{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T18:13:42Z","timestamp":1788200022565,"version":"build-2803163510"},"reference-count":43,"publisher":"Public Library of Science (PLoS)","issue":"8","license":[{"start":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T00:00:00Z","timestamp":1788134400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100004484","name":"Tehran University of Medical Sciences and Health Services","doi-asserted-by":"publisher","award":["75492"],"award-info":[{"award-number":["75492"]}],"id":[{"id":"10.13039\/501100004484","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100004484","name":"Tehran University of Medical Sciences and Health Services","doi-asserted-by":"publisher","award":["73611"],"award-info":[{"award-number":["73611"]}],"id":[{"id":"10.13039\/501100004484","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:p>Non-communicable diseases (NCDs) account for more than 81% of all deaths in Iran and impose a substantial burden on the national health system. Although Iran has implemented multiple initiatives, including the World Health Organization\u2019s STEPwise Approach to NCD Risk Factor Surveillance (STEPS), to monitor NCD risk factors, critical gaps remain in longitudinal outcome assessment, particularly in the post\u2013COVID-19 period, for which national data are limited. Moreover, in the context of declining fertility rates and demographic challenges in Iran, emerging evidence suggests that metabolic and lifestyle-related NCD risk factors are associated with impaired reproductive health, fertility potential, and childbearing behaviors. Therefore, the assessment of reproductive outcomes within population-based NCD surveillance frameworks addresses an important knowledge gap in Iran. The Iran STEPS Follow-Up Cohort (ISFUC) is established to evaluate mortality, health outcomes related to NCD risk factors, and fertility related outcomes using population-based data from the 2021 STEPS survey. The ISFUC is a population-based cohort study established through follow-up of participants from the nationally representative 2021 Iranian STEPS survey. The 2021 STEPS survey constitutes the baseline assessment, whereas ISFUC represents the subsequent follow-up phase. Baseline assessments were collected through interviewer-administered questionnaires, standardized physical measurements, and laboratory analyses of blood and urine biomarkers. Follow-up began in 4 April 2025, a five-years interval after baseline, and is ongoing. It will be conducted through structured telephone interviews by trained staff after renewed verbal consent. Study outcomes include all-cause mortality, healthcare utilization, injuries, reproductive health indicators, fertility-related behaviors and attitudes, and use of governmental childbearing support policies. Mortality outcomes are validated through linkage with the national death registry. Questionnaire validity was ensured using expert review, the Content Validity Ratio, and the Content Validity Index methods. By linking comprehensive 2021 STEPS baseline data with follow-up information on health, healthcare utilization, mortality, and reproductive outcomes, ISFUC provides a national platform for investigating Iran\u2019s evolving epidemiological and demographic health challenges.<\/jats:p>","DOI":"10.1371\/journal.pone.0356802","type":"journal-article","created":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T17:23:04Z","timestamp":1788196984000},"page":"e0356802","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Mortality and health outcomes associated with non-communicable disease risk factors: Protocol for the IRAN-STEPS Follow-Up Cohort (ISFUC) based on the 2021 national survey"],"prefix":"10.1371","volume":"21","author":[{"given":"Hosein","family":"Ataei-Goujani","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarmad","family":"Salehi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pardis","family":"Zarepour","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0188-9721","authenticated-orcid":true,"given":"Ozra","family":"Tabatabaei-Malazy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nazila","family":"Rezaei","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mina","family":"Mirzad","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anis","family":"Gharajeh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samaneh","family":"Akbarpour","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3875-3871","authenticated-orcid":true,"given":"Yosra","family":"Azizpour","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,8,31]]},"reference":[{"issue":"10513","key":"pone.0356802.ref001","doi-asserted-by":"crossref","first-page":"1811","DOI":"10.1016\/S0140-6736(25)01917-8","article-title":"Global burden of 292 causes of death in 204 countries and territories and 660 subnational locations, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023","volume":"406","year":"2025","journal-title":"Lancet"},{"issue":"1","key":"pone.0356802.ref002","doi-asserted-by":"crossref","first-page":"8975","DOI":"10.1038\/s41598-025-92897-7","article-title":"Non-communicable diseases challenges and opportunities in Iran: a qualitative study","volume":"15","author":"Z Torabi","year":"2025","journal-title":"Sci Rep"},{"key":"pone.0356802.ref003","unstructured":"(IHME) IfHMaE. Global Burden of Disease (GBD) Results Tool: IHME. 2023. Available from: https:\/\/vizhub.healthdata.org\/gbd-results\/"},{"key":"pone.0356802.ref004","doi-asserted-by":"crossref","first-page":"105839","DOI":"10.1016\/j.puhe.2025.105839","article-title":"Barriers to engagement in non-communicable disease prevention and public health care programs in Iran: a qualitative study","volume":"246","author":"N Zarei Jelyani","year":"2025","journal-title":"Public Health"},{"issue":"1","key":"pone.0356802.ref005","doi-asserted-by":"crossref","first-page":"2275","DOI":"10.1186\/s12889-021-12326-y","article-title":"Non-communicable diseases in the southwest of Iran: profile and baseline data from the Shahrekord PERSIAN Cohort Study","volume":"21","author":"A Ahmadi","year":"2021","journal-title":"BMC Public Health"},{"issue":"1","key":"pone.0356802.ref006","doi-asserted-by":"crossref","first-page":"74","DOI":"10.2105\/AJPH.2015.302962","article-title":"The World Health Organization STEPwise Approach to Noncommunicable Disease Risk-Factor Surveillance: Methods, Challenges, and Opportunities","volume":"106","author":"L Riley","year":"2016","journal-title":"Am J Public Health"},{"issue":"9","key":"pone.0356802.ref007","doi-asserted-by":"crossref","first-page":"591","DOI":"10.34172\/aim.2022.94","article-title":"Prevalence of Diabetes and Prediabetes, and Achievements in Diabetes Control in Iran; The Results of the STEPS of 2016","volume":"25","author":"S Shahraz","year":"2022","journal-title":"Arch Iran Med"},{"issue":"1","key":"pone.0356802.ref008","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1186\/s12889-024-21168-3","article-title":"Evaluation of the effectiveness of the Iran-package of essential non-communicable disease (IraPEN) program in reducing cardiovascular disease risk in pilot areas","volume":"25","author":"S Derakhshan","year":"2025","journal-title":"BMC Public Health"},{"key":"pone.0356802.ref009","doi-asserted-by":"crossref","DOI":"10.4178\/epih.e2023027","article-title":"National trends and projection of chronic kidney disease incidence according to etiology from 1990 to 2030 in Iran: a Bayesian age-period-cohort modeling study","volume":"45","author":"F Shahbazi","year":"2023","journal-title":"Epidemiol Health"},{"key":"pone.0356802.ref010","volume-title":"Iran (Islamic Republic of), Diabetes country report 2000 \u2014 2050","year":"2024"},{"issue":"2","key":"pone.0356802.ref011","first-page":"82","article-title":"The future of Iran\u2019s population: balancing aging trends and fertility rates","volume":"17","author":"L Kashani","year":"2025","journal-title":"Avicenna J Med Biotechnol"},{"issue":"1","key":"pone.0356802.ref012","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1007\/s13679-025-00629-9","article-title":"When weight matters: how obesity impacts reproductive health and pregnancy-a systematic review","volume":"14","author":"K Barbouni","year":"2025","journal-title":"Curr Obes Rep"},{"issue":"17","key":"pone.0356802.ref013","doi-asserted-by":"crossref","DOI":"10.3390\/ijms26178574","article-title":"The impact of lifestyle on reproductive health: microbial complexity, hormonal dysfunction, and pregnancy outcomes","volume":"26","author":"E Barraza-Ortega","year":"2025","journal-title":"Int J Mol Sci"},{"key":"pone.0356802.ref014","doi-asserted-by":"crossref","first-page":"1582039","DOI":"10.3389\/fcell.2025.1582039","article-title":"Impact of hyperglycaemia on cellular microenvironment and function of endometrium and uterine tube: scoping review focused on infertility in diabetic women","volume":"13","author":"P Jackuliak","year":"2025","journal-title":"Front Cell Dev Biol"},{"issue":"5","key":"pone.0356802.ref015","doi-asserted-by":"crossref","first-page":"1067","DOI":"10.1016\/j.fertnstert.2020.05.041","article-title":"Couples\u2019 prepregnancy body mass index and time to pregnancy among those attempting to conceive their first pregnancy","volume":"114","author":"Y Zhang","year":"2020","journal-title":"Fertil Steril"},{"issue":"2","key":"pone.0356802.ref016","doi-asserted-by":"crossref","first-page":"505","DOI":"10.1016\/j.fertnstert.2021.02.009","article-title":"Fertility outcomes in women with pre-existing type 2 diabetes-a prospective cohort study","volume":"116","author":"K Mattsson","year":"2021","journal-title":"Fertil Steril"},{"issue":"1","key":"pone.0356802.ref017","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1080\/0167482X.2020.1778666","article-title":"Life stressors, hypertensive disorders of pregnancy, and preterm birth","volume":"43","author":"N Morgan","year":"2022","journal-title":"J Psychosom Obstet Gynaecol"},{"issue":"1","key":"pone.0356802.ref018","doi-asserted-by":"crossref","first-page":"1777","DOI":"10.1186\/s12889-025-22856-4","article-title":"Cohort profile: the Korean National Health Examination Baseline (KNHEB) cohort for longitudinal health monitoring in South Korea","volume":"25","author":"S Jo","year":"2025","journal-title":"BMC Public Health"},{"issue":"1","key":"pone.0356802.ref019","doi-asserted-by":"crossref","first-page":"1090","DOI":"10.1186\/s12889-016-3760-z","article-title":"A cohort study protocol to analyze the predisposing factors to common chronic non-communicable diseases in rural areas: Fasa Cohort Study","volume":"16","author":"M Farjam","year":"2016","journal-title":"BMC Public Health"},{"issue":"1","key":"pone.0356802.ref020","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1093\/ije\/dyp161","article-title":"Cohort Profile: The Golestan Cohort Study--a prospective study of oesophageal cancer in northern Iran","volume":"39","author":"A Pourshams","year":"2010","journal-title":"Int J Epidemiol"},{"issue":"2","key":"pone.0356802.ref021","doi-asserted-by":"crossref","DOI":"10.2196\/resprot.6050","article-title":"Rationale and design of a genetic study on cardiometabolic risk factors: protocol for the Tehran Cardiometabolic Genetic Study (TCGS)","volume":"6","author":"MS Daneshpour","year":"2017","journal-title":"JMIR Res Protoc"},{"issue":"3","key":"pone.0356802.ref022","doi-asserted-by":"crossref","first-page":"697","DOI":"10.1093\/ije\/dyx231","article-title":"Cohort Profile: The Yazd Health Study (YaHS): a population-based study of adults aged 20-70 years (study design and baseline population data)","volume":"47","author":"M Mirzaei","year":"2018","journal-title":"Int J Epidemiol"},{"issue":"4","key":"pone.0356802.ref023","doi-asserted-by":"crossref","first-page":"647","DOI":"10.1093\/aje\/kwx314","article-title":"Prospective Epidemiological Research Studies in Iran (the PERSIAN Cohort Study): rationale, objectives, and design","volume":"187","author":"H Poustchi","year":"2018","journal-title":"Am J Epidemiol"},{"issue":"1","key":"pone.0356802.ref024","doi-asserted-by":"crossref","first-page":"913","DOI":"10.1007\/s40200-022-01143-8","article-title":"The first nationally and sub-nationally representative non-communicable diseases cohort study in Iran: Iran Cohort Study (ICS) protocol","volume":"22","author":"S Djalalinia","year":"2022","journal-title":"J Diabetes Metab Disord"},{"issue":"9","key":"pone.0356802.ref025","first-page":"608","article-title":"Protocol design for large-scale cross-sectional studies of surveillance of risk factors of non-communicable diseases in Iran: STEPs 2016","volume":"20","author":"S Djalalinia","year":"2017","journal-title":"Arch Iran Med"},{"key":"pone.0356802.ref026","first-page":"174","article-title":"The effect of the COVID-19 pandemic on non-communicable disease prevention and management services in the primary health care system of Iran","volume":"36","author":"M Afkar","year":"2022","journal-title":"Med J Islam Repub Iran"},{"issue":"9","key":"pone.0356802.ref027","doi-asserted-by":"crossref","first-page":"634","DOI":"10.34172\/aim.2022.99","article-title":"Protocol Design for surveillance of risk factors of non-communicable diseases during the COVID-19 pandemic: an experience from Iran STEPS survey 2021","volume":"25","author":"S Djalalinia","year":"2022","journal-title":"Arch Iran Med"},{"issue":"12","key":"pone.0356802.ref028","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0296292","article-title":"Can phone surveys be representative in low- and middle-income countries? An application to Myanmar","volume":"18","author":"I Lambrecht","year":"2023","journal-title":"PLoS One"},{"issue":"1","key":"pone.0356802.ref029","doi-asserted-by":"crossref","first-page":"32","DOI":"10.1186\/s12963-021-00258-z","article-title":"A cost study for mobile phone health surveys using interactive voice response for assessing risk factors of noncommunicable diseases","volume":"19","author":"AI Vecino-Ortiz","year":"2021","journal-title":"Popul Health Metr"},{"issue":"5","key":"pone.0356802.ref030","doi-asserted-by":"crossref","DOI":"10.2196\/jmir.7302","article-title":"Moving the agenda on noncommunicable diseases: policy implications of mobile phone surveys in low and middle-income countries","volume":"19","author":"GW Pariyo","year":"2017","journal-title":"J Med Internet Res"},{"issue":"2","key":"pone.0356802.ref031","article-title":"Using mobile phone data collection tool, surveda, for noncommunicable disease surveillance in five low- and middle-income countries","volume":"12","author":"Y Song","year":"2020","journal-title":"Online J Public Health Inform"},{"key":"pone.0356802.ref032","unstructured":"Iran ICAo. Support of Family and Youthful Population Act. 2021."},{"issue":"1","key":"pone.0356802.ref033","doi-asserted-by":"crossref","first-page":"1131","DOI":"10.1186\/s12889-023-16044-5","article-title":"Development of the Malay Language of understanding, attitude, practice and health literacy questionnaire on COVID-19 (MUAPHQ C-19): content validity & face validity analysis","volume":"23","author":"I Dalawi","year":"2023","journal-title":"BMC Public Health"},{"issue":"2","key":"pone.0356802.ref034","doi-asserted-by":"crossref","first-page":"165","DOI":"10.15171\/jcs.2015.017","article-title":"Design and implementation content validity study: development of an instrument for measuring patient-centered communication","volume":"4","author":"V Zamanzadeh","year":"2015","journal-title":"J Caring Sci"},{"issue":"8","key":"pone.0356802.ref035","doi-asserted-by":"crossref","first-page":"181","DOI":"10.3390\/tropicalmed9080181","article-title":"The content validity of an instrument that measures health-seeking behavior for tuberculosis among people living with HIV in India","volume":"9","author":"AM Jacob","year":"2024","journal-title":"Trop Med Infect Dis"},{"issue":"4","key":"pone.0356802.ref036","article-title":"Dealing with confounding in observational studies","volume":"49","author":"C Fumo-Dos-Santos","year":"2023","journal-title":"J Bras Pneumol"},{"issue":"1","key":"pone.0356802.ref037","doi-asserted-by":"crossref","first-page":"110","DOI":"10.2307\/2533101","article-title":"Regression models for mixed discrete and continuous responses with potentially missing values","volume":"53","author":"GM Fitzmaurice","year":"1997","journal-title":"Biometrics"},{"key":"pone.0356802.ref038","unstructured":"Obesity Atlas 2025. 2025."},{"issue":"7","key":"pone.0356802.ref039","doi-asserted-by":"crossref","first-page":"1189","DOI":"10.1007\/s40520-020-01601-4","article-title":"The potential long-term impact of the COVID-19 outbreak on patients with non-communicable diseases in Europe: consequences for healthy ageing","volume":"32","author":"K Palmer","year":"2020","journal-title":"Aging Clin Exp Res"},{"issue":"7","key":"pone.0356802.ref040","first-page":"899","article-title":"Non-communicable diseases during the COVID-19 pandemic and beyond","volume":"7","author":"X-F Pan","year":"2021","journal-title":"Engineering (Beijing)"},{"issue":"8","key":"pone.0356802.ref041","doi-asserted-by":"crossref","first-page":"965","DOI":"10.3390\/biom14080965","article-title":"The significance of endothelial dysfunction in long COVID-19 for the possible future pandemic of chronic kidney disease and cardiovascular disease","volume":"14","author":"H Yanai","year":"2024","journal-title":"Biomolecules"},{"issue":"9","key":"pone.0356802.ref042","doi-asserted-by":"crossref","first-page":"906","DOI":"10.1002\/jac5.70054","article-title":"Research and scholarly methods: Mitigating information bias","volume":"8","author":"GL Cochran","year":"2025","journal-title":"J Am Coll Clin Pharm"},{"issue":"5","key":"pone.0356802.ref043","doi-asserted-by":"crossref","DOI":"10.2196\/jmir.7329","article-title":"Health surveys using mobile phones in developing countries: automated active strata monitoring and other statistical considerations for improving precision and reducing biases","volume":"19","author":"A Labrique","year":"2017","journal-title":"J Med Internet Res"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0356802","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T17:23:10Z","timestamp":1788196990000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0356802"}},"subtitle":[],"editor":[{"given":"Fatemeh","family":"Zarei","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,8,31]]},"references-count":43,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8,31]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0356802","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,31]]}}}