Service quality: perspective of people with type 2 diabetes mellitus and hypertension in rural and urban public primary healthcare centers in Iran

OBJECTIVE

This study aimed to assess the service quality (SQ) for Type 2 diabetes mellitus (T2DM) and hypertension in primary healthcare settings from the perspective of service users in Iran.

METHODS

The Cross-sectional study was conducted from January to March 2020 in urban and rural public health centers in the East Azerbaijan province of Iran. A total of 561 individuals aged 18 or above with either or both conditions of T2DM and hypertension were eligible to participate in the study. The study employed a two-step stratified sampling method in East Azerbaijan province, Iran. A validated questionnaire assessed SQ. Data were analyzed using One-way ANOVA and multiple linear regression statistical models in STATA-17.

RESULTS

Among the 561 individuals who participated in the study 176 (31.3%) were individuals with hypertension, 165 (29.4%) with T2DM, and 220 (39.2%) with both hypertension and T2DM mutually. The participants' anthropometric indicators and biochemical characteristics showed that the mean Fasting Blood Glucose (FBG) in individuals with T2DM was 174.4 (Standard deviation (SD) = 73.57) in patients with T2DM without hypertension and 159.4 (SD = 65.46) in patients with both T2DM and hypertension. The total SQ scores were 82.37 (SD = 12.19), 82.48 (SD = 12.45), and 81.69 (SD = 11.75) for hypertension, T2DM, and both conditions, respectively. Among people with hypertension and without diabetes, those who had specific service providers had higher SQ scores (b = 7.03; p = 0.001) compared to their peers who did not have specific service providers. Those who resided in rural areas had lower SQ scores (b = -6.07; p = 0.020) compared to their counterparts in urban areas. In the group of patients with T2DM and without hypertension, those who were living in non-metropolitan cities reported greater SQ scores compared to patients in metropolitan areas (b = 5.09; p = 0.038). Additionally, a one-point increase in self-management total score was related with a 0.13-point decrease in SQ score (P = 0.018). In the group of people with both hypertension and T2DM, those who had specific service providers had higher SQ scores (b = 8.32; p < 0.001) compared to the group without specific service providers.

CONCLUSION

Study reveals gaps in T2DM and hypertension care quality despite routine check-ups. Higher SQ correlates with better self-care. Improving service quality in primary healthcare settings necessitates a comprehensive approach that prioritizes patient empowerment, continuity of care, and equitable access to services, particularly for vulnerable populations in rural areas.

Reforms and innovations in primary health care in different countries: scoping review

INTRODUCTION

The World Health Organization (WHO) recommends focusing on primary health care (PHC) as the first strategy of countries to achieve the improvement of the health level of communities and has emphasized it again in 2021. Therefore, we intend to take a different look at the PHC system with reform, innovation, and initiative by using the experiences of leading countries and identify practical and evidence-based solutions to achieve greater health.

METHODS

This is a scoping review study that has identified innovations and reforms related to PHC since the beginning of 2000 to the end of 2022. In this study, Scopus, Web Of Science, and PubMed databases have been searched using appropriate keywords. This study is done in six steps using Arkesy and O'Malley framework. In this study, the framework of six building blocks of WHO was used to summarize and report the findings.

RESULTS

By searching in different databases, we identified 39426 studies related to reforms in primary care, and after the screening process, 106 studies were analyzed. Our findings were classified and reported into 9 categories (aims, stewardship/leadership, financing & payment, service delivery, health workforce, information, outcomes, policies/considerations, and limitations).

CONCLUSION

The necessity and importance of strengthening PHC is obvious to everyone due to its great consequences, which requires a lot of will, effort, and coordination at the macro-level of the country, various organizations, and health teams, as well as the participation of people and society.

Costs of inpatient care and out-of-pocket payments for COVID-19 patients: A systematic review

OBJECTIVE

To identify the costs of hospital care for patients with COVID-19 and the amount of out-of-pocket payments.

METHODS

We conducted a systematic review using Scopus and WEB OF SCIENCE and PubMed databases in April 5, 2022 and then updated in January 15, 2023. English articles with no publication year restrictions were included with study designs of cost-of-illness (COI) studies, cost analyses, and observational reports (cross-sectional studies and prospective and retrospective cohorts) that calculated the patient-level cost of care for COVID-19. Costs are reported in USD with purchasing power parity (PPP) conversion in 2020. The PROSPERO registration number is CRD42022334337.

RESULTS

The results showed that the highest total cost of hospitalization in intensive care per patient was 100789 USD, which was reported in Germany, and the lowest cost was 5436.77 USD, which was reported in Romania. In the present study, in the special care department, the highest percentage of total expenses is related to treatment expenses (42.23 percent), while in the inpatient department, the highest percentage of total expenses is related to the costs of hospital beds/day of routine services (39.07 percent). The highest percentage of out-of-pocket payments was 30.65 percent, reported in China, and the lowest percentage of out-of-pocket payments was 1.12 percent, reported in Iran. The highest indirect cost per hospitalization was 16049 USD, reported in USA, and the lowest was 449.07 USD, reported in India.

CONCLUSION

The results show that the COVID-19 disease imposed a high cost of hospitalization, mainly the cost of hospital beds/day of routine services. Studies have used different methods for calculating the costs, and this has negatively impacted the comparability costs across studies. Therefore, it would be beneficial for researchers to use a similar cost calculation model to increase the compatibility of different studies. Systematic review registration: PROSPERO CRD42022334337.

The roles and challenges of the primary health care systems in epidemic management: a scoping review

BACKGROUND AND AIM

During the early stage of pandemics, primary health care (PHC) is the first point of contact with the health system for people. This study aimed to find the leading roles and challenges of the PHC system in dealing with the outbreak of infectious diseases.

METHODS

The current scoping review was conducted in 2022 using the Arkesy and O'Malley framework. A bibliographic search was conducted in PubMed, Web of Science, and Scopus databases. Following a Google Scholar search, a manual search in some journals, reference checks for articles, and a review of organizational reports, websites, and other sources of information were also conducted. Data were analyzed using the content-analysis method.

FINDINGS

Finally, 65 documents (42 articles and 23 reports, books, and news) were included in the study. Initially, 626 codes were extracted, and 132 final codes were categorized into eight main themes and 44 sub-themes. The main themes for the roles of PHC included: service provision, education and knowledge, surveillance, access, coordination and communication, management and leadership, infrastructure change and rapid preparation, and patient and community management. Regarding the challenges faced by PHC in the epidemic of infectious diseases, 24 key challenges were identified and categorized into four major areas.

CONCLUSIONS

Based on the results of the present study, there is a need for further studies to formulate and theorize the specific roles of PHC in managing infectious disease epidemics. The results of this study can be utilized by researchers and officials to inform their efforts in addressing this purpose.

A framework for elderly participation in Primary Health Care in Tabriz Health complexes

BACKGROUND

A framework for increasing elderly participation in Primary Health Care (PHC) is a vital issue considering the growing population. After examining the situation and elderly participation in the provision of PHC in the health complexes of Tabriz City, the present study presents the framework of elderly participation in PHC.

METHODS

This is a mixed-method study. First, we reviewed the models of elderly participation in PHC worldwide using a comprehensive search of literature. Then, we extracted the service providers' and the elderly's views regarding the obstacles and solutions for the elderly participation in PHC in Iran using the interviews and focus group discussions (FGD). We conducted three FGDs (8-10 people) and seven individual interviews. Data were analyzed using the content analysis method. We developed the proposed framework for the participation of the elderly in PHC using a panel of experts and checked and confirmed the framework's validity using the Delphi technique with 11 experts from the content validity index and modified kappa coefficient.

RESULTS

Based on the result of included studies in the systematic review, the characteristics of the participation models were classified into five areas: the characteristics of the service user, the main facilitator of the intervention, the type of ownership of the center, the subject and the method of participation. The solutions and obstacles, and problems presented by the service providers and users in different areas include 12 themes (elderly participation, home care, and self-care, respect for the elderly, cooperation of different organizations, service package for the elderly, referral system, planning for the elderly, considering insurance for the elderly, the role of informing the elderly, mental health of the elderly, physical space of centers and training of elderly caregivers) and 46 sub-themes. The final framework also includes five themes (approaches and strategies to attract participation, indicators, and consequences of participation of the elderly, implementation strategies of elderly care, implementation infrastructure and goals and areas of participation of the elderly) and sub-themes.

CONCLUSION

The results of the study indicate that the final framework obtained should be used based on a systematic model for elderly participation in PHC and should be implemented and followed up based on local strategies and specific indicators, considering all capacities.

Barriers to community participation in primary health care of district health: a qualitative study

INTRODUCTION

Community participation is one of the principles of primary health care (PHC). However, it has not been adequately institutionalized due to numerous barriers. Therefore, the present study is conducted to identify barriers to community participation in primary health care in the district health network from the perspectives of stakeholders.

METHODS

This qualitative case study was conducted in 2021 in Divandareh city, Iran. A total of 23 specialists and experts experienced in community participation, including nine health experts, six community health workers, four community members, and four health directors in primary health care programs, were selected using the purposive sampling method until complete saturation. Data was collected using semi-structured interviews and analyzed simultaneously using qualitative content analysis.

RESULTS

After data analysis, 44 codes, 14 sub-themes, and five themes were identified as barriers to community participation in primary health care in the district health network. The themes included community trust in the healthcare system, the status of community participation programs, the community and system's perception of participation programs, health system management approaches, and cultural barriers and institutional obstacles.

CONCLUSION

Based on the results of this study most important barriers to community participation relate to community trust, the organizational structure, community and the health profession's perception regarding the participatory programs. It seems necessary to take measures to remove barriers in order to realize community participation in primary healthcare system.

Future of myocardial infarction mortality in Iran: a scenario-based study

This study defines futures myocardial infarction landscapes and proposes a few policy options to reduce the burden of cardiovascular diseases using the scenario development method. We identified the effective drivers of myocardial infarction by reviewing the literature and completed the returned list with "experts" opinions. The results were classified using the STEEP (Social, Technological, Environmental, Economic, and Political) framework. We plotted the critical uncertainties in a two-dimensional ranking of "effect" and "uncertainty" levels. Eleven drivers with uncertainty and high potential impact were selected and categorized into three groups: Political Development, Access to health services, and Self-Care. Scenarios were developed, and 3 scenarios (optimistic, pessimistic, and possible) were selected based on scoring. For each scenario, policy options were formulated. Utilizing the capacity of Non-Governmental Organizations and charities and strengthening restrictive and punitive legislation was chosen as policy options for addressing possible scenarios. Building infrastructure and improving prevention services, designing and regenerating curative infrastructure were selected as optimal strategies for addressing issues related to the optimistic scenario. Strengthening restrictive and punitive legislation related to community health and population empowerment were proposed as critical policy options for health improvement regarding the pessimistic scenario. Increasing people's participation, strengthening infrastructure and punitive policies can be effective in Myocardial infarction mortality prevention policies in Iran.

The challenges facing programs for the prevention and control of non-communicable diseases in Iran: a qualitative study of senior managers' viewpoints

Background

Despite significant achievements in the prevention and control of NCDs in Iran, these conditions are still the biggest challenges to Iran's healthcare system and are estimated to account for 78.1 percent of all deaths. Therefore, this study aimed to reflect on the potential challenges standing in the way to implement the relevant policies, empower the dimensions of governance, and react in an effective and timely manner by Iran's healthcare system to NCDs.

Methods

This study was conducted with a qualitative approach using the conventional content analysis method. A total of 46 senior managers involved in the prevention and control of NCDs at the medical sciences universities across Iran were recruited through the purposive sampling method and were interviewed via semi-structured interviews. Graneheim and Lundman's approach was utilized to analyze the data.

Results

According to the analysis of the senior managers' viewpoints, current challenges to implement the program for the prevention and control of NCDs in Iran could be placed into six main categories, including financing, human resources, infrastructure and inputs, legal, executive, administrative, as well as inter-sectoral collaboration, and management and policy-making challenges with their own sub-categories.

Conclusion

The results revealed that financing was the biggest challenge to successfully implementing the program for the prevention and control of NCDs in Iran. However, strengthening Iran's healthcare system in the field of the prevention of NCDs demanded more innovative measures and strategies, such as the empowerment of human resources, the effective use of intra- and inter-sectoral collaboration, and non-governmental organizations and charities, along with the exploitation of evidence-based studies during policy-making and decision-making processes, with no need for financial resources.

Estimation of myocardial infarction death in Iran: artificial neural network

BACKGROUND

Examining past trends and predicting the future helps policymakers to design effective interventions to deal with myocardial infarction (MI) with a clear understanding of the current and future situation. The aim of this study was to estimate the death rate due to MI in Iran by artificial neural network (ANN).

METHODS

In this ecological study, the prevalence of diabetes, hypercholesterolemia over 200, hypertension, overweight and obesity were estimated for the years 2017-2025. ANN and Linear regression model were used. Also, Specialists were also asked to predict the death rate due to MI by considering the conditions of 3 conditions (optimistic, pessimistic, and probable), and the predicted process was compared with the modeling process.

RESULTS

Death rate due to MI in Iran is expected to decrease on average, while there will be a significant decrease in the prevalence of hypercholesterolemia 1.031 (- 24.81, 26.88). Also, the trend of diabetes 10.48 (111.45, - 132.42), blood pressure - 110.48 (- 174.04, - 46.91) and obesity and overweight - 35.84 (- 18.66, - 5.02) are slowly increasing. MI death rate in Iran is higher in men but is decreasing on average. Experts' forecasts are different and have predicted a completely upward trend.

CONCLUSION

The trend predicted by the modeling shows that the death rate due to MI will decrease in the future with a low slope. Improving the infrastructure for providing preventive services to reduce the risk factors for cardiovascular disease in the community is one of the priority measures in the current situation.

Social, Economic, Technological, and Environmental Factors Affecting Cardiovascular Diseases: A Systematic Review and Thematic Analysis

Background

Today, cardiovascular disease (CVD) is the leading cause of mortality in both sexes. There are several risk factors for heart diseases; some controllable, others not. However, socioeconomic, technological, and environmental factors can impact CVD as well as exclusive risk factors. Accurate identification and assessment of these factors are often difficult. In the present systematic review, we aimed to explore factors affecting CVD.

Methods

Multiple databases (MEDLINE, Scopus, ISI Web of Science, and Cochrane) and gray literature were searched. The included studies described at least one determinant of CVD. The framework method was applied to analyze the qualitative data.

Results

A total of 64 studies from 26 countries were included. The contextual determinants of CVD were categorized into 45 determinants, 15 factors, and 4 main social, economic, technological, and environmental categories. The 15 potentially reversible factors were identified as sociodemographic, violence, smoking, occupation, positive childhood experience, social inequalities, psychological distress, eating habits, neighborhood, family income, rapid technology, environmental pollution, living environments, noise, and disaster.

Conclusions

Devolution and more efficient health policies are required to achieve further sustained reduction in CVD mortality, increase life expectancy, and reduce its associated risk factors. Policymakers should fully address the value of social, economic, technological, and environmental factors. In fact, a prevention agenda should be developed and updated collaboratively in terms of the determinant factors.

A Qualitative Study on the Establishment of an Interpersonal Violence Registry System in Iran

Establishment of an interpersonal-violence registry system (IPVRS) is a promising initiative to tackle violence. This qualitative study aimed to fill the gap in knowledge regarding the feasibility of establishing the IPVRS in the East-Azerbaijan province of Iran. This qualitative study using content analysis was conducted to explore the importance, challenges, and facilitating factors of establishing the IPVRS from the viewpoints of stakeholders. Forty-six individuals from the Forensic Medical Organization, the University, the Welfare Organization, the Training and Education Organization, hospitals, and primary health centers participated in the study. Six themes and 13 sub-themes were identified. The importance of the establishment of the IPVRS was sub-categorized into two main themes, including violence as a public health priority and severe consequences of violence including intensive health and social outcomes and high use of medical services. The most critical challenges of establishing the IPVRS were categorized into two main themes including victims' under-reporting due to financial difficulties as well as psychosocial barriers and structural barriers such as organizational barriers and methodological challenges. Inter-sectoral partnership was identified as the main facilitating factor in the successful establishment of the IPVRS. The participants recommended improving the development of the IPVRS by stepwise development of the program, resource absorption from other beneficiary organizations, and making more coverage in the registry system. In conclusion, the establishment of the IPVRS is identified as an effective strategy to tackle violence-related issues. Close collaboration with different governmental and non-governmental sectors and the gradual development of the registry system can pave the way for establishing the IPVRS. This study has several implications for identifying potential challenges and facilitators of the IPVRS applicable to other developing countries with similar contexts.

Viewpoint changes of medical sciences graduates in evaluating the performance of faculty members: a qualitative study

BACKGROUND

This study aimed to identify which dimensions of faculty members' evaluation criteria changed from the viewpoint of students after their graduation, and to determine the effective factors in changing their viewpoints.

METHODS

This study was carried out through the qualitative approach and with conventional content analysis method. The target population included all graduates who accomplished their job duty and had a working experience of 2-4 years. A purposive sampling technique with maximum variation used to recruit and interview. Twenty-eight in depth semi-structured interviews were conducted in Tabriz University of Medical Sciences (TBZMED), Iran. The data were analyzed using content analysis.

RESULTS

The data analysis led to the development of two themes and 8 categories. The two types of changes in the viewpoint that were experienced by graduates in evaluating the performance of faculty members were: individual and environmental. Individual factors included the responsibility of graduates, social maturity, personal experience, intellectual maturity, understanding the causes of teachers' behaviors, and understanding the importance of evaluation. The environmental factors were applicability of learning experiences in the work environment and workplace conditions.

CONCLUSION

From the perspective of graduates, the importance of some evaluation criteria in the educational, professional, and personal dimensions changed over their study period due to some factors, such as personal experience, experiences in the work environment, workplace conditions, and intellectual maturity.

The Characteristics and Results of Parent Training Interventions in Children with Autism Spectrum Disorder: A Systematic Review

Background: The role of parents in taking care of children with Autism Spectrum Disorder (ASD) is critical. This systematic review aimed to investigate the characteristics and results of parent training interventions for autistic children. Methods: All relevant studies were searched using Boolean operators such as "AND" and "OR" with the keywords such as “Autism Spectrum Disorders,” “Autism,” “Autistic disorder,” “Asperger syndrome,” “Rett’s syndrome”, “Childhood disintegrative disorder”, “Non-specific pervasive disorder”, Parent*, Education*, train*, teach*, indoctrinate*, and instruct* in electronic databases such as PubMed, Scopus, Google Scholar, Cochrane Library, Science Direct, Web of knowledge, and also via manual searching in relevant journals, checking the reference list of articles, expert contact, and grey literature from 1 Jan 2000 to 30 Feb 2020. The retrieved studies were screened and reviewed then quality assessed by CONSORT checklist. The qualitative data were analyzed using content analysis method. Results: Eventually, 53 articles were considered in which 1758 parents with autistic children participated. Overall, 49 studies were conducted in high-income countries, 19 at home, 25 in training centers, 14 carried out only in training way, 39 in training along with practices and assignments, 30 individual interventions, and 21 in groups. Moreover, the effectiveness of interventions was studied in both parents and children groups. The results for parents show direct and indirect favorable impacts of interventions on them. The results for the children indicate direct and indirect favorable effects of the parents-based interventions on the child and the symptoms of their disorder. Conclusion: According to the included studies, parents-based training interventions significantly impact parents and their children's behavior.

Development, validation, and pilot implementation of the minimum datasheet for a domestic violence registry system: The case of a developing country

Background

Domestic violence (DV) is a universal issue and an important public health priority. Establishing a DV Registry System (DVRS) can help to systematically integrate data from several sources and provide valid and reliable information on the scope and severity of harms. The main objective of this study was to develop, validate, and pilot-test a minimum datasheet for a DVRS to register DV victims in medical facilities.

Materials and methods

This study was conducted in two main phases. Phase one includes developing the datasheet for registration of DV in the DVRS. In phase two, the datasheet designed in the previous step was used in a pilot implementation of the DVRS for 12 months to find practical challenges. The preliminary datasheet was first developed using information on similar registry programs and guidelines of the World Health Organization (WHO) and then reviewed by four expert panels. Through a two-round Delphi technique, experts evaluated the instrument using the Content Validity Index (CVI) and Content Validity Ratio (CVR). The consistency of the responses was evaluated by test-retest analysis. Finally, two physicians in two forensic medical clinics registered the victims of physical and/or sexual violence perpetrated by a family member.

Results

Preliminary datasheet consisted of 31 items. In the first round of Delphi, fifteen items had good content validity (I-CVI and CVR) and were kept, and seven items were moved to the next round. Also, in the first round of Delphi, experts suggested adding three items, including history of the violence, custody of the child, and custody of the elderly. All items evaluated in the second round were kept due to good CVR and CVI scores. As a result of Test-retest correlation coefficients for self-reprted items, two items including perpetrator’s alcohol and drug use status were excluded (r(30) = +.43, and +.38, p< .01, two-tailed, respectively). Finally, 24 items were included in the datasheet including 15 items for individuals’ characteristics (victims’ characteristics and perpetrators’ characteristics), eight items for incidents’ characteristics, and one item for past history of violence experience. A total of 369 cases were registered from September 23, 2019, to July 21, 2020. The majority of the reported cases were female (82%) and were 19–40 years old. No physical and/or sexual violence was reported from rural areas, which calls upon researchers to explore how services for detecting and treating the victims can be made accessible to these areas.

Conclusion

DVRS can show trends in DV by age, sex, the context of the violence, and incidence characteristics at every point in time. This is particularly valuable in planning and prioritizing research areas and interventions for DV prevention. Additionally, DVRS can be linked to other disease registry programs which can contribute to continuity and coordination of care, and major research in the future. Although a DVRS can be a promising initiative in identifying the areas in need of urgent interventions, there is no guarantee for its proper implementation due to limited resources and other challenges.

A systematic review of racial/ethnic and socioeconomic disparities in COVID-19

BACKGROUND

Preliminary evidence from the COVID-19 pandemic shows the presence of health disparities, especially in terms of morbidity and mortality. This study aimed to systematically review the evidence on the association of racial/ethnic and socioeconomic status (SES) with health outcomes and access to healthcare services during the COVID-19 pandemic.

METHODS

We retrieved published evidence from late December 2019 through March 1, 2021. The target population was the population of the countries during the COVID-19 pandemic. The exposures were defined as belonging to racial/ethnic minority groups and/or low SES. The primary outcomes of interest include (1) death from COVID-19, (2) COVID-19 incidence/infection, (3) COVID-19 hospitalization, (4) ICU admission, (5) need for mechanical ventilation, (6) confirmed diagnosis, and (7) access to testing. We systematically synthesized the findings from different studies and provided a narrative explanation of the results.

RESULTS

After removing the duplicate results and screening for relevant titles and abstracts, 77 studies were selected for full-text review. Finally, 52 studies were included in the review. The majority of the studies were from the United States (37 studies). Despite the significant incongruity among the studies, most of them showed that racial/ethnic minority groups had higher risks of COVID-19 infection and hospitalization, confirmed diagnosis, and death. Additionally, most of the studies cited factors such as low level of education, poverty, poor housing conditions, low household income, speaking in a language other than the national language in a country, and living in overcrowded households as risk factors of COVID-19 incidence/infection, death, and confirmed diagnosis. However, findings in terms of the association of lack of health insurance coverage and unemployment with the outcome measures as well as the association of requiring mechanical ventilation, ICU admission, and access to testing for COVID-19 with race/ethnicity were limited and inconsistent.

CONCLUSION

It is evident that racial/ethnic minority groups and those from low SES are more vulnerable to COVID-19; therefore, public health policymakers, practitioners, and clinicians should be aware of these inequalities and strive to narrow the gap by focusing on vulnerable populations. This systematic review also revealed a major incongruity in the definition of the racial/ethnic minority groups and SES among the studies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020190105.

Effectiveness of non-pharmaceutical public health interventions against COVID-19: A systematic review and meta-analysis

Non-Pharmaceutical Public Health Interventions (NPHIs) have been used by different countries to control the spread of the COVID-19. Despite available evidence regarding the effectiveness of NPHSs, there is still no consensus about how policymakers can trust these results. Studies on the effectiveness of NPHSs are single studies conducted in specific communities. Therefore, they cannot individually prove if these interventions have been effective in reducing the spread of the infection and its adverse health outcomes. In this systematic review, we aimed to examine the effects of NPHIs on the COVID-19 case growth rate, death growth rate, Intensive Care Unit (ICU) admission, and reproduction number in countries, where NPHIs have been implemented. We searched relevant electronic databases, including Medline (via PubMed), Scopus, CINAHL, Web of Science, etc. from late December 2019 to February 1, 2021. The key terms were primarily drawn from Medical Subject Heading (MeSh and Emtree), literature review, and opinions of experts. Peer-reviewed quasi-experimental studies were included in the review. The PROSPERO registration number is CRD42020186855. Interventions were NPHIs categorized as lockdown, stay-at-home orders, social distancing, and other interventions (mask-wearing, contact tracing, and school closure). We used PRISMA 2020 guidance for abstracting the data and used Cochrane Effective Practice and Organization of Practice (EPOC) Risk of Bias Tool for quality appraisal of the studies. Hartung-Knapp-Sidik-Jonkman random-effects model was performed. Main outcomes included COVID-19 case growth rate (percentage daily changes), COVID-19 mortality growth rate (percentage daily changes), COVID-19 ICU admission (percentage daily changes), and COVID-19 reproduction number changes. Our search strategies in major databases yielded 12,523 results, which decreased to 7,540 articles after eliminating duplicates. Finally, 35 articles qualified to be included in the systematic review among which 23 studies were included in the meta-analysis. Although studies were from both low-income and high-income countries, the majority of them were from the United States (13 studies) and China (five studies). Results of the meta-analysis showed that adoption of NPHIs has resulted in a 4.68% (95% CI, -6.94 to -2.78) decrease in daily case growth rates, 4.8% (95 CI, -8.34 to -1.40) decrease in daily death growth rates, 1.90 (95% CI, -2.23 to -1.58) decrease in the COVID-19 reproduction number, and 16.5% (95% CI, -19.68 to -13.32) decrease in COVID-19 daily ICU admission. A few studies showed that, early enforcement of lockdown, when the incidence rate is not high, contributed to a shorter duration of lockdown and a lower increase of the case growth rate in the post-lockdown era. The majority of NPHIs had positive effects on restraining the COVID-19 spread. With the problems that remain regarding universal access to vaccines and their effectiveness and considering the drastic impact of the nationwide lockdown and other harsh restrictions on the economy and people's life, such interventions should be mitigated by adopting other NPHIs such as mass mask-wearing, patient/suspected case isolation strategies, and contact tracing. Studies need to address the impact of NPHIs on the population's other health problems than COVID-19.

Disparities in the quality of and access to services in children with autism spectrum disorders: a structural equation modeling

Background

Socioeconomic disparities in health and healthcare are global issues that affect both adults as well as children. Children with exceptional healthcare needs, especially those with developmental impairments, including Autism Spectrum Disorders (ASD), encounter major disparities in access to and quality of health services. However, disparities in the population of children are rarely studied. The main aim of this paper is to study the socioeconomic disparities in children with ASD by examining the association between their Social Determinants of Health (SDH) status and access to and the quality of services.

Methods

This is a cross-sectional study on 202 children with ASD conducted in 2019 in two provinces including Ardabil and East-Azerbaijan, in the North-West of Iran. A structured, valid questionnaire was used to collect data on demographic, SDH status, quality of services, and access to services in a population of children with ASD aged 2–16-year-old. Around 77% participants were male and the mean age of children was 2 years and 6 months. Structural Equation Modeling (SEM) were used to assess the relationship.

Results

Based on the results of this study, the overall mean scores of the quality of services, access to services, and SDH status were 61.23 (30.01), 65.91 (21.89), and 29.50 (22.32) out of 100, respectively. All the associations between the quality and access dimensions and quality (B: 0.464–0.704) and access (B: 0.265–0.726) scales were statistically significant (P < 0.001). By adjusting to covariates, the access was also significantly related to service quality (P = 0.004). Finally, the associations between SDH score with service quality (P = 0.039) and access (P < 0.001) were positively significant.

Conclusions

There are socioeconomic disparities in the quality of and access to services among children with ASD, who use ASD services, in the North-West of Iran. We recommend health/medical centers, where children are diagnosed with ASD, conducting SDH screening and providing families of low-SDH status with specific information about the quality of and access to services for children with ASD. Additionally, medical universities must have a plan to routinely monitor the quality of and access to services provided for the children with low SDH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-021-00577-5.

Considerations about the implementation of an autism screening program in Iran from the viewpoints of professionals and parents: a qualitative study

BACKGROUND

The aims of this study were to explore to explore the viewpoints of parents of children with Autism Spectrum Disorders (ASD) and professionals regarding the implementation of screening programs for ASD, to explore the challenges of the implementation of a universal screening program for ASD in Iran from their viewpoints, and, to explore their recommendations to overcome the potential challenges.

METHOD

This qualitative study was conducted using an inductive content analysis, between June 2018 and December 2018, in East-Azerbaijan province of Iran. Data was collected through in-depth interviews and focus group discussions. The participants were purposively selected among two groups: representatives of health system and representatives of children with ASD. A sample of 32 parents and 30 professionals were recruited in this study.

RESULTS

Totally, 9 main themes and 23 sub-themes were extracted in three main areas including: viewpoints of the participants about universal screening for ASD, challenges in implementation of the universal screening program, and participants' recommendations about how to overcome the potential challenges. Main challenges in implementation of the universal screening program included: shortages of ASD screening tools, weakness of the health system, lack of coordination among the ASD service providers, and social and ethical issues.

CONCLUSION

The parents and the professionals had different viewpoints about the implementation of ASD universal screening program in Iran. According to the professionals, there is not enough rational to implement ASD screening program for all children. However, the parents believed that universal screening program is inevitable, and it should be implemented in primary health centers during the early child-care visits. The results of this study open up unspoken issues that could help in initiating the screening program not only in Iran but also in other low- and middle-income countries as well.

Dilemmas of empowering families of children with autism spectrum disorders: a qualitative case study

Purpose

The purpose of this study was to identify the challenges and solutions in the empowerment of families of children with autism in Tabriz located in the North West of Iran.

Design/methodology/approach

In this exploratory and qualitative study, which was conducted from January to March 2019, 14 in-depth face-to-face interviews and 1 focus group (n = 5) were conducted with family empowerment experts. Data analysis was performed based on a content analysis approach via MAXQDA v 10.

Findings

Results revealed that empowerment challenges can be classified into six main themes including shortage of facilities and specialists, family-related problems, administrative and organizational, cultural and societal, financial and other problems. The most important empowerment solutions were divided into three main themes including informing and training skills by holding empowerment programs, governmental and insurance companies support, and organizational and administrative solutions.

Research limitations/implications

Limitation of this study is that families are not included; as families may also provide or challenge other solutions for empowerment based on their needs, ignoring their views may be losing part of vital information in this field. It is recommended that this research be conducted in the future from the perspective of families of people with autism and other stakeholders.

Practical implications

Based on the results of this study, stakeholders in the field of autism and the family empowerment can address the identified challenges and utilize solutions to improve the process of family empowerment and make more effective decisions in this regard.

Originality/value

Literature searches revealed a lack of any completed research in Iran specific to identifying empowerment challenges and related solutions. Efforts must be taken on root challenges which have been identified scientifically.

Effectiveness of the non-pharmaceutical public health interventions against COVID-19; a protocol of a systematic review and realist review

Background

Without any pharmaceutical intervention and vaccination, the only way to combat Coronavirus Disease 2019 (COVID-19) is to slow down the spread of the disease by adopting non-pharmaceutical public health interventions (PHIs). Patient isolation, lockdown, quarantine, social distancing, changes in health care provision, and mass screening are the most common non-pharmaceutical PHIs to cope with the epidemic. However, there is neither systematic evidence on the effectiveness of non-pharmaceutical PHIs in controlling the COVID-19 nor on how these interventions work in different contexts. Therefore, in this study we will address two main objectives: 1) to assess the effectiveness of the non-pharmaceutical PHIs in controlling the spread of COVID-19 using a systematic review and meta-analyses; 2) to explore why, how, and for whom these interventions work using a realist review.

Materials and methods

This review study has two main phases. In the first phase of this study, we will extract data from two main types of studies including quasi-experimental studies (such as quasi-randomized trials, controlled before-after studies (CBAs) and interrupted time series studies (ITSs)) and observational studies (such as cohort, case-control, and cross-sectional studies), written in the English language. We will explore effectiveness of the non-pharmaceutical PHIs targeted either suppression or mitigation strategies (or a combination of both) in controlling the COVID-19 epidemics in the community level. Effectiveness will be considered as the changes in mortality rate, incidence rate, basic reproduction number rate, morbidity rate, rates of hospitalization, rates of intensive care unit (ICU) hospitalization, and other health outcomes where possible. We will perform random-effects meta-analyses, if possible, using CMA software. In the second phase, we will conduct a realist review to find out how, why, for whom, and in what circumstances the non-pharmaceutical PHIs work. At the realist review, we will identify and explore Context-Mechanism-Outcome configurations to provide a robust explanation on the effectiveness of the interventions in different contexts using Pawson's 5-step realist review template including: "clarify scope; search for evidence; appraise primary studies and extract data; synthesize evidence and draw conclusions; and disseminate, implement and evaluate". Although the steps are presented in a linear manner, in practice, we will follow them in iterative stages to fill any potential overlap.

Discussion

The findings of this research will provide a crucial insight into how and in which context the non-pharmaceutical PHIs work in controlling the spread of COVID-19. Conducting a systematic review and meta-analysis in line with a realist review will allow us to draw a robust conclusion on the effects and the way in which the interventions work. Understanding the role of contextual factors in the effectiveness of non-pharmaceutical PHIs and the mechanism of this process could enable policymakers to implement appropriate policies and manage the COVID-19 epidemics more efficiently.

Systematic review registration

CRD42020186855.

Preventive Community-Based Strategies of Cardiovascular Diseases in Iran: A Multi-Method Study

BACKGROUND

Community-based strategies for preventing non-communicable diseases, particularly cardiovascular diseases, are of great importance.

AIMS

This study aimed to formulate a policy brief to identify and prioritize community-based strategies to prevent cardiovascular disease in Iran.

METHODS

This multi-method study was conducted over three phases. In the first phase, rapid review, community-based strategies which mentioned to people's participation had been identified. PubMed and Scopus had been searched. In the second phase, a focus group discussion (FGD) was held by the participation of 15 experts from different disciplines to have been summarized and finalized the community-based strategies to prevent cardiovascular disease as policy options. Content analysis method was used. In the third phase, policy options were prioritized. In addition, the points of interest and the appropriate budget were suggested for each policy option by using the Delphi method with the participation of 15 experts.

RESULTS

Community-based approach includes six strategies: engagement of non-governmental and charitable organizations, use of health marketing strategies, activating the role of community health workers, implementing of mobile health programs, social prescribing, and peripheral medicine.‌‌‌ Utilizing Community health workers, using mobile health and engaging NGOs and charities were ported in higher levels. In all policy options, public-private partnership as the best investment as well as the Ministry of Health as the best focal point were proposed.

CONCLUSION

Implementing multiple prevention strategies in the form of public engagement, incorporating prevention programs delivered by community health workers and increasing public-private partnership financial support may be effective in reducing cardiovascular disease.

Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression

Background

Type 2 diabetes mellitus (T2DM) is a metabolic disease with complex causes, manifestations, complications and management. Understanding the wide range of risk factors for T2DM can facilitate diagnosis, proper classification and cost-effective management of the disease.

Aims

To compare the power of an artificial neural network (ANN) and logistic regression in identifying T2DM risk factors.

Methods

This descriptive and analytical study was conducted in 2013. The study samples were all residents aged 15-64 years of rural and urban areas in East Azerbaijan, Islamic Republic of Iran, who consented to participate (n = 990). The latest data available were collected from the Noncommunicable Disease Surveillance System of East Azerbaijan Province (2007). Data were analysed using SPSS version 19.

Results

Based on multiple logistic regression, age, family history of T2DM and residence were the most important risk factors for T2DM. Based on ANN, age, body mass index and current smoking were most important. To test for generalization, ANN and logistic regression were evaluated using the area under the receiver operating characteristic curve (AUC). The AUC was 0.726 (SE = 0.025) and 0.717 (SE = 0.026) for logistic regression and ANN, respectively (P < 0.001).

Conclusions

The logistic regression model is better than ANN and it is clinically more comprehensible.

A framework to assess management performance in district health systems: a qualitative and quantitative case study in Iran

The aim was to design a district health management performance framework for Iran's healthcare system. The mixed-method study was conducted between September 2015 and May 2016 in Tabriz, Iran. In this study, the indicators of district health management performance were obtained by analyzing the 45 semi-structured surveys of experts in the public health system. Content validity of performance indicators which were generated in qualitative part were reviewed and confirmed based on content validity index (CVI). Also content validity ratio (CVR) was calculated using data acquired from a survey of 21 experts in quantitative part. The result of this study indicated that, initially, 81 indicators were considered in framework of district health management performance and, at the end, 53 indicators were validated and confirmed. These indicators were classified in 11 categories which include: human resources and organizational creativity, management and leadership, rules and ethics, planning and evaluation, district managing, health resources management and economics, community participation, quality improvement, research in health system, health information management, epidemiology and situation analysis. The designed framework model can be used to assess the district health management and facilitates performance improvement at the district level.

Service quality from the perspective of myocardial infarction patients

OBJECTIVE

Service quality (SQ) generally refers to the nonclinical aspects of health services and primarily focuses on the relationship between the care provider and the customers, and the environment in which care services are delivered. The aim of this study was to assess the SQ provided for myocardial infarction (MI) from the patients' perspective.

METHODS

A cross-sectional study was conducted with 164 patients with MI at the Tabriz Shahid Madani cardiology clinic. Study participants were selected using convenience sampling. SQ was measured using a validated Comprehensive Quality Measurement in Healthcare SQ questionnaire. The reliability was confirmed based on Cronbach's alpha coefficient (α=0.81). SQ was calculated using the formula SQ=10- (importance × performance), based on the importance and performance of non-health-related aspects from the customers' perspective. Importance scores ranged from 1 to 10 and performance was scored between 0 and 1.

RESULTS

Of 164 participants, about 75% were men and almost 44% were between 51 and 65 years of age. From the customers' perspective, the total SQ score was 6.80 (0-10 scale), and the individual scores for all SQ aspects were below an acceptable level. Confidentiality, dignity and continuity were given the highest scores, while availability of support groups had the lowest score.

CONCLUSION

The study findings revealed an opportunity to improve SQ. Patient and provider participation in quality improvement activities could be an effective strategy to improve the aspects of health care quality that were most important to the customers and those with low scores, such as availability of support groups.

Evaluation of the district health management fellowship training programme: a case study in Iran

OBJECTIVE

To evaluate the district health management fellowship training programme in the north-west of Iran.

DATA SOURCES/STUDY SETTING

The programme was introduced to build the managerial capacity of district health managers in Iran. Eighty-nine heads of units in the province's health centre, district health managers and the health deputies of the district health centres in the north-west provinces of Iran had registered for the district health management fellowship training programme in Tabriz in 2015-2016.

STUDY DESIGN

This was an educational evaluation study to evaluate training courses to measure participants' reactions and learning and, to a lesser extent, application of training to their job and the organisational impact.

DATA COLLECTION/EXTRACTION METHODS

Valid and reliable questionnaires were used to assess learning techniques and views towards the fellowship, and self-assessment of health managers' knowledge and skills. Also, pretest and post-test examinations were conducted in each course and a portfolio was provided to the trainees to be completed in their work settings.

PRINCIPAL FINDINGS

About 63% of the participants were medical doctors and 42.3% of them had over 20 years of experience. Learning by practice (scored 18.37 out of 20) and access to publications (17.27) were the most useful methods of training in health planning and management from the participants' perspective. Moreover, meeting peers from other districts and the academic credibility of teachers were the most important features of the current programme. Based on the managers' self-assessment, they were most skilful in quality improvement, managing, planning and evaluation of the district. The results of the post-test analysis on data collected from district health managers showed the highest scores in managing the district (77 out of 100) and planning and evaluation (69) of the courses.

CONCLUSION

The results of this study indicated that training courses, methods and improvement in managers' knowledge about the health system and the skills necessary to manage their organisation were acceptable.

Managerial barriers and challenges in Iran public health system: East Azerbaijan health managers' perspective

OBJECTIVE

To investigate managerial barriers and challenges facing East Azerbaijan Province health system.

METHODS

This qualitative study was conducted in Tabriz, Iran, from August 2014 to August 2015, and comprised professionals, experts and informants working at the East Azerbaijan Health Centre. Data was collected through focus group discussions and semi-structured, face-to-face, individual and group interviews were conducted. Interviews and focus group discussions were taped, transcribed and analysed using content analysis method..

RESULTS

Of the 46 participants, 29(63%) were male and 17(37%) were female. Moreover, 15(33%) participants were head of their respective units and 8(17%) were district health managers. Managerial barriers witnessed during the study period differed between the three managerial levels of interest, i.e., district health centres, provincial health centre departments and top levels of provincial health centre and macro-management systems outside the health centre. Lack of management training, inadequate resources, unclear duties and responsibilities were considered to be the most common barriers facing district health centres. Unclear budgeting mechanisms, instability of management positions and shortage of trained staff on provincial and district levels were reported to be managerial barriers in provincial health centre departments. Political interference in technical decisions, treatment-based approaches, lack of clear career paths on all levels of health system management, unnecessary bureaucracy lying within inter-organisational relationships and ineffective employment legislation were identified as managerial barriers on top levels of the provincial health system and in macro-management systems independent of the health system.

CONCLUSIONS

Diverse challenges influenced the performance of health managers.

Developing management capacity building package to district health manager in northwest of Iran: A sequential mixed method study

OBJECTIVE

To assess districts health managers educational needs and develop management training programmes.

METHODS

This mixed-method study was carried out between August 2014 and August 2015 in Tabriz, Iran. Four focus group discussion sessions and three semi-structured face-to-face interviews were conducted among district health managers and experts of a health centre. Besides, 52 questionnaires were completed to weigh and finalise management education module and courses. Interviews and focus group discussions were tape-recorded, transcribed and analysed using content analysis method. Data was analysed using SPSS17.

RESULTS

There were 52 participants, of whom 40(78.8%) were men and 12(21.2%) were women. All of the subjects (100%) took part in the quantitative phase, while 25(48.08%) participated in the qualitative phase. In the qualitative section, 11(44%) participants were heads of unit/departments in provincial health centre and 14(56%) were district health managers. In the quantitative phase, 30(57.7%) participants were district health managers and 8(28.8%) were heads of units/departments. Moreover, 33(63.4%) participants had medical education. The job experience of 3(5.8%) participants in the current position was below five years. Districts health management training programme consisted of 10modules with 53 educational topics. The normalised score out of a total of 100 for rules and ethics was 75.51, health information management 71.19, management and leadership 69.27, district management 68.08, human resources and organisational creativity 67.58,quality improvement 66.6, health resources management 62.37, planning and evaluation 61.87, research in health system 59.15, and community participation was 53.15.

CONCLUSIONS

Considering district health managers' qualification in health and medicine, they had not been trained in basic management. Almost all the management and leadership courses were prioritised as most necessary.

Customer's self-audit to improve the technical quality of maternity care in Tabriz: a community trial

Pregnant women have a major role to play in assessing and improving their own quality of care. This study in Tabriz, Islamic Republic of Iran, aimed to assess the effectiveness of an intervention for pregnant women-based on education and support groups and involvement in quality assessment activities-in order to improve the technical quality of public maternity care at public health centres. The intervention phase began in September 2011 and lasted 8 months. The outcome measure was health-care providers' degree of adherence to the Iranian maternity care standards. An intervention group of 92 pregnant women from 10 health centres was compared with a control group of 93 pregnant women from 11 centres. Logistic regression analysis showed that the self-assessed technical quality of maternity care received by the women was significantly better in the intervention that the control group for several of the standards concerning clinical examinations, maternal education and vitamin and mineral supplements.

Service quality of delivered care from the perception of women with caesarean section and normal delivery

BACKGROUND

Our aim was to determine the service quality of delivered care for people with Caesarean Section and Normal Delivery.

METHODS

A cross-sectional study was conducted among 200 people who had caesarean section and normal delivery in Al-Zahra Teaching Hospital in Tabriz, north western Iran. Service quality was calculated using: Service Quality = 10 - (Importance × Performance) based on importance and performance of service quality aspects from the postpartum women's perspective.A hierarchical regression analysis was applied in two steps using the enter method to examine the associations between demographics and SQ scores. Data were analysed using the SPSS-17 software.

RESULTS

"Confidentiality", "autonomy", "choice of care provider" and "communication" achieved scores at the highest level of quality; and "support group", "prompt attention", "prevention and early detection", "continuity of care", "dignity", "safety", "accessibility and "basic amenities" got service quality score less than eight. Statistically significant relationship was found between service quality score and continuity of care (P=0.008).

CONCLUSION

A notable gap between the participants‟ expectations and what they have actually received in most aspects of provided care. So, there is an opportunityto improve the quality of delivered care.

Perception and expectation of iran neonatal transport expert regard to developing neonatal transport system in iran: a qualitative research

Introduction:

This study was aimed to reach expert's expectations of neonatal transport system for developing neonatal transport system in Iran.

Materials and Methods:

This is a qualitative study conducted by using focus group discussion (FGD) to present expert's perspectives and expectancy about neonatal transport system. Participants was selected from all experts and specialist about neonatal transport in Iran countryside. Finally 48 experts, participate in this study. To data collection 4 FGD were conducted, data were analyzed by content analyses. All subthemes were categorized in main themes according to conceptual relationship as an expert panels opinions. In order to comply with the ethical issues involved in the study was voluntary, also permission for the recording session were taken and confidentiality was also ensured.

Result:

According to FGD results, 11 themes and 90 subthemes were founded related to neonatal transport system, the main identified themes included: Aims, necessity and models of neonatal transport system, organizing the transport system, management and quality of instruments in the transport system, Neonatal transport system staff, Human resource management and issue related to human resources, conditions and requirements of neonatal transport system, facilitating factors in neonatal transport system, information management and communication system and weakness of neonatal transport system.

Conclusion:

Neonatal transport systems in different countries must adapted according to situation and component of each country have different strength and weakness and in implementing a system must attend to geographical conditions, financial ability and access to professionals, health system structure, facilities related to neonatal health care, antenatal services in regain, health care related, health care program about neonates and pregnant women and epidemiological status and mortality and morbidity in deferent locals and regains in countryside.

Comparing performance of Tabriz obstetrics and gynaecology hospitals managed as autonomous and budgetary units using Pabon Lasso method

BACKGROUND

Considering governmental scrutiny and financial constraints in medicine, the need for improved performance, which can provide acceptable care for medical consumers, leads to the conduct of new managerial methods to improve effectiveness.

AIMS

This study aimed to compare performance indicators of obstetrics and gynaecology teaching hospitals in Tabriz.

METHOD

A longitudinal, retrospective study was conducted to compare performance indexes of Tabriz obstetrics and gynaecology teaching hospitals during 2010-2012. Al-Zahra is Tabriz's central teaching hospital in obstetrics and gynaecology that is authorised under a board of trustees as an autonomous hospital and Taleghani hospital is managed under centralised administration. Study variables included: Average Length of Stay (ALOS), Bed Occupancy Rate (BOR), and Bed Turnover Ratio (BTR). The data was extracted via the Hospital Information Systems (HIS) within the hospitals' admission and discharge units. Pabon Lasso model was used to assess hospital performance. Data was analysed and graphs were plotted using the SPSS-17 software package.

RESULTS

According to study findings, overall ALOS in Al-Zahra hospital is 3.15 (2.15) days (1.88 (0.97) days for prenatal wards and 6.13 (0.97) days for neonatal wards) and ALOS in Taleghani Hospital is 3.37 (3.09) days (1.74 (0.14) days for perinatal wards and 5.96 (3.55) days for neonatal wards). In this regard, Al-Zahra hospital holds the maximum BOR with 86.92 per cent and the minimum BOR was attributed to Taleghani hospital at 68.44 per cent (P<0.001). Study findings indicate that BOR in neonatal wards is greater than prenatal wards. On the other hand, BOR in Al-Zahra is greater than Taleghani (P<0.001), whereas BOR trend shows an increasing pattern in both hospitals.

CONCLUSION

Results of this study showed that the performance of Al- Zahra Hospital is better than Taleghani Hospital. These two hospitals are similar in different aspects except Al-Zahra is under a board of trustees and Taleghani is not. We should also consider that Al-Zahra Hospital has more facilities than Taleghani.

Technical Quality of Maternity Care: the Pregnant Women's Perspective

BACKGROUND

Improving adherence to care standards is one way to improve quality of delivered care. This study aimed to determine the degree of providers' adherence to maternity care standards from the perspective of pregnant women.

METHODS

This cross-sectional study was conducted on 185 pregnant women in their ninth month of pregnancy who received maternity care from health centres in Tabriz, Iran. Participants were selected randomly from 40 health centres. Data collection used a researcher-developed questionnaire based on Iranian Ministry of Health (MOH) standards for maternity care. Questionnaire validity was reviewed and confirmed by 10 experts.

RESULTS

About 69% of pregnant mothers during their 9-month pregnancy received at least six items of standard maternity care. Almost two-thirds of participants received recommended maternity care at or above minimal standards for some aspect, such as the number of care during pregnancy, referral to health centre physician, and weight and blood pressure measurement. Some other services such as measuring uterus height, review for oedema and varicosities, referral to a dentist, listening for fetal heart sound and vaginal examination, were reported at very low adherence to the Ministry of Health guidelines Conclusion: A notable proportion of pregnant mothers reported receiving suboptimal care indicating significant room for improving the quality of maternity care based on Iranian MOH standards and guidelines. The results indicate potential benefits from interventions to improve health care providers training and the awareness of pregnant women about the standards for good maternity care.