Institutionalization for good governance to reach sustainable health development: a framework analysis.

BACKGROUND: This article explores the concept of institutionalization, which is the process of transforming ideas into programs and automating actions, in the context of health system governance and sustainable development. Institutionalization is a key mechanism for creating accountable and transparent institutions, which are essential for achieving health system resilience and sustainability. This study identifies the components and dimensions of institutionalization in the health system and its relationship with good governance and sustainable health development. MAIN TEXT: We applied a scoping review method in five steps. First, we formulated a question for our research. Then, we concluded a comprehensive literature search in five electronic databases for identifying relevant studies. This review has two phases: identifying the concept of institutional approach and its components in health system, and its relationship with good governance to reach Sustainable Health Development (SHD). The third step was study selection, and the 1st author performed data abstraction. The key issues which are identified in our review, related to the concepts of SDH, its goals, pillars and principles; positive peace; good governance; components of institutional approach components, and their relations. Finally, we summarized and organized our findings in a format of a proposed conceptual framework, to underpin the role of institutionalization in the health system to achieve sustainable development. CONCLUSION: Institutionalization is a key concept for achieving positive peace and good governance, which requires meaningful involvement of leaders, politicians, civil society, and public participation. It also depends on the conditions of justice, human rights, transparency, accountability and rule of law. In the wake of COVID-19, institutionalization is more crucial than ever for advancing sustainable development, especially in the context of low and middle-income countries (LMICs).

The challenges associated with the prevention of smuggling and counterfeiting health goods in Iran.

BACKGROUND: Smuggling health goods given the importance and critical nature of health services should be undeniably addressed and controlled by all countries. This issue is especially more widespread in developing countries with more damaging consequences. This paper therefore aims to identify and analyze the challenges of preventing smuggling of health goods in Iran. METHOD: Within this qualitative study, we conducted face-to-face, semi-structured interviews with 30 purposefully recruited key informants and stakeholders in the detection, prevention, and combating of health goods smuggling. Each interview was analyzed thematically, using an inductive approach to generate codes, then categorized and presented in the form of main themes and sub-themes. Maxqda 11 assisted in coding, analysis, and data management. RESULTS: Three main themes emerged representing the challenges of prevention of smuggling in Iran in the areas of anti-smuggling policy development, including categories of inefficient policy and plan, and failure to reach agenda; policy implementation; categorized into actors, resources and instruments, and implementation guarantee; and finally monitoring and evaluation; including, procedures and practices, and the role of surveyors. CONCLUSION: Prevention of smuggling health goods proves to be a highly complex, challenging, and multi-faceted practice. Therefore, strengthening policy-making, regulatory frameworks, and facilitation functions about smuggling, counterfeiting, and corruption should be promoted in parallel.

The experiences and perceptions of people with chronic and rare diseases during political-economic sanctions in Iran: a qualitative study.

BACKGROUND: Economic sanctions aim to exert pressure on political and economic foundations. Hypothesizing that sanctions might affect various aspects of population health, this study, as a component of a broader investigation to ascertain the trend effects of sanctions on selected health outcomes in Iran, seeks to explore the experiences of Iranian citizens associated with the imposed sanctions. METHODS: This is a qualitative study. We conducted 31 semi-structured interviews with randomly selected patients diagnosed with at least one chronic and rare disease from diverse backgrounds across four provinces in Iran. We analyzed data using an inductive content analysis approach, facilitated by the MAXQDA10 software. RESULTS: We identified three primary themes: direct effects, side effects, and coping strategies. The immediate effects were perceived to be manifested through the restriction of healthcare service availability and affordability for citizens. The side effects included the economic hardships experienced in individuals' lives and the perceived devastation caused by these difficulties. Some coping mechanisms adopted by patients or their families/relatives included prioritizing comorbidities, prioritizing health needs within families with multiple ill members, and readjusting health/illness requirements in light of daily living needs. CONCLUSION: In addition to the inherent burden of their illness, patients faced substantial healthcare costs as a result of sanctions, restricted access to medications, and availability of low-quality medications. We advocate considering these challenges within the healthcare system resilience framework as a crucial first step for policymakers, aiming to determine actionable measures and mitigate the adverse effects of sanctions on citizens, particularly the most vulnerable groups.

A framework for health information governance: a scoping review.

BACKGROUND: As a newly emerged concept and a product of the twenty-first century, health information governance is expanding at a rapid rate. The necessity of information governance in the healthcare industry is evident, given the significance of health information and the current need to manage it. The objective of the present scoping review is to identify the dimensions and components of health information governance to discover how these factors impact the enhancement of healthcare systems and services. METHODS: PubMed, Scopus, Web of Science, ProQuest and the Google Scholar search engine were searched from inception to June 2024. Methodological study quality was assessed using CASP checklists for selected documents. Endnote 20 was utilized to select and review articles and manage references, and MAXQDA 2020 was used for content analysis. RESULTS: A total of 37 documents, including 18 review, 9 qualitative and 10 mixed-method studies, were identified by literature search. Based on the findings, six core categories (including health information governance goals, advantages and applications, principles, components or elements, roles and responsibilities and processes) and 48 subcategories were identified to form a unified general framework comprising all extracted dimensions and components. CONCLUSIONS: Based on the findings of this scoping review, health information governance should be regarded as a necessity in the health systems of various countries to improve and achieve their goals, particularly in developing and underdeveloped countries. Moreover, in light of the undesirable effects of the coronavirus disease 2019 (COVID-19) pandemic in various countries, the development and implementation of health information governance models at organizational, national and international levels are among the pressing concerns. Researchers can use the present findings as a comprehensive model for developing health information governance models. A possible limitation of this study is our limited access to some databases.

Health condition of Afghan refugees residing in Iran in comparison to Germany: a systematic review of empirical studies.

BACKGROUND: The re-emerging dominance of the Taliban in Afghanistan in 2021 caused a new wave of Afghan refugees heading Iran and neighboring countries. Iran in the Middle East and Germany in Europe are two major host countries to the largest populations of Afghan refugees. In both countries, several studies have been done to assess the health condition of refugees. OBJECTIVES: To systematically review the existing literature to identify similarities and differences of health conditions of Afghan refugees living in the two countries, and to synthesize evidence on the health status and health care access of these populations. METHODS: Related electronic databases and grey literature of Iran and Germany on the health of Afghan refugees were scanned and searched up for the period 2000-2020. Key terms were formed by combining "Afghan refugees or immigrants or populations or asylum seekers", "Physical or mental health", "Healthcare service or access or use", "Iran or Germany". Empirical studies were considered if they contained samples of Afghan refugees with particular outcomes for Afghans. Results were categorized for both countries in the three main areas of physical health, mental health, and access/use of healthcare services. RESULTS: Nine hundred twenty-two documents were extracted, of which 75 full-texts were finally reviewed. 60 documents belonged to the health condition of Afghan refugees residing in Iran including 43 in physical health, 6 in mental health, 8 in healthcare access and use, and 3 in multiple aspects of health, and 15 belonged to Germany including 7 in physical health, 4 in mental health, 2 in healthcare access and use, and 2 in multiple aspects of health. A less explicit evaluation of the overall health condition of Afghan refugees was observable, particularly for Germany. While matches on the study subject exist for both countries, in comparison to Germany, we extracted more quantitative and qualitative health studies on Afghan refugees of the mentioned areas from Iran. German health studies were rare, less qualitative, and more on the health condition of diverse refugee groups in general. CONCLUSIONS: Wide gaps and unanswered questions related to mental health and overall health status of the Afghan refugee population are observable, especially in Germany. Our systematic review identified the gap in evidence, which we would recommend to bridge using a wider lens to comprehensively assess the overall condition of refugees considering associations between health and socio-economic and cultural determinants instead of a one-dimensional approach. Further, within health studies on refugee populations, we recommend stratification of results by the country of origin to capture the within-group diversity among refugees with different countries of origin.

Health Equity Impact Assessment (HEIA) reporting tool: developing a checklist for policymakers.

INTRODUCTION: Health Equity Impact Assessment (HEIA) is a decision support tool that shows users how a new program, policy, or innovation affects health equity in different population groups. Various HEIA reporting and dissemination tools are available, nevertheless, a practical standard tool to present the results of HEIA in an appropriate period to policymakers is lacking. This work reports the development of a tool (a checklist) for HEIA reporting at the decision-making level, aiming to promote the application of HEIA evidence for improving health equity. METHODS: This is a mixed-method study that was carried out over four stages in 2022-2023: 1) identifying HEIA models, checklists, and reporting instruments; 2) development of the initial HEIA reporting checklist; 3) checklist validation; and 4) piloting the checklist. We also analyzed the Face, CVR, and CVI validity of the tool. RESULTS: We developed the initial checklist through analysis of 53 included studies and the opinions of experts. The final checklist comprised five sections: policy introduction (eight subsections), managing the HEIA of policy (seven subsections), scope of the affected population (three subsections), HEIA results (seven subsections), and recommendations (three subsections). CONCLUSION: Needs assessment, monitoring during implementation, health impact assessment, and other tools such as monitoring outcome reports, appraisals, and checklists are all methods for assessing health equity impact. Other equity-focused indicators, such as the equity lens and equity appraisal, may have slightly different goals than the HEIA. Similarly, the formats for presenting and publishing HEIA reports might vary, depending on the target population and the importance of the report.

The application of artificial intelligence in health financing: a scoping review.

INTRODUCTION: Artificial Intelligence (AI) represents a significant advancement in technology, and it is crucial for policymakers to incorporate AI thinking into policies and to fully explore, analyze and utilize massive data and conduct AI-related policies. AI has the potential to optimize healthcare financing systems. This study provides an overview of the AI application domains in healthcare financing. METHOD: We conducted a scoping review in six steps: formulating research questions, identifying relevant studies by conducting a comprehensive literature search using appropriate keywords, screening titles and abstracts for relevance, reviewing full texts of relevant articles, charting extracted data, and compiling and summarizing findings. Specifically, the research question sought to identify the applications of artificial intelligence in health financing supported by the published literature and explore potential future applications. PubMed, Scopus, and Web of Science databases were searched between 2000 and 2023. RESULTS: We discovered that AI has a significant impact on various aspects of health financing, such as governance, revenue raising, pooling, and strategic purchasing. We provide evidence-based recommendations for establishing and improving the health financing system based on AI. CONCLUSIONS: To ensure that vulnerable groups face minimum challenges and benefit from improved health financing, we urge national and international institutions worldwide to use and adopt AI tools and applications.

Policy analysis of nutrition stewardship for prevention and control of Non-communicable diseases in Iran.

BACKGROUND: Non- communicable diseases (NCDs) are the main cause of death, which lead to over 73% of death and 62% of DALYs globally. As an unhealthy diet is the leading behavioral risk factor of NCDs, in line with the national action plan for the prevention and control of NCD, this study explored the nutrition-related stewardship problems to reduce the burden of NCDs in Iran. METHODS: This is a qualitative study. We interviewed 30 purposefully identified key informants, i.e., stakeholders, policymakers, and academics, from December 2018 to August 2019. All interviews were recorded and transcribed verbatim. We analyzed data using qualitative content analysis facilitated by MAXQDA 11 software. RESULTS: Ample policies and laws were identified, most of which were not or partially implemented. Despite some plausible efforts, NCDs do not seem to be a top priority for high-level managers and decision-makers. Besides, the role of non-state actors, i.e., the private sector, is marginal in NCD's planning and management. Whereas the government, e.g., the Food and Drug Organization (FDO), is the biggest player. Worse still, many harmful products are advertised and easily distributed across the country. CONCLUSION: Iran's government has created a noticeable roadmap to battle NCDs despite imposing many sanctions and related socioeconomic problems. Nevertheless, more interventions are needed to strengthen the stewardship of NCDs by various stakeholders. We recommend the government to monitor the implementation of policies and advertisement of harmful products to prioritize prevention and control of NCDs. In addition, we advocate employing the capacity of non-state actors to reduce the consumption of unhealthy food and the burden of NCDs across the country, ultimately.

The application of artificial intelligence in health policy: a scoping review.

BACKGROUND: Policymakers require precise and in-time information to make informed decisions in complex environments such as health systems. Artificial intelligence (AI) is a novel approach that makes collecting and analyzing data in complex systems more accessible. This study highlights recent research on AI's application and capabilities in health policymaking. METHODS: We searched PubMed, Scopus, and the Web of Science databases to find relevant studies from 2000 to 2023, using the keywords "artificial intelligence" and "policymaking." We used Walt and Gilson's policy triangle framework for charting the data. RESULTS: The results revealed that using AI in health policy paved the way for novel analyses and innovative solutions for intelligent decision-making and data collection, potentially enhancing policymaking capacities, particularly in the evaluation phase. It can also be employed to create innovative agendas with fewer political constraints and greater rationality, resulting in evidence-based policies. By creating new platforms and toolkits, AI also offers the chance to make judgments based on solid facts. The majority of the proposed AI solutions for health policy aim to improve decision-making rather than replace experts. CONCLUSION: Numerous approaches exist for AI to influence the health policymaking process. Health systems can benefit from AI's potential to foster the meaningful use of evidence-based policymaking.

Inequality in prevalence, awareness, treatment, and control of hypertension in Iran: the analysis of national households' data.

BACKGROUND: Providing an equitable Universal Health Coverage (UHC) is key for progressing towards the sustainable development goals in the health systems. To help policymakers make hypertension services more equitable with existing (limited) resources in Iran, we examined the inequality of the prevalence, awareness, treatment, and control (PATC) of hypertension as the four indicators of hypertension UHC in Iran.  METHODS: This research was a cross-sectional study of inequality of PATC of hypertension using a representative sample of Iranians aged ≥ 25 years from the Iran 2016 STEP wise approach to Surveillance study (STEPS). Outcome variables consisted of PATC of hypertension. Covariates were demographic (age, sex, and marital status) and living standard (area of residence, wealth status, education, and health insurance) indicators. We drew concentration curves (CC) and estimated concentration indices (C). We also conducted normalized Erreygers decomposition analysis for binary outcomes to identify covariates that explain the wealth-related inequality in the outcomes. Analysis was conducted in STATA 14.1. RESULTS: The normalized concentration index of hypertension prevalence and control was -0.066 (p < .001) and 0.082 (p < .001), respectively. The C of awareness and treatment showed nonsignificant difference between the richest and poorest. Inequality in the hypertension prevalence of females was significantly higher than males (C = -0.103 vs. male C = -0.023, p < .001). Our analyses explained 33% of variation in the C of hypertension prevalence and 99.7% of variation in the C of control. Education, wealth index, and complementary insurance explained most inequality in the prevalence. Area of residence, education, wealth status, and complementary insurance had the largest contribution to C of control by 30%, 28%, 26%, and 21%, respectively. CONCLUSIONS: This study showed a pro-rich inequality in the prevalence and control of hypertension in Iran. We call for expanding the coverage of complementary insurance to reduce inequality of hypertension prevalence and control as compared with other factors it can be manipulated in short run. We furthermore advocate for interventions to reduce the inequality of hypertension control between rural and urban areas.

Intersectoral collaboration in the management of non-communicable disease's risk factors in Iran: stakeholders and social network analysis.

INTRODUCTION: As the major cause of premature death worldwide, noncommunicable diseases (NCDs) are complex and multidimensional, prevention and control of which need global, national, local, and multisectoral collaboration. Governmental stakeholder analysis and social network analysis (SNA) are among the recognized techniques to understand and improve collaboration. Through stakeholder analysis, social network analysis, and identifying the leverage points, we investigated the intersectoral collaboration (ISC) in preventing and controlling NCDs-related risk factors in Iran. METHODS: This is a mixed-methods study based on semi-structured interviews and reviewing of the legal documents and acts to identify and assess the interest, position, and power of collective decision-making centers on NCDs, followed by the social network analysis of related councils and the risk factors of NCDs. We used Gephi software version 0.9.2 to facilitate SNA. We determined the supreme councils' interest, position, power, and influence on NCDs and related risk factors. The Intervention Level Framework (ILF) and expert opinion were utilized to identify interventions to enhance inter-sectoral collaboration. RESULTS: We identified 113 national collective decision-making centers. Five councils had the highest evaluation score for the four criteria (Interest, Position, Power, and Influence), including the Supreme Council for Health and Food Security (SCHFS), Supreme Council for Standards (SCS), Supreme Council for Environmental Protection (SCIP), Supreme Council for Health Insurance (SCHI) and Supreme Council of the Centers of Excellence for Medical Sciences. We calculated degree, in degree, out-degree, weighted out-degree, closeness centrality, betweenness centrality, and Eigenvector centrality for all councils. Supreme Council for Standards and SCHFS have the highest betweenness centrality, showing Node's higher importance in information flow. Interventions to facilitate inter-sectoral collaboration were identified and reported based on Intervention Level Framework's five levels (ILF). CONCLUSION: A variety of stakeholders influences the risk factors of non-communicable diseases. Through an investigation of stakeholders and their social networks, we determined the primary actors for each risk factor. Through the different (levels and types) of interventions identified in this study, the MoHME can leverage the ability of identified stakeholders to improve risk factors management. The proposed interventions for identified stakeholders could facilitate intersectoral collaboration, which is critical for more effective prevention and control of modifiable risk factors for NCDs in Iran. Supreme councils and their members could serve as key hubs for implementing targeted inter-sectoral approaches to address NCDs' risk factors.

The impact of social determinants of health on early childhood development: a qualitative context analysis in Iran.

BACKGROUND: Social determinants have a significant impact on children's development and their abilities and capacities, especially in early childhood. They can bring about inequity in living conditions of children and, as a result, lead to differences in various dimensions of development including the social, psychological, cognitive and emotional aspects. We aimed to identify and analyze the social determinants of Early Childhood Development (ECD) in Iran and provide policy implications to improve this social context. METHODS: In a qualitative study, data were collected through semi-structured interviews with 40 experts from October 2017 to June 2018. Based on Leichter's (1979) framework and using the deductive approach, two independent researchers conducted the data analysis. We used MAXQDA.11 software for data management. RESULTS: We identified challenges related to ECD context in the form of 8 themes and 22 subthemes in 4 analytical categories relevant to the social determinants of ECD including: Structural factors (economic factors: 6 subthemes, political factors: 2 subthemes), Socio-cultural factors (the socio-cultural setting of society: 6 subthemes, the socio-cultural setting of family: 4 subthemes), Environmental or International factors (the role of international organizations: 1 subtheme, political sanctions: 1 subtheme), and Situational factors (genetic factors: 1 subtheme, the phenomenon of air pollution: 1 subtheme). We could identify 24 policy recommendations to improve the existing ECD context from the interviews and literature. CONCLUSION: With regard to the challenges related to the social determinants of ECD, such as increasing social harms, decreasing social capital, lack of public awareness, increasing socio-economic inequities, economic instability, which can lead to the abuse and neglect of children or unfair differences in their growth and development, the following policy-making options are proposed: focusing on equity from early years in policies and programs, creating integration between policies and programs from different sectors, prioritizing children in the welfare umbrella, empowering families, raising community awareness, and expanding services and support for families, specially the deprived families subject to special subsidies.

Setting and prioritizing evidence-informed policies to control childhood obesity in Iran: a mixed Delphi and policy dialogue approach.

BACKGROUND: The prevalence of childhood obesity (CO) and related complications is high and alarmingly increasing in Iran. This study applied a mixed Delphi & Policy Dialogue approach to exploring and prioritizing policy options to control childhood obesity in Iran. METHODS: This study is organized in three Delphi phases followed by a policy dialogue session. This study applied the advocacy collation framework and evidence-informed policy-making approach to enhance the chance of a feasible and acceptable policy package. The first step consisted of interviews with 30 experts and primary stakeholders. Based on their answers and a comprehensive literature review, a list of presumed effective policy options to combat CO in Iran was made. Then, panelists were asked to score each policy option using a five-point Likert scale in seven constructs. To maximize the spread of opinions, panelists were chosen to represent three perspectives: policy-makers at different levels, presidents of various organizations who would implement potential policy options, and academics. Twenty-one stakeholders were invited to discuss the policy options in a policy dialogue section. RESULTS: We introduced 27 policy options and asked stakeholders to rank them using seven criteria on a five-level Likert scale. Totally, 41 experts participated in round 2 (66.2% response rate), and 33 experts took part in round 3 (72% response rate). Participants believed that healthy schools, creating healthy environments in kindergartens and other child care centers, subsidizing healthy foods, educating healthy lifestyles in mass media, and increasing access to physical activity facilities are the most effective and feasible policies in controlling CO. After the policy dialogue, the healthy school remained the most prioritized policy. a policy package to combat CO in Iran was designed with the participation of all stakeholders. CONCLUSION: The advocacy collation framework and the evidence-informed policy-making approach were used to draft a policy package to combat CO, increasing the acceptability and feasibility of the developed policy package.

"To enroll or not to enroll": a qualitative study on preferences for dental insurance in Iran.

BACKGROUND: Oral public health services are included in primary healthcare. Although oral diseases are preventable, improving oral health has become a concern in many countries. Evidence shows that functioning insurance coverage can significantly increase the use of dental health services, improve quality of services, and reduce financial barriers to utilization. Little evidence exists on households' preferences for dental insurance in Iran. This study seeks to identify the households' preferences for dental insurance in Tehran-Iran. METHOD: This is a qualitative study. We interviewed 84 participants who visited selected public and private dental clinics in Tehran-Iran, from October 2018 until January 2019. All interviews were recorded and transcribed verbatim. We used a mixed inductive/deductive approach for thematic analysis of the interviews. RESULTS: We identified two main themes and 12 sub-themes: pecuniary attributes (insurance premium, coinsurance, insurance coverage granted, discounting option, reimbursement of expenses), and non-pecuniary attributes (notification status, ethical issues, benefits package, contract providers with health insurance, quality of service centers, administrative process, and dental insurance scheme). CONCLUSION: Our participants considered both pecuniary and non-pecuniary attributes for choosing a dental insurance package. Our findings could help, we envisage, policymakers understand Iranian households' preferences for a dental insurance scheme that they afford to buy.

Short and Long-term Impacts of COVID-19 Pandemic on Health Equity: A Comprehensive Review.

Background: The impact of the COVID-19 pandemic on human life has led to profound consequences in almost all societies worldwide, and this includes its significant impact on all aspects of health. Health equity has been among the main challenges in any healthcare system. However, with the COVID-19 crisis worsening health inequalities, the need to prioritize health equity in upstream national and international plans must receive scholarly attention. Therefore, this paper reports the findings of a review of the current synthesized evidence about the impact of the COVID-19 pandemic on health equity. Methods: This is a comprehensive review in which we retrieved relevant studies during the period starting from 12/01/2019 to 01/15/2021 are retrieved from various databases. The PRISMA flow diagram and a narrative approach are used for synthesizing the evidence. Results: We initially retrieved 1173 studies, and after a primary quality appraisal process, 40 studies entered the final phase of analysis. The included studies were categorized into five main outcome variables: Accessibility (95%), Utilization (65.8%), Financial protection: 15 (36.5%), Poverty (31.7%), and Racism (21.9%) Conclusion: COVID-19 pandemic has been the most devastating global challenge in recent history. While the COVID-19 crisis is still unfolding, its multidimensional adverse effects are yet to be revealed. Nevertheless, some people, e.g., the elderly, minorities, as well as marginalized and poor persons, have suffered the COVID-19 consequences more than others. In line with the whole government/whole society approach, we advocate that governments need to strengthen their special efforts to reduce the extra burden of the pandemic on the most vulnerable populations.

Application of discrete choice experiments to estimate value of life: a national study protocol in Iran.

BACKGROUND: Global concerns regarding the significant burden of non-communicable diseases and injuries (NCDIs) exist from both public health and economic perspectives. Our research focuses on the reduction of fatal risks due to NCDIs and the citizens' preferences about health programs and intervention to reduce premature death due to NCDIs. Governments and health authorities need reliable evidence and information to prioritize the interests of their citizens. One crucial piece of evidence to justify the resources spent on NCDIs is the value derived from the interventions on prevention and NCDIs control. This concept is usually called "Value of Statistical Life" (VSL), meaning the monetary value that individuals place on changes in the risk levels of life- threatening events. To the best of our knowledge, for the first time, our study will estimate the statistical value of life for selected interventions for the prevention and control of NCDIs at both national and sub-national levels in the context of Iran. This paper reports the development of a national protocol through Discrete Choice Experiments (DCEs) method. METHODS AND DESIGNS: Our study comprises several stages: (a) a literature review to identify the attributes and levels of the prevention programs and Willingness to Pay (WTP) for reducing the NCDI's fatal risks; (b) experimental design to assessing, prioritizing, and finalizing the identified attributes and levels; (c) instrumental design to conduct face-to-face structured survey interviews of 3180 respondents aged 18-69 across the entire country; (d) statistical analysis to estimate the results through the Mixed Multinomial logit (MMNL) model. DISCUSSION: We anticipate that our findings will help build a stronger empirical basis for monetizing the value of small changes in selected fatality risks. It paves the way for other national or vast VSL estimates for NCDIs, as well as other major causes of morbidity and mortality in the context of Iran, and perhaps other low and middle-income countries (LMICs).

Analysis for policy to overcome barriers to reducing the prevalence of vitamin a deficiency among children (15-23 months) in Iran.

BACKGROUND: About 30% of children < 5 years old are estimated to experience vitamin A deficiency worldwide. Globally, vitamin A deficiency can be reduced by five major interventions: supplementation, dietary modification, fortification, promotion of both public health, and breastfeeding. This prospective policy analysis (Prospective policy analysis focuses on the future outcomes of a proposed policy. Adapted from Patton, CV, and Sawicki DS. Basic Methods of Policy Analysis and Planning, Prentice-Hall, Inc. New Jersey,1993). (Patton A, Carl V, and David S. Basic methods of policy analysis and planning, prentice-hall, 3th ed. 2012) aimed to identify evidence-based policy options to minimize prevalence (VAD) among 15-23 months-children in Iran. METHODS: Thirty-eight semi-structured face-to-face interviews were held with experts at high, middle, and low managerial levels in Iran's health system, as well as at Schools of Nutrition Sciences and dietetics, using purposive and snowball sampling. All interviews were recorded by a digital voice recorder and then transcribed, codified, and eventually analyzed using a mixed approach (inductive-deductive) by MAXQDA software version 10. RESULTS: Most policies related to VAD reduction in this age group are supplementation, expansion of education, and awareness. Three main factors affecting VAD reduction policies emerged from the analysis: basic factors (governance, infrastructure, and organization), underlying factors (social factors, economy), and immediate factors (services). Due to its cross-sectoral nature, evaluating the results of the implementation of this policy requires strong and coherent inter-sectoral cooperation. The existing primary healthcare network (PHC) is a crucial means for successful implementation of policies to address VAD in Iran. CONCLUSIONS: In addition to supplementation and assistance in this age group, other policies should be also planned to reduce VAD in various regions. In addition to the Ministry of Health & Medical Education (MoHME), other actors need to be involved, we advocate, throughout the entire policymaking process of policy-making to reduce VAD in Iran.

"Applying Intersectionality in designing and implementing health interventions: a scoping review".

BACKGROUND: Given the potential of intersectionality to identify the causes of inequalities, there is a growing tendency toward applying it in the field of health. Nevertheless, the extent of the application of intersectionality in designing and implementing health interventions is unclear. Therefore, this study aimed to determine the extent to which previous studies have applied intersectionality and its principles in designing and implementing health interventions. METHODS: The title and abstract of the articles which were published in different databases e.g. PubMed, Web of Science, Proquest, Embase, Scopus, Cochrane, and PsychInfo were screened. Those articles that met the screening criteria were reviewed in full text. The data about the application of principles of intersectionality, according to the stages heuristic model (problem identification, design & implementation, and evaluation), were extracted through a 38-item researcher-made checklist. RESULTS: Initially, 2677 articles were found through reviewing the target databases. After removing the duplicated ones and screening the titles and abstracts of 1601 studies, 107 articles were selected to be reviewed in detail and 4 articles could meet the criteria. The most frequently considered intersectionality principles were "intersecting categories" and "power", particularly at the stages of 'problem identification' as well as 'design & implementation'. The results showed that "multilevel analysis" principle received less attention; most of the studies conducted the interventions at the micro level and did not aim at bringing about change at structural levels. There was a lack of clarity regarding the attention to some of the main items of principles such as "reflexivity" as well as "social justice and equity". These principles might have been implemented in the selected articles; however, the authors have not explicitly discussed them in their studies. CONCLUSIONS: Given the small number of included studies, there is still insufficient evidence within empirical studies to show the implication of intersectionality in designing and conducting health interventions. To operationalize the intersectionality, there is a need to address the principles at various stages of health policies and interventions. To this end, designing and availability of user-friendly tools may help researchers and health policymakers appropriately apply the intersectionality.

Integrated early childhood development policy in Iran: a qualitative policy process analysis.

BACKGROUND: Integrated early childhood development (IECD) is a comprehensive approach to optimal development of children in different developmental domains from fetal stage to eight years of age. The aim of this study was to identify the factors affecting the process of policy-making for early childhood development and to clarify how these factors affect decision-making and create challenges in this regard. METHOD: In a qualitative study, we used two main data sources including document analyses and interviews. Using purposive sampling, forty semi-structured interviews with policymakers and informants in the fields related to children were conducted in Tehran from October 2017 to June 2018. Also, 62 national and 10 international relevant documents were reviewed. A deductive-inductive approach was used to analyze the data. We used the MAXQDA11 software for data management. RESULTS: we identified 13 themes and 29 subthemes related to the stages of policymaking process including: Agenda setting (problem stream, policy stream, politics stream), Policy formulation (formulation and approval process, policy sustainability, mechanisms of stakeholders' participation in policymaking), Policy implementation (conceptual ambiguity, intersectoral and trans-sectoral issues, structural capacities, mobilization of resources), and Policy evaluation (continuous and routine data registry system, comprehensiveness of indexes). We propose 19 policy recommendations to improve the situation. CONCLUSION: As a multidisciplinary and multi-sectoral field with different domains, early childhood development (ECD) requires a more active role on the part of policymakers in governmental levels in supporting the related policies. Unless policymakers change their approach to decrease nonintegrated and non-comprehensive policymaking for ECD, child development will be compromised, which endangers the eventual sustainability of the society since improved IECD policy-making process improves developmental outcomes in children. In this regard, attention should be paid to the role of reinforcing intersectoral collaboration through incorporating it in the missions and the evaluation items of organizations, creating commitment in high organizational levels, and developing an inter-ministerial policymaking framework that clearly specifies the roles and responsibilities of every single sector and their interactions and collaborations.

Socioeconomic determinants of unmet need for outpatient healthcare services in Iran: a national cross-sectional study.

BACKGROUND: Unmet need is a critical indicator of access to healthcare services. Despite concrete evidence about unmet need in Iran's health system, no recent evidence of this negative outcome is available. This study aimed to measure the subjective unmet need (SUN), the factors associated with it and various reasons behind it in Iran. METHODS: We used the data of 13,005 respondents over the age of 15 from the Iranian Utilization of Healthcare Services Survey in 2016. SUN was defined as citizens whose needs were not sought through formal healthcare services, while they did not show a history of self-medication. The reasons for SUN were categorized into availability, accessibility, responsibility and acceptability of the health system. The multivariable logistic regression was used to determine significant predictors of SUN and associated major reasons. RESULTS: About 17% of the respondents (N = 2217) had unmet need for outpatient services. Nearly 40% of the respondents chose only accessibility, 4% selected only availability, 78% chose only responsibility, and 13% selected only acceptability as the main reasons for their unmet need. Higher outpatient needs was the only factor that significantly increased SUN, responsibility-related SUN and acceptability-related SUN. Low education was associated with higher SUN and responsibility-related SUN, while it could also reduce acceptability-related SUN. While SUN and responsibility-related SUN were prevalent among lower economic quintiles, having a complementary insurance was associated with decreased SUN and responsibility-related SUN. The people with basic insurance had lower chances to face with responsibility-related SUN, while employed individuals were at risk to experience SUN. Although the middle-aged group had higher odds to experience SUN, the responsibility-related SUN were prevalent among elderly, while higher age groups had significant chance to be exposed to acceptability-related SUN. CONCLUSION: It seems that Iran is still suffering from unmet need for outpatient services, most of which emerges from its health system performance. The majority of the unmet health needs could be addressed through improving financial as well as organizational policies. Special attention is needed to address the unmet need among individuals with poor health status.