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

BACKGROUND: Community participation is currently utilized as a national strategy to promote public health and mitigate health inequalities across the world. While community participation is acknowledged as a civic right in the Constitution of Iran and other related upstream documents, the government has typically failed in translating, integrating and implementing community participation in health system policy. The present study was conducted to determine the level of public voice consideration within the health policy in Iran and address fundamental interventions required to promote the public voice in the context of Islamic Republic of Iran (IRI). This study has originality because there is no study that addresses the requirements of institutionalizing community participation especially in low-middle-income countries, so Iran's experience can be useful for other countries. METHODS: Methodologically, this study utilized a multi-method and multi-strand sequential research design, including qualitative, comparative and documentary studies. In the first phase, the current level of community participation in the health policy cycle of Iran was identified using the International Association for Public Participation (IAP2) spectrum. In the second phase, a comparative study was designed to identify relevant interventions to promote the community participation level in the selected countries under study. In the third phase, a qualitative study was conducted to address the barriers, facilitators and strategies for improving the level of public participation. Accordingly, appropriate interventions and policy options were recommended. Interventions were reviewed in a policy dialogue with policy-makers and community representatives, and their effectiveness, applicability and practical feasibility were evaluated. RESULTS: Based on the IAP2 spectrum, the level of community participation in the health policy-making process is non-participation, while empowerment is set at the highest level in the upstream documents. Moreover, capacity-building, demand, mobilization of the local population, provision of resources and setting a specific structure were found to be among the key interventions to improve the level of community participation in Iran's health sector. More importantly, "political will for action" was identified as the driving force for implementing the necessary health interventions. CONCLUSIONS: To sum up, a paradigm shift in the governing social, economic and political philosophy; establishing a real-world and moral dialogue and communication between the government and the society; identifying and managing the conflicts of interest in the leading stockholders of the healthcare system; and, more importantly, maintaining a stable political will for action are integral to promote and institutionalize participatory governance in the health sector of Iran. All of the above will lead us to scheme, implement and institutionalize suitable interventions for participatory governance in health and medicine.

"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.

Being at the center of attention: Iranian women's experience after suicide attempts.

PURPOSE: A history of suicide attempts is the most important predictor of suicide. The aim of this study was to understand the experience of women after suicide attempts. DESIGN AND METHODS: A purposive sampling method using semistructured in-depth interviews with seven Iranian women was implemented for data collection, and an interpretative phenomenological approach with the van Manen method was used for data analysis. FINDINGS: The main theme was "being at the center of attention," from which emerged two subthemes: "loved ones keeping an eye on them" and "rain of love." PRACTICAL IMPLICATIONS: The study participants experienced satisfaction with their suicide attempt, and some of them felt that they are now being restricted. The study recommends that a special caregiver training program would be beneficial to educate the families in appropriate behavior after a loved one's suicide attempt.

Setting research priorities to achieve long-term health targets in Iran.

BACKGROUND: In 2015, it was estimated that the burden of disease in Iran comprised of 19 million disability-adjusted life years (DALYs), 74% of which were due to non-communicable diseases (NCDs). The observed leading causes of death were cardiovascular diseases (41.9%), neoplasms (14.9%), and road traffic injuries (7.4%). Even so, the health research investment in Iran continues to remain limited. This study aims to identify national health research priorities in Iran for the next five years to assist the efficient use of resources towards achieving the long-term health targets. METHODS: Adapting the Child Health and Nutrition Research Initiative (CHNRI) method, this study engaged 48 prominent Iranian academic leaders in the areas related to Iran's long-term health targets, a group of research funders and policy makers, and 68 stakeholders from the wider society. 128 proposed research questions were scored independently using a set of five criteria: feasibility, impact on health, impact on economy, capacity building, and equity. FINDINGS: The top-10 priorities were focused on the research questions relating to: health insurance system reforms to improve equity; integration of NCDs prevention strategy into primary health care; cost-effective population-level interventions for NCDs and road traffic injury prevention; tailoring medical qualifications; epidemiological assessment of NCDs by geographic areas; equality in the distribution of health resources and services; current and future common health problems in Iran's elderly and strategies to reduce their economic burden; the status of antibiotic resistance in Iran and strategies to promote rational use of antibiotics; the health impacts of water crisis; and research to replace the physician-centered health system with a team-based one. CONCLUSIONS: These findings highlight consensus amongst various prominent Iranian researchers and stakeholders over the research priorities that require investment to generate information and knowledge relevant to the national health targets and policies. The exercise should assist in addressing the knowledge gaps to support both the National General Health Policies by 2025 and the health targets of the United Nations' Sustainable Development Goals by 2030.

Patterns of marriage and reproductive practices: is there any relationship?

Today, a transition from traditional to modern marriages can be observed in many countries. This shift in patterns of marriage has evidently affected childbearing and reproductive practices. This study aimed to examine the relationship between patterns of marriage and reproductive practices in Iran. Hence, 880 married women, aged 15-49 years old, living in the North of Iran were selected using a multi-stage cluster sampling strategy and their patterns of marriage and reproductive practices were cross sectionally studied. The results revealed that there were no significant differences in the reproductive practices by three main patterns of marriage in Babol, Iran. The study also indicated that there were no significant differences in reproductive practices in three patterns of marriage after controlling for socio-economic variables. It seems that apart from the patterns of marriage, other influencing factors are the determinants of fertility in women, and the policy-makers of Iran need to pay attention to these determinants before making any decisions in this area.

Safe Delivery Posts: an intervention to provide equitable childbirth care services to vulnerable groups in Zahedan, Iran.

BACKGROUND: Recently, there has been a shift towards alternative childbirth services to increase access to skilled care during childbirth. OBJECTIVE: This study aims to assess the past 10 years of experience of the first Safe Delivery Posts (SDPs) established in Zahedan, Iran to determine the number of deliveries and the intrapartum transfer rates, and to examine the reasons why women choose to give birth at a Safe Delivery Post and not in one of the four large hospitals in Zahedan. DESIGN: A mixed-methods research strategy was used for this study. In the quantitative phase, an analysis was performed on the existing data that are routinely collected in the health-care sector. In the qualitative phase, a grounded theory approach was used to collect and analyse narrative data from in-depth interviews with women who had given birth to their children at the Safe Delivery Posts. SETTING: Women were selected from two Safe Delivery Posts in Zahedan city in southeast Iran. PARTICIPANTS: Nineteen mothers who had given birth in the Safe Delivery Posts were interviewed. FINDINGS: During the 10-year period, 22,753 low-risk women gave birth in the Safe Delivery Posts, according to the records. Of all the women who were admitted to the Safe Delivery Posts, on average 2.1% were transferred to the hospital during labour or the postpartum period. Three key categories emerged from the analysis: barriers to hospital use, opposition to home birth and finally, reasons for choosing the childbirth care provided by the SDPs. KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE: Implementing a model of midwifery care that offers the benefits of modern medical care and meets the needs of the local population is feasible and sustainable. This model of care reduces the cost of giving birth and ensures equitable access to care among vulnerable groups in Zahedan.

Expert approaches to promote adolescent physical activity in Iran: development of the promoting strategies using the Nominal Group Technique meeting.

BACKGROUND: Several studies have shown that physical activity decreases as the age increases. This study was for evaluating the perspectives of health sciences specialists or informants on the strategies for increasing physical activity among Iranian adolescents using Nominal Group Technique (NGT). METHODS: a semiquantitative/qualitative methodology research using NGT for prioritizing the strategies for alleviating the physical activities among Iranian adolescents based on the opinions of health sciences experts. This study conducted in Tehran, Iran, 2011. RESULTS: Overall, 16 items received scores from 2-29 and were further listed as the accepted strategies for promoting physical activity among adolescents. The most and least recommended strategies were respectively in the categories of school, neighborhood and family. This study findings show 'the constructionist activities or strategies (eg, claim-making, image-making, myth-constructing and framing) among adolescents using main claim-makers of Iranian society, including the state-sponsored media.,' received the highest score by all the participants of NGT. CONCLUSIONS: The interesting finding of this study is the special view point of the specialists to role of socioecological factors in promoting physical activity in the context of Iranian society.

Home birth and barriers to referring women with obstetric complications to hospitals: a mixed-methods study in Zahedan, southeastern Iran.

BACKGROUND: One factor that contributes to high maternal mortality in developing countries is the delayed use of Emergency Obstetric-Care (EmOC) facilities. The objective of this study was to determine the factors that hinder midwives and parturient women from using hospitals when complications occur during home birth in Sistan and Baluchestan province, Iran, where 23% of all deliveries take place in non- hospital settings. METHODS: In the study and data management, a mixed-methods approach was used. In the quantitative phase, we compared the existing health-sector data with World Health Organization (WHO) standards for the availability and use of EmOC services. The qualitative phase included collection and analysis of interviews with midwives and traditional birth attendants and twenty-one in-depth interviews with mothers. The data collected in this phase were managed according to the principles of qualitative data analysis. RESULTS: The findings demonstrate that three distinct factors lead to indecisiveness and delay in the use of EmOC by the midwives and mothers studied. Socio-cultural and familial reasons compel some women to choose to give birth at home and to hesitate seeking professional emergency care for delivery complications. Apprehension about being insulted by physicians, the necessity of protecting their professional integrity in front of patients and an inability to persuade their patients lead to an over-insistence by midwives on completing deliveries at the mothers' homes and a reluctance to refer their patients to hospitals. The low quality and expense of EmOC and the mothers' lack of health insurance also contribute to delays in referral. CONCLUSIONS: Women who choose to give birth at home accept the risk that complications may arise. Training midwives and persuading mothers and significant others who make decisions about the value of referring women to hospitals at the onset of life-threatening complications are central factors to increasing the use of available hospitals. The hospitals must be safe, comfortable and attractive environments for parturition and should give appropriate consideration to the ethical and cultural concerns of the women. Appropriate management of financial and insurance-related issues can help midwives and mothers make a rational decision when complications arise.