Public health improvement in Iran—lessons from the last 20 years

The challenges of voluntary care provision for hospitalized patients with COVID-19: A qualitative study of the public volunteers' experiences

INTRODUCTION

During the COVID-19 pandemic, there was a remarkable increase in public volunteering for the care of hospitalized patients. They faced challenges during their voluntary care provision. This study aimed at exploring public volunteers' experiences of the challenges of the voluntary care provision to hospitalized patients with COVID-19.

METHODS

A descriptive qualitative study with an inductive content analysis method was conducted, 2022-2023. Eighteen public volunteers providing care to hospitalized patients with COVID-19 were purposefully selected among 10 hospitals, specialized in COVID-19 care in Tehran and Shiraz, Iran. Data were collected over 7 months through in-depth semistructured interviews and concurrently analyzed using conventional content analysis methods.

FINDINGS

The challenges of voluntary care provision to hospitalized patients with COVID-19 were illustrated in five main categories, each with two subcategories. The categories included structural challenges, interpersonal conflicts, financial constraints, covert participation and the deteriorating condition of care provision. The subcategories comprised lack of volunteer recruitment bases, ineffective organization of voluntary activities, pervasive distrust, heightened risk of clinical errors, conflicts between volunteer commitments and primary occupation, lack of financial support, lack of family support, isolation by friends, mental trauma and physical exhaustion.

CONCLUSION

Public volunteers encounter diverse challenges while providing care to hospitalized patients with COVID-19, which negatively impacts their motivation to serve. By addressing these challenges, we can create a more supportive environment for volunteers and enhance the quality of care provided to patients during public health emergencies. Identifying such challenges can assist healthcare managers and policymakers develop effective strategies to mitigate mounting difficulties and enhance volunteer services, thereby improving the overall quality of care provided to patients during public health crises.

PATIENT CONTRIBUTIONS

Participants were identified and recruited after the study objectives were explained in person to the managers. The participants were approached and interviewed by one author. Participation was voluntary and the participants did not receive any financial compensation for their time.

Sustainable political commitment is necessary for institutionalizing community participation in health policy-making: Insights from Iran

BACKGROUND

Community participation is currently utilized as a national strategy to promote public health and mitigate health inequalities across the world. While community participation is acknowledged as a civic right in the Constitution of Iran and other related upstream documents, the government has typically failed in translating, integrating and implementing community participation in health system policy. The present study was conducted to determine the level of public voice consideration within the health policy in Iran and address fundamental interventions required to promote the public voice in the context of Islamic Republic of Iran (IRI). This study has originality because there is no study that addresses the requirements of institutionalizing community participation especially in low-middle-income countries, so Iran's experience can be useful for other countries.

METHODS

Methodologically, this study utilized a multi-method and multi-strand sequential research design, including qualitative, comparative and documentary studies. In the first phase, the current level of community participation in the health policy cycle of Iran was identified using the International Association for Public Participation (IAP2) spectrum. In the second phase, a comparative study was designed to identify relevant interventions to promote the community participation level in the selected countries under study. In the third phase, a qualitative study was conducted to address the barriers, facilitators and strategies for improving the level of public participation. Accordingly, appropriate interventions and policy options were recommended. Interventions were reviewed in a policy dialogue with policy-makers and community representatives, and their effectiveness, applicability and practical feasibility were evaluated.

RESULTS

Based on the IAP2 spectrum, the level of community participation in the health policy-making process is non-participation, while empowerment is set at the highest level in the upstream documents. Moreover, capacity-building, demand, mobilization of the local population, provision of resources and setting a specific structure were found to be among the key interventions to improve the level of community participation in Iran's health sector. More importantly, "political will for action" was identified as the driving force for implementing the necessary health interventions.

CONCLUSIONS

To sum up, a paradigm shift in the governing social, economic and political philosophy; establishing a real-world and moral dialogue and communication between the government and the society; identifying and managing the conflicts of interest in the leading stockholders of the healthcare system; and, more importantly, maintaining a stable political will for action are integral to promote and institutionalize participatory governance in the health sector of Iran. All of the above will lead us to scheme, implement and institutionalize suitable interventions for participatory governance in health and medicine.

Prevalence of mental disorders among middle-aged population of primary healthcare centers in Northeastern Iran

BACKGROUND

Primary healthcare centers (PHCs) serve as the cornerstone of accessible medical services in society, playing a crucial role in screening, detecting, and treating various health issues. This study aimed to investigate the prevalence of psychiatric disorders in middle-aged individuals who refer to PHCs and the potential of PHCs in diagnosing mental disorders.

METHODS

This cross-sectional study was implemented at PHCs under the supervision of Mashhad University of Medical Sciences (MUMS) in northeast Iran in 2018. The enrolled subjects were middle-aged adults who had electronic medical records in SINA, an integrated health management system, and the electronic medical records of MUMS. The prevalence of psychiatric disorders by type and their relationship with demographic information was evaluated by a Chi-square test using SPSS 22.

RESULTS

This study involved 218,341 middle-aged participants. Prevalence of psychiatric disorders was 8.59%, and depression (53.72%) and anxiety (42.02%) were the most common psychiatric disorders in both males and females. The prevalence of mental disorders was significantly higher in females than in males (88.18% vs. 18.81%; P < 0.0001). Indeed, a significant higher prevalence of depression, anxiety, somatoform, childhood psychiatric disorder, and bipolar disorders was observed in females compared to males (P < 0.05). In addition, individuals between the age of 45-60 years, and those from rural areas showed more prevalence of mental disorders than others, but these differences were not significant.

CONCLUSIONS

Considering the previous studies in Iran, the prevalence of mental disorders among patients presenting to PHCs was noticeably lower than expected rates. It seems probable that this huge difference is due to poor screening and detection of mental illness in PHCs of MUMS. It is recommended that health policymakers pursue specific measures to make PHCs more helpful for people with mental health problems in the community.

Network analysis of Iranian's health insurance ecosystem before and after the introduction of Universal Health Insurance law

INTRODUCTION

The policy-making process in health reform is challenging due to the complexity of organizations, overlapping roles, and diversity of responsibilities. The present study aims to investigate and analyze the network of actors in the Iran health insurance ecosystem regarding the laws before and after the adoption of the Universal Health Insurance (UHI).

METHODS

The present study was done by sequential exploratory mixed method research, consisting of two distinct phases. During the qualitative phase, the actors and issues pertaining to the laws of the Iranian health insurance ecosystem from 1971 to 2021 were identified through a systematic search of the laws and regulations section of the Research Center of the Islamic Legislative Assembly website. Qualitative data was analyzed in three steps using directed content analysis. During the quantitative phase, in order to draw the communication network of the actors in Iran's health insurance ecosystem, the data related to the nodes and links of the networks was collected. The communication networks were drawn using Gephi software and the micro- and macro-indicators of network were calculated and analyzed.

RESULTS

There were 245 laws and 510 articles identified in the field of health insurance in Iran from 1971 to 2021. Most of the legal comments were on financial matters and credit allocation, and the payment of premiums. The number of actors before and after the enactment of the UHI Law was 33 and 137, respectively. The Ministry of Health and Medical Education and the Iran Health Insurance Organization were found the two main actors in the network before and after the approval of this law.

CONCLUSIONS

Adopting a UHI Law and delegating various legal missions and tasks, often with support to the health insurance organization, have facilitated the achievement of the law objectives. However, it has created a poor governance system and a network of actors with low coherence. Based on the results of the study, it is suggested to reduce actor roles and separate them for better governance and to prevent corruption in health insurance ecosystem. Introducing knowledge and technology brokers can be effective in strengthening governance and filling the structural gaps between actors.

Public-private partnership in primary health care: an experience from Iran

AIM

The aim of this paper is to introduce the experience of applying public-private partnership (PPP) in providing primary health care (PHC) in East Azerbaijan Province (EAP), Iran.

BACKGROUND

Moving toward the Universal Health Coverage (UHC) involves using of all health-related resources. Certainly, one of the key strategies for achieving UHC is PPP. Since 2015, a PPP in PHC policy has begun in EAP as a major strategy for strengthening the health system and achieving UHC.

METHODS

In this case study, data were collected through interviews with stakeholders, document analysis, reviewing of health indexes and published studies. The data were analyzed using content analysis.

FINDING

PPP in PHC policy was designed and implemented in EAP with the aim of social justice, strengthening the health system and achieving UHC in the framework of health complexes (HCs). HCs provide a defined service package according to the contract. The reimbursement method is a combination of per capita, fee for services and bonus methods. Part of the payments is fixed and the other part is based on the pay for quality system and paid according to the results of monitoring and evaluation. According to the study results, the most important strength of the plan is to improve access to services, especially in marginalized areas. The main weakness is not providing infrastructures before the implementation of the plan, and the most important challenges are financial, political and organizational unsustainability and, sometimes, poor cooperation by the other organizations. The findings show that PPP in PHC in EAP is an effective strategy to provide social justice, implement family practice and achieve UHC.

The analysis of National Health Accounts and financial communications network in Iran health insurance ecosystem

BACKGROUND

One of the major reforms in the health system of any country is the financing reform. Network analysis as a practical method for investigating complex systems allows distinguishing prominent actors in the relation networks. Leading to the identification of the effective actors and key links between them, the analysis of financial networks helps policymakers to implement reformations by providing appropriate evidence. This study aimed to design and analyze the network of National Health Accounts (NHA) and the cost network in the Iran health insurance ecosystem.

METHODS

The present study is a network analysis study based on the data from NHA, and both cost and referral rates that was conducted in 2021. Data, which was for the years 2014 to 2018 and related to NHA, was collected from the Statistical Center of Iran, and cost data and referral rates, which were both related to Basic Insurance Organizations (BIOs), were collected from statistical yearbooks. To analyze the network and identify the key actors, macro indicators, such as network size and density, and micro indicators, such as centrality indicators and the combined importance index, were used.

RESULTS

In the financing of the health system in Iran, insurance organizations, as agents and sources of financing, do not have a very good position, so direct payments have become a key element in the network of NHA. Providing treatment-oriented services is quite prior. Regarded to health services, hospitals and outpatient services, such as pharmacies and physicians are the key elements of cost and referral rates respectively.

CONCLUSION

Consisting of several organizations with different insurance policies and being supervised under different ministries, Iran's health financing system lacks a coherent structure. It is suggested to create a coherent insurance system by creating a single governance system and paying more attention to health-oriented instead of treatment-oriented services. The health insurance ecosystem has become a health-oriented system to reduce the direct payments as well as cost management.

Comparison of challenges of the nursing educational system in Iran and Turkey

OBJECTIVES

This study compares the challenges of the nursing educational system in Iran and Turkey at the undergraduate, postgraduate, and Ph.D. levels.

DESIGN

A narrative review.

DATA SOURCES

A comprehensive computer-based search was conducted in PubMed, Scopus, ProQuest, ISI web of knowledge, Cochrane, Google Scholar, and Science direct databases, without time limit, until May 2022. Finally, 31 article were finally included in the study. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines were used.

RESULTS

Some challenges of the nursing educational system were common to the two countries such as: problems in the student enrollment system, the need to add courses to improve critical thinking skills and problem solving and creativity, lack of part-time courses for postgraduate and doctoral students, lack of attention to training community health students, employment of students in hospitals without assessment of clinical skills, lack of job opportunities for PhD students in hospitals. In Turkey, compared to Iran, there are strengths in the nursing educational system, including: have an accreditation program, giving importance to the discussion of research and evidence-based care in undergraduate and strengthening the clinical skills of doctoral students.

CONCLUSIONS

Iranian policymakers can use the strengths of the Turkish nursing education system, which is close to Iran in terms of context, to help improve this education system. Given the many challenges the two countries face in this regard, we suggest that by comparing and modeling the nursing education system of leading countries in this field such, both Iran and Turkey take effective steps to grow and improve the nursing education system.

Influencing factors on the tendency of general practitioners to join in urban family physician program: a cross-sectional survey on Iranian physicians

Background

Urban family physician program (UFPP) is initiated as pilot by policy makers as a main reform in future of primary health care in Iran. Despite an ongoing pilot implementation of this program from 2012, it remains a main question about providing sufficient number of general practitioners (GPs). This study aimed to investigate the factors which affect GPs’ decision to join in the UFPP.

Methods

In this national cross-sectional study a sample of 666 GPs, using convenience sampling, filled a self-report questionnaire. The multivariate logistic regression was applied to explore the demographic, practice and views determinants of the tendency of GPs to join in the UFPP.

Results

More than half of GPs (58.6%) participated in the study had a positive tendency to join in the UFPP. Older GPs (adjusted OR = 3.72; 95%CI 1.05–13.09), working in public sector (adjusted OR = 2.26; 95%CI 1.43–3.58), lower income level (adjusted OR = 6.69; 95%CI 2.95–15.16), higher economic expectations (adjusted OR = 2.08; 95%CI 1.19–3.63), and higher satisfaction from medicine profession (adjusted OR = 2.00; 95%CI 1.14–3.51) were the main factors which increased the GPs tendency to enter in UFPP.

Conclusions

Decision for joining in the program is mainly affected by GPs’ economic status. This clarifies that if the program can make them closer to their target income, they would be more likely to decide for joining in the program.

A Regionalization Model to Increase Equity of Access to Maternal and Neonatal Care Services in Iran

Objectives

Access to maternal and neonatal care services (MNCS) is an important goal of health policy in developing countries. In this study, we proposed a 3-level hierarchical location-allocation model to maximize the coverage of MNCS providers in Iran.

Methods

First, the necessary criteria for designing an MNCS network were explored. Birth data, including gestational age and birth weight, were collected from the data bank of the Iranian Maternal and Neonatal Network national registry based on 3 service levels (I, II, and III). Vehicular travel times between the points of demand and MNCS providers were considered. Alternative MNCS were mapped in some cities to reduce access difficulties.

Results

It was found that 130, 121, and 86 MNCS providers were needed to respond to level I, II, and III demands, respectively, in 373 cities. Service level III was not available in 39 cities within the determined travel time, which led to an increased average travel time of 173 minutes to the nearest MNCS provider.

Conclusions

This study revealed inequalities in the distribution of MNCS providers. Management of the distribution of MNCS providers can be used to enhance spatial access to health services and reduce the risk of neonatal mortality and morbidity. This method may provide a sustainable healthcare solution at the policy and decision-making level for regional, or even universal, healthcare networks.

The influential factors for achieving universal health coverage in Iran: a multimethod study

BACKGROUND

The initial purpose of healthcare systems around the world is to promote and maintain the health of the population. Universal Health Coverage (UHC) is a new approach by which a healthcare system can reach its goals. World Health Organization (WHO) emphasized maximum population coverage, health service coverage, and financial protection, as three dimensions of UHC. In progress for achieving UHC, recognizing the influential factors allows us to accelerate such progress. Therefore, this study aimed to identify the influential factors to achieve UHC in Iran.

METHODS

This is a multi-method study was conducted in four phases: First, a systematic review of the literature was conducted to identify the factors in PubMed, Web of Science, Embase, Scopus, ProQuest, Cochrane library, and Science Direct databases, and hand searching google scholar search engine. For recognizing the unmentioned factors, a qualitative study consisting of one session of Focus Group Discussion (FGD) and five semi-structured interviews with experts was designed. The extracted factors were merged and categorized by round table discussion. Finally, the pre-categorized factors were refined and re-categorized under the health system's control knobs framework during three expert panel sessions.

RESULTS

Finally, 33 studies were included. Eight hundred two factors were extracted through systematic review and 96 factors through FGD and interviews (totally, 898). After refining them by the experts' panel, 105 factors were categorized within the control knob framework (financing 19, payment system7, Organization 23, regulation and supervision 33, Behavior 11, and Others 12). The majority of the identified factors were related to the "regulation and supervision" dimension, whilst the "payment system" entailed the fewest. The political commitment during political turmoil, excessive attention to the treatment, referral system, paying out of pocket(OOP) and protection against high costs, economic growth, sanctions, conflict of interests, weakness of the information system, prioritization of services, health system fragmented, lack of managerial support and lack of standard benefits packages were identified as the leading factors on the way to UHC.

CONCLUSION

Considering the distinctive role of the context in policymaking, the identification of the factors affecting UHC accompanying by the countries' experiences about UHC, can boost our speed toward it. Moreover, adopting a long-term plan toward UHC based on these factors and the robust implementation of it pave the way for Iran to achieve better outcomes comparing to their efforts.

Assessing the Preparedness of Healthcare Facilities for Disasters and Emergencies in Damghan, Iran

OBJECTIVES

Iran is exposed to a wide range of natural and man-made hazards. Health-care facilities can play a significant role in providing life-saving measures in the minutes and hours immediately following the impact or exposure. The aim of this study was to determine the preparedness of health-care facilities in disasters and emergencies.

METHODS

This cross-sectional study was conducted in Damghan, Semnan Province, in 2019. The samples consisted of all the 11 health-care facilities located in Damghan County. A developed checklist was used to collect the data, including 272 questions in 4 sections: understanding threatening hazards, functional, structural, and nonstructural vulnerability of health-care facilities. The data were analyzed using SPSS 21.

RESULTS

The results revealed that the health-care facilities were exposed to 22 different natural and man-made hazards throughout the county. The total level of preparedness of the health-care centers under assessment was 45.8%. The average functional, structural, and nonstructural vulnerability was assessed at 49.3%, 31.6%, and 56.4%, respectively.

CONCLUSIONS

Conducting mitigation measures is necessary for promoting the functional and structural preparedness. Disaster educational programs and exercises are recommended among the health staff in health-care facilities.

How do primary care providers work together in the Iranian PHC system?

Background: Providing coordinated services and forming appropriate cooperation among the members of the health team have a significant impact on other aspects of service provision, including accessibility and continuity of services. Methods: In this study information was obtained from a national study titled, "Evaluation of Primary Health Care in Iran", and framework analysis was conducted from the perspective of interprofessional cooperation status using the Amour model based on 5 underlying concepts of sharing, partnership, power, interdependency, and process. This is a mixed-method study of the transformative sequential type. In this study triangulation method was used, and data were collected by the Primary Care Evaluation Tool (PCET), interviewing experts and executive directors, and systematic review of the Primary Health Care (PHC) challenges in Iran. Results: The challenges of the PHC system in Iran are analyzed for providing coordinated care in the form of multidisciplinary teamwork based on the Amour model. The corresponding solutions for improving challenges of the concept are also presented. Conclusion: Based on the findings of this study the followings are suggested: sharing a collective specialized outlook; designing an integrated information system; improving the educational system through providing on-the-need academic education; strengthening the cooperation of community representatives and people's trustees in providing care; developing interdepartmental partnerships with related organizations with collective interests; moderating the workload of human resources; using electronic health records and automated referral of individuals in addition to appropriate training and promoting the culture from the existing philosophy of primary health care; highlighting the role of service providers as members of the care team; eliminating factors causing instability of suppliers, plans, and programs; and stability in the management approach despite changes in senior management.

Comparing Growth and Development of Low and Normal Birth Weight Children at Age of 60 Months

Background: Low birth weight (LBW < 2500 g) is one of the most serious problems in today’s world. It is also a predictor for mortality and stunting. Objectives: This study aimed to compare the growth and development at the age of 60 months between children born with low and normal birth weight in Shiraz, Iran. Methods: This study is part of the Fars birth cohort (FBC) study with the data of children who were born in 2011. We called mothers and asked them to bring their children to the FBC clinic for further evaluation. We also determined the level of development at the age of 60 months for each child by using the Ages and Stages questionnaire (ASQ) for the children. Results: Of the children, 304 (51.4%) were girls. Most of them had normal birth weight (93.2%), had exclusive breastfeeding for five to six months (79.9%), and did not have any chronic diseases (77.8%). Growth indices at the age of 60 months were significantly higher in children with normal birth weight than in their LBW peers (P < 0.001). However, we found no significant difference in children’s development at the age of 60 months between normal and low birth weight children. Conclusions: Although growth indices of children at the age of 60 months were higher in children with normal birth weight, we found no significant difference in children’s development at the age of 60 months between normal and low birth weight children.

Factors related to delay in initiating post-exposure prophylaxis for rabies prevention among animal bite victims: a cross-sectional study in Northwest of Iran

OBJECTIVES

The aim of the present study was to identify factors associated with h delayed initiation of post-exposure prophylaxis (PEP) among animal bite victims.

METHODS

This cross-sectional study assessed biting patterns among 3032 cases that were referred to Tabriz Rabies Center. The delay was described as the initiation of PEP more than 48 hours (h) after possible exposure to the rabies virus. Determinants of delay in initiating PEP were recognized by a decision tree model.

RESULTS

Totally, 8.5% of the victims who were bitten by an animal had a delay of more than 48 h in the initiation of PEP. The relative frequency of a delay more than 48 h in females was higher than in males (12.9% compared to 8.5%) (p-value= 0.004). Relative frequency of a delay of more of 48 h from carnivorous (dog, jackal, fox) was significantly less than others (p-value< 0.001). Of the decision tree, the overall classification accuracy was 89.5%, with 44.1% sensitivity and 92.3% specificity. The identified variables included gender, biting place (rural, urban), and type of animal.

CONCLUSION

according to the results of the present study, among the various variables that affect the delayed initiation of PEP, rural residents and being female, in particular, were the major factors associated with a delay in the initiation of PEP for rabies prevention. We found relatively low rates of vaccine completion. Our findings indicat that providing training and patient education are required to ensure the completion of appropriate treatment.

The impact of sanction and healthcare system reform on the healthcare performance and pharmaceutical market in Iran; 2001-2016

BACKGROUND

Iranian government has introduced multiple healthcare system reforms during the last 30 years aiming at improving accessibility and affordability of care. Pharmaceutical products are one of the major sources of financial burden on the healthcare system. The healthcare system and pharmaceutical sector have been balanced out by the partially counteracting effects of the HSEP (Health sector evolution plan) and the imposed sanctions.

METHODS

This research investigates the healthcare system performance as well as the pharmaceutical market trend mostly based on the financial criteria from 2001. The correlation between the two change patterns was studied to understand the underlying driving market forces.

RESULTS

During 2001 to 2013, total health expenditure has grown 25.6% in average. THE (Total health expenditure) share of the GDP remains between 6-7%, while the out of pocket payment has dropped to 37% in 2015 from 57% in 2001, and most health services been directed to the inpatient facilities. Iranian pharmaceutical market has grown rapidly in recent years and grew 28.38% per year and drug consumption per capita reached 34.43$ from 2.28$. However, the import drove most of the market expansion. Noteworthy, the share of pharmaceuticals from THE has also increased.

CONCLUSIONS

It is concluded that the sanctions and HSEP have enforced partially counteracting forces on the pharmaceutical market to maintain its consistent growing trend.

Students' Nutrition Literacy and the Existence of Health Care Providers in Iranian Schools

Background: The objective of this study was to investigate the relationship between Students' nutrition literacy and the existence of health care providers in Iranian schools.

Study design: A cross-sectional study.

Methods: This study was conducted on 504 students in Ardebil City, northwestern Iran from Oct 2017 to Jan 2018. The FLINT questionnaire was used to assessment the food and nutrition literacy. Socio-demographic characteristics and the existence of health care providers were collected using demographic questionnaire.

Results: Nearly 75% of students had not a health care provider. Most students had a low FNLIT (62% males and 58.1% females). The probability of low FNLIT was lower in students with health care providers than those without them (OR=0.46, CI 95%; 0.10, 0.91).

Conclusion: One of the reasons for the low nutritional literacy of students may be due to the lack of health care providers in schools. Health educational administrators employ specialized health care providers in Iranian schools.

Seven Decades of Primary Healthcare during Various Development Plans in Iran: A Historical Review

OBJECTIVE

To explore historically primary healthcare (PHC) development in Iran in the light of development plans before and after the Islamic Revolution. The results of this study can be used to outline the future of PHC in the Iranian health system.

METHODS

We conducted a retrospective analysis of the PHC development in the Iranian health system using data from relevant published and unpublished policy documents. The literature was retrieved and reviewed on the basis of predetermined inclusion criteria with no language or date restriction. The data were integrated and analyzed using content analysis.

RESULTS

During various upstream development plans, the attitude of the policy makers to PHC has been very different, resulting in fundamental differences in addressing such an important issue and the consequent outcomes. In the aftermath of Iran's revolution, due to more understanding of PHC services importance and the principal slogans of the revolution to pay attention to villagers and vulnerable people, health policymakers paid more attention to PHC, which was not evident in previous periods.

CONCLUSION

Despite considerable achievements in PHC, the history of PHC in Iran indicates frequent changes in planning and health provision structure. This suggests that the challenges facing the health sector today, the evolving needs and demands of the people, and population changes necessitate reinforcement and reform in the structure of the current PHC network as the main mission of Iran's Ministry of Health.

Estimating the cost of vaccination in southeastern Iran

Background: Specification of vaccination cost of children would help policymakers in determining the nation-wide budget needed for the maintenance of the vaccination program. The budget came these days under scrutiny due to the imposed sanctions tightening the public funds. This study aims at estimating the cost of vaccination in southeastern Iran for obtaining more accurate budget projections. Methods: Fifty-two healthcare centers from 10 cities in south-east Iran participated in using a quota sampling method for their selection. A bottom-up method determined the human resource use, the consumption, and the overhead costs to estimate the cost of vaccination. Data collection used a standard tool that was adjusted to local conditions. Sensitivity analyses were performed. Results: The overall vaccination cost for the region was estimated at around 5,984,000 USD for the year 2015. Salaries took the largest part of the cost estimate (64%), while vaccine cost and its equipment were much lower (22%). The average cost per vaccine dose administrated was 40.94 USD. Sensitivity analysis of the population and inflation rate indicates that the vaccination cost may fluctuate between 37% and 53% over 6 years (2021) from the data of 2015. Conclusion: Maintaining vaccination has a substantial cost. The results of the study will support the budget planning and decision making and will define more precisely the resource allocation needed for maintaining the vaccination at a high level across the country. It may also help to facilitate the assessment of cost-benefit and cost-effectiveness analysis when new vaccines should be introduced.

Neonatal sepsis in Iran: A systematic review and meta-analysis on national prevalence and causative pathogens

Background

Neonatal sepsis is accounted for 30–50% of annual neonatal deaths in developing countries. We performed a systematic review and meta-analysis study to evaluate the national prevalence and identification of the etiological pathogens of neonatal sepsis in Iran.

Methods

A comprehensive literature search was done on the national and international databases for studies published between 2000 and 2019. The DerSimonian and Laird random-effects model was used to calculate pooled prevalence estimates, with 95% confidence intervals (CIs). Subgroup analyses and meta-regressions regarding the gender, type of sepsis and time during were also performed. Data were extracted, analyzed, and presented according to PRISMA guideline.

Results

Of 944 publications identified, 22 studies containing 14,683 neonates met the eligibility criteria. The pooled national prevalence of sepsis in Iran was 15.98% (95%CI, 11.96–20.46%; 1,367/14,683). Prevalence rate in boys (20.42%; 95%CI, 9.03–34.8%) was slightly higher than girls (18.5%; 95%CI, 7.4–32.8). A decreasing trend in prevalence of neonatal sepsis was found in recent years, although not statistically significant (c = -0.005; P value = 0.4). The most prevalent causative bacterial pathogens were Enterobacter spp. (23.04%), followed by Klebsiella pneumoniae (17.54%), coagulase-negative Staphylococci (14.06%), Escherichia coli (13.92%), Pseudomonas aeruginosa (12.67%), and Staphylococcus aureus (11.48%).

Conclusion

Our findings showed a high prevalence of neonatal sepsis in suspected neonates, suggesting the need to implement preventive measures, routine assessment, and close monitoring of neonates. Also, Enterobacter spp. and Klebsiella pneumoniae were identified as the principal bacterial pathogens responsible for neonatal septicemia in Iran.

Age, period and cohort analysis of high cholesterol levels in Iranian adults over a 20-year period

PURPOSE

Hypercholesterolemia is one of the most important modifiable risk factors of non-communicable diseases and data on their values in different societies and their trend of changes should be updated every couple of years. Many studies have focused on assessing the prevalence of high cholesterol. We must emphasise that most of these studies were cross-sectional and did not directly investigate the temporal trends of change for age, period and birth cohort (APC). The aim of this study is to evaluate the effect of age, period and birth cohort on the prevalence of borderline to high cholesterol levels in Iranian adult population.

METHODS

The data were collected from 110,302 subjects between 25 and 69 years of age over the period of 1990-2011. Data from these subjects were collected by using five national cross-sectional surveys conducted in 1990-91, 1999, 2003, 2007 and 2011. The APC effect on the prevalence of borderline and high cholesterol levels was assessed using the Intrinsic Estimator model.

RESULTS

The overall prevalence of borderline cholesterol level among male subjects was found to be lower than that of females (39.8% vs. 46.3%). Similarly, the prevalence of high cholesterol level in men was reported to be 13.1%, which was lower than the 18.0% calculated in women. The prevalence of borderline and high cholesterol levels increased with age in men between the ages of 45-49. Then it stayed quite steady and eventually declined. Then it stayed quite steady and eventually declined. The prevalence in women also increased with age, with its maximum rise after the ages of menopause and a slight decline at the ages of 65-69. As for the birth cohorts, the prevalence of borderline and high cholesterol levels followed a declining trend by going from earlier birth cohorts to the later ones.

CONCLUSION

The present study provides evidence that age, period and birth cohort affect the prevalence of borderline and high cholesterol levels. Thus, these factors should be considered when developing and implementing care plans for people with hypercholesterolemia.

Randomized controlled trial protocol to evaluate the effect of an educational intervention using information, motivation and behavioral skills model on sexual satisfaction of new couples in Iran

Background

Sexual satisfaction is considered as one of the key factors in assessing a person’s quality of life and the quality and continuity of marital relationships. According to the results of reports in Iran, many couples are dissatisfied with their sexual lives. Sexuality education is one of the important strategies to prevent early sexual problems and improve sexual satisfaction. The aim of this randomized controlled trial is to compare the efficacy of sexual and marital enrichment package using information, motivation and behavioral skills model on sexual satisfaction of new couples in Iran to routine sexual care program that provided at governmental health centers.

Methods

This is a randomized, controlled, superiority trial with two parallel groups. One hundred new couples (n = 200) will be recruited and randomized with simple randomization method and a 1:1 allocation. Recruitment will be from governmental health centers and calling on social networks. Couples will be randomized to intervention which will receive Sexual and Marital Enrichment package and control group (routine care at health centers). Couples will be followed up for 4 months. Then primary outcomes (mean score of couples’ sexual information, motivation and behavior skills) and secondary outcome (mean score of couples’ sexual satisfaction) of study will be measured through the online questionnaire.

Discussion

This trial will be examined the impact of the sexual and marital skills training package tailored to the values and norms governing the sexual life of Iranian couples on their sexual satisfaction. If the trial is effective, its results will be presented to policy makers for implementation at national level.

Trial registration

(Iranian Registry of Clinical Trials (IRCT) number): IRCT20181211041926N1. Date of registration: March 2, 2019.

Effects of Iranian healthcare transformation plan on discharge against medical advice rate and related factors in 2012 and 2016

OBJECTIVE

Discharge against medical advice (DAMA) is a critical problem in hospitals and has several consequences for healthcare systems. The aim of this study was to determine and compare the rate of DAMA and its related factors before and after executing the healthcare transformation plan (HTP) in Iran.

METHODS

In a two-phase, cross-sectional study, the DAMA information of 200 patients in 2016 (after HTP) and the patients of a previous study in 2012 (before HTP) was compared. Samples were randomly selected from the main referral centre in the north-west of Iran. Data were collected using a validated and reliable questionnaire and analysed using the SPSS V.16 software.

RESULTS

In the post-HTP plan period, the rate of DAMA was 3.9%, while this rate was 5.49% in 2012 (p=0.029). A total of 15% (108 out of 721) of patients in the postreform group and 13.5% (101 out of 747) in the prereform group were rehospitalised (p=0.411). The three main categories of reasons for DAMA in 2012 and 2016 were as follows: patient-related factors, 27% vs 45%; staff-related factors, 33% vs 30%; and hospital-related factors (basic amenities), 40% vs 25%. In both periods, the average scores of patient satisfaction were almost the same; however, satisfaction regarding environmental and human factors in hospitals had changed significantly after HTP (p<0.05).

CONCLUSIONS

There was a decrease in the rate of DAMA after HTP in Iran. Considering DAMA as a multifactorial phenomenon, this might be due to the higher relative satisfaction after HTP, indicating an increase in public confidence in general hospitals.

Health services utilisation and responsiveness profiles in Iran: a provincial household study

Objective

The aim of this study was to describe health services utilisation and responsiveness in East Azerbaijan province, Iran.

Design

A cross-sectional household study as part of a larger research on primary healthcare system.

Setting

We carried out the study in East Azerbaijan Province, northwest Iran from July to September 2015.

Participants

A total of 1318 households were included.

Results

Most of the participating households had social security health insurance. Heart failure or hypertension care, general outpatient care and arthritis care were the most used services. High services cost and inadequate medicine and medical equipment were introduced to be the main barriers to health services utilisation in Tabriz and province representative sample (PRS), respectively. Health system responsiveness mean score (the maximum is 100) was 33.71±16.15 (95% CI 32.45 to 34.97) in Tabriz and 32.02±14.3 (95% CI 30.9 to 33.13) in PRS, which showed significant difference (p≤0.02).

Conclusions

Differences in the utilisation and responsiveness of health services and distribution of health resources were observed between Tabriz and PRS. Evidently, health system responsiveness in both Tabriz and PRS was at low level. The results demonstrate the need for changing resource distribution policies and employing reactive health policies to response the public health.

Pediatric Palliative Care in Iran: Applying Regionalization of Health Care Systems

Background: Establishing palliative care services is a priority in the health system of Iran. Considering the necessity of integrating these services into the health system, this study aimed to explore the stakeholders’ perceptions about the provision of a conceptual framework for palliative care services for children with cancer according to the health system in of Iran. Methods: The present qualitative study was conducted through in-depth semi-structured interviews held with 29 participants including palliative care specialists, policy-makers, health care providers, the parents of children with cancer selected through purposive sampling, between August 2016 and February 2017. Interviews continued until saturation of data. All interviews were recorded, transcribed and analyzed using MAXQDA10 software. Results: The codes extracted from interviews produced the main theme “ classes of palliative care services” with the two main categories “comprehensive care” including, strengthening family shelter, maintaining the child in a familiar environment, achieving stability and “establishing social justice” including, easy access to services, financial relief and quality care. Conclusion: Presenting a framework based on level of palliative care services, the findings of this study paves the way for integrating these services into Iranian health system.

New public management in Iran's health complex: a management framework for primary health care system

BACKGROUND

New public management (NPM) was developed as a management reform to improve the efficiency and effectiveness in public organizations, especially in health sector. Using the features of private sector management, the managers of health organizations may try to implement the elements of NPM with the hope to improve the performance of their systems.AimsOur aim in the present study was to identify the elements and infrastructures suitable for implementing NPM in the Iranian health complex.

METHOD

In this qualitative study with conventional content analysis approach, we tried to explore the NPM elements and infrastructures in Iranian public health sector. A series of semi-structured interviews (n=48) were conducted in 2016 with a managers in public and private health complex. Three focus group discussions with nine faculty members were also conducted. A data collection form was used to collect the demographic characteristics and perspectives of the participants.FindingsFrom the perspective of managers, managerialism, decentralization, using market mechanism, performance management, customer orientation and performance budgeting were the main elements of NPM in the Iranian context. The most important infrastructures for implementing this reform were as follows: education and training, information technology, the proper use of human resources, decision support systems, top management commitment, organizational culture, flexibility of rules, rehabilitating of the aging infrastructures, and expanding the coverage of services.

CONCLUSION

The NPM was generally identified to be an effective replacement for the traditional administration method. These reforms may be helpful in strengthening the public health complex and the management capacity, as well. NPM also seems to be useful in interacting the public health sector with the private sector in terms of personnel and resources, performance, reward structure, and methods of doing business.

National action plan for non-communicable diseases prevention and control in Iran; a response to emerging epidemic

Emerging Non-communicable diseases burden move United Nation to call for 25% reduction by 2025 in premature mortality from non-communicable diseases (NCDs). The World Health Organization (WHO) developed global action plan for prevention and control NCDs, but the countries' contexts, priorities, and health care system might be different. Therefore, WHO expects from countries to meet national commitments to achieve the 25 by 25 goal through adapted targets and action plan. In this regards, sustainable high-level political statement plays a key role in rules and regulation support, and multi-sectoral collaborations to NCDs' prevention and control by considering the sustainable development goals and universal health coverage factors. Therefore, Iran established the national authority's structure as Iranian Non Communicable Diseases Committee (INCDC) and developed NCDs' national action plan through multi-sectoral approach and collaboration researchers and policy makers. Translation Iran's expertise could be benefit to mobilizing leadership in other countries for practical action to save the millions of peoples.

Identifying the Challenges of Iran's Health Houses and Presenting a Solution

Introduction

After more than three decades of network system design, epidemiological transition, as well as the change in needs and expectations of rural communities, have brought some challenges for Iran’s health houses. So, this study is aimed at identifying these challenges through a qualitative study.

Methods

This was a qualitative and phenomenological study which was carried out in three phases in Iran in 2015. In the first phase, the required data was collected through semi-structured interviews with selected experts, health workers and referrals to Iran’s health houses, so that all were selected purposefully. In the second phase, two expert panels were conducted to provide solutions. In the third phase the strengths, weaknesses, opportunities and threats were evaluated using the Strengths, Weaknesses, Opportunities, Threats (SWOT) method. The data of the first two phases were analyzed using the Collaizi method.

Results

Fourteen subthemes under five themes of ; quality of provided services, human resources, infrastructure, inter-sectorial and intra-sectorial relations, and contextual factors were identified as the challenges of Iran’s health houses, and consist of fourteen sub themes. Continuous education of health workers, equipping and renovating old buildings, improving inter and intra-sectorial relationships and the proportionating workload with a number of workers, were the most important solutions.

Conclusion

The study showed that, over time, many of the functions of Iran’s health houses have been faced with problems, therefore, training the manpower, equipping Iran’s health houses and creating better public spaces and building culture are recommended to enhance the effectiveness and revisions based on the study.

A Qualitative Study of Bottlenecks and Causes of Fractions for Dedicated Incomes of Health Centers and Solutions for their Reduction

BACKGROUND

Primary health care is one of effective approaches for improving public health. Providing optimal cares requires supplication of various resources such as financial resources. "Fractions of incomes" in health centers is one of the remarkable problems for the domain of financial resources management in Iran. This study was aimed to identify bottlenecks and causes of fractions for incomes in health centers and solutions for their reduction.

METHODS

The current study was conducted in a qualitative phenomenology method in East Azerbaijan province of Iran in 2014. Data collection method was focus group discussion and semi-structured interview. Purposive sampling was used for selecting participants. Focus group discussions and interviews were conducted based on pre-prepared guidance and continued till data saturation. Validity of guidance was approved by qualitative studies experts. Data were analyzed using content analysis method.

RESULTS

Based on the opinions of participants, two and six themes were respectively extracted for bottlenecks of fractions and causes and solutions for their reduction. Themes for bottlenecks of fractions included cash (monetary) and non-cash (non-monetary) fractions and themes for causes and solutions included causes and solutions for fractions per capita, insurance deductions, fractions related to sending documents, registration fractions, discounts fractions, and incomplete deposit of cash incomes.

CONCLUSION

All cash and non-cash incomes of health centers are subject to fractions. The causes of fractions are related to the whole process of converting services to incomes and insurance requirements. Identified solutions and interventions also focus on these areas.

Maternal near miss approach to evaluate quality of care in Alborz province, Iran

OBJECTIVE

the maternal near miss approach has been developed by World Health Organization for assessing and improving the quality of care. This study aimed to examine the incidence, characteristics, and features of the care provided for maternal near-miss cases in public and private hospitals in Alborz province, Iran.

METHODS

a cross sectional, facility-based study was conducted in all 13 public and private hospitals of Alborz province between April 2012 and December 2012. The World Health Organization near miss criteria were applied to gather and analyse the data, and indicators related to maternal near miss, access to and quality of maternal care.

FINDINGS

38,715 deliveries were assessed. There were 38,663 live births, 419 (1.08%) had potentially life-threatening conditions and 199 had severe maternal outcomes (SMO) (192 near miss cases and 7 maternal deaths). The maternal near-miss ratio was 4.97 cases per 1000 live births. The incidence of severe maternal outcome was 5.15 cases per 1000 live births. Severe mortality outcomes index within 12 hours of hospital stay from admission (SMO12) was 3.52%. The proportion of SMO12 cases from the total SMO cases was 99.5%. The Intensive Care Unit (ICU) admission rate among women with SMO was 72.7%, while the overall admission rate was 0.7%. Overall, hypertensive disorder was the most frequent condition among women with potentially life-threatening conditions and maternal near-miss cases. Cardiovascular dysfunction and respiratory dysfunction were the most prevalent dysfunctions among maternal near miss (MNM) cases and maternal death cases respectively.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

the WHO maternal near miss criteria help to identify issues that may lead to life threatening conditions and can be used to monitor and improve the quality of care in maternity settings. Hypertensive disorders related to near miss conditions need more attention to prevent maternal severe outcomes in Alborz province. Most of the process indicators were not satisfactory. The WHO tool enables health managers to improve maternal health care.

Motivation of Community Health Volunteers in rural Uganda: the interconnectedness of knowledge, relationship and action

OBJECTIVES

In some countries, full-time Community Health Workers (CHWs) have contributed to improvements in under-5 morbidity and mortality. Based on these successes, other low- and middle-income countries are in the process of reconsidering their current health care delivery systems and integrating CHWs as a means by which to fill the gaps. It may be important to make the distinction between CHWs and Community Health Volunteers (CHVs), both of which have a unique but complementary role. While remuneration in motivation of CHWs has been extensively discussed in the literature, other motivators that may prevent high attrition rates amongst volunteers have gained less attention. The objective of this study was to understand whether full-time professional CHWs can potentially work with volunteers in the community to widen their reach and scope and if so what motivators might be of key importance to the CHVs remaining active in the field.

STUDY DESIGN

CHVs were selected and trained in eight villages in East Uganda as part of a mixed-method trial conducted between March 2014 and February 2015.

METHODS

Eight to twelve CHVs from each village were trained by CHWs to make home-visits to pregnant women and newborn babies and to improve hygiene. This paper reports on a) demographic data about CHVs (n = 81) and; b) in-depth interviews with retained CHVs (n = 81).

RESULTS

There was a 95% retention rate amongst CHVs. In-depth interviews showed that acquisition and sharing of knowledge, relationship building and seeing health-related knowledge put into action were more important motivators than the transport allowances or the hope of gaining employment. Additionally, CHVs put what they learnt into practice by building tippy taps, having dish-racks and purifying water in their homes and as such were role models in the community.

CONCLUSION

CHVs can be retained and motivated by factors other than remuneration. Gaining and sharing of knowledge with community members, relationship building and community action were inter-related and ranked higher by CHVs as motivators than the hope of employment or the transport allowance.

HOW MANY REPETITIONS OF CHILD CARE SKILLS ARE REQUIRED FOR HEALTH WORKER STUDENTS TO ACHIEVE PROFICIENCY? LEARNING CURVE PATTERNS IN CHILD CARE SKILLS ACQUISITION

Introduction:

The vulnerability of children under 5 years old requires paying more attention to the health of this group. In the Iranian health care system, health workers are the first line of human resources for health care in rural areas. Because most health workers begin working in conditions with minimal facilities, their clinical qualifications are crucial. The aim of this study was to determine the number of repetitions of child care skills, required for health worker students to achieve proficiency based on the learning curve.

Methods:

A time series research design was used. Participants in this study were first year health worker students enrolled in three health schools in 2011. Data were collected using a questionnaire consisting of demographic information and a checklist evaluating the health worker students’ clinical skills proficiency for child care. Data were analyzed using SPSS version 16.0 software (SPSS Inc., Chicago, IL) using descriptive and inferential statistics including Kruskal-Wallis and Pearson correlation coefficient tests.

Results:

Learning curve patterns in child care skills acquisition showed that for less than 20 and between 20 to 29 times, the level of skill acquisition had an upward slope. Between 30- 39 the learning curve was descending, however the slope became ascending once more and then it leveled off (with change of less than 5%).

Conclusion:

It seems that 40 repetitions of child care skills are sufficient for health worker students to achieve proficiency. This suggests that time, resources and additional costs for training health worker students’ trainees can be saved by this level of repetition.

Acceptability and trust of community health workers offering maternal and newborn health education in rural Uganda

When trusted, Community Health Workers (CHWs) can contribute to improving maternal and newborn health outcomes in low- and middle-income countries through education. Issues of acceptability of CHWs by communities were explored through experiences gained in a qualitative study that is part of a cluster randomized trial in East Uganda. Initially, focus group discussions with key community members and leaders were undertaken regarding preventative health and 40 CHWs were observed making home visits by supervisors during the initial 6 months of fieldwork of the trial in eight villages in the Jinja District in Uganda. The results were analyzed using the 5-SPICE framework. Observation of CHWs in the field identified a number of unanticipated issues including a general mistrust of the public health system by community members in areas that had an impact on maternal and newborn health. At the outset, CHWs often did not trust their own abilities and faced community expectations that they would provide curative rather than preventative care. Early community engagement, non-threatening home visits that enhanced friendship and supportive supervision improved the confidence of the CHWs and improved the trust and acceptance of the CHWs and the willingness of the community members to act on what was discussed.

The effect of payment and incentives on motivation and focus of community health workers: five case studies from low- and middle-income countries

INTRODUCTION

Community health workers (CHWs) have been proposed as a means for bridging gaps in healthcare delivery in rural communities. Recent CHW programmes have been shown to improve child and neonatal health outcomes, and it is increasingly being suggested that paid CHWs become an integral part of health systems. Remuneration of CHWs can potentially effect their motivation and focus. Broadly, programmes follow a social, monetary or mixed market approach to remuneration. Conscious understanding of the differences, and of what each has to offer, is important in selecting the most appropriate approach according to the context.

CASE DESCRIPTIONS

The objective of this review is to identify and examine different remuneration models of CHWs that have been utilized in large-scale sustained programmes to gain insight into the effect that remuneration has on the motivation and focus of CHWs. A MEDLINE search using Ovid SP was undertaken and data collected from secondary sources about CHW programmes in Iran, Ethiopia, India, Bangladesh and Nepal. Five main approaches were identified: part-time volunteer CHWs without regular financial incentives, volunteers that sell health-related merchandise, volunteers with financial incentives, paid full-time CHWs and a mixed model of paid and volunteer CHWs.

DISCUSSION AND EVALUATION

Both volunteer and remunerated CHWs are potentially effective and can bring something to the health arena that the other may not. For example, well-trained, supervised volunteers and full-time CHWs who receive regular payment, or a combination of both, are more likely to engage the community in grass-roots health-related empowerment. Programmes that utilize minimal economic incentives to part-time CHWs tend to limit their focus, with financially incentivized activities becoming central. They can, however, improve outcomes in well-circumscribed areas. In order to maintain benefits from different approaches, there is a need to distinguish between CHWs that are trained and remunerated to be a part of an existing health system and those who, with little training, take on roles and are motivated by a range of contextual factors. Governments and planners can benefit from understanding the programme that can best be supported in their communities, thereby maximizing motivation and effectiveness.

The dysfunctional consequences of a performance measurement system: the case of the Iranian national hospital grading programme

Objectives

Performance measurement systems are increasingly used to reward and improve provider performance. However, such initiatives may also inadvertently induce a range of unintended and dysfunctional side-effects. This study explores the unintended and adverse consequences induced by the Iranian national hospital grading programme, which incorporates financial incentives for meeting nationally defined standards.

Methods

We interviewed key informants across four key groups with a legitimate interest in healthcare performance: four purposively selected hospitals; four health insurance organizations; the Iranian hospital accreditation body; and one grading agency. The transcribed interviews and field notes were analysed thematically, and subsequently, member checking was conducted.

Results

Seven dysfunctional consequences were identified: misrepresentation of data by hospitals; increased anxiety and stress among hospital employees; tunnel vision; financial pressures on poorly graded hospitals; incentives to purchase unnecessary equipment; erosion of public trust; and restricting access to hospital services by patients. These were caused by the way the grading system was implemented: poor standards of audit; the way in which the audit process was conducted; and the timing of audits. The pay for performance element of the grading system and the focus on structural aspects in the standards made improvement in grading particularly difficult for those hospitals that had been assessed as under-performing.

Conclusion

Although the Iranian hospital grading system has resulted in a significant increase in the adoption of national standards, it has nevertheless induced a range of perverse outcomes. To mitigate these requires further refinement and recalibration of the system.

Paul Tessier facial reconstruction in 1970 Iran, a series of post-noma defects

BACKGROUND

Paul Tessier was a pioneering plastic surgeon who founded craniofacial surgery and had an international influence in the field of reconstructive surgery. We reviewed his techniques in the reconstruction of post-noma defects in Iran in the late 1970s.

PATIENTS AND METHODS

We studied a series of 23 patients operated on by Tessier from 1974 to 1978 in Iran (property of Association Française des Chirurgiens de la Face). They all suffered from noma in childhood with major facial defects.

RESULTS

Ten suffered from simple lip and cheek defects, nine also from nose defects and four from extensive facial defects. Abbe flaps were used in 15 patients to reconstruct the lips completed by commissuroplasty in six patients. Nose defects were reconstructed with nasofrontal flaps (ten cases). The outer cheek was reconstructed with a rotation flap (four cases), or with a frontotemporal flap (six cases). The inner cheek was reconstructed using a Barron-Tessier myocutaneous flap (ten cases). Of the 23 patients, partial flap necrosis occurred in five cases.

CONCLUSIONS

Tessier was a pioneering plastic surgeon who used local flaps to reconstruct these important facial defects. He had a high rate of success, although nowadays local flaps are commonly replaced by free flaps.

Perceived risk of exposure to indoor residential radon and its relationship to willingness to test among health care providers in Tehran

BACKGROUND

Radon exposure is the second cause of lung cancer after exposure to tobacco smoke and the first cause in nonsmokers. The purpose of this study was to assess perceived risk of exposure to indoor residential radon among health care providers in urban and rural health centers affiliated to Tehran University of Medical Sciences.

METHOD

In 2012-2013, a survey was carried out on 462 health care providers to assess their awareness and risk perception about exposure to indoor residential radon. Only subjects who had previously heard about radon were asked to answer knowledge-based and risk perception questions and report source of knowledge, willingness to test and willingness to pay for radon test kits.

RESULTS

About 67% of responders had heard about radon before this study and of these, 83.5 % recognized it as being hazardous and 34.5 % identified lung cancer as the main health outcome of exposure to radon. Overall, 33% of 310 subjects had knowledgeable awareness. Seventy percent of responders who had previously heard about radon, had high perceived risk and they were more willing to test their houses and more willing to pay for radon test kits.

CONCLUSION

Having knowledge about radon and perceiving it as a risk had a significant association with willing to take relevant health related behaviors. Furthermore, risk perception contributes to willing to spend more money when health is a concern. Education of health care providers seems to be a pre-requisite to public campaigns on radon awareness and testing.

Maternal mortality in the Islamic Republic of Iran: on track and in transition

The Maternal Mortality Ratio is an important public health indicator that reflects both the quality of a health care system and the role of women within that society. In September 2000 the United Nations Millennium Declaration outlined the eight Millennium Development Goals (MDGs) that set targets to be achieved by 2015. MDG 5 focused on improving maternal health. It had two clear subgoals: to reduce maternal mortality globally by three quarters between 1990 and 2015 and to obtain universal access to reproductive health for women. Despite a global trend of declining maternal mortality only a handful of nations are currently 'on track' to achieve their MDG targets by 2015. The Islamic Republic of Iran is one of these nations. In just over three decades, Iran has undergone demographic transition with significant reductions in total fertility and population growth rates. In concert with this transition, Iran has achieved a dramatic decline in the maternal mortality ratio that has fallen to a rate comparable with developed nations. Significantly Iran has also experienced a paradigm shift in its major causes of maternal mortality from those characteristic of developing nations (postpartum haemorrhage, infection) to causes more commonly seen in developed nations (pulmonary embolus, stroke). There is no single explanation that may account for this transition, rather it is the product of a number of different initiatives that have incorporated family planning, grass roots focus and wider improvements within the health care system of Iran over the past three decades. However the experience of this nation may provide a useful example to other developing countries looking to reduce maternal mortality.

Prevalence, awareness and risk factors of hypertension in a large cohort of Iranian adult population

BACKGROUND

There is considerable variation in hypertension prevalence and awareness, and their correlates, across different geographic locations and ethnic groups. We performed this cross-sectional analysis on data from the Golestan Cohort Study (GCS).

METHODS

Enrollment in this study occurred in 2004-2008, and included 50,045 healthy individuals from Golestan Province in northeastern Iran. Hypertension was defined as a SBP at least 140 mmHg, a DBP at least 90 mmHg, a prior diagnosis of hypertension, or the use of antihypertensive drugs. Potential correlates of hypertension and its awareness were analyzed by logistic regression adjusted for sex, age, BMI, place of residence, literacy, ethnicity, physical activity, smoking, black and green tea consumption and wealth score.

RESULTS

Of the total cohort participants, 21,350 (42.7%) were hypertensive. Age-standardized prevalence of hypertension, using the 2001 WHO standard world population, was 41.8% (95% confidence interval: 38.3-45.2%). Hypertension was directly associated with female sex, increased BMI, Turkmen ethnicity, and lack of physical activity, and inversely associated with drinking black tea and wealth score. Among hypertensive patients, 46.2% were aware of their disease, 17.6% were receiving antihypertensive medication, and 32.1% of the treated patients had controlled hypertension. Hypertension awareness was greater among women, the elderly, overweight and obese patients, and those with a higher wealth score.

CONCLUSION

Hypertension is highly prevalent in rural Iran, many of the affected individuals are unaware of their disease, and the rate of control by antihypertensive medications is low. Increasing hypertension awareness and access to health services, especially among less privileged residents are recommended.