 cases and deaths across u.s. counties. healthcare. 2021. doi: 10.1016/j.hjdsi.2020.100495. 28. clay sl, woodson mj, mazurek k, antonio b. racial disparities and covid-19: exploring the relationship between race/ethnicity, personal factors, health access/affordability, and conditions associated with an increased severity of covid-19. race soc probl. 2021. doi: 10.1007/s12552-021-09320-9. https://doi.org/10.47108/jidhealth.vol5.iss1.206 al-rawi ra, journal of ideas in health 2022;5(1):643-648 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access knowledge, attitude and practice towards covid-19 among healthcare workers in iraq ru’ya abdulhadi al-rawi1 abstract background: in the absence of effective treatment, coronavirus disease (covid-19) poses severe risks to public health. this study aimed to explore the knowledge, attitude, and practice towards the covid-19 pandemic among healthcare workers. methods: an online approach was adopted to conduct a cross-sectional study from 1st to 31st october 2020 among iraqi healthcare workers in anbar province, west of iraq. a semi-structured and self-administered questionnaire was recruited to collect the data. the study tool contains four parts sociodemographic, knowledge, attitude, and practice assessment. multiple linear regression was performed to test the association between the dependent and the independent variables. spss version 16 was used to analyze the data, and the statistical significance level was considered at less than 0.05 p-values. results: a total of 209 health workers were included in this study. most of the respondents (54.5%) were doctors (physician, dentist, and pharmacist), males (60.8%), married (74.2%), aged less than 45 years (53.1%), urban region (64.6%), with a monthly income of usd 400 and above (61.7%) and 75.1% of them perceived their health good. the mean knowledge, attitude, and practice level of participants were 14.43 (± 2.01), 27.68 (± 2.74), and 4.33 (± 0.97), respectively. in the regression analysis, doctors (p-value = 0.000) aged 45 years and above (p-value=0.008) and urban residents (p-value=0.007) were significantly associated with upper knowledge scores. female gender (p-value =0.022) was significantly related to positive attitude scores. while married (p-value = 0.038), those with experience of 10 years and above (p-value=0.041) showed better practice. conclusion: the level of knowledge, attitudes, and practices of healthcare workers in anbar province was adequate. however, with the expected new waves of pandemics, the policy of continuous training to update healthcare workers is inevitable to control and prevention of covid-19. keywords: covid-19, knowledge, attitude, practice, healthcare workers, anbar, iraq background almost all world countries have been invaded by the covid-19 pandemic, regardless of economic power, the quality of services, and the availability of human and logistical resources for health. since the world health organization announced that the epidemic had turned into a pandemic on march 11, 2020, the world should have prepared to meet successive waves [1,2]. the most prominent means of addressing the pandemic were the sustainable health system and health education. therefore, the success of countries in responding to the pandemic depends on the integrity of the health system infrastructure and the competence of health workers. several studies have been conducted to evaluate the knowledge, attitude, and practice of the population and healthcare workers towards the covid-19 pandemic [3-13]. most surveyed people showed acceptable kap towards covid-19 [14-17]. the biggest challenge was to ensure the competence of health personnel to face the pandemic. lake et al. [3] systematically reviewed eleven studies concerned with evaluating the kap toward covid-19 among health professionals. the authors found that respondents have good knowledge, positive attitude, and bad practices on average 79.4%, 73.7%, and 40.3%, respectively. service providers bear an additional burden and greater responsibility than the rest of society due to the direct confrontation with the pandemic and the high possibility of infection. mbachu et al. [4] found that 48.64% of health professionals were negatively affected by covid-19. ___________________________________________________ ruyasaeed73@gmail.com 1department of family and community medicine, faculty of medicine, anbar university, iraq a full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol5.iss1.206 http://www.jidhealth.com/ al-rawi ra, journal of ideas in health (2022); 5(1):643-648 644 moreover, asdaq et al. [5] concluded that practicing healthcare professionals toward covid-19 has improved significantly with increasing the knowledge and attitude. iraq has witnessed multiple epidemic waves since the first case was announced in march 2020 [18]. despite the weakness of the health system [19], healthcare providers showed their interest in taking responsibility for responding to the pandemic. however, the risks in the workplace have escalated with the increasing spread of covid-19 across iraq. most healthcare workers are exposed to covid-19 infection due to direct contact with patients [20]. the international red cross and red crescent (icrc) report indicate that iraqi healthcare workers' workplace is not safe. many iraqi health care workers have become the target of unjustified physical and verbal violence by patients and their relatives [21]. iraq already has a high turnover intention among healthcare workers [22,23]. therefore, the situation could worsen due to the battle to contain the covid-19 pandemic, especially in the absence of scientific competencies that handle crisis management. this study aimed to assess the knowledge, attitude, the practice of iraqi healthcare workers toward the covid-19 pandemic. methods study population a cross-sectional study designed to evaluate healthcare workers' knowledge, attitude, and practice towards the covid-19 pandemic. data was collected using a self-administered survey from october to december 2020 in anbar province, western iraq. the current study is part of a larger research initiative [1416], in which we recruited a web-based survey to explore the knowledge, attitude, and practice among the general population. inclusion and exclusion criteria both private and public healthcare workers (academic and nonacademic sectors), whatever the gender and willingness to participate, are invited to participate in this study. at the same time, employees in the health unit, such as recorders, cleaners and porters, students, and those not willing to participate or provided incomplete data, were excluded from the study. sample size the sample size calculator arrived at 195 participants, using a margin of error of ± 7%, a confidence level of 95%, and a 50% response distribution [24]. non-response correction = 10%. thus, the total sample size was (195+20) 215. supervision during the data collection phase was ensured in all stages. after excluding six incomplete documents, the sample was 209 for final analysis. study instrument and data collection in this study, an earlier tried semi-structured and selfadministered questionnaire was modified and recruited to collect the data [3-13]. media such as whatsapp have been employed to distribute the google form link among social groups, including healthcare workers. the questionnaire was written in the english language, and then it was translated into the arabic language. fifteen respondents (not included in the study) were used to test pilot the study tool. the first page of the questionnaire contains full details of the purpose of the study and how to answer the questions, along with "assurance of the freedom to participate or withdraw and that all information and opinions submitted would be anonymous and confidential". moreover, there will be a consent form that must be signed before respondents are allowed to participate in the study. the questionnaire was divided into four sections. the first section was about the participants' social and demographic characteristics, including age, gender, marital status, place of residency, occupation, income level, and self-rated health status. the second, third, and fourth sections include 17,7,5 close-ended questions to test the healthcare knowledge, attitude, and practice about covid-19. independent variables for sociodemographic variables, gender was coded as one for females and zero for males. the age variable was reported in five groups: "25–34", "35-44", "45-54", "55-64", and ">64" years old. moreover, the age was categorized into two categories: zero for less than 45 years and one for 45 years and above. marital status was captured as binary, and a value of one was used for married and zero for otherwise (unmarried). place of residency coded as zero for rural and one for urban. monthly income (iraqi dinar (iqd)1 = united state dollar (usd) 0.0008, the exchange rate on october 15, 2020) was divided into two categories: less than usd 400 and more than usd 400. the occupation was recorded and coded into "one" for doctors (physician, dentist, pharmacist) and the code of "zero" for axillary staff (nurses, laboratory scientists, etc.). years of experience categorized into "less than ten years" and has given the code of “zero” and code of “one” has given to the experience of “10 years and above”. the self-rated health status was reported on a scale ranging from "very bad" to "very good," a scale ranging from "1" to "5". moreover, the self-rated health status was categorized into poor health (very bad, bad, moderate) and good health (good and very good). dependent variables three options, "true/false/i do not know," were appointed to determine the answers have given in response to knowledgerelated questions. each correct response was given a "1" point code, while the incorrect and unknown responses were given "0" points. the overall knowledge score ranged from zero to 17, with higher scores indicating better knowledge of covid-19. items were evaluated for internal reliability using cronbach's alpha. cronbach's alpha coefficient was 0.72, indicating internal reliability. likert scale was recruited to calculate the respondents’ answers on the questions related to attitude toward covid-19: "1=strongly disagree, 2=disagree, 3=undecided, 4=agree, and 5=strongly agree". scores were calculated by averaging respondents’ answers to the seven statements. total scores ranged from seven to 35, with high scores indicating positive attitudes. the likert scales were assessed for internal reliability, using cronbach’s alpha. cronbach's alpha coefficient was 0.78, indicating internal reliability. the options "yes" or "no" allowed respondents to rank their practice toward covid-19 infection. each answer that reflected good practice was given one score, and a score of zero was given for answers that reflected bad practice. the total score ranged from zero to five, with high scores indicating better practices. al-rawi ra, journal of ideas in health (2022); 5(1):643-648 645 statistical analysis univariate analysis was recruited to tabulate the frequency of social and demographic statistics. numerical variables like age were summarized using mean and standard deviation. age was further categorized during the analysis. categorical variables such as gender, age group, marital status, tribe, profession, denomination, and years of experience were summarized using frequency and percentages. an independent sample t-test was used to assess differences in mean values for kap scores. a multivariable linear regression analysis was performed to identify knowledge, attitudes, and practice factors. all analyses were conducted using spss version 16. results sociodemographic factors a total of two hundred and nine respondents were included in the study. most of them were men (60.8%), aged less than 45 years (53.1%), married (74.2%), and residents in the urban region (64.6%). doctors (physicians, dentists, and pharmacist) constitute more than half (54.5%) of the surveyed sample, with a monthly income of usd 400 and above (61.7%), and 75.1% of them perceived their health good (table 1). table 1: social and demographic characteristics of the study participants (n=209) variables category number (%) gender male 127 (60.8) female 82 (39.2) age group < 45 years 111 (53.1) 45 years and more 98 (46.9) marital status married 155(74.2) single 54 (25.8) area residence urban 135 (64.6) rural 74 (35.4) occupation doctors 114(54.5) axillary staff 95(45.5) years of experience ten years and more 126 (60.3) <10 years 83 (39.7) level of income $ 400 and above 129(61.7) $ <400 80 (38.3) self-rated health status good health 157 (75.1) poor health 52 (24.9) descriptive statistics of kap scores as shown in table 2, the knowledge score (14.43 ± 2.01, range: 0-17) having an overall 85.12% (14.47/17*100) of correct rate was significantly varied across residency occupation, years of services, income level, and self-ranked health status (p <0.05). the mean attitude score for covid-19 was 27.68 (sd = 2.74, range: 7-35), indicating positive attitudes and significantly varied across gender (p <0.05). the mean score for practices for covid-19 was 4.33 (sd = 0.97, range: 0–5), indicating good practices and significantly varied across marital status and years of services (p <0.05). kap scores by social and demographic characteristics table 3 presents the mean of kap scores towards covid-19 by different social and demographic characteristics in iraq. knowledge scores significantly differed across occupation, years of services, income level, and self-ranked health status. gender has been shown as an influential factor in attitude scores, while marital status and years of service influenced the practice scores (p <0.05). regression results of kap-related factors regression analysis showed that doctors (p-value = 0.000, <0.05), aged 45 years and above (p-value=0.008, <0.05) and urban residents (p-value=0.007, <0.05) were significantly associated with upper knowledge score. female gender is significantly associated with positive attitude scores. regarding practice score, married (p-value = 0.038, <0.05), and those with experience of 10 years and above (p-value=0.041, <0.05) had better practice (table 4). discussion the healthcare workers in anbar province showed high awareness of the covid-19 epidemic. the correct answer rate on the knowledge side was 85.12%, with a positive attitude (79.10%) and adequate use of preventive practices (86.60%). participants in our study demonstrated a good knowledge of the clinical symptoms related to covid-19 infection, such as high fever, cough, fatigue or myalgia, and shortness of breath. moreover, most of them were well aware of the effectiveness of hygiene principles such as wearing medical masks, regular hand washing, use of sanitizer, isolation from patients, self-isolation in homes, maintaining social distancing, and covering mouth and nose during coughing and sneezing as effective means to prevent and limit the spread of the coronavirus. similar findings were reported in several earlier studies conducted in baghdad [25] and in other different countries such as nigeria [4], saudi arabia [5], nepal [6], south korea [7], chine [8], ethiopia [9], pakistan [10], egypt [11], greece [12], and vietnam [13]. when the study samples were collected, coronavirus information constantly spread globally across various social media. therefore, the closest explanation for the encouraging results in this study is the multiplicity of information sources with the keenness of healthcare workers to learn about the pandemic and take the necessary protection measures at the personal and societal levels. unsurprisingly, older doctors, dentists, and pharmacists demonstrated greater knowledge about covid-19 than their fellow health care workers. this can be attributed to many reasons, including the curriculum, the accumulated experience, and the scientific dilemma related to coronavirus. moreover, it is the professional responsibility of the doctors to be familiar with the characteristics of the disease, the ways of transmission, and how to protect people from being contracted. our findings align with an earlier study conducted in lebanon [26]. the authors found that physicians aged 40 and over were 2.16 times more likely to have good knowledge than physicians under 40. in the linear regression analysis, women showed a more positive attitude (p=0.022) toward covid-19 than men. several previous studies [14-16,27-31] reported higher morbidity and mortality rates among men than women. peckham et al. [28] found that the likelihood of needing an intensive therapy unit is approximately three times higher for men than for women. the results of our study coincide with the results of previous studies conducted by galasso et al. [30] and de la vega et al. [31], which confirmed that women take the covid-19 pandemic more seriously and adhere to the standards of protection from the coronavirus more than men. al-rawi ra, journal of ideas in health (2022); 5(1):643-648 646 table 2: number of questions, range, scores, and levels of knowledge, attitude, and practice variables number of questions range of score total scores (mean ± sd) accuracy rate (%) knowledge 17 0-17 14.43± 2.01 85.12 attitude 7 7-35 27.68 ± 2.74 79.10 practice 5 0-5 4.33 ± 0.97 86.60 table 3: kap scores by sociodemographic and economic characteristics (n=209) variables categories total (%) knowledge score (mean ± sd) pvalue attitude score (mean ± sd) pvalue practice score (mean ± sd) p-value gender male 127 (60.8) 14.34 ±2.30 0.235 27.35 ±2.71 0.026 4.26±1.01 0.165 female 82 (39.2) 14.69±1.79 28.21 ±2.72 4.45±0.85 age < 45 years 111 (53.1) 14.26±1.95 0.115 27.82 ±2.68 0.448 4.36±0.95 0.688 45 and above 98 (46.9) 14.72±2.28 27.53 ±2.81 4.31±1.00 marital status married 155(74.2) 14.61±2.18 0.139 27.64 ±2.62 0.685 4.25±1.04 0.023 unmarried 54 (25.8) 14.11±1.90 27.81 ±3.09 4.59±0.69 residency urban 135 (64.6) 14.89±2.00 0.000 27.47 ±2.81 0.121 4.31±0.99 0.633 rural 74 (35.4) 13.72±2.12 28.08 ±2.57 4.38±0.93 occupation doctors 114 (54.5) 15.87±0.79 0.000 27.76 ±2.75 0.649 4.25±1.08 0.190 axillary staff 95(45.5) 12.71±1.64 27.59 ±2.73 4.43±0.82 years of services ten years and above 126 (60.3) 14.13±1.90 0.035 27.69 ±2.71 0.927 4.22±1.09 0.039 <10 years 83 (39.7) 14.71±2.22 27.66 ±2.70 4.51±0.72 income level $ 400 and above 129 (61.7) 14.70±2.02 0.039 27.64 ±2.79 0.746 4.32±0.95 0.748 < $ 400 80 (38.3) 14.11±2.23 27.76 ±2.66 4.36±1.00 self-ranked good health 157 (75.1) 14.78±2.03 0.000 27.63±2.76 0.624 4.29±1.01 0.280 health status poor health 52 (24.9) 13.56±2.13 27.85 ±2.71 4.46±0.83 table 4: regression results of kap-related factors for covid-19 (n=209) variable b se beta t p-value 95% ci tolerance vif lower-upper knowledge (durbin-watson= 1.865) doctors (vs axillary staff) 3.101 0.179 0.770 17.334 0.000 (2.748,3.453) 0.927 1.079 45 and above (vs < 45 years) 0.309 0.178 0.077 1.735 0.008 (0.042,0.659) 0.934 1.071 urban (vs rural) 0.343 0.189 0.082 1.809 0.007 (0.031,0.716) 0.896 1.116 attitude (durbin-watson= 1.798) female (vs male) 0.912 0.396 0.163 2.304 0.022 (0.131,1.692) 0.940 1.064 practice (durbin-watson= 1.754) married (vs unmarried) 0.277 0.159 0.125 1.739 0.038 (0.037,0.590) 0.908 1.007 10 years and above (vs < 10 years) 0.209 0.142 0.105 1.467 0.041 (0.072,0.489) 0.951 1.105 in line with previous studies [14,16, 32], regression analysis showed that married (p=0.038) and those who have experience of 10 years and above (p=0.038) showed an optimistic attitude towards the covid-19 pandemic. moreover, senior health professionals have acquired the skills and knowledge to act wisely when dealing with health crises such as the covid-19 pandemic [33]. shi et al. [8] found that among the determinants of knowledge, attitude, and practice toward the covid-19 were practical experience and continuous training. the study complained of some limitations, including the cross-sectional study design, which cannot establish a causal relationship between the variables. the study was conducted in one iraqi province; therefore, the results would not be nationally generalized. the web-based study may be subject to response bias because the author does not have information on nonresponders, especially those who have difficulty accessing the internet. conclusion in conclusion, iraq healthcare workers in anbar province had adequate knowledge, attitude, and practice towards the covid19 pandemic. in the regression analysis, age, gender, marital status, place of residence, occupation, years of experience, and income, were the most determinants of knowledge, attitudes, and practices toward the coronavirus. doctors (physician, dentist, and pharmacist) showed higher knowledge levels than nurses and auxiliary staff. therefore, we suggest that the health directorate take additional measures to train and qualify all employees to prepare for emergencies and face any environmental or health disaster. al-rawi ra, journal of ideas in health (2022); 5(1):643-648 647 abbreviation covid-19: coronavirus disease 2019, kap: knowledge, attitude and practice; icrc: the international red cross and red crescent; psu: postgraduate studies unit; iqd: iraqi dinar; usd: united state dollar declaration acknowledgment the authors would like to express gratitude to all respondents who agreed to participate in this study. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing ruyasaeed73@gmail.com authors’ contributions ru’ya abdulhadi al-rawi is the responsible for the concept, design, literature search, data analysis, and data acquisition, manuscript writing, editing, and reviewing. author has read and confirmed the final draft. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the ethical protocol was approved by the ethics committee of the scientific issues and postgraduate studies unit (psu), college of medicine, university of anbar (ref: sr/368 at 19-july-2020). moreover, web-based informed consent was obtained from each participant after explaining the study objectives and the guarantee of secrecy. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of family and community medicine, faculty of medicine, anbar university, iraq. article info received: 15 february 2022 accepted: 14 march 2022 published: 21 march 2022 references 1. world health organization, who director-general's opening remarks at the media briefing on covid-19 march 11, 2020. available from: https://www.who.int/director-general/speeches/detail/whodirector-general-s-opening-remarks-at-the-media-briefingon-covid-19---11-march-2020 [accessed on october 25, 2020]. 2. ali jadoo sa. the second wave of covid-19 is knocking at the doors: have we learned the lesson? journal of ideas in health. 2020 oct. 8;3(special1):183-4. doi: 10.47108/jidhealth.vol3.issspecial1.72. 3. lake ea, demissie bw, gebeyehu na, wassie ay, gelaw ka, azeze ga. knowledge, attitude and practice towards covid-19 among health professionals in ethiopia: a systematic review and meta-analysis. plos one. 2021 feb 19;16(2): e0247204. doi: 10.1371/journal.pone.0247204. 4. mbachu cnp, azubuike cm, mbachu ii, ndukwu ci, ezeuko ay, udigwe ib, nnamani cp, umeh um, ezeagwuna da, onah sk, eze ho, okereke uc, orjiifeanyi en. covid-19 infection: knowledge, attitude, practices, and impact among healthcare workers in a south-eastern nigerian state. j infect dev ctries. 2020 sep 30;14(9):943-952. doi: 10.3855/jidc.13248. pmid: 33031078. 5. asdaq smb, imran m, alshrari as, imran m, sreeharsha n, sultana r. knowledge, attitude and practices of healthcare professionals of riyadh, saudi arabia towards covid-19: a cross-sectional study. saudi j biol sci. 2021 may 24. doi: 10.1016/j.sjbs.2021.05.036. 6. tamang n, rai p, dhungana s, et al. covid-19: a national survey on perceived level of knowledge, attitude and practice among frontline healthcare workers in nepal. bmc public health 2020; 20(1): 1905. https://doi.org/10.1186/s12889-020-10025-8 7. lee m, kang ba and you m. knowledge, attitudes, and practices (kap) toward covid-19: a cross-sectional study in south korea. bmc public health 2021; 21(1): 295.24. https://doi.org/10.1186/s12889-021-10285-y 8. shi y, wang j, yang y, wang z, wang g, hashimoto k, zhang k, liu h. knowledge and attitudes of medical staff in chinese psychiatric hospitals regarding covid-19. brain behav immun health. 2020 apr; 4:100064. doi: 10.1016/j.bbih.2020.100064. 9. malik ur, atif n, hashmi fk, saleem f, saeed h, islam m, jiang m, zhao m, yang c, fang y. knowledge, attitude, and practices of healthcare professionals on covid-19 and risk assessment to prevent the epidemic spread: a multicenter cross-sectional study from punjab, pakistan. international journal of environmental research and public health. 2020; 17(17):6395. https://doi.org/10.3390/ijerph17176395 10. abdel wahed wy, hefzy em, ahmed mi, hamed ns. assessment of knowledge, attitudes, and perception of health care workers regarding covid-19, a crosssectional study from egypt. j community health. 2020 dec;45(6):1242-1251. doi: 10.1007/s10900-020-00882-0. al-rawi ra, journal of ideas in health (2022); 5(1):643-648 648 11. papagiannis d, malli f, raptis dg, papathanasiou iv, fradelos ec, daniil z, rachiotis g, gourgoulianis ki. assessment of knowledge, attitudes, and practices towards new coronavirus (sars-cov-2) of health care professionals in greece before the outbreak period. int j environ res public health. 2020 jul 8;17(14):4925. doi: 10.3390/ijerph17144925. 12. huynh g, nguyen mq, tran tt, nguyen vt, nguyen tv, do tht, nguyen phn, phan thy, vu tt, nguyen tnh. knowledge, attitude, and practices regarding covid-19 among chronic illness patients at outpatient departments in ho chi minh city, vietnam. risk manag healthc policy. 2020 sep 14; 13:1571-1578. doi: 10.2147/rmhp.s268876. 13. ali jadoo sa, alhusseiny a, yaseen s, al-samarrai m, al-rawi r, al-delaimy a, abed m, hassooni h. knowledge, attitude, and practice toward covid-19 among iraqi people: a web-based cross-sectional study. journal of ideas in health2020;3(special2):258-65. doi: 10.47108/jidhealth.vol3.issspecial2.59 14. ali jadoo sa, dastan i, al-samarrai m, yaseen s, abbasi a, alkhdar h, al saad m, danfour o. knowledge, attitude, and practice towards covid-19 among syrian people resident in turkey. journal of ideas in health 2020;3(special2):278-85. 15. ali jadoo sa, danfour o, zerzah m, abujazia m, torun p, al-samarrai m, yaseen s. knowledge, attitude, and practice towards covid-19 among libyan peoplea webbased cross-sectional study. journal of ideas in health 2021;4(special1):348-56. doi: 10.47108/jidhealth.vol4.issspecial1.97 16. kalliath j, kizhatil a, rose b, kuncheria a, john a. knowledge, attitude, and practice regarding covid-19 pandemic among medical students of ernakulam, india. journal of ideas in health 2021;4(special1):337-42. doi: 10.47108/jidhealth.vol4.issspecial1.103 17. world health organization, early covid-19 preparation saved lives in iraq. available from: http://www.emro.who.int/irq/iraq-news/early-covid-19preparation-saved-lives-in-iraq.html [accessed on october 25, 2020]. 18. ali jadoo sa, alhusseiny a, yaseen s, al-samarrai m, mahmood a. evaluation of health system in iraq from people’s point of view: a comparative study of two different eras. journal of ideas in health 2021;4(2):380-8. doi: 10.47108/jidhealth.vol4.iss2.100 19. mustafa salim and louisa loveluck, "iraqi hospitals become nexus of infection as coronavirus cases rise dramatically among doctors", in the washington post, june 19 2020, https://wapo.st/3dfewnx. 20. the international red cross and red crescent (icrc), violence against health workers must cease to help contain covid-19 emergency, august 09, 2020. https://www.icrc.org/en/document/violence-against-healthworkers-must-cease-to-help-contain-covid-19-emergency 21. ali jadoo sa, torun p, dastan i, al-samarrai m. impact of conflict related and workplace related violence on job satisfaction among physicians from iraq a descriptive cross-sectional multicentre study. journal of ideas in health 2018;1(1):14-2. https://doi.org/10.47108/jidhealth.vol1.iss1.4. 22. al-samarrai ma, ali jadoo sa. iraqi medical students are still planning to leave after graduation. journal of ideas in health 2018;1(1):23-8. https://doi.org/10.47108/jidhealth.vol1.iss1.5 23. raosoft, sample size calculator. available from: http://www.raosoft.com/samplesize.html?nosurvey [accessed on 06-october 2020]. 24. alshatari sa-h, al kazzaz hh. knowledge, attitude, and practice of medical staff toward covid-19: sample from baghdad. european journal of molecular & clinical medicine, 2020; 7(10): 117-129. 25. abou-abbas l, nasser z, fares y, chahrour m, el haidari r, atoui r. knowledge and practice of physicians during covid-19 pandemic: a cross-sectional study in lebanon. bmc public health. 2020 sep 29;20(1):1474. doi: 10.1186/s12889-020-09585-6. 26. jin jm, bai p, he w, wu f, liu xf, han dm, liu s, yang jk. gender differences in patients with covid-19: focus on severity and mortality. front public health. 2020 april 29; 8:152. doi: 10.3389/fpubh.2020.00152. 27. peckham h, de gruijter nm, raine c, radziszewska a, ciurtin c, wedderburn lr, rosser ec, webb k, deakin ct. male sex identified by global covid-19 metaanalysis as a risk factor for death and itu admission. nat commun. 2020 december 09;11(1):6317. doi: 10.1038/s41467-020-19741-6. 28. adeyemo o, sofoluwe n, ganiyu y, ibrahim o, oyeyinka o. sex differences on the contextual factors and physical activity levels among the nigerian people during the covid-19. journal of ideas in health 2021;4(1):293-7. https://doi.org/10.47108/jidhealth.vol4.iss1.85 29. scully ep, schumock g, fu m, massaccesi g, muschelli j, betz j, klein ey, west ne, robinson m, garibaldi bt, bandeen-roche k, zeger s, klein sl, gupta a; jhcrown registry team. sex and gender differences in covid testing, hospital admission, presentation, and drivers of severe outcomes in the dc/maryland region. medrxiv [preprint]. 2021 apr 7:2021.04.05.21253827. doi: 10.1101/2021.04.05.21253827. 30. galasso v, pons v, profeta p, becher m, brouard s, foucault m. gender differences in covid-19 attitudes and behavior: panel evidence from eight countries. proc natl acad sci u s a. 2020 nov 3;117(44):27285-27291. doi: 10.1073/pnas.2012520117. 31. de la vega r, ruíz-barquín r, boros s, szabo a. could attitudes toward covid-19 in spain render men more vulnerable than women? global public health. 2020 sep;15(9):1278-1291. 32. bekele f, sheleme t, fekadu g, bekele k. patterns and associated factors of covid-19 knowledge, attitude, and practice among general population and health care workers: a systematic review. sage open med. 2020 november ;8: 2050312120970721. doi: 10.1177/2050312120970721 https://doi.org/10.47108/jidhealth.vol5.iss2.223 yahyaa bt, et al., journal of ideas in health 2022;5(2):673-678 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author (s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access knowledge and attitude of iraqi women in reproductive age group about risk factors in pregnancy badeaa thamer yahyaa1*, mahasin ali altaha1, ru’ya abdulhadi al-rawi1, mustafa ali mustafa alsamarrai1, saad ahmed ali jadoo2 abstract improved knowledge among women about maternal risk factors significantly reduced the likelihood of adverse events in pregnancy and childbirth. this study aimed to explore iraqi women's knowledge and attitudes about maternal risk factors in pregnancy. a multicenter cross-sectional survey was conducted from 01 january to 31 march 2019 among women of the reproductive age (15-49 years). a convenient sampling technique using a semi-structured questionnaire was recruited to interview the sample. spss version 16.0 was used to analyze the data. descriptive and inferential statistics (chi-square test) were used to present data with the significance level considered at <0.05. data of 250 women underwent final analysis. the mean age of respondents was 27.76 (±6.3 years). most of the respondents (79.9%) correctly knew the maternal risk factors in pregnancy. a large percentage of women knew that poor nutrition, anemia (95.6%), smoking and passive smoke (95.6%), and obesity (85.2%) during pregnancy are risk factors affecting the fetus’ health. however, about 40.0% of women thought there was no harm during pregnancy, and therefore there was no need for medical check-ups regularly. in bivariate analysis, there was a significant association between knowledge and level of education. the higher the level of education, the greater the women's knowledge about risk factors such as malnutrition and anemia (p=<0.001), obesity (p=0.04), diabetes (p=0.002), repeated urinary tract infection (p=0.017), rh incompatibility (<0.001), history of previous cesarean section (p=0.010), smoking and passive smoking (p=0.014) and evidence of bleeding (p=0.001). in conclusion, iraqi pregnant women demonstrated a good level of knowledge about the risk factors during the pregnancy. keywords: knowledge, attitude, reproductive age, risk factors, pregnancy, women, al-falluja, iraq background undoubtedly, increased knowledge among women about risk factors during pregnancy reduces mortality and morbidity among mothers and children. pregnancy is an excellent opportunity to adopt a healthy lifestyle that can benefit mothers and newborns. age is one of the most important determinants and risk factors for pregnancy. teens under 15 are at high risk of gestational complications such as preeclampsia, anemia, premature delivery, low birth weight, and congenital fetal anomalies [1]. on the other hand, pregnancy over the age of 35 is associated with worse outcomes and is treated as a high-risk pregnancy due to the potential for a higher rate of chronic. medical conditions. combined age-related factors, such as reduced fertility, genetic risks, miscarriage, and stillbirth, can make it more difficult for a woman to get pregnant [2]. adequate nutrition is a fundamental cornerstone of any individual's health, especially critical for pregnant women because inadequate nutrition affects women's health and their children's health. children of malnourished women are more likely to face cognitive impairments, short stature, lower resistance to infections, and a higher risk of disease and death [3,4]. according to the world health organization, many women do not get enough micronutrients in their diets during reproductive age and pregnancy, contributing to about one-third of all child deaths and impairing their development [5]. moreover, the significant consequence of nutritional insufficiency is obesity. during pregnancy, there are many complications associated with obesity, such as first and thirdtrimester miscarriage, preeclampsia, gestational diabetes, failure ___________________________________________________ med.badeaa.thamir@uoanbar.edu.iq 1department of family and community medicine, faculty of medicine, anbar university, anbar, iraq. a full list of author information is available at the end of the article. https://doi.org/10.47108/jidhealth.vol5.iss2.223 http://www.jidhealth.com/ yahyaa bt, et al., journal of ideas in health (2022); 5(2):673-678 674 to induce labor, and increased rates of cesarean sections [6]. over the last few decades, high blood pressure in pregnancy steadily increased. bateman et al. [7] reported that "1 in every 12 to 17 pregnancies" in the us develop high blood pressure between 20 to 44 years old. daviglus et al. [8] found that the prevalence is higher in rural areas, especially among the females in the reproductive age group. although high blood pressure is preventable and treatable during pregnancy, inappropriate diagnosis and treatment bear high risk for mothers and babies such as preeclampsia, eclampsia, stroke, and preterm delivery [9]. high blood sugar develops during pregnancy is called “gestational diabetes”. fortunately, it normally disappears after birth. the likelihood of having problems is significantly reduced when properly controlling the blood sugar levels. high blood sugar in the first weeks of pregnancyassociated birth defects, an increased risk of miscarriage, a high rate of cesarean sections, and postpartum complications. babies born to a woman with gestational diabetes are often much larger, a condition called ‘giantism’ [10]. pregnant women experience many hormonal and mechanical changes that enhance urinary stasis and vesicoureteral reflux. urinary tract infection (uti) is associated with pyelonephritis, preterm labor, low birth weight, and an increased risk of perinatal mortality [11]. having an rh-negative blood type requires special attention during each pregnancy. historically, rh-negative women were often at risk for miscarriage in the second or third trimester. it has become rare as pregnant rhnegative women are routinely given the rhogam injection to lessen this risk [12]. most women take some kind of drug or medication without realizing the potential for harm. some of these substances may cross the placenta and reach the developing fetus. the possible effects may include developmental delay “erotogenic”, intellectual disability, birth defects, miscarriage, and stillbirth, and the potential harm depends on the amount and frequency of use [13]. undergoing several abortions or enduring more than one miscarriage increase is the risk of problematic subsequent pregnancies. these women face higher chances of vaginal bleeding, preterm birth, low birth weight, and placenta complications [14]. smoking during pregnancy can lead to probable complications later on, so it is sensible to completely avoid any kind of exposure to smoking or passive smoking to reduce the worse consequences such as newborn low birth weight, congenital disabilities, premature labor, miscarriage, and sudden infant death syndrome [15]. this study aimed to determine the knowledge and attitude of women in the reproductive age group regarding the risk factors associated with pregnancy. methods study design a cross-sectional multicenter interview-based survey was conducted from 01 january to 31 march 2019. a convenient sample technique was used to collect the data from the outpatient gynecological services of four health centers located in al-falluja and baghdad, iraq. we conducted the research following the declaration of helsinki. the author conducted the research following the declaration of helsinki. the study's protocol was approved by the ethics committee of the faculty of medicine, university of anbar, 2019. moreover, informed consent was obtained from each participant after explaining the study objectives and the guarantee of secrecy. inclusion and exclusion criteria all the iraqi pregnant women of the reproductive age (15-49) and willing to participate have been included. women aged out of the reproductive life, unable to answer the questionnaire, and not willing to participate have been excluded from the study. sample size according to a local study conducted by al abedi ga et al. [16], the knowledge of pregnant women about the risk of pregnancy in iraq was 42.0% in 2019. the sample size calculator arrived at 257 participants, using a margin of error of ±6.0%, a confidence level of 95%, and a 42.0% response distribution. study instrument and data collection a semi-structured questionnaire was developed to interview the participants. the questionnaire was divided into three sections: first sections: socio-demographic data including age, marital status, occupation, level of education, number of children, number of abortions, and number of dead children. for analysis, the education variable was categorized as either “mild education” for illiterate women, “moderate education” for those who can read and write or in the primary and intermediate school, and “high education” for those who were in secondary school or undergraduate level. second sections: twelve close-ended questions to assess the knowledge of women about pregnancy-related risk factors such as the effect of nutritional state, obesity, hypertension, diabetes miletus, urinary tract infection, abo and rh system blood group, non-prescribed drugs, and smoking. third section: five closed-ended questions to assess a woman’s attitude towards pregnancy, such as harm caused by pregnancy, regular check-ups with doctors, and attention to doctors’ advice regarding nutrition and pregnancy planning. statistical analysis the univariate analysis is presented in the form of mean, standard deviation (sd), and percentage. bivariate analysis using the chi-square test was performed to evaluate the association between the women’s knowledge (yes and no) and the education level of respondents (mild, moderate, and high). a p-value of ≤ 0.05 was considered statistically significant. the statistical analysis was carried out by using spss 16. results socio-demographic, obstetrics, and gynecology characteristics out of 257 respondents, the data of 250 respondents have undergone the final analysis. women were of the reproductive age (15-49) with a mean age of 27.76 ± 6.3 years. most of the respondents (21.6%) in the age group (30-34 years) were married (96.8%), highly educated (34.0%), housewives (83.2%), and primiparous women (22.4%). about 21.2% experienced abortion, and 9.2% had a child death (table 1). yahyaa bt, et al., journal of ideas in health (2022); 5(2):673-678 675 table 1: socio-demographic, obstetrics, and gynecology characteristics of the study sample (n=250) variables categories n % age (years) mean ± sd 27.76 ± 6.3 <20 years 18 7.2 20 – 24 years 70 28 25 – 29 years 75 30 30 – 34 years 54 21.6 35 – 39 years 14 5.6 40 years and above 19 7.6 social status of women married 242 96.8 widow 7 2.8 divorced 1 0.4 education of women illiterate 18 7.2 read & write 24 9.6 primary 33 13.2 intermediate 50 20 secondary 40 16 university 85 34 occupation of women housewife 208 83.2 employed 42 16.8 parity (0) 68 27.2 1 56 22.4 2 51 20.4 3 39 15.6 4 18 7.2 5+ 18 7.2 abortion 53 21.2 child deaths 23 9.2 the knowledge regarding risk factors in pregnancy a high percentage (79.9%) of women showed good knowledge of pregnancy-related risk factors. about half of them (50.6%) knew that the pregnancy at the age above the 35years causes congenital anomalies, compared to 73.2% of them who knew that pregnancy at age 15 or younger puts the life of the mother and fetus at risk and the possibility of a cesarean section. most mothers knew the leading risk factor during pregnancy. more than ninety percent agreed that malnutrition (95.6%) causes preterm labor, smoking (95.6%) is harmful to the health of the fetus, and those who experienced previous abortion or cesarean section (90.8%) are more likely to need frequent doctor visits. more than eighty percent of mothers knew using drugs not prescribed by the doctor during pregnancy may cause fetus malformations (89.2%), obesity (85.2%) may cause complications during pregnancy, bleeding at the beginning or during pregnancy may cause abortion (86.0%) and, the repeated urinary tract infection during pregnancy is a risk factor (82.0%). more than seventy percent of mothers knew that high blood pressure during pregnancy could cause maternal death (76.0%), and parents' rh-group incompatibility (70.8%) may expose the fetus to fall or deformation. about 63.9% know that diabetes can cause miscarriage (table 2). table 2: women’s knowledge about risk factors during pregnancy (n=250) no. questions categories no. % 1. pregnancy with an age greater than 35 years may lead to fetal abnormalities. yes 127 50.8 no 123 49.2 2. the malnutrition and anemia of the pregnant woman result in low birth weight or premature birth. yes 239 95.6 no 11 4.4 3. high blood pressure during pregnancy can cause maternal death. yes 190 76.0 no 60 24.0 4. obesity in the pregnant mother may cause complications during pregnancy. yes 213 85.2 no 37 14.8 5. diabetes during pregnancy may cause miscarriage or the birth of a large-weight child. yes 159 63.6 no 91 36.4 6. pregnancy at the age of 15 or less presents the life of the mother and fetus at risk and the probability of a cesarean section. yes 183 73.2 no 67 26.8 7 repeated urinary tract infection during pregnancy or swollen feet is a risk factor for pregnancy. yes 205 82.0 no 45 18.0 8 if the mother's blood type is negative and the father is cheerful (rh incompatibility), the fetus is exposed to fall or deformation. yes 177 70.8 no 73 29.2 9 the doctor's use of drugs not prescribed during pregnancy presents the fetus with malformations. yes 223 89.2 no 27 10.8 10 if the mother has projections or a previous cesarean section, she needs frequent doctor reviews. yes 227 90.8 no 23 9.2 yahyaa bt, et al., journal of ideas in health (2022); 5(2):673-678 676 11 smoking and passive smoking are harmful to fetal health. yes 239 95.6 no 11 4.4 12 any bleeding at the beginning or during pregnancy is a risk factor. yes 215 86.0 no 35 14 women’s attitude towards some risk factors during pregnancy the women’s attitudes toward some risk factors during pregnancy showed that about forty percent agreed that they do not find harm in pregnancy every year and thought it was unnecessary to regularly visit the doctor or health care center when the pregnancy is normal. a large proportion (92.0%) of women agreed to visit the doctor immediately if they had bleeding during pregnancy. moreover, eighty-eight percent agreed that pregnant women should follow the doctor’s advice on nutrition during pregnancy. about twothirds of pregnant women agreed on four or fewer children (table 3). table 3: attitude of women towards some risks with pregnancy (n = 250) questions categories n % do not find harm in pregnancy every year. agree 101 40.4 disagree 149 59.6 i do not think it is necessary to check the doctor or care regularly when my pregnancy is normal. agree 103 41.2 disagree 147 58.8 follow the doctor's advice on nutrition during pregnancy. agree 221 88.4 disagree 29 11.6 see your doctor immediately if you have bleeding during pregnancy. agree 230 92.0 disagree 20 8.0 have four or fewer children. agree 196 67.6 disagree 81 32.4 association between women’s knowledge and the educational level bivariate analysis showed a significant association between knowledge and level of education. the high educated women have significantly more knowledge than the mild and moderate educated women in terms of knowing the impact of malnutrition and anemia (p<0.001), obesity (p=0.039), diabetes mellitus (p=0.002), repeated urinary tract infection(p=0.017), parents’ rh incompatibility (p=<0.001), history of previous cesarean section (p=0.010), and bleeding during pregnancy (p=0.014), respectively (table 4). table 4: association between women's knowledge about risk factors in pregnancy and the educational level (n=250) questions knowledge mild n(%) moderate n(%) high n(%) *p-value age of pregnant women ˃35 years yes 34(13.6) 47(18.8) 46(18.4) 0.274 no 4(16.4) 43(17.2) 39(15.6) malnutrition and anemia during pregnancy yes 66(26.4) 88(35.2) 85(34.0) <0.001 no 9(3.6) 2(0.8) 0(0.0) obesity of the pregnant mother yes 38(15.2) 85(34.0) 90(36.0) 0.039 no 10(0.4) 18(7.2) 9(3.6) diabetes mellitus during pregnancy yes 19(7.6) 90(36.0) 50(20.0) 0.002 no 40(16.0) 21(8.4) 30(12.0) age of pregnant women 15 years or less yes 83(33.2) 45(18.0) 55(22.0) 0.180 no 34(13.6) 20(8.0) 13(5.2) repeated urinary tract infection during pregnancy yes 65(26.0) 50(20.0) 90(36.0) 0.017 no 25(10.0) 5(2.0) 15(6.0) parents’ rh incompatibility yes 75(30.0) 80(32.0) 22(8.8) <0.001 no 25(10.0) 18(7.2) 30(12.0) using drugs not prescribed by the doctor during pregnancy yes 73(29.2) 100(40) 50(20.0) 0.768 no 12(4.8) 7(2.8) 8(3.2) mothers have a previous cesarean section. yes 88(35.2) 44(17.6) 95(38.0) 0.010 no 16(6.4) 2(0.8) 5(2.0) smoking and passive smoking yes 95(38.8) 89(35.6) 60(24.0) 0.014 no 6(2.4) 5(2.0) 0(0.0) bleeding at the beginning or during pregnancy yes 35(14.0) 89(35.6) 91(36.4) no 15(6.0) 11(4.4) 9(3.6) yahyaa bt, et al., journal of ideas in health (2022); 5(2):673-678 677 discussion in this study, we tried to assess the knowledge and attitude of iraq women toward pregnancy-related risk factors. our target population was the pregnant women of the reproductive age (15-49 years) attending four outpatient clinics in al-falluja and baghdad city. most of our respondents (30.0%) were in the age group (25-29 years), and 7.6% were aged 40 and above, which is lower than that reported by espansito et al. [17] and mastroiacvone et al. [18]. moreover, the percentage of highly educated women was higher than that reported by earlier studies from nepal [19] and sudan [20]. however, most of our respondents were housewives (83.2%) because of fewer chances for employment in iraq [4], especially among the families exposed to internal displacement [21,22]. most of the respondents were multiparous women. a similar finding was reported in a previous study in iraq, confirming that the average iraqi family is seven members [23]. in this study, most respondents had good knowledge (79.9%) about the main risk factors in pregnancy. indeed, the findings showed that most surveyed samples knew that malnutrition, obesity, smoking, diabetes, and bleeding were pregnancy-related risk factors. similarly, findings were reported in other studies in italy [24] and the usa [25], indicating that smoking is the risk factor affecting pregnancy. shub et al. [26] found that pregnant women have adequate knowledge about the association of obesity with pregnancy complications [26]. regarding knowledge of women about risk factors in pregnancy, almost 96.5% of all respondents knew malnutrition and anemia in pregnant women might lead to low birth weight or premature birth. our results were higher than those reported by eniolorunda et al. [27] in nigeria (36.7%) but lower than that reported by ghimire and pande (98.0%) [19]. likewise, to the finding reported by mahejabin et al. [28] in bangladesh, our respondents showed excellent knowledge that a mother who has a history of abortion and cesarean section should do frequent doctor's visits for antenatal care. moreover, uzun et al. [29] indicated that fear is one of the important motives behind the woman's desire to undergo tests. a large percentage of women knew that using a drug during pregnancy without a doctor's advice and pregnancy with age greater than 35 years might lead to fetus malformation (89.6%) compared to findings reported by eniolorunda et al. [27]. in light of the attitude of women towards the risk factors in pregnancy, about sixty percent of them were worried about the liability of harm to their fetus or newborn baby and the necessity to contact healthcare providers during the pregnancy. however, still, forty percent did not care for harm and refused to see doctors when the pregnancy was normal. such a finding is probably due to the lower education of surveyed women. our result disagrees with findings reported elsewhere in nigeria [27]. furthermore, 88.4% of women agreed to follow the doctor's advice on nutrition during pregnancy, reflecting high awareness regarding their nutrition. moreover, about 67.0% of them favored having four children or fewer, reflecting a good attitude. however, long-term development programs such as integrated management of neonate and child health are ideal for enhancing women's education and children's health protection [30]. this study complained about several limitations, including the cross-sectional design. bias in data collection is liable because of the face-to-face interview. this study also had a small sample selected from a few centers. therefore, the findings may not be generalizable. nevertheless, our results may help evaluate the knowledge and attitude of an important segment of iraqi society. conclusion in conclusion, the findings of this study showed that pregnant women had adequate knowledge regarding most of the pregnancy-related risk factors, including smoking, obesity, and malnutrition in pregnancy. forty percent of the women expressed a lack of knowledge of the risks of pregnancy and did not bother to see doctors during pregnancy. therefore, it is crucial and effective to implement measures to promote appropriate behaviors in women before pregnancy, including assessing pregnant women's knowledge and behaviors about key risk factors. abbreviation uti: urinary tract infection; sd: standard deviation declaration acknowledgment we would like to thank all the participants for their responses and insight during the data collection process. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing med.badeaa.thamir@uoanbar.edu.iq. authors’ contributions all authors equally contributed to the concept, design, literature search, data analysis, data acquisition, manuscript writing, editing, and reviewing. all authors have read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the study protocol was approved by the ethics committee of the faculty of medicine, university of anbar (2019). all patients gave written informed consent. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author (s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of family and community medicine, faculty of medicine, anbar university, anbar, iraq.2department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey. article info received: 16 april 2022 accepted: 13 may 2022 published: 15 may 2022 references 1. cary e, seladi j. teenage pregnancy, and health line media. healthline, on 30 july 2018. available from: https://www.healthline.com/health/adolescent-pregnancy yahyaa bt, et al., journal of ideas in health (2022); 5(2):673-678 678 2. braveman fr. pregnancy in patients of advanced maternal age. anesthesiol clin. 2006 sep;24(3):637-46. doi: 10.1016/j.atc.2006.05.002. 3. elder l, ransom e. nutrition of women and adolescent girlswhy it matters. 21 july 2003. available from: https://www.prb.org/resources/nutrition-of-women-andadolescent-girls-why-it-matters/ 4. al-samarrai m, al-rawi r, yaseen s, ali jadoo s. knowledge, attitude, and practice of mothers about complementary feeding for infants aged 6-12 months in anbar province, iraq. journal of ideas in health 2020;3(1):125-9. https://doi.org/10.47108/jidhealth.vol3.iss1.17 5. world health organization, malnutrition, key facts; 09 june 2021. available from: https://www.who.int/news-room/factsheets/detail/malnutrition 6. wolfe kb, rossi ra, warshak cr. the effect of maternal obesity on the rate of failed induction of labor. am j obstet gynecol. 2011 aug;205(2): 128.e1-7. doi: 10.1016/j.ajog.2011.03.051. 7. bateman bt, shaw km, kuklina ev, callaghan wm, seely ew, hernandez-diaz s. hypertension in women of reproductive age in the united states: nhanes 1999-2008external icon. plos one. 2012;7(4): e36171. 8. daviglus mi, stamler j, pizzada a, yan ll, garside db, et al. favorable cardiovascular risk profile in young women and long term risk of cardiovascular and all-cause mortality, jama,2004; 292:158 – 1592. 9. center for disease control and prevention, high blood pressure during pregnancy. available from: https://www.cdc.gov/bloodpressure/pregnancy.htm [accessed on 02 september 2021] 10. centers for disease control and prevention. diabetes during pregnancy. available from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/diab etes-during-pregnancy.htm 11. kalinderi k, delkos d, kalinderis m, athanasiadis a, kalogiannidis i. urinary tract infection during pregnancy: current concepts on a common multifaceted problem. j obstet gynaecol. 2018 may;38(4):448-453. doi: 10.1080/01443615.2017.1370579. 12. danielsson k. did my miscarriage happen because i'm rhnegative? very well family. updated on 07 december 2019. available from: https://www.verywellfamily.com/can-being-rhnegative-cause-a-miscarriage-2371474 13. ross e, graham d, money k, et al. developmental consequences of fetal exposure to drugs: what we know and what we still must learn. neuropsychopharmacology.2015; 40: 61–87. https://doi.org/10.1038/npp.2014.147 14. gerdts c, dobkin l, foster dg, schwarz eb. side effects, physical health consequences, and mortality associated with abortion and birth after an unwanted pregnancy. womens health issues. 2016 jan-feb;26(1):55-9. doi: 10.1016/j.whi.2015.10.001. 15. rabinerson d, from a, borovich a. [active and secondhand (passive) smoking during pregnancy]. harefuah. 2020 jul;159(7):503-507. 16. al abedi ga, arar aa, radhi ta. assessment of knowledge for pregnant women toward risk of pregnancy in al-amara primary health care centers at southern iraq. indian journal of public health research & development. 2019;10 (6): 931-935. 17. esposito g, ambrosio r, napolitano f, di giuseppe g. women's knowledge, attitudes and behavior about maternal risk factors in pregnancy. plos one. 2015 dec 29;10(12):e0145873. doi: 10.1371/journal.pone.0145873. 18. mastroiacovo p, nilsen rm, leoncini e, gastaldi p, allegri v, boiani a, et al. prevalence of maternal preconception risk factors: an italian multicenter survey. ital j pediatr. 2014 nov 23; 40:91. doi: 10.1186/s13052-014-0091-5. 19. chimire n, panchy n. knowledge and practice of mothers regarding preventing anemia during pregnancy in teaching hospital kathmandu. jcmc.2013; 3(5): 14 –17. 20. ahmed kym, elbashir imh, ibrahim sm, et al., knowledge attitude and practice of perception care among sudanese women in reproductive age about rheumatic heart disease. international journal public health research.2015;3(5): 223 – 227. 21. al-samarrai mam, alany bn, al-delaimy ak, yahyaa bt, ali jadoo sa. impact of internal displacement on psychosocial and health status of students residing in the hostel of anbar university, iraq. jidhealth [internet]. 2020 may 25 [cited 2022 may 14];3(1):140-4. doi: 10.47108/jidhealth.vol3.iss1.25 22. ali jadoo sa, sarhan yt, al-samarrai mam, al-taha ma, al any bn, soofi ak, yahyaa bt, al-rawi ra. the impact of displacement on the social, economic and health situation on a sample of internally displaced families in anbar province, iraq. jidhealth [internet]. 2019 may 8 [cited 2022 may 14];2(1):56-9. doi: 10.47108/jidhealth.vol2.iss1.16 23. yahyaa bt, al-samarrai mam, ali jadoo sa. prevalence and perception of women about consanguineous marriage in alramadi city. indian journal of public health research and development 2019;10(4): 567-573. 24. esposito g, ambrosio r, napolitano f, di giuseppe g. women's knowledge, attitudes and behavior about maternal risk factors in pregnancy. plos one. 2015 dec 29;10(12):e0145873. doi: 10.1371/journal.pone.0145873. 25. frey ka, files ja. preconception healthcare: what women know and believe. matern child health j.2006; 10: s73–s77. 26. shub a, huning ey, campbell kj, mccarthy ea. pregnant women's knowledge of weight, weight gain, complications of obesity and weight management strategies in pregnancy. bmc res notes. 2013; 6:278. doi: 10.1186/1756-0500-6-278 27. eni-olorunda t, akinbode oo, akinbode ao. knowledge and attitude of mothers on risk factors influencing pregnancy outcomes in abeokuta south local government area, ogun state. european scientific journal2015; 11(11); 1857 -7881. 28. mahejabin f, parveen s, sajani tt. (2017). ante-natal care practices in some selected rural areas of bangladesh. anwer khan modern medical college journal2017; 7: 6-11. 29. uzun a, öztürk g, bozkurt z, çavuşoğlu m. investigating of fear of covid-19 after pregnancy and association with breastfeeding. journal of ideas in health 2021;4(1):327-33. https://doi.org/10.47108/jidhealth.vol4.iss1.98 30. al-samarrai ma, ali jadoo sa. impact of training on practical skills of iraqi health providers towards integrated management of neonate and child health a multicentre cross-sectional study. journal of ideas in health2018;1(1):1-6. https://doi.org/10.47108/jidhealth.vol1.iss1.2 ali a, et al., journal of ideas in health 2020;3(4):254-257 © the author(s). 2020 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access to which extent a convalescent plasma therapy could be a benefit for covid-19 patients? abdelmonem ali1, ahmed abuelhassan1, ebtehal fawzi1, alfatih aboalbasher2, sheima elbasheer3, nagia suliman4*, alaa elhussein5, mayada ali6 abstract the emergence of an unprecedented pandemic sars-cov-2 caused perplexed in the medical community because of a high infection rate and rising mortality among covid-19 patients. till now, there is no particular treatment for the disease; nevertheless, there is an extensive effort from scientists to find out an immediate therapeutic plan to show how to deal with the current situation. one of the solutions currently presented is convalescence plasma (cp). through this narrative review, we will shed light on cp's efficiency as a therapeutic agent for covid-19, especially there is no proven vaccine or antiviral available up to date. cp could be considered one of the therapeutic approaches, but some limitations are still considered before it is established as a therapeutic agent. along with evaluating cp from blood donors, the plasma companies could take future steps by manufacturing a target dose of globulins that contain standardized antibody, to reach the terms of health setting administering therapy. keywords: convalescence plasma, covid-19, transfusion, neutralizing antibodies, sudan background in the time of covid-19, where coronavirus disease has spread severe respiratory distress symptoms caused by sars-cov-2 are considered a newly emerged beta coronavirus responsible for covid-19. it was first reported in wuhan, china, in december 2019, when around 81 767 cases with 3281 deaths have been recorded [1]. later in march, the who proclaimed covid-19 a pandemic disease when it appeared in approximately 195 countries [2]. the mechanism of the pathogenesis of covid-19 infection has not been fully clarified [3]. there is no proven vaccine or therapy for covid-19 until now. the disease's clinical management protocol recommended by who focuses on infection prevention, monitoring, and detection [4]. despite the continued lack of accuracy and transparency about the covid-19, scientists are still trying to figure out ideal strategies to develop a treatment for covid-19. one of the promising strategies is convalescent plasma therapy (cpt). up to date, using cpt for covid-9 patients has been demonstrated in multiple studies to reduce the mortality rate in this unprecedented pandemic situation. the investigators in these studies relied on the fact that the cpt is not a new technique, its efficacy and safety had already been tested in other causative agents similar to sars-cov-2, despite the presence of a few difference between sars-cov-2 and other types of coronavirus, but the mechanism of cp could be the same. [5,6,7]. the issue of using the convalescent plasma has grown in importance in light of pandemic covid-19, especially in the absence of availability of vaccine or other treatment, so in the current review, we will attempts to discuss the desired benefits and some limitation of cpt. previous utilization of convalescent plasma convalescent plasma (cp) therapy is known for a long time and was used for many viral and bacterial diseases. previously cp used to treat patients with various viral infections, such as treating the spanish flu in 1918, h1n1 infection in 2009, ebola patients in 2014, and middle east respiratory syndrome (mers) in 2015 [8,9,10]. thereby, cp was suggested as one of the therapeutic options for covid‐19 patients [11]. the cpt mechanism is based on plasma transfusion from recovered individuals (who are harmful to covid‐19) to patients with covid-19 [12,13]. this transfusion is considered as a type of passive immunity, whereas the plasma transfused from patients recovered to patients exposed to the same virus (the plasma contains a neutralizing antibodies (nabs)) (figure 1) [14,15]. ___________________________________________________ nagiasuliman@hotmail.com 4department of clinical chemistry, college of medical laboratory science, al gezira university, sudan full list of author information is available at the end of the article http://www.jidhealth.com/ ali a, et al., journal of ideas in health (2020); 3(4):254-257 255 this therapy's efficacy has been associated with the concentration of nabs in plasma from recovered donors [16]. the neutralizing antibodies against sars-cov-2 that has been isolated from donors may serve as a promising intervention to sars-cov-2 (figure 2) [17]. discussion donors of cp should fulfill the standard eligibility requirements [18], in accordance with the national guide on preparation, in addition to following the recommendations from an accredited agency such as who. multiple published studies have discussed cp antibodies' ability to viremia clearance, some of these studies support using cpt for covid-19, but before starting the process of plasma transfusion, all precaution rules should be applied strictly [19,20]. for instance, sudan is one of the developing countries that struggle against the spreading of covid-19. one of the sudanese studies reported the benefits of using convalescent plasma to treat covid-19 symptomatic patients. this study has mentioned that specific criteria should be followed for both patient and donor before starting the process of transfusion. one of the cp transfusion criteria from a donor, the donor, should be free from sars-cov-2 infection at the time of plasma transfusion. on the other hand, one of the most important cp transfusion criteria to a patient is that the patient should have a clear symptomatic and confirmed diagnosis for covid-19 depending on the official sudanese therapeutic protocol for covid -19. furthermore, this study recommended using cpt in covid-19 sudanese patients at least currently is considered an available costless therapeutic option, especially all other covid-19 therapeutics alternatives still under investigation studies [21]. neutralizing antibodies in donor convalescent sera could be used for critical covid-19 patients as recommended in one of the previous issues by the food and drug administration [22,23,24]. however, the similarity between some human amino acid sequences with sars-cov-2 sequence could unintentionally way induce the autoimmune system [25]. hence, a rapid vaccination strategy is needed to study interference between viral particles and human molecules to avoid an undesired self-immunity reaction, especially for those who suffer from previous medical history with autoimmune disease. up to date, a few original practical studies used cpt for covid-19 patients, but noteworthy still, the validation of the efficacy of cp is a controversial issue between supporters and opponents. despite this, some reports reveal less hospitalization and a low mortality rate among patients who have been given convalescent plasma [26]. challenges facing the use of convalescent plasma dante mário and his colleagues had mentioned that there are some challenges when we were thinking of using convalescent plasma therapy for covid -19 patients. some of these challenges are: a. is the convalescent plasma transfusion being more protective if compared with other antiviral treatments? b. which one is more effective for patients, plasma from donors who have no symptoms or plasma from donors with symptoms? c. what is the best time to transfuse plasma to covid-19 patients, in other words, early-stage or late-stage? some previous studies have also mentioned that there are expected complications accompanied by plasma transfusions, such as circulatory overload, anaphylactic reactions, and alloimmunization [27]. these are logical questions that need to be answered before starting accrediting plasma as an acceptable treatment for covid-19. the current status of therapeutic efforts made with covid-19 until the time of writing the current manuscript, the medical scientists are working day and night to find an effective and suitable vaccine for controlling the deadly covid-19. most vaccine clinical trials platforms are done in developed countries, such as the usa, uk, germany, russia, and china. it seems there is an unprecedented race between these countries, which country would be the first one to produce an effective and safe covid-19 vaccine for the entire world. instead of racing between vaccine production companies, it would be better if there are information exchange and collaboration to help reach wisdom decision regarding covid-19 [28]. global cooperation will help avoid and repeat the mistakes made at the beginning of the covid-19 crisis due to a lack of information transparency [29]. however, till that time, when the effective and trust vaccine appears and could apply confidently for patients, cpt is considered an optimal and available option for covid-19. ali a, et al., journal of ideas in health (2020); 3(4):254-257 256 conclusion to sum up, based on the previously published data, the cpt could be an efficient option, at least in the current time, to minimize the morbidity and mortality rate of patients with covid-19. however, the extreme benefit of using cpt for covid-19 still needs tremendous investigation. as it is recommended, it would be better if used a well-designed study such as controlled experiments with large sample size. abbreviation ards: acute respiratory distress syndrome; covid-19: corona virus disease of 2019; cp: convalescence plasma; cpt: convalescent plasma therapy; fda: food and drug administration; hi1n1: influenza a virus subtype; mers: middle east respiratory syndrome; nabs: neutralizing antibodies; sars: severe acute respiratory syndrome. declaration acknowledgement our great thanks to the sudanese medical laboratory technologist in oman (smlto) for their logistic support. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing nagiasuliman@hotmail.com authors’ contributions ahmed abuelhassan (aa), ebtehal fawzi (ef), alfatih aboalbasher (aa), sheima elbasheer (se), nagia suliman (ns), alaa el-hussein (ae), mayada ali (ma) have contributed equally to the study concept, design, writing of original draft. abdelmonem ali (aa) has reviewed and edited the manuscript. all authors read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, review articles need no ethics committee approval. consent for publication not applicable competing interest the author declares that he has no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of clinical chemistry, college of medical laboratory science, alneelain university, sudan. 2department of hematology, college of medical laboratory science, university of alzaiem al azhari, sudan. 3department of microbiology, college of medical laboratory science, university of alzaiem al azhari, sudan. 4department of clinical chemistry, college of medical laboratory science, al gezira university, sudan. 5department of hematology and immunohematology, sudan university of science and technology, sudan. 6department of medical microbiology, college of medical laboratory science, al gezira university, sudan. article info received: 10 october 2020 accepted: 01 november 2020 published: 24 november 2020 references 1. owji h, negahdaripour m, hajighahramani n. immunotherapeutic approaches to curtail covid-19. int immunopharmacol. 2020; 88:106924. https://doi.org/10.1016/j.intimp.2020.106924 2. shen c, wang z, zhao f, yang y, li j, yuan j, et al. treatment of 5 critically ill patients with covid-19 with convalescent plasma. jama.2020;323(16):1582-1589. https://doi.org/10.1001/jama.2020.4783 3. nagoba b, gavkare a, jamadar n, mumbre s, selkar s. positive aspects, negative aspects and limitations of plasma therapy with special reference to covid-19. j infect public health. 2020 sep 01. https://doi.org/10.1016/j.jiph.2020.08.011 4. yılmaz s, örüç ne, özcebe oi, azap a, çetin at, yenicesu i, et al. regulatory consideration on preparation and clinical use of covid-19 convalescent plasma. transfusion and apheresis science. 2020;59(5):102846. https://doi.org/10.1016/j.transci.2020.102846 5. casadevall a, pirofski la. the convalescent sera option for containing covid-19. j clin invest. 2020 apr 1;130(4):15451548. https://doi.org/10.1172/jci138003 6. roback jd, guarner j. convalescent plasma to treat covid-19: possibilities and challenges. jama. 2020 apr 28;323(16):15611562. https://doi.org/10.1001/jama.2020.4940 7. chen l, xiong j, bao l, shi y. convalescent plasma as a potential therapy for covid-19. lancet infect dis. 2020 apr;20(4):398-400. https://doi.org/10.1016/s14733099(20)30141-9 8. perotti c, del fante c, baldanti f, franchini m, percivalle e, vecchio nepita e, seminari e, de silvestri a, bruno r, klersy c. plasma from donors recovered from the new coronavirus 2019 as therapy for critical patients with covid-19 (covid-19 plasma study): a multicentre study protocol. intern emerg med. 2020 aug;15(5):819-824. https://doi.org/10.1007/s11739-020-02384-2 9. abolghasemi h, eshghi p, cheraghali am, imani fooladi aa, bolouki moghaddam f, imanizadeh s, et al. clinical efficacy of convalescent plasma for treatment of covid-19 infections: results of a multicenter clinical study. transfus apher sci. 2020; 59(5):102875. https://dx.doi.org/10.1016%2fj.transci.2020.102875 10. al-tawfiq ja, arabi y. convalescent plasma therapy for coronavirus infection: experience from mers and application in ali a, et al., journal of ideas in health (2020); 3(4):254-257 257 covid-19. hum vaccin immunother. 2020 sep 3:1-7. https://doi.org/10.1080/21645515.2020.1793712 11. ye m, fu d, ren y, wang f, wang d, zhang f, xia x, lv t. treatment with convalescent plasma for covid-19 patients in wuhan, china. j med virol. 2020:10.1002/jmv.25882. https://doi.org/10.1002/jmv.25882 12. syal k. covid-19: herd immunity and convalescent plasma transfer therapy. j med virol. 2020 apr 13:10.1002/jmv. 25870. https://doi.org/10.1002/jmv.25870 13. majbour n, el-agnaf o. plasma-derived therapy: can the survivors of covid-19 help the defenseless? diagnosis (berl). 2020 nov 18;7(4):373-376. https://doi.org/10.1515/dx-2020-0053 14. kumar s, sharma v, priya k. battle against covid-19: efficacy of convalescent plasma as an emergency therapy. am j emerg med. 2020 jun 2: s0735-6757(20)30465-4. https://dx.doi.org/10.1016%2fj.ajem.2020.05.101 15. islam a, rafiq s, karim s, laher i, rashid h. convalescent plasma therapy in the treatment of covid-19: practical considerations: correspondence. int j surg. 2020; 79:204-205. https://doi.org/10.1016/j.ijsu.2020.05.079 16. zhao q, he y. challenges of convalescent plasma therapy on covid-19. j clin virol. 2020 jun; 127:104358. https://doi.org/10.1016/j.jcv.2020.104358 17. cao y, su b, guo x, sun w, deng y, bao l, et al. potent neutralizing antibodies against sars-cov-2 identified by highthroughput single-cell sequencing of convalescent patients’ b cells. cell, 2020. 182(1):73-84. e16. https://doi.org/10.1016/j.cell.2020.05.025 18. epstein j, burnouf t. points to consider in the preparation and transfusion of covid-19 convalescent plasma. vox sang. 2020 aug;115(6):485-487. https://doi.org/10.1111/vox.12939 19. duan k, liu b, li c, zhang h, yu t, qu j, et al. effectiveness of convalescent plasma therapy in severe covid-19 patients. proc natl acad sci u s a. 2020 apr 28;117(17):9490-9496. https://doi.org/10.1073/pnas.2004168117 20. focosi d, anderson ao, tang jw, tuccori m. convalescent plasma therapy for covid-19: state of the art. clin microbiol rev. 2020 aug 12;33(4): e00072-20: https://doi.org/10.1128/cmr.00072-20 21. hassan mo, osman, aa, abd elbasit he, hassan he, rufai h, satti mmm, et al. convalescent plasma as a treatment modality for coronavirus disease 2019 in sudan. transfusion and apheresis science. 2020:102918. https://doi.org/10.1016/j.transci.2020.102918 22. lee wt, girardin cg, dupuis ii ap, kulas ke, payne af, et al. neutralizing antibody responses in covid-19 convalescent sera, the journal of infectious diseases.2020; jiaa673. https://doi.org/10.1093/infdis/jiaa673 23. han g, zhou y-h. thinking more about therapy with convalescent plasma for covid-19 patients. human vaccines & immunotherapeutic. 2020. https://doi.org/10.1080/21645515.2020.1787073 24. franchini m. why should we use convalescent plasma for covid-19? eur j intern med. 2020 jul; 77:150-151. https://doi.org/10.1016/j.ejim.2020.05.019 25. anand p, puranik a, aravamudan m, venkatakrishnan aj, soundararajan v. sars-cov-2 strategically mimics proteolytic activation of human enac. elife. 2020 may 26;9: e58603. https://doi.org/10.7554/elife.58603 26. joyner mj, bruno ka, klassen sa, kunze kl, johnson pw, lesser er, et al. safety update: covid-19 convalescent plasma in 20,000 hospitalized patients. mayo clin proc.2020;95(9):18881897. https://doi.org/10.1016/j.mayocp.2020.06.028 27. kakaiya r, campbell-lee s. plasma transfusion: current status and future directions. transfusion. 2012;52 suppl 1:1s: https://doi.org/10.1111/j.1537-2995.2012.03625.x 28. katib a. research ethics challenges during the covid-19 pandemic: what should and what should not be done. journal of ideas in health2020;3(special1):185-187. https://doi.org/10.47108/jidhealth.vol3.issspecial1.49 29. ali jadoo sa. was the world ready to face a crisis like covid19? journal of ideas in health2020;3(1):123-4. https://doi.org/10.47108/jidhealth.vol3.iss1.45 https://doi.org/10.47108/jidhealth.vol4.iss1.82 alhusseiny ah, et al., journal of ideas in health 2021;4(1):304-306 © the author(s). 2021 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access covid-19 in iraq: an estimated cost to treat patients at a private clinic adil hassan alhusseiny1, ismail ibrahim latif1, saad ahmed ali jadoo2* abstract the impact of the covid-19 pandemic extended to health, social and economic aspects of human life. the international failure to combat this crisis has left many countries suffering under the influence of successive waves of the pandemic. in this report, we present a private medical clinic's experience dealing with the covid-19 epidemic in iraq. the adopted protocol to treat covid-19 patients has briefly been discussed with an estimated cost of treatment in the private sector. we found that most covid-19 patients recovered from the disease, except for cases that were associated with co-morbidities. the cost of treatment in the private sector is expensive, and most infected people could not afford it without public sector support. keywords: covid-19, private clinic, interleukin-6, protocol, estimated cost, diyala, iraq background many cases of coronavirus infiltrated iraq early; however, the first case's official announcement was in the city of najaf in march 2020 [1]. most iraqis underestimated the epidemic and largely neglected prevention measures. among the iraqis, the infection was considered a social stigma that forced many to hide the infection [2]. such social behavior contributed to the worsening of the infected cases and the spread of the epidemic quietly and dramatically throughout the country. the world was not ready to deal with such a huge pandemic [3], especially in countries like iraq, where the health system is depleted and reeling under the influence of rampant corruption [4]. failure to comply with preventive measures has made the public health institutions an active source of transmitting the infection to the clients. most of the healthcare providers were infected with covid-19 and became a carrier of infection in their communities. most patients are reluctant to contact public health institutions and resort to private medical clinics for treatment away from the people's eyes and in search of safety and quality [5]. our private clinic was among several other working clinics in baquba city, diyala province, in the northeast of iraq. independently, out of 596, 193 [6] covid19 positive polymerase chain reaction (pcr) cases recorded in iraq up to 31st december 2020, we received more than two thousand patients over the period from april to the end of december 2020. our clinic had changed into a covid-19 clinic. like published worldwide data, the mortality and morbidity rates were highest at the old age group; however, many mortalities were reported in the younger age group. several reasons backed behind such high rates among iraqis, including the limited capacity of the public health institutions and the steady increase in the prevalence of covid-19 infection. many families were forced to provide medication and oxygen therapy (o2) to their patients at their expense, which constituted an additional burden on those with limited income. covid-19 is typically a biopsychosocial disease [7]. psychological difficulties and prolonged fatigue are seen in less than a third of our clinic patients. depression, sleeping difficulties, and anxiety are seen after recovering in about a fifth of patients regardless of age but correlated with lung involvement severity. depending on our experience in managing the covid-19 pandemic, patients presented with symptoms of an upper respiratory infection such as loss of smell and taste usually experience benign course compared to those presented with typical presentation such as high fever, shortness of breath, sore throat, cough, sneezing, runny nose, nasal congestion, sneezing, achy muscles, and headache. however, the more fatal and challenging situation when the infection progresses involves the lower respiratory system (airways and lungs). symptoms may worsen, such as "severe productive cough, shortness of breath, chest tightness”. we found that the pulmonary in situ vascular thrombosis is a significant cause of late after cure mortality, so we extended the course of anticoagulants eliquis (apixaban) and xarelto (rivaroxaban) up to 30 days to reduce the likelihood of blood clotting and systemic embolism. moreover, less likely cerebrovascular accident (cva) or peripheral arterial thrombosis have been seen, and there is no evidence of deep venous thrombosis (dvt) have noted. late or long-term ___________________________________________________ drsaadalezzi@gmail.com 1department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol4.iss1.82 http://www.jidhealth.com/ alhusseiny ah, et al., journal of ideas in health (2021); 4(1):304-306 305 sequelae has been reported among patients with prolonged hypoxia (weeks or months); however, no long-term fibrosis is seen in tuberculosis patients (tb) [8]. after six months from recovery, one patient still has exertional dyspnea and needs supplemental oxygen therapy at night. chest x-ray shows residual fibrotic lesions, suggesting the possibility of long-term sequences. however, some cases presented with gastroenteritis, however elevation in the liver enzymes' level is not uncommon, but less than four folds associated with epigastric pain and vomiting. additionally, when covid-19 being a systemic infection, some patients presented with arthritis, rash, pericardial effusion, severe hepatitis, nephritis, orchitis, thrombocytopenia, and urinary tract infection (uti). we here confirm what other literature indicated [9] that covid-19 is diabetogenic, especially with dexamethasone regardless the age. the risk of coronavirus infection doubles for diabetics, and at the same time, new cases of diabetes have been recorded and the emergence of severe complications in preexisting diabetes due to coronavirus infection. private medical clinic protocol to treat covid-19 patients there is no proven and effective antiviral therapy nor an efficient vaccine for covid-19 infection based on our knowledge. moreover, antibiotics are never of any benefit in changing the course of illness. the most effective interventions are actemra (tocilizumab), the interleukin-6 (il-6) receptor antagonists, convalescent plasma, anticoagulant, dexamethasone in addition to oxygen (o2) therapy. the il-6 has the potential of anti-cytokine storm ability by slowing down the systemic inflammatory response to viral infection in its early stages [10]. table 1 shows the general protocol used to treat covid-19 positive pcr cases. most private clinics are concerned with conducting clinical and physical examination only, while the rest of the medications and therapies are taken from private pharmacies. moreover, except for the pcr, and computed tomography (ct-scan) the patients depend on the private laboratories to perform the hematological, and the serological tests. however, several patients rely on private radiological clinics to confirm or exclude the covid-19 via ct-scan when necessary. estimated cost to treat covid-19 patients at private clinics an average estimated cost was calculated for each covid-19 case treated in private clinics (table 1). the average cost for a patient treated from coronavirus in a range of five to ten days is approximately (iqd 573,228) (equivalent to usd 477.69, exchange rate 1 us dollar (usd)= iraqi dinar (iqd)1200 in november 2020 ). the cost is directly proportional to the period of treatment and the emergence of complications [11]. the patient who does not respond to simple protocol needs a more extended treatment period, such as continuous oxygen therapy for several weeks, or the need for further intervention, such as actimera infusion (il6 antagonist) when the il6 is extremely high. in such cases, the total cost may rise to iqd 3,173,232 (equivalent to usd 2,644.36) when meropenem injection and actimera infusion used to treat the severe and complicated cases. local governments in iraq provide free of charge oxygen for covid-19 patients, however, citizens must buy oxygen bottles on their expense. the cost of one empty oxygen bottle about iqd 20,000 (equivalent to usd 16.67) in the private sector. actimera infusion (il-6 antagonist) is a lifesaving in severe and deteriorated covid-19 cases, however, considering absence of the government support the drug is costly. a10 ml of actimera infusion may cost about iqd 2,250,000 (equivalent to usd 1875). the cost per doctor’s visit ranged between iqd 15,000 to 25,000 (equivalent to usd 12.5 to 20.83). nursing services for covid-19 patients are essential to follow the treatment protocol at home. the cost per nurse’s visit about iqd 5000 (equivalent to usd 4.16). this study complaint of several limitations. first, the lack of a national drug pricing policy in iraq, the diversity of drug sources, and the absence of quality control program allowed for a wide gap in treatment costs to emerge. therefore, the cost of treatment may change dramatically when the protocol switching from ceftriaxone injection to meropenem injection or when switching from a lesser quality product to a high-specification product. second, elderly patients with chronic diseases are more likely to have complications that require a more extended treatment period. moreover, some services are provided by the state for free, such as pcr, and ct-scan, and conversely, only the ct-scan costs about iqd 50,000 (equivalent to usd 41.67) in the private sector. third, all the information regarding cost prices is approximate, depending on the private pharmacies' pricing in iraq. fourth, the study did not include other incurred costs such as transportation costs, food, time, and the cost related to job absenteeism of patient; therefore, we cannot claim an economic evaluation. the need to reform the iraqi health system has become an urgent necessity through the implementation of effective health economic policies, such as the adoption of universal health insurance (uhi). moreover, technical, and clinical systems such as the diagnosis related group (drg) or case-mix are preferable systems that precisely detect the allocated cost per service and patient cost estimation [11,12]. conclusion more than 90.0% of the confirmed positive pcr covid-19 cases, which were undergone to management in our private clinic, made a full recovery at different times. however, very few real-second attacks have been recorded by new ct lesion after resolution and pcr positivity after becoming negative from the first attack. treating covid-19 patient in the private sector is expensive. there is a wide difference in the cost of treatment at the local level. the cost doubles with the length of treatment and the need for actimera infusion (il6 antagonist).we are dealing with a fierce enemy that arose in mysterious circumstances and had the ability to change and attack other times. therefore, what we say today about the way of dealing with, and the treatment protocol may change completely tomorrow. abbreviation covid-19: coronavirus; pcr: polymerase chain reaction; ct-scan: computed tomography; cva: cerebrovascular accident (cva); dvt: deep venous thrombosis; tb: tuberculosis; uti: urinary tract infection; o2: oxygen; il-6: interleukin-6; iqd: iraqi dinar; usd: united state dollar alhusseiny ah, et al., journal of ideas in health (2021); 4(1):304-306 306 table 1 an estimated cost to treat covid-19 patient at a private clinic in iraq declaration acknowledgment none. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing drsaadalezzi@gmail.com authors’ contributions authors are equally participated in this work. all authors have read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, the world report needs no ethics committee approval. consent for publication not applicable competing interest the authors declare that they have no competing interest. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of internal medicine, faculty of medicine, diyala university, iraq. 2department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey article info received: 10 october 2020 accepted: 25 december 2020 published: 18 march 2021 references 1. world health organization, early covid-19 preparation saved lives in iraq. available from: http://www.emro.who.int/irq/iraq-news/earlycovid-19-preparation-saved-lives-in-iraq.html [accessed on 25 october 2020]. 2. ali jadoo sa, alhusseiny a, yaseen s, al-samarrai m, al-rawi r, al-delaimy a, abed m, hassooni h. knowledge, attitude, and practice toward covid-19 among iraqi people: a web-based cross-sectional study. journal of ideas in health 2020;3(special2):258-65. https://doi.org/10.47108/jidhealth.vol3.issspecial%202.59 3. ali jadoo sa. was the world ready to face a crisis like covid-19? journal of ideas in health2020;3(1):123-4. https://doi.org/10.47108/jidhealth.vol3.iss1.45 4. ali jadoo sa, yaseen s, al-samarrai m, mahmood a. patient satisfaction in outpatient medical care: the case of iraq. journal of ideas in health2020;3(2):176-82. https://doi.org/10.47108/jidhealth.vol3.iss2.44 5. medecins sans frontiers, severe covid-19 patients in iraq “were almost sure to die”. available from: https://www.msf.org/worryingsituation-severe-covid-19-patients-baghdad-iraq. 6. worldometer, iraq. available from: https://www.worldometers.info/coronavirus/country/iraq/ [accessed on 05 january 2021] 7. ali jadoo sa. covid -19 pandemic is a worldwide typical biopsychosocial crisis. journal of ideas in health2020;3(2):152-4. https://doi.org/10.47108/jidhealth.vol3.iss2.58 8. cdc. late sequelae of covid-19. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/latesequelae.html [accessed on 18 january 2021] 9. rubino f, amiel sa, zimmet p, alberti g, bornstein s, eckel rh, et al. new-onset diabetes in covid-19. n engl j med. 2020;383(8):789790. https://doi.org/10.1056/nejmc2018688. 10. coperchini f, chiovato l, croce l, magri f, rotondi m. the cytokine storm in covid-19: an overview of the involvement of the chemokine/chemokine-receptor system. cytokine growth factor rev. 2020 jun;53:25-32. https://doi.org/10.1016/j.cytogfr.2020.05.003. 11. aljunid sm, ali jadoo sa. factors ınfluencing the total ınpatient pharmacy cost at a tertiary hospital in malaysia: a retrospective study. inquiry. 2018;55:46958018755483. https://doi.org/10.1177/0046958018755483. 12. ali jadoo sa, aljunid sm, nur am, ahmed z, van dort d. development of my-drg casemix pharmacy service weights in ukm medical centre in malaysia. daru j pharm sci 23, 14 (2015). https://doi.org/10.1186/s40199-014-0075-4 no. therapy indication dose given cost per item (iqd) duration total cost (iqd) total cost (usd) 1 paracetamol fever and aches 500mg x 3 750 ten days 2,250 1.88 2 metoclopramide injection nausea and vomiting 10 mg 1x 2 1,000 5 days 10,000 8.33 3 vitamin d3(cholecalciferol) supplementary 125mcg (50000 iu) x1 12,000 2-4 weeks 12,000 10.00 4 intravenous fluid dehydration and or diminished feeding n/s, gw5% (4 liters) 3,000 5 days 120, 000 100.00 5 rivaroxaban thrombosis prophylaxis 5-10 mg x 1 55,000 30 days 55,000 45.83 6 o2 therapy hypoxia on need 2,0000 on need 20,000 16.67 7 dexamethasone injection hypoxia 6 mg/2m i.v. 3,000 ten days 30,000 25.00 8 antibiotics: 8a ceftriaxone injection infection 1gram i.v. x 2 6,000 7 days 84,000 70.00 8b meropenem injection infection 1 gram i.v x 2 25,000 7 days 350,000 291.67 8c azithromycin (zithromax) infection 500 mg x 1 5,000 6 days 5,000 4.16 9 actimera infusion (il6 antiagonist) patient not responded, il6 is very high 20mg/ml (10 ml x 1) 1,000,0002,250,000 1-2 times (on need) 2,250,000 1,875.0 10 labrotuary tests full investigation repeated on need 120,000 100.0 11 chest x-ray anterior/ posterior 20,000 twice 40,000 33.33 12 fees paid to doctor per visit 20,000 twice 40,000 33.33 13 fees paid to nurses per visit 5,000 five times 35,000 29.16 https://doi.org/10.47108/jidhealth.vol5.iss2.215 hwaid ah, et al., journal of ideas in health 2022;5(2):685-692 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access prevalence of occult hepatitis b infection in diyala province, iraq ansam dawod salman1, iman abbas ali1, asmaa haseeb hwaid2* abstract background: occult hbv infection (obi) is the absence of hepatitis surface antigens (hbsag) that is not apparent during detection by serological tests despite the presence of virus dna. this study aimed to explore the prevalence of obi infection among various populations in diyala province, iraq. methods: a prospective cross-sectional study was conducted from 1st january to 30th september, 2021, at ibn sina dialysis center, baquba teaching hospital, iraq. three hundred and sixty participants were equally involved (90 individuals for each) from the dialysis department, the thalassemia department, blood bank donation centre, and the control group. study populations were screened for hbv ag, hbv c igg, hbv c igm, abusing the enzyme-linked immunosorbent assay (elisa) test, and detecting hb core gene. demographic data of the study group were recorded. descriptive analysis was done using spss version 25, and the p-value was considered significant wherever it was below 0.05. results: the positivity rate of serological markers of obi among the study population was (6.7%) of the participants were hbs ag positive. whereas 22 (6.1%) were anti-hbc igg positive and 3 (0.8%) were anti-hbc igm positive. the detection rates of the pcr products of 76 participants after amplification using specific primers for (core-gene) have been presented to the gel electrophoresis, which showed none of the 76 participants were positive for the hbc gene. conclusion: the current study showed a medium percentage of anti-hbc igg in the serum of the study groups without the presence of hbs ag, which indicates the presence of a previous infection that was resolved or the occurrence of occult hepatitis b infection. the current study results also showed that the serum of any of the study groups was not positive for the core gene, which confirms the possibility of infection with obi. keywords: occult hepatitis b virus, hbc igm, hbc igg, core gene, diyala, iraq background occult hbv infection (obi) is the absence of hepatitis surface antigens (hbsag) that is not apparent during detection by serological tests despite the presence of virus dna [1,2]. antihepatitis b virus in the serum of the sick person is an important factor for detection and tracking of obi cases. the prevalence of infection with occult hepatitis is affected by several factors such as geographical differences, the presence of co-morbidities such as chronic hepatitis c infection as well as the sensitivity of different diagnostic methods [3,4]. the prevalence of obi in iraq, especially in diyala province, was recorded in 3.9% of blood donors in 2012 [5], and 2014 [6], however the prevalence come up to 5.12% in 2018 [7]. findings from erbil city (north of iraq) showed that the seropositivity of obi was 39.1% (108/276) [8]. in basra city (south of iraq), the prevalence was 14.0% in hbc abs positive donors [9]. in nearby and abroad countries, the frequency of obi was reported at 0.0% in turkey and iran [10, 11] and 1.25 % in saudi arabia [12]. this study aimed to explore the prevalence of obi infection among various populations in diyala province, iraq. methods study design and sample in diyala province, east of iraq, a prospective cross-sectional study was conducted from 1st january to 30th september 2021. four study populations were included in the current study: a. ninety patients with renal failure who are regularly attending the ibn-sina dialysis center-diyala directorate of health for hemodialysis. ___________________________________________________ asmaa.haseeb@ymail.com 2department of biology, college of education for pure sciences, university of diyala, iraq. full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol5.iss2.215 http://www.jidhealth.com/ hwaid ah, et al., journal of ideas in health (2022); 5(2):685-692 686 b. ninety patients with beta-thalassemia who are regularly attending the blood specialist center-diyala directorate of health for treatment including blood transfusion. c. ninety blood donor individuals who are attending blood bank donation centre, diyala directorate of health. d. ninety healthy volunteers collected from the outpatient clinics of baquba teaching hospital as control. the participants were interviewed with a semi-structured questionnaire to collect information about their age, gender, place of residency, level of education, and hbv vaccination. detection of serological marker hbs ag (serum), anti-hbc igg, and anti-hbc igm this test was performed using a commercially available kit (dia.pro, italy hbs ag elisa). reactive results were indicated by the absorbance reading of 1.1 and above, while the non-reactive results were indicated by the absorbance reading of less than 0.9. nucleic acid extraction genomic dna was isolated from serum samples according to the protocol of the qiaamp® minelute® virus spin kit. primer sets of polymerase chain reaction (pcr) primers for the core hepatitis b virus gene have been used in the conventional pcr amplification to get pcr products used in the sequencing method for genotyping the virus and phylogenetic tree analysis. these primers were used for positive samples detected by the elisa test for detected hbvs ag, anti-hbc igg, and antihbc igm. primers were provided by macrogen/ korea and sequences (table 1). table 1: primers used for detection of hbv-core gene t y p e o f v ir u s t a r g e t g e n e p r im e r oligo sequence [5'-3'] a n n e a li n g t e m p e r a tu r e [o c ] p r o d u c t si z e [b p ] r e fe r e n c e h b v c o re f o rw a rd 1 5`-cag gtc ttg ccc aac gtc tta-3. ` 5 6 9 7 6 f a r o o q e t a l. , [4 0 ] h b v c o re r 1 5`-ctg tca gag ggc cca cat att -3. ` h b v c o re f o rw a rd 2 5`-gac cga cct tga ggc ata ttt-3. ` 6 5 7 9 0 h b v c o re r e v e rs e 2 5`-tcc cac ctt atg agt cca agg-3.` assay optimization following the optimization process of primer concentration, polymerase chain reaction detection hbv core gene was carried out. in order to detect “the optimum annealing temperature, gradient pcr was set at 56°c”. the best condition for the hbv was obtained, and then samples along with negative (water) and positive controls (previously known pcrpositive samples of hbv) were amplified. hbv core gene pcr detection procedures of molecular detection of hbv dna were carried out as follows: a. “an initial activation was set at 95°c/5 minutes, 40 cycles at 94°c/30 seconds, 56°c/30 seconds, and 72°c/30 seconds”. b. “the final extension step was of 72°c/10 minutes”. c. “semi-nest pcr amplifications were carried out which are similar to the first step using different reverse primers”. d. “hepatitis b virus genotyping was performed under the same conditions but using other primer pairs which targeted the s gene on hbv dna-positive samples”. all reactions were performed in duplicate and the presence of negative and positive controls. the final products were detected by electrophoresis on 2.0% agarose gel, and the size of the pcr statistical analysis statistical analysis was carried out using the statistical packages for social sciences (spss) version 25. description of data presented as frequency, percentage, mean, standard deviation, and range (minimum-maximum values). an independent student t-test, paired t-test and the anova test were recruited to compare between different means. the significance of the difference among different percentages was tested using the pearson chi-square test with the application of yate's correction or fisher exact test. statistical significance was considered whenever the p-value was equal to or less than 0.05. results serological markers the positivity rate of serological markers of hbv among the study population is shown in the table 2. twenty-four (6.7%) of the participants were hbs ag positive, 22 (6.1%) were antihbc igg positive and 3 (0.8%) were anti-hbc igm positive. hwaid ah, et al., journal of ideas in health (2022); 5(2):685-692 687 table 2: positivity rate of hbv and hcv serological markers marker status no. (%) hbsag positive 24 (6.7) negative 336 (93.3) anti-hb core igg positive 22 (6.1) negative 338 (93.9) anti-hb core igm positive 3 (0.8) negative 357 (99.2) distribution of serological markers according to study groups table 3 revealed that the hbs ag positivity rate among each group of participants (renal dialysis, thalassemia patients, blood donors, and healthy individuals) were 4.4%, 6.7%, 7.8%, and 7.8%, respectively. however, the difference among the study groups was statistically insignificant (p= 0.748). regarding the anti-hbc igg antibody, the results showed that the anti-hbc igg ab was positive among 16 (17.8%) of renal dialysis patients, and 6 (6.7%) of thalassemia patients. the difference was statistically significant (p= 0.0001). however, all individuals in the blood donors and healthy individuals were negative for this marker, and there was no statistical analysis could be applied. two (2.2%) of renal dialysis patients were positive of the anti-hbc igm ab and one (1.1%) of thalassemia patients. the difference was statistically insignificant (p= 0.296). again, none of the individuals in the blood donors and health groups were positive for anti-hbc igm ab, so statistical analysis could not apply. table 3: distribution of study groups according to serological markers (n=360) serological markers renal dialysis n=90 thalassemia n=90 blood donors n=90 control individuals n=90 p value hbsag n (%) n (%) n (%) n (%) positive 4 (4.4) 6 (6.7) 7 (7.8) 7 (7.8) 0.784 negative 86 (95.6) 84 (93.3) 83 (92.2) 83(92.2) anti-hbv core igg positive 16 (17.8) 6 (6.7) 0.0001* negative 74 (82.2) 84 (93.3) 90 (100) 90 (100) anti-hbv core igm positive 2 (2.2) 1(1.1) 0.296 negative 88 (97.8) 89 (98.9) 90 (100) 90 (100) relationship between hbs ag positivity rate and serological markers table 4 shows that out of 24 (6.7%) hbs ag positive participants 2 (8.3%) of them were also positive for anti-hbc igg ab compared to 22 (91.7%) of hbs ag positive participants were anti-hbc igg negative. moreover, 20(6.0%) of hbs ag negative participants were positive for anti-hbc igg ab, and 316 (94.0%) were negative for anti-hbc igg ab. the difference was statistically insignificant (p= 0.638). furthermore, none (0.0%) of the hbs ag positive participants were positive for anti-hbc igm ab, but all of them (24; 100%) were negative for anti-hbc igm ab. additionally, 3(0.9%) of hbs ag negative participants were anti-hbc igm positive compared to 333(99.1%) were negative for anti-hbc igm ab. the difference was statistically insignificant (p= 0.642). table 4: relationship between hbs ag positivity rate and serological markers (n=360) serological marker hbs ag positive n=24 (6.7%) hbs ag negative n=336(93.3%) pvalue n% n% anti-hbc igg positive 2(8.3) 20(6.0) 0.638 negative 22(91.7) 316(94.0) anti-hbc igm positive 3(0.9) 0.642 negative 24(100) 333(99.1) *significant difference between proportions using pearson chi-square test at 0.05 level. relationship between anti-hbc igg positivity rate and serological markers results in table 5 found that out of 22 (6.1%) of anti-hbc igg positive participants, 2 (9.1%) were hbs ag positive, while 20 (90.9%) were hbs ag negative. at the same time, among the 338(93.9%) of anti-hbc igg negative participants, 22(6.5%) were hbs ag positive, while 316 (93.5%) were hbs ag negative. the difference was statistically insignificant (p= 0.638). similarly, table 5 found that out of 22 (6.1%) of antihbc igg positive participants, 2 (9.1%) were anti-hbc igm positive, while 20 (90.9%) were anti-hbc igm negative. however, among the 338(93.9%) of anti-hbc igg negative participants, 1(0.3%) was anti-hbc igm positive, while 337 (99.7%) were anti-hbc igm negative. the difference was statistically significant (p= 0.0001). table 5: relationship between anti-hbc igg positivity rate and serological markers (n=360) serological marker anti-hbc igg positive n=22 (6.1%) anti-hbc igg negative n=338(93.9%) p-value n% n% hbs ag positive 2(9.1) 22(6.5) 0.638 negative 20(90.9) 316(93.5) anti-hbc igm positive 2(9.1) 1(0.3) 0.0001* negative 20(90.9) 337(99.7) *significant difference between proportions using pearson chi-square test at 0.05 level. hwaid ah, et al., journal of ideas in health (2022); 5(2):685-692 688 relationship between anti-hbc igm positivity rate and serological markers results in table 6 found that none (0.0%) of the 3 positive participants for anti-hbc igm (0.8%) was positive for hbs ag, and all of them were negative for anti-hbc igm. however, 24 (6.7%) of anti-hbc igm negative participants were positive for hbs ag compared to 333(93.3%) were negative for hbs ag. thus, the statistical comparison was inapplicable. the results also found that out of 3 (0.8%) of anti-hbc igm positive participants, 2 (66.7%) were positive for hbs ag, while 1 (33.3%) were hbs ag negative. however, among the 357(99.2%) of anti-hbc igm negative participants, 20(5.6%) were anti-hbc igg positive, while 337 (94.4%) were anti-hbc igg negative. the difference was statistically significant (p= 0.0001). table 6: relationship between anti-hbc igm positivity rate and serological markers (n=360) serological marker anti-hbc igm positive n=3 (0.8%) anti-hbc igm negative n=357(99.2%) p-value n (%) n (%) hbs ag positive 24(6.7) negative 3(100.0) 333(93.3) anti-hbc igg positive 2(66.7) 20 (5.6) 0.0001* negative 1(33.3) 337(94.4) molecular detection amplifying of hbv [core] gene by conventional pcr table 7 revealed the detection rates of the pcr products 76 participants after amplification using specific primers for (coregene) have been presented to the gel electrophoresis, which showed none of the 76 participants were positive for hbc gene. association positivity of anti-hbc igg with molecular marker table 8 illustrates the anti-hbc igg positivity rate distribution according to the molecular marker included in this study. about the hbc gene, the results found that the gene was undetectable neither among participants with positive anti-hbc igg nor those with anti-hbc igg negative; thus, no statistical analysis was applicable. association positivity of anti-hbc igm with molecular marker regarding the hb core gene and hcv core sc2 gene, the results found that neither anti-hbc igm positive nor anti-hbc igm negative participants had detected the hbv core gene and hcv core sc2 gene. thus, statistical comparisons were inapplicable. all details are shown in the table 9. table 7: detection rate of hbv and hcv genes among participants (n=360) genes status n (%) hbv core gene at 791bp detected not-detected 76 (21.1) not done 284 (78.9) table 8: association positivity of anti-hbc igg with a molecular marker (n=360) molecule marker anti-hbc igg positive n=22 anti-hbc igg negative n=338 p-value hb core gene at 791 bp n (%) n (%) detected not-detected 20 (90.9) 56(16.6) not done 2(9.1) 282(83.4) table 9: association positivity of anti-hbc igm with a molecular marker (n=360) molecule marker anti-hbc igm positive n=3 anti-hbc igm negative n=357 p-value hb core gene at 791 bp n (%) n (%) detected not-detected 3(100.0) 73 (20.4) not done 284 (79.6) discussion in this study the positivity rate of hbs ag was 6.7% which is higher than previous studies conducted in iraq that reported a positivity rate of 0.4%, 3.0%, 1.3%, 3.0%, and 0.7% respectively [7,14,15,16]. also, higher than the rates reported in iran (3.8%), saudi arabia (3.24%), and turkey (0.3%), respectively [17,18,19]. in our study the positivity rate of antihbc igg was 6.1% which is lower than earlier local studies conducted in diyala province (9.65%) and mosul province (8.3%) but higher than that rate reported in duhok province (3.49%) respectively [7,20,21]. moreover, the positivity rate of anti-hbc igg was lower than that reported in iran (11.6%), but higher than that reported in saudi arabia (0.28%) and turkey (1.2%), respectively [22,18,19]. like to rate reported in mosul (1.0 %) [23], the positivity rate for anti-hbc igm was 0.8%, but was lower than the rate reported among blood donors between 2011-2012 in diyala province (3.2%) [5]. also, our finding was lower than rates reported in iran (8.5%) [22], egypt (2.25%) [24], nigeria (5.8%) [25], and turkey (7.5%) [26], respectively. in the current study, hbs ag was detected in 4.4% of renal dialysis patients which is higher than the rates reported in a previous studies conducted in baghdad city (1.3%) [15] and in the duhok province by zana et al (3.49%) [21] and by ibrahim et al. (3.2%) [27]. however, the situation was completely different in mosul province; al-taan and khalid [20] found anti-hbs ag positive among 66.0% of examined hemodialysis (hd) patients. concerning the neighboring countries our result was higher than that reported by rastegarvand et al. [28] in iran and that reported by kizilates et al. [29] in turkey. the prevalence of hbsag among the thalassemia patients was 6.7%, which is higher than earlier local findings from mosul province (0.55%) [30], and babylon province (3.0%) [16]. also, the finding was higher than that reported by dumaidi et al. [31] among palestinian thalassemia patients (0.7%). additionally, out of ninety blood donors, 7 (7.8%) were positive for hbs ag, which was higher than previously hwaid ah, et al., journal of ideas in health (2022); 5(2):685-692 689 published studies in different provinces of iraq including diyala (0.4%) [7], duhok (0.24%) [32], and erbil (3.0 %) [8], respectively. moreover, our finding was higher than results from saudi arabia (3.24%) [18], and kuwait (3.5%) [33]. the current study found that renal dialysis patients' hbc igm and hbc igg positivity rates were 2.2% and 17.8%, respectively. similar local findings were found by al-taan gs, khalid md in mosul province [20] and by zana et al. [21] in duhok province of iraq. however, samadi et al. [34] reported an antihbc ab rate of 23.5% in iran. the rates of hbc igm and igg in our study were 1.1% and 6.7% among thalassemia patients, respectively. such findings were lower than the rates reported worldwide such as palestine (19.0%), nigeria (2.49%), and iran (4.33%), respectively [31,35,36]. however, local studies conducted by salim and abdullah [30] reported similar finding of 1.1% positivity rate of hbc ab among thalassemia patients in mosul province. while al-sharifi et al. [16] reported that 12.0% of thalassemia patients had a positive anti-hbc ab in babylon province of iraq. as for blood donor individuals, the current result was 0.0% for antihbc ab, however, other iraqi studies conducted in diyala province [7] and erbil province [8], reported 5.01% and 2.27% of anti-hbc ab positive rate, respectively. bahrami et al. [22] reported 11.6% of anti-hbc ab positive among blood donors in iran, while alzahrani et al. [18] reported 0.28% in saudi arabia. table (4) showed that among hbs ag positive participants (8.3%) and (0.0%) were positive for anti-hbc igg and antihbc igm, respectively, against (6.0%), (100%) of hbs ag negative participants were positive for anti-hbc igg ab and anti-hbc igm respectively. similarly, hassan et al. [7] reported 5.01% positive to anti-hbc igg and anti-hbc igm respectively among hbs ag positive participants in diyala province, east of iraq. however, our findings were different from study conducted by abdulla and goreal [37] in duhok city, north of iraq. authors reported 100% and 0.0% positive for anti-hbc igg and anti-hbc igm, respectively, among hbs ag positive participants [37]. also, our results differed from the study conducted by al-zubaidi et al. [38] in al-diwaniya, south of iraq. authors found that 12.0% and 10.0% positive for antihbc igg and anti-hbc igm, respectively, among hbs ag positive participants. additionally, our findings were consistent with some global studies in terms of the distribution of hbs ag positivity rate by anti-hbc igg and anti-hbc igm [24,39,40]. generally, the several agreed that the anti-hbc ab test increased the detection rate of hbv positive in the community. the reason might because uncovered the occult hbv infection, which gave hbsag negative, but they were positive for antihbc antibodies [41,42]. aiming to minimize the transfusion transmission risk of hbv, the current study and others are concordant that the addition of anti-hbc ab (igm or igg) test for screening policy of blood gives marvelous results [7,43]. actually, in diyala province, this decision was implemented in the local blood bank in 2014. among the fascinating results of this study is that out of 24 hbs ag positive participants 2 (8.3%) were positive for both hbs ag and anti-hbc igg, while 22(91.7%) were positive for hbs ag but negative for anti-hbc igg. additionally, none (0.0%) were positive for both hbsag and anti-hbc igm, but all the positive hbs ag (24, 100%) were negative for anti-hbc igm. so, there was a problem in diyala province called "occult hbv infection," and probably this problem became more prominent in high-risk groups. among such risky groups, this phenomenon may arise due to the pressure of hbv vaccination or anti-viral therapy. further serological or molecular studies are recommended in this respect. indeed, anti-hbc in the serum without serological hbs ag indicates occult hbv infection, as suggested by several studies [21,23,38,44]. the results in table (5) were consistent with other iraqi studies [21,23,38] that reported 50.0%, 10.0%, and 3.49% of participants with anti-hbc igg positive were hbs ag positive, respectively. moreover, other studies from poland [44] and saudi arabia [45] also reported similar results. it is well documented that participants presented with anti-hbc igg positive only indicating a previous infection with hbv. whereas hbs ag testing used to review acute and chronic hbv infection [38]. the presence of anti-hbc in the serum without serological hbsag is indicative of a resolved hbv infection. however, it is a sign of occult hbv infection, as suggested by several researchers [21,23,38,44,46]. findings in table 5 and 6 showed statistically significant difference in the anti-hbc igg positivity rate distribution according to anti-hbc igm. the above-mentioned results agreed with other results reported by local studies [23,24,38]. the igm class of the anti-hbc is the first to appear even late in the incubation period and indicates a recent infection. so antihbc igm is an excellent marker for hbv infection in hbsag negative participants. while the igg class of anti-hbc appears later and indicates a past infection. individuals with anti-hbc igg may not be infectious, and their blood is suitable for blood transfusion as they may have antihbs, which are protective in nature [24]. the current study confirms previous findings reported by other local studies [23,38] where none of those positive participants for anti-hbc igm was positive for hbs ag. however, several international studies reported different results. abdou et al. [24] reported 2.25% of samples [hbs ag negative] were positive for anti-hbc igm. ogunfemi et al. [25] found that the prevalence of anti-hbc igm was positive at 5.7% among nigerian patients. ayatollahi et al. [47] reported that 2.4% anti-hbc igm was positive among hbs ag negative. the igm class of the anti-hbc is the first to appear even late in the incubation period and indicates a recent infection. ogunfemi et al. [25] indicated that “the finding of anti-hbc igm alone may result from the presence of anti-hbc igm during the window period following acute hbv infection” [25]. so anti-hbc igm is an excellent marker for hbv infection in hbsag negative individuals. the igg class of anti-hbc appears later of anti-hbc igm and indicates a past infection. individuals with antihbc igg may not be infected, and their blood is suitable for blood transfusion as they may have sufficiently high titers of antihbs, which are protective [48]. so, the results of our study agreed with other studies that reported significant differences in the distribution of anti-hbc igm positivity rate among antihbc igg positive individuals [23,24,38,47]. part of our results showed that none of the participants were positive for the hbv core gene at 791bp. similarly, riosocampo et al. [49] reported the absence of positive pcr results for the core region in patients. however, different findings reported by hassan and hussain [8] in north of iraq. the author found that 37.0% of the study population was positive for hbv hwaid ah, et al., journal of ideas in health (2022); 5(2):685-692 690 core gene. additionally, rastegarvand et al. [28] revealed that two (0.98%) were positive for pre-core regions among all hbsag-negative samples. concerning the hbc gene, the gene was undetectable neither among participants with positive anti-hbc igg nor those with anti-hbc igg negative. however, ayatollahi et al. [47] detected 2.4% hbc gene among participants with positive anti-hbc igg. the difference in the results might be due to the sensitivity and specificity of the elisa and pcr technique for the detection, primers used, and technical conditions. unlike to previous international studies [23,24,38,47,50], none of the hb core genes tested subjects were positive among antihbc igm positive participants. the disparity among results may be due to clearance of hbv infection, elisa test, or hbv pcr kits, rarely that a person has intermittent or lowlevel viremia. conclusion the overall obi among study participants (hemodialysis patients, thalassemia patients, blood donors, and the control group) indicates that diyala province is still in the intermediate zone of endemicity. the hbc gene at 791 bp was not detected among any included specimens since the hbc genes are restricted to the hepatocytes. further molecular studies on detecting these genes in liver biopsies, especially for the risky groups, are recommended. abbreviation obi: occult hepatitis b infection; hbs ag: hepatitis b surface antigen; hbc igg: hepatitis b core immunoglobulin g; hbc igm: hepatitis b core immunoglobulin m; elisa: enzymelinked immunosorbent assay; pcr: polymerase chain reaction. declaration acknowledgment our appreciations go to diyala university and the college of education for pure science for postgraduate studies, which gave us this opportunity to complete the study requirements. we offer a personal expression of gratitude to all the staff of different hospitals in diyala province, especially the staff of ibn-sina dialysis center-diyala directorate of health, staff of blood specialist center-diyala directorate of health, and staff of blood bank – diyala directorate of health, for their kind support and help me in specimens collection stage. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing asmaa.haseeb@ymail.com authors’ contributions ansam dawod salman (ads) designed the experiments and wrote and reviewed the manuscript. iman abass ali (iaa) reviewed, revised, and edited the manuscript. ansam dawod salman, iman abass ali, and asmaa haseeb hwaid (ahh) participated in the study design, performed the experiments, and collected and analyzed the data. all authors contributed to the article and approved the submitted version. ethics approval and consent to participate we conducted the research following the declaration of helsinki. ethical permission was granted by the ethics committee (department of higher education), college of education for pure sciences, university of diyala, iraq (ref no. 5103/12-13 november 2019) and ethical approval granted by centre of training and human development, knowledge and research management of the institution of health directorate in diyala province (ref no. 45024/ on 18 november 2019). all patients gave written informed consent. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of biology, college of sciences, university of diyala, iraq. 2*department of biology, college of education for pure sciences, university of diyala, iraq. article info received: 26 march 2022 accepted: 08 may 2022 published: 10 june 2022 references 1. pak k, ordway s, torres d. occult hbv infection: a case series at a military treatment facility. mil med. 2020 jun 8;185(5-6): e795-e798. doi: 10.1093/milmed/usz379. 2. makvandi m. update on occult hepatitis b virus infection. world j gastroenterol. 2016 oct 21;22(39):8720-8734. doi: 10.3748/wjg. v22.i39.8720. 3. allain jp. occult hepatitis b virus infection. transfus clin biol. 2004 feb;11(1):18-25. doi: 10.1016/j.tracli.2003.11.007. 4. kwak ms, kim yj. occult hepatitis b virus infection. world j hepatol. 2014;6(12):860-869. doi:10.4254/wjh. v6.i12.860. 5. hasan as. prevalence of antibodies to hepatitis b virus antigens and occult hepatitis b virus infection in blood donors. diyala journal of medicine. 2012;3(1):57-61. 6. abdu an, hasan ar, al-azi ih. detection of occult hepatitis b virus infection in diyala province. diyala journal for pure science. 2014;10(4): 69-81. 7. hasan as, fayyadh hm, al-taie ws. prevalence of hepatitis b surface antigen and anti-hepatitis b core antibodies among blood donors in diyala, iraq. asian journal of nursing education and research. 2018;8(4):489-92. doi : 10.5958/2349-2996.2018.00100.3. hwaid ah, et al., journal of ideas in health (2022); 5(2):685-692 691 8. hassan rn, hussain ah. hepatitis b virus dna in blood donors positive of anti-hepatitis b core antibodies and negative for surface antigen in hawler major blood bank, kurdistan region, iraq. journal of the faculty of medicine baghdad. 2018 apr 1;60[1]:57-61. 9. hasan as, al-aboudi sa, al-hmudi ha. some of immunogenetic status of hbsag negative, hbcab positive blood donors in basra province-iraq. annals of biological research. 2015;6(4):47-54. 10. findik d, arslan u, baykan m. determination of hepatitis b virus dna incidence, viral load, and mutations in blood donors with hbsag and anti-hbs-negative serology and antibodies to hepatitis b core antigen. eur j intern med. 2007 dec;18(8):571-5. doi: 10.1016/j.ejim.2007.07.001. 11. karimi g, zadsar m, vafaei n, sharifi z, falahtafti m. prevalence of antibody to hepatitis b core antigen and hepatitis b virus dna in hbsag negative healthy blood donors. virol j. 2016 mar 5; 13:36. doi: 10.1186/s12985016-0492-8. 12. zekri ar, awlia aa, mahalawi he, ismail ef, mabrouk gm. evaluation of blood units with isolated anti hbc for the presence of hbv dna. disease markers. 2002 jan 1;18(3):107-10. https://doi.org/10.1155/2002/156359. 13. farooq a, waheed u, saba n, kaleem m, majeed n, wazeer a, cheema na, ahmed s, arshad m. molecular and genetic characterization of hepatitis b virus among multitransfused thalassaemia patients in islamabad, pakistan. j family med prim care. 2021 feb;10(2):9981002. doi: 10.4103/jfmpc.jfmpc_1880_20. epub 2021 feb 27.. 14. aboud rs, aboud as, saleh gm, fadil hy, abid sg. seroprevalence of hepatitis b markers in iraqi patients with chronic hepatitis b virus. iosr journal of pharmacy and biological sciences. 2018;13(1):01-04. doi: 10.9790/3008-1301050104. 15. nasir na, abdilazeem ma. prevalence of viral hepatitis b, c, and human immunodeficiency virus among end stage renal disease patients on hemodialysis. iraqi postgraduate medical journal. 2019;18(2):79-86. 16. al-sharifi lm, murtadha j, shahad a, mohammed y, sura j, waleed z, raheeq m, sura a, ehab h, shahad m, abbas q. prevalence of hepatitis b and c in thalassemic patients and its relation with type of thalassemia, frequency of blood transfusion, and spleen status. medical journal of babylon. 2019 apr 1;16)2):108-111. doi: 10.4103/mjbl.mjbl_6_19. 17. hoseini h. seroprevalence of hepatitis b, hepatitis c and human immunodeficiency virus in patients with thalassemia major in zahedan, southeast of iran. jcbr. 2019; 3 (1): 29-33.doi: 10.29252/jcbr.3.1.29. 18. alzahrani fm, muzaheed, shaikh ss, alomar ai, acharya s, elhadi n. prevalence of hepatitis b virus (hbv) among blood donors in eastern saudi arabia: results from a five-year retrospective study of hbv seromarkers. ann lab med. 2019 jan;39(1):81-85. doi: 10.3343/alm.2019.39.1.81. 19. acikgoz a, cimrin d, kizildag s, esen n, balci p, sayiner aa. hepatitis a, b and c seropositivity among first-year healthcare students in western turkey: a seroprevalence study. bmc infect dis. 2020 jul 22;20(1):529. doi: 10.1186/s12879-020-05247-5. 20. al-taan gs, khalid md. prevalence of hepatitis b virus in hemodialysis patients infected with hepatitis c virus in mosul district/iraq. american academic scientific research journal for engineering, technology, and sciences. 2020 jan 8;63(1):1-6. 21. zana sm, ibrahim an, nawfal rh, mohammad sj, noaman js, haji rs, et al. the prevalence of hepatitis b and c virus in patients with end-stage kidney disease on regular hemodialysis in duhok, iraq: a brief report. avicenna j clin microbiol infect. 2020;7: 31-33. doi: 10.34172/ajcmi.2020.06. 22. bahrami a, sharifi z, parsania m, haghighat s. prevalence of anti-hbc in hbsag negative blood donors using two enzyme immunoassays kits. sci j iran blood transfus organ 2020, 17(2): 83-90. 23. khalid md. detection of anti-hbc and hbv-dna in blood donors negative for hepatitis b virus surface antigen in mosul central blood bank-iraq. iraqi journal of biotechnology. 2014;13(2-2):119-127. 24. abdou a, hasssan m, el gamal s, el dewi d. the role of detection of anti-hbc igm in hbs ag negative blood donors. journal of recent advances in medicine. 2020 jul 1;1(2):67-74. doi: 10.21608/jram.2020.19827.1020. 25. ogunfemi mk, olawumi ho, olokoba ab, kagu mb, biliaminu sa, durowade ka, durotoye ia, shittu ao. prevalence of antibody to hepatitis b core antigen among hepatitis b surface antigen-negative blood donors in ilorin, nigeria: a cross-sectional study. malawi med j. 2017 mar;29(1):32-36. doi: 10.4314/mmj. v29i1.7. 26. ercaliskan a, eskazan ae, yurttas no, kucukyurt s, salihoglu a, keskin d, ozmen d, elverdi t, ar mc, soysal t. the real-life data on the outcome of hepatitis b infection in patients with b-cell lymphoproliferative neoplasms treated with ibrutinib. blood. 2019 nov 13; 134:4316. https://doi.org/10.1182/blood-2019-127794. 27. ibrahim nm, saleem zs, hussein nr. the prevalence of hiv, hcv, and hbv among hemodialysis patients attending duhok hemodialysis center. int j infect. 2018;5(1): e63246. doi: 10.5812/iji.63246. 28. rastegarvand n, makvandi m, samarbafzadeh a, rasti m, neisi n, pouremamali a, teimoori a, shabani a. molecular characterization of pre-core/core and s region of hepatitis b virus in hemodialysis patients with occult hepatitis b infection. jundishapur j microbiol. 2015 oct 26;8(10): e23686. doi: 10.5812/jjm.23686. 29. kizilates f, berk h, coban m, seyman d, sarikaya m, sari f, oztoprak n. seroprevalence of hepatitis b and c virus in patients who undergo hemodialysis in antalya province, turkey. asian biomedicine. 2016 aug 1;10(4):339-44. https://doi.org/10.5372/19057415.1004.496. 30. salim rw, abdullah ba. the prevalence of hepatitis b virus in high risk groups in nineveh governorate/iraq. baghdad science journal. june 2014;11(2):888-893. 31. dumaidi k, al-jawabreh a, samarah f, rabayaa m. prevalence of sero-molecular markers of hepatitis c and b viruses among patients with β-thalassemia major in northern west bank, palestine. can j infect dis med microbiol. 2018 sep 5;2018: 1039423. doi: 10.1155/2018/1039423. 32. hussein nr, haj sm, almizori la, taha aa. the prevalence of hepatitis b and c viruses among blood donors attending blood bank in duhok, kurdistan region, iraq. int j infect. 2017;4(1): e39008. doi: 10.17795/iji39008. 33. ameen r, sanad n, al‐shemmari s, siddique i, chowdhury ri, al‐hamdan s, al‐bashir a. prevalence of viral markers among first‐time arab blood donors in hwaid ah, et al., journal of ideas in health (2022); 5(2):685-692 692 kuwait. transfusion. 2005 dec;45(12):1973-80. https://doi.org/10.1111/j.1537-2995.2005.00635.x. 34. samadi e, mirshahabi h, motamed n, sadeghi h. prevalence of occult hepatitis b virus infection in hemodialysis patients using nested pcr. rep biochem mol biol. 2020 apr;9(1):82-88. doi: 10.29252/rbmb.9.1.82. 35. mohammed n, ashafa am, aminu m. seroprevalence of hepatitis b virus e antigen among blood donors in kaduna state, nigeria. international journal of science for global sustainability. 2020 oct 8;6(3):89. 36. ramezani a, aghasadeghi mr, ahmadi f, razeghi e, eslamifar a, banifazl m, et al. isolated anti-hbc and occult hbv infection in dialysis patients. nephrourol mon. 2014 nov 30;7(1): e22674. doi: 10.5812/numonthly.22674. 37. abdulla im, goreal aa. detection of hepatitis-b virus genotypes among chronic carriers in duhok-iraq. journal of the faculty of medicine baghdad. 2016 jul 3;58(2):170175. 38. al-zubaidi ma, bahreini m, al-rubaye ws. detection and determination of hepatitis b using molecular and serological methods in patients with hepatitis b in aldiwaniya iraq. al-qadisiyah medical journal. 2019 aug 26;15(1):87-97. 39. alabdallat ng, bin dukhyil aaa. significance of hbv nat among hbs antigen-negative blood donors in saudi arabia. lab med. 2018 oct 11;49(4):342-346. doi: 10.1093/labmed/lmy023.. 40. mansour-ghanaei f, joukar f, naghipour m, hassanipour s, yeganeh s, sepehrimanesh m, fathalipour m. epidemiologic profile of viral hepatitis b and c in north of iran: results from persian guilan cohort study (pgcs). bmc res notes. 2021 feb 10;14(1):59. doi: 10.1186/s13104-021-05474-2. 41. makroo rn, chowdhry m, bhatia a, arora b, rosamma nl. hepatitis b core antibody testing in indian blood donors: a double-edged sword! asian j transfus sci. 2012 jan;6(1):10-3. doi: 10.4103/0973-6247.95043. 42. allain jp. global epidemiology of occult hbv infection. annals of blood. 2017; 2(7):1-13. http://dx.doi.org/10.21037/aob.2017.06.01. 43. al-rubaye a, tariq z, alrubaiy l. prevalence of hepatitis b seromarkers and hepatitis c antibodies in blood donors in basra, iraq. bmj open gastroenterol. 2016 jan 4;3(1):e000067. doi: 10.1136/bmjgast-2015-000067. 44. ganczak m, topczewska k, budnik-szymoniuk m, korzeń m. seroprevalence of anti-hbc, risk factors of occupationally acquired hbv infection and hbv vaccination among hospital staff in poland: a multicenter study. bmc public health. 2019 mar 12;19(1):298. doi: 10.1186/s12889-019-6628-1. 45. al-momen ak, alghamdi e, al-humaidan h, al-mishari m, suhaibani o, alnowaiser a. current management of blood donors with positive anti-hbc in saudi arabia. blood.2016; 128(22): 5041. https://doi.org/10.1182/blood.v128.22.5041.5041. 46. coppola n, gentile i, pasquale g, buonomo ar, capoluongo n, d'armiento m, borgia g, sagnelli e. antihbc positivity was associated with histological cirrhosis in patients with chronic hepatitis c. ann hepatol. 2013 jan2014 feb;13(1):20-6. 47. ayatollahi j, jahanabadi s, sharifyazdi m, hemayati r, vakili m, shahcheraghi sh. the prevalence of occult hepatitis b virus in the hemodialysis patients in yazd, iran. acta med iran. 2016 dec;54(12):784-787. 48. esposito a, sabia c, iannone c, nicoletti gf, sommese l, napoli c. occult hepatitis infection in transfusion medicine: screening policy and assessment of current use of anti-hbc testing. transfus med hemother. 2017 aug;44(4):263-272. doi: 10.1159/000460301. 49. rios-ocampo wa, cortes-mancera f, olarte jc, soto a, navas mc. occult hepatitis b virus infection among blood donors in colombia. virol j. 2014; 11:206. doi: 10.1186/s12985-014-0206-z. 50. hiva s, negar k, mohammad-reza p, gholam-reza g, mohsen a, ali-asghar ng, mohammed-jafar s. high level of vaccination and protection against hepatitis b with low rate of hcv infection markers among hospital health care personnel in north of iran: a cross-sectional study. bmc public health. 2020 jun 12;20(1):920. doi: 10.1186/s12889-020-09032-6. al-samarrai & ali jadoo, journal of ideas in health 2018;1(1):23-28 © the author(s). 2018 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. journal homepage: www.jidhealth.com open access iraqi medical students are still planning to leave after graduation mustafa ali mustafa al-samarrai 1*, saad ahmed ali jadoo 2 abstract background: medical students constitute the backbone of the future human resource for health, and therefore, as much as attention should be given to secure a high level of education, it should also be given to understand their wishes to leave or to stay at home country. this study aimed to find out the prominent factors associated with iraqi medical students' planning to leave their country after graduation. methods: a descriptive cross-sectional study was conducted among clinical medical students (fourth, fifth, and sixth classes) of two medical colleges (the university of anbar and university of fallujah) in anbar governorate from 1st to 14th march 2018. a total of 183 students (response rate: 72,6%.) completed a self-administered questionnaire consisting of 15 close-ended questions related to the socio-demographic factors, economic characteristics, and some other factors inspired from iraq's situation. moreover, one open-ended question was designed to explore the main reasons for migration from the student's point of view. results: although 109 students (60%) felt that serving their citizens and country is a priority, however, the vast majority of 133 (73%) of the surveyed students had a plan to leave iraq. about two thirds (69 %) of students intended to migrate as soon as they manage to: obtain their graduation certificate (49%); have enough money (34%), and the remaining 18% when they get parents’ permission. conclusion: our results suggest that living environments and work-related variables are significantly associated with medical students' intention of migration; however, social reasons and inspiring academic achievement were the main factors triggering students to leave iraq. keywords: intention of migration, medical students, conflict, anbar, fallujah, iraq background during the last decade, the event of a migration of iraqi doctors has been escalated, especially in areas of conflict. the demands of human resources have been rapidly growing worldwide for several demographic and epidemiological conditions [1]. a significant consequence was an accelerated international migration of health workers, mainly from developing countries to more developed countries, a phenomenon known as "brain drain"[2,3]. the most favorable destination for doctors migrating from iraqi and other medium tolow-income countries (donors) are united states, united kingdom, canada, and australia, the so-calledrecipient countries. eventually, those practicing doctors acquired the term, international medical graduates, and constituted about 25% of all physicians there [2]. year after year, the brain drains kept going, and the problem aggravated for both the donor and the recipient countries. unfortunately, this problem was not detected until very recently [2], when the developed countries have registered an expanded gap between demand and supply of physicians, and the developing countries complained of insufficient healthcare providers, resulting in an additional economic divide between them [4]. a situation of "push" and "pull" factors, i.e., factors acting simultaneously as extruder from home and attractive towards abroad [5]. the most common push factors were "the poor salary structure and poor quality of training" [6]; however, ali jadoo [7,8] and his colleagues found a more robust history of job dissatisfaction, violent events, and harassment among iraqi doctors who were intending to migrate. moreover, some pull factors in the developed countries are evident, such as smooth immigration policies, higher quality of life, and more professional training make migration even more exciting [9-12]. findings from a research study conducted in south africa manifested that the second considerable reason for migration was offering better job opportunities [13]. last but not least, print and electronic media may also have a significant role to establish migration intentions, particularly in the absence of active legislation and firm regulations, where the private sector offers valuable vacancies in local newspapers with high salaries and privileges [14]. other varieties of mass media are ___________________________________________________ ma_m776@yahoo.com 1department of family and community medicine, faculty of medicine, anbar university, anbar, iraq.. full list of author information is available at the end of the article. http://www.jidhealth.com/ al-samarrai & ali jadoo, journal of ideas in health 2018; 1(1):23-28 24 tv channels that act as a double stroke in "pull" and "push" factors by exhibiting the shiny aspects of west destinations, whereas they exaggerate the disadvantages of the regional health system and lifestyle [14]. after the us-led invasion in 2003, iraqi intelligentsia in general and doctors, in particular, faced intolerable levels of violence and systematic targeting [7,8,15]. health care facilities were looted and destroyed; doctors had to defend them with arms, sacrificing their safety [16]. the iraqi government responded poorly; it neither protected those left inside iraq nor initiated a serious investigation [17]. although wages increased after 2003, from "us$380 annually to us$5,100 annually", they remain relatively low if we consider the workload and high risks [18]. the deterioration of medical education infrastructure is unprecedented, with a shocking absence of mandatory continuing medical education and proper certification programs [19]. in 2010, the iraqi government offered immediate job placement for doctors upon their return to iraq and promised to improve security measures and protect doctors, yet that was not enough to convince doctors to stay in or return to iraq [20]. the revival plan of the iraqi health care system seems to be very limp so far; lack of security, lousy management, the politicization of the ministry of health, corruption, and inadequate training are all problems that successive decisionmakers have failed to solve since 2003 [21-24]. this failure further repelled doctors; 55% of them were severe to look for another job [8]. many of those leaving their posts are senior doctors, resulting in a critical leadership and mentorship void and, in some cases, the complete disappearance of certain specialties [25]. the peak incidence of migration among iraqi doctors was in the year 2008. an estimated "20,000 out of 34,000 physicians (registered before 2003) have left or lost (58.8%); 2,000 of them have been killed, and over 250 kidnapped" [26]. consequently, in 2011, iraqi primary health care clinics were nearly 40% deficient in physicians [24]. the national loss of brain drain can be catastrophic, especially when physicians are involved. subsequently, an inevitable deterioration of the health system and the quality of medical services are the main consequences. many international studies declared that the migration of junior doctors is much higher than in older, and most of them had such planning since college time. previous studies conducted in iraq focused on doctors rather than the undergraduates [7,8]. therefore, this is the first local study that highlights the early causes behind the migration of iraqi doctors and how to prevent them. methods study design and subjects a descriptive cross-sectional survey was conducted among the medical students of two universities (anbar and fallujah) in the anbar governorate, west of iraq. the target population were clinical students, namely: the fourth, fifth and sixth classes from anbar college of medicine and the fourth and fifth classes from fallujah college of medicine (in the academic year of 20172018, fallujah college of medicine has no sixth class students yet). a qualified and trained research team was recruited to trace students in their college. lists of all targeted medical students were obtained from the registration office of the two included college of medicine. all clinical medical students with iraqi nationality, who were available at the time of study and were willing to participate have been included (figure 1). the pre-clinical students (first, second, and third classes), foreign nationality students, and those who were not willing to participate or absent at the time of study have been excluded. each eligible student has consented and received the arabic copy of the semi-structured questionnaire. data were collected in two weeks (1st to 14th march 2018). a total of 183 students (response rate: 72,6%.) completed a self-administered questionnaire consisting of closed-ended questions related to the socio-demographic factors and economic characteristics and some other predictors inspired by iraq's situation which may affect student's migration intention. lastly, an open-ended question was designed to explore the main reasons for migration. responses measured with a three-point likert-type scale ranging from a= "yes", b="not sure" and c = "no", with some modification. figure 1 flow chart of the study statistical analysis data was collected and analyzed using microsoft excel spreadsheet. descriptive analysis was performed concerning the overall migration and the 21 items to obtain the percentages. results and discussion descriptive analyses table 1 shows the full details of the socio-economic aspects for anbar and fallujah medical students separately. the subject looks rather sensitive and embarrassing to many students so that writing of student's details in the module of the questionnaire was optional, however among all the respondents (n= 183); male to female ratio was 41: 59, yet; over 20% of them refused to participate. as usual in iraq, most of the surveyed students (119, 65%) belong to a big family (more than seven members). two-thirds of respondents (121, 66%) are resident in anbar governorate and one third (62, 34%) outside anbar. fortunately, the average income was swinging equally from middle to high level, but 22% (40) of families had at least one member exposed to considerable violent attacks, and 15% of them had a brother or sister studying in west countries. anbar university faculty of medicine fallujah university faculty of medicine 4th class (36) 36 5th class (69) 6th class (94) 4th class (39) 36 5th class (14) the total population of 252 absent 18 not willing 51 total respondents 183 al-samarrai & ali jadoo, journal of ideas in health 2018; 1(1):23-28 25 table 1 socio-demographic distribution of anbar medical students (n=183) university anbar fallujah total class fourth n (%) fifth n (%) sixth n (%) forth n (%) fifth n (%) total n (%) total number of students 36(14.3) 69(27.4) 94(37.3) 39(15.5) 14(5.5) 252(100%) number of participants 29(80) 60(87) 48(51) 33(85) 13(93) 183(72.6) gender of students number of females 14(48) 34(75) 33(69) 18(55) 9(70) 108(59.0) number of males 15(52) 26(25) 15(31) 15(45) 4(30) 75(41.0) the number of family members < 7 10(34) 23(38) 12(25) 15(45) 4(30) 64(35.0) > 7 19(66) 37(62) 36(75) 18(55) 9(70) 119(65.0) current home address anbar province 22(76) 40(67) 25(52) 23(70) 11(85) 121(66.0) other governorates 7(24) 20(33) 23(48) 10(30) 2(15) 62(34.0) average family income medium 19(66) 22(37) 21(44) 20(60) 10(77) 92(50.2) good 10(34) 38(63) 27(56) 13(40) 3(23) 91(49.8) exposed to severe violence yes 7(24) 15(25) 7(15) 10(30) 1(8) 40(21.9) no 22 45(75) 41(85) 23(70) 12(92) 143(78.1) is there a family member in the west? yes 5 3(5) 1(2) 3(10) 3(23) 15(8.2) no 24 57(95) 47(98) 30(90) 10(77) 168(91.8) migration intention table 2 shows the more closely related details with migration. the highest percent (42%) intended to live outside the country after they have been graduated, and 32% preferred the capital of iraq (baghdad) to live in than their province (anbar). findings showed that baghdad was a preferable choice for students who were already left anbar and residents in baghdad since the islamic state of iraq and syria (isis) invasion in 2014 and mostly arranged their life to persist there. the vast majority of 133 (73%) of the surveyed students had a plan to leave iraq, but in over half of them (98, 53.6%) preferred to leave with their family. at the same time, about 25.1% (46) had a plan to leave iraq permanently; however, 77 (42%) claimed that they would be back a few years later after gaining citizenship of the recipient country. furthermore, about half (86, 47%) of the surveyed students were not sure whether living abroad is more beneficial from the economic point of view or not. nevertheless, the vast majority 135 (74%) of medical students still believed that security situation would stay critical for a long time and could be an excellent motivator for migration, and 106 students (58%) expected that migration might probably offer a better future for them and their families. indeed, this is an alarming situation; because physicians of anbar governorate are almost always local, i.e., no doctors drain from other governorates. the doctor who leaves anbar will not be substituted; eventually, a further deficiency in physicians will be manifested. reasons for migration concerning gender, table 3 presents the findings concerning the main reasons behind the decision of clinical medical students to migrate. out of 183 respondents, 127 (69.4%) have actively responded to the open-ended question, and each has recorded the most impelling factor towards migration. results revealed five principal causes that have been categorized and arranged in descending order: personal, social, academic, security, and tourism (table 3). about half (59, 45.0%) of them (especially among the female gender 47%) were hesitated to explore the real reason for migration and reported as special reasons (personal), i.e., related to the students' circumstances and orientation. hesitation was evident among students having a family member outside the country and among those with highly educated parents. the ratio of personal reasons is slightly higher in latter classes (fifth and sixth) than the fourth one who seemed less alert than earlier colleagues or most likely has no specific goal. they just want to escape problems instead of facing them and showing impotent awareness of early and late disadvantages of westering. this behavior looks rather peculiar and not listed in similar studies where respondents have determined their triggers for migration precisely [27-30]. the social reason was the second important factor triggering students to leave or to stay in iraq. about (69, 40.0%) of the presented students stated that iraq still had better social and religious environments, and the same proportion (71) believed not. al-samarrai & ali jadoo, journal of ideas in health 2018; 1(1):23-28 26 table 2 factors related to migration distributed in medical classes of anbar and fallujah universities (n=183) university anbar fallujah total class forth n (%) fifth n (%) sixth n (%) forth n (%) fifth n (%) total n (%) after graduation, i intend to live in: ain my province 8(28) 10(17) 18(38) 9(27) 3(23) 48(26.2) bin the capital 9(31) 24(40) 14(31) 9(27) 1(62) 58(31.7) c. outside the country 12(41) 26(43) 15(31) 15(46) 9(15) 77(42.1) i want to emigrate: aalone 5(17) 18(30) 4(9) 5(15) 3(23) 35(19.1) bwith my family 15(52) 32(53) 28(58) 15(46) 8(62) 98(53.6) cno wish 9(31) 10(17) 16(33) 13(39) 2(15) 50(27.3) i plan to travel: apermanently 3(10) 25(42) 10(20) 5(15) 3(23) 46(25.1) buntil i have a nationality or residency 7(24) 11(18) 4(9) 10(30) 4(30) 36(19.7) cfor tourism only 19(66) 24(40) 34(71) 18(55) 6(47) 101(55.2) i think that working outside the country offers a higher economic: ayes 7(24) 33(55) 13(27) 13(39) 1(8) 67(36.6) bno 8(28) 4(7) 7(15) 6(18) 5(38) 30(16.4) cnot sure 14(48) 23(38) 28(58) 14(43) 7(54) 86(47.0) i fear that the security situation of the country will remain awkward for a long time: ayes 16(55) 48(80) 35(73) 25(76) 12(92) 136(74.3) bnot sure 13(45) 12(20) 13(27) 8(24) 1(8) 47(25.7) immigration abroad will provide my family with a better future aoften 17(59) 37(62) 22(46) 24(73) 7(54) 107(58.5) b not sure 4(14) 20(33) 15(31) 4(12) 4(31) 47(25.7) ci do not think so 8(28) 3(5) 11(23) 5(15) 2(15) 29(15.8) considering religion and social, i still believe that life in iraq is the best: ayes 10(35) 19(32) 21(44) 18(55) 1(8) 69(37.7) bnot sure 4(14) 14(23) 15(31) 8(24) 2(15) 43(23.5) cno 15(51) 27(45) 12(25) 7(21) 10(77) 71(38.8) the inner feeling in the need to serve my family and my country: a does not exist 5(17) 11(18) 2(4) 1(3) 1(9) 20(10.9) b not submitted to my interests 3(10) 19(32) 14(29) 12(36) 6(46) 54(29.5) cit comes first 21(73) 30(50) 32(67) 20(61) 6(46) 109(59.6) for those who intend to migrate, the main determinants of travel time are: ai have a graduation certificate 13(45) 34(57) 21(44) 18(55) 6(46) 92(50.0) bavailability of sufficient funds 12(41) 16(26) 16(33) 9(27) 5(39) 58(32.0) cparental consent 4(14) 10(17) 11(23) 6(18) 2(15) 33(18.0) my final decision regarding travel is ayes 21(73) 44(73) 30(62) 20(61) 12(92) 127(69.4) bno 8(27) 16(27) 18(28) 13(39) 1(8) 56(30.6) al-samarrai & ali jadoo, journal of ideas in health 2018; 1(1):23-28 27 table 3 reasons for migration in anbar and fallujah medical students in relation to gender (n=127) furthermore, 58% declared that they look for a better future for their family outside iraq. it seems that the religion and looking for a better future for their family were the main variables influencing tow third (69.0%) of students to choose the personal and social reasons as the main triggering factors for migration. they were inspiring of academic achievement, as indicated in 20 (16.0%) of surveyed students. this could be explained partly by the job dissatisfaction of previous colleagues who practiced medicine as rotators in low rank and unsatisfactory accreditation of local medical institutions and is supported by regional studies conducted in iraq and lebanon [8, 23, 27]. gender variation is not correlated with all causes. apart from academic reasons, females were generally more interested in training improvement, and higher education than males [31], which might be simply justified by the higher number of females in all included medical classes; otherwise, no obvious factor can be correlated. unlikely, the security situation was at the bottom of the list to be a reason to migrate among 14 (11%) students, which most likely attributed to the relative feeling of safety among people of the anbar governorate after liberation from isis; thus, security has not taken as a priority. moreover, the apparent gender difference in the security is related to exposure to violence rather than gender itself, i.e., nearly all students who had previously exposed to violent attacks, against them or their families; were accepting security as the main reason regardless of their gender [8]. surprisingly, none of the responded medical students considered a financial factor as the leading cause to leave as it was in the1990s of the last century and the early 2000s of the current century [8]. this finding may go partly with students' belief that iraq is still more beneficial than other states from the economic point of view, probably owing to satisfaction with their current income (50% high, 50% middle, 0 % low) and relatively adequate income for medical doctors in all of the iraqi medical structures weather it was the governmental or private sector. lastly, the difference between anbar and fallujah students were not eligible, and the same was true among middle and late classes. about 60% of students (109) felt that serving their citizens and country comes first, and 54 (30%) confessed that the sake of their country comes after their interest, unlike 18 (10%) who lacked national belong and loyalty in their decision. despite these outputs that were sound encouraging, the last reading looks the contrary instead; more than two thirds (126, 69.0%) of students intended to migrate as soon as they manage to: obtain their graduation certificate in half of them (83, 49%); have enough money (42, 34%), and the remaining (22, 18%) when they get parents' permission. on the other hand, and only one third (31%) overtook all the above challenges and decided to stay whatever it costs. there is no significant gender difference concerning other leading causes, as illustrated in table 3. there are some limitations to this study. first, researchers measured intentions to leave rather than actual migration, which could be changed after the student graduated. furthermore, there might be a response bias, because we had no information about the non-respondent students which were relatively high (27.4%). some students (about 10%) were not in their mood at the time of the survey for being busy with exams. as a result, their answers were rather aggressive. because of a cross-sectional design, the study could not be possible to build a causal relationship among the variables. this survey included only students from anbar and fallujah universities so that students in other universities of the country could likely have had differing plans and intentions. conclusion over the last three decades, the iraqi healthcare system had a complaint with a serious shortage of qualified doctors. intention to migrate reported in over fifty percent of medical doctors. although it has not disclosed, the relative sense of security after liberation from isis was directly affected the students' way of thinking. among the remarkable results of this study was the high percentage (69.0%) of medical students who wish to leave the country after graduation. it is clear that security concerns still affect the students' decision-making process. most of the surveyed students justified their intention to migrate for personal or social reasons; however, this interpretation contradicts the high proportion of intention to leave. the urgent and thoughtful intervention at an undergraduate level has become necessary to avoid further brain drain. more reassuring measures for medical students to ensure future career, training opportunities, attending scientific conferences, improving salaries, providing legal protection, and guiding society to express more respect to health workers. abbreviations isis: islamic state of iraq and syria; n or n: number declarations acknowledgment we render our special thanks to all directors in anbar and fallujah universities. we are also grateful to all the medical students for their help, time, and openness during the data collection. funding the author (s) received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing ma_m776@yahool.com. authors’ contributions ma is the principal investigator of the study who designed the study and coordinated all aspects of the research, including all steps of the manuscript preparation. he is responsible for the study concept, design, writing, reviewing, editing, and approving the manuscript in its final form. saaj contributed in the study design, analysis and interpretation of data, drafting the work, writing the manuscript and reviewed and approved the manuscript. all authors read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki, and the ethical committee of the faculty of medicine, university of anbar, the main reason for travel male n (%) female n (%) total n (%) special (not identified) 19 (46) 40 (47) 59 (46) social 9 (22) 20 (23) 29 (23) for academic achievement 4 (10) 16 (19) 20 (16) security 6 (15) 8 (9) 14 (11) tourism 3 (7) 2 (2) 5 (4) financial total 41 86 127 al-samarrai & ali jadoo, journal of ideas in health 2018; 1(1):23-28 28 approved the protocol (ref: official letter no. 249 issued on 27th february 2018). confidentiality was assured with signed informed consent. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of family and community medicine, faculty of medicine, anbar university, anbar, iraq. 2department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey. article info received: 05 may 2018 accepted: 27 may 2018 published: 31 may 2018 references 1. gupta n, diallo k, zurn p, dal poz m. assessing human resources for health: what can be learned from labour force surveys? human resources for health 2003; 1(1):5 2. mullan f. the metrics of the physician brain drain. n engl j med 2005; 353(17):1810-1818. 3. akl ea, mustafa r, bdair f, schünemann hj. the united states physician workforce and international medical graduates: trends and characteristics. j gen intern med. 2007; 22(2):264-268. 4. aluwihare apr: physician migration: donor country impact. j contin educ health prof 2005; 25(1):15-21. 5. klein d, hofmeister m, lockyear j, crutcher r, fidler h. push, pull, and plant: the personal side of physician immigration to alberta, canada. fam med 2009; 41(3):197-201. 6. syed na, khimani f, andrades m, ali sk, paul r. reasons for migration among medical students from karachi. medical education 2008; 42(1):61-68. 7. ali jadoo sa, torun p, dastan i, al-samarrai m. impact of conflict related and workplace related violence on job satisfaction among physicians from iraq a descriptive cross-sectional multicentre study. journal of ideas in health 2018; 1(1): 14-22. 8. ali jadoo sa, aljunid sm, dastan i, tawfeeq rs, mustafa ma, ganasegeran k, aldubai sa. job satisfaction and turnover intention among iraqi doctors-a descriptive cross-sectional multicentre study. hum resour health 2015; 13:21 9. hagopian a, thompson m, fordyce m, johnson k, hart lg. the migration of physicians from sub-saharan africa to the united states of america: measures of the african brain drain. hum resour health 2004; 2:17. 10. ong p, liu jm. us immigration policies and asian migration. in the new asian immigration in los angeles and global restructuring. edited by: ong p, bonacich e, cheng lh. temple university press, philadelphia; 1994:45-73. 11. arah oa, ogbu uc, okeke ce. too poor to leave, too rich to stay: developmental and global health correlates of physician migration to the united states, canada, australia, and the united kingdom. am j public health 2008; 98(1):148. 12. kaushik m, jaiswal a, shah n, mahal a. high-end physician migration from india. bull world health organ 2008; 86(1):40-45. 13. bezuidenhout mm, joubert g, hiemstra la, struwig mc. reasons for doctor migration from south africa. sa fam pract 2009; 51(3):211215. 14. happer c, philo g. the role of the media in the construction of belief and social change. journal of social and political psychology 2013; 1(1): 321–336. 15. jalili i. iraqi academics and doctors: innocent victims of a wider geopolitical struggle. humanities2007; 22:23. 16. kapp c. anarchy pushes iraqi health system to brink of collapse. lancet 2003; 361:1351. . 17. alwan na. the killing of doctors in iraq must stop. bmj 2011; 343. 18. ihsanoglu e. assessing the human tragedy in iraq. int. rev. red cross2007; 89:915. 19. mosawi aja. medical education and the physician workforce of iraq. j contin educ health prof 2008; 28: 103105. 20. burnham g, malik s, al-shibli as, mahjoub ar, baqer aq, baqer zq, et al. understanding the impact of conflict on health services in iraq. information from 401 iraqi refugee doctors in jordan. int j health plann manage 2012;27(1): e51-64. 21. dyer o. iraqi healthcare system still crippled five years after invasion, says report. bmj 2008; 336:113. 22. webster p. reconstruction efforts in iraq failing health care. lancet2009; 373:617620 23. webster p. medical faculties decimated by violence in iraq. cmaj 2009; 181:576 24. webster p. iraq’s health system yet to heal from ravages of war. lancet 2000; 378:863866 25. doocy s, malik s, burnham g. experiences of iraqi doctors in jordan during conflict and factors associated with migration. am j disaster med 2010; 5: 41. 26. o’hanlon me, livingston i. iraq index: tracking variables of reconstruction & security in iraq. brookings institution, washington, 2011, dc. 27. akl ea, maroun n, major s, afif c, abdo a, choucair j, et al. post-graduation migration intentions of students of lebanese medical schools: a survey study. bmc public health 2008; 8(1):191. 28. george g, reardon c. preparing for export? medical and nursing student migration intentions post-qualification in south africa. afr j prim health care fam med 2013;5(1): 483. 29. pitó k. the migration potential of graduates at a medical school in romania: does minority status matter?: a qualitative approach. corvinus journal of sociology and social policy2015; 6 (1):129-151. 30. santric-milicevic mm, terzic-supic zj, matejic br, vasic v, ricketts tc. firstand fifth-year medical students’ intention for emigration and practice abroad: a case study of serbia. health policy, 2014; 118:173–83. 31. quenzel g, hurrelmann k. the growing gender gap in education. international journal of adolescence and youth2013; 18: 69-84. https://doi.org/10.47108/jidhealth.vol3.iss2.56 saha s., journal of ideas in health 2020;3(2):167-172 © the author(s). 2020 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access a juxtaposition of safety outcomes between various doses of sodiumglucose co-transporter inhibitors, in insulin-treated type-1 diabetes mellitus patients: a protocol for systematic review and meta-analysis of randomized controlled trials sumanta saha 1* abstract: background: several clinical trials have tested the safety profile of sodium-glucose co-transport inhibitors’ (sgltis) in adult type 1 diabetes mellitus (t1dm) patients. however, no systematic review has yet compared its variation between large and low dose sgltis. henceforth, a review protocol is proposed here to review it. methods: different electronic databases will be searched for randomized-controlled trials (published in the english language) studying the above objective, irrespective of their publication date. after selecting the eligible trials, their data on the study design, population characteristics, compared interventions, and outcomes of interest will be extracted. then, utilizing the cochrane tool, each trial's risk of selection bias, detection bias, performance bias, attrition bias, reporting bias, and other bias will be judged. next, depending on clinical heterogeneity among the trials, a random-effect or fixed-effect model meta-analysis will be used to compare the respective outcomes. via the chi2 and i2 statistics, the statistical inconsistency among the trials will be estimated. when this is substantial, subgroup analysis will follow. publication bias will be evaluated by funnel plots and egger’s test. a sensitivity analysis will be done to check different assumptions. if a quantitative juxtaposition is not possible, a narrative reporting will ensue. conclusion: the proposed study will perform a dose-wise juxtaposition of the safety profile of sgltis in insulintreated t1dm patients. registration: prospective register of systematic reviews (prospero) (registration no. crd42019146578) keywords: type 1 diabetes, sodium-glucose transporter 1, sodium-glucose transporter 2, drug-related side effects and adverse reactions, randomized controlled trial background the autoimmune destruction of insulin (an anabolic hormone) producing pancreatic beta-cells leads to type 1 diabetes mellitus (t1dm), a disease characterized by hyperglycemia [1,2]. although the exact etiology of the disease is unknown, the genetic predisposition may have some role. individuals with certain human leukocyte antigen alleles (dr and dq) are at greater risk of developing t1dm upon exposure to various trigger agents like viruses, environmental toxins, and dietary factors [1]. t1dm frequently begins between 4-6 and 10-14year-olds, although it can start at any age [1]. about 5-10% of diabetes patients are t1dm patients [1]. complications of t1dm often include neuropathy, nephropathy, retinopathy, hypoglycemia, diabetic ketoacidosis, cardiomyopathy, and diabetic foot disease [1]. to prevent these hyperglycemic complications in t1dm patients, insulin, the mainstay of treatment, is required lifelong [1–3]. however, this entire insulin dependence doesn't suit every t1dm patient, because of the inconveniences of insulin therapy like multiple daily insulin injections and daily finger pricks to control and self-monitor the blood glucose levels, respectively.[4,5] besides, there are adverse consequences of intensive insulin therapy on the health like lipohypertrophy or atrophy (when insulin is repeatedly injected at the same site), unwanted weight gain, raised risk of hypoglycemic episodes, and glycemic variations [6]. some of these complications of ___________________________________________________ sumanta.saha@uq.net.au 1independent researcher full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol3.iss2.56 http://www.jidhealth.com/ saha s., journal of ideas in health (2020); 3(2):167-172 168 absolute insulin therapy might affect the health and treatment of t1dm patients further. for instance, the subsequent injections in insulin-induced lipohypertrophied areas can slow down insulin absorption [6]. likewise, the insulin-induced weight gain might raise the risk of cardiometabolic complications by decreasing compliance with the insulin regimen [6]. therefore, to reduce the discomforts and complications of intensive insulin therapy, the role of insulin-independent adjunct therapeutics is vital in the treatment of t1dm patients. in this regard, sodiumglucose co-transport inhibitors (sgltis) have drawn significant attention of the medical community. sgltis are phlorizin compounds [2,4]. by inhibiting sodium-glucose transporter 1 (sglt1) and sodium-glucose transporter 2 (sglt2) receptors, sgltis cause glycosuria and decreased intestinal absorption of glucose [4]. sglt2 receptors in the proximal convoluted tubule reabsorb almost 90% of the filtered glucose [6–8]. examples of sglt2 inhibitors include dapagliflozin, empagliflozin, and canagliflozin [9]. sglt1 is predominantly found in the intestine, and its inhibition regulates the blood glucose level by increasing the release of gastrointestinal hormones through increased glucose delivery to the distal small intestine [6]. sotagliflozin is a dual sglt2/1 blocker; its capacity to inhibit sglt1 receptors provides an additional benefit in decreasing the glucose levels postprandially [2]. existing early stage trials suggested several efficacies of sgltis in t1dm patients. such trials comparing sglt2 inhibitors (dapagliflozin: 5 mg and 10 mg, empagliflozin: 25 mg, 10 mg, and 2.5 mg, and canagliflozin: 100 mg and 300 mg) to placebo in insulin-treated inadequately controlled t1dm patients, demonstrated an improvement in glycemic control, body weight, and insulin requirement [10–12]. likewise, trials that investigated sotagliflozin in t1dm patients and type 2 diabetes mellitus (t2dm) patients, observed improvement in glycemic control (by limiting the post-meal glycemic excursions), weight control, and daily insulin requirements [13]. a recent meta-analysis suggested that mega-dose empagliflozin treatment in insulin-treated t1dm patients with optimum renal functioning aids in achieving better glycemic control, compared to the placebo [14]. however, despite these benefits, due to safety concerns, both sotagliflozin [15] and sglt2 inhibitors are currently not approved by the u.s. food and drug administration [16]. therefore, it is crucial to research the safety of sgltis extensively. contemporarily, several randomized controlled clinical trials have reported the safety profile of sgltis in t1dm patients [12,17–19]. although a statistical comparison of these side effects between the treatment arms was not available, based on its frequency, some idea about the safety profile of sgltis can be made. the trials [12,17,18] on t1dm patients that compared the safety profile between large and low dose empagliflozin, canagliflozin, dapagliflozin observed that the overall percentage of side-effects due to any cause were higher in the recipients of the former. in these large dose recipients this was 100%, 68%, and 67% in empagliflozin (25 mg), canagliflozin (300 mg), and dapagliflozin (10 mg), respectively [12,17,18]. while the serious side effects did not happen with any dosages of empagliflozin in a trial [17], in dapagliflozin recipients, it was more frequent with the low dose (5mg, 7%) than the large dose (10mg, 2.6%) [18]. the serious side effects were found in 12.5% of t1dm patients using 400 mg sotagliflozin in a trial [19]. in t1dm patients, the proportion of hypoglycemic side effects was dose irrespectively high in all canagliflozin users (98-99%) [12], but in empagliflozin users, it varied dose-wise (2.5mg: 84%, 10mg: 68%, 25mg: 94%) [17]. given the safety concerns leading to non-approval of these drugs' use in t1dm patients by the us fda and agglomeration of available clinical trials that tested their safety profile, it is imperative to synthesize novel evidence in this regard. interestingly, the existing review articles have primarily compared the safety profile of sgltis with the placebo [20– 23]. although review attempts have been made to study the safety profile between large and low doses of specific sglt2 inhibitors like empagliflozin and dapagliflozin [24,25], none have contrasted it across multiple sgltis to synthesize summative evidence in this context. therefore, to explore this under-reviewed area, we propose this systematic review and meta-analysis protocol. methods the proposed review’s inclusion criteria will be the following: a. study design: parallel-arm (any number of arms) randomized controlled trials. b. participants: adult (18 years or older) insulin-treated t1dm patients irrespective of their gender. the diagnosis of t1dm will be accepted as per the trialists. c. intervention arm: the intervention groups should receive a mega-dose of dapagliflozin (10 mg), empagliflozin (25 mg), canagliflozin (300 mg), or sotagliflozin (400 mg) every day. the determination of these mega doses was based on the maximum dose in which they were tested in t1dm patients in different clinical trials [12,17–19]. when the proposed review commences, if trials on any other sgltis are found (besides those mentioned-above like ertugliflozin) matching the inclusion criteria, we will include those too in the same manner. d. comparator arm: the comparator group/s should receive the same drugs as the intervention arm, however, at a lower dose. e. outcome: trials reporting side effects of sgltis will be included. the definitions of these outcomes will be accepted as per the trialists. the exclusion criteria will incorporate the following: a. trial population diagnosed with type-2 diabetes, gestational diabetes, or maturity-onset diabetes of young. b. studies of other designs like crossover trials or quasi-experimental studies. the proposed review protocol is registered in prospective register of systematic reviews (prospero) (registration no. crd42019146578) [26]. this protocol follows the prisma-p checklist [27]. search for eligible trials next, the eligible trials’ titles and abstracts will be searched in various electronic databases (pubmed, embase, and scopus). the search will not be limited to any date, but it will be restricted to the english language only. the search strategy to be used in the pubmed database is described here. following search terms will be used: ‘safety’ or ‘tolerance’ or ‘adverse event’ or ‘side effect’ or ‘sideeffect’ and ‘canagliflozin’ or ‘dapagliflozin’ or ‘empagliflozin’ or ‘sotagliflozin’ or ‘sodium-glucose cotransporter’ or cotransporter* or sglt* and ‘type-1’ or ‘type 1’ and ‘diabetes.’ the search will be narrowed down to saha s., journal of ideas in health (2020); 3(2):167-172 169 clinical trials by using the filter ‘randomized controlled trial’ and ‘clinical trial.’ for other databases without such filters, instead, the following search terms will be used ‘trial’ or ‘randomized’ or ‘randomized’ or ‘controlled.’ additionally, eligible trials will also be searched in the references of papers included in the proposed review. selection of eligible trials the database search results will be uploaded to the rayyan [28] systematic reviews software. then, after excluding the duplicates, the titles and abstracts of papers will be read to find trials matching the above-mentioned eligibility criteria. a paper will be read in entirety if it seems to be eligible for inclusion in this review or when a decision of inclusion or exclusion cannot be made by reading the excerpts alone. the list of publications excluded after reading full-text will be retained with their reasons for elimination. the entire study selection process will adhere to the prisma 2009 flow diagram [29]. when multiple trials source data from the same study population, one that counted the overall side effects (cause irrespective) based on the maximum number of side effects will be reviewed. if these latter are identical between trials, one with the longest follow-up time for adverse effects will be included in the review. data extraction from the recruited trials, information about its details, participant characteristics, interventions compared, and outcomes of interest will be extracted. in trial details, its registration number, randomization method, blinding, duration, number of intervention arms, site (single centered or multicentric), participant consent, ethical clearance, country (where conducted), and funding information will be collected. the following participant characteristics will be gathered diagnosis, their number in each intervention arm, mean age, the average duration for which they have been diagnosed with t1dm, and their number for whom the outcome data of interest is not available. concerning intervention information, the dosage and treatment regimen of each of the intervention arm will be collected. finally, for the outcomes of interest, the number of participants experiencing it after taking at least one dose of the tested intervention will be extracted from each of the intervention groups. risk of bias assessment for each trial, using the cochrane tool, the risk of selection bias, performance bias, detection bias, attrition bias, reporting bias, and miscellaneous bias will be evaluated and categorized as low risk, high risk, or unclear (if it does not meet the low or high-risk categorization) [30]. the selection bias will be assessed by the random sequence generation method used to allocate interventions to the participants and the means used to conceal this allocation from the participants [30]. the performance bias will be based on the adequate blinding of study participants and personnel [30]. depending on the blinding mechanism of the outcome assessors, the detection bias will be judged [30]. based on the reasons and balance in missing outcome data between treatment arms, attrition bias will be evaluated [30,31]. by comparing the variation in a trial's reported findings from its protocol or prestated plans, the reporting bias will be assessed [30]. author’s roles the review authors will independently do the literature search, data abstraction, and risk of bias assessment, and resolve conflict in opinions by discourse. if such disagreements sustain, a third-party opinion will be sought. meta-analysis for binomial outcomes, risk ratios will be estimated. whereas, for continuous outcomes, meta-analytic standardized or weighted mean difference estimation will use the endpoint means and its standard deviations (sd). if this endpoint sd for an outcome is unavailable in a trial, it will be substituted by the sd of the baseline mean of that outcome, and the meta-analysis will be performed using the mean changes and its sd changes from the baseline (using correlation coefficient 0.5). in trials with more than one intervention arms testing the low dosages, the respective outcome data will be combined across these treatment arms. the summary estimate from meta-analysis will be analyzed using either a random-effect model (der simonian and laird method) or a fixed-effect model (inverse variance method). this model choice will depend on the clinical heterogeneity of the trials like trial settings, study design, participant characteristics, etc. and not the pre-determined statistical inconsistency. if the reviewed trials are clinically heterogeneous, a random-effect model will be used or viceversa. a trial will be excluded from the meta-analysis if the outcome does not happen in both of the contrasting treatment arms. however, for dichotomous outcomes, when it happens in either of these arms, 0.5 will be added to each cell of the 2x2 table, and the trial will be incorporated in the meta-analysis. for summary estimates of meta-analysis, a statistical significance will be determined at a p <0.05 (and 95% confidence interval). the trials with a high risk of bias will not be included in the meta-analysis. any outcome for which a quantitative juxtaposition is not possible, a narrative reporting will ensue. heterogeneity and publication bias using the i2 and chi2 statistics, the statistical inconsistency among the trials will be determined. at the i2 statistics values of 0-40%, 30-60%, 50-90%, and 75-100%, the heterogeneity will be categorized as less, moderate, substantial, and considerable, respectively [30]. at a p <0.1, the statistical significance of the chi2 statistics will be estimated [30]. if considerable statistical heterogeneity is detected in a metaanalysis of at least 10 trials, a subgroup analysis will be done. it will be done between the trials testing sglt2 inhibitors and the dual sglt2/1 inhibitor, between the trials in which the participants’ estimated glomerular filtration rate (gfr) was less than 60 ml/min/1.73 m2 and more than 60 ml/min/1.73 m2, and based on missing outcome data. publication bias will be assessed using funnel plots. additionally, an egger’s test will be used when at least ten trials are available for meta-analysis. additional analysis the following types of sensitivity analysis will be done by repeating the meta-analysisa. by using a different meta saha s., journal of ideas in health (2020); 3(2):167-172 170 analysis model (fixed effect or random effect) then that was used during the preliminary analysis. b. by dropping one trial every time. c. by eliminating trials shorter than two weeks duration. d. by excluding trials that included trial population with gfr less than 60 ml/min/1.73 m2. e. if the mean changes and their sds are used for any meta-analysis, the analysis will be iterated using a different correlation coefficient to determine the sd change (e.g., 0.8). in the subgroup and sensitivity analysis proposed above, the rationale for using the benchmark of an optimum gfr (60 ml/min/1.73 m2) is that sglt2 inhibitors is not recommended in t2dm patients with very low gfr [2]. therefore, the notion is to see if such gfr plays any role in t1dm patients too. finally, for the dichotomous outcomes with statistically significant meta-analytic results, imputation case analysis (ica) will be done to test the robustness of the preliminary analysis [32]. assuming the event's occurrence and non-occurrence in all of the missing participants, the ica-1 and ica-0 analyses will be conducted, respectively. moreover, the bestand worst-case scenario will be assessed along with the gamble-hollis analysis [33]. statistically significant outcomes' will be graded for the quality of evidence using the grades of recommendation, assessment, development, and evaluation (grade) working group’s grade approach [34]. all analyses will be performed in stata statistical software version 16 (statacorp, college station, texas, usa). discussion the chief implication of the prospective systematic review is that it will be one of the preliminary attempts to synthesize evidence in this context. it will perhaps help physicians, pharma companies, and relevant health authorities to understand how the side effects of sgltis vary between different doses. additionally, the proposed study's findings will help in comparing the results with similar research conducted on t2dm patients. regarding the strengths, evidence generated from the proposed review is likely to be rigorous since it will be based on randomized controlled trials (the highest level of epidemiological evidence). its comprehensiveness is likely to be ensured due to not limiting the database search to any date range. furthermore, the range of proposed sensitivity and imputation analysis will provide an idea of the robustness of the evidence generated from the review. despite these strengths, the suggested review is likely to have few weaknesses. at the review level, the inclusion of randomized controlled trials only limits its scope of reviewing studies of other designs like crossover trials or quasiexperimental studies, or good quality observational studies. besides, limiting the database search to the english language literature only narrows down the scope of reviewing trials published (if any) in other languages. lastly, since the diagnosis of t1dm and outcome definitions will be accepted as per the trialists, if the trials are extremely heterogenous in this context, the synthesized evidence may be at risk of bias. conclusion the proposed review will compare the safety profile between high and low doses of sgltis in insulin-treated t1dm patients. abbreviation gfr: glomerular filtration rate; grade: grades of recommendation, assessment, development, and evaluation; ica: imputation case analysis; prospero: prospective register of systematic reviews; sgltis: sodium-glucose co-transport inhibitors; sglt1: sodiumglucose transporter 1; sglt2: sodium-glucose transporter 2; sd: standard deviations ; t1dm: type 1 diabetes mellitus ; t2dm: type 2 diabetes mellitus declarations acknowledgment none funding the author received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing sumanta.saha@uq.net.au authors’ contributions sumanta saha (ss) is the principal investigator of this manuscript (review). ss is the responsible author for the study concept, design, writing, reviewing, editing, and approving the manuscript in its final form. ss has read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, review articles need no ethics committee approval. consent for publication not applicable competing interest the author declares that he has no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1independent researcher, sumanta.saha@uq.net.au article info received: 29 july 2020 accepted: 16 august 2020 published: 20 august 2020 references 1. lucier j, weinstock rs. diabetes mellitus type 1. statpearls treasure isl statpearls publ [internet]. 2020. available from: http://www.ncbi.nlm.nih.gov/pubmed/29939535 saha s., journal of ideas in health (2020); 3(2):167-172 171 2. fattah h, vallon v. the potential role of sglt2 inhibitors in the treatment of type 1 diabetes mellitus. drugs. 2018;78(7):717726. doi:10.1007/s40265-018-0901-y 3. cherney dz, perkins ba, soleymanlou n, har r, fagan n, johansen o, et al. the effect of empagliflozin on arterial stiffness and heart rate variability in subjects with uncomplicated type 1 diabetes mellitus. cardiovasc diabetol 2014; 13:28. available from: http://cardiab.biomedcentral.com/articles/10.1186/14752840-13-28 4. dellepiane s, ben nasr m, assi e, usuelli v, letizia t, d’addio f, et al. sodium glucose cotransporters inhibitors in type 1 diabetes. pharmacol res. 2018; 133:1–8. available from: http://www.ncbi.nlm.nih.gov/pubmed/29689314 5. alvarado-martel d, velasco r, sánchez-hernández rm, carrillo a, nóvoa fj, wägner am. quality of life and type 1 diabetes: a study assessing patients’ perceptions and self-management needs. patient prefer adherence 2015; 9:1315–23. available from: http://www.ncbi.nlm.nih.gov/pubmed/26396503 6. subramanian s, baidal d, skyler js, hirsch ib. the management of type 1 diabetes [internet]. endotext. 2000. available from: http://www.ncbi.nlm.nih.gov/pubmed/25905338 7. boeder s, edelman s v. sodium‐glucose co‐transporter inhibitors as adjunctive treatment to insulin in type 1 diabetes: a review of randomized controlled trials. diabetes, obes metab. 2019; 21:62– 77. available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/dom.13749 8. davidson ja. sglt2 inhibitors in patients with type 2 diabetes and renal disease: overview of current evidence. postgrad med. 2019; 131:251–60. available from: https://www.tandfonline.com/doi/full/10.1080/00325481.2019.16 01404 9. australian prescriber. new drug: ertugliflozin for type 2 diabetes. 2019;42:68. available from: http://care.diabetesjournals.org/lookup/doi/10.2337/dc18-s006 10. mathieu c, dandona p, phillip m, oron t, lind m, hansen l, et al. glucose variables in type 1 diabetes studies with dapagliflozin: pooled analysis of continuous glucose monitoring data from depict-1 and -2. diabetes care 2019; 42:1081–7. available from: http://care.diabetesjournals.org/lookup/doi/10.2337/dc18-1983 11. rosenstock j, marquard j, laffel lm, neubacher d, kaspers s, cherney dz, et al. empagliflozin as adjunctive to insulin therapy in type 1 diabetes: the ease trials. diabetes care 2018; 41:2560–9. available from: http://care.diabetesjournals.org/lookup/doi/10.2337/dc18-1749 12. henry rr, thakkar p, tong c, polidori d, alba m. efficacy and safety of canagliflozin, a sodium–glucose cotransporter 2 inhibitor, as add-on to insulin in patients with type 1 diabetes. diabetes care 2015; 38:2258–65. available from: http://care.diabetesjournals.org/lookup/doi/10.2337/dc15-1730 13. sims h, smith kh, bramlage p, minguet j. sotagliflozin: a dual sodium-glucose co-transporter-1 and -2 inhibitor for the management of type 1 and type 2 diabetes mellitus. diabet med. 2018; 35:1037–48. available from: http://www.ncbi.nlm.nih.gov/pubmed/29637608 14. saha s, saha s. a systematic review and meta-analysis of randomized controlled trials, juxtaposing the control of glycemia and blood pressure between large dose empagliflozin and placebo among type 1 diabetes patients. int j health sci (qassim). 2020; 14:40–52. available from: https://www.ijhs.org.sa/index.php/journal/article/view/4346 15. reuters. fda rejects sanofi-lexicon add-on pill for type 1 diabetes. health (irvine. calif). [cited 2020 apr 23]. available from: https://in.reuters.com/article/us-sanofi-fr-fda/fda-rejectssanofi-lexicon-add-on-pill-for-type-1-diabetes-idinkcn1r32dm 16. u.s. food and drug administration. sodium-glucose cotransporter-2 (sglt2) inhibitors [internet]. 2018 [cited 2019 dec 26]. available from: https://www.fda.gov/drugs/postmarketdrug-safety-information-patients-and-providers/sodium-glucosecotransporter-2-sglt2-inhibitors 17. pieber tr, famulla s, eilbracht j, cescutti j, soleymanlou n, johansen oe, et al. empagliflozin as adjunct to insulin in patients with type 1 diabetes: a 4-week, randomized, placebo-controlled trial (ease-1). diabetes, obes metab. 2015; 17:928–35. available from: http://doi.wiley.com/10.1111/dom.12494 18. mathieu c, dandona p, gillard p, senior p, hasslacher c, araki e, et al. efficacy and safety of dapagliflozin in patients with inadequately controlled type 1 diabetes (the depict-2 study): 24-week results from a randomized controlled trial. diabetes care. 2018; 41:1938–46. available from: http://care.diabetesjournals.org/lookup/doi/10.2337/dc18-0623 19. sands at, zambrowicz bp, rosenstock j, lapuerta p, bode bw, garg sk, et al. sotagliflozin, a dual sglt1 and sglt2 inhibitor, as adjunct therapy to insulin in type 1 diabetes. diabetes care. 2015; 38:1181–8. available from: http://www.ncbi.nlm.nih.gov/pubmed/26049551 20. saha s, saha s. a systematic review and meta-analysis of randomised controlled trials, contrasting the safety profile between sodium-glucose cotransporter-2 inhibitors and placebo in type 1 diabetes mellitus patients. int j diabetes metab [internet]. s. karger ag; 2020;1–12. available from: https://www.karger.com/article/fulltext/506366 21. yamada t, shojima n, noma h, yamauchi t, kadowaki t. sodium‐glucose co‐transporter‐2 inhibitors as add‐on therapy to insulin for type 1 diabetes mellitus: systematic review and meta‐ analysis of randomized controlled trials. diabetes, obes metab. 2018; 20:1755–61. available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/dom.13260 22. saha s. an appraisal of a systematic review and meta-analysis of randomized clinical trials on the efficacy and safety of sodium-glucose cotransporter-2 inhibitors as an adjunct to insulin therapy in type 1 diabetes patients. int j diabetes metab. s. karger ag; 2019;1–1. available from: https://www.karger.com/article/fulltext/502743 23. lu j, tang l, meng h, zhao j, liang y. effects of sodiumglucose cotransporter (sglt) inhibitors in addition to insulin therapy on glucose control and safety outcomes in adults with type 1 diabetes: a meta-analysis of randomized controlled trials. diabetes metab res rev. 2019; e3169. available from: http://www.ncbi.nlm.nih.gov/pubmed/30974510 24. saha s, saha s. the comparison of efficacy and safety between different doses of empagliflozin in insulin-treated type 1 diabetes mellitus patients: a systematic review and meta-analysis protocol. j diabetes metab disord. 2020; 19:545–50. available from: http://link.springer.com/10.1007/s40200-020-00544-x 25. saha s, saha s. a systematic review and meta-analysis of randomized controlled trials comparing the safety of saha s., journal of ideas in health (2020); 3(2):167-172 172 dapagliflozin in type 1 diabetes patients. iran j heal sci. 2020;8. available from: http://jhs.mazums.ac.ir/article-1-708-en.html 26. saha s, saha s. comparison between sodium-glucose cotransporter inhibitors of high dose and low dose, and with placebo in contemporary insulin-treated type-1 diabetes patients: a systematic review and meta-analysis of randomised controlled trials. [internet]. prospero 2019 crd42019146578. [cited 2019 dec 8]. available from: https://www.crd.york.ac.uk/prospero/display_record.php?id=cr d42019146578 27. moher d, shamseer l, clarke m, ghersi d, liberati a, petticrew m, et al. preferred reporting items for systematic review and metaanalysis protocols (prisma-p) 2015 statement. syst rev [internet]. 2015; 4:1. available from: https://systematicreviewsjournal.biomedcentral.com/articles/10.11 86/2046-4053-4-1 28. ouzzani m, hammady h, fedorowicz z, elmagarmid a. rayyan—a web and mobile app for systematic reviews. syst rev [internet]. 2016; 5:210. available from: http://systematicreviewsjournal.biomedcentral.com/articles/10.118 6/s13643-016-0384-4 29. liberati a, altman dg, tetzlaff j, mulrow c, gøtzsche pc, ioannidis jpa, et al. the prisma statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. j clin epidemiol [internet]. 2009;62: e1–34. available from: https://linkinghub.elsevier.com/retrieve/pii/s0895435609001802 30. higgins jpt gs (editors). cochrane handbook for systematic reviews of interventions version 5.1.0 [updated march 2011]. [internet]. cochrane collab. 2011. available from: www.cochrane-handbook.org 31. saha s. impact of missingness on clinical trials on the effectiveness of antenatal vitamin d supplementation in gestational diabetes mellitus patients. j ideas heal [internet]. 2020; 3:138–9. available from: https://www.jidhealth.com/index.php/jidhealth/article/view/47 32. higgins jp, white ir, wood am. imputation methods for missing outcome data in meta-analysis of clinical trials. clin trials j soc clin trials [internet]. 2008; 5:225–39. available from: http://journals.sagepub.com/doi/10.1177/1740774508091600 33. gamble c, hollis s. uncertainty method improved on best–worst case analysis in a binary meta-analysis. j clin epidemiol [internet]. 2005; 58:579–88. available from: https://linkinghub.elsevier.com/retrieve/pii/s0895435605000417 34. 34. atkins d, best d, briss pa, eccles m, falck-ytter y, flottorp s, et al. grading quality of evidence and strength of recommendations. bmj [internet]. 2004; 328:1490. available from: http://www.bmj.com/lookup/doi/10.1136/bmj.328.7454.1490 hassooni et al., journal of ideas in health 2018; 1(1):29-33 © the author(s). 2018 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. journal homepage: www.jidhealth.com open access upper respiratory infection and otitis media are clinically and microbiologically associated hanan raheem hassooni1*, samih faiq fadhil 2, raed m. hameed 2, adil hassan alhusseiny 3, saad ahmed ali jadoo 4 abstract background: although significant improvement has been achieved in terms of antibiotic care, otitis media (om) continues to be a worldwide health problem that may develop serious complications. this study aimed to detect the growth of organisms and to find out the most susceptible factors related to om among the iraqi population. methods: a prospective cross-sectional study was conducted at the out-patient department (opd) of ear, nose, and throat (ent) at the baquba teaching hospital at the faculty of medicine, diyala university from november 2017 to march 2018. a total of 300 ear samples collected from 87 (29.0%) patients of acute otitis media (aom), 104 (34.7%) patients of otitis media with effusion (ome), and 109 (36.3%) patients of chronic otitis media (com). standard microbiological procedures were recruited to investigate the samples using aerobic and anaerobic culture methods. results: the highest incidence of om 218 (72.7%) was observed among the age group of fewer than ten years old. the most common bacteria isolated were pseudomonas aeruginosa (35.0%), staphylococcus aureus (25.0%), proteus spp. (24.0%), escherichia coli (7.0%), streptococcus pneumonia (6.0%), klebsiella pneumonia (2.0%) and streptococcus pyogenes (1.0%). it was found that upper respiratory infection (urti), adenoid inflammation with (urti), adenoid inflammation, the practices of complementary and alternative medicine (cam), and the accident or trauma are the main factors related to om in about (42.0%), (31.0%), (11.0%), (10.0%) and (6.0%) of cases respectively. conclusion: our findings suggest that om was effectively related to urti and adenoid inflammation with (urti) in about 73.0% of cases. more attention should be given to early diagnosis and treatment of urti before progressing to undesirable om. keywords: acute otitis media, chronic otitis media, otitis media with effusion, urti, baquba, diyala, iraq background the term "otitis media" (om) is used to describe the inflammatory process occurring in the middle ear. clinically om covers a broad spectrum of illnesses such as acute otitis media (aom), otitis media with effusion (ome), and chronic suppurative otitis media (csom) [1]. unfortunately, om is one of the most common cases among children that require outpatient department (opd) visits and is frequently preceded by or accompanied by some types of upper respiratory infections (uris) [2]; however, the leading causes that may participate in om have not well understood. anatomically, the well-known eustachian tube (et) runs between the nasopharynx and the middle ear. usually, the young age group is more prone to have ear infection than adults because et is shorter, narrower, and more horizontal in children compared to the older age group [3,4]. the vital small size et may get plugged, resulting in a case called eustachian tube dysfunction (etd). the blocked et or etd is commonly being a target for many viral and bacterial infections, or the normal flora moving from the upper respiratory tract and eventually attack the middle air [5]. furthermore, the risk factors related to allergy towards some kinds of foods, environmental, social, racial, host, immunological, and genetic factors found to be significantly related to the high incidence of om [6-8]. uris with nasopharyngeal colonization is strongly related to om [9]. the risk of aom among children would be more likely to increase if the bacterial growth was positive in the nasopharynx [10]. the viral infection was indicated to be the initial cause of uris in most cases of om; however, a superadded infection of both viral and bacterial infection has been widely seen [11]. ___________________________________________________ hanan6319@gmail.com 1department of biology, faculty of education for pure science, diyala university. full list of author information is available at the end of the article. http://www.jidhealth.com/ hassooni et al., journal of ideas in health 2018; 1(1):29-33 30 although om is not a life-threatening disease, however, a list of severe acute and chronic complications such as labyrinthitis, mastoiditis, facial nerve palsy, and intracranial complications have been reported [12,13]. different microorganisms have been isolated from different cultures of the ear discharge; however, the streptococcus pneumoniae, streptococcus pyogenes, staphylococcus aureus, pseudomonas aeruginosa, escherichia coli, klebsiella spp., and proteus spp. were the most common pathogens knowing to cause om and usually come from contaminated water [14]. this study aimed to investigate the growth of (aerobic and anaerobic) organisms and to find out the most important related factors of om among the iraqi population. methods study design and subjects a cross-sectional descriptive-analytical study was conducted at the opd of ear, nose, and throat (ent) of baquba teaching hospital at the faculty of medicine, diyala university. a prospective data of three hundred (300) diagnosed otitis media (om) patients of all ages, and both genders were collected during the period of 1st november 2017 to 30th march 2018. a convenience sampling technique was recruited; however, only one sample was allowed for each patient to avoid selection bias. moreover, the one-sided sample was considered in all cases presented with bilateral infection. at the time of the study, patients presented with "acute bacterial infection of the middle ear of fewer than six weeks duration" are diagnosed with aom, however, when "infection persists in the middle ear space for more than three months and is associated with a chronic perforation of the tympanic membrane" referred to csom. cases of om presented with "fluid in the middle ear without signs or symptoms of inflammation" are defined as ome. most of ome occurs just before or persist after infection for a few days or up to many weeks [3,13,15]. table 1 presents the inclusion and exclusion criteria. table 1 inclusion and exclusion criteria. inclusion and exclusion criteria aom ome com impaired hearing + + + pain (otalgia) + tenderness purulent drainage (otorrhea) + + systemic symptoms (i.e., fever, malaise) + current antibiotic therapy (topical or systemic) use or used in the preceding two weeks + + recent ear surgery or an in-situ grommet or tympanostomy tube mastoid surgery in the preceding 12 months congenital ear, obstructed middle ear (e.g., polyp) and hearing problems patients with ear discharge due to cholesteatoma ome: otitis media with effusion; aom: acute otitis media; com: chronic otitis media. (+): referred to inclusion criteria; (-): referred to exclusion criteria collection of the sample each eligible patient has undergone to scientific standard procedure. all measures have been taken to avoid sample contamination. sterile cotton with normal saline (0.85% nacl) was used to remove the contaminated discharge in the outer part of the infected ear. then, under bull's lamp with a head mirror, a sterile cotton swab containing a test tube was recruited to take a pus sample from the deep region close to the tympanic membrane through a sterile ear speculum. transport of sample consideration was taken to maintain the viability of microorganisms. an icebox was used to keep all collected samples in sterile test tubes and sent within 1 hour to the microbiology department of baquba teaching hospital. individual patient data, such as name, date, and age, were included in the corresponding labeled test tubes. stain and culture process all the swabs were gram-stained (gs) to identify the pathogenic organisms. only the positive gs swabs directly inoculated in a suitable culture media. three types of agar (blood, chocolate, and macconkey agars) were used to culture the organisms. according to the standard microbiological methods [16,17], “five percent sheep blood agar and macconkey agar plates were incubated aerobically, while chocolate agar was incubated under 5% co2 atmosphere at 37°c for 24–48 h” [14]. otitis media-related factors the patient was diagnosed as urti if clinically "presented with an episode of common cold along with one of the following symptoms: (i) cough; (ii) rhinorrhea; (iii) nasal congestion or if presented with a common cold, pharyngitis or tonsillitis" [1820]. adenoids (pharyngeal tonsils) are groups of lymphatic tissues located in the throat just behind the nose. adenoid and the tonsils are the first line of defense against bacteria and viruses invasion. adenoid inflammation is "the enlargement of the nasopharyngeal tonsils" [21] and "clinically presented with or without typical adenoid facies and difficulty in breathing, repeated upper respiratory tract infection, snoring, mouth breathing, secretory otitis media, nasal speech, and sometimes obstructive sleep apnoea" [22]. information on the complementary and alternative medicine (cam) options for om treatment were collected from the participants. in this study, participants were asked if they tried any of cam ( acupuncture, homeopathy, herbal medicine/phytotherapy, osteopathy, chiropractic, xylitol, ear candling, vitamin d supplement, and systemic and topical probiotics) in the form of introduction of unconventional ear drops and concoctions such as oil and honey, etc. into the middle ear [23,24]. different types of trauma (accidents) such as foreign objects, barotrauma, and concussive trauma may directly or indirectly affect the ear. foreign objects were the most common ear trauma that may cause damage or perforation to the tympanic membrane (tm) or eardrum as a result of introducing objects such as keys, hairpins, paperclips, and swabs. both of barotrauma and concussive trauma result from rapid change in hassooni et al., journal of ideas in health 2018; 1(1):29-33 31 pressure between the middle ear and the outside air. a sudden and extreme change in pressure around the tm may occur following driving up and down in the mountains or scuba diving blow to the ear. also, when flying and water skiing or when exposed to the sound of an explosion or the concussion from a gunshot near the ear. statistical analysis data was collected and analyzed using microsoft excel spreadsheet. descriptive analysis was performed concerning the most common related factors to otitis media and the common pathogen isolate. results descriptive analyses out of 300 collected ear swabs, the vast majority of 218 (72.7%) of patients were in the age group of fewer than ten years old compared to 82 (27.3%) cases of ten or more than ten years old. in general, each com (109, 36.3%) and ome (104, 34.7%) constitute separately about two-third of the studied sample compared to 87 (29.0%) cases of aom (table 2). the primary diagnosis was ome in 86 (28.7%) cases under ten years old, while the com was diagnosed in 34(11.3%). om with urti was found in 126 (42.0%) of cases, and 93 (31.0%) of patients have diagnosed om with adenoid inflammation and urti (table 2). in table 3, the most common organisms isolated were pseudomonas aeruginosa 105 (35.0%), staphylococcus aureus 75(25.0%), and proteus ssp. 72 (24.0%) respectively. however, enterobacteriaceae members such as escherichia coli were isolated in 21(7%) of patients and streptococcus pneumonia in 18 (6%) of patients, respectively (table 3). discussion in this study, three different groups of om, namely: aom, ome, and com, have been diagnosed; however, the incident was not much different. com was in the highest incidence and reported in 36.3% of cases indicating the improper medical treatment of aom and ome in iraq [25, 26]. indeed, after the us-led invasion of iraq in 2003, the security, health care services, and socio-economic status have been worsened significantly [27]. a great number of iraqi families who are living in rural regions and even the displaced families who are forced to live in small camps with poor hygiene, malnutrition, and over-crowding were more liable to develop different diseases, including om [26,28]. besides all these factors, the lack or poor implementation of child health care programs such as integrated management of neonate and child health (imnch), the insufficient number of trained and specialized staff [27,29] and the deficiency of effective treatment have either led to misdiagnosis or the evolution of om from acute to chronic status. moreover, the short and straight et in children is more likely to ease moving of pathogens directly from nose, adenoids, and sinuses to middle ear "particularly during coughing, sneezing, vomiting, and forced feeding commonly practiced in our environment with the child's nose blocked, while being held head down and half prone” [30,31]. our clinical findings were agreed with this fact, in which the incidence of om (aom, ome, and com) was higher among children under ten years old. similar results were reported in nigari [24], iraq [26], nibal [30], egypt [32], saudi arabia [33] and china [34]. in this study, some contributing factors found to be clinically related to the emerging of om. the highest percentage was among children presented with urti and om. such findings are shedding light on the role of respiratory diseases in the occurrence of otitis media. the results of this study were supported by earlier findings from studies among nigerian children [2], and school-aged children in yemen [35]. children are prone to urti due to the immature immune system that minimally protects them against the opportunistic organisms [36]. although the vast majority of otitis media cases occur in children under the age of 10 years, especially in the first six years of age, the adult population is not immune to this affliction [37]. in this study, the most commonly isolated pathogen was pseudomonas aeruginosa (35.0%), followed by staphylococcus aureus (25.0%) and proteus ssp. (24.0%) respectively. this trend is similar to findings observed in iraq [38], gaza strip, palestine [14], kashmir, india [39], ethiopia [40], and pakistan [41]. however, other studies reported a reverse sequence to our results where proteus spp., followed by s. aureus and pseudomonas spp. were the predominant isolates [42-43]. pseudomonas aeruginosa known to be the most common secondary bacterium associated with an ear infection, because of "its ability to survive in competition with other organisms and resistance to antibiotics" [40]. this may explain the reason behind the dominance of pseudomonas aeruginosa in an ear infection partly. "moreover, p. aeruginosa uses its pili to attach to the necrotic or diseased epithelium of the middle ear. once attached, the organism produces enzymes like proteases to elude the normal defense mechanism of the body required for fighting infections"[ 40,42]. furthermore, the isolation of fecal pathogens such as k. pneumonia and e. coli indicating that the source of infection with these bacteria does not have to be from the nasal pharyngeal canal but can be obtained through fecal contamination of the auditory tube by improperly cleaning the ear and swimming in polluted water. this study has some limitations; because of the limited patient details in terms of sociodemographic variables, it was impossible to perform further analysis. the main objective was to confirm the clinical relationship between the urti and om, so there was no need to make antimicrobial susceptibility testing; however, the earlier local study in iraq found that p. aeruginosa were sensitive to imipenem (100%), amikacin (85.0%) and ciprofloxacin (62.5%) respectively [38]. conclusion in conclusion, the present study emphasized that om and urtis are clinically and microbiologically related. otitis media was found to be highly prevalent among children of less than ten years; however, adults are not so far from the disease. in this study, the most prevalent pathogens isolated were pseudomonas aeruginosa 105(35.0%), staphylococcus aureus 75(25.0%), and proteus ssp.72 (24.0%) respectively. in iraq, om is among the serious health condition that required further research to help to understand the progress of the disease. scientific and strategic plans are required to formulate better therapeutic and preventive measures. hassooni et al., journal of ideas in health 2018; 1(1):29-33 32 table 2 the most common related factors to otitis media (n=300) related factors less than ten years old ten years and more n (%) aom ome com aom ome com urti 10 41 39 7 13 16 126 (42) adenoid inflammation with (urti) 27 35 11 13 3 4 93(31) adenoid inflammation 13 8 5 5 2 0 33(11) complementary and alternative medicine (cam) 5 2 12 2 0 9 30(10) trauma 2 0 8 3 0 5 18(6) total 57 86 75 30 18 34 300(100) table 3 aerobic bacteria isolated from discharging ear. no. isolated bacteria n % 1 pseudomonas aeruginosa 105 35 2 staphylococcus aureus 75 25 3 proteus ssp. 72 24 4 escherichia coli 21 7 5 streptococcus pneumonia 18 6 6 klebsiella pneumonia 6 2 7 streptococcus pyogenes 3 1 total 300 100% n: number of patients abbreviations om: otitis media aom: acute otitis media ome: otitis media with effusion csom: chronic suppurative otitis media com: chronic otitis media opd: out-patient department uris: upper respiratory infections et: eustachian tube etd: eustachian tube dysfunction ent: ear, nose and throat gs: gram stain h: hour cam complementary and alternative medicine tm: tympanic membrane imnch: integrated management of neonate and child health declarations acknowledgment we render our special thanks to all medical and paramedical staff in baquba teaching hospital for their help, time, and openness during the data collection. funding the author (s) received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing hanan6319@gmail.com. authors’ contributions hrh is the principal investigator of the study who designed the study and coordinated all aspects of the research, including all steps of the manuscript preparation. she is responsible for the study concept, design, writing, reviewing, editing, and approving the manuscript in its final form. sf, rmh, and ah contributed to the study design, analysis, and reviewed and approved the manuscript. saaj contributed in the study design, analysis and interpretation of data, drafting the work, writing the manuscript and reviewed and approved the manuscript. all authors read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki, and the center of training and human resource development, diyala province health directorate, ministry of health, iraq approved protocol (ref: official letter no. 303 issued on 21st january 2018). confidentiality was assured with signed informed consent. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of biology, faculty of education for pure science, diyala university.2department of otorhinolaryngology, faculty of medicine, baghdad university.3department of internal medicine, faculty of medicine, diyala university, iraq. 4department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey. article info received: 10 june 2018 accepted: 01 july 2018 published: 03 july 2018 references 1. lieberthal as, carroll ae, chonmaitree t, ganiats tg, hoberman a, jackson ma, et al. the diagnosis and management of acute otitis media. pediatrics 2013; 131(3): e964-99. 2. afolabi oa, kodiya am, bakari a, ahmad bm. otological emergencies among nigerian children. east central afr j surg 2008; 13: 91-95. 3. acuin j. chronic suppurative otitis media: burden of illness and management options. world health organization (who). 2006. available from: http://www.who.int/pbd/publications/chronicsuppurativeotitis_media.p df, [accessed on 12 june 2018]. 4. cinamon u. the growth rate and size of the mastoid air cell system and mastoid bone: a review and reference. eur arch otorhinolaryngol 2009; 266(6):781-776. 5. ruohola a, meurman o, nikkari s, skottman t, salmi a, waris m, et al. microbiology of acute otitis media in children with tympanostomy tubes: prevalences of bacteria and viruses. clinical infectious diseases2006; 43:1417–1422. 6. akinpelu ov, amusa yb, komolafe eo, adeolu aa, oladele ao, ameye sa. challenges in management of chronic suppurative otitis media in a developing country. j. laryngol otology2008; 122: 16-20. 7. rye ms, blackwell jm, jamieson se. genetic susceptibility to otitis media in childhood. laryngoscope 2012; 122(3):665-75. 8. balan s, viswanatha b. microbiology of chronic suppurative otitis media: a prospective study in a tertiary care hospital. journal of otolaryngology-ent research2017; 9(1):1-4. hassooni et al., journal of ideas in health 2018; 1(1):29-33 33 9. ravi k, mamidi d, chonmaitree t. association of nasopharyngeal bacterial colonization during upper respiratory tract infection and the development of acute otitis media. clinical infectious diseases2008; 46:34–37. 10. rayner mg, zhang y, gorry mc, chen y, ehrlich fd. evidence of bacterial metabolic activity in culture negative otitis media with effusion: clin invest j jama1998; 279:296-299. 11. verhoeven d, xu q, pichichero me, differential impact of respiratory syncytial virus and parainfluenza virus on the frequency of acute otitis media is explained by lower adaptive and innate immune responses in otitis-prone children. clin infect dis 2014; 59(3): 376-383. 12. penido nde o, chandrasekhar ss, borin a, maranhão as, gurgel testa jr. complications of otitis media a potentially lethal problem still present. braz j otorhinolaryngol 2016; 82(3):253-262. 13. laulajainen-hongisto a. acute severe complications of otitis media in children and adults.2016. hans print, vantaa, helsinki, finland. available from: https://helda.helsinki.fi/bitstream/handle/10138/161434/acutesev.pdf?se quence=1, [accessed on 12 june 2018]. 14. elmanama a, abu tayyem n, nassr allah s. the bacterial etiology of otitis media and their antibiogram among children in gaza strip, palestine egyptian journal of ear, nose, throat and allied sciences 2014; 15: 87–91. 15. roland ps. all otitis is not created equal: aom vs ome. medscape education infectious diseases. available from: https://www.medscape.org/viewarticle/730698 [accessed on 11 june 2018]. 16. clinical and laboratory standard institute. performance standards for antimicrobial susceptibility testing. clinical and laboratory standards institute, wayne. 22nd inform suppl. 2012; 32(3): m100 s21. 17. clsi. performance standards for antimicrobial susceptibility testing, seventeenth informational supplement, document m100-s17; 2007, 27 no. 1. 18. alexandrino as, santos r, melo c, bastos jm. risk factors for respiratory infections among children attending day care centres. fam pract 2016; 33(2):161-66. 19. chen y, williams e, kirk m. risk factors for acute respiratory infection in the australian community. plos one 2014; 9: e101440. 20. dales re, cakmak s, brand k, judek s. respiratory illness in children attending daycare. pediatr pulmonol 2004; 38: 64-69. 21. gates ga, muntz hr, gaylis b. adenoidectomy and otitis media. ann otol rhinol laryngol suppl 1992; 155:24-32. 22. karodpati n, shinde v, deogawkar s, ghate g. adenoid hypertrophy in adults a myth or reality. webmedcentral otorhinolaryngol 2013; 4: wmc004079. 23. marom t, marchisio p, tamir so, torretta s, gavriel h, esposito s. complementary and alternative medicine treatment options for otitis media: a systematic review. medicine (baltimore) 2016; 95(6): e2695. 24. nwokoye n, egwari l, coker a, olubi o, ugoji e, nwachukwu s. predisposing and bacteriological features of otitis media. afr j microbiol res2012; 6(3):520-525. 25. qader sn, yaseen ma. management of acute otitis externa using aural wick versus local drops. zanco j med sci 2012; 16 (3):187-193. 26. jameel gh, al-ezzy aba. evaluation of antifungal activity of calvatia craniiformis and ivermectin as novel alternative therapies for aspergillus niger associated acute otitis media with special refer to sociodemographic factors among rural children of diyala province-iraq. international journal of pharmaceutical and clinical research 2017; 9(8): 581-589. 27. ali jadoo sa, aljunid sm, dastan i, tawfeeq rs, mustafa ma, ganasegeran k, aldubai sa. job satisfaction and turnover intention among iraqi doctors-a descriptive cross-sectional multicenter study. hum resour health2015; 13:21 28. lasisi ao, sulaiman oa, afolabi oa. socio-economic status and hearing loss in chronic suppurative otitis media in nigeria. ann trop paediatr 2007, 27:291-96. 29. al-samarrai m, ali jadoo sa. impact of training on practical skills of iraqi health providers towards integrated management of neonatal and childhood illness-a multi-center cross sectional study. journal of ideas in health 2018; 1(1): 1-6. 30. basnet r, sharma s, rana jc, shah pk. bacteriological study of otitis media and its antibiotic susceptibility pattern. j nepal health res counc. 2017 sep 8; 15(2):124-129. 31. nwabuisi c, ologe fe. pathogenic agents of chronic suppurative otitis media in iiorin, nigeria. east afr med j.2002; 79(4):202-205. 32. khallaf n, el-ansary s, hassan m. acute respiratory infections: sentinel survey in egypt. world health forum 17 (1996) 297–300. 33. arguedas a, kvaerner k, liese j, schilder agm, pelton si. otitis media across nine countries: disease burden and management. int. j. pediatr. otorhinolaryngol2010; 74 (12):1419–1424. 34. zhang z, wei j, xu m, zhang q, zhang x, zhang z, et al. prevalence of otitis media with effusion among children in xi’an, china: a randomized survey in china’s mainland. ann otol rhinol laryngol 2011; 120(9):617-21. 35. muftah s, mackenzie i, faragher b, brabin b. prevalence of chronic suppurative otitis media (csom) and associated hearing impairment among school-aged children in yemen. oman medical journal 2015; 30(5): 358-65. 36. gordon ma, grunstein e, burton wb. the effect of season on otitis media with effusion resolution rate in the new york metropolitan area. int j pediatr otorhinolarngol 2004; 68: 191-195. 37. danishyar a, ashurst jv. otitis, media, acute. statpearls, 2017. available from: https://www.ncbi.nlm.nih.gov/books/nbk470332/ [accessed 01 june 2018]. 38. al-zubaidy i. microbiological assessment of chronic suppurative otitis media. kufa journal for nursing science 2014; 3(4):101-105 39. nazir a, kadri sm. aerobic bacteriology of chronic suppurative otitis media: a hospital based study. int j res med sci 2014; 2(4):15211525. 40. hailu d, mekonnen d, derbie a, mulu w, abera b. pathogenic bacteria profile and antimicrobial susceptibility patterns of ear infection at bahir dar regional health research laboratory center, ethiopia. springerplus2016; 5:466. 41. fatima g, shoaib m, raza mz, bilal s. antimicrobial susceptibility pattern of bacterial and fungal isolates from patients with chronic suppurative otitis media in perspective of emerging resistance. pak j otolaryngo 2013; 29:49-53. 42. seid a, deribe f, ali k, kibru g. bacterial otitis media in all age group of patients seen at dessie referral hospital, north east ethiopia. egypt j ear nose throat allied sci 2013; 14:73–78 43. denboba aa, abejew aa, mekonnen ag. antibiotic-resistant bacteria are major threats of otitis media in wollo area, northeastern ethiopia: a ten-year retrospective analysis. int j microbiol 2016:8724671. https://doi.org/10.47108/jidhealth.vol3.issspecial2.88 bhandari s, et al., journal of ideas in health 2020;3(special 2):286-292 © the author(s). 2020 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access evidence-based decision making and covid-19: what a posteriori probability distributions speak sudhir bhandari1, ajit singh shaktawat1, amit tak2*, jyotsna shukla3, bhoopendra patel4, sanjay singhal3, jitentdra gupta3, shivankan kakkar5, amitabh dube3, sunita dia6, mahendra dia7, todd c. wehner7 abstract background: in the absence of any pharmaceutical interventions, the management of the covid-19 pandemic is based on public health measures. the present study fosters evidence-based decision making by estimating various “a posteriori probability distributions" from covid-19 patients. methods: in this retrospective observational study, 987 rt-pcr positive covid-19 patients from sms medical college, jaipur, india, were enrolled after approval of the institutional ethics committee. the data regarding age, gender, and outcome were collected. the univariate and bivariate distributions of covid-19 cases with respect to age, gender, and outcome were estimated. the age distribution of covid-19 cases was compared with the general population's age distribution using the goodness of fit  test. the independence of attributes in bivariate distributions was evaluated using the chi-square test for independence. results: the age group ‘25-29’ has shown highest probability of covid-19 cases (p [25-29] = 0.14, 95% ci: 0.12 0.16). the men (p [male] = 0.62, 95%ci: 0.59-0.65) were dominant sufferers. the most common outcome was recovery (p [recovered] = 0.79, 95%ci: 0.76-0.81) followed by admitted cases (p [active]= 0.13, 95%ci: 0.11-0.15) and death (p [death] = 0.08, 95%ci: 0.06-0.10). the age distribution of covid-19 cases differs significantly from the age distribution of the general population ( =399.04, p < 0.001). the bivariate distribution of covid-19 across age and outcome was not independent ( =106.21, df = 32, p < 0.001). conclusion: the knowledge of disease frequency patterns helps in the optimum allocation of limited resources and manpower. the study provides information to various epidemiological models for further analysis. keywords: covid-19, a posteriori probability distributions, epidemiology, evidence-based decision making, public health, sars cov-2, india background according to the world health organization report, 8,061,550 confirmed cases and 440,290 confirmed deaths due to coronavirus disease-19 (covid-19) were recorded by 18 june 2020 across 216 countries globally [1]. in the absence of a vaccine, disease pandemic control includes public health measures such as lockdown and social distancing. the effectiveness of social distancing and the duration of lockdown was investigated using various mathematical models. “mathematical models are a simplified representation of how infection spreads across a population over time” [2]. several epidemiological models, such as the “mutually exclusive compartments sir” model (susceptible, infectious, or recovered), used structured age data and social contact matrices to study the progress of the covid-19 epidemic [3]. implementation of scientific evidence in making management decisions, developing policies and programs is the essence of evidence-based decision making [4]. a long time has been elapsed since the pandemic's commencement, and a considerable amount of data has been available. the information can be extracted from this data in the form of ‘a posterior probability distributions”. these distributions generate scientific evidence for further decision making [5]. the pattern of disease frequency distributions in a community is a function of cultural habits and social contacts. the lesser frequency of occurrence of covid-19 in children might be due to their having fewer outdoor activities and less international travel [6]. ___________________________________________________ dramitttak@gmail.com 2national centre of disease informatics and research, indian council of medical research, bengaluru, karnataka, india full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol3.issspecial2.88 http://www.jidhealth.com/ bhandari s, et al., journal of ideas in health (2020); 3(special 2):286-292 287 furthermore, the effects of public health measures such as lockdown, social distancing, and personal protective measures are reflected in the probability distributions. the probability distributions of various predictors of mortality risk, such as random blood sugar overages, reveals causes of mortality [7]. the present study's objective is the estimation of probabilities for univariate and bivariate distributions of covid-19 cases over different ages and genders, as observed in patients attending the tertiary care hospitals in rajasthan. methods in this hospital-based retrospective observational study, 987 real-time rt pcr, sars cov-2 positive cases from sms medical college and hospital, jaipur, rajasthan, india, were enrolled. among the patients, 129 were admitted, 80 had died and, 778 had recovered from covid-19. data collection the age, gender, and outcome data were recorded from the case sheets of the patients. the age distribution of population and age-specific mortality rates were sourced from the government of india repository [8]. observations were excluded if there were missing data of age, gender, or mortality. data analysis procedure the univariate discrete probability distributions of age, gender, and outcome were estimated. p[death], expressed as a percent, is also known as the case fatality rate [9]. the bivariate discrete probability distribution of age and gender, age and outcome, and gender and outcome were also estimated. the conditional probability distributions of p [age | outcome], p [outcome | age], p [age | gender], p [gender | age], p [gender | outcome] and p [outcome | gender] were obtained using the law of conditional probability: 𝑃[𝐶│𝐷] = 𝑃[𝐶 ∩ 𝐷]/𝑃[𝐷] where p [c | d] is the conditional probability of occurrence of event c when event d has already occurred, p [c∩d] is the probability of occurrence of event c and d simultaneously, and p [d] is the probability of occurrence of event d [5]. the age distribution of covid-19 was compared with the general age distribution. comparisons were also made for means of age between various levels of gender and outcome. finally, we compared the outcome among various levels of gender and age groups. statistical analysis the quantitative variables were expressed as mean and standard deviation, estimates were expressed as 95% confidence intervals, and comparison was performed using a two-tailed student t-test. the qualitative variables were expressed as proportions and compared with the chi-square test. the goodness of fit chi-square test was used to test distributions. the statistical level of significance was considered at 5%. the statistical analyses were done using jasp software [10] and matlab 2016a [11]. results the univariate probability distribution of age (p [age]) of coronavirus disease-19 cases has showed maximum probability in the ‘25-29’ age group followed by the ‘30-34’ age group and there was a minimum probability in the ‘75-79’ age group. the occurrence of covid-19 cases across age was significantly different ( = 411.53, df = 16, p < 0.001) (figure 1 and table 1). table 1 shows the univariate probability distribution of age in covid-19 patients with 95% confidence intervals age p [age] 95% ci ll ul 0-4 0.024 0.016 0.036 5-9 0.021 0.013 0.032 10-14 0.034 0.024 0.048 15-19 0.055 0.041 0.071 20-24 0.108 0.09 0.129 25-29 0.142 0.121 0.165 30-34 0.121 0.101 0.143 35-39 0.082 0.066 0.101 40-44 0.09 0.073 0.11 45-49 0.057 0.043 0.073 50-54 0.057 0.043 0.073 55-59 0.062 0.048 0.079 60-64 0.07 0.055 0.088 65-69 0.031 0.021 0.044 70-74 0.019 0.012 0.03 75-79 0.012 0.006 0.021 80 and above 0.014 0.008 0.024 the age distribution of covid-19 cases differed significantly with age distribution of the population ( = 399.04, p < 0.001) (figure 2). the probability of men (p [male] = 0.62, 95% ci: 0.59-0.65) suffering from covid-19 was higher than for women (p [female] = 0.38, 95% ci: 0.35-0.41) (figure 3 panel a and table 2). table 2 shows univariate probability distribution of gender in covid-19 patients with a 95% confidence interval. gender p [gender] 95% ci ll ul female 0.38 0.35 0.41 male 0.62 0.59 0.65 the probability of recovered cases (p [recovered] = 0.79, 95%ci: 0.76 – 0.81) was higher than for death cases (p [death] = 0.08, 95%ci: 0.06-0.10) or admitted cases (p [active]= 0.13, 95% ci: 0.11 – 0.15) (figure 3 panel b and table 3). table 3 shows univariate discrete probability distribution of outcome with a 95% confidence interval. outcome p [outcome] 95% ci ll ul recovered 0.79 0.76 0.81 death 0.08 0.06 0.10 active 0.13 0.11 0.15 the bivariate probability distribution of age and gender showed males in the ‘25-29’ age group constituted maximum cases of covid-19 (table 4). the conditional probability of age for both genders (p [age | male] and p [age | female]) was highest in the ‘25-29’ age group (figure 4 panel a and panel b). the distribution of covid-19 cases across age and gender was independent ( =21.30, df = 16, p = 0.17). bhandari s, et al., journal of ideas in health (2020); 3(special 2):286-292 288 table 4 bivariate probability distribution of age and gender (n = 987). the age and gender are independent attributes ( =21.30, df = 16, p = 0.17) age group gender p[age] female male 0-4 0.013 0.011 0.024 5-9 0.008 0.013 0.021 10-14 0.013 0.021 0.034 15-19 0.019 0.035 0.055 20-24 0.045 0.064 0.108 25-29 0.063 0.079 0.142 30-34 0.056 0.065 0.121 35-39 0.026 0.056 0.082 40-44 0.029 0.061 0.090 45-49 0.015 0.042 0.057 50-54 0.024 0.032 0.057 55-59 0.020 0.042 0.062 60-64 0.022 0.048 0.070 65-69 0.012 0.019 0.031 70-74 0.003 0.016 0.019 75-79 0.005 0.007 0.012 80 and above 0.004 0.010 0.014 p[gender] p [female] = 0.379 p [male] = 0.621 total = 1.00 the distribution of covid-19 cases across age and outcome was not independent ( =106.21, df = 32, p < 0.001) (figure 5 panel a). the conditional probability distribution of age for given deaths (p [ age | death]) was highest in the ‘60-64’ age group, but the conditional probability for death for a given age (p [ death | age]) was highest in the ‘75-79’ age group (figure 5 panel b and table 5). table 5 bivariate probability distribution of age and outcome (n=987). the age and outcome are dependent (( =106.21, df = 32, p < 0.001) age group outcome p [age] recovered death active 0-4 0.017 0.003 0.004 0.024 5-9 0.017 0.000 0.004 0.021 10-14 0.031 0.001 0.002 0.034 15-19 0.053 0.001 0.001 0.055 20-24 0.083 0.008 0.017 0.108 25-29 0.115 0.002 0.025 0.142 30-34 0.101 0.004 0.015 0.121 35-39 0.067 0.004 0.011 0.082 40-44 0.080 0.003 0.007 0.090 45-49 0.044 0.005 0.008 0.057 50-54 0.044 0.008 0.005 0.057 55-59 0.043 0.007 0.012 0.062 60-64 0.043 0.013 0.011 0.067 65-69 0.020 0.010 0.001 0.031 70-74 0.013 0.003 0.003 0.019 75-79 0.005 0.005 0.002 0.012 80 and above 0.010 0.003 0.001 0.014 p [outcome] p [recovered] = 0.785 p [death] = 0.081 p [ active] = 0.131 total = 1.00 the bivariate probability distribution of gender and outcome showed that the highest proportion of coronavirus cases were male and recovered (table 6). table 6 bivariate probability distribution of gender and outcome in covid-19 patients (n = 987). the gender and outcome attributes are independent (= 0.264, df = 2, p = 0.88) gender outcome p [gender] recovered death active male 0.302 0.029 0.048 p [male] = 0.379 female 0.486 0.052 0.083 p [female] = 0.621 p[outcome] p[recovered] = 0.788 p [death] = 0.081 p [active] = 0.131 1.00 the distribution of covid-19 cases across gender and outcome was independent ( =0.264, df = 2, p = 0.88). the conditional probabilities for males for a given outcome were higher than for females (figure 6 panel a-c). the conditional probabilities of outcome for a given gender were higher for recovered cases, followed by active cases and death. (figure 7, panel a-c). discussion management of the covid-19 pandemic with limited resources and human resources is challenging for public health authorities. the knowledge of disease patterns helps in decision making as well as for the optimum allocation of resources. the observed disease patterns are affected by biological susceptibility, social contact structure, and cultural habits. the rate of evolution of the epidemic curve in rajasthan is among the top eight states of india [12]. the mean age of covid-19 cases was 37.08 years in rajasthan, which was lower than the mean age-based on 65 research articles [13-15]. the age distribution of the general population of rajasthan was rightskewed. the mode of the general age distribution curve was the '10-14', age group. in contrast, the mode of the age distribution of covid-19 cases occurs at the '25-29' age group. this could be explained by the decision of early closure of schools and colleges by the government [16]. the lower frequency of occurrence of covid-19 in children might result from fewer outdoor activities and less international travel [16]. a national study from china on 2135 pediatric patients showed no significant difference in susceptibility across age groups, although clinical manifestations in children were less severe [17]. the study showed that men constitute more cases of covid-19, which might be due to higher independence compared to females [13,18]. however, the sex ratio of rajasthan is 926 females per 1000 males [8]. the case fatality rate was 8.1%, which is more than reported for china, i.e., 7.2% [19]. the higher rate may be due to fewer testing facilities and less contact tracing [20]. in an epidemiological study, covid19 cases in maharashtra and new delhi also showed males' dominance and no association between gender and mortality. the age-specific mortality rate was also high among patients aged 61-70 years (19.2%), 71-80 years (15.8%), and above 80 years (13.9%) as in our study (figure 5. panel b, red line graph). the p [death | age] suggests the probability of death in older age groups was higher, but p [age |death] suggests that the need for life-saving equipment was equal in all age groups. bhandari s, et al., journal of ideas in health (2020); 3(special 2):286-292 289 similarly, the p [active |age] suggests that hospital beds' requirement was equal over age groups, but p [age |active] suggests that younger age groups occupied more hospital beds. in the indian context, we collated a few recommendations based on estimated a posteriori probability distributions: recommendation 1: the probability of death in elderly group p [ death| > 60] is higher. the people above 60 years should stay at home. recommendation 2: the number of active cases helps in the estimation of requirements for hospital beds and medical equipment. the p [age |active] suggests that younger age groups occupy most hospital beds. p [death |age] suggested that younger age groups have a low mortality risk, and management strategies for mild cases might include home isolation. that would free up more hospital beds for the elderly population who are at higher risk of mortality. recommendation 3: the case fatality rate is quite high in our study, possibly due to low covid-19 testing. thus, there is a need to increase covid-19 testing to improve the estimation of the fatality rate. furthermore, we recommend the involvement of experts from multiple fields, such as operations research, epidemiology, economics, management, and sociology in policymaking. in addition to above, the psychologists have a key role in managing pandemic of psycho-social disorders contributed by the covid-19 [21]. this study complains of some limitation. the study estimates probability distributions from the early dataset of covid-19 cases. as decisions on public health measures like lockdown, contact tracing, and testing guidelines are modified, those, in turn, affect the patterns of disease. thus, real-time estimations are required and should be adjusted for the confounding effects. conclusion the patterns of covid-19 cases and hospital outcomes across age and gender form the basis of evidence-based decision making in the public health domain. additional demographic, clinical, and laboratory data permit us to determine the magnitude of medical resources and human resources required, along with public health measures. figure 1 box plot of univariate discrete age distribution of covid-19 cases (n = 987) with error bars (blue) at 95% confidence intervals in the state of rajasthan figure 2 stem plot of age distribution of observed (blue dots) cases of covid-19 and expected cases (red dots) in the state of rajasthan bhandari s, et al., journal of ideas in health (2020); 3(special 2):286-292 290 figure 3 pie charts of univariate discrete probability distribution of covid-19 cases (n = 987) in the state of rajasthan (a) p[gender] (b) p[outcome] figure 4 histograms of conditional probability distributions of age and gender of covid-19 cases (n = 987) in the state of rajasthan. panel a: p [age| male], panel b: p [age| female], panel c: p [male| age], and panel d: p [ female |age] figure 5 line plots of conditional probability distributions of age and outcome of covid-19 cases (n = 987) in the state of rajasthan. panel a: p [age| recovered] (blue line) and p [recovered| age] (red line), panel b: p[age| death] (blue line) and p[death| age] (red line), and panel c: p[age| active] (blue line) and p[active| age] (red line) bhandari s, et al., journal of ideas in health (2020); 3(special 2):286-292 291 figure 6 pie charts of conditional probability distributions of gender for given outcome (n = 987) in the state of rajasthan. panel a: p [gender| recovered], panel b: p [gender| death] (c), and panel c: p [gender| active] figure 7 pie charts of conditional probability distributions of outcome for given gender (n = 987) in the state of rajasthan. panel a: p [outcome| female], and panel b: p [outcome| male] abbreviation sir: susceptible, infectious, or recovered; ci: confidence interval; covid-19: coronavirus disease-19; p[age]: discrete probability distribution of age ; p[gender]: discrete probability distribution of gender; p[outcome]: discrete probability distribution of outcome; p[age | gender]: conditional discrete probability distribution of age for a given gender; p[ gender | age]: conditional discrete probability distribution of gender for a given age; p[age | outcome]: conditional discrete probability distribution of age for a given outcome ; p[ outcome | age]: conditional discrete probability distribution of outcome for a given age; p[gender | outcome]: conditional discrete probability distribution of gender for a given outcome; p[outcome | gender]: conditional discrete probability distribution of outcome for a given gender; sars cov-2: severe acute respiratory syndrome coronavirus 2 declaration acknowledgment none. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing atifkatib@gmail.com authors’ contributions at designed the study and coordinated all aspects of the research, including all manuscript preparation steps. he is responsible for studying, designing, writing, reviewing, editing, and approving the manuscript in its final form. sk, ajs, helps in the provision of patients and data collection. sb, js, and ad provide administrative support, reviewed, and approved the bhandari s, et al., journal of ideas in health (2020); 3(2):154-155 292 manuscript. ss, bp, sk, jg, sd, md, and tw contributed to drafting the work, writing the manuscript, and reviewed and approved the manuscript. all authors read and approved the final manuscript. ethics approval and consent to participate the authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the declaration of helsinki. the research has been approved by sms medical college, jaipur ethics committee, and the corresponding approval number is 512/mc/ec/2020 dated 6 jul 2020. the retrospective data were used in the study. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of medicine, sms medical college, and hospitals, jaipur, rajasthan, india; 2national centre for disease informatics and research, indian council of medical research, bangalore, karnataka, india. 3department of physiology, sms medical college and hospitals, jaipur, rajasthan, india. 4department of physiology, government medical college, barmer, rajasthan, india. 5department of pharmacology, sms medical college and hospitals, jaipur, rajasthan, india. 6department of rheumatology, medstar washington hospital center, washington dc 20010, usa. 7department of horticultural science, north carolina state university, raleigh, nc 27695-7609, usa. article info received: 10 november 2020 accepted: 25 december 2020 published: 31 december 2020 references 1. world health organization, coronavirus disease2019. available from: https://www.who.int/emergencies/diseases/novelcoronavirus-2019 [accessed on 18 june 2020]. 2. rodrigues hs. application of sir epidemiological model: new trends. intern. j appl math inf.2016; 10: 92–97. 3. singh r, adhikari r. age-structured impact of social distancing on the covid-19 epidemic in india.2020; arxiv preprint arxiv:2003.12055. 4. brownson rc, gurney jg, land gh. evidence-based decision making in public health. j public health manag pract.1999;5(5):86-97. http://dx.doi.org/10.1097/00124784199909000-00012. 5. indrayan a, malhotra rk. medical biostatistics. 4th ed. in relationships: qualitative dependent, crc press, taylor & francis group, florida, usa. 2018 pp. 180-182. 6. lee pi, hu yl, chen py, huang yc, hsueh pr. are children less susceptible to covid-19? j microbiol immunol infect.2020;53(3):371-372. http://dx.doi.org/10.1016/j.jmii.2020.02.011 7. bhandari s, shaktawat as, tak a, patel b, shukla j, singhal s, et al. logistic regression analysis to predict mortality risk in covid-19 patients from routine hematologic parameters. ibnosina j med biomed sci.2020;12(2):123-9. 8. census of india 2011, government of india. available from: https://censusindia.gov.in/2011-provresults/paper2/data_files/raj/7-popu-10-19.pdf [accessed on 19 june 2020]. 9. epidemiology group of the new coronavirus pneumonia emergency response mechanism of the chinese center for disease control and prevention. epidemiological characteristics of the new coronavirus pneumonia[j/ol]. chinese journal of epidemiology2020;41 (2020-0217). http://dx.doi.org/10.3760/cma.j.issn.0254-6450.2020.02.003 10. jasp team, jasp version 0.12.2 [computer software] university of amsterdam, netherlands; copyright 2013-2019 11. matlab team, statistics and machine learning toolbox 10.2, classification learner app, matlab. version 9.0.0.341360 (r 2016a). natick, massachusetts: the mathworks inc. 12. bhandari s, shaktawat as, tak a, patel b, gupta k, gupta j, et al. a multistate ecological study comparing evolution of cumulative cases (trends) in top eight covid-19 hit indian states with regression modeling. int j acad med 2020; 6 (2):91-95. http://dx.doi.org/10.4103/ijam.ijam_60_20 13. adhikari sp, meng s, wu y-j, mao y-p, ye r-x, wang q-z, et al. epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (covid-19) during the early outbreak period: a scoping review. infectious diseases of poverty 2020;17: 9(1). http://dx.doi.org/10.1186/s40249-02000646-x 14. gandhi pa, kathirvel s. epidemiological studies on coronavirus disease 2019 pandemic in india: too little and too late? med j armed forces india. 2020; 76(3): 364–365. http://dx.doi.org/10.1016/j.mjafi.2020.05.003 15. kakkar s, bhandari s, shaktawat a, sharma r, dube a, banerjee s, et al. a preliminary clinico-epidemiological portrayal of covid-19 pandemic at a premier medical institution of north india. annals of thoracic medicine2020;15(3):146. http://dx.doi.org/10.4103/atm.atm_182_20 16. times of india. available from: https://timesofindia.indiatimes.com/home/education/news/govtannounces-closure-of-all-educational-establishments-across-indiatill-march-31/articleshow/74659627.cms [accessed on 19 jun 2020]. 17. dong y, mo x, hu y, qi x, jiang f, jiang z, et al. epidemiology of covid-19 among children in china. pediatrics2020; 145 (6): e20200702. https://doi.org/10.1542/peds.2020-0702 18. ram u, strohschein l, gaur k. gender socialization: differences between male and female youth in india and associations with mental health. international journal of population research 2014; 2014:1–11. http://dx.doi.org/10.1155/2014/357145 19. chowdhury sd, oommen am. epidemiology of covid-19. journal of digestive endoscopy2020;11(1):3–7. http://dx.doi.org/10.1055/s-0040-1712187 20. rajagopalan, shruti and tabarrok, alexander t., pandemic policy in developing countries: recommendations for india (april 9, 2020). mercatus special edition policy brief, available at ssrn: https://ssrn.com/abstract=3593011 or http://dx.doi.org/10.2139/ssrn.3593011 21. bhandari s, shaktawat a, patel b, dube a, kakkar s, tak a, gupta j, rankawat g. the sequel to covid-19: the antithesis to life. journal of ideas in health 2020;3(special1):205-12. https://doi.org/10.47108/jidhealth.vol3.issspecial1.69 https://doi.org/10.47108/jidhealth.vol4.iss4.193 lazar am, journal of ideas in health 2021;4(special 4):615-622 © the author(s). 2021 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access hyperferritinemia: the link between covid-19, inflammation, and patient comorbidities angela madalina lazar 1* abstract ferritin is a key molecule in iron metabolism, as it stores the iron in a non-toxic form for the cells. serum ferritin is a parameter that reflects the iron content of the body. however, serum ferritin is also an acute-phase reactant protein, as increased levels of serum ferritin are reported in many diseases associated with inflammation. hyperferritinemia was also reported in covid-19 (the coronavirus disease 19) patients, where it is considered an independent prognostic factor for the patients, indicating increased severity of the disease, risk for complications, and death. certain categories of patients (older, those with comorbidities) have an increased risk of sars-cov-2 (severe acute respiratory syndrome coronavirus 2) infectivity and developing more severe forms of covid-19. chronic/acute systemic inflammatory states often characterize such preexisting comorbidities. in the current paper, a new pathogenic link is proposed and analyzed: between preexisting hyperferritinemia in the context of patient comorbidities (metabolic, cardiovascular, kidney, inflammatory, autoimmune, cancer) and the risk of sars-cov-2 infectivity and of developing more severe forms of infection. ferritin per se can be a causal agent in covid-19, as it can generate and aggravate inflammation and contributes to the development of a severe cytokine storm. a severe, uncontrolled inflammatory state occurs, triggered by the high levels of serum ferritin, preexisting comorbidities, and sars-cov-2 infection, cause of lethality in many patients. the inflammatory stimuli can further aggravate the infection by activating adam-17 (disintegrin and metalloprotease 17), a key enzyme involved in ace2 (angiotensin-converting enzyme 2) activation and viral infectivity. in this context, iron chelators and antioxidants could become potential lines of treatment in covid19. keywords: hyperferritinemia, serum ferritin, sars-cov-2; covid-19, metabolic, cardiovascular; inflammatory; diseases, cancer; cytokine storm, romania background ferritin functions and structural features ferritin is a highly conserved molecule, present from prokaryotes to vertebrate organisms, first described in 1937 by victor laufberger and extracted from horse spleen [1-4]. it is a nanocage protein that is a key player in iron metabolism, as it stores iron in a non-toxic form for the cell [5, 6]. it is also essential for iron recycling depending on cellular needs. iron is required for a vast array of processes and reactions, being able to act as a donor/receiver of electrons and intervening in various processes either as a cofactor or a catalyst: cell energy production, mitochondrial respiration, rna and dna synthesis, protein synthesis; it is essential for the production of the heme groups of hemoglobin and therefore for oxygen transport and cellular oxygenation; synthesis of other molecules similar to hemoglobin, such as myoglobin, cytochromes; irondependent histone demethylases; various enzymes; formation of iron-sulfur clusters; cell survival and proliferation; prevention of oxidative damage (antioxidant role of ferritin) or, on the contrary, generation of free oxygen reactive species (free iron); immuno-modulatory functions [6-9]. free iron is very toxic as it can accept or donate electrons to other molecules, leading to cellular damage; it also reacts with free oxygen radicals (fenton and haber-weiss reactions) and leads to even more aggressive reactive oxygen species [8-11]. therefore, iron metabolism, circulation, oxidation states, and storage must be very tightly regulated processes, impeding free iron toxicity and iron overload but allowing for an adequate release of iron for the cellular needs [12]. the classical, ubiquitously present ferritin comprises 24 subunits that self-assemble into an almost spherical cage with an external and internal diameter of 12 nm and 8 nm, respectively [1, 7]. invertebrates, two types of ferritin ___________________________________________________ angelalazar.2008@yahoo.com 1department of functional sciences, university of medicine and pharmacy “carol davila” bucharest, romania. full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol4.iss4.193 http://www.jidhealth.com/ lazar am, journal of ideas in health (2021); 4(special 4):615-622 616 subunits assemble to form the ferritin molecule: l (light) and h (heavy) ferritins, genetically encoded on the 11q and 19q chromosomes in humans. the ratio of h/l–ferritin subunits is variable depending on the tissue, type of cell, cell subcompartment, metabolic rate, environmental factors, growth factors, translational and post-translational changes, and the presence of a large array of diseases [3, 4, 6, 8, 10, 13, 14]. the h-subunit has ferroxidase activity and plays the key role of oxidizing ferrous ions (fe2+) to ferric ions (fe3+) that can be further be stored in a mineralized, stable internal core of ferritin [6, 13]. out of the multiple oxidation iron states (from -2 to +6), fe3+ is the most stable, non-toxic iron state [7, 15]. the process of iron oxidation from fe2+ to fe3+ is therefore essential for the conversion of iron to a non-toxic form that can be stored inside of the cell; it is also important as it consumes free oxygen radicals in the process of iron oxidation that would otherwise accumulate and lead to cell damage [3, 8]. l-ferritin subunit lacks a ferroxidase activity; it has a salt bridge in its folds and therefore plays a role only in the stability of the ferritin cage and in the ferric iron storage [1, 13]. as the two subtypes of ferritin units have functional and structural differences, the ratio between the two in the ferritin nanocage differs between tissues, depending on the metabolic rate and need for a fast release of iron for incorporation into proteins. for example, in tissues characterized by high metabolic rates and the generation of a considerable amount of reactive oxygen species, such as the brain, heart, kidney, there is a predominant expression of the hferritin in the ferritin nanocage. instead, in tissues characterized by important iron storage, such as the liver and spleen, there is more l-ferritin than h-ferritin into the cells [3, 6, 9]. types of ferritin there are three types of intracellular ferritin in humans: cytosolic, nuclear, and mitochondrial [9]. nuclear ferritin forms h-subunits, while both land h-ferritins are present in the cytosol [6]. mitochondrial ferritin is very similar to the hsubunit ferritin, with a 79% homology between the two; it is expressed mainly in the tissues characterized by high metabolic rates, having a protective role against the oxidative stress, and being uncorrelated to the cellular iron content [1, 3]. cellular ferritin synthesis is stimulated by high iron levels, oxidative stress, inflammatory stimuli/pathways. as hand lferritin promoters have an antioxidant responsive element, ferritin synthesis is influenced by oxidative stress. also, there is a hypoxia-responsive element in the 5'-promoter region of the ferritins, explaining why cellular ferritin levels increase during hypoxia [3]. serum ferritin ferritin is also found in the serum and various liquids, such as cerebrospinal fluid, synovial fluid, and urine, being constituted only from l-subunits [3, 9]. serum l-ferritin is one of the tiniest understood molecules, although it is a laboratory test more and more requested in clinical practice [10]. it is not known if it is a monomeric or multimeric structure, and its functions are of unclear significance yet. although insufficiently ascertained, circulating l-ferritin would act as an iron deliverer for cells [9]. despite the limitations regarding its knowledge, serum ferritin is considered a very valuable clinical parameter. it can provide information regarding the body's iron content and differentiate between iron-deficiency anemia and other causes of anemia [5, 6, 9, 10]. however, serum ferritin levels do not always correlate well with the iron organism levels, as they can be influenced by many factors and diseases [6, 9, 10, 16, 17]. also, serum ferritin stores only a small amount of iron [4], and therefore its quantification offers only limited information in this regard. the sources of serum ferritin are non-classical pathways secretion out of the cells into the serum; and release into the serum as a result of cell damage and death [1, 9, 10, 18, 19]. various stimuli, such as proinflammatory cytokines (interleukin 1 (il-1), interleukin 6 (il6), interleukin 10 (il-10), tumor necrosis factor-alpha (tnfalpha), and interferon-gamma (ifn-gamma) that act via nf-kb pathway), growth factor or hypoxia can lead to increased secretion of ferritin [9, 10]. one of the significant sources of ferritin is the macrophages, which secrete it along with other cytokines [6, 19]; another important source can be the hepatocytes [9, 10]. after macrophage release, serum ferritin is physiologically glycosylated to a necessary extent (50-80% of the serum ferritin); a lower or a higher level of glycosylation has been associated with various diseases [6, 10]. the normal serum ferritin range is up to 200 μg/l in females and up to 300 μg/l in males [5, 10]. the serum ferritin appears to correlate well with the levels of intracellular ferritin, and high intracellular ferritin will be usually paralleled by hyperferritinemia. hyperferritinemia can indicate a high level of iron or, maybe even more frequently, the presence of one/multiple diseases characterized by inflammatory states. a high level of iron is toxic [17] and determines an increase in ferritin generation via the iron regulatory proteins 1 and 2 (irp 1 and 2) acting on ire (iron response elements) present at the 5’utr of the ferritin transcripts [1, 2, 10]. it was reported that inflammatory stimuli mainly induce an increase in h-ferritin level, while high iron levels of l-ferritin [9]. increased serum ferritin levels in diseases serum ferritin and intracellular ferritin have markedly increased levels in many inflammatory autoimmune diseases and acute phase reactions [10, 19, 20]. such diseases that are characterized by chronic or acute inflammation, altered iron metabolism, and associate high serum ferritin levels include infections (acute, chronic, sepsis; viral, such as influenza infection, hcv and hiv; bacterial (including tuberculosis); autoimmune diseases, such as rheumatoid arthritis, systemic erythematosus lupus; kidney diseases; cancer (breast, colorectal, non-small lung cancer, prostate, pancreatic, oral, ovarian, renal); metabolic diseases (diabetes mellitus, obesity, dyslipidemia); cardiovascular diseases including hypertension; neurodegenerative diseases, such as parkinson, alzheimer, multiple sclerosis [1, 2, 4, 10, 13, 16, 21-35]. the inflammatory state/chronic inflammatory microenvironment is considered a consequence, a trigger, and/or an aggravating factor for the diseases mentioned above, leading to increased patient morbidity and mortality rates and the development of other severe chronic diseases [30 36-39]. older age and male patients usually have higher serum ferritin levels than younger and female counterparts [40-45]. an elevated serum ferritin level in such diseases is considered an inflammatory marker, an acute phase reactant. it can be used along with other markers (creactive protein, procalcitonin, lactate dehydrogenase (ldh), fibrinogen, d-dimers, erythrocyte sedimentation rate (esr), il6, etc.) for a better interpretation of disease evolution. the significantly increased levels of serum ferritin seen in the mentioned diseases and states correlate very well with the severity degree of the disease. therefore, serum ferritin levels can be used as prognostic markers for the disease evolution, risk of developing severe complications, and death [19, 20]. it was reported that a ferritin level higher than 200 μg/l is a clear indicator for an increased risk of mortality for the patients with the previously mentioned diseases, the most critical cumulative lazar am, journal of ideas in health (2021); 4(special 4):615-622 617 risk being at ferritin levels higher than 600 μg/l [10]. also, elevated serum ferritin levels can predict the development of such diseases that develop under chronic systemic proinflammatory states [46-48]. even a link between inflammation– metabolic syndromehigh serum ferritin levels and the risk of developing other diseases, such as cardiovascular, was reported [49, 50]. that is, ferritin level holds a prognostic significance. however, it is not known whether the high levels of serum ferritin seen in the multiple diseases mentioned above are a cause or a secondary consequence, nor if they can exhibit protecting or, on the contrary, aggravating effects in the course of a pathological process. it is not known whether there is an etiologic role for ferritin in the mentioned diseases [6, 10, 51]. some studies report a pro-inflammatory effect of ferritin per se [10, 14, 16, 51], while others consider that ferritin can act as a protective factor in specific pathologies (e.g., protective effects of hferritin against acute kidney injury or vascular calcification) [1]. the increase in the ferritin levels seen in the inflammatory states can initially represent a mechanism of protection against a dangerous external agent (virus, bacteria, fungi) or internal (abnormal, compromised, toxic structures, such as in autoimmune diseases, neurodegenerative diseases, metabolic diseases, cancer). pathogens and cancer cells require high iron levels for their survival and multiplication; in the case of cancers, iron is also essential for epithelial to mesenchymal transition, migration, and metastasis [6]. in the scenario of infections, ferritin might be a protective molecule as it sequestrates into intracellular stores, preventing the iron from being used by the pathogenic agents [9]; also, it has an antioxidant role. at the same time, serum ferritin could display immune-modulatory or even immunosuppressive roles, limiting the detrimental uncontrolled inflammatory storm [2, 9, 51]. by its anti-apoptotic functions, ferritin might determine a chronic tolerance to infections like hepatitis c virus, malaria, mycobacteria, hiv, and even sepsis [1, 9]. in infections and ferritin, another player intervenes as well: hepcidin. hepcidin, a relatively newly described molecule produced in the liver, physiologically prevents iron release from the cells via ferroportin; hepcidin also inhibits iron absorption by the enterocytes. therefore, hepcidin also limits pathogens' iron access [4, 8, 10, 11]. however, the opposite, detrimental effect of deregulated hyperferritinemia is even more frequently reported as a pathogenic vicious circle of disease can occur. ferritin can determine more inflammation, aggravating the infection [14]. more ferritin can release more free iron from the cells; high free iron signals for even more ferritin synthesis, oxidative stress, inflammation, and cellular damage; excess ferritin can lead to the generation of ferritin aggregates, as described in some genetic ferritin disorders [3]. such a deregulated process has also been described in neurodegenerative diseases (alzheimer, parkinson), although it is unclear whether ferritin metabolism alteration is the etiologic agent or only a consequence of the disease. however, in infections, hepcidin production is increased, leading to pronounced sequestration of iron into the cells, especially into macrophages, aiming to deprive the pathogens of it [8, 12]. this explains a chronic inflammatory type of anemia in such chronic diseases [4, 8]. at the same time, important iron sequestration into the host cells (via increased intracellular ferritin and following hepcidin production) would potentially become toxic; the ferritin iron storage capacity is probably saturable, and upon iron saturation, ferritinophagy and ferritinoptosis will ensue; there will be freer iron into the cells, oxidative damage, and cell death. in cancer, more ferritin and intracellular iron stores have also been described. iron is helpful for the cancer cells as it is a catalyst for the histone demethylation, a process required for epigenetic plasticity; also, more intracellular ferritin protects the cell from oxidative damage; otherwise, such significant oxidative stress could easily affect the cells characterized by high metabolic rates, as cancer cells [1, 6, 9]. ferritin might be pro-oncogenic by promoting oxidative stress, followed by lipid peroxidation, dna strand damage, mutagenesis [4,10]. however, elevated ferritin levels can activate pro-inflammatory macrophages associated with cancer cells that appear to function for cancer progression [6, 9]. ferritina link between various comorbidities and covid19 a recent observation is that in covid-19 infection, there are increased levels of serum ferritin (hyperferritinemia, that is more than 300 μg ferritin/l), along with other pro-inflammatory markers (il-1, il-6, tnf-alpha, ifn-gamma, d-dimers, ldh, procalcitonin, c-reactive protein). in fact, a 3 to 4 times higher serum ferritin level was reported in the covid-19 nonsurvivors [2, 6, 16, 19, 51]. also, higher serum ferritin levels were reported in patients with thrombotic complications than in the others [16]. hyperferritinemia correlates well with the severity of the covid-19, and the serum ferritin levels increase during the aggravation of the infection [19, 52]. therefore, high serum ferritin levels indicate a very severe infection and poor prognosis, predicting the development of life-threatening complications, such as respiratory failure, organ dysfunction, need for icu hospitalization, and death [11, 14, 16, 19, 20]. interestingly, serum ferritin levels begin to decrease when the covid-19 patients’ state begins to ameliorate [51]. actually, ferritin levels are considered an independent prognostic factor for covid-19 patients [19]. also, ferritin levels have been proposed as a marker of viral replication [16]. it is already ascertained that specific categories of patients have a higher risk of sars-cov-2 infectivity and developing more aggressive, severe forms of covid-19. such categories are older, male patients; also patients with preexisting comorbidities such as hypertension, cardiovascular diseases; metabolic diseases (diabetes mellitus, obesity, dyslipidemia, and steatosis); kidney diseases; cancer; inflammatory and autoimmune diseases [1, 16, 19, 29, 53-58]. until now, no apparent, final, and unanimous explanation was found regarding the mechanisms behind such vulnerability for the sars-cov-2 severe infections in the categories mentioned above of patients. as ace2 are the receptors for the sars-cov-2 [59], a temporary hypothesis was a higher expression of ace2 receptors in such diseases, male patients, and older age, increasing the risk and severity of sars-cov-2 infection [53, 60-65]. however, this hypothesis was not validated afterward. for example, children have higher levels of whole-membrane ace2 receptors, but instead, they have a low risk of infectivity or of developing symptomatic or severe forms of covid-19. usually, if they are infected, they develop asymptomatic/oligosymptomatic mild forms of infection, and only children with preexisting severe comorbidities can present more severe forms of the disease [66]. the explanation, therefore, could come not from a higher expression of ace2 receptors but their hyperferritinemia status, cause and/or consequence, as well as a contributor to their chronic inflammatory states. there is already a report where the authors consider a link between inflammation, cancer, and more severe forms of sars-cov-2 infection [29]. in this context, we hypothesize a causal link between preexisting elevated serum ferritin levels due to various patient lazar am, journal of ideas in health (2021); 4(special 4):615-622 618 comorbidities (that associate an inflammatory state and oxidative stress) and a higher risk of sars-cov-2 infectivity of developing more severe forms of infection. the chronic/acute inflammation reported in such diseases sustained by hyperferritinemia creates a vulnerable status for other infections, including sars-cov-2 infection. such a vulnerability fueled by the preexisting immune dysregulation and severe pro-inflammatory status [16] can more rapidly trigger a veritable cytokine storm. it is ascertained that the inflammatory states, via cytokines and chemokines, determine an upregulation of ferritin expression with the accumulation of more and more ferritin into the cells [14]. pro-inflammatory cytokines such as il-1, il-6, il-10, tnf-alpha, and ifngamma, massively produced in covid-19 as well, will therefore increase ferritin levels [1, 10, 20, 51]. it appears that once produced in excess; ferritin will feed a positive feedback loop, determining more inflammation, the generation of more pro-inflammatory cytokines, and the activation of m1 macrophages [51]. ferritin (h-ferritin) was reported to activate m1 macrophages, production of cytokines, leading to inflammation and even pyroptotic cell death [14,16]; it regulates many intracellular signaling pathways, such as proinflammatory pathways, with the activation of the nf-kb (nuclear factor kappa-b) that leads to more inflammation; it also regulates c-jun n-terminal kinase (jnk) pathway (ferritin inhibits it, preventing cell apoptosis and promoting survival); erk pathway, mapk-pathway, and others [3, 4, 6, 9]. it has also been reported that ferritin can directly, at the nuclear level, stimulate the gene expression of several pro-inflammatory cytokines, such as il-1 beta, il-6, tnf-alpha, and others [9, 19]. the excessively produced inflammatory mediators will stimulate ferritinophagy, with increased intracellular free iron, leading to oxidative stress, lipid peroxidation, and ferroptosis [2, 6]. ferroptosis is an iron-regulated form of cell death [3]. ferroptosis will promote inflammation, oxidative stress, and cell damage [9, 11]. covid-19 itself is also a disease that is characterized by an exaggerated uncontrolled systemic inflammation and cytokine storm, similar to the macrophage activation syndrome, leading to organ dysfunction and damage, increased infection severity, and mortality [2, 11, 16, 19, 20, 58, 67-70]. therefore, a positive feedback loop of inflammation triggered by preexisting high ferritin levels [14] (in the context of diseases associated with chronic inflammatory states) could be detrimental for sure. systemic inflammation with uncontrolled cytokine storm is recognized as a cause of mortality in covid-19 patients [6, 14, 51]. in infections like covid-19, cell damage by the viruses is another source of ferritin release into the serum, as reported in liver diseases. as ferritin assembly is dependent on environmental factors, including ph, ferritin molecules will be able to disassemble into the serum, releasing toxic free iron that will determine oxidative stress, more inflammation, cytokine storm, and cellular damage, leading to multiple organ dysfunction and even death [10, 11]. the sars-cov-2 virus also attacks hemoglobin, releasing toxic free iron, leading to oxidative stress and inflammation. the inflammatory state will determine more ferritin being produced [4]; in fact, a vicious, positive feedback loop is described between cytokines and ferritin [19]. the released free iron, the result of the hemoglobin attack by the virus, will also stimulate ferritin production; the result will be more inflammation and a pro-thrombotic state (free iron determines fibrinogen conversion to fibrin) [11]. sars-cov-2 can also mimic hepcidin, leading to increased ferritin levels and further inflammation [11]. therefore, as ferritin per se can also lead to/aggravate inflammation [9, 14], it could be a key player in covid-19 pathogenesis. the cytokine storm and ferritin lead to acute respiratory distress syndrome (ards) [16]. in this context, there are reports after postmortem analysis that sars-cov-2 does not determine pneumonia or ards per se; instead, free iron leads to oxidative damage, inflammation, and cellular and organ damage [11]. that could be the explanation why in covid-19 patients, extremely high levels of serum ferritins (that signal or even trigger inflammation) were observed in severe forms of infection, along with the occurrence of complications and correlated with a poor prognostic and survival. additional mechanisms to explain why a preexisting inflammatory status (as reported in patients with essential comorbidities) has an increased risk of sars-cov-2 infection could intervene. inflammatory stimuli and reactive oxygen species (the result of increased levels of iron released from cells) lead to an activation of key enzymes for viral infectivities, such as adam-17 or even of ace2, that could intervene as an activating enzyme for the sars-cov-2 as well, as hypothesized in a recent study [71-74]. adam-17, also known as tace, is known to activate membrane ace2, a process important for viral infectivity; also, it can act as an activator enzyme for the sars-cov-2 as well, with putative cleavage of the spike protein required for viral fusion to the host cells [7174]. future perspectives in this context, considering that ferritin is one of the least understood molecules in disease, more research would be needed: to establish whether ferritin can act as a triggering factor for infections and other diseases or whether its increased levels are only a consequence. in this concern, international, large-scale multicentric research should be performed to link the serum ferritin and iron levels in various diseases and the risk of sars-cov-2 infectivity/risk of developing more severe forms of infection. however, such research is hindered by the difficulties in iron quantification in the serum and at intercellular levels. also, more in vitro studies should be performed; macrophages and other cells, in various environmental conditions, should be exposed to different ferritin levels/ different types of ferritins, and the levels and types of released cytokines are measured afterward. in covid19, a new question should be raised supplementary: whether ferritin does not indirectly/directly affect the expression and functionality of the membrane ace2 receptors. this question appears of significance as in severe covid-19 patients, hyperferritinemia (along with other serum pro-inflammatory markers) can be seen but paralleled by an increase in the serum enzymatic activity of ace2 [52]. understanding the hyperferritinemia significance in covid-19 patients with significant comorbidities gains considerable significance. such an understanding would be useful in designing prevention strategies for the patients' categories at increased risk of severe forms of disease and in treating such patients more efficiently. at the same time, the design and implementation of specific preventive strategies for the patients at risk are essential, as it was shown that we could not control pandemics only through measures of isolation and quarantine, especially when dealing with a virus that can reappear in successive waves across the globe, due to its impressive registry of mutations [75-78]. suppose we accept the ferritin causal roles in infections like covid-19. in that case, we could intervene with iron chelators (deferoxamine, deferasirox, deferiprone, or the natural lactoferrin) and antioxidants at the initial stages/in the course of lazar am, journal of ideas in health (2021); 4(special 4):615-622 619 the infection to limit the progress and the severity of the disease. some authors already propose an attitude to fight cancer progression and severe infections, such as aids and covid-19 [9-11]. in covid-19, iron chelators could even prevent the sars-cov-2 from binding to its cellular receptors, as described by some authors [11]. one explanation for this effect could be that the iron chelators bind the virus; the other is that the chelators bind the viral membrane receptors. also, lactoferrin binds to heparan sulfate proteoglycans that appear essential for sars-cov-2 binding to the ace2 receptors. it appears that lactoferrin could also repress intracellular viral replication (11). we could also exploit the bio-ferritin nanocages to deliver enhanced therapies for covid-19 patients, as envisioned already for cancer therapy [6]. such an example would be artemisia-derived drugs, used to treat malaria and considered in treating sars-cov-2 infected patients. artesunate can increase the lysosomal degradation of intracellular ferritin with the release of free iron and oxidative stress, leading to the death of the infected cells (therapeutic induction of ferroptosis) [6, 79, 80]. therefore, there is a clear need for more research to enable knowledge on the exact link between preexisting patient comorbidities, serum ferritin levels, and covid-19. such a discovery would make possible a better prediction and prevention of sars-cov-2 infectivity, based on a clinically generally available determination of serum ferritin levels. a single aspect regarding ferritin and disease can be ascertained for now: nothing is for sure yet. until better knowledge is achieved, valuable information, however, emerges: the usefulness of ferritin levels in predicting the course of covid-19 and other diseases. abbreviation sars-cov-2: severe acute respiratory syndrome coronavirus 2; covid-19: the coronavirus disease 19; ace2: angiotensin-converting enzyme 2; adam 17: disintegrin and metalloprotease 17 (adam-17), also known as tace (tumor necrosis factor-α-converting enzyme); rna: ribonucleic acid; dna: deoxyribonucleic acid; l-ferritin: light ferritin; h-ferritin: heavy ferritin; fe2+: ferrous ions; fe3+: ferric ions; il: interleukin; il-1: interleukin 1; il-6: interleukin 6; il-10: interleukin 10; tnf-alpha: tumornecrosis factor alpha; ifn-gamma: interferon gamma; nfkb: nuclear factor kappa-b; irp 1 and 2: iron regulatory proteins 1 and 2; ire: iron response elements; hcv: hepatitis c virus; hiv: human immunodeficiency virus; ldh: lactate dehydrogenase; esr: erythrocyte sedimentation rate; icu: intensive care unit; jnk: c-jun n-terminal kinase pathway; erk: extracellular signal‑regulated kinase pathway; mapk pathway: mitogen-activated protein kinase pathway; ards: acute respiratory distress syndrome; aids: acquired immunodeficiency syndrome.. declaration acknowledgment none. funding the author received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing angelalazar.2008@yahoo.com authors’ contributions angela madalina lazar (aml) is the principal investigator of this manuscript (viewpoint). aml is the responsible author for the study concept, design, writing, reviewing, editing, and approving the manuscript in its final form. aml has read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. however, viewpoint articles need no ethics committee approval. consent for publication not applicable competing interest the authors declare that they have no competing interest. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of functional sciences, university of medicine and pharmacy “carol davila” bucharest, romania. article info received: 03 december 2021 accepted: 23 december 2020 published: 31 december 2021 references 1. mccullough k, bolisetty s. ferritins in kidney disease. semin nephrol 2020; 40(2):160-172. doi:10.1016/j.semnephrol.2020.01.007. 2. alam jm, ali h. significance of ferritin as biomarker in sars corona virus (covid-19) infection and complications: a review. chemistry research journal 2020; 5(6): 59-64. 3. zhang j, chen x, hong j, tang a, liu y, xie n, nie g, yan x, liang m. biochemistry of mammalian ferritins in the regulation of cellular iron homeostasis and oxidative responses. science china life sciences 2020; 64(3):352-362 (2021); https://doi.org/10.1007/s11427-020-1795-4. 4. wang w, knovich ma, coffman lg, torti fm, torti sv. serum ferritin: past, present, future. biochim biophys acta 2010; 1800(8): 760-769. doi:10.1016/j.bbagen.2010.03.011. 5. anderson gj, bardou-jacquet e. revisiting hemochromatosis : genetic vs. phenotypic manifestations. ann transl med 2021; 9(8): 731. http://dx.doi.org/10.21037/atm-20-5512. 6. plays m, müller s, rodriguez r. chemistry and biology of ferritin. metallomics. 2021;13(5):mfab021. doi:10.1093/mtomcs/mfab021. 7. bradley jm, pullin j, moore gr, svistunenko da, hemmings am, le brun ne. routes of iron entry into, and exit from, the catalytic ferroxidase sites of the prokaryotic ferritin synftn. dalton trans 2020; 49:1545-1554. doi:10.1039/c9dt03570b. 8. azeez m. the role of ferritin in iron homeostasis. idosr journal of biology, chemistry and pharmacy 2020; 5(1):5-11. 9. moreira ac, mesquita g, gomes ms. ferritin: an inflammatory player keeping iron at the core of pathogen-host interactions. lazar am, journal of ideas in health (2021); 4(special 4):615-622 620 microorganisms 2020; 8:589. doi:10.3390/microorganisms8040589. 10. sandnes m, ulvik rj, vorland m, reikvam h. hyperferritinemia a clinical overview. journal of clinical medicine 2021; 10:2008. https://doi.org/10.3390/jcm10092008. 11. habib hm, ibrahim s, zaim a, ibrahim wh. the role of iron in the pathogenesis of covid-19 and possible treatment with lactoferrin and other iron chelators. biomedicine &pharmacotherapy 2021; 136:111228.https://doi.org/10.1016/j.biopha.2021.111228. 12. kowdley kv, gochanour em, sundaram v, shah ra, handa p. hepcidin signaling in health and disease: ironing out the details. hepatology communications 2021; 5(5):723-735. 13. irimia-dominguez j, sun c, li k, muhoberac bb, hallinan gi, garringer hj, ghetti b, jiang w, vidal r. cryo-em structures and functional characterization of homoand heteropolymers of human ferritin variants. scientific reports 2020; 10:20666.https://doi.org/10.1038/s41598-020-77717-4. 14. ruscitti p, di benedetto p, berardicurti o, panzera n, grazia n, lizzi ar, cipriani p, shoenfeld y, giacomelli r. proinflammatory properties of h-ferritin on human macrophages, ex vivo and in vitro observations. scientific reports 2020; 10:12232. 15. noemia lm, carmen vl . ferritin: could be a health indicator. j fam med dis prev 2018;4:078. doi.org/10.23937/24695793/1510078. 16. cheng l, li h, li l, liu c, yan s, chen h, li y. ferritin in the coronavirus disease 2019 (covid-19): a systematic review and meta-analysis. j clin lab anal 2020; 34: e23618. https://doi.org/10.1002/jcla.23618. 17. piperno a, pelucchi s, mariani r. inherited iron overload disorders. trans gastroenterol hepatol 2020; 5:25. https://dx.doi.org/10.21037/tgh.2019.11.15. 18. kell db , pretorius e . serum ferritin is an important inflammatory disease marker, as it is mainly a leakage product from damaged cells. metallomics 2014; 6: 748-773. doi: 10.1039/c3mt00347g. 19. deng f, zhang l, lyu l, lu z, gao d, ma x, guo y, wang r, gong s, jiang w. increased levels of ferritin on admission predicts intensive care unit mortality in patients with covid-19. med clin (barc) 2021; 509: 324331.https://doi.org/10.1016/j.cca.2020.06.033. 20. ahmed s, ahmed za, siddiqui i, rashid nh, mansoor m, jafri l. annals of medicine and surgery 2021; 63:102163. https://doi.org/10.1016/j.amsu.2021.02.009. 21. kadoglou npe, biddulph jp, rafnsson sb, trivella m, nihoyannopoulos p, demakakos p. the association of ferritin with cardiovascular and all-cause mortality in communitydwellers: the english longitudinal study of ageing. plos one 2017; 12(6):e0178994. 22. avila f, echeverría g, pérez d, martinez c, strobel p, castillo o, villaroel l, mezzano d, rozowski j, urquiaga i, leighton f. serum ferritin is associated with metabolic syndrome and red meat consumption. oxid med cell longev. 2015;2015:769739. doi: 10.1155/2015/769739. 23. andrade-oliveira v, foresto-neto o, watanabe ikm, zatz r, câmara nos. inflammation in renal diseases: new and old players. front pharmacol. 2019;10:1192. doi: 10.3389/fphar.2019.01192. 24. fioranelli m, bottaccioli ag, bottaccioli f, bianchi m, rovesti m, roccia mg. stress and inflammation in coronary artery disease: a review psychoneuroendocrineimmunology-based. front immunol. 2018;9:2031. doi: 10.3389/fimmu.2018.02031. 25. tbahriti hf, meknassi d, moussaoui r, messaoudi a, zemour l, kaddous a, bouchenak m, mekki k. inflammatory status in chronic renal failure: the role of homocysteinemia and proinflammatory cytokines. world j nephrol. 2013;2(2):31-7. doi: 10.5527/wjn.v2.i2.31. 26. lopez-candales a, hernández burgos pm, hernandez-suarez df, harris d. linking chronic inflammation with cardiovascular disease: from normal aging to the metabolic syndrome. j nat sci. 2017;3(4):e341. 27. djuric zora. chapter 41reducing proinflammatory states with the mediterranean diet: possible mechanism for cancer prevention. academic press 2015; pages 451-459. https://doi.org/10.1016/b978-0-12-407849-9.00041-5 28. sachinidis a, doumas m, imprialos k, stavropoulos k, katsimardou a, athyros vg. dysmetabolic iron overload in metabolic syndrome. current pharmaceutical design 2020; 26(10); https://doi.org/10.2174/1381612826666200130090703. 29. dettorre gm, dolly s, loizidou a on behalf of oncovid study group, et al. systemic pro-inflammatory response identifies patients with cancer with adverse outcomes from sars-cov-2 infection: the oncovid inflammatory score. journal for immunotherapy of cancer 2021;9:e002277. doi: 10.1136/jitc2020-002277. 30. qu x, tang y, hua s. immunological approaches towards cancer and inflammation: a cross talk. front immunol. 2018;9:563. doi: 10.3389/fimmu.2018.00563. 31. di lorenzo c, dell'agli m, colombo e, sangiovanni e, restani p. metabolic syndrome and inflammation: a critical review of in vitro and clinical approaches for benefit assessment of plant food supplements. evid based complement alternat med. 2013;2013:782461. doi: 10.1155/2013/782461. 32. monserrat-mesquida m, quetglas-llabrés m, capó x, et al. metabolic syndrome is associated with oxidative stress and proinflammatory state. antioxidants (basel). 2020;9(3):236.doi:10.3390/antiox9030236. 33. devaraj s, dasu mr, jialal i. diabetes is a proinflammatory state: a translational perspective. expert rev endocrinol metab. 2010; 5(1):19-28. doi:10.1586/eem.09.44. 34. guedes jm, neto jbm, andaki ac, pereira pf , dias de oliveira m, dias rs, de paula so, natali aj, de paula rogério a, edmar lacerda mendes el. association of inflammation, dyslipidemia, obesity and physical activity status in children. motriz, rio claro 2016; 22 (2) 18-26.https://doi.org/10.1590/s19806574201600020003. 35. tzang bs, chen vc, hsieh cc, wang wk, weng yp, ho hy, hsu yt, hsaio hp, weng jc, chen yl. differential associations of proinflammatory and anti-inflammatory cytokines with depression severity from noncancer status to breast cancer course and subsequent chemotherapy. bmc cancer. 2020;20(1):686. doi: 10.1186/s12885-020-07181-w. 36. amin mn, siddiqui sa, ibrahim m, hakim ml, ahammed ms, kabir a, sultana f. inflammatory cytokines in the pathogenesis of cardiovascular disease and cancer. sage open med. 2020; 8:2050312120965752. doi: 10.1177/2050312120965752. 37. gonzalez ll, garrie k, turner md. type 2 diabetes an autoinflammatory disease driven by metabolic stress. biochim biophys acta mol basis dis. 2018;1864(11):3805-3823. doi: 10.1016/j.bbadis.2018.08.034. lazar am, journal of ideas in health (2021); 4(special 4):615-622 621 38. coussens lm, werb z. inflammation and cancer. nature. 2002;420(6917):860-867. doi:10.1038/nature01322. 39. grivennikov si, greten fr, karin m. immunity, inflammation, and cancer. cell. 2010;140(6):883-899. doi:10.1016/j.cell.2010.01.025. 40. oh hl, lee ja, kim dh, lim js. reference values for serum ferritin and percentage of transferrin saturation in korean children and adolescents. blood research 2018; 53(1): 18-24. 41. rushton dh, barth jh. what is the evidence for gender differences in ferritin and haemoglobin? critical reviews in oncology/hematology 2010; 73:1-9. 42. lee y-t, wang w-y, kuo c-h, lee m-y, lu y-c, hsiao c-y, hsu y-h, hung p-h. older age and high serum ferritin levels associated with the risk of chronic cytopenia in hemodialysis patients. frontiers in medicine 2020; 7:568350. doi=10.3389/fmed.2020.568350. 43. goldhaber g, segal g, dagan a. hyperferritinemia in the elderly can differentiate the bad from the worst: a retrospective cohort analysis. medicine (baltimore). 2020;99(31):e21419. doi:10.1097/md.0000000000021419. 44. seong jm, yoon ys, lee ks, bae ny, gi my, yoon h. gender difference in relationship between serum ferritin and 25hydroxyvitamin d in korean adults. plos one 2017; 12(5): e0177722. https://doi.org/10.1371/journal.pone.0177722. 45. casale g, bonora c, migliavacca a, zurita ie, de nicola p. serum ferritin and aging. age and ageing 1981; 10(2): 119-122; https://doi.org/10.1093/aging/10.2.119. 46. liu j-r, liu y, yin f-z, liu b-w. sarrum ferritin, an early marker of cardiovascular risk : a study in chinese men of fisrtdegree relatives with family history of type 2 diabetes. bmc cardiovascular disorders 2019; 19:82. 47. sackett k, cunderlik m, sahni n, killeen aa, olson ap. extreme hyperferritinemia:  causes and impact on diagnostic reasoning. am j clin pathol. 2016;145(5):646-50. doi: 10.1093/ajcp/aqw053. 48. kim mk, baek hk, song k-h, kang mi,choi jh, bae jc, park cy, lee wy, oh kw. increased serum ferritin predicts the development of hypertension among middle-aged men. american journal of hypertension 2012; 25(4): 492-497. 49. tofano rj, pescinni-salzedas lm, chagas efb, detregiachi crp, araujo ac, bechara md, rubira cj, barbalho sm. association of metabolic syndrome and hyperferritinemia in patients at cardiovascular risk. diabetes, metabolic syndrome and obesity: targets and therapy 2020; 13: 3239-3248. 50. battineni g, sagaro gg, chintalapudi n, amenta f, tomassoni d, tayebati sk. impact of obesity-induced inflammation on cardiovascular diseases (cvd). int j mol sci. 2021;22(9):4798. doi: 10.3390/ijms22094798. 51. gomez-pastora j, weigand m, kim j, wu x, strayer j, palmer af, zborowski m, yazer m, chalmers jj. hyperferritinemia in critically ill covid-19 patientsis ferritin the product of inflammation or a pathogenic mediator? clinica chimica acta 2020; 249-251. 52. nagy b, fejes z, szentkereszty z, suto r, varkonyi i, ajzner e et al.. a dramatic rise in serum ace2 in a critically ill covid-19 patient. international journal of infectious diseases 2021;103:412414. 53. fang l, karakiulakis g, roth m. are patients with hypertension and diabetes mellitus at increased risk for covid-19 infection? lancet respir med. 2020;8(4):e21. doi: 10.1016/s22132600(20)30116-8. erratum in: lancet respir med. 2020 jun;8(6):e54. 54. tadic m, cuspidi c. the influence of diabetes and hypertension on outcome in covid‐19 patients: do we mix apples and oranges?. j clin hypertens 2021; 23: 235-237. https://doi.org/10.1111/jch.14145. 55. apicella m, campopiano mc, mantuano m, mazoni l, coppelli a, del prato s. covid-19 in people with diabetes: understanding the reasons for worse outcomes. lancet diabetes endocrinol 2020: 8; 782–92; https://doi.org/10.1016/s2213-8587(20)30238-2. 56. rastad, h., ejtahed, hs., mahdavi-ghorabi, a., arzaghi m, safari a, shahrestanaki e, et al. factors associated with the poor outcomes in diabetic patients with covid-19. j diabetes metab disord 2020; 19: 1293–1302; https://doi.org/10.1007/s40200-02000646-6. 57. parit r, jajavel s. association of ace inhibitors and angiotensin type ii blockers with ace2 overexpression in covid-19 comorbidities: a pathway-based analytical study. european journal of pharmacology 2021; 896: 173899. https://doi.org/10.1016/j.ejphar.2021.173899. 58. lazar am. renin-angiotensin-aldosterone system inhibitors – a realm of confusion in covid-19. journal of ideas in health 2021; 4 (special2): 389-394. https://doi.org/10.47108/jidhealth.vol4.issspecial2.125. 59. lazar am. understanding sars-cov-2 features of infectivity, aggressiveness, and transmissibility: an insect-vector theory for sars-cov-2 dissemination. journal of ideas in health 2021; 4(special 1): 343-347; https://doi.org/10.47108/jidhealth.vol4.issspecial1.109. 60. pinto bgg, oliveira aer, singh y, jimenez l, gonçalves ana, ogava rlt, creighton r, schatzmann peron jp, nakaya hi. ace2 expression is increased in the lungs of patients with comorbidities associated with severe covid-19. j infect dis. 2020;222(4):556-563. doi: 10.1093/infdis/jiaa332. 61. jacobs m, hannelore p. van eeckhoutte, sara r. a. wijnant, wim janssens, guy f. joos, guy g. brusselle, ken r. bracke.increased expression of ace2, the sars-cov-2 entry receptor, in alveolar and bronchial epithelium of smokers and copd subjects. european respiratory journal 2020; 56: 2002378; doi: 10.1183/13993003.02378-2020. 62. kaseb ao, mohamed yi, malek ae, raad ii, altameemi l, li d, kaseb oa, kaseb sa, selim a, ma q. theimpact of angiotensin-converting enzyme 2 (ace2) expression on the incidence and severity of covid-19 infection. pathogens 2021; 10: 379.https://doi.org/10.3390/pathogens10030379. 63. baker sa, kwok s, berry gj, montine tj. angiotensinconverting enzyme 2 (ace2) expression increases with age in patients requiring mechanical ventilation. plos one 2021; 16(2):e0247060. https://doi.org/10.1371/journal.pone.0247060. 64. iannelli a, favre g, frey s, esnault v, gugenheim j, bouam s, schiavo l, tran a, alifano m. obesity and covid-19: ace 2, the missing tile. obes surg. 2020;30(11):4615-4617. doi:10.1007/s11695-020-04734-7. 65. chen l, li x, chen m, feng y, xiong c. the ace2 expression in human heart indicates new potential mechanism of heart injury among patients infected with sars-cov-2 [published correction appears in cardiovasc res. 2020;116(12):1994]. cardiovasc res. 2020;116(6):1097-1100. doi:10.1093/cvr/cvaa078. 66. zimmermann p, curtis n. arch dis child 2020;0:1–11. doi:10.1136/archdischild-2020-320338. lazar am, journal of ideas in health (2021); 4(special 4):615-622 622 67. del valle dm, kim-schulze s, huang hh, beckmann nd, nirenberg s, wang b, lavin y, swartz th, madduri d, stock a, marron tu, xie h, patel m, tuballes k, van oekelen o, rahman a, kovatch p, aberg ja, schadt e, jagannath s, mazumdar m, charney aw, firpo-betancourt a, mendu dr, jhang j, reich d, sigel k, cordon-cardo c, feldmann m, parekh s, merad m, gnjatic s. an inflammatory cytokine signature predicts covid19 severity and survival. nat med. 2020;26(10):1636-1643. doi: 10.1038/s41591-020-1051-9. 68. costela-ruiz vj, illescas-montes r, puerta-puerta jm, ruiz c, melguizo-rodríguez l. sars-cov-2 infection: the role of cytokines in covid-19 disease. cytokine growth factor rev. 2020;54:62-75. doi: 10.1016/j.cytogfr.2020.06.001. 69. yang, l., xie, x., tu, z. , fu j, xu d, zhou y. the signal pathways and treatment of cytokine storm in covid-19. sig transduct target ther 2021;6: 255. https://doi.org/10.1038/s41392-021-00679-0. 70. rowaiye ab, okpalefe oa, onuh adejoke o, ogidigo jo, hannah oladipo o, ogu ac, oli an, olofinase s, onyekwere o, rabiu abubakar a, jahan d, islam s, dutta s, haque m. attenuating the effects of novel covid-19 (sars-cov-2) infection-induced cytokine storm and the implications. journal of inflammation research. 2021 ;14:1487-1510. doi: 10.2147/jir.s301784. 71. haga s, yamamoto n, nakai-murakami c, osawa y, tokunaga k, sata t et al. modulation of tnf-α-converting enzyme by the spike protein of sars-cov and ace2 induces tnf-α production and facilitates viral entry. pnas 2008; 105 (22): 7809-7814. doi: 10.1073/pnas.0711241105. 72. lazar am. ace2 enzymatic role in the sars-cov-2 activation: a perspective through the evolutionary promiscuy and substrate diversity of enzymes. journal of ideas in health 2021; 4(4): 581587. https://doi.org/10.47108/jidhealth.vol4iss4.169. 73. heurich a, hofmann-winkler h, gierer s, liepold th, jahn o, pöhlmann s. (2014). tmprss2 and adam17 cleave ace2 differentially and only proteolysis by tmprss2 augments entry driven by the severe acute respiratory syndrome coronavirus spike protein. journal of virology 88 (2), 12931307. 74. liu m, wang t, zhou y, zhao y, zhang y, li j. potential role of ace2 in coronavirus disease 2019 (covid-19) prevention and management. journal of translational internal medicine 2020 ; 8(1): 9-19. 75. ali jadoo sa (2020). the second wave of covid-19 is knocking at the doors: have we learned the lesson? journal of ideas in health. 2020; 3 (special 1):183-184; https://doi.org/10.47108/jidhealth.vol3.issspecial1.72. 76. alhusseiny a, latif i, ali jadoo sa. covid-19 in iraq: an estimated cost to treat patients at a private clinic. journal of ideas in health2021; 4(1): 304-306. https://doi.org/10.47108/jidhealth.vol4.iss1.82. 77. ali jadoo sa, alhusseiny a, yaseen s, al-samarrai m, alrawi r, al-delaimy a, abed m, hassooni h. knowledge, attitude, and practice toward covid-19 among iraqi people: a web-based cross-sectional study. journal of ideas in health 2020; 3(special2):258-65. https://doi.org/10.47108/jidhealth.vol3.issspecial 2.59. 78. rochman nd, wolf yi, faure g, mutz p, zhang f, koonin ev. ongoing global and regional adaptive evolution of sars-cov-2. proc natl acad sci u s a. 2021;118(29):e2104241118. doi:10.1073/pnas.2104241118. 79. rein t. harnessing autophagy to fight sars-cov-2: an update in view of recent drug development efforts. j cell biochem 2021; 1-6. doi: 10.1002/jcb.30166. 80. yu s, jia j, zheng j, zhou y, jia d, wang j. recent progress of ferroptosis in lung diseases. front. cell. dev.biol. 2021; 9: 789517. doi: 10.3389/fcell.2021.789517. https://doi.org/ 10.47108/jidhealth.vol5.issspecial1.224 sökmen s and ünal e, et al., journal of ideas in health 2022;5(special 1):707-715 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access evaluation of the knowledge, attitudes, vaccine hesitancy, and behaviors of anesthesia technicians on adult vaccination serdal sökmen1*, egemen ünal1 abstract background: anesthesia technicians work in places with a high risk of infectious diseases. vaccination is one of the most essential methods that protect society and healthcare workers against infectious diseases. this study aims to determine anesthesia technicians' knowledge, behavior, attitude, and vaccine hesitancy. methods: a cross-sectional web-based study was conducted between october 2021 and february 2022 at the ankara yildirim beyazit university, turkiye. a semi-structured and self-reported online survey was recruited to collect data from the turkish anesthesia technicians’ community. data of 1600 participants have undergone descriptive and univariate analyses to evaluate the differences in mean scores on knowledge, attitudes, and vaccine hesitancy. results: the mean age of respondents was 24 years (±6.15). more than two-thirds (79.2%) were females, single (84.9%), aged less than 30 years (88.4%), and unemployed (61.1%); however, 12.4% had chronic diseases. the mean knowledge, attitude, and vaccine hesitancy score were 13.24± 3.22 (range: 0-21), 11.19 ± 3.19 (range: 0-15), and 28.67± 6.64, range: 12–60), respectively. most respondents had information (1458, 91.1%) about covid-19 vaccines, and 1247(77.9%) had been vaccinated. however, 240 (16.3%) did not receive vaccines at all compared to 59 (3.7%) who completed the thirteen recommended vaccines in turkiye. the mean of vaccine hesitancy was significantly higher among females (p=0.001), unemployed (p=0.007), residents in southeast anatolia (p=0.001), and those who did not use medication continuously (p=0.016). however, participants aged 40 years and above (p=0.013) showed the lowest mean of vaccine hesitancy than the other age groups. conclusion: appropriate training and guidance might increase the vaccination information and enhance the vaccination rates among anesthesia technicians. keywords: covid-19, vaccination, knowledge, anesthesia technicians, vaccination hesitancy, turkey background demographic changes in societies, increase in global travel, migration, and adaptation of microorganisms with these conditions made infectious diseases a renewed threat to the world. [1]. infectious diseases have caused many epidemics and millions of morbidities and mortalities throughout history (such as the antonine plague (165-180 ad), black plague (14th century), typhoid epidemic (19th century), spanish flu (19th century), hiv/aids (1960), the covid -19 pandemic (2019), etc. moreover, infectious diseases were responsible for extending hospital stays, prolonged inability to work, economic loss, and social unrest [2]. protection against infectious diseases with significant social consequences has always been one of the goals of humanity. in this sense, there are many methods to combat infectious diseases. the most successful of these methods is vaccination [3]. furthermore, it is essential to protect groups that work in places with a high risk of infectious diseases, such as healthcare facilities [4]. in vaccination, microorganisms or toxins whose infectious power has been destroyed or weakened are identified and administered to the body to protect a healthy person from the disease. when the body encounters the same microorganisms or toxins again in the future, it stimulates the immune system and destroys the microorganisms [5]. in order to remain healthy throughout life, it is necessary to immunize the entire society in childhood and adulthood through vaccination. in turkey, the ministry of health recommended covid -19, hepatitis b, influenza, diphtheria, tetanus, pertussis, hepatitis a, chicken pox pneumococcal (pneumonia), measles mumps rubella, haemophilus influenza type b, meningococcus and inactivated polio vaccines for adults [6]. ___________________________________________________ serdalkerem19@gmail.com 1department of public health, ankara yildirim beyazit university institute of health sciences, ankara, turkey full list of author information is available at the end of the article 10.47108/jidhealth.vol5.issspecial1.224 http://www.jidhealth.com/ sökmen s and ünal e, et al., journal of ideas in health (2022); 5(special 1):707-715 708 all those who work in healthcare facilities, including physicians, nurses, anesthesiologists/technicians, and who ensure the continuation of preventive and curative health services are referred to as healthcare workers (hcws). hcws employed under the anesthesiologist's responsibility to safely induce, maintain, and terminate anesthesia are anesthesia technicians. in turkey, hcws who graduated from a vocational school of health care services until 2017 are referred to as "anesthesia teknisyeni" in turkish, and those who graduated from a vocational school of health care services of higher education (2 years of post-high school education) in anesthesia programs since 1984-1985 are referred to as "anesthesia teknikleri" in turkish [7]. however, in this study, we will call both "anesthesia technicians" for simplicity. priority to vaccination shall be given to those in direct contact with patients, including the anesthesia technicians, to protect them and their patients. however, high vaccine hesitancy rates were recorded among hcws worldwide. arghittu et al. [8] found that only 30.6% hcws in an italian university hospital had the “flu vaccination”. tian et al. [9] found that among 1739 chinees anesthesiologists, 91.9% were exposed to sharps injuries, and 79.4% received three "hbv vaccination doses". however, half of them received reminder hbv vaccination doses. goins et al. [10] reported that among 1,819 surveyed american hcws, 13.0% had the intention to get the pertussis vaccine. moreover, the authors found that 38.0% of those who refused the pertussis vaccine thought there was no risk of getting pertussis. all health professionals, including anesthesia technicians, contribute to delivering health guidance to the population. therefore, their knowledge, attitudes, and behaviors can help increase immunization coverage. this study aims to assess the knowledge, attitudes, behaviors, and vaccine hesitancy according to recommendations of the ministry of health in the republic of turkey. methods study design a cross-sectional web-based study was conducted between october 2021 and february 2022 at the department of public health, ankara yildirim beyazit university, turkiye. in response to the health protection procedures imposed due to the covid-19 pandemic and to improve the accessibility of the whole of turkey, the survey method was more appropriate to reach the target population. the google docs form was recruited to prepare an online self-reported questionnaire. the link has been shared with many social media sites concerned with disseminating anesthesia-related knowledge. inclusion and exclusion criteria all anesthesia technicians who graduated from the department of anesthesia, both genders, using social media regularly and willing to participate, were included in the study. however, anesthesia students, other health department workers, incomplete data, and those who did not feel willing to participate were excluded from the study. sample size the authors aimed to reach the broader target population (anesthesia technicians). out of 11064 anesthesia technicians listed in the republic of turkey ministry of health's personnel allocation plan [7], about 5000 anesthesia technicians are estimated to use anesthesia-related social media pages. the sample size calculator arrived at 357 participants, using a margin of error of ±5.0%, a confidence level of 95%, a 50% response distribution, and 5000 people. however, 1709 subjects were collected in the system [11]. the final sample was 1600 after excluding 109 none anesthesia technicians. study tool first sections: this part included the sociodemographic factors such as gender, age (0-22 years, 23-29 years, 30-39 years, 40 years and above), marital status, number of children, place of residence, education (vocational high school, vocational school), number of years worked, institution (university hospital, training and research hospital, state hospital, private hospital, other), the location of the workplace (central district, rural district), monthly income, chronic disease status, continuous drug use and chronic diseases in fellow residents. second sections: this part included one question with 12 subitems according to the "turkey vaccine hesitancy scales" created by kiliçarslan and his friends in 2020 [12]. the assessment was based on a 5-point likert scale. because the first 4-questions contained statements in favor of the vaccine, they were reverse scored. participants rated the response to each question between 1 and 5, and survey respondents received a total score between 12 and 60 (inclusive) points. cronbach's alpha reliability coefficients range from 0.71 to 0.86, corresponding to high-reliability levels. third sections: this part included 11 main questions and ten sub-items established as a result of the literature review to determine the level of knowledge about vaccination in adults. responses were scored on a 3-point likert scale. correct answers were scored 1 point, and incorrect and "i have no idea" answers were scored 0 points. a participant scored between 0 and 21 (inclusive). as the score increases, the level of knowledge increases. fourth section: this part included 15 questions developed from the literature review on adult vaccination to determine the level of attitude. responses were scored on a 3-point likert scale. questions 38, 39, 40, and 46 were reverse scored because they contained statements about vaccine hesitancy. correct answers were scored 1 point; incorrect and "i have no idea" answers were scored 0 points. a participant scored between 0 and 15 (inclusive) points. as the score increases, the level of attitude increases. fifth section: this part included two questions developed to determine the respondents’ information about the recommended vaccines by the ministry of health in turkiye and whether they had received the vaccines. dependent and independent variables the dependent variables included the level of knowledge, attitude, behavior, and vaccine hesitancy. the independent variables are sociodemographic factors. statistical analysis the collected data were analyzed using the program ibm spss version 20.0. in the descriptive results section, categorical variables were presented as numbers and percentages and sökmen s and ünal e, et al., journal of ideas in health (2022); 5(special 1):707-715 709 continuous variables as mean ± standard deviation and median. we found that the dependent variables, which are “level of knowledge, attitude, behavior, and value of vaccine hesitancy”, did not have a kolmogorov-smirnov normal distribution. mann-whitney u and kruskal-wallis tests were used for statistical analysis. the statistical significance threshold was set at p≤0.05. results sociodemographic characteristics a total of 1600 respondents were included in the final analysis. the mean age was 24 ± 6.15 years. most of them were females (79.2%), single (84.9%), aged less than 30 years (88.4%), unemployed (61.1%), and lived in the marmara region (31.2%); however, 12.4% had a history of chronic disease. out of 623 employed respondents, 205(32.9%) work in the private sector within the central district (541, 86.8%). the participants ‘characteristics are shown in table 1. table 1. the distribution of participants according to sociodemographic characteristics (n=1600) variable categorized variables n % gender male 332 20.8 female 1268 79.2 age group 0-22 years 879 54.9 23-29 years 534 33.4 30-39 years 118 7.4 40 years and over 69 4.3 marital status married 241 15.1 single 1359 84.9 number of children no children 1423 88.9 1 child 69 4.3 2 children or more 108 6.8 place of residence (region) marmara 499 31.2 aegean 144 9.0 mediterranean 153 9.6 central anatolia 447 27.9 black sea 135 8.4 eastern anatolia 107 6.7 southeast anatolia 115 7.2 education vocational high school 63 3.9 vocational school of higher education 1537 96.1 number of years worked not working 977 61.1 1 9 years 479 29.9 10 19 years 89 5.6 20 years or more 55 3.4 work institution university hospital 41 2.5 training and research hospital 162 10.1 state hospital 161 10.1 private hospital 205 12.9 other 54 3.3 not working 977 61.1 district of workplace central district 541 86.8 rural district 82 13.2 monthly income 3000 tl or less 1034 64.6 3001 5000 tl 251 15.7 5001 7000 tl 241 15.1 7001 tl or more 74 4.6 chronic disease status yes 199 12.4 no 1401 87.6 continuous medication use yes 38 2.6 no 1399 97.4 chronic disease status in fellow residents yes 675 42.2 no 925 57.8 level of knowledge the mean knowledge score was 13.24 (± 3.22) (range: 0-21), giving an overall 63.05% (13.24 /21*100) correct response. the knowledge score was significantly higher among respondents who were males (13.70 ± 3.40, p=0.001), aged 40 years and above (14.39 ± 3.22, p<0.001), married (13.74 ± 3.18, p=0.005), had 2 children or more (14.49 ± 3.27, p=0.009), the experience of 20 years and above (14.49 ± 3.27, p<0.001), monthly income of 7001 tl and above (14.47 ± 3.17, p<0.001), history of chronic disease (13.84 ± 3.27, p=0.001), and those continuously use medication (13.64 ± 3.35, p=0.030), respectively. information and behavior towards vaccination table 3 presents the participants' responses about whether they have information about the recommended list of vaccines by the republic of turkey (ministry of health) or not and whether they have received the vaccine. the first three most well-known vaccines by respondents were covid -19 (91.1%), hepatitis b (70.0%), and influenza (60.8%). while the least known vaccines are inactivated polio (14.6%), meningococcal (14.8%), and hemophilus influenza type b (23.3%). moreover, more than half of the respondents do not know about hepatitis a, pneumococcal, and measles mumps rubella vaccines. the most frequently administered vaccines by participants were covid -19 (77.9%), hepatitis b (63.4%), and measles-rubellamumps (53.8%). meningococcal vaccine, hemophilus influenza type b vaccine, and inactivated polio vaccine were the least used vaccines (10.5%). furthermore, diphtheria, pertussis, varicella, hepatitis a, pneumococcal, influenza, and diphtheriatetanus-acellular pertussis vaccinations were administered among less than half of the participants. adult vaccines taken by respondents table 4 shows the percentage of adult vaccines taken by respondents. the list of recommended vaccines by the ministry of health in turkey included thirteen vaccines. two hundred and sixty (16.3%) respondents declared that they did not receive any vaccine. the highest percentage of the taken vaccines was reported by 270 (16.9%), 224 (14.0%), and 198(12.4%) respondents for the three, two, and four vaccines, respectively. however, 21(1.3%) of respondents received only one vaccine, and 59(3.7%) received all the thirteen recommended vaccines. sökmen s and ünal e, et al., journal of ideas in health (2022); 5(special 1):707-715 710 table 2. distribution of participants' knowledge level scores on sociodemographic characteristics (n=1600) variable categorized variables mean knowledge score (± sd) p value gender* male 13.70 ± 3.40 0.001 female 13.12 ± 3.16 age group ** 0-22 years 13.14 ± 3.25 <0.001 22-29 years 13.10 ± 3.14 30-39 years 13.99 ± 3.21 40 years and over 14.39 ± 3.22 marital status * married 13.74 ± 3.18 0.005 single 13.15 ± 3.22 number of children ** no children 13.16 ± 3.21 0.009 1 child 13.65 ± 3.06 2 children or more 14.02 ± 3.31 place of residence (region)** marmara 13.27 ± 3.06 0.107 aegean 13.61 ± 3.04 mediterranean 13.56 ± 3.40 central anatolia 13.24 ± 3.28 black sea 13.37 ± 3.31 eastern anatolia 12.61 ± 3.36 southeast anatolia 12.63 ± 3.28 education * vocational high school 13.20 ± 3.90 0.393 vocational school of higher education 13.24 ± 3.19 number of years worked ** not working 13.00 ± 3.28 <0.001 1 9 years 13.38 ± 3.00 10 19 years 14.40 ± 3.26 20 years or more 14.49 ± 3.27 district of workplace * central district 13.67 ± 2.97 0.679 rural district 13.26 ± 3.78 work institution** university hospital 13.63 ± 3.11 0.525 training and research hospital 13.64 ± 3.24 state hospital 13.52 ± 3.22 private hospital 13.83 ± 2.94 other 13.01 ± 2.74 monthly income** 3000 tl or less 13.03 ± 3.24 <0.001 3001 5000 tl 13.40 ± 3.14 5001 7000 tl 13.61 ± 3.11 7001 tl or more 14.47 ± 3.17 chronic disease status* yes 13.84 ± 3.27 0.001 no 13.15 ± 3.20 continuous medication use* yes 13.64 ± 3.35 0.030 no 13.18 ± 3.20 chronic disease status in fellow residents* yes 13.26 ± 3.07 0.883 no 13.23 ± 3.22 table 3. participants' information and behavior towards vaccines recommended by the republic of turkey ministry of health (n=1600). vaccines has information n (%) no information n (%) has vaccinated n (%) not vaccinated n (%) covid-19 1458 (91.1) 142 (8.9) 1247 (77.9) 353 (22.1) hepatitis b 1120 (70.0) 480 (30.0) 1015 (63.4) 585 (36.6) influenza 973 (60.8) 627 (39.2) 435 (27.2) 1165 (72.8) diphtheria 924 (57.8) 676 (42.3) 568 (35.5) 1032 (64.5) tetanus 924 (57.8) 676 (42.3) 568 (35.5) 1032 (64.5) pertussis 924 (57.8) 676 (42.3) 568 (35.5) 1032 (64.5) hepatitis a 762 (47.6) 838 (52.4) 619 (38.7) 981 (61.3) chickenpox 755 (47.1) 845 (52.9) 791 (49.4) 809 (51.6) pneumococcus 703 (43.9) 897 (56.1) 241 (15.1) 1359 (84.9) measles mumps – rubella 577 (36.1) 1023 (63.9) 860 (53.8) 740 (46.3) hemophilus influenza type b 372 (23.3) 1228 (76.8) 168 (10.5) 1432 (89.5) meningococcus 237 (14.8) 1363 (85.2) 168 (10.5) 1432 (89.5) inactive polio 233 (14.6) 1367 (85.4) 168(10.5) 1432(89,5) sökmen s and ünal e, et al., journal of ideas in health (2022); 5(special 1):707-715 711 table 4. number of vaccinations taken by participants vaccination count n % 0 260 16.3 1 21 1.3 2 198 12.4 3 270 16.9 4 224 14.0 5 188 11.8 6 147 9.2 7 82 5.1 8 44 2.8 9 32 2.0 10 34 2.1 11 18 1.1 12 23 1.4 13 59 3.7 level of attitude vaccine hesitancy the mean attitude score was 11.19 (± 3.19) (range: 0-15), giving an overall 74.6% (11.19 /15*100) correct response. however, none of the sociodemographic factors significantly affect the mean attitude score (p > 0.05). therefore, we did not include the related data. vaccine hesitancy the mean vaccine hesitancy score was 28.67 (± 6.64) (range: 12-60), giving an overall 47.8% (28.67 /60*100) correct response. the mean vaccine hesitancy score was significantly higher among respondents who were females (28.98 ± 6.70, p=0.001), unemployed (28.93 ± 6.60, p=0.007), resident in southeast anatolia (30,80 ± 6,67, p=0.001), and those who did not use drugs continuously (28.78 ± 6.56, p=0.016), however, respondents aged 40 years and above (26.10 ± 5.23, p=0.013) have the lowest mean vaccine hesitancy score than the other age groups. the distribution of participants' hesitancy rate to vaccination by sociodemographic structure is shown in table 5. discussion to our knowledge, this study is the first national study to explore turkish anesthesia technicians' knowledge, attitude, behavior, and vaccination hesitancy rates. the mean knowledge score was 13.24 (± 3.22), with a 63.05% correct knowledge rate about the vaccine. about two-thirds of our sample (anesthesia technicians) answered the information questions correctly because any knowledge about vaccination is very valuable. moreover, the rate of those who answered all information questions correctly was acceptable, indicating adequate vaccination training during education and in-institution training of anesthesia technicians. a german study reported a similar finding [13]. authors reported that the level of knowledge was average to very good among 93.3% of respondents. moreover, the knowledge increases with advanced training. oğuzöncül et al. [14] found that the knowledge of family physicians about the vaccine in elazığ province (turkey) was 7.59 (± 2.17), with a 63.25% correct answer rate. el-sanafi and sallam [15] found that the covid-19 vaccine acceptance rate was 83.3% among hcws in kuwait, and the vaccine hesitancy rate was higher among females than males. a systematic review and metaanalysis study conducted by zintel et al. [16] reported that 58.0% of articles from different countries indicated that fewer females had the intention to get vaccinated than males, "or 1.41 (95% ci 1.28 to 1.55)". moreover, hcws showed a bigger difference compared to the general population. similarly, in our study, the male gender has more knowledge about vaccination than the female (13.70 ± 3.40, p=0.001). the reason why the knowledge level of men about vaccination was higher than that of women might be because women have just started their profession, and their average age and work experience are lower than that of their male counterparts. the vaccination knowledge was higher among anesthesia technicians older than 40 years than in other age groups. similar to our study, al-hanawi et al. [17] found that willingness to get vaccinated was higher among saudi males aged fifty years and above than their counterparts “an or: 2.277; 95% ci: 1.092 to 4.745". margüello et al. [18] indicated that respondents aged 65 years and older were positive toward the benefits of vaccines and their effectiveness". unlike our finding, oğuzöncül et al. [14] reported that there was no association between the age group of hcws and vaccine knowledge level [15]. the reason behind the high level of knowledge among people aged 40 years and older is the increasing awareness of diseases with age. the elderly see vaccination as a preventive health service, especially due to the deadly impact of the covid -19 pandemic on the advanced age group, quarantine, vaccination, etc. moreover, the increase in vaccination information may be due to the use of precautions, especially in older age groups. in this study, the participants with chronic diseases (p=0.001) and constant drug use (p=0.030) were more informed about vaccination. similarly, medetalibeyoglu et al. [19] reported that more than fifty percent of patients admitted to intensive care units due to infectious diseases, especially during the pandemic covid -19, had chronic diseases and were constantly taking drugs. the high awareness of people with chronic diseases and the need to take medications continuously is that the recovery process is more difficult when exposed to infectious diseases. they may spend part of their treatment in the icu. for this reason, they are thought to be receptive to vaccination to protect themselves, and therefore their level of knowledge is high. the top three vaccines acknowledged by our sample were covid-19, hepatitis b, and influenza vaccines. in a recent turkish study conducted by han-yekdeş et al. [20], the top three vaccines recommended and surveyed by physicians were hepatitis b, influenza, and tetanus-diphtheria. several reasons might explain why the covid-19 vaccine topped the list of the most known vaccine among our respondents; for example, the pandemic is still active, and the covid-19 vaccine has rapidly been used worldwide. moreover, information about the covid-19 vaccine has been disseminated throughout social media and mass media. the hepatitis b vaccine is rated after the covid19 vaccine because anesthesia technicians are among the healthcare providers who might expose to workplace injuries due to handling the piercing and cutting tools. therefore, the possibility of hepatitis b infection is very high. moreover, examining the hepatitis b serum antibodies is routine during periodic health checks. acikgoz et al. [21] reported that 86.0% of the healthcare students received the hepatitis b vaccine. dayyab et al. [22] found that 44.51% of the surveyed nigerian hcws had good knowledge of the hepatitis b vaccine, and 46.70% received at least one vaccine against it. sökmen s and ünal e, et al., journal of ideas in health (2022); 5(special 1):707-715 712 table 5. distribution of participants' hesitancy rate to vaccination on sociodemographic characteristics (n=1600) variable categorized variables mean hesitancy score (± sd) p value gender* male 27.49 ± 6.25 <0.001 female 28.98 ± 6.70 age group** 0-22 years 28.81 ± 6.53 0.013 23-29 years 28.68 ± 6.49 30-39 years 29.08 ± 9.39 40 years or more 26.10 ± 5.23 number of children ** no children 28.73 ± 6.54 0.152 1 child 27.26 ± 6.36 2 children or more 28.73 ± 7.98 place of residence (region)** marmara 28.23 ± 6.35 0.001 aegean 28.44 ± 6.86 mediterranean 28.08 ± 6.68 central anatolia 28.51 ± 6.85 black sea 29.10 ± 5.70 eastern anatolia 29.66 ± 7.35 southeast anatolia 30.80 ± 6.67 marital status * married 28.52 ± 7.44 0.307 single 28.70 ± 6.49 education * vocational high school 28.35 ± 6.44 0.517 vocational school of higher education 28.68 ± 6.65 number of years worked ** not working 28.93 ± 6.60 0.007 1 9 years 28.46 ± 6.43 10 19 years 28.55 ± 8.07 20 years or more 26.02 ± 6.16 district of workplace * central district 28.09 ± 6.61 0.229 rural district 28.83 ± 6.88 work institution** university hospital 29.29 ± 8.49 0.330 training and research hospital 27.87 ± 6.69 state hospital 28.34 ± 6.32 private hospital 27.92 ± 6.37 other 29.69 ± 7.27 monthly income** 3000 tl or less 28.90 ± 6.62 0.199 3001 5000 tl 28.55 ± 6.90 5001 7000 tl 28.10 ± 6.43 7001 tl or more 27.72 ± 6.58 chronic disease status* yes 28.19 ± 6.96 0.118 no 28.74 ± 6.59 continuous medication use* yes 27.91 ± 7.15 0.016 no 28.78 ± 6.56 chronic disease status in fellow residents* yes 28.67 ± 6.63 0.659 no 28.67 ± 6.56 the influenza vaccine takes a healthy and economic dimension due to the settlement of influenza as endemic, especially in large cities. sometimes influenza turns into epidemics, causing a burden on employees and health institutions. employers are often forced to grant workers healthcare at no cost, especially during the fall months. unlike our findings, arghittu et al. [8] reported that 30.6% of italian hcws received the flu vaccination. furthermore, inactivated polio, meningococcal, and haemophilus influenza type b vaccines occupy the last three list items. in fact, the anesthesia technicians have less knowledge about the three vaccines mentioned above because they are either rarely exposed to these infections or because the usual preoperative tests do not include inactive polio, meningococcal, and haemophilus influenza type b vaccination as it should be done about covid -19, hepatitis, etc. hanyekdeş et al. [8] reported that turkish physicians recommended and surveyed the least known vaccines, the five-mix vaccine, the meningococcal vaccine, and the human papillomavirus vaccine. the participants' attitude level was 74.6%, with a mean of 11.19 ± 3.19. our result was consistent with an earlier study conducted by pelullo et al. [23] among italian hcws. the authors reported that the level of attitude towards adult vaccines was high. furthermore, the high level of attitude in the current study might be that anesthesia technicians, like all other sökmen s and ünal e, et al., journal of ideas in health (2022); 5(special 1):707-715 713 healthcare workers, want to protect themselves, their environment, and their patients. a systematic review [24] to assess the attitude toward covid-19 vaccination found that "two-thirds" of the reviewed articles have a "positive attitude (≥50%)" compared to one-quarter that showed a negative attitude (<50%)". sociodemographic, professional, and factors related to the safety of vaccines might stand against the acceptance of the vaccine. similarly, in our study, the immunization knowledge of anesthesia technicians was acceptable, and their attitude was positive. the percentage of anesthesia technicians who did not have adult vaccination was 16.3%. a similar finding was reported by scatigna et al. [25]. the authors found that most hcws in a hospital setting had significantly inadequate vaccination rates. unlike our finding, pelullo et al. [23] reported that the rate of hcws who had received at least one vaccination was 16.9%, compared to 1.3% in our study. the average number of vaccinations received by our participants was four, and the rate of those who received all vaccinations was only 3.7%. our result was inconsistent with pulello et al. [23]. the authors found that 14.1% of respondents were aware of all recommended vaccinations. in evaluating these results, it was noted that the vaccination rates of the anesthesia technicians in our study were low. the reason for this could be the lack of active campaigns for all adult vaccines, the lack of information about vaccines, the hesitation expressed by nonprofessionals on social media, the fact that some vaccines have a cost, the idea that some vaccines are only for children, and the lack of sufficient information about adult vaccination. similar to our study, graitcer et al. [26] reported in a study of health care workers that the number one reason for unvaccinated individuals was the "lack of an active offer for vaccines. in our study, the most applied vaccines were covid 19, hepatitis b, and measles mumps – rubella vaccines. the first two vaccines anesthesia technicians knew the most about and the first two vaccines they were administered showed parallels. however, the third most commonly known influenza vaccine lagged behind in use. this could be because people thought the flu vaccine's effectiveness was low. in addition, the low reported cases of influenza in 2021 during the covid -19 pandemic might be due to masking, social distance, and cleaning measures leading to an increase in the reluctance to vaccinate. about half (47.8%) of the respondents have vaccine hesitancy. different rates have been reported across the hcws in turkey. i̇kiışık et al. [27] reported that the vaccine hesitancy rate was 29.0%, and 20.7% of respondents refused the covid19 vaccine in a "district of istanbul city". kaya et al. [28] found that 48.8% of surveyed midwives had vaccine hesitancy, and 10.5% declared that they disliked getting vaccinated. karamüftüoğlu et al. [29] indicated that 12.9% of the studied dentist had not been vaccinated yet. el-sanafi et al. [18] [30] reported that the rate of vaccination hesitancy among kuwaiti hcws was 7.7%, and 9.0% refused the vaccine. in our study, the vaccination hesitancy was higher among women than men. i̇kiışık et al. [27] showed that male doctors had a higher acceptance rate than females. yilmaz et al. [31] briefly reported that fear and lack of confidence were the most cited reasons related to vaccine hesitancy among hcws. in addition to the average age and professional experience, pregnancy and breastfeeding were the most common reasons for vaccine hesitancy among females. the anesthesia technicians aged 3039 showed more vaccine hesitancy than the other age groups. indeed, the young age group feels healthier and has fewer chronic diseases. moreover, the southeastern anatolia region showed more vaccine hesitancy than other regions in turkey for reasons related to the representative sample. the unemployed anesthesia technicians have more vaccine hesitancy than the employed participants. the people who regularly attend a workplace prefer to be vaccinated for self-protection due to the high working environment risk. there is a significant difference in the rate of vaccination hesitancy in those who do not have a chronic disease and do not take medications compared to their counterparts. healthy people are less receptive to preventive health services and do not emphasize vaccination because they do not feel at risk. the lack of a standard scale to measure vaccine knowledge and participant attitudes in the literature and the inability to reach our entire universe because of covid-19 conditions represent limitations of the research. in addition, the fact that our study has a cross-sectional design creates a limitation for revealing causality. policy implication in turkey, employment in the healthcare field is increasing, especially due to the new city hospitals, the increase in private sector investment in healthcare, and the development of health tourism. in parallel, the number of anesthesia technicians is increasing daily, which is an important part of the ministry of health. however, there are no direct studies in the literature about anesthesia technicians' views on immunization, either in our country or worldwide. however, few studies generalized under the name of "other healthcare workers". our study might help fill this gap in the literature. anesthesia technicians typically receive information about vaccinations during the school period and in-institution education courses. notably, during the covid-19 pandemic, both face-to-face and ininstitution collective training were suspended and replaced with online training. in parallel, both the number and followers of social media sites offering anesthesia training increased, especially the pages that provide anesthesia training, such as "anestezi_günlüğü", "ahmetemreazaklı", anestezinin_içsesi", etc. some pages have more than 10 thousand followers, of which about 5000 are anesthesia technicians. such pages became an effective mass communication and educational tool throughout the country. we thank the educational posts they publish both immediately and repeatedly. conclusion in conclusion, 63.05% of turkish anesthesia technicians showed adequate knowledge, and 74.6% expressed a high attitude toward adult vaccination. therefore, 91.1% of participants had information about covid-19 vaccines, and 77.9% received the vaccine. however, the vaccine hesitancy rate was 47.8% among anesthesia technicians, and only 3.7% had completed the thirteen vaccines recommended by the ministry of health in turkey. females have higher vaccine hesitancy than males (p=0.001) and unemployed anesthesia technicians (p=0.007). the old respondents (40 years and above) had the lowest vaccine hesitancy of the other age groups (p=0.013). we recommend raising the level of knowledge and reducing hesitation against vaccines by adopting training of anesthesia technicians on social media. sökmen s and ünal e, et al., journal of ideas in health (2022); 5(special 1):707-715 714 abbreviation ad: after christ; hiv: human immunodeficiency virus; aids: acquired immune deficiency syndrome; covid-19: coronavirus disease-2019; ibm: international business machines; spss: statistical package for the social sciences; sd: standard deviation; icu: intensive care unit; od: odis ratio declaration acknowledgment we thank all the anesthesia technicians who participated in our survey. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing serdalkerem19@gmail.com authors’ contributions all authors equally contributed to the concept, design, literature search, data analysis, data acquisition, manuscript writing, editing, and reviewing. all authors have read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the protocol was approved by ankara yildirim beyazit university ethics committee (ref: sr/05 at 22-september-2021); in addition, web-based informed consent was obtained from each participant after the study objectives and confidentiality guarantee was explained. consent for publication not applicable competing interest the authors declare that they have no competing interest. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of public health, ankara yildirim beyazit university institute of health sciences, ankara, turkey. orcid: 0000-0001-7555-2174 orcid: 0000-0002-9939-9191 article info received: 21 april 2022 accepted: 05 july 2022 published: 19 july 2022 references 1. adult immunization guide. turkish infectious diseases and clinical microbiology specialization association (ekmud), adult immunization guide working group. 2019. available from: https://www.ekmud.org.tr/rehberler/1-ekmud-rehberleri (accessed on 10th may 2021). 2. türk a, ak b, ak r. economic and social effects of pandemics in the historical process (tarihsel süreçte yaşanan pandemilerin ekonomik ve sosyal etkileri). gaziantep university journal of social sciences 19 (covid-19 special issue):612–32.2020.doi: 10.21547/jss.766717. 3. dubé e, laberge c, guay m, bramadat p, roy r, julie a. bettinger ja. vaccine hesitancy. human vaccines & immunotherapeutics2013; 9:(8): 1763-1773. doi: 10.4161/hv.24657. 4. galanakis e, jansen a, lopalco pl, giesecke j. ethics of mandatory vaccination for healthcare workers. euro surveill. 2013;18(45);20627 5. t.c. ministry of health, vaccine portal. available from: https://asi.saglik.gov.tr. (accessed on 26th march 2022). 6. kartal ed. prophylaxis in health personnel. symposium series. february 2008; 61: 215-222. 7. t.c. ministry of health, general directorate of management services, personnel distribution chart (pdc) updated: august 24, 2021, https://yhgm.saglik.gov.tr/tr-42988/personel-dagilimcetveli-pdc.html (access date: 07.11.2021) 8. arghittu a, dettori m, azara a, gentili d, serra a, contu b, castiglia p. flu vaccination attitudes, behaviours, and knowledge among health workers. int j environ res public health. 2020 may 3;17(9):3185. doi: 10.3390/ijerph17093185. 9. tian j, tan f, lai l, deng y, chi x, geng h, zhu q. anesthesiologists' acquisition of hepatitis b virus infection: risk and prevention. medicine (baltimore). 2019 jul;98(29): e16416. doi: 10.1097/md.0000000000016416. 10. goins wp, schaffner w, edwards km, talbot tr. healthcare workers' knowledge and attitudes about pertussis and pertussis vaccination. infect control hosp epidemiol. 2007 nov;28(11):1284-9. doi: 10.1086/521654. 11. sample size calculator by raosoft, inc.; 2021. available from: http://www.raosoft.com/samplesize.html. [accessed on 17 september 2021]. 12. kılınçarslan, mg, sarıgül b, toraman ç, şahin em. development of valid and reliable scale of vaccine hesitancy in turkish language. konuralp medical journal. 2020;12(3):420429. doi: 10.18521/ktd.693711. 13. berg tt, wicker s. knowledge, attitude and behavior towards vaccinations among nursingand health care students in hesse. an observational study. gms j med educ. 2021 nov 15;38(7):doc115. doi: 10.3205/zma001511. 14. oğuzöncül af, tuncer-kara k, deveci se. knowledge, attitudes and behaviors of primary healthcare physicians about vaccines. klimik derg. 2021; 34(2): 123-8. doi:10.36519/kd.2021.3300. 15. al-sanafi m, sallam m. psychological determinants of covid19 vaccine acceptance among healthcare workers in kuwait: a cross-sectional study using the 5c and vaccine conspiracy beliefs scales. vaccines. 2021; 9(7):701. https://doi.org/10.3390/vaccines9070701 16. zintel s, flock c, arbogast al, forster a, von wagner c, sieverding m. gender differences in the intention to vaccinate against covid-19: a systematic review and meta-analysis. z gesundh wiss. 2022 jan 7:1-25. doi: 10.1007/s10389-021-01677w. 17. al-hanawi mk, alshareef n, el-sokkary rh. willingness to receive covid-19 vaccination among older adults in saudi arabia: a community-based survey. vaccines (basel). 2021 oct 31;9(11):1257. doi: 10.3390/vaccines9111257. sökmen s and ünal e, et al., journal of ideas in health (2022); 5(special 1):707-715 715 18. redondo margüello e, trilla a, munguira ilb, lópez-herce aj, cotarelo suárez m. knowledge, attitudes, beliefs and barriers of healthcare professionals and adults ≥ 65 years about vaccinepreventable diseases in spain: the adult vaccination drivers and barriers (advise) study. hum vaccin immunother. 2022 dec 31;18(1):2025007. doi: 10.1080/21645515.2021.2025007. 19. medetalibeyoglu a, ezirmik e, senkal n, bayrakdar s, aktar i, akas r, et al. patient characteristics and risk factors for mortality in 504 patient characteristics and risk factors for mortality in 504 hospitalized patients due to covid-19. j ist faculty med 2022;85(1):1-8. doi: 10.26650/iuitfd.932128. 20. han-yekdeş d, altunok a, eskiocak m, marangoz b. immunization attitudes of physicians at a university hospital. klimik derg. 2020; 33(3): 255-9. doi:10.5152/kd.2020.52 21. acikgoz a, yoruk s, kissal a, kadicesme sy, catal e, kamaci g, et al. healthcare students’ vaccination status, knowledge, and protective behaviors regarding hepatitis b: a cross-sectional study in turkey, human vaccines & immunotherapeutics 2021; 17(11): 4595-4602, doi: 10.1080/21645515.2021.1973321. 22. dayyab fm, iliyasu g, ahmad bg, bako at, ngamariju ss, habib ag. hepatitis b vaccine knowledge and self-reported vaccination status among healthcare workers in a conflict region in northeastern nigeria. ther adv vaccines immunother. 2020 jan 16; 8:2515135519900743. doi: 10.1177/2515135519900743. 23. pelullo cp, della polla g, napolitano f, di giuseppe g, angelillo if. healthcare workers' knowledge, attitudes, and practices about vaccinations: a cross-sectional study in italy. vaccines (basel). 2020 mar 26;8(2):148. doi: 10.3390/vaccines8020148. 24. hajure m, tariku m, bekele f, abdu z, dule a, mohammedhussein m, tsegaye t. attitude towards covid-19 vaccination among healthcare workers: a systematic review. infect drug resist. 2021 sep 21; 14:3883-3897. doi: 10.2147/idr.s332792. 25. scatigna m, fabiani l, micolucci g, santilli f, mormile p, giuliani ar. attitudinal variables and a possible mediating mechanism for vaccination practice in health care workers of a local hospital in l'aquila (italy). hum vaccin immunother. 2017 jan 2;13(1):198-205. doi: 10.1080/21645515.2016.1225638. 26. graitcer sb, kim d, lindley m. comprehensive efforts to increase healthcare personnel immunization. hum vaccin immunother. 2014;10(9):2625-6. doi: 10.4161/hv.36090. 27. i̇kiışık h, sezerol ma, taşçı y, maral i. covid-19 vaccine hesitancy and related factors among primary healthcare workers in a district of istanbul: a cross-sectional study from turkey. fam med community health. 2022 apr;10(2):e001430. doi: 10.1136/fmch-2021-001430. 28. kaya l, aydın-kartal y. hesitancy towards a covid-19 vaccine among midwives in turkey during the covid-19 pandemic: a cross-sectional web-based survey. european journal of midwifery. 2022;6(january):1-8. doi:10.18332/ejm/143874. 29. karamüftüoğlu n, korkmaz öner fs, uğraş dikmen a, özkan s. prevalence of covid-19 vaccine hesitancy among dentists in turkey. archives of current medical research2022; 3 (2): 86-96. 30. el-sanafi m, sallam m. psychological determinants of covid19 vaccine acceptance among healthcare workers in kuwait: a cross-sectional study using the 5c and vaccine conspiracy beliefs scales. vaccines (basel). 2021 jun 25;9(7):701. doi:10.3390/vaccines9070701. 31. yilmaz s, çolak fü, yilmaz e, ak r, hökenek nm, altıntaş mm. vaccine hesitancy of health-care workers: another challenge in the fight against covid-19 in istanbul. disaster medicine and public health preparedness. cambridge university press; 2022;16(3):1134–40. doi:10.1017/dmp.2021.257. https://doi.org/10.47108/jidhealth.vol4.iss1.85 adeyemo os, et al., journal of ideas in health 2021;4(1):293-297 © the author(s). 2021 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access sex differences on the contextual factors and physical activity levels among the nigerian people during the covid-19 oladotun sunday adeyemo1*, nurudeen afolabi sofoluwe2, yinusa olumuyiwa ganiyu3, odusanya abidemi ibrahim4, oyelami, lukman oyeyinka5 abstract background: in the context of flattening the curve of the spread of coronavirus in nigeria, some factors were considered. this study aimed to investigate the relationship between some of the considered factors and physical activity and investigate sex differences on physical activity during the coronavirus pandemic in nigeria. methods: the study was cross-sectional using an online survey and recruited participants from nigeria's southwest geopolitical zone through the snowball sampling technique. descriptive statistics (such as percentages), correlation analyses, and t-test of independent measures were used to analyze the data collected. the data collection was conducted from april to june 2020. results: the participants' age ranges from 18 to 73years, with a mean age of 42.9 years, a median of 43years, and a standard deviation of 5.41. the result showed a significant difference between males and females (x ̅= 1001.21; sd=1371.83) on moderate physical activity during the pandemic in nigeria. however, there was no significant relationship between contextual factors; perception of the spread [r (467) =0.028; p>0.05], fear of contracting covid19 [r (467) =0.041; p>0.05], stay at home measures [r (467) =-0.030; p>0.05], sensitizing others about covid-19 [r (467) =-0.044; p>0.05], compliance with safety rules and regulations [r (467) =0.052; p>0.05] and overall physical activity. conclusion: the study concluded that the relationship between contextual variables and physical activity among nigerian people during the covid-19 pandemic is not significant. secondly, males and females are not different on vigorous and walking physical activity levels. keywords: covid-19, physical activity, contextual measures, sex differences, coronavirus, nigeria background the word pandemic is used to describe a disease that can affect people all over the world. such disease should be novel, have the ability to spread in an unanticipated manner across boundaries of the world, severe enough to cause high mortality, have high rate of transmission, and must be communicable [1]. humankind has at different times experienced diseases with the highlighted characteristics; however, the one the whole world is grappling with now is a coronavirus, also known as covid-19. coronavirus is a novel single strand of ribonucleic acid (rna) viruses caused by severe acute respiratory syndrome coroanavirus-2 (sars-cov-2) with pneumonia-like symptoms. with the index case in wuhan china by the end of the year 2019, the number of cases worldwide is in astronomical proportion. like 2003 sars, coronavirus has affinity for respiratory organs, and it is more contagious because there is no immunity against the virus yet [2]. as the whole world is feeling the impacts of this disease, africa could be having a triple tragic impact of the pandemic on her health, economy, and political systems [3]. in the context of stemming the spread of the virus, different countries of the world prescribed various public health measures in order to flatten the curve of the spread of the virus. some of these contextual measures in nigeria included full or partial national lockdowns of some cities, travel bans, social distancing, constant hand washing with alcohol-based sanitizers, coughing into the elbow, compulsory wearing of face masks in public places, washing of hands with soap, and water among other approaches. specifically, lockdowns, travel restrictions, and social distancing strategies in some nigerian states during the early periods of the pandemic were total, while others relaxed the measures for people to go out after a while ___________________________________________________ os.adeyemo@oouagoiwoye.edu.ng 1department of psychology, faculty of social sciences, olabisi onabanjo university, ago-iwoye, nigeria full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol4.iss1.85 http://www.jidhealth.com/ ademeyo os, et al., journal of ideas in health (2021); 4(1):293-297 294 [4]. these prescriptions have been revealed to have an inadvertent iatrogenic effect on people as they could likely lead to a lower level of engagement in any level of physical activity [5-7]. in turn, they could affect immunity, making it challenging to suppress some lifestyle illnesses such as diabetes, high blood pressure, which could be risk factors of or worsen the condition of covid-19 illness [8]. ordinarily, physical activity levels reflect the intensity of energy an individual burns through either engaging in walking, doing moderate physical activity, or engaging in vigorous physical activity. interestingly, engaging in some physical activity parameters (walking, transportation to work, etc.) has an additive effect on physical activity [9]. the contextual variables containing the spread of covid-19 considered in this study are public health measures, perception of the spread of covid-19, fear of covid-19, stay at home order, sensitizing others, and compliance measures. all these measures are believed to aid the control of the spread of coronavirus [10]. expectedly, these measures are instituted to target minimal movements of humans, suggesting that the fewer people move around, the less the spread of the disease. to a large extent, people in low and middle-income countries (lmics) such as nigerians are physically active mainly through transportations to their jobs and other places [11]. unfortunately, the contextual control measures of covid-19 make this impossible. as it was reported the fear of contracting covid-19 was very high among those experiencing lockdowns [12,13] explained that exercising may induce the fear of contracting the virus, thereby causing physical inactivity. while assertion may be logical [13], there are places where people still engage in outdoor physical activity [14]. we hypothesized that contextual factors would have a significant relationship with physical activity during the lockdown period resulting from nigeria's coronavirus pandemic. less has been done as regards gender issues during covid19 [15]. this is shown in the number of commentaries that have been written about the effects of measures to contain the pandemic on physical activity, with little attention given to differences among males and females on physical activity levels. we found few studies which looked into gendered implications of lockdowns on physical activity during covid19 among adolescents in croatia [16, 17] and sicilian adults [18]. sekulic et al. [17] found out that girls engaged more in overall physical activity than boys. the lockdown measures nearly made boys engage less in vigorous physical activities which typically found in gyms and clubs; however, such places are banned during the pandemic. other studies conducted by karuc et al. [16] and giustino et al. [18] revealed that males tended to be more involved in physical activity than females. from the foregoing, we hypothesized that there would be a significant difference between males and females on each physical activity level during the lockdown measures occasioned by covid-19 in nigeria. this study would aid in providing sex-disaggregated evidence on physical activity level during the covid-19 pandemic. it would also help in policy directions on tailor-made public health information on physical activity during the pandemic. this study would also fill the data gap regarding physical activity during the pandemic in nigeria. moreover, we could not find any previous study looking into this construct in nigeria. methods online responses are elicited from a set of people who experienced lockdown caused by the covid-19 pandemic in southwest nigeria. southwest nigeria is one of the leading geopolitical zones mostly ravaged by the pandemic in the country. the questionnaires were distributed via popular social media in nigeria through the online cross-sectional survey, including whatsapp media tool and facebook. a total of 565 responses were received from the respondents in the study area. out of the total responses received, 467 were found useful, representing 82.65% of the participants. the participants' responses were elicited some weeks after the national and the southwest state governments' initial lockdown, which started march 30th, 2020. the chosen area of study was then the epicenter of the coronavirus pandemic in the country. lagos, a state in nigeria's study region and former capital, currently tops the chart with 59.97% of confirmed cases as of april 19th, 2020, and even now. information on health-related physical activities was collected in addition to perception and reactions to covid-19 pandemic control strategies advocated by both national and state governments. the survey covered information on walking, moderate and vigorous physical activity levels carried out by the respondents, as well as time spent (number of minutes per day) on each activity in the past 7-days of stay at home. data collection was conducted between april to june 2020. the snowball sampling technique was used to collect the data. the participants received the questionnaire as a google form on their whatsapp groups or facebook messenger groups and were encouraged to send it to other groups they belonged to, thereby recruiting participants who share some characteristics with them. questions on the survey were guided by international physical activity questionnaire (ipaq) and scoring protocol. this study used ipaq short form, which has been previously used in nigeria [19, 20]. the participants' level of activities (walking, moderate and vigorous) was assessed in the number of hours and minutes they engaged in the three activities per day and then in the last seven days. the scoring protocol for ipaq can be found in (www.ipaq.ki.se). statistical analysis descriptive statistics (such as percentages), correlation analyses, and t-test of independent measures were used to analyze the data collected. results the participants’ age ranges from 18 to 73 years. the overall mean age of respondents is 42.82 ± 9.60 years. the percentage age distribution between 30 and 50 years is 65.1%; 32.2% are between 31 and 40 years, while 32.9% are between 41 and 50. a lower percentage (24.2%) of respondents lies between 51 and 60 years. about 10.1% of the sample is less than 30 years, while 0.7% is older than 60 years. the sample is dominated mainly by the male (72.6%) and 27.4% of the female. the majority (75.4%) were married, with single constituting 23.1 percent of the sample (table 1). involvement in different types of physical activity varies among the respondents. a higher percentage (69.6%) of the sample did not participate in vigorous physical activity such as heavy lifting, aerobics, and fast bicycling, while 30.4% reported ademeyo os, et al., journal of ideas in health (2021); 4(1):293-297 295 their involvement in vigorous physical activity. on the contrary, a larger percentage (61.2%) of respondents reported moderate physical activity, while 38.8% did not indicate their involvement in a moderate activity such as playing table tennis, bicycling at a regular pace, and carrying light loads. table 1 socio-demographic characteristics and involvement in vigorous and moderate physical activity variable description % age (years) < 30 10.1 31-40 32.2 41-50 32.9 51-60 24.2 > 60 0.7 mean 42.82 std. deviation 9.60 gender male 72.6 female 27.4 marital single 23.1 married 75.4 separated 0.9 widowed/widower 0.6 physical activity vigorous activity yes 30.4 no 69.6 moderate activity yes 61.2 no 38.8 from table 2 above, it was shown that participants’ perception of the spread of covid-19 [r (467) =-0.215; p<0.01] significantly has a negative relationship with fear of covid19. this simply means that the lower the perceptions of the spread of covid-19, the more the fear of contracting covid19. also, participants’ perceptions of covid-19 [r (467) =0.121; p<0.01] significantly have a positive relationship with staying at home. this means that the more the participants positively perceive covid-19, the more they intend to stay at home. less participation in sensitization to others about covid-19 has a negative correlation with perceptions of the spread of covid-19 [r (467) =-0.122; p<0.01]. however, stay at home measures [r (467) =0.160; p<0.01] significantly have a positive relationship with sensitization about covid-19 to others; this means that the more participants obey the restriction order to stay at home, the more they get to sensitize others about covid-19. furthermore, the more participants’ fear of contracting covid-19 [r (467) =0.104; p<0.01], the more their level of compliance to safety rules. this suggests that fear of contracting covid-19 significantly has a positive relationship with compliance to covid-19 safety rules and regulation. however, stay at home order [r (467) = -0.128; p<0.01] significantly has a negative correlation with compliance with safety rules and regulation. that is, the more people stay at home, the less they comply with covid-19 safety rules and regulations. more so, participation in sensitizing others about covid-19 [r (467) =0.233; p<0.01] is negatively associated with compliance with safety rules. the more participants sensitize the public and relatives about covid-19, the less their compliance with safety rules. however, perception of the spread [r (467) =0.028; p>0.05], fear of contracting covid-19 [r (467) =0.041; p>=0.05], stay at home measures [r (467) =-0.030; p>0.05], sensitizing others about covid-19 [r (467) =0-.044; p>0.05], compliance with safety rules and regulations [r (467) =0.052; p>0.05] did not have any significant relationship with participants’ overall physical activity. this means that the hypothesis is not accepted. the results in table 3 showed that sex (t (465) = 0.62, p>0.05) has no significant difference on vigorous physical activity, as male participants (x ̅ = 1744.25; sd=3063.75) are not significantly different from the female participants (x =̅ 1548.75; sd=2846.99). however, sex (t (465) =-1.84, p<0.05) is significantly different on moderate physical activity. specifically, female participants (x ̅= 1001.21; sd=1371.83) are significantly different from the male participants (x ̅= 768.14; sd=1153.28). this simply implies that female participants were significantly involved in moderate physical activity than male participants. moreover, sex (t (465) = 0.39, p>0.05) has no significant difference on walking physical activity, as male participants (x ̅= 307.18; sd=605.76) did not significantly different from the female participants (x ̅= 218.35; sd=671.62). discussion plato (427-347) asserted that lack of activity destroys human beings' good condition, while movement and methodical physical exercise save it and preserve it. this unarguably pinpoints physical activity's relevance in maintaining good well-being right from a very long time ago. our study investigated this assertion in the context of lockdown and similar orders by the nigerian government occasioned by coronavirus disease. our study provides insight into the physical activity levels of individuals during the period of lockdown. the study also provides sex differences results of different physical activity levels during the coronavirus pandemic in nigeria. projections from other studies were that coronavirus containment measures would significantly reduce participation in physical activity [5,7]. however, our study’s result contradicted this assertion. this probably points to differences in the characteristics of our participants as different from other studies. we measured our participants based on their physical activity some weeks after the lockdown measures were instituted without recourse to their physical activity levels before lockdown. simultaneously, others [16,17] investigated the pre-lockdown physical activity to have a baseline score. it was shown from our results that more participants engage in moderate physical activity than vigorous physical activity. furthermore, based on the cumulative nature [9] of physical activity, it could mean that our participants engage in domestic physical activities that accumulate over time to be moderate physical activity levels rather than involving in structured vigorous-intensity physical activity. likewise, as pointed out by [4], people still move around despite the public health efforts to contain the pandemic. future studies can investigate the influence of socio-cultural factors on physical activity during the covid-19 pandemic in nigeria. ademeyo os, et al., journal of ideas in health (2021); 4(1):293-297 296 table 2 summary of correlation analysis showing the association among contextual factors (public health measures, perception of the spread of covid-19, fear of covid-19, stay at home, sensitizing and compliance), and walking, moderate, vigorous, and overall physical activity for met minutes for a week (7days). table 3 summary of t-test of independent samples showing sex differences on walking, moderate and vigorous physical activities dependent variable gender n �̅� sd df t f p male 339 1744.25 3063.75 1. vpa 465 0.62 0.96 >0.05 female 128 1548.75 2846.99 male 339 768.14 1153.28 2. mpa 465 -1.84 6.76 <0.05 female 128 1001.21 1371.83 male 339 307.18 605.76 3. wpa 465 0.39 0.01 >0.05 female 128 281.35 671.62 dependent variables: 1. vigorous physical activity (vpa), 2. moderate physical activity (mpa), 3. walking physical activity (wpa) there was no sex difference in physical activity engagement in our study’s results, especially as we showed that both males and females are similar in walking and vigorous physical activity levels. our findings disagree with the results from croatia [17] and sicilia [18]. another finding from our study revealed that females engage more in moderate physical activity than males. this is a surprising result as an earlier study [16] revealed that there was a significant dip in moderate-vigorous physical activity for males more than females. there are some noticeable differences in the participants of some of these studies to ours. karuc et al. [16], and sekulic et al. [17] used secondary school-age students and defined physical activity levels using school health action, planning, and evaluation system (shapes) and physical activity questionnaires. in contrast, we recruited participants in 18-70 years and operationalized physical activity using international physical activity questionnaire (ipaq). these two studies measured physical activity levels pre-pandemic and during the pandemic, while the present study only asked participants about their physical activity levels during the experience of the measures to contain the spread of coronavirus. other studies could retrospectively determine the reasons for these gendered results in physical activity levels during this pandemic in nigeria. one major strength of this study is the online-based data collection method, which gave the study a geographical spread advantage as we effectively covered the southwest states where coronavirus was the worst hit. this also ensured we complied with the presidential task force's restriction orders on the covid-19 pandemic in nigeria. the self-report questionnaires used in this study could inadvertently contribute to limitation as participants might be biased in answering the questionnaires' items. another limitation that other researchers should be aware of is that of generalizability. the study's participants are limited to nigeria's southwest geopolitical zone, and the result should be interpreted in that context. conclusion from our results, we can conclude that the relationship between contextual variables and physical activity among nigerians during the covid-19 pandemic is insignificant. secondly, males and females are not different on vigorous and walking physical activity levels, while there was more female participation in moderate physical activity than males during covid-19 lockdown measures. abbreviation covid-19: coronavirus, sars-cov-2: severe acute respiratory syndrome coroanavirus-2, shapes: school health action, planning, and evaluation system, ipaq: international physical activity questionnaire, lmics: low and middle-income countries, vpa: vigorous physical activity, mpa: moderate physical activity, wpa: walking physical activity declaration acknowledgment the authors would like to express gratitude to participants who helped in filling the google form. variables 1 2 3 4 5 6 7 8 9 �̅� sd 1. perception of the spread 1 2.93 1.76 2. fear of covid19 -0.215** 1 5.92 1.64 3. stay at home 0.121** -0.085 1 1.04 0.19 4. sensitizing 0.031 -0.122** 0.160** 1 1.05 0.22 5. compliance -0.047 0.104* -0.128** -0.233** 1 4.27 0.95 6. walking physical activity 0.004 0.040 -0.040 -0.053 0.034 1 1690.67 3004.15 7. moderate physical activity 0.034 0.048 -0.03 -0.008 0.083 0.390** 1 832.03 1220.02 8. vigorous physical activity 0.081 -0.043 0.037 0.006 -0.02 -0.043 -0.038 1 300.10 623.88 9. overall met minutes for physical activity 0.028 0.041 -0.030 -0.044 0.052 0.938** 0.644** 0.122** 1 2822.80 3680.06 ademeyo os, et al., journal of ideas in health (2021); 4(1):293-297 297 funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing os.adeyemo@oouagoiwoye.edu.ng authors’ contributions oladotun sunday adeyemo conceived the idea, contributed to the design of the questionnaire, wrote the ethical protocol and the manuscripts. nurudeen afolabi sofoluwe contributed to the design of the questionnaire and spearheaded the analysis of the data. yinusa olumuyiwa ganiyu assisted in the design of questionnaires and writing of ethical protocol and significantly contributed to data collection. odusanya abidemi ibrahim contributed to the design of the questionnaires, review of the manuscripts, editing of the manuscripts and data collection. oyelami, lukman oyeyinka contributed in the design of the questionnaire, helped in data collection and analysis, and also in editing of the manuscript. all authors have read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki. the ethical protocol was approved by olabisi onabanjo university teaching hospital health research ethics committee (oouth-hrec) with approval number oouth/hrec/354/2020ap. the participants were assured of confidentiality as stated in the google form. consent for publication not applicable competing interest the authors declare that they have no competing interest. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of psychology, faculty of social sciences, olabisi onabanjo university, ago-iwoye, nigeria. 2department of cooperative & rural development, olabisi onabanjo university, ago-iwoye, nigeria. 3department of banking & finance, olabisi onabanjo university, ago-iwoye, nigeria.4department of economics, olabisi onabanjo university, ago-iwoye, nigeria, 5distance learning institute (economics unit), university of lagos, akoka, nigeria. article info received: 28 october 2020 accepted: 10 january 2021 published: 13 march 2021 references 1. qui w, rutherford s, mao a, chu c. the pandemic and its impacts. health, culture and society; 2017:9-10. https://doi.org/10.5195/hcs.2017.221 2. world health organization. coronavirus disease 2019 (covid19) situation report – 32. available from: https://www.who.int/docs/default-source/coronaviruse/situationreports/20200221-sitrep-32-covid-19.pdf. 3. african arguments. coronavirus’ triple hit in africa on health, the economy and politics. (the effects of the global pandemic will go far beyond just health concerns). available from: https://africanarguments.org/2020/03/coronavirus-triple-hit-inafrica-on-health-the-economy-and-politics/ 4. amzat j, aminu k, kolo vi, akinyele aa, ogundairo ja, danjibbo mc. coronavirus outbreak in nigeria: burden and sociomedical response during the first 100 days. international journal of infectious disease 2020; 98: 218-224. https://doi.org/10.1016/j.ijid.2020.06.067 5. duncan ge, avery ar, edmund s, tsang s. perceived change in physical activity levels and mental health during covid-19: findings among adult twin pairs. plos one 2020;15(8): e0237695, https://doi.org/10.1371/journal. pone.0237695 6. chen p, mao l, nassis gp, harmer p, ainsworth be, li f. coronavirus disease (covid-19): the need to maintain regular physical activity while taking precautions. journal of sport and health science2020; 9(2):103104. https://doi.org/10.1016/j.jshs.2020.02.001 7. lesser ia, nienhuis cp. the impact of covid-19 on physical activity behaviour and well-being of canadians. international. journal of environmental research and public health 2020;17(11): 3899. https://doi.org/10.3390/ijerph17113899 8. jakobsson j, malm c, furberg c, ekelund u, svenssson m. physical activity during the coronavirus (covid-19) pandemic: prevention of a decline in metabolic and immunological functions. frontier in sports and active living: 30 april 2020. https://doi.org/10.3389/fspor.2020.00057. 9. kang b, moudon av, hurvitz pm, saelens be. increased walking’s additive and no substitution effect on total physical activity. med sci sports exerc 2018; 50(3):468 475. https://doi.org/10.1249/mss.0000000000001450. 10. onder m, rezza g, brusaferro s. case-fatality rate and characteristics of patients dying in relation to covid-19 in italy. jama 2020; 323(18):1775-1776. https://doi.org/10.1001/jama.2020.4683. 11. guthold r, louazani sa, riley lm, cowan mj, bovet p, damasceno a, et al. physical activity in 22 african countries: results from the world health organization step wise approach to chronic disease risk factor surveillance. american journal of preventive medicine 2011; 41(1):52– 60. 12. ilesanmi o, afolabi a. perception and practices during the covid19 pandemic in an urban community in nigeria: a cross-sectional study. peerj 2020; 8: e10038. http://dx.doi.org/10.7717/peerj.10038 13. diamond r, waite f. physical activity in a pandemic: a new treatment target for psychological therapy. psychol psychother 2020;10.1111/papt.12294. https://doi.org/10.1111/papt.12294 14. stables j. garmin data reveals how the world is working out during the lockdown: garmin users are still getting sweaty. garmin wearable tech news, april 11, 2020. available from: https://www.wareable.com/garmin/garmin-data-lockdown-7940 [accessed on 04 july 2020] 15. wenham c, smith j, morgan r. covid-19: the gendered impacts of the outbreak. lancet 2020;395(10227):846-848. https://doi.org/10.1016/s0140-6736(20)30526-2. 16. karuc j, soric m, radman m, misigoj-durakovic m. moderators of change in physical activity levels during restrictions due to covid-19 pandemic in young urban adults. sustainability 2020; 12(16): 6392. https://doi.org/10.3390/su12166392 17. sekulic d, blazevic m, gilic b, kvesic i, zenic n. prospective analysis of levels and correlates of physical activity during covid-19 pandemic and imposed rules of social distancing: gender specific study among adolescents from southern croatia. sustainability2020;12: 4072. https://doi.org/10.3390/su12104072 18. giustino v, parroco am, gennaro a, musumeci g, palma a, battaglia g. physical activity levels and related energy expenditure during covid-19 quarantine among the sicilian active population: a cross-sectional online survey study. sustainability2020;12(11):4356. https://doi.org/10.3390/su12114356 19. adegoke boa, oyeyemi al. physical inactivity in nigerian young adults: prevalence and socio-demographic correlates. journal of physical activity and health 2011; 8: 1135 -1142. 20. awotidebe to, adedoyin ra, adegbesan oa, babalola jf, olukoju io, mbada c, et al. psychosocial correlates of physical activity participation among nigerian university students. international journal of sports science 2014; 4(6): 205-211. https://doi.org/10.5923/j.sports.20140406.01 https://doi.org/10.47108/jidhealth.vol5.iss2.207 anonna ta, et al., journal of ideas in health 2022;5(2):655-663 © the author(s). 2022 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access why pandemic coronavirus (sars-cov-2) hit different age groups of people in southeast asia? a case study in bangladesh tasnim abdary anonna1, md moniruzzaman2*, abdul hadi al nafi khan2, ashis kumar sarker3, palas samanta4, mohammad iqbal naser5, shamim ahmed6, hafiz al asad3 abstract the new catastrophe of a novel coronavirus (covid-19s) with unstable symptoms has rapidly pulled danger to all age groups worldwide. we investigate possible causes of the different nature and demography of covid-19. we collected and used secondary data from the iedcr website and “worldometer” from 1st april to 24th june for the statistical analyses, including multi-criteria decision-making method (mcdm), topsis, advanced topsis, simple additive weighting (saw) and weighting product method (wpm) and pca. the total number of known covid-19 patients in bangladesh was 122,709 as of 24th june. radical growth will be found with 4912 cases in one day on 16th july as per the timeseries forecasting. the infection rate among the young (<30) was highest, i.e., 37.8%, while the elderly (>60) had the maximum death rate (≈39%). both of india and bangladesh, approximately one-third of total covid-19 cases belong to the under 30 age group. preliminary observation finds india and bangladesh have a high risk for young people and the working class. pca indicates the highest positive association among the youths and the highest negative association among the older. in this study, older age (>60) individuals are in danger with the fifth rank, and the young and working-age people are at comparatively lower risk with a third to the fourth rank in terms of infection rate as indicated by mcdm. 41-50 age group remains at lower risk with the first rank in all cases. the nature of activities of younger people and the poor immunity system of older people are the reason for the non-homogenous attitude toward the coronavirus among different age groups. in bangladesh, drug addiction, gambling habits, uncontrolled lifestyle, and social obliquity have led the youth through danger, threatening the older age of family and society. keywords: covid-19, age-group, transmission, youngsters, older-age, immunity, risk analysis, bangladesh background the present-day coronavirus pandemic of 2019 (covid-19) has become a global concern. since december 2019, in wuhan, hubei province, china, coronavirus ailment (covid-19), a recently developing irresistible pneumonia with unknown causes, was reported [1,2]. the covid-19 pandemic has created a terrible crisis that led the world's health system and medical science to question [3, 4, 5, 6, 7]. the new coronavirus termed sars-cov-2 is the germ to spread this disease [8, 9, 10, 11, 12] and has extended its claw up to 213 countries and territories [13]. as of june 24, 2020, statistics from johns hopkins university showed that nearly 9.07 million people had been affected by this virus, while nearly half a million lives were taken [14]. after its earliest exposure in china at the end of 2019 [11], covid-19 patients started being detected in other parts of the world. thailand, japan, the usa, and south korea reported their respective first covid-19 patient was midjanuary [15, 16]. in europe, france was the first country to report the emergence of coronavirus on january 24, 2020. after that, it took only six weeks to spread its claw to the whole continent [17, 18]. the earlier transmission of coronavirus in south asian countries started from late january to early march 2020. within the indian sub-continent, the first reported case of covid-19 was found in nepal on january 23, 2020 [19]. in india, covid-19 was first revealed on january 30, 2020 [20], while the number of patients did not see any lift up to february 2020. despite having fewer patients, india could not manage to limit the spread. as a result, the transmission pace got momentum from the start of april [21]. the most delayed coronavirus transmission among south asian countries occurred in bangladesh, its first appearance on 7th march 2020 ___________________________________________________ monir1.gm@gmail.com 2isotope hydrology division, institute of nuclear science and technology, aere, bangladesh atomic energy commission, dhaka, bangladesh full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol5.iss2.207 http://www.jidhealth.com/ anonna ta, et al., journal of ideas in health (2022); 5(2):655-663 656 [22]. nonetheless, this country also failed to have the situation under control. as of august 16, 2021, the number of infected persons in india and bangladesh is 1,418,902 and 32,225,513, respectively [13]. outside of south asia, maximum patients (>2.4 m) and deaths (nearly 0.13 m) have been reported in the usa. the european countries, italy, spain, the united kingdom, germany, and france have seen large death tolls and a huge number of growing patients. except for germany, each country has experienced 28-43 thousand deaths. the number of affected patients diverges from approximately 0.16-0.28m in most affected european countries. recently, brazil has been devastated by an intensified attack of covid-19, having more than 50 thousand death and approximately half a million affected [13]. demographic science is always important in conceptualizing the dynamics of a pandemic [23]. several studies have been published where the role of age structure in death rates and transmission of the different viral diseases like hepatitis b [24], influenza [23], la crosse virus [25], etc., have been investigated. similar age-dependent studies are also available for covid-19 [26,27]. unlike europe and the usa, the subcontinent holds a relatively younger population. in european countries and also in the usa, people with age more than 65 hold a large share of the total population, for example, italy (23.1%), spain (19.38%), france (20.5%), united kingdom (18.4%), germany (17.88%), usa (15.81%). in india (6.18%) and bangladesh (5.16%), the portion of 65+ aged people is much lower in comparison with the developed countries [28]. as of 18th june 2020, the number of affected patients and the death toll are still comparatively higher in the western countries (although transmission has been heavy recently) and the usa, where the major portion of death and transmission belong to the elderly people. in countries like china, italy, france, the united kingdom, and spain, less than 30% of patients are below 40 [21]. in the usa, 42% of patients have an age limit of ≤45 [29], while in germany, it is presumably less than 50% [21]. however, it becomes a great concern for the subcontinent since young people are highly affected. the latest report from iedcr shows that 65% of covid-19 patients in bangladesh are from the 0-39 years group [30], while in india, the share becomes 58.25%, as of a statistical report [21]. newspapers and mass media have reported this crisis where the working group 21-50 has been identified as the most vulnerable class in india [31] and bangladesh [32]. owing to the mobility and unwillingness to maintain a disciplined life, young people may have played a vital role in spreading the coronavirus worldwide [33]. since all age groups should be equally susceptible to the pandemic in the ideal case [34], studying the reason and mode of infection among young individuals in south asian countries is necessary. studies show that young ones can be asymptomatic and transmit the disease to children and the most vulnerable elderly people with greater ease [35-37]. in countries like bangladesh and india, youngster infections have shown a dimension in the international community [36]. statistical methods are always important to find out the risk groups of the society when any threat is posed to them. several research studies have successfully demonstrated the risk groups and the associated factors in the recent and historical pandemics, including the recent covid-19 [38-43]. very little research on covid-19 in bangladesh has been published, and those works mostly focused on medical, biomedical, and mental health issues. the demography is mostly absent in those researches except in hossain et al. [44] and paul et al. [20]. most of the work failed to address any notable research explaining the nature and reason for the high infection rate among young groups. the authors aim to present the scenario of youngsters' infection by the coronavirus and provide statistical analysis to find the associated factors with the aid of statistical and demographic analysis. studying the age distribution will help understand the transmission mode of this viral disease among the youths and help policymakers save the whole community from being affected. methods data collection a retrospective study recruiting secondary data was conducted from 1st april to 24th june of 2020. the source of data was the institute of epidemiology, disease control and research (iedcr, https://dghs-dashboard.com/pages/covid19.php, 24th june 2020), worldometer (https://www.worldometers.info/coronavirus/, 24th june 2020), and statista (https://www.statista.com/topics/5994/the-coronavirus-disease-covid19-outbreak/#dossiercontents__outerwrapper, 25th june 2020). some ideas on young people's psychological and behavioral issues were taken from a short pilot survey on different blogs on the social networking site (facebook) among young aged people. these were observed before june 2020. data analysis statistical analysis time series forecasting models were calculated using the builtin program named "forecast sheet" in excel 19. principle component analysis (pca) was carried out with excel 19 using the xlstat statistical software as add-in. multi-criteria decision-making method (mcdm) covid-19 infection prevalence in various countries has differed according to different age groups. the multi-criteria decision-making method provided a ranking solution for assessing overall risk analysis among five countries in different age groups. this method makes detecting specific findings simple and allows one to make more accurate decisions. entropy weight: c= [ 𝐶11 𝐶12 ⋯ 𝐶1𝑛 𝐶21 𝐶22 ⋯ 𝐶2𝑛 𝐶31 𝐶32 ⋯ 𝐶3𝑛 ⋮ ⋮ ⋮ ⋮ 𝐶𝑚1 𝐶𝑚2 ⋯ 𝐶𝑚𝑛] here, cij is the matrix component. step-1: the normalize matrix of c is, r= [ 𝑅11 𝑅12 ⋯ 𝑅1𝑛 𝑅21 𝑅22 ⋯ 𝑅2𝑛 𝑅31 𝑅32 ⋯ 𝑅3𝑛 ⋮ ⋮ ⋮ ⋮ 𝑅𝑚1 𝑅𝑚2 ⋯ 𝑅𝑚𝑛] , where, rij= 𝑪𝒊𝒋 ∑ 𝑪𝒊𝒋 𝒎 𝒊=𝟏 anonna ta, et al., journal of ideas in health (2022); 5(2):655-663 657 step-2: the output entropy of the jth factor is calculated as, 𝑒𝑗 = −𝑘∑ 𝑅𝑖𝑗 𝑚 𝑖=1 𝑙𝑛𝑅𝑖𝑗, where k= 1/ln(m) step-3: then the entropy weight can be calculated as follows, 𝑤𝑗 = 1−𝑒𝑗 ∑ 1−𝑒𝑗 𝑛 𝑗−1 [45, 46] topsis method: it's a compensatory aggregation method that compares a set of alternatives by determining weights for each criterion, normalizing scores for each criterion, and calculating the geometric distance between each alternative and the ideal alternative, which is the one with the best score in each criterion. step-1: here, the standard normalized matrix is, r= [ 𝑅11 𝑅12 ⋯ 𝑅1𝑛 𝑅21 𝑅22 ⋯ 𝑅2𝑛 𝑅31 𝑅32 ⋯ 𝑅3𝑛 ⋮ ⋮ ⋮ ⋮ 𝑅𝑚1 𝑅𝑚2 ⋯ 𝑅𝑚𝑛] [47] where, rij = 𝐶𝑖𝑗/[∑ 𝐶𝑖𝑗 2𝑚 𝑖=1 ] step-2: weighted normalized decision matrix can be calculated as 𝑉𝑖𝑗 = 𝑅𝑖𝑗 ∗ 𝑤𝑗 where wj is the entropy weight. step-3: positive and negative ideal solution can be determined as follows, { 𝑣+ = 𝑚𝑎𝑥{𝑣1𝑗,𝑣2𝑗 ⋯𝑣𝑚𝑗} 𝑣− = 𝑚𝑖𝑛{𝑣1𝑗,𝑣2𝑗 ⋯𝑣𝑚𝑗} (𝑗 = 1,2,….𝑛) step-4: euclidian distance between the positive-ideal and the negative-ideal reference points can be calculated as { 𝑑+ = √∑ (𝑣𝑖𝑗 − 𝑣 +) 2𝑛 𝑗=1 𝑑− = √∑ (𝑣𝑖𝑗 − 𝑣 −) 2 𝑛 𝑗=1 step-5: the final step of the topsis method is to determine the closeness coefficient, and the formula is 𝐶𝐶 = 𝑑− 𝑑++𝑑− the higher value of cc is considered the better alternative [4547]. advance topsis method: topsis is a valuable strategy for dealing with multi-attribute or multi-criteria decision-making situations in the real world. it aids decision-makers in organizing issues to be addressed and conducting analyses, comparisons, and rankings of options. in the advance topsis method, the euclidian distances are calculated as follows. { 𝑑+ = √∑𝑤𝑗(𝑣𝑖𝑗 − 𝑣 +) 2 𝑛 𝑗=1 𝑑− = √∑𝑤𝑗(𝑣𝑖𝑗 − 𝑣 −) 2 𝑛 𝑗=1 then, the relative closeness coefficient of a particular alternative can be calculated by the following formula, 𝐶𝐶 = 𝑑− 𝑑++𝑑− [30]. simple additive weighting (saw) and weighting product method (wpm): one of the strategies for solving multi-attribute choice issues is simple additive weighting (saw). the saw method's core principle of determining the number of weighted performance ratings for each option on all qualities is quite valuable. a weighted product model (wpm) is a straightforward and widely used method for resolving multi-criteria decision analysis (mcda) issues. to achieve a score, just multiply all of the characteristics' values. the greater the number, the better. a normalized decision matrix again needs to be created in this method. the equations are as follows: 𝑟𝑖𝑗 = 𝐶𝑖𝑗 𝑀𝑎𝑥(𝐶𝑖𝑗) (benefit) 𝑟𝑖𝑗 = 𝑀𝑖𝑛(𝐶𝑖𝑗) 𝐶𝑖𝑗 (cost) in saw, the preference value for each variable can be calculated as, 𝑣𝑖 = ∑ 𝑤𝑗𝑟𝑖𝑗 𝑛 𝑗=1 [48, 46] in wpm, preference values can be calculated as, 𝑣𝑖 = ∏ (𝑟𝑖𝑗 𝑤𝑗 )𝑛𝑗=1 [46] results and discussion covid-19 infections in bangladesh in bangladesh, the first 3 cases of covid-19 were reported on the 8th of march and increased gently over time. nevertheless, the number of cases increased significantly over time from the first week of april. the total number of covid-19 cases identified during april and may are 7716 and 39,486, respectively, while 51 cases were found between 8th march to 31st march (iedcr, https://dghsdashboard.com/pages/covid19.php, 5th may 2020). another 75,507 cases were found until 24th june (iedcr, https://dghsdashboard.com/pages/covid19.php, 24th june 2020). figure 1: number of new covid-19 cases per day; cumulative percentage curve shows the regular increment rate of patients. anonna ta, et al., journal of ideas in health (2022); 5(2):655-663 658 this enormous increase of covid-19 patients may have evolved as negligence of people about covid-19, and the different stakeholders have made some paradoxical decisions. for example, the light coming from europe arrives at the airport, though the country restricts all the national and international flights [49]. the government authority announced public shouldn't move their station during lockdown to avoid community transmission. however, the people did not restrict their movement immediately, which led them outside of the capital. therefore, people spread the covid-19 to every part of the country. furthermore, bgmea decided to open the garments factories on 4th april 2020. garment workers started moving toward their workplace. latterly, the same institution changed its decision to close the factories to consider on behalf of the health risk to the workers. community transmission mostly occurred at that time through their arrival and subsequent departure. the number of infected patients increases day by day, and the cumulative number of patients also accelerates (figure 1 and figure 2). figure 2: ogive curve showing cumulative growth of covid-19 cases. trend and forecast of covid-19 infections in bangladesh although the 1st covid-19 case was identified in early march, the rapid growth of infected people started in april. here, data for the time series forecasting and trend analysis were shown from 1st april to 24th june (12 weeks). additional four weeks of infection prediction also be added in the time series. the line chart showed the forecasting line, including the 16th week. the total number of affected persons was approximately 4912 as per time series forecasting in a single day with an r-squared value of 0.92 (figure 3). figure 3: time series plot of covid-19 cases within 16th july; the forecast line moves upward, as the number of patients will increased day by day. from this trend analysis, the upper confidence bound showed a speedy increase of patients in the upcoming days. the lower confidence bound indicated that the number of cases would remain similar (figure 3). some factors can fluctuate the number of cases depending on the day. because bangladesh is cladding insufficiency of the testing kit, for this reason, some covid-19 patients cannot be adequately detected. these circumstances can affect the actual number of patients as the management reopened well through the offices, marketplaces, and transport. however, peoples are still frequently moving from place to place without taking safety measures. social distancing is not appropriately maintained by most of the people in bangladesh. these types of negligence may cause a significant increase in covid-19 patients. infected rate vs. death rate in bangladesh in bangladesh, about 37.8% of people owing to below 30 years were diagnosed with novel coronavirus, according to iedcr data (24th june 2020). however, recent statistics of iedcr showed that the death rate of old people was higher, about 39%. hence, the infection rate and age death rate showed an inverse relationship (figure 4). the key reasons for people of young age (<30) being more infected because of disobeying and don't care about the authority decisions even though declared lockdown remains. usually, this younger age group gets rid of this virus after a few days, having a high immune system. on the other hand, the elderly (>60) has a weakened immune system and suffer from numerous senile diseases such as fatigue, body ache, rheumatic pain, dementia, sinus infection, trouble breathing, asthma, palpitation, high blood pressure, incompetence micturition, etc. [50]. the patients had already suffered from one or more of these diseases are likely to be in a riskier situation. these days, older people are rare without multiple health issues. therefore, the death toll is high in the 60+ age group in bangladesh, even though being in the comparatively less affected class. figure 4: infected vs death rate graph; death rate is high (39%) at >60 age group and higher infected rate (37.8%) is under <30 age group. comparison of covid-19 infection among bangladesh and other countries by age group neighboring country india showed nearly the same curve as bangladesh. it had the highest 32.78% of patients in the <30 age group (37.8% in bangladesh) and the lowest 13.07% of patients in the>60 age group against 7% in bangladesh for the same age group. the comparative information has been presented in a line chart and box-whisker plot (figure 5a, 5b). anonna ta, et al., journal of ideas in health (2022); 5(2):655-663 659 other countries like the usa, spain, and china had the highest percentage of patients (32.33%, 31.2%, and 47%) in the>60 age group, respectively. the lowest share of covid-19 cases (14.96%) belongs to the 41-50 age group in the usa. moreover, 10.2% and 8% cases were found in the <30 age group in china and spain, respectively. figure 5: age distribution of infected people; (a) line chart shows the different patterns of infected patients by age among different countries; (b) box-whisker plot shows the distribution of mean, median, mode, 1st quartile, 3rd quartile and outliners at different age group. demography is certainly a significant cause of this type of difference, as we guessed primarily. according to the bangladesh population census (2011), about 61% of people belong to the < 30 age group. similarly, per the indian population pyramid (2016), about 57.2% of people belong to the <30 age group. the number of older people is growing faster than the younger generation in the usa. according to the us census bureau, the growth rate is around 31.5% for the generation group of 45-64 and 15.1% for the age group of >65. in spain, about 24.94 % of the population belongs to the 0-24 age group, about 30.59 % in the>55 age group, and the remainder (about 55.53 %) belongs to the 25-54 age group (population pyramid, 2017). about 22.62% of the population in china belongs to the>60 age group (china pyramid of population, 2018). therefore, the overall number of young and working-age people is comparatively higher in india and bangladesh. the socio-cultural infrastructure and lifestyle of the young and working-age population pose many similarities. the most common phenomenon between these two countries is fanaticism and superstition. these two characteristics led a significant portion of society to lead a stubborn and unhealthy life. the infected prevalence showed the same trend in different age groups. as the number of older people is higher in the usa, the level of the infected rate for older age groups in the united states is higher. in spain, the percentage of the>55 age group is comparatively higher than in others, so the incidence of infection within this group is high. china also displayed the same trend as spain and the usa. figure 6 (a): scree plot of the pca. around 31% of those affected were over 60 years of age. all of this information has been summarized in figure 6 (a). as the health status started to worsen with age due to several senile diseases [51], covid-19 affects the people of >60 age groups more. except for demography, others factors are also responsible for the variation of covid-19 cases among different age groups in these countries. one of these issues, i.e., socio-cultural thoughts, are sometimes difficult to present with some lacking authentic data sources. however, a few issues can be discussed based on social media and different social networking sites. for instance, in developing countries like the usa, spain, and china, young people may have updated recreational facilities, which is very much needed during the lockdown. this sort of facility is more helpful in keeping the young people at home and making them safe. on the contrary, those countries' authorities can convince the people about the covid-19 pandemic situation. though india is now being developed to some extent, most of its young people may not be able to have these sorts of facilities like the developed world. bangladesh is still a developing country, and most people live underneath the neediness line. so, the young people can't get those kinds of facilities. also, the authorities and defense forces are unable to control people. principal component analysis (pca) pca analysis was applied to determine the association between the parameters and principal components. eigenvalues greater than one were considered to demarcate the principal components. the scree plot of the pca is shown in figure 6 (b). therefore, two principal components were derived from the analysis. these two components explained 97.91% of the variation in the data. amongst different age groups, pc1 explains the highest 72.79% of the variation, whereas pc2 explains 25.12% of the total variation. the age group of <30 and 31-40 had the highest positive relation with pc1, while >60 and 51-60 had the highest negative association with pc1. besides, the 41-50 age group had the highest positive relation with pc2, whereas a strong negative association couldn't find in pc2 (table 1). anonna ta, et al., journal of ideas in health (2022); 5(2):655-663 660 figure 6 (b): biplot showing the relation of components in rotated space. table 1: component matrix for pca analysis. variables (age group) pc1 pc2 <30 0.986 -0.149 31-40 0.985 0.162 >60 -0.981 -0.148 51-60 -0.805 0.545 41-50 0.296 0.943 eigenvalue 3.64 1.26 variability (%) 72.79 25.12 cumulative % 72.79 97.91 multi-criteria decision making (mcdm) entropy weight: here the weight of entropy for each parameter, i.e., different age groups and five countries, is determined. the weighted entropy values for each parameter are shown below (table 2). these weighted entropy values are used to determine the ranking solutions of mcdm methods, including topsis, advance topsis, saw, and wpm. table 2: entropy weight for calculating the ranks of topsis, advance topsis, saw and wpm methods of mcdm. age distribution (%) >60 51-60 41-50 31-40 <30 0.43 0.05 0.013 0.09 0.41 country usa china spain india bangladesh 0.07 0.09 0.41 0.12 0.29 topsis and advance topsis method: topsis and advance topsis methods showed that the>60 age group was at higher risk of infection in the five countries with the rank of five (table-3). this applied method suggested that between 51-60 and <30 age groups rank varied between 3rd to 4th with moderate risk and 41-50 age group always showed the first rank with lower risk thread in terms of infection rate of covid-19. table 3: values and rankings of topsis, advance topsis, saw, and wpm methods topsis advance topsis saw wpm age group closeness coefficient rank closeness coefficient rank v rank v rank >60 0.38 5 0.50 5 1.09 5 1.71e-05 5 51-60 0.44 4 0.57 3 1.55 2 4.28e-04 2 41-50 0.49 1 0.66 1 1.77 1 7.35e-04 1 31-40 0.45 2 0.61 2 1.44 3 1.38e-04 3 <30 0.44 3 0.55 4 1.17 4 2.57e-05 4 simple additive weighting (saw) and weight product method (wpm): simple additives weighting and weight product method showed the same rating as topsis and advanced topsis. according to these criteria, >60 age group people are at higher risk of infection rate for covid-19 with the fifth rank. the age group below <30 has a comparatively low-risk infection compared to group >60 with fourth rank (table 3). people under 41-50 age groups are safe worldwide with the first rank const causes to affect young and working-age people in bangladesh by covid-19 during the covid-19 pandemic, young and working-age individuals are affected most, as seen from the study's observed data and subsequent analysis. the high infected rate occurred mainly due to the lacking knowledge and awareness. workingage individuals are predominantly involved in work and business activities. these guys are always threatening older people, especially in a joint family. according to the pilot survey among young people, most youngsters prefer not to stay at home due to dysfunctional relationships with parents and other family members, freedom-seeking inclination, boredom, gang activities, etc. gang activities lead to underage smoking, gambling habits, and drug abuse, which in turn causes societal demoralization. nearly 25 lakhs are substance addicts. around 80 % of drug users in bangladesh are teenagers and young people between the ages of 15 and 30 [52]. after opioid abuse, about 80% of drug users lose control in their everyday lives and continue to lose morals and judgments [44]. this is one of the significant factors to get them alienated from the family, which also drives them to have negative health consequences. like most members of civil society, young individuals are likely to move out of the house too. this form of inclination has increased because of societal practices and family issues. to get this sort of anxiety instantly released, people start going outside. this could also be because those affected by covid-19 are young and working-age. wide exposure to the outer environment coupled with uncontrolled as well as unhealthy lifestyles has made the young ones more vulnerable to the disease. ignoring the rapid pace of covid-19 transmission, anonna ta, et al., journal of ideas in health (2022); 5(2):655-663 661 people in bangladesh are still adamant about visiting the markets and other crowded places. sometimes, they visit those places without any significant reasons. these types of activities have proven to be life-threatening and risky in this country. in the context of bangladesh, young people from all classes/sectors can pose a threat to other family members since they can work as a bearer of the disease. the threat is more severe for the elderly ones in a pandemic like covid-19. the resultant scenario would be more satisfactory if the analysis was conducted on a wide-angle dataset. limitations of this study the covid-19-infected were only studied for 12 weeks over the summer from april 1st to june 24th. participants in this research range from under 30 to over 60 years old. the prevalence of infection in children and pregnant women must be considered while analyzing the data since these groups are more vulnerable to covid-19's effects. in this study, only the summer impacts were examined; therefore, winter effects might likely differ. conclusion in this study, the time series forecasting method, pca, and mcdm were utilized to foresee the eventual fate of the covid-19 pandemic in bangladesh. analysis has also been made to assess and disseminate risk for various age groups and discover the potential reasons for variety among the age groups in different countries. within 108 days of the covid-19 pandemic, 122,709 patients were found, and as indicated by time-series forecasting, the number of patients will be roughly 211843. if this sort of progression stays at its genuine rate, at that point, the nearest future will be an excess of trying for bangladesh through the health sector, which is not prepared to carry the load. preliminary statistical analysis showed differences in covid-19 cases in certain age groups in bangladesh and india compared to europe and the usa. unlike the developed countries, bangladesh has got much younger patients, while the death toll is higher among the old people as expected. the pca analysis specifically determines the highest positive association among the youths and demonstrates the highest negative association among the older in pc1. on the other hand, the 41-50 age group had the highest positive relation with pc2, whereas a strong negative association couldn't be found in pc2. again, the mcdm ranking solutions demonstrated the general risk investigation for various age groups among various nations. as per the mcdm result, the fifth position was constantly saved of infection rate for >60 age group, which was in peril, and the age bunch <30 switches its position between 3rd to the fourth rank showing the nearly lower chance of getting infected. dissimilarity among the various age group in various nations happened because india and bangladesh hold a relatively higher number of young and working-age people. in contrast, the usa, spain, and china hold many old individuals. moreover, the infection among adolescents was involved in employment and business activities. various sorts of addiction and gambling activities, social demoralization, dysfunctional relationship with guardians and relatives, freedom looking for intentions, and so on also lead them towards the danger due to covid-19. these make a huge threat to the old guardians and other family members and the community too. immunity and discipline in lifestyle are most significant for the covid-19 pandemic and its control. youngsters have nearly dynamic immunity but less control over their life. therefore, it makes them highly likely to be affected, while they get rid of easily through gifted immunity. however, the risk is carried through the veteran part of the community in the meantime. abbreviation covid-19: coronavirus disease-19; who: world health organization; mcdm: multi-criteria decision making; saw: simple additive weighting; wpm: weighting product method; pca: principal component analysis; iedcr: institute of epidemiology, disease control and research declaration acknowledgment the authors are grateful to the authority of bangladesh atomic energy commission, institute of epidemiology, disease control and research (iedcr), worldometer and statista for providing data facilities and others logistic support during the research period. funding the author received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing monir1.gm@gmail.com; monir@korea.ac.kr authors’ contributions mm designed, planned, conceptualized, mm, taa and ahank drafted the original manuscript. taa, aks, ps, min, sa and haa was involved in statistical analysis and interpretation; min, sa and haa contributed in data analysis, and validation; mm, taa, ahank, aks and ps contributed to editing the manuscript, literature review, and proofreading; taa, haa and mm, were involved in software, mapping, and proofreading during the manuscript drafting stage. ethics approval and consent to participate we conducted the research following the declaration of helsinki, and data is open for use from the original sites that is why authors no need to any approval and consent to participation. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. anonna ta, et al., journal of ideas in health (2022); 5(2):655-663 662 author details 1department of geography and environment, school of physical science, shahjalal university of science and technology, sylhet, bangladesh.2isotope hydrology division, institute of nuclear science and technology, aere, bangladesh atomic energy commission, dhaka, bangladesh. 3department of chemistry, mawlana bhashani science & technology university, santosh, tangail-1902, bangladesh. 4deptartment of environmental science, sukanta mahavidyalaya, university of north bengal, dhupguri, jalpaiguri-735210, west bengal, india. 5department of international relations, dhaka university, dhaka, bangladesh. 6department of geology and mining, university of rajshahi, rajshahi, bangladesh. article info received: 25 february 2022 accepted: 27 april 2022 published: 13 may 2022 references 1. zhu n, zhang d, wang w, li x, yang b, song j, zhao x, huang b, shi w, lu r, niu p, zhan f, ma x, wang d, xu w, wu g, gao gf, tan w; china novel coronavirus investigating and research team. a novel coronavirus from patients with pneumonia in china, 2019. n engl j med. 2020 feb 20;382(8):727-733. doi: 10.1056/nejmoa2001017. 2. qian g, yang n, ma ahy, wang l, li g, chen x, chen x. covid-19 transmission within a family cluster by presymptomatic carriers in china. clin infect dis. 2020 jul 28;71(15):861-862. doi: 10.1093/cid/ciaa316. 3. bavel jj, baicker k, boggio ps, capraro v, cichocka a, cikara m, crockett mj, crum aj, douglas km, druckman jn, drury j. using social and behavioral science to support covid-19 pandemic response. nature human behaviour. 2020 may;4(5):46071. doi:10.1038/s41562-020-0884-z 4. ioannidis, j. p. (2020). a fiasco in the making? as the coronavirus pandemic takes hold, we make decisions without reliable data. url: https://www.statnews.com/2020/03/17/a-fiasco-in-themaking-as-the-coronavirus-pandemic-takes-hold-we-are-makingdecisions-without-reliable-data/. 17th march 2020. 5. watkins j. preventing a covid-19 pandemic. bmj. 2020 feb 28;368. doi: 10.1136/bmj.m810. 6. gates b. responding to covid-19—a once-in-a-century pandemic?. new england journal of medicine. 2020 apr 30;382(18):1677-9. doi: 10.1056/nejmp2003762. 7. emanuel ej, persad g, upshur r, thome b, parker m, glickman a, zhang c, boyle c, smith m, phillips jp. fair allocation of scarce medical resources in the time of covid-19. new england journal of medicine. 2020 may 21;382(21):2049-55. doi: 10.1056/nejmsb2005114. 8. chen h, guo j, wang c, luo f, yu x, zhang w, li j, zhao d, xu d, gong q, liao j. clinical characteristics and intrauterine vertical transmission potential of covid-19 infection in nine pregnant women: a retrospective review of medical records. the lancet. 2020 mar 7;395(10226):809-15. doi: 10.1016/s01406736(20)30360-3. 9. tang cs, paleologos ek, vitone c, du yj, li js, jiang nj, deng yf, chu j, shen z, koda e, dominijanni a. environmental geotechnics: challenges and opportunities in the post-covid-19 world. environmental geotechnics. 2020 oct 2;8(3):172-92. doi: 10.1680/jenge.20.00054. 10. acter t, uddin n, das j, akhter a, choudhury tr, kim s. evolution of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) as coronavirus disease 2019 (covid-19) pandemic: a global health emergency. science of the total environment. 2020 aug 15; 730:138996. doi: 10.1016/j.scitotenv.2020.138996. 11. lai cc, shih tp, ko wc, tang hj, hsueh pr. severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and coronavirus disease-2019 (covid-19): the epidemic and the challenges. international journal of antimicrobial agents. 2020 mar 1;55(3):105924. doi: 10.1016/j.ijantimicag.2020.105924. 12. wan dy, luo xy, dong w, zhang zw. current practice and potential strategy in diagnosing covid-19. eur rev med pharmacol sci. 2020 apr 1;24(8):4548-53. doi: 10.26355/eurrev_202004_21039 13. worldometer, “coronavirus update (live): cases and deaths from covid-19 virus pandemic,”. https://www.worldometers.info/coronavirus/ 25thjune, 2020. 14. “home johns hopkins coronavirus resource center.” https://coronavirus.jhu.edu. 25th june 2020. 15. who, “novel coronavirus (2019-ncov) situation report 1,” who bull., no. january, pp. 1–7, 2020. https://www.who.int/docs/default-source/coronaviruse/situationreports/20200121-sitrep-1-2019-ncov.pdf 16. who, “novel coronavirus (2019-ncov) situation report 3,” who bull., no. january, pp. 1–7, 2020. https://www.who.int/docs/default-source/coronaviruse/situationreports/20200123-sitrep-3-2019-ncov.pdf 17. spiteri g, fielding j, diercke m, campese c, enouf v, gaymard a, bella a, sognamiglio p, moros mj, riutort an, demina yv. first cases of coronavirus disease 2019 (covid-19) in the who european region, 24 january to 21 february 2020. eurosurveillance. 2020 mar 5;25(9):2000178. doi: 10.2807/15607917.es.2020.25.9.2000178. 18. spiteri g, fielding j, diercke m, campese c, enouf v, gaymard a, bella a, sognamiglio p, moros mj, riutort an, demina yv. first cases of coronavirus disease 2019 (covid-19) in the who european region, 24 january to 21 february 2020. eurosurveillance. 2020 mar 5;25(9):2000178. doi: 10.1080/10255842.2020.1759560. 19. who, “novel coronavirus (2019-ncov) situation report 7,” who bull., no. january, pp. 1–7, 2020. https://www.who.int/docs/default-source/coronaviruse/situationreports/20200127-sitrep-7-2019--ncov.pdf 20. paul a, sikdar d, hossain mm, amin mr, deeba f, mahanta j, jabed ma, islam mm, noon sj, nath tk. knowledge, attitudes, and practices toward the novel coronavirus among bangladeshis: implications for mitigation measures. plos one. 2020 sep 2;15(9):e0238492. doi: 10.1371/journal.pone.0238492. 21. statista, “daily cumulative of the coronavirus (covid-19) confirmed, recovered and deceased numbers across india from january 2020 to june 2020.” https://www.statista.com/statistics/1104054/india-coronaviruscovid-19-daily-confirmed-recovered-death-cases/ 22. paul a, chatterjee s, bairagi n. prediction on covid-19 epidemic for different countries: focusing on south asia under various precautionary measures. medrxiv. 2020 jan 1. doi: 10.1101/2020.04.08.20055095. 23. laskowski m, mostaço-guidolin lc, greer al, wu j, moghadas sm. the impact of demographic variables on disease spread: influenza in remote communities. scientific reports. 2011 oct 4;1(1):1-7. doi: 10.1038/srep00105. 24. keeffe eb, dieterich dt, han sh, jacobson im, martin p, schiff er, tobias h. a treatment algorithm for managing chronic hepatitis b virus infection in the united states: 2008 update. clinical gastroenterology and hepatology. 2008 dec 1;6(12):131541. doi: 10.1016/j.cgh.2008.08.021. 25. haddow ad, bixler d, schuh aj. the demographic and socioeconomic factors predictive for populations at high-risk for anonna ta, et al., journal of ideas in health (2022); 5(2):655-663 663 la crosse virus infection in west virginia. plos one. 2011 sep 28;6(9):e25739. doi: 10.1371/journal.pone.0025739. 26. davies ng, klepac p, liu y, prem k, jit m, eggo rm. agedependent effects in the transmission and control of covid-19 epidemics. nature medicine. 2020 aug;26(8):1205-11. doi: 10.1038/s41591-020-0962-9. 27. dowd jb, andriano l, brazel dm, rotondi v, block p, ding x, liu y, mills mc. demographic science aids in understanding the spread and fatality rates of covid-19. proceedings of the national academy of sciences. 2020 may 5;117(18):9696-8. doi: 10.1073/pnas.2004911117. 28. statista, “statista the statistics portal for market data, market research and market studies,” statista, 2019. https://www.statista.com/topics/5994/the-coronavirus-diseasecovid-19-outbreak/#topicheader__wrapper. 25th june, 2020. 29. centers for disease control and prevention, "cases in the us" https://www.cdc.gov/. 25th june, 2020. 30. khan nm, barman nc. a review on novel coronavirus outbreak: current scenario of bangladesh. 2020 oct. 15. 8(t1):314-2. doi: 10.3889/oamjms.2020.5171. 31. the times of india, “share of under-60 age group in india’s covid deaths rises | india news times of india.” https://timesofindia.indiatimes.com/india/share-of-under-60-agegroup-in-indias-covid-deaths-rises/articleshow/75481761.cms. 1st may, 2020. 32. newage, “young, working-age people mostly infected with covid-19 in bangladesh,” newage bangladesh. https://www.newagebd.net/article/104307/young-working-agepeople-mostly-infected-with-covid-19-in-bangladesh. 13th april, 2020. 33. liao j, fan s, chen j, wu j, xu s, guo y, li c, zhang x, wu c, mou h, song c. epidemiological and clinical characteristics of covid-19 in adolescents and young adults. the innovation. 2020 may 21;1(1):100001. doi: 10.1016/j.xinn.2020.04.001. 34. fisman dn, greer al, tuite ar. standardization and agedistribution of covid-19: implications for variability in case fatality and outbreak identification. medrxiv. 2020 jan 1. doi: 10.1101/2020.04.09.20059832. 35. huang l, zhang x, zhang x, wei z, zhang l, xu j, liang p, xu y, zhang c, xu a. rapid asymptomatic transmission of covid19 during the incubation period demonstrating strong infectivity in a cluster of youngsters aged 16-23 years outside wuhan and characteristics of young patients with covid-19: a prospective contact-tracing study. journal of infection. 2020 jun 1;80(6): e1-3. doi: 10.1016/j.jinf.2020.03.006. 36. esteve a, permanyer i, boertien d, vaupel jw. national age and coresidence patterns shape covid-19 vulnerability. proceedings of the national academy of sciences. 2020 jul 14;117(28):1611820. doi: 10.1073/pnas.2008764117. 37. apolloni a, poletto c, colizza v. age-specific contacts and travel patterns in the spatial spread of 2009 h1n1 influenza pandemic. bmc infectious diseases. 2013 dec;13(1):1-8. doi: 10.1186/1471-2334-13-176. 38. piret j, boivin g. pandemics throughout history. frontiers in microbiology. 2021:3594. doi: 10.3389/fmicb.2020.631736. 39. rhodes cj, demetrius l. evolutionary entropy determines invasion success in emergent epidemics. plos one. 2010 sep 23;5(9):e12951. doi: 10.1371/journal.pone.0012951. 40. lee ss, wong ns. relationship between population configuration and the spatial pattern of pandemic influenza a (h1n1) 2009 in hong kong. hong kong med j. 2012 aug 1;18(4):310-7. url: https://www.hkmj.org/abstracts/v18n4/310.htm 41. nickbakhsh s, ho a, marques df, mcmenamin j, gunson rn, murcia pr. epidemiology of seasonal coronaviruses: establishing the context for the emergence of coronavirus disease 2019. the journal of infectious diseases. 2020 jun 16;222(1):17-25. doi: 10.1093/infdis/jiaa185. 42. harding n, nigmatullin r, prokopenko m. thermodynamic efficiency of contagions: a statistical mechanical analysis of the sis epidemic model. interface focus. 2018 dec 6;8(6):20180036. doi: 10.1098/rsfs.2018.0036. 43. tao y. maximum entropy method for estimating the reproduction number: an investigation for covid-19 in china and the united states. physical review e. 2020 sep 22;102(3):032136. doi: 10.1101/2020.03.14.20035659. 44. hossain, irin & khan, manzurul & rahman, shafiur & mullick, ashekur & aktaruzzaman, m m. (2020). the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) in bangladesh: a descriptive study. journal of medicinal science and clinical research. 2020 april; 8(04). doi: 18535/jmscr/v8i4.94. 45. feng cm, wang rt. performance evaluation for airlines including the consideration of financial ratios. journal of air transport management. 2000 jul 1;6(3):133-42. doi: 10.1016/s0969-6997(00)00003-x. 46. dashore k, pawar ss, sohani n, verma ds. product evaluation using entropy and multi criteria decision making methods. international journal of engineering trend and technology (ijett). 2013 may;4(5). url: http://ijettjournal.org/archive/ijettv4i5p169. 47. li p, wu j, qian h. groundwater quality assessment based on rough sets attribute reduction and topsis method in a semi-arid area, china. environmental monitoring and assessment. 2012 aug;184(8):4841-54. doi: 10.1007/s10661-011-2306-1. 48. abadi s, huda m, basiron b, ihwani ss, jasmi ka, hehsan a, safar j, mohamed ak, embong wh, mohamad am, noor ss. implementation of fuzzy analytical hierarchy process on notebook selection. international journal of engineering and technology. 2018;7(2.27):238-43. url: http://eprints.utm.my/id/eprint/84748/. 49. newage, “bangladesh bans travellers’ entry from europe”, new age bangladesh. 2020. https://www.newagebd.net/article/102202/bangladesh-banstravellers-entry-from-europe. 14th march, 2020. 50. barikdar a, ahmed t, lasker sp. the situation of the elderly in bangladesh. bangladesh journal of bioethics. 2016 aug 15;7(1):27-36. doi: 10.3329/bioethics. v7i1.29303. 51. sun s, chen j, johannesson m, kind p, xu l, zhang y, burström k. population health status in china: eq-5d results, by age, sex and socio-economic status, from the national health services survey 2008. quality of life research. 2011 apr;20(3):309-20. doi: 10.1007/s11136-010-9762-x. 52. shazzad mn, abdal sj, majumder ms, ali sm, ahmed s. drug addiction in bangladesh and its effect. medicine today. 2013;25(2):84-9. doi: 10.3329/medtoday. v25i2.17927. ali jadoo et al., journal of ideas in health 2018; 1(2):42-49 © the author(s). 2018 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. eissn: 3456-3546 journal homepage: www.jidhealth.com open access predictors of emotional exhaustion among physicians from iraq a descriptive cross-sectional multicentre study saad ahmed ali jadoo1*, ilker dastan2, mustafa ali mustafa al samarrai3, shukur mahmood yaseen4, perihan torun1 abstract background: doctors and paramedics in countries suffering from long-acting conflicts, including iraq, are working in severe and exceptional conditions, putting them under severe physical and psychological pressure, therefore examining burnout is important when dealing with the quality of care and working conditions. this study aimed to assess the point prevalence and to explore factors associated with emotional exhaustion (ee) among medical doctors in iraq. methods: descriptive and a cross-sectional study was conducted (january to june 2014) among a randomly selected sample of medical doctors (n=576, 87.3% response rate) working in twenty large general hospitals and medical centers. in addition to ee, the self-administered questionnaire used was consisting of questions on sociodemographic, work-related characteristics, conflict-related variables, and job satisfaction. ee was measured using the emotional exhaustion subscale of the maslach burnout inventory (mbi). results: the prevalence of ee reported by 60.0% of the respondents. in multiple linear regression analysis, the emotional burnout was higher among doctors who were married, female, bearing children, being threatened, displaced internally, non-specialist doctors, working more than 40 hours per week, experienced unsafe medical practice, disagreed with the way manager handle the staff and those who reported that the doctor-patient relationship as not excellent. conclusion: our findings suggest that job dissatisfaction, conflict, and violence-related factors were significantly associated with a high level of emotional exhaustion among iraqi physicians. keywords: emotional exhaustion, burnout, workplace, doctors, job satisfaction, conflict, iraq background the burnout syndrome has widely discussed since its first time emerged in its three dimensions; emotional exhaustion, depersonalization, and low personal accomplishment [1]. workrelated burnout is becoming increasingly recognized as a serious problem affecting many people working in human services, especially healthcare workers [2]. work-related burnout found to be directly related to a considerable list of adverse outcomes, including absenteeism from work, increased turnover, and poor job performance [3]. burnout has shown to have an impact on physicians and their mental and physical health [4,5]. moreover, burnout may reflect on clinical performance and the quality of care [6,7]. these features have been regularly reviewed and recognized over the past fifty years [8]. literature suggests that burnout is a common health problem among doctors in different countries globally [9-12]. however, despite such full recognition in western societies, the subject of burnout has not received the required attention from the middle east researchers until the beginning of the 21st century, and to our knowledge, there is a lack of national studies on burnout among iraqi health workers. this is a particular problem in iraq, where the health care system has suffered a long-standing catastrophic collapse since 1991 and has overloaded since that time [13]. furthermore, after the us-led invasion of iraq in 2003, the health system exposed to deliberate destruction of its infrastructure accompanied by a new exodus of brain drain, including the medical doctors [14]. the high level of violence ___________________________________________________ drsaadalezzi@gmail.com 1department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey full list of author information is available at the end of the article http://www.jidhealth.com/ ali jadoo et al., journal of ideas in health 2018; 1(2): 42-49 43 in conflict zones such as iraq produced chronic stress among health personnel, so that continuity in work became almost impossible [15]. moreover, lack of services and the attempt of the government to spoil the doctor-patient relationship by directing the media to focus mainly on the performance of health care providers made them victims of unfortunate and unjustified incidents of different types of abuse [15,16]. thus, the combination of lack of security, work, and violence-related and political factors has significantly contributed to raising the level of turnover intention and migration among iraqi doctors. consequently, the staying doctors, who are still working in iraq, were not able to cope with the resultant weakness in the level of health service presented to the patients who already feel dissatisfied and carry a negative impression against this service [17-19]. as a result, the doctors are more likely to pass into a state of an inevitable physical and emotional exhaustion (ee) ending to an exaggerated motivation to leave the job and looking for a better opportunity outside their country [14-19]. this study aimed to predict the main factors related to emotional burnout among iraqi doctors working in different health care centers during the eruption of armed conflict in 2014. the study focused on job satisfaction, violence-related variables, work-related variables, and socio-demographic factors to investigate their interrelationships with ee. methods study design and subjects this cross-sectional study was conducted among iraqi medical doctors to test the impact of violence-related and workplacerelated variables on the overall ee. the present study is part of a larger research initiative [14,15], in which we recruited a multistage sampling technique to drew a random sample of 660 physicians from twenty large general hospitals and medical centers covering the main five geographically regions in iraq (north, west, south, central, and the capital city). design, sampling, and data collection have been reported in detail previously [14,15]. in the current analysis, responses received from 576 physicians (response rate of 87.3%). at the time of the survey, all iraqi physicians working at the selected hospitals were included and received a copy of the self-administered questionnaire manually with a contact number and email of the data collector. the exclusion criteria included the chief medical officers (cmo), hospital managers, and their deputies. outcome variable emotional burnout assessed by nine items of ee subscale of the validated maslach burnout inventory (mbi) [20-22]. ee answered in terms of frequency on a 7-point likert scale ranging from 0 (never) to 6 (every day). the overall ee was measured by summing the scores of the nine items (in range of 0 to 54). a higher score indicated greater emotional exhaustion [3] and, accordingly, a higher emotional burnout. the cronbach’s alpha coefficient of the ee subscale reported in this study was 0.89. independent variables job satisfaction measured with the 10-item warr-cook-wall (wcw) job satisfaction (seven-point likert-type) scale ranging from 1 = "very dissatisfied" to 7 = "very satisfied". the overall job satisfaction was measured by summing the scores of the ten items (in range of 10 to 70). the socio-demographic variables collapsed and coded as follows: age (more or less than 40 years old), gender (male or female), marital status (married or single), presence of children (yes or no), residency (urban or rural). variables of conflicts or war-related violence were collapsed and coded as either (1) "yes" or (0) "no" in response to the following questions: "because of war violence in iraq, have you been lost a family member?"; "have you been threatened?"; "have you been displaced internally?"; "do you think that medical practice is safe?" and "the doctor-patient-relationship is excellent?”. individual work-related variables were categorized as follows: the current professional level (specialist or not); the working hours per week (more or less than 40 hours/week); the number of years spent at their work or the same facility (more or less than ten years); the type of employment (government only or dual in government and private); the training and educational opportunities (yes or no); the way the senior manager handles the staff is effective (agreed or disagreed). statistical analysis the statistical package for social sciences (spss) version 16.0 used to analyze data in this study. a descriptive analysis of sociodemographic, conflict-related variables, work-related characteristics, and job satisfaction has performed. the nine items of emotional exhaustion subscale summed to obtain the total score (0 to 54). a high degree of emotional burnout determined based on the cut-off point of the emotional exhaustion subscale in the mbi (≥27) [3]. the test of normality of the total score of emotional exhaustion conducted, and the data presented as mean and standard deviation (sd). student’s 𝑡-test used to compare the mean of emotional burnout score across demographic variables, work-related characteristics, conflict-related variables, and job satisfaction. categorical data presented as numbers and percentages, and the chi-squared test used for statistical analysis. multivariate linear regression using the "backward" technique was employed to obtain factors associated significantly with emotional burnout scores. variables that were significantly associated with burnout in the bivariate analysis included in the multivariate analysis. the accepted level of significance set below 0.05 (𝑃 < 0.05). results descriptive analyses table 1 shows the descriptive characteristics of the sociodemographic variables. the mean age (±sd) was 40.43 years (±8.59) (in range of 27-56). more than half of respondents (53.8%) were females, married (64.2%), living in urban regions (63.4%), and bearing children (51.2%). there was a significant difference in overall emotional exhaustion. overall emotional exhaustion was higher among female doctors (95% ci = 0.793.16, p=0.001), married (95% ci = 0.99-3.46, p=<0.000), and those who are bearing children (95% ci = 0.59-2.96, p=0.003). ali jadoo et al., journal of ideas in health 2018; 1(2): 42-49 44 table 1 socio-demographic variables on overall emotional exhaustion (n=576) variable category n% mean + sd t-test p-value 95% ci upper-lower age > or=40 years old 291(50.5) 28.73±7.46 1.355 0.176 0.37-2.02 <40 years old 285(49.5) 27.90±7.12 gender female 310 (53.8) 29.23±7.81 3.262 0.001 0.79-3.16 male 266 (46.2) 27.26±6.51 marital status married 370 (64.2) 29.11±7.32 3.542 0.000 0.99-3.46 single 206(35.8) 26.89±7.05 presence of children yes 295(51.2) 29.18±6.96 2.935 0.003 0.59-2.96 no 281(48.8) 27.41±7.55 residency urban 365 (63.4) 28.49±7.34 0.747 0.456 0.77-1.71 rural 211 (36.6) 28.02±7.24 emotional exhaustion (burnout) the mean (±sd) value on the total emotional exhaustion score was 28.72 (±7.30). three hundred and forty-five respondents (60.0%) experienced a high level of emotional burnout (table 2). table 2 descriptive statistics of the nine items and overall emotional exhaustion scale no. emotional exhaustion (burnout) mean s.d. min. max. 1 i feel emotionally drained from the work 3.18 1.63 0 6 2 i feel used up at the end of the workday 3.26 1.69 0 6 3 i feel fatigued when i get up in the morning and have to face another day on the job 3.10 1.71 0 6 4 working with people all day is really a strain for me 3.12 1.66 0 6 5 i feel burned out from the work 3.07 1.70 0 6 6 i feel frustrated by my job 3.25 1.69 0 6 7 i feel i'm working too hard on my job 3.00 1.72 0 6 8 working with people directly puts too much stress on me 3.43 1.72 0 6 9 i feel like i'm at the end of my rope 2.90 1.68 0 6 10 overall scale emotional exhaustion 28.72 7.30 0 54 conflict-related variables on overall emotional exhaustion in table 3, about one-fourth (26.6%) had lost one or more of their close relatives, 54.3% have threatened, 39.1% have internally displaced at least once, 66.8% experienced unsafe medical practice; however, 70.7% of them described their relationship with the patient as excellent. most of the conflict or war-related variables showed a significant difference in overall emotional exhaustion. overall emotional exhaustion was higher among doctors who have been threatened or kidnapped (95% ci = 0.75-3.13, p=0.000), internally displaced (95% ci = 1.503.91, p= <0.000), experienced unsafe medical practice (95% ci = 01.06-3.57, p=<0.000), and those who described the doctorspatients relationship was unwell (95% ci = 1.40-3.99, p=<0.000). work-related variables on overall emotional exhaustion in table 4, the vast majority (73.3%) of respondents spent more than ten years in the same health facility and were not being specialist yet (60.2%); however, more than half of them (55.7%) have a dual job (government and private) and were satisfied with the available training and educational opportunities. overall emotional exhaustion was higher among doctors who were not specialist (95% ci = 0.72-3.14, p=0.002), disagreed with the way manager handles the staff (95% ci = 0.72-3.14, p=0.003) and those who are working more than 40 hours per week (95% ci = 0.59-2.97, p=0.003). predictors of burnout table 5 shows the results of multiple linear regression analysis to identify the associated variables with emotional burnout. in backward elimination (or backward deletion), the multivariate linear regression analysis (after excluding non-contributing variables) was statistically significant, and overall, explained 24.8% of the variance in the overall emotional exhaustion, f (11, 16.845) = 680.670, p < .0005. the “internally displaced" and the "doctor-patient relationship” appeared to be the strongest factors predicting the ee (table 5). doctors who were internally displaced were more likely to have high ee (b = 0.269, p < .0005). doctors who considered the doctor-patient relationship is not excellent were more likely to have high ee (b = 0.267, p < .0005). in general, the emotional burnout was higher among doctors who were married, female, bearing children, being threatened, displaced internally, non-specialist doctors, working more than 40 hours per week, experienced unsafe medical practice, disagreed with the way manager handle the staff and considered the doctor-patient relationship as not excellent. ali jadoo et al., journal of ideas in health 2018; 1(2): 42-49 45 table 3 conflict and war-related variables on overall emotional exhaustion (n=576) table 4 work-related variables on overall emotional exhaustion (n=576) table 5 factors associated with emotional exhaustion in multiple linear regressions (n=576) variables b s.e. beta t-test sig. 95% ci lower-upper tolerance vif constant 39.048 1.302 29.994 0.000 36.49-41.61 overall job satisfaction 0.048 0.023 0.098 2.115 0.035 0.03-0.93 0.626 1.598 working more than40 h/week 1.426 0.570 0.098 2.501 0.013 0.31-2.55 0.872 1.147 40 h/week or less reference female 1.261 0.552 0.078 2.283 0.023 0.18-2.35 0.928 1.078 male reference non -specialist 1.602 0.657 0.108 2.438 0.015 0.31-2.89 0.677 1.477 specialist reference not agree with way manger handle staff 1.482 0.549 0.100 2.700 0.007 0.41-2.56 0.970 1.031 agree reference the doctor-patient relationship is not excellent 4.244 0.688 0.267 6.165 0.000 2.89-5.60 0.715 1.398 excellent reference displaced internally 4.398 0.624 0.296 7.052 0.000 3.17-5.62 0.759 1.317 not reference presence of children 1.929 0.545 0.133 3.538 0.000 0.86-3.00 0.948 1.055 not reference married 2.924 0.682 0.193 4.287 0.000 1.58-4.26 0.661 1.514 single, divorced, widow reference have been threatened 1.928 0.582 0.132 3.314 0.001 0.79-3.07 0.838 1.193 not reference medical practice is not safe 4.036 0.715 0.261 5.642 0.000 2.63-5.44 0.625 1.601 medical practice is safe reference variable category n% mean+ sd t-test p-value 95%ci upper-lower loss of family member no 423(73.4) 28.39±7.31 0.395 0.693 1.08-1.63 yes 153 (26.6) 28.12±7.29 exposure to threat or kidnapped yes 313(54.3) 29.20±7.33 3.207 0.001 0.75-3.13 no 263(45.7) 27.26±7.13 internally displaced yes 225(39.1) 29.96±7.73 4.404 0.000 1.50-3.91 no 351(60.9) 27.26±6.82 medical practice in iraq is safe. no 385 (66.8) 29.09±7.48 3.623 0.000 1.06-3.57 yes 191(33.2) 26.77±7.48 the doctor-patient relationship is excellent no 169(29.3) 30.22±7.02 4.096 0.000 1.40-3.99 yes 407(70.7) 27.53+7.27 variable category n% mean+ sd t-test p-value 95%ci upper-lower current professional level non-specialist 347(60.2) 29.08±6.97 3.124 0.002 0.72-3.14 specialist 229(39.8) 27.16±7.63 way managers handle staff. agreed (yes) 343(59.5) 27.56±7.37 3.034 0.003 0.66-3.07 disagreed (no) 233(40.5) 29.43±7.07 training and educational opportunities yes 316(54.9) 28.84±7.33 1.881 0.060 0.05-2.34 no 260(45.1) 27.79±7.23 years of service >10 years 422(73.3) 28.55±7.37 1.283 0.216 0.50-2.20 < or = 10 years 154(26.7) 27.69±7.07 hours of work/week >40 h 267(46.4) 29.27±7.21 2.941 0.003 0.59-2.97 <or=40 h 309(53.6) 27.49±7.17 type of employment government and private 321(55.7) 28.58±7.43 0.977 0.329 0.60-1.80 government only 255(44.3) 27.98±7.13 ali jadoo et al., journal of ideas in health 2018; 1(2): 42-49 46 discussion it was an interesting exercise to test several factors that may predict the ee among iraqi doctors. however, it was not possible to capture all possible factors. only 24.8% of the variation was explained; 75.2% of the variation remained unexplained, which indicated other factors might affect ee. in this study, the mean value of the total burnout score among iraqi physicians found to be 28.72 (sd=7.3, range 0-54). around 60% of the study participants revealed experiencing a high level of emotional burnout. this finding is consistent with other international studies. elsewhere in the middle east, burnout found to be quite common among health professionals in tunisia [23]. in saudi arabia, a high prevalence of burnout among multinational health professionals has been reported [24]. a quarter of the health professionals had suffered from high levels of burnout in egypt [25]. in contrast, a study conducted in qatar found that only 12.6% of responding primary care physicians experienced burnout [26]. the first step in coping with burnout threats is to identify the most common causes. the results from previous studies show that among the doctors, burnout is the result of exposure to factors associated with both personal and work environments. taking into consideration the conclusions from previous studies and the difference in the health system and culture in iraq, in the current study, several factors (table 1,2,3,4) were investigated for their association with burnout and aiming to reduce burnout among iraqi doctors. eleven of these factors maintained in the backward regression analysis. thus, burnout is potentially multi-determined; therefore, any type of prevention or intervention will require multi-faceted approaches. in our study, multivariate regression analysis of variables affecting burnout revealed that among the demographic factors, being female, having children or being married are significant predictors of burnout among the study population in iraq. regarding the role of gender in burnout, some papers found female doctors to be at a higher risk of burnout [27,28], which agrees with the findings of the present study. however, only a few studies reported burnout by sex, and a study conducted across europe found burnout to be more prevalent amongst males [29]. in our study, married physicians and physicians having children expected to have a higher level of burnout than their counterparts. in a study in turkey, the authors reported that problems with childcare were significantly associated with burnout [30]. disequilibrium between family and work demands found to be one of the most critical factors contributing to burnout among iraqi physicians [31]. in contrast, unmarried physicians found to have a higher level of burnout and more desensitization in a few other studies [32,33]. physicians exposed to a variety of work-related factors that are important in creating burnout. this study showed that the prevalence of burnout is higher in physicians reporting lower job satisfaction. the entire literature evaluating the correlation between job satisfaction and burnout has yielded the same result [34-38]. however, the majority of the literature is based on cross-sectional surveys as it does in this study, which makes it difficult to verify a causality. while the researchers suggest that low job satisfaction was a risk factor for burnout, it can be asserted that burnout is a risk factor for low job satisfaction, or poor job satisfaction may itself be a symptom of burnout. further research is needed to clarify the negative relationship. among the work-related factors, work time and the doctorpatient relationship are two other factors that shown to be related to burnout in both this and previous studies [39-42]. physicians in the current study who worked more than 40 hours per week or reported dissatisfaction with the doctor-patient relationship had significantly higher burnout rates. the iraqi healthcare system has faced a catastrophic collapse since 1991. iraqi doctors have left the country due to falling wages and worsening security conditions during the sanction years and after the 2003 invasion [43]. even though the migration rates have slowed more recently, about half of the doctors have estimated to be already left iraq after the 2003 invasion, and most healthcare providers have significant turnover intentions or to leave the country [44]. additionally, the health care system has been rapidly changing in recent years, which has increased many doctors' responsibilities, as well as the demands of their patients. as a result, doctors are working longer hours and taking less time to communicate with patients, and medical disputes often occur caused by patient dissatisfaction. these combined effects have created an increasing conflict between patients and doctors and damaged the doctor-patient relationship [14]. consequently, organizational interventions such as reducing long working hours and developing doctorpatient relationships should be considered in the new health care reforms. the doctor-patient relationship improved through the implementation of various measures, including malpractice insurance for physicians, and improving doctor-patient communication [45]. there is broad acceptance that work satisfaction and burnout levels are strongly affected by the leadership skills of senior managers. previous studies have shown that relationship with managers is an important factor that affects burnout [46,47]. poor relationships with managers can lead to feelings of exclusion and loneliness among physicians that can easily turn into burnout [20]. our study reported similar results; physicians who reported low managerial skills of their immediate supervisors have higher rates of burnout. the findings in this study contribute to the understanding that high levels of managerial support and skills have positive effects on fighting with burnout. the reduction of occupational stress, the development of managerial skills of supervisors, and strengthening relationship with managers can decrease burnout and improve the quality of life of physicians, as seen in other studies [48] [50]. further, non-specialist physicians found to be at high risk of burnout in our study group. similar findings found in other studies, for example, in a finnish study, the highest burnout scores were noted in general practitioners and non-specialists working in health centers, which may be related to heavy patient loads, long hours of work, low salaries, and professional identity issues [49]. conflict-related factors and workplace violence have not systematically examined as a predictor of physician burnout except for a few studies. the present study results demonstrated that physicians who threatened, displaced ali jadoo et al., journal of ideas in health 2018; 1(2): 42-49 47 internally, or believed the medical practice was not safe were more likely to have higher burnout rates in our studied sample. previous studies in egypt, poland, turkey, and a meta-sample of seven studies from different regions also demonstrated that workplace violence, conflicts, personal threats, or incivility were positively associated with the psychological conditions of physicians, including burnout [25,50,51]. there are some limitations to this study. first of all, because the study design was cross-sectional, a causal relationship could not be established. second, because we had no information about the non-respondents, response bias is a possible bias. third, this study conducted during peak crises of conflict in 2014, which affected the accessibility to the hospitals and districts, and consequently, selection bias is another possible bias. fourth, “although we have test piloted the english version of the questionnaire, the language barrier could be a limitation because the native language of the respondent is arabic". policy implication the above findings may be applied to the design and implementation of burnout reduction programs in iraq and facilitate the development of rational strategies. for example, the results showed burnout in physicians to be higher in females, married, or individuals with children. therefore, we suggest that the target group of burnout reduction programs should primarily focus on these physicians. intervention strategies may cover communication skill training, stress, and time management. further, burnout found to be associated with work-related factors: job satisfaction, working hours, being non-specialist, poor relationships with managers and patients. improving working conditions of iraqi doctors should be an essential goal for their job satisfaction and low burnout levels. policy reforms can address these factors contributing to burnout by reducing workload, reasonable welfare, a healthier working environment, and senior-junior support groups. increasing compensation can be an effective method to help to attract and retain good doctors. a large percentage of patients affect the quality of care and the doctor-patient relationship, and thus the burning of doctors. a comprehensive health care reform is needed to strengthen primary health care intended to address the overutilization of hospitals, which may involve government hiring and training more staff. conflict and violence-related factors found to be significantly associated with burnout of iraqi physicians in the current study. measures to prevent violence in the workplace against doctors are needed to reduce risk and negative consequences. although health institutions, in general, have made considerable progress in the development of programs to prevent violence in iraq, there are still shortcomings in the legislation prohibiting violence at work, and laws must be enacted to improve the medical environment and prevent violence at work. in order to effectively carry out these policies, government and health care organizations must develop, implement, and encourage a strong safety and security environment. [51]. conclusion a high level of emotional exhaustion detected in about twothird (60.0%) of participants. the findings of this study show that various socio-demographic, occupational, and conflictrelated factors are important determinants of the burnout of iraqi doctors. the results of this study would, therefore, be of great interest to iraqi policymakers and health care managers seeking to reduce physician burnout levels. the importance of burnout in physicians should not be underestimated, and many of the associated factors identified may potentially be reversed. this study may serve as a guide for setting effective interventions and treatment. according to the results, the focus should not only be on providing financial incentives but also on extraordinary efforts to create a safe and acceptable work environment. abbreviations ee: emotional exhaustion cmo: chief medical officers wcw: warr-cook-wall sd: standard deviation ci: confidence interval or: odds ratio who: world health organization gdp: gross domestic product declarations acknowledgment we render our special thanks to all directors of hospitals and medical centers we visited. we are also grateful to all the iraqi doctors and the paramedical staff for their working every day to serve their public in the face of violence and for their time and openness during the data collection. funding the author (s) received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing drsaadalezzi@gmail.com. authors’ contributions saaj is the principal investigator of the study who designed the study and coordinated all aspects of the research, including all steps of the manuscript preparation. he is responsible for the study concept, design, writing, reviewing, editing, and approving the manuscript in its final form. id, ma, sy, and pt contributed to the study design, analysis and interpretation of data, drafting the work, writing the manuscript and reviewed and approved the manuscript. all authors read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki, and the ethics committee of the izmir university of economics approved the protocol (ref: b.30.2.ieu.0.05.05-020-014). confidentiality was assured with signed informed consent. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. author details 1department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey. 2department of economics, izmir university of economics, izmir, turkey. 3department of public health, faculty of medicine, anbar university, anbar, iraq. 4department of ali jadoo et al., journal of ideas in health 2018; 1(2): 42-49 48 medical biology and anatomy, faculty of medicine, diyala university, diyala, iraq. article info received: 23 may 2018 accepted: 08 november 2018 published: 08 december 2018 references 1. maslach c, jackson se. the measurement of experienced burnout. journal of occupational behaviour 1981; 2:99-113. 2. sørgaard kw, ryan p, hill r, dawson i; oscar group. sources of stress and burnout in acute psychiatric care: inpatient vs. community staff. soc psychiatry psychiatr epidemiol 2007;42(10):794–802. 3. maslach cc, schaufeli wb, leiter mp. job burnout. annu rev psychol 2001; 52:397–422. 4. deary ij, blenkin h, agius rm, endler ns, zealley h, wood r. models of job-related stress and personal achievement among consultant doctors. british journal of psychology1996: 87(1):3– 29. 5. deckard g, meterko m, field d. physician burnout: an examination of personal, professional, and organizational relationships. medical care 1994; 32: 745– 754. 6. mccue jd. the effects of stress on physicians and their medical practice. n engl j med 1982; 306:458–463. 7. shanafelt td, bradley ka, wipf je, back al. burnout and selfreported patient care in an internal medicine residency program. ann intern med 2002; 136:358–367. 8. felton js. burnout as a clinical entityits importance in health care workers. j occup health1998; 48: 237–50. 9. balch cm, freischlag ja, shanafelt td. stress and burnout among surgeons: understanding and managing the syndrome and avoiding the adverse consequences. archives of surgery2009; 144:371–376. 10. houkes i, winants y, twellaar m. specific determinants of burnout among male and female general practitioners: a crosslagged panel analysis. journal of occupational and organizational psychology 2008; 81: 249–276. 11. schaufeli w, enzmann d. the burnout companion to study and practice: a critical analysis. london: taylor & francis, 1998. 12. wu s, zhu w, li h, wang z, wang m. relationship between job burnout and occupational stress among doctors in china. stress and health 2008; 24: 143–149. 13. squires a, sindi a, fennie k. health system reconstruction: perspectives of iraqi physicians. global public health2010; 5:561–77. 14. ali jadoo sa, aljunid sm, dastan i, tawfeeq rs, mustafa ma, ganasegeran k, aldubai sa. job satisfaction and turnover intention among iraqi doctors-a descriptive cross-sectional multicentre study. hum resour health2015; 13: 21. 15. ali jadoo sa, torun p, dastan i, al-samarrai m. impact of conflict related and workplace related violence on job satisfaction among physicians from iraq –a descriptive cross-sectional multicentre study. journal of ideas in health 2018; 1(1): 14-22. 16. al-samarrai m, ali jadoo sa. iraqi medical students are still planning to leave after graduation. journal of ideas in health 2018;1(1):23-28. 17. sa’adoon a a, hussien ah, museher tr. patients’ satisfaction for health care services at thi-qar province, iraq. thi-qar medical journal (tqmj) 2008; 2(1):39–45. 18. shabila np, al-tawil ng, al-hadithi ts, sondorp e: a qualitative assessment of the iraqi primary health care system. world health popul 2012; 13(3): 18-27. 19. webster p. reconstruction efforts in iraq failing health care. lancet 2009; 373: 617-620. 20. ozyurt a, hayran o, sur h. predictors of burnout and job satisfaction among turkish physicians. qjm 2006; 99(3): 161– 169. 21. beckstead jw. confirmatory factor analysis of the maslach burnout inventory among florida nurses. international journal of nursing studies 2002; 39 (8): 785–792. 22. al-dubai sar, ganasegeran k, perianayagam w, rampal kg. emotional burnout, perceived sources of job stress, professional fulfillment, and engagement among medical residents in malaysia. scientific world journal 2013; 2013: 137620. 23. halayem-dhouib s, zaghdoudi l, zremdini r, maalej i, béchir mb, labbène r. burnout en psychiatrie: une experience tunisienne [burnout among mental health professionals: a tunisian experience]. rev epidemiol sante publique 2010;58(6):403–408. 24. al-turki ha, al-turki ra, al-dardas ha, al-gazal mr, al maghrabi gh, al-enizi nh, et al. burnout syndrome among multinational nurses working in saudi arabia. ann afr med 2010;9(4):226–229. 25. abdo sam, el-sallamy rm, el-sherbiny aam, kabbash ia. burnout among physicians and nursing staff working in the emergency hospital of tanta university, egypt. east mediterr health j. 2016; 21(12): 906-915. 26. abdulla l, al-qahtani dm, al-kuwari mg. prevalence and determinants of burnout syndrome among primary healthcare physicians in qatar. south african family practice journal. 2011;53(4):380–383. 27. dyrbye ln, shanafelt td, balch cm, satele d, sloan j, freischlag j. relationship between work-home conflicts and burnout among american surgeons: a comparison by sex. arch surg 2011; 146:211–217. 28. shanafelt td, oreskovich mr, dyrbye ln, satele dv, hanks jb, sloan ja, et al. avoiding burnout: the personal health habits and wellness practices of us surgeons. ann surg 2012;255(4):625– 633. 29. soler jk, yaman h, esteva m, dobbs f, asenova rs, katic m, et al. burnout in european family doctors: the egprn study. fam pract 2008; 25:245–265. 30. demir a, ulusoy m, ulusoy mf. investigation of factors influencing burnout levels in the professional and private lives of nurses. int j nurs stud 2003;40(8):807–27. 31. lagerström m, josephson m, arsalan n, fallahi-khoshknab m. striving for balance between family and work demands among iranian nurses. nurs sci q 2010;23(2):166–172. 32. prins jt, van der heijden fm, hoekstra-weebers je, bakker ab, van de wiel hb, jacobs b, et al. burnout, engagement and resident physicians’ self-reported errors. psychol health med 2009; 14: 654−66. 33. wang, zhihui, zhenyu xie, junming dai, liqian zhang, yunbiao huang, and bo chen. "physician burnout and its associated factors: a cross-sectional study in shanghai." journal of occupational health 56, no. 1 (2014): 73-83. 34. mcmanus ic, winder bc, gordon d. the causal links between stress and burnout in a longitudinal study of uk doctors. lancet 2002; 359: 2089–90. 35. visser mrm, smets ema, oort fj, de haes hcjm. stress, satisfaction and burnout among dutch medical specialists. cmaj 2003; 168(3): 271–75. 36. elit l, trim k, mand-bains ih, sussman j, grunfeld e, and in conjunction with the society of gynecologic oncology canada. job satisfaction, stress and burnout among canadian gynecologic oncologists. gynecol oncol 2004; 94(1):134–139. 37. thomsen s, soares j, nolan p, dallender j, arnetz b. feelings of professional fulfillment and exhaustion in mental health personnel: the importance of organizational and individual factors. psychother psychosom 1999; 68:157–64. 38. renzi c, tabolli s, ianni a, di pietro c, puddu p. burnout and job satisfaction comparing healthcare staff of a dermatological hospital and a general hospital. j eur acad dermatol venereol 2005; 19:153–157. 39. maccacaro g, di tommaso f, ferrai p, bonatti d, bombana s, merseburger a. the effort of being male: a survey on gender and burnout. med lav 2011; 102:286–296. 40. piko bf. burnout, role conflict, job satisfaction and psychosocial health among hungarian health care staff: a questionnaire survey. int j nurs stud 2006; 43:311–318. 41. wu h, liu l, wang y, gao f, zhao x, wang l. factors associated with burnout among chinese hospital doctors: a crosssectional study. bmc public health 2013; 13(1): 786. 42. al-dubai sa, rampal kg. prevalence and associated factors of burnout among doctors in yemen. j occup health 2010; 52:58– 65. 43. al-dewachi o. the professionalization of the iraqi medical doctors in britain. ann arbor, united states: harvard university; 2008. ali jadoo et al., journal of ideas in health 2018; 1(2): 42-49 49 44. webster pc. iraq’s health system yet to heal from ravages of war. lancet. 2011;378(9794):863–6. 45. gong y, han t, chen w, dib hh, yang g, zhuang r, lu z. prevalence of anxiety and depressive symptoms and related risk factors among physicians in china: a cross-sectional study. plos one 2014; 9(7): e103242. 46. escribà-agüir v, martín-baena d, pérez-hoyos s: psychosocial work environment and burnout among emergency medical and nursing staff. int arch occup environ health 2006; 80:127–133. 47. karasek r, theorell t. healthy work: stress, productivity, and the reconstruction of working life. new york: basic books; 1990. 48. wang h, zhang n: analysis on the status of occupational burnout among doctors. zhong guo jian kang xin li xue za zhi 2008; 16:397–399. 49. olkinuora m, asp s, juntunen j, kauttu k, strid l, aärimaa m, et al. stress symptoms, burnout and suicidal thoughts in finnish physicians. soc psychiatr epidemiol 1990; 25(2):81–86. 50. merecz d, drabek m, moscicka a. aggression at the workplace– psychological consequences of abusive encounter with coworkers and clients. international journal of occupational medicine and environme tal health2009; 22: 243–260. 51. 51. aytac s, dursun s. the effect on employees of violence climate in the workplace. work 41 suppl 1;2012: 3026–3031. hassooni et al., journal of ideas in health 2018;1(2):50-55 © the author(s). 2018 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access medical students carry more virulent microorganisms at their throat than that of patients’ accompaniers hanan raheem hassooni 1*, abbas aboud farhan1, hameed m. jasim2, adil hassan alhusseiny3 abstract background: transition of medical students from a non-clinical to a clinical situation carries a considerable risk that needs further investigation. this study aims to detect and compare the throat bacterial colonization between medical students and patients' accompaniers in a tertiary hospital. methods: across-sectional descriptive study was conducted at the outpatient clinics of the baquba teaching hospital at the faculty of medicine, diyala university, iraq. a total of 120 throat swabs collected from a sample of 70 medical students (fifth stage) and 50 volunteers as a control group who were selected conveniently during their outpatient visits over september 2018. aerobic and anaerobic culture methods were recruited to investigate the samples following the standard microbiological procedures. results: finding of this study indicate a high rate of bacterial throat colonization among medical students compared to the control group. male gender showed high susceptibility for infection than females. the most common bacteria isolated among medical students were staphylococcus aureus, and escherichia coli 26 (37.1%), followed by streptococcus pneumonia appeared in 23 samples (32.8%), viridians streptococci 19 (27.1%), acinetobacter spp.14 (20%), enterobacter spp. 4 (5.7%), candida spp. 3 (4.2%), pseudomonas aeruginosa 2 (2.8%) respectively. conclusion: our findings suggest that medical students may contribute significantly to the transmission and dissemination of nosocomial pathogens among patients and vice versa. keywords: medical students, patients’ accompaniers, throat, normal flora, baquba, diyala, iraq background normal flora (normal resident flora) or sometimes called commensals defined as a group of different microorganisms such as bacteria, fungi, protozoa, and viruses that continuously inhabited the human body. normal flora has been detected at six important human body openings-related sites that usually exposed to the external environment, including the skin, eyes and ears, respiratory tract, oral cavity (mouth), gastrointestinal tract, and urogenital tract. bacteria are the most commonly seen normal flora, compared to fungi and other commensals [1,2]. normal flora plays an active role in the prevention of diseases and maintaining health. it helps in the prevention of colonization by pathogens via bacterial intervention mechanisms [2,3]. as usual, the fetus and the internal body organs such as the spleen, liver, pancreas, bladder, lymph, blood and cerebrospinal fluids (csf) are free of normal flora; however, the opportunistic microbes can easily attack the fetus or body organs and cause infection when the number of normal flora significantly reduced. the number and variety of normal flora depend on multiple factors which might be physiological (such as the change in body temperature), the geographical habitat (such as hospital attendance), diet (presence of particular nutrient in mouth), age (neglected kids and old age), gender, the immune system status (immune deficiency diseases ) and chronic disease [3,4]. frandah et al. (2013) found that “patients with diabetes and a history of recent proton pump inhibitors (ppis) use are more likely to have abnormal oral flora on admission to the medical intensive care unit (micu)” [5]. unfortunately, visitors of the hospital, whether they had been admitted or in an outpatient clinic and even their accompaniers, are most likely to have a risk of the transmission of pathogens from health workers and hospital instruments. microorganisms have been isolated from the white coat of medical doctors and students [6,7], medical uniforms [8], the nasal cavity of medical students [9-11] and other health workers ___________________________________________________ hanan6319@gmail.com 1department of biology, faculty of education for pure science, diyala university, iraq. full list of author information is available at the end of the article. http://www.jidhealth.com/ hassooni et al., journal of ideas in health 2018;1(2):50-55 51 [11], hands of medical doctors and students [12-15], stethoscopes, medical students’ cell phone [16], medical charts [17], ward fomites [18,19], and the frequently touched objects in hospital [20]. the objectives of this study were (1) to determine the normal flora or the bacterial growth in the throat of medical students who are undergoing training education in the hospital and being in direct contact with patients, (2) to determine the bacterial growth or the normal flora in the throat of the control group of the patient's accompaniers, (3) to compare the results of isolated bacterial growth between medical students and the control group. methods study design and subjects a cross-sectional descriptive-analytical study was performed among medical students, faculty of medicine, diyala university, iraq. data were collected from 1st to 30th september 2018. to investigate the normal flora in the throat, all the fifth stage medical students (the academic year of 20182019) who were undergoing clinical training and being in direct contact with patients at the baquba teaching hospital of diyala university were included. because of inclusion and exclusion criteria (table 1), swabs were collected from the throat of 70 medical students compare to 50 volunteers in the control group, who were accompanying patients during their outpatient visits. at the time of the study, both the sample and control groups clinically examined. table 1 presents the main inclusion and exclusion criteria. table 1 inclusion and exclusion criteria inclusion and exclusion criteria medical student control group fifth stage medical students. + patient's accompaniers who have visited the hospital + willing to participate. + + acute or chronic rhinitis. pharyngitis, cryptic tonsillitis, sinusitis, and otitis media sino bronchial syndrome. disorders related to airways or nasopharyngeal way. smoking and alcohol drinking. diabetes or hypertensive. current antibiotic therapy (oral or systemic) use or used in the preceding two weeks. recent tonsil or throat surgeries. dental surgery in the preceding two weeks +: referred to inclusion criteria; -: referred to exclusion criteria collection of the sample researchers followed the standard clinical methods to collect throat swab samples. all samples were extracted in a well-lit room, considering the comfortable sitting of participants and facing a light source. precautions were taken to avoid swab contamination before and after the swab collecting procedure. a sterile tongue blade or spoon was used to depress the tongue. attention was given not to touch all sides or top of the mouth, including the tongue, while moving the swab. a firm and quick rubbing of the swab on the back of the throat and the tonsils has performed. swabs have soon placed in the provided culture medium. transport of sample in order to ensure the viability of pathogens, samples were sent directly to the baquba teaching hospital's microbiology department in a sterile transport medium. moreover, each sample was provided with individual participant data such as name, date, age, and gender to facilitate data collection for analysis. stain and culture process blood, chocolate, and macconkey agars were separately used to culture the organisms. according to the standard microbiological methods, "five percent sheep blood agar and macconkey agar plates were incubated aerobically, while chocolate agar was incubated under 5% co2 atmosphere at 37°c for 24–48 h". the isolates then stained with gram stain to identify the shape and color of the colonies under the microscope. the isolates were cultured on the differential and diagnostic medium and then diagnosed with a vitek-2 compact system. statistical analysis data was collected and analyzed using microsoft excel spreadsheet. descriptive analysis performed concerning the most common pathogen isolated in both medical student and control groups and the gender differences. results descriptive analyses more than half (55.7%, 39) of the 70 throat swab samples collected from fifth class medical school students were females compared to 44.3%, 31 males. in the control group, the 50 throat swab samples equally distributed between the male and female participants (figure 1). each participant of medical students and the control group was in the average age of 22 years old. table 2 presents the bacterial growth in medical students and control groups. the most common bacterial growth in the female, 55.7% female, 50.0% male, 44.3% male, 50.0% 0% 20% 40% 60% 80% 100% medical students control group figure 1 male to female ratio among the medical students and control groups hassooni et al., journal of ideas in health 2018;1(2):50-55 52 samples of medical students was staphylococcus aureus, escherichia coli, streptococcus pneumoniae, viridians streptococci, acinetobacter spp. the highest percentage of 26 (37.1%) was reported at an equal rate among staphylococcus aureus and escherichia coli. while streptococcus pneumoniae appeared in 23 samples (32.8%), viridians streptococci 19 (27.1%), acinetobacter spp. 14 (20%), enterobacter spp. 4(5.7%), candida spp. 3(4.2%), pseudomonas aeruginosa 2(2.8%). however, the lowest percentage was at an equal percentage of 1.4% (1 sample) for each of proteus spp., streptococcus pyogenes, staphylococcus albicans. regarding the control group, the bacterial growth limited to five spp.; haemophilus spp., viridians streptococci, streptococcus pneumoniae, staphylococcus aureus and streptococcus pyogenes at a percent of 21(42%), 18(36%), 9(18%), 4(8%) and 1(2%) respectively. table 3 presents the bacterial growth according to gender. there is a difference between males and females within the students and control groups in this study. in the student samples, almost all isolated bacterial spp. (staphylococcus aureus, escherichia coli, streptococcus pneumoniae, viridians streptococci, acinetobacter spp.) recorded high bacterial growth among the male gender compared to the female gender. however, the opposite was reported in the control group, where the isolated bacterial growth, such as haemophilus spp., appeared more among female gender than the male gender. table 2 bacterial growth in the healthy students and control group table 3 bacterial growth in the healthy students and control group according to sex medical students control group bacteria male female bacteria male female staphylococcus aureus 15 11 haemophilus spp. 9 12 escherichia coli 17 9 viridians streptococci 9 9 streptococcus pneumoniae 15 8 streptococcus pneumoniae 4 5 viridians streptococci 10 9 staphylococcus aureus 2 2 acinetobacter spp. 8 6 streptococcus pyogenes 0 1 enterobacter spp. 3 1 candida spp. 2 1 pseudomonas aeruginosa 2 0 proteus spp 0 1 streptococcus pyogenes 0 1 discussion in this study, different numbers and types of bacterial growths have been detected in the throats of both medical students and control groups. twelve different bacterial spp. (table 2) have been isolated from the throats of the medical student group compare to five bacterial spp. (table 3) from the control group. the results of the study confirmed the existence of two different environments [11] with marked changes that happened like the normal resident flora in the throats of students. most normal flora components are harmless in healthy individuals; however, normal flora could be changed to an inflammatory agent when stimulated by other organisms [1, 4]. the upper respiratory tract (urt) is often the main colonization place by pathogens compare to the lower respiratory tract (lrt), which usually stays sterile, due to the difficulty of bacteria to reach it [1,21,22]. collins (2008) identified three essential elements for the transmission of disease within health institutions: “a source of infecting microorganisms, a susceptible host, and a means of transmission for the microorganism to the host” [23]. health medical students control group bacteria n % bacteria n % staphylococcus aureus 26 37.1 haemophilus spp. 21 42 escherichia coli 26 37.1 viridians streptococci 18 36 streptococcus pneumoniae 23 32.8 streptococcus pneumoniae 9 18 viridians streptococci 19 27.1 staphylococcus aureus 4 8 acinetobacter spp. 14 20 streptococcus pyogenes 1 2 enterobacter spp. 4 5.7 candida spp. 3 4.2 pseudomonas aeruginosa 2 2.8 proteus spp. 1 1.4 streptococcus pyogenes 1 1.4 hassooni et al., journal of ideas in health 2018;1(2):50-55 54 care personnel, including medical students, are vulnerable to bacterial infection when they have direct contact with the patient or any of his or her contaminated discharges [23], which may explain partly the possibility of medical students in our study might have been exposed to microorganisms from patients during their training education in the hospital. furthermore, although the undergraduate medical students are out of the normal medical staff in health institutions, they contribute seriously to be a source and means of transmitting nosocomial infections because health training requires frequent contact with patients. [10,24-27]. this study's findings showed that the prevalence rate of s. aureus and escherichia coli throat colonization was 37.1% among the sample of medical students compared to 8.0% among the control group sample. although it is a normal inhabitant of the oral cavity, throat, and nose [28], s. aureus considered among the most common pathogens responsible for many infectious diseases in both community and health institutions [29]. bhatta et al. (2018), in his study among nepalese medical students, found that "the prevalence of s. aureus was significantly higher among clinical sciences students compared to preclinical sciences students" [30]. al-tamimi et al. (2018) reported that the prevalence rate of s. aureus nasal colonization among medical students as an international trend was 14 to 45%, which is close to our findings of 37.1% throat colonization among medical students [10]. results showed that medical students throat colonization with another group of infectious pathogens (escherichia coli, streptococcus pneumoniae, viridians streptococci, acinetobacter spp.) no less dangerous than s. aureus. international research indicated that most of these organisms act as resistant bacteria in oral cavities [31-34]. results of this study might be explained based on either the medical students have exposed to nosocomial infections from the direct contact with patients as it was discussed earlier in this research, or the behavior of medical students agreed with the nature of the community of excessive and unjustified use of antibiotics, which results in bacterial resistance, and this is beyond the current research. although "females were generally more interested in training improvement and higher education than males" [35], which generally required them to attend more training and clinical sessions in hospital, however finding of this study showed that most of the bacterial growing were among the males' group compared to females (table 3). two main factors (genetic differences and endocrine, immune reactions) were reported to determine the immunological differences between the sexes [36]. differences in gene expression and sex steroid hormones help to obtain a difference in immune responses between males and females [37,38]. females showed a robust immune response to antigenic challenges such as infection and vaccination and subsequently more resistant to infection thane males [36,39]. females give more frequent and severe reactions to viral and bacterial vaccines than men [36,40]; however, they are more susceptible to autoimmune disorders and diseases than their counterparts [41]. predicting the transmission of severe pathogens from patients to medical students or the reverse can be reached by regular screening of clinical medical students. the clinical medical students are more likely responsible for transmitting and disseminating the pathogens within the health care institution than other health care providers because the medical students are undergoing to a rotational training program in different wards/units of the hospital, while doctors and nurses are usually working in predetermined wards/units depending on their specialty. in light of our results and similar studies, the availability of data will significantly reduce the transmission of diseases among hospital departments, especially among high-risk patients such as icu, burn, postoperative, and neonates. policy about the standard medical practice, including awareness/orientation program should be strictly implemented in the level of health care personnel and medical students to avoid the transmission of nosocomial pathogens. the strength of this study lies in comparing medical students with patient's accompaniers belonging to two different environments. however, this study had a complaint from some limitations. first: we collected our data during the autumn/summer season (september); however, the seasonal variation in the colonization rate was ignored in this study. second: antibiotic sensitivity of the isolated pathogens was not done. third, the transmission of isolated pathogens from the sample of medical students to the control group, patients, or the other healthcare personnel, and vice versa, was not included in the current study. fourth: the study results cannot be generalized to other medical students because the sample was from one medical college of diyala university, iraq. conclusion this study compared a sample of undergraduate medical students (fifth class) with patients’ accompaniers attending outpatient clinics. the student is usually visiting different departments within the hospital following their clinical teaching curriculum. the results of this study found that the medical students complained from a high rate of bacterial throat colonization compared to the control group. such evidence may increase the possibility that medical students play a role in transmitting and disseminating the infection among patients and health care personnel. efforts should be adequate to raise knowledge and awareness among medical students and steadfast adherence to infection control protocols to minimize the transmission of nosocomial diseases in healthcare institutions. declarations abbreviations csf: cerebro spinal fluids ppis: proton pump inhibitors; micu: medical intensive care unit; urt: upper respiratory tract; urti: upper respiratory tract infection; lrt: lower respiratory tract acknowledgment we render our special thanks to all directors in diyala university and baquba teaching hospital. we are also grateful to all the medical students for their help, time, and openness during the data collection funding the author (s) received no financial support for the research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing hanan6319@gmail.com. mailto:hanan6319@gmail.com hassooni et al., journal of ideas in health 2018;1(2):50-55 54 authors’ contributions hrh is the principal investigator of the study who designed the study and coordinated all aspects of the research, including all steps of the manuscript preparation. she is responsible for the study concept, design, writing, reviewing, editing, and approving the manuscript in its final form. aaf, hmj, and aha contributed to the study design, analysis, and reviewed and approved the manuscript. all authors read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki, and the center of training and human resource development, diyala province health directorate, ministry of health, iraq approved the protocol (ref: official letter no. 303 issued on 21st january 2018). confidentiality was assured with signed informed consent. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated author details 1department of biology, faculty of education for pure science, diyala university.2college of biotechnology, al-nahrain university, baghdad, iraq. 3department of internal medicine, faculty of medicine, diyala university, iraq. article info received: 11 november 2018 accepted: 21 december 2018 published: 23 december 2018 references 1. abhilash a, zainab a, gangadharas, annet o, sunil p. a clinical study of oropharyngeal microbial flora in laryngopharyngeal reflux disease. journal of microbiology and biotechnology 2014; 3(2):14-18. 2. cui l, morris a, ghedin e. the human mycobiome in health and disease. genome med 2013; 5(7): 63. 3. lynne vm. normal flora: diversity and functions, microbial ecology in health and disease 2000; 12(4):193-207. 4. jayashree k, sanjeev d, inam d. an initial study on normal commensel flora of throat, journal of dental and medical sciences 2016; 15(7): 132-134. 5. frandah w, colmer-hamood j, mojazi amiri h, raj r, nugent k. oropharyngeal flora in patients admitted to the medical intensive care unit: clinical factors and acid suppressive therapy. j med microbiol. 2013;62(pt 5):778–84. 6. noor f, jayanthi rs. the study of microbial flora on doctors white coats in tertiary care hospital in outskirts of hyderabad, telangana, india. int j res med sci. 2016; 4(7): 2705-2712. 7. qaday j, sariko m, mwakyoma a, kifaro e, mosha d, tarimo r, et al. bacterial contamination of medical doctors and students white coats at kilimanjaro christian medical centre, moshi, tanzania. int j bacteriol. 2015; 2015: 507890. 8. du zy, zhang mx, shi mh, zhou hq, yu y. bacterial contamination of medical uniforms: a cross-sectional study from suzhou city, china. j pak med assoc. 2017; 67(11): 1740-1742. 9. susethira ar, vigneshwari rs, krishnaveni m, uma a, thirumalaikolundusubbramaniam s, jeyaseelan senthinath t, et al. nasal floral changes among medical students on exposure to formaldehyde. int j curr microbiol app sci. 2013; 2(6): 246-253. 10. al-tamimi m, himsawi n, abu-raideh j, abu jazar d, aljawaldeh h, sameer mahmoud a, et al. nasal colonization by methicillin-sensitive and methicillin-resistant staphylococcus aureus among medical students. j infect dev ctries. 2018; 12(5): 326-335. 11. muhammed sa, mohammed aw, wadi as, mohammed dl. a comparative study on detecting bacterial flora of the nasal cavity in normal healthy workers that work in cement factory and the healthy students in koya university. iosr journal of pharmacy and biological sciences (iosr-jpbs) 2014; 9(4): 07-15. 12. monistrol o, lópez ml, riera m, font r, nicolás c, escobar ma, et al. hand contamination during routine care in medical wards: the role of hand hygiene compliance. j med microbiol. 2013; 62: 623–629. 13. amin tt, al noaim ki, bu saad ma, al malhm ta, al mulhim aa, al awas ma. standard precautions and infection control, medical students’ knowledge and behavior at a saudi university: the need for change. glob j health sci. 2013; 5(4): 114–25. 14. chauhan k, mullan s. evaluation of contamination of hands of the medical students in a medical teaching tertiary care hospital. advances in microbiology 2017; 7: 666-671. 15. longtin y, schneider a, tschopp c, renzi g, gayet-ageron a, schrenzel j, et al. contamination of stethoscopes and physicians’ hands after a physical examination. mayo clin proc 2014; 89(3): 291–299. 16. jalalmanesh s, darvishi m, rahimi m, akhlaghdoust m. contamination of senior medical students’ cell phones by nosocomial ınfections: a survey in a university-affiliated hospital in tehran. shiraz e-med j 2017; 18(4): e43920. 17. chen k-h, chen l-r, wang y-k. contamination of medical charts: an important source of potential infection in hospitals. plos one 2014; 9(2): e78512. 18. xiao s, tang jw, li y. airborne or fomite transmission for norovirus? a case study revisited. int. j. environ. res. public health 2017; 14: 1571. 19. nwankwo e. isolation of pathogenic bacteria from fomites in the operating rooms of a specialist hospital in kano, north-western nigeria. pan afr med j 2012; 12: 90. 20. bhatta dr, hamal d, shrestha r, hosuru subramanya s, baral n, singh rk, et al. bacterial contamination of frequently touched objects in a tertiary care hospital of pokhara, nepal: how safe are our hands?. antimicrob resist infect control 2018; 7: 97. 21. bista m, amatya m, basnet p. tonsillar microbial flora: a comparison of infected and noninfected tonsils. kathmandu university medical journal 2006; 4 (1): 18-23. 22. hassooni h, fadhil s, hameed r, alhusseiny a, ali jadoo sa. upper respiratory tract infection and otitis media are clinically and microbiologically associated. journal of ideas in health 2018; 1(1): 2933. hassooni et al., journal of ideas in health 2018;1(2):50-55 55 23. collins as: preventing health care-associated infections. patient safety and quality: an evidence-based handbook for nurses. edited by: hughes rg. 2008, rockville (md): agency for healthcare research and quality, u.s. department of health and human services. 24. zakai sa. prevalence of methicillin-resistant staphylococcus aureus nasal colonization among medical students in jeddah, saudi arabia. saudi med j 2015; 36: 807-812. 25. okamo b, moremi n, seni j, mirambo mm, kidenya br, mshana se. prevalence and antimicrobial susceptibility profiles of staphylococcus aureus nasal carriage among preclinical and clinical medical students in a tanzanian university. bmc res notes 2016; 9: 47. 26. john a, tomas me, hari a, wilson bm, donskey cj. do medical students receive training in correct use of personal protective equipment? med educ online 2017; 22: 1264125. 27. orlin i, rokney a, onn a, glikman d, peretz a. hospital clones of methicillin-resistant staphylococcus aureus are carried by medical students even before healthcare exposure. antimicrob resist infect control 2017; 6: 15. 28. mccormack mg, smith aj, akram an, jackson m, robertson d, edwards g, et al. staphylococcus aureus and the oral cavity: an overlooked source of carriage and infection? am j infect control 2015; 43: 35–37. 29. rodriguez m, hogan pg, burnham ca, fritz sa, et al. molecular epidemiology of staphylococcus aureus in households of children with community‐associated s. aureus skin and soft tissue infections. j pediatr 2014; 164: 105–111. 30. bhatta dr, hamal d, shrestha r, parajuli r, baral n, subramanya sh. nasal and pharyngeal colonization by bacterial pathogens: a comparative study between preclinical and clinical sciences medical students. can j infect dis med microbiol 2018; 2018: 7258672. 31. bryskier a. viridans group streptococci: a reservoir of resistant bacteria in oral cavities. clin microbiol infect 2002; 8(2): 65-69. 32. de lv, malosh re, aiello ae, foxman b. prevalence of escherichia coli carriage in the oropharynx of ambulatory children and adults with and without upper respiratory symptoms. ann am thorac soc. 2015; 12: 461–463. 33. wang l, qiao x, ai l, zhai j, wang x. isolation of antimicrobial resistant bacteria in upper respiratory tract infections of patients. biotech 2016; 6(2): 166. 34. deepthi m, narsimloo k. role of usage of antibiotics in pharyngitis: a prospective study. int j otorhinolaryngol head neck surg 2017; 3(2): 303-307. 35. al-samarrai ma, ali jadoo sa. iraqi medical students, are still planning to leave after graduation. journal of ideas in health 2018; 1(1): 23-28. 36. anna r, simona a, antonell d, luciana g, marina v. the influence of sex and gender on immunity, infection and vaccination, ann ist super sanità 2016; 52(2): 198-204. 37. pinheiro i, dejager l, libert c. x-chromosome-located micrornas in immunity: might they explain male/female differences? the x chromosome-genomic context may affect x-located mirnas and downstream signaling, thereby contributing to the enhanced immune response of females, bioessays 2011; 33(11): 791-802. 38. ying sy, lin sl. current perspectives in intronic micro rnas (mirnas). j biomed sci 2006; 13: 5–15. 39. klein sl, jedlicka a, pekosz a. the xs and y of immune responses to viral vaccines, lancet infect dis 2010; 10(5):33849. 40. cook if. sexual dimorphism of humoral immunity with human vaccines. vaccine 2008; 4; 26(29-30): 3551-5. 41. voskuhl r. sex differences in autoimmune diseases. biol sex differ 2011; 2(1):1-21. https://doi.org/10.47108/jidhealth.vol3.issspecial2.59 ali jadoo sa, et al., journal of ideas in health 2020;3(special 2):258-265 © the author(s). 2020 this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. e issn: 2645-9248 journal homepage: www.jidhealth.com open access knowledge, attitude, and practice toward covid-19 among iraqi people: a web-based cross-sectional study saad ahmed ali jadoo1*, adil hassan alhusseiny2, shukur mahmood yaseen3, mustafa ali mustafa al-samarrai4, ru’ya abdulhadi al-rawi4, ahmed k. al-delaimy4, mohammed waheeb abed5, hanan raheem hassooni6 abstract background: iraq was among the first countries invaded by the novel human coronavirus (sars-cov-2) after china. this study aimed to assess the iraqi people's knowledge, attitudes, and practices toward covid-19 during the pandemic. methods: a cross-sectional study recruiting an online self-reported survey conducted from 17-31 july 2020. data of 877 participants have undergone descriptive, univariate, and multivariable regression analyses, respectively, to assess the differences in mean scores and identify factors associated with knowledge, attitudes, and practices (kap) toward covid-19. results: most of the respondents (78.8%) from the urban region, highly educated (69.7%), aged less than 45 years (61.2%), females (58.3%), married (51.9%), and 74.0% self-ranked health as good. less than half (45.4%) were employed; however, the average monthly income was usd 400 or more in about 66.8% of them. the mean knowledge, attitude and practice score was 15.57 ± 2.46 (range: 0-20), 38.88 (sd = 3.57, (range: 11-55), and 5.13 (sd = 1.14, range: 0–6), respectively. findings of regression analysis showed that higher educated (p< 0.001), urban residents (p <0.001), employed (p =0.040), and having an income level of usd 400 or more (p <0.001) were significantly associated with upper knowledge score. female gender and employed respondents are significantly associated with positive attitude scores, but inversely respondents with an income of usd 400 or more are significantly associated with a negative attitude. regarding practice score, the female gender and those living in an urban region had better practice, but the young age group (0-44 years) was significantly associated with the weak practice. conclusion: although iraq has adopted a preventive and precautionary plan to control the spread of coronavirus. however, the public's knowledge and attitude toward covid-19, coupled with the unstable political and security situation, have greatly affected the commitment to preventive measures. keywords: covid-19, knowledge, attitude, practice, public, preventive measures, iraq background iraq was among the countries that were early hit by the first wave of the covid-19 pandemic. since the appearance of the first case at the end of february 2020, iraq has taken a series of measures to contain the pandemic [1]. however, the response to the escalating emergencies was not well planned. the decisions made by the iraqi higher committee for health and national safety (ihchns) did not consider the social and economic situation in iraq [2]. for example, the imposition of a total lockdown and its extension several times without providing livelihood alternatives to many groups of society increased the population's suffering and non-compliance [3]. reports indicate that a small percentage of the population understood the country's serious health situation and respected the lockdown measures. most of the educational campaigns that were led by the iraqi government and the non-government organizations (ngos) at the local and international levels were broken in front of the rock of stubbornness and indifference of many citizens. on the contrary, a high percentage of the population in iraq followed the statements of the party and religious leaderships that deliberately weakened the central state's decisions and allowed their followers to mix and practice party ___________________________________________________ drsaadalezzi@gmail.com 1department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey full list of author information is available at the end of the article https://doi.org/10.47108/jidhealth.vol3.issspecial2.59 http://www.jidhealth.com/ ali jadoo sa, et al., journal of ideas in health (2020); 3(special 2):258-265 259 and religious rites despite the spread of the pandemic throughout the country [4]. unfortunately, people did not realize the seriousness of the situation until the pandemic reached their homes. lack of health awareness was a prominent characteristic of the iraqi people. many infected people have avoided treatment due to the social stigma associated with coronavirus and the prevailing belief that health institutions have become a host for transmission. others believed that the coronavirus pandemic was a conspiracy and a political game. therefore, many cases come late to the hospital with severe respiratory distress [5]. people began to realize how bad the situation was when they or a loved one were brought to a hospital, and they saw patients quickly die every day [6]. iraq witnessed an alarming increase in the number of cases in the summer, especially in july, august, and september 2020. according to the world meter statistics [worldometer], the number of confirmed cases in iraq exceeded 387,121, at a rate of 3,500 new cases per day during the past six weeks [7]. despite the continuing spread of the pandemic, the ihchns decided to ease restrictions on combating the coronavirus by allowing the movement of people between provinces and reopening the borders and crossings in addition to tourism facilities and sporting events [8]. there is no doubt that it is protecting the individuals and preserving society's health among the duties of the central government. nevertheless, people have an essential role in implementing plans and strategies to prevent diseases and epidemics. this study aimed to assess the knowledge, attitude, and practice (kap) towards the covid19 pandemic among the iraqi people. methods study design and sample a cross-sectional study was conducted from 17 july 2020 to 31 july 2020 among iraq's general population. given the lockdowns and the restricted movement, data was collected via an online self-reported questionnaire using google docs forms. the researchers distributed the survey link to the participants via twitter, whatsapp, and viber groups. inclusion and exclusion criteria all iraqi people living in iraq understood the questionnaire's content and agreed to participate are included in the study. however, the study excluded the participants from outside iraq. sample size the researchers sought to improve the generalizability of the study by maximizing the target sample size. according to world bank data, iraq's total population was estimated at 39,309.78 in 2019 [9]. the sample size calculator [10] arrived at 1,037 participants, using a margin of error of ± 4.0%, a confidence level of 99%, a 50% response distribution, and 39,309.78 people. study tool the authors developed the self-reported questionnaire following the guidelines of the centers for disease control and prevention (cdc) [11]. moreover, several published articles related to knowledge, attitude, and practice towards the covid-19 pandemic have been considered [12-23]. initially, the questionnaire was written in the english language, and then it was translated into the arabic language. the questionnaire test piloted among 20 respondents not included in the study. content validation was performed using the content validity rate [24-26]. the online questionnaire's first page contained an assurance of the freedom to participate or withdraw and that all information and opinions submitted would be anonymous and confidential. the questionnaire contains four main sections. the first section is devoted to information on the participants' sociodemographic characteristics, including age, gender, marital status, level of education, employment, place of residency, income level, and self-rated health status. the second section of the questionnaire is dedicated to assessing participants' knowledge of covid-19. this section contained 20 items focusing on the ways of transmitting the coronavirus, the clinical symptoms that appear on the infected person, the treatment protocol, and what groups are most at risk of infection, in addition to information on the strategies of isolation, prevention, and control of the pandemic. the third section of the questionnaire included 11 items to assess participants 'attitudes towards covid-19, using a five-point likert scale to determine the level of participants' agreement ranging from "1" 'strongly disagree' to "5" 'strongly agree'. the fourth section of the questionnaire has six questions recruited to evaluate respondents' practices and behaviors toward covid19. independent variables for sociodemographic variables, gender was coded as one for females and zero for males. the age variable was reported in six groups: "<18","18-24", "25–34", "35-44", "45-54", "55-64", "65-74" and ">74" years old. moreover, the age was categorized into two categorize codded zero for more than 44 years and coded one for 44 years and below. marital status was captured as binary, and a value of one was used for married and zero for otherwise. education was categorized and coded into one (high educated) for college/university degree, and postgraduate degree and zero (low educated) for high school or below. work status categorized and the value of zero given to unemployed and value of one given to employed. place of residency coded as zero for rural and one for urban. monthly income (iraqi dinar (iqd)1 = united state dollar (usd) 0.0008, exchange rate on 10 july 2020) was divided into four categories: <usd 200, usd 200 to <400, usd 400 to1000, and more than usd1000. the self-rated health status was reported in a scale ranged from "very bad" to "very good" in a scale ranged from "1" to "5". moreover, the self-rated health status was categorized into poor health (very bad, bad, moderate) and good health (good and very good). dependent variables as with other pandemics, covid-19 has revealed the respondents were asked to respond to knowledge items as either true or false, with an additional "do not know" option. incorrect or uncertain (do not know) responses were given a score of zero, and correct answers were assigned a score of one. the total score for knowledge ranged from zero to 20, with high scores indicating better knowledge of covid-19. items were evaluated for internal reliability, using cronbach's a. cronbach's alpha coefficient was 0.72, indicating internal reliability. in the section on attitudes, scores were calculated based on the respondents' answers to each attitudinal statement, 1 = ali jadoo sa, et al., journal of ideas in health (2020); 3(special 2):258-265 260 strongly disagree, 2=disagree, 3=undecided, 4=agree, and 5=strongly agree. scores were calculated by averaging respondents' answers to the eleven statements. total scores ranged from eleven to 55, with high scores indicating positive attitudes. the likert scales were assessed for internal reliability, using cronbach's a. cronbach's alpha coefficient was 0.83, indicating internal reliability. in the section on practices, respondents were asked to respond "yes" or "no" to the items. a score of one was given for answers that reflected good practice, and a score of zero was given for answers that reflected bad practice. the total score ranged from zero to six, with high scores indicating better practices. statistical analysis this study employed primarily univariate and multivariable regression data analyses. univariate analysis was used to tabulate the frequency of social and demographic statistics. an independent sample t-test and one-way analysis of variance (anova) were used to assess differences in mean values for kap scores. because the scores were continuous, the overall mean differences were estimated using a bartlett test [27]. a multivariable linear regression analysis was performed to identify factors related to knowledge, attitudes, and practice. all analyses were conducted using spss version 16. results social and demographic characteristics a total of 931 participants completed the questionnaire. after excluding 54 respondents who reported living outside iraq, the final sample consisted of 877 participants. table 1 shows the social and demographic characteristics of the study participants. more than half of the sample (53.5%) were between the ages of 18 and 44. of the participants, 455 were married (61.9%), and 422 were unmarried (48.1%). more than two-thirds of the sample (69.7%) had a college or university degree. the vast majority (691, 78.8%) of respondent resident in the urban region. in terms of work status, 479 (54.6%) were unemployed. respondents were grouped according to monthly income, with 291 (33.2%) in the < usd 400 group, and 586 (66.8%) in the group of usd 400 and more. of the sample, 360 (41.0%), 289 (33.0%) self-ranked health as good and very good, respectively (table 1). descriptive statistics of kap scores as shown in table 2, the knowledge score (15.57 ± 2.46, range: 0-20) having an overall 77.85% (15.57/20*100) of correct rate was significantly varied across marital status, education, residency, employment, income level and self-ranked health status (p <0.05). the mean attitude score for covid-19 was 38.88 (sd = 3.57, range: 11-55), indicating positive attitudes and significantly varied across income level (p <0.05). the mean score for practices for covid-19 was 5.13 (sd = 1.14, range: 0–6), indicating good practices and significantly varied across residency (p <0.05). kap scores by social and demographic characteristics table 3 presents the mean of kap scores towards covid-19 by different social and demographic characteristics in iraq. knowledge scores significantly differed across marital status categories, residence places, education level and level of income, and health status. level of income and residence places are shown as an influential factor in attitude scores and practice scores (p <0.05). table 1 socio demographic factors (n=877) variabales category n % gender female 511 58.3 male 366 41.7 age group 0-17 67 7.6 18-24 188 21.4 25-34 145 16.5 34-44 137 15.6 45-54 105 12.0 55-64 106 12.1 65-74 72 8.2 > 75 57 6.5 marital status married 455 51.9 single 422 48.1 education high education 611 30.3 low education 266 69.7 residency urban 691 78.8 rural 186 21.2 employment unemployed 479 54.6 employed 398 45.4 level of income <$200 73 8.3 $200-399 218 24.9 $400-1000 320 36.5 >$1000 266 30.3 self-ranked health status very poor 22 2.5 poor 47 5.4 acceptable 159 18.1 good 360 41.0 very good 289 33.0 regression results of kap-related factors regression analysis showed that higher educated (p-value = 0.000, <0.05), urban residents (p-value=0.000, <0.05), employed (p-value=0.040, <0.05), and having income level of usd 400 or more (p-value=0.000, <0.05) were significantly associated with upper knowledge score. female gender and employed respondents are significantly associated with positive attitude scores, but inversely, respondents with an income of usd 400 or more are significantly associated with a negative attitude. regarding practice score, the female gender and those living in the urban region had better practice, but the young age group (0-44 years) was significantly associated with weak practice (table 4). as presented in table 5, more than 90% of the total sample had accurate knowledge related to "washing hands, wearing medical masks, avoiding touching their eyes, nose, and mouth with the unwashed hand ", "clinical symptoms and its importance", "spreads through cough and sneeze by infected people", "elderly people, people with chronic diseases in higher risk" and "the importance of healthy food and drinking water and isolation". however, 34.8% had a misconception that afebrile patients will not transmit the virus to others. moreover, 49.8% have insufficient knowledge about antibiotics' effectiveness, and 38.7% do not have accurate knowledge about children affected by covid-19. 31.4% had difficulty distinguishing coronavirus from influenza. furthermore, there was a lack of information among the participants regarding pregnant women, and the possibility of infection with coronavirus (63.4%), contact with wild animals (59.4%), and the importance of wearing a face mask when infected or being close to an infected person (51.4%). ali jadoo sa, et al., journal of ideas in health (2020); 3(special 2):258-265 261 more than 95% of "maintaining a reasonable distance" and "washing hands" protect individuals and society from coronavirus. 86.2% reported that they do not believe in staying at home as an effective preventive measure. about 50% of them thought coronavirus would be controlled, and 54.9% feel that it was too late for the implication of lockdown at the beginning of the epidemic. just 50.6% of them thought the iraqi government's strict measures were enough to win the battle against coronavirus. also, 72.3% of participants thought complying with the national safety committee of the ministry of health's instructions will prevent the spread of coronavirus. 25.4% thought the announced number related to infected and dead persons due to coronavirus are exaggerated, 54.9% of them have a growing concern about the second peak of coronavirus cases (table 6). in terms of practice towards covid-19 that are presented in table 7 in annex, 15.7% of participants had attended a social event involving many people, 28.3% were in a crowded place, 84.5% did not avoid social behavior such as shake hands or kiss people, 9.1% did not think seriously about social distancing, 6.6% were not interested about washing hands after going to a public place, or after blowing your nose, coughing, or sneezing, 11.9% were not interested about washing things from outside the home. table 2 number of questions, range, scores, and levels of knowledge, attitude, and practice variables number of questions range of score total scores (mean ± sd) accuracy rate (%) knowledge 20 0-20 15.57 ± 2.46 77.85 attitude 11 11-55 38.88 ± 3.57 70.69 practice 6 0-6 5.13 ± 1.14 85.50 table 3 kap scores by socio-demographic and economic characteristics variables categories total (%) knowledge score (mean ± sd) p-value attitude score (mean ± sd) p-value practice score (mean ± sd) p-value gender female 511(58.3) 15.64 ±2.35 0.348 39.01 ±3.57 0.228 5.18±1.13 0.102 male 366(41.7) 15.49±2.61 38.71 ±3.57 5.05±1.14 age 0-44 years 537(61.2) 15.68±2.49 0.126 38.77 ±3.63 0.312 5.10±1.16 0.388 >40 years 340(38.8) 15.41±2.42 39.04 ±3.47 5.17±1.11 marital status married 455(51.9) 15.77±2.45 0.016 38.94 ±3.49 0.645 5.16±1.13 0.427 unmarried 422(48.1) 15.37±2.47 38.83 ±3.66 5.10±1.15 education high education 611(69.7) 15.94±2.33 0.000 39.87 ±3.61 0.733 5.17±1.12 0.117 low education 266(30.3) 14.73±2.56 38.94 ±3.50 5.04±1.18 residency urban 691(78.8) 15.83±2.37 0.000 38.83 ±3.47 0.375 5.18±1.12 0.020 rural 186(21.2) 14.61±2.62 39.09 ±3.98 4.96±1.18 employment employed 398(45.4) 15.93±2.30 0.000 38.97 ±3.44 0.521 5.14±1.12 0.825 unemployed 479(54.6) 15.28±2.56 38.81 ±3.68 5.12±1.15 income level > usd 400 586(66.8) 15.90±2.76 0.000 38.72 ±3.50 0.053 5.16±1.09 0.329 < usd 400 291(33.2) 14.91±2.23 39.22 ±3.70 5.08±1.23 self-ranked good health 649(74.0) 15.74±2.39 0.000 38.90 ±3.65 0.885 5.12±1.17 0.807 health status poor health 228(26.0) 15.10±2.60 38.86 ±3.34 5.14±1.05 table 4 regression results of kap-related factors for covid-19 variable b se beta t p-value 95% ci tolerance vif lower-upper knowledge (durbin-watson= 1.865) higher educated (vs low educated) 0.801 0.189 0.149 4.246 0.000 (0.431,1.171) 0.840 1.191 urban (vs rural) 0.830 0.203 0.138 4.089 0.000 (0.432,1.229) 0.916 1.091 employed (vs unemployed) 0.285 0.168 0.058 1.696 0.040 (0.045,0.615) 0.902 1.109 > usd 400(vs < usd400) 0.645 0.175 0.123 3.682 0.000 (0.301,0.988) 0.929 1.076 attitude (durbin-watson= 1.757) female (vs male) 0.447 0.263 0.062 1.696 0.040 (-0.070,0.963) 0.859 1.165 > usd 400(vs < usd400) -0.559 0.259 -0.047 -2.161 0.031 (0.051,1.067) 0.976 1.025 employed (vs unemployed) 0.395 0.263 0.055 1.498 0.013 (-1.123,0.912) 0.841 1.188 practice (durbin-watson= 1.754) urban (vs rural) 0.195 0.097 0.070 2.006 0.030 (0.075,0.315) 0.911 1.097 female (vs male) 0.156 0.081 0.068 1.919 0.045 (0.044,0.386) 0.925 1.081 0-44 years (vs >44 years) -1.122 0.081 -0.052 -1.510 0.021 (-0.036,0.280) 0.951 1.051 ali jadoo sa, et al., journal of ideas in health (2020); 3(special 2):258-265 262 discussion to our knowledge, this study is the first national study to explore the knowledge, attitude, and practice of the iraqis towards the novel coronavirus in 2020. the iraqis scored 77.85% correct rate of knowledge about the covid-19 pandemic. the results of this study did not differ from a previous study conducted in sudan (78.20%) [12], and higher than rates reported in studies from egypt and nigeria (61.6%) [13], and bangladesh (48.3%) [14], however, the rate was lower than the rates recorded in other countries such as china (90.0%) [15], cameroon (84.19%) [16], saudi arabi (81.64%) [17], malaysia (80.5%) [18]. like other studies conducted in bangladesh [14], china [19], india [20], and egypt [21], the higher rates of knowledge correlated with a higher level of education among the respondents with a numerical advantage for the youth population. the youth component of high schools and the undergraduate students represent the group that most social media users, which reinforces the hypothesis of having more access to news and information about the covid-19 pandemic than the elderly. moreover, the linear regression analysis showed that knowledge was affected by a high percentage of respondents in urban areas. similar findings were seen in india [20] and ethiopia [22]. iraq suffers from a chronic shortage in the supply of electricity and low internet services, especially in rural areas, which significantly contributed to depriving rural residents of regular access to confidential information and the up to date data about the covoid-19. furthermore, having a job with a salary is significantly associated with good knowledge about covid-19. similar findings were reported in malaysia [18], egypt [21]. covid-19 caused a deterioration in the global economic situation, which negatively affected the population's physical and psychological health state in general [28,29]. coronavirus's impact was more severe on countries that already suffer from an unstable political and economic situation, such as iraq. there was a limitation to access information among the unemployed and low-income families. lack of essential services coupled with the deteriorating economic situation in iraq has made most people interested in securing an income to meet the family's needs rather than improving the knowledge about the corona epidemic. similar to findings reported in china [19], bangladesh [14], egypt, and nigeria [13], the vast majority of iraqis agree that leaving a social distance (95.7%), washing hands (97.6%), and staying at home (86.2%) are the best ways to control the epidemic. unlike previous studies [17, 20, 23], the iraqis expressed a pessimistic attitude towards the covid19 epidemic: 45.5% of respondents believed that the coronavirus pandemic would not be successfully controlled, and 45.4% of respondents do not have confidence in the iraqi government's measures to win the battle against the virus. nevertheless, 72.3% of the respondents emphasized the need to adhere to the national safety committee's instructions at the ministry of health to prevent the spread of coronavirus. although 89.3% of respondents believed that the complete lockdown was an effective measure to prevent the coronavirus spread, it harmed the family's economic situation, and 49.3% felt that the implementation was too late. our survey showed that females were significantly associated with a positive attitude to covid-19 (p=0.040) than counterpart men. our survey results coincide with the results of a study conducted in spain [30], which confirmed that women take the epidemic seriously and are more committed to the standards of protection against the coronavirus with more responsibility than men. not surprisingly, employed respondents (p=0.013) were significantly associated with a positive attitude toward the covidpandemic compared to unemployed people. although this study did not distinguish between government and self or private employment, getting a job with a sufficient income was a challenge in iraq. the worldwide lockdown led to massive unemployment; therefore, maintaining or getting a job has dramatically mitigated the economic impact of the covid-19 pandemic and improved the attitude towards pandemic. however, respondents with high incomes had a negative attitude towards coronavirus, perhaps because they believe that the pandemic would be prolonged, which could reduce their salaries or lose their jobs later. similar results have been reported in vietnam. dang et al. [31] found that the coronavirus pandemic-related decline in income was at an average of 61.6% among two-thirds of the study participants and that more than a quarter of them had a salary deficit at forty percent or more. although the pessimistic attitude prevailed among the respondents, they reacted positively, and the majority of them adhered to the necessary precautions to prevent infection with the covid-19 virus. more than 84.0% avoided social events and social behavior, such as shaking hands or kissing. moreover, over 90.0% become interested in practicing social distancing and washing hands or things brought from outside the home. on the other hand, 28.3% of the respondents reported that they went to crowded places and 15.0% of them attended meetings and social events, explaining the emergence of recurrent infection hotspots in different regions of iraq, which causes delays or failure of the plans of the competent authorities to combat the coronavirus. findings of the regression analysis showed that urban residents (p= 0.030), female sex (p= 0.045), and those aged more than 44 years (p= 0.021) were significantly more likely to practice protective measures against the spread of the coronavirus than their counterparts. similarly, yue et al. [19] found that urban area was "associated with a higher practice score" toward covid-19 than the rural area. moreover, it is known that urban residents are more concerned with their rights to health services and generally tend to adhere to health instructions compared to rural residents [32]. brooks dj and saad l [33] found that males are less interested in the coronavirus than females. therefore, the mortality rate due to coronavirus was higher among male patients than females. galasso et al. [34] found that most women considered coronavirus as a severe health problem. women were keener to know about the coronavirus pandemic, listen to the instructions, committed to safety measures, and comply with policies than men. although there is no definitive evidence to exclude a particular age group from infection with coronavirus, however, published reports from the world health organization [35] indicated that young people are at a lower risk of contracting coronavirus based on less severe physical and clinical signs and symptoms associated with covid-19 than the old age group. like other studies [17, 35], our study found that young people are less committed to health prevention measures and have less practice. moreover, older people are ali jadoo sa, et al., journal of ideas in health (2020); 3(special 2):258-265 263 distinguished by knowledge, wisdom, and responsibility, reflected in better practices than the young age group. unfortunately, since 2003, political, financial, and administrative corruption in iraq has created an environment for a dilapidated health system [36]. most of the bright medical professionals have emigrated. more than half of already in workplace have the intention to leave on both the graduate and undergraduate levels [36,37], because there is no clear law to protect them from of the recurrent exposure to different types of violation [38]. faced with all these aforementioned challenges, the central government in iraq is unable to implement very restrictive measures including complete national lockdown, banning all public gatherings, encouraging social distancing, and the compulsory use of face masks, becomes risky behaviors among the study population. table 5 correct responses to knowledge statements regarding covid-19 (n=877). no. statement number (%) 1 corona is a viral disease that spreads from person to person at a distance of up to two meters (6 feet) 630(71.8) 2 corona spreads through respiratory droplets that occur when infected people cough and sneeze. 834(95.1) 3 corona infection may occur by touching or kissing the contaminated surfaces or objects and then touching the mouth, nose, or possibly the eyes. 834(95.1) 4 eating or touching wild animals can lead to infection with the coronavirus. 355(40.5) 5 people infected with covid-19 cannot transmit the virus to others when a fever is not present. 572(65.2) 6 the main clinical symptoms of covid-19 are fever, fatigue, dry cough, myalgia, and shortness of breath. 849(96.8) 7 unlike the common cold, congestion, runny nose, and sneezing are less common in people infected with covid-19. 602(68.6) 8 antibiotics are effective in treating covid-19. 440(50.2) 9 currently, there is no effective cure for covid-19, but early symptomatic and supportive treatment can help most patients recover from the diseases. 764(87.1) 10 the elderly and people who suffer from severe chronic diseases such as heart or lung disease and diabetes have a doubled risk of developing severe complications from developing a covid-19. 840(95.8) 11 pregnant women are more susceptible to infections than non-pregnant women. 318(36.6) 12 children are less likely to be infected with covid19 than adults. 538(61.3) 13 it is not necessary for children or young people to take protective measures against covid-19 transmission. 754(86.0) 14 people must wash their hands with soap and water or use a hand sanitizer containing at least 60% alcohol for at least 20 seconds. after being in a public place, after nose-blowing, coughing, or sneezing, 788(89.9) 15 as a precaution, people should avoid touching their eyes, nose, and mouth with unwashed hands. 858(97.8) 16 wearing medical masks is very important to prevent corona infection. 840(95.8) 17 people should only wear a mask if they are infected with the virus or if they are caring for someone with suspected covid-19 infection. 426(48.6) 18 healthy food and drinking water strengthen the body's immunity and resistance against covid-19. 765(87.2) 19 isolation and treatment of people infected with the covid-19 are effective ways to reduce the spread of coronavirus. 855(97.5) 20 people being in contact with someone infected with covid-19 should be immediately quarantined, in an appropriate location, for a general observation period of 14 days. 797(90.9) table 6 responses to attitudinal statements regarding covid-19 (n=877). no. statements strongly agree agree do not know disagree strongly disagree 1 maintaining a reasonable distance from others is very important to avoid the spread of coronavirus 441(50.3) 398(45.4) 23(2.6) 7(0.8) 8(0.9) 2 hand washing is necessary to protect individuals and society from coronavirus. 496(56.6) 360(41.0) 13(1.5) 1 (0.1) 7(0.8) 3 staying at home is an effective preventive measure to protect individuals and society from exposure to corona 318(36.3) 438(49.9) 41(4.7) 69(7.9) 11(1.3) 4 i think the corona epidemic can be successfully controlled. 94 (10.7) 349(39.8) 286(32.6) 116(13.2) 32(3.6) 5 the strict measures taken by the iraqi government are sufficient to win the battle against coronavirus. 90(10.3) 353(40.3) 184(21.0) 160(18.2) 90(10.3) 6 complying with the national safety committee of the ministry of health instructions will prevent the spread of corona. 162(18.5) 472(53.8) 172(19.6) 55(6.3) 16(1.8) 7 the complete lockdown was an effective measure to prevent the spread of coronavirus, but it negatively affected the family's economic situation. 334(38.1) 449(51.2) 38(4.3) 48(5.5) 8(0.9) 8 i think the figures that announced the number of infected people and the number of deaths due to coronavirus are exaggerated. 60(6.8) 163(18.6) 297(33.9) 238(27.1) 119(13.6) 9 i still think that corona virus is a hoax, and there is no need to take precautions. 7(0.8) 14(1.6) 74(8.4) 311(35.5) 471(53.7) 10 i have a growing concern about the second peak of coronavirus cases 101(11.5) 381(43.4) 255(29.1) 119(13.6) 21(2.4) 11 when the lockdown introduced at the beginning of the epidemic, i felt it was implemented too late 123(14.0) 310(35.3) 178(20.3) 244(27.8) 22(2.5) conclusion in conclusion, this study found that the level of knowledge, attitude, and practice of the iraqis towards covid-19 was acceptable. several factors, including gender, educational level, employment, place of residence, and income, were among kap determinants towards covid-19. likewise, previous studies indicated that the level of kap is positively and negatively affected by the extent to which the awareness of the population develops and the community's ability to contain diseases and pandemics. in light of the coronavirus pandemic, many researchers have made valuable efforts to study the kap of people toward the covid-19. often the results were positive, recording reassuring proportions of how well people knew about the new pandemic. nevertheless, the spread of the pandemic at such a rapid speed in different and distant societies raises questions about the extent to which people are serious about adhering to health institutions' instructions. ali jadoo sa, et al., journal of ideas in health (2020); 3(special 2):258-265 264 table 7 practices related to covid-19 (n=877). no. statement yes no 1 have you recently attended a social event (such as a wedding party, funeral parlor, etc.) involving many people? 138(15.7) 739(84.3) 2 have you recently been in a crowded place? 248(28.3) 629(71.7) 3 have you recently avoided shaking hands or kissing or any social behavior that calls for meeting and closeness? 136(15.5) 741(84.5) 4 have you seriously thought about practicing social distancing and leaving a distance when talking to people? 797 (90.9) 80(9.1) 5 have you recently become more interested in washing your hands with soap and water frequently for at least 20 seconds, especially after going to a public place or after blowing your nose, coughing, or sneezing? 819(93.4) 58(6.6) 6 have you recently become more interested in washing things that you bring from outside the home, including fruits and vegetables? 773(88.1) 104(11.9) abbreviation covid-19: coronavirus; ihchns: iraqi higher committee for health and national safety; ngos: non-government organizations; cdc: centers for disease control and prevention; kap: knowledge, attitude, practice; iqd: iraqi dinar; usd: united state dollar declaration acknowledgment we would like to thank mr. anmar shukur mahmood for his great efforts in helping to prepare the questionnaires and the necessary links and distribution through the social networking sites. we also extend our thanks to all respondents to the survey during the coronavirus pandemic. funding the authors received no financial support for their research, authorship, and/or publication of this article. availability of data and materials data will be available by emailing drsaadalezzi@gmail.com authors’ contributions saad ahmed ali jadoo (saaj) is the principal investigator of this manuscript (original manuscript) who designed the study and coordinated all aspects of the research including the study design, analysis, and interpretation of data, drafting the work, writing the manuscript, and reviewed and approved the manuscript. saaj, mama, smy contributed to the study concept, design, writing, reviewing, editing, and approving the manuscript in its final form. mwa contributed to data collection. raa, and aka contributed to drafting the manuscript. all authors have read and approved the final manuscript. ethics approval and consent to participate we conducted the research following the declaration of helsinki, and the protocol was approved by the ethics committee of the scientific issues and postgraduate studies unit (psu), college of medicine, university of anbar (ref: sr/368 at 19-july-2020); the ethics committee of the college of medicine, diyala university (ref: 1250 at 15-july-2020); national cancer institute, misrata, libya (ref: 0000 at 91-august-2020). moreover, web-based informed consent obtained from each participant after explanation of the study objectives and the guarantee of secrecy. consent for publication not applicable competing interest the authors declare that they have no competing interests. open access this article is distributed under the terms of the creative commons attribution 4.0 international license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. author details 1department of public health, faculty of medicine, bezmialem vakif university, istanbul, turkey.2 department of internal medicine, faculty of medicine, diyala university, iraq. 3department of anatomy, molecular genetics, faculty of medicine, university of diyala, diyala, iraq. 4ddepartment of family and community medicine, faculty of medicine, anbar university, anbar, iraq. 5department of physiology, faculty of medicine, diyala university, diyala, iraq.6department of biology, faculty of education for pure science, diyala university, iraq. article info received: 13 august 2020 accepted: 01 october 2020 published: 19 december 2020 references 1. world health organization, early covid-19 preparation saved lives in iraq. available from: http://www.emro.who.int/irq/iraqnews/early-covid-19-preparation-saved-lives-in-iraq.html [accessed on 25 october 2020] 2. government of iraq, covid-19: higher committee for health and national safety announces new measures. available from: https://gds.gov.iq/covid-19-higher-committee-for-health-andnational-safety-announces-new-measures/ [accessed on 25 october 2020] 3. epic, iraq’s health system at risk: the struggle to fight covid-19 and save lives, june 25, 2020. available from: https://enablingpeace.org/iraqs-health-system-at-risk/ [accessed on 25 october 2020] 4. al-dahhan wh, al-mashhadani mh, raheem r, yousif e. iraq faces the covid-19 with limited health capabilities and major medical challenges. bionatura 2020;5(3):1271-1274. 10.21931/rb/2020.05.03.19 5. rubin aj. stigma hampers iraqi efforts to fight the coronavirus. the new york times, april 14, 2020. available from: https://www.nytimes.com/2020/04/14/world/middleeast/iraqcoronavirus-stigma-quarantine.html [accessed on 25 october 2020] 6. medicine sans fronters (msf). covid-19 outbreak in baghdad is “very alarming”, 24 sep 2020. available from: ali jadoo sa, et al., journal of ideas in health (2020); 3(special 2):258-265 265 https://www.msf.org/covid-19-outbreak-baghdad-iraq-veryalarming [accessed on 25 october 2020]. 7. worldometer, iraq. available from: https://www.worldometers.info/coronavirus/country/iraq/ [accessed on 06 october 2020] 8. gardaworld. iraqi authorities allow ease of covid-19 restrictions on september 8; follow authority directives, 08 sep 2020. available from: https://www.garda.com/crisis24/newsalerts/377066/iraq-authorities-ease-covid-19-restrictionsseptember-8-update-50 [accessed on 06-october 2020] 9. the world bank, data, population, total. availabe at: https://data.worldbank.org/indicator/sp.pop.totl [accessed 04 on july 2020] 10. raosoft, sample size calculator. available from: http://www.raosoft.com/samplesize.html?nosurvey [accessed 06october 2020] 11. cdc. centers for disease control and prevention: coronavirus (covid-19) 2020. available online at: https://www.cdc.gov/coronavirus/2019-ncov/index.html [accessed on 1 july 2020]. 12. 12. hezima a, aljafari a, aljafari a, mohammad a, adel i. knowledge, attitudes, and practices of sudanese residents towards covid-19. east mediterr health j. 2020 jun 24;26(6):646-651. https://doi.org/10.26719/emhj.20.076. 13. hager e, odetokun ia, bolarinwa o, zainab a, okechukwu o, al-mustapha ai. knowledge, attitude, and perceptions towards the 2019 coronavirus pandemic: a bi-national survey in africa. plos one 2020; 15(7): e0236918. https://doi.org/10.1371/journal.pone.0236918 14. ferdous mz, islam ms, sikder mt, mosaddek asm, zegarravaldivia ja, gozal d.knowledge, attitude, and practice regarding covid-19 outbreak in bangladesh: an online-based crosssectional study. plos one2020; 15(10): e0239254. https://doi.org/10.1371/journal.pone.0239254 15. zhong bl, luo w, li hm, zhang qq, liu xg, li wt, li y. knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online cross-sectional survey. int j biol sci. 2020 mar 15;16(10):1745-1752. https://doi.org/10.7150/ijbs.45221 16. ngwewondo a, nkengazong l, ambe la, ebogo jt, mba fm, goni ho, nyunaï n, ngonde mc, oyono je. knowledge, attitudes, practices of/towards covid 19 preventive measures and symptoms: a cross-sectional study during the exponential rise of the outbreak in cameroon. plos negl trop dis. 2020 sep 4;14(9): e0008700. https://doi.org/10.1371/journal.pntd.0008700 17. al-hanawi mk, angawi k, alshareef n, qattan amn, helmy hz, abudawood y, alqurashi m, kattan wm, kadasah na, chirwa gc, alsharqi o. knowledge, attitude and practice toward covid-19 among the public in the kingdom of saudi arabia: a cross-sectional study. front public health. 2020 may 27; 8:217. https://doi.org/10.3389/fpubh.2020.00217 18. azlan aa, hamzah mr, sern tj, ayub sh, mohamad e. public knowledge, attitudes and practices towards covid-19: a crosssectional study in malaysia. plos one. 2020 may 21;15(5): e0233668. https://doi.org/10.1371/journal.pone.0233668 19. yue s, zhang j, cao m, chen b. knowledge, attitudes and practices of covid-19 among urban and rural residents in china: a cross-sectional study. j community health. 2020 aug 5:1–6. https://doi.org/10.1007/s10900-020-00877-x 20. pal r, yadav u, grover s, saboo b, verma a, bhadada sk. knowledge, attitudes and practices towards covid-19 among young adults with type 1 diabetes mellitus amid the nationwide lockdown in india: a cross-sectional survey. diabetes res clin pract 2020; 166:108344. https://doi.org/10.1016/j.diabres.2020.108344 21. abdelhafiz as, mohammed z, ibrahim me, ziady hh, alorabi m, ayyad m, sultan ea. knowledge, perceptions, and attitude of egyptians towards the novel coronavirus disease (covid-19). j community health. 2020 oct;45(5):881-890. https://doi.org/10.1007/s10900-020-00827-7 22. akalu y, ayelign b, molla md. knowledge, attitude and practice towards covid-19 among chronic disease patients at addis zemen hospital, northwest ethiopia. infect drug resist. 2020; 13:1949-1960. https://doi.org/10.2147/idr.s258736 23. hussain a, garima t, singh b, ram r, tripti r. knowledge, attitudes, and practices towards covid-19 among nepalese residents: a quick online cross-sectional survey. ajms 2020;11(3):6-1 https://doi.org/10.3126/ajms.v11i3.28485 24. ali jadoo sa, aljunid sm, seher nur sulku, al-dubai sar, wan puteh se, ahmed z, abdul manaf mr, sulong sb, nur am. health system reform from the people’s point of view: development of reliable and valid questionnaire. malaysian journal of public health medicine 2013;13(2):65-76. 25. al-samarrai m, al-rawi r, yaseen s, ali jadoo s. knowledge, attitude, and practice of mothers about complementary feeding for infants aged 6-12 months in anbar province, iraq. journal of ideas in health 2020; 3(1):125-9. https://doi.org/10.47108/jidhealth.vol3.iss1.17 26. ali jadoo sa, sulku sn, aljunid sm, dastan i. validity and reliability analysis of knowledge of, attitude toward and practice of a case-mix questionnaire among turkish healthcare providers. jheor. 2014;2(1):96–107. 27. wetzels r, grasman rp, wagenmakers e-j. a default bayesian hypothesis test for anova designs. am statist. (2012) 66:104– 11 https://doi.org/10.1080/00031305.2012.695956 28. desai m, khan a, kulkarni r, hegde b. the psychological impact of covid-19 and the subsequent social isolation on the general population of karnataka, india. journal of ideas in health.2020;3(special1):190-5. https://doi.org/10.47108/jidhealth.vol3.issspecial1.51 29. ali jadoo sa. covid -19 pandemic is a worldwide typical biopsychosocial crisis. journal of ideas in health.2020;3(2):152-4. https://doi.org/10.47108/jidhealth.vol3.iss2.58 30. de la vega r, ruíz-barquín r, boros s, szabo a. could attitudes toward covid-19 in spain render men more vulnerable than women? global public health. 2020 sep;15(9):1278-1291. https://doi.org/10.1080/17441692.2020.1791212 31. dang ak, le xtt, le ht, tran bx, do ttt, phan htb, et al. evidence of covid-19 impacts on occupations during the first vietnamese national lockdown. annals of global health. 2020;86(1):112. http://doi.org/10.5334/aogh.2976 32. ali jadoo sa, yaseen s, al-samarrai m, mahmood a. patient satisfaction in outpatient medical care: the case of iraq. journal of ideas in health 2020;3(2):176-182. https://doi.org/10.47108/jidhealth.vol3.iss2.44 33. deborah jordan brooks, lydia saad. double whammy: why the underrepresentation of women among workplace and political decision-makers matters in pandemic times. politics & gender, 2020; 1 https://doi.org/10.1017/s1743923x20000628 34. galasso v, pons v, profeta p, becher m, brouard s, foucault m. gender differences in covid-19 attitudes and behavior: panel evidence from eight countries. proceedings of the national academy of sciences 2020; 117 (44): 27285-27291; doi: 10.1073/pnas.2012520117 35. who (2020), statement – older people are at highest risk from covid-19, but all must act to prevent community spread, http://www.euro.who.int/en/health-topics/healthemergencies/coronavirus-covid-19/statements/statement-olderpeople-are-at-highest-risk-from-covid-19,-but-all-must-act-toprevent-community-spread. 36. ali jadoo sa, aljunid sm, dastan i, tawfeeq rs, mustafa ma, ganasegeran k, aldubai sa. job satisfaction and turnover intention among iraqi doctors-a descriptive cross-sectional multicenter study. hum resour health2015; 13:21. https://doi.org/10.1186/s12960-015-0014-6 37. al-samarrai ma, ali jadoo sa. iraqi medical students are still planning to leave after graduation. journal of ideas in health 2018;1(1):23-8. https://doi.org/10.47108/jidhealth.vol1.iss1.5 38. ali jadoo sa, torun p, dastan i, al-samarrai m. impact of conflict related and workplace related violence on job satisfaction among physicians from iraq a descriptive cross-sectional multicentre study. journal of ideas in health 2018;1(1):14-2. https://doi.org/10.47108/jidhealth.vol1.iss1.4