Impact of rural family physician program on child mortality rates in Iran: a time-series study.

BACKGROUND: The rural family physician program and social protection scheme were started in Iran about 10 years ago, and no comprehensive study has been carried out to investigate the effects of this program on mortality-related health indicators yet. The present study aims to examine the impacts of implementation of the family physician program and rural insurance program, which was launched in June 2005, on neonatal (NMR), infant (IMR), and under-5-year (U5MR) mortality rates in rural areas of Iran between 1995 and 2011, using a time-series analysis. METHODS: Three segmented regression models were built to evaluate the effects of the program on NMR, IMR, and U5MR, and several independent variables were entered into the models, including annual incremental effect of the program (variable of interest), time effect, behvarz density, effect of the family physician and rural insurance programs, as well as socioeconomic variables including years of schooling, wealth index, sex ratio, and logarithmic scales of rural population size in each area. Data were gathered from secondary sources and other studies. Data pertaining to the year 2007 were excluded from the final analysis due to their inaccuracy. RESULTS: Our results show that the incremental effect of implementing the rural family physician program is associated with significant reductions in NMR (ß = - 0.341. p - value = 0.003) and IMR (ß = - 0.016. p - value = 0.009). Although the association between this effect and reductions in U5MR were evident, they were not statistically significant (ß = - 0.003. p - value = 0.542). Moreover, wealth status of inhabitants was associated with reductions in NMR (ß = - 0.889. p - value = 0.001), IMR (ß = - 0.052. p - value < 0.001), and U5MR (ß = - 0.055. p - value < 0.001) in the time period of the study. CONCLUSIONS: In this nationally representative study, we showed that implementation of the second health system reform in Iran, known as the family physician program and social protection scheme for rural inhabitants, is associated with significant reductions in NMR and IMR. However, reported reductions in U5MR were not found to be statistically associated with the launch of the program. The advantage of this study was the ability to depict a more precise picture of the outcomes of a national-level intervention.

Cilostazol adjunctive therapy in treatment of negative symptoms in chronic schizophrenia: Randomized, double-blind, placebo-controlled study.

OBJECTIVE: To evaluate the efficacy and safety of cilostazol, a selective inhibitor of phosphodiesterase III, as an adjunctive to risperidone in alleviating the negative symptoms of schizophrenia. METHODS: Eighty-four in-patients with diagnosis of chronic schizophrenia participated in a randomized, placebo-controlled trial and underwent 8 weeks of treatment with either cilostazol (50 mg twice a day) or placebo as an adjuvant to risperidone. Participants were assessed using the positive and negative syndrome scale (PANSS) at baseline and at weeks 2, 4, 6, and 8. The primary outcome measure of the trial was to evaluate the efficacy of cilostazol compared to placebo in improving the PANSS negative subscale score. RESULT: General linear model repeated measures demonstrated significant effect for time × treatment interaction on negative subscale scores (p < .001) and PANSS total (p = .006) but did not demonstrate significant effect on the PANSS positive (p = .37) and general (p = .06) subscales. Frequency of adverse events was not significantly different between the 2 treatment groups. No serious adverse event was observed. CONCLUSION: An 8-week course of treatment with cilostazol as an adjunct to risperidone showed a favorable safety and efficacy profile in patients with schizophrenia.

Truth-telling and hematopoietic stem cell transplantation: Iranian nurses' experiences.

BACKGROUND: Hematopoietic stem cell transplantation is a potential cure for a range of life-threatening diseases, but is also associated with a high mortality rate. Nurses encounter a variety of situations wherein they are faced with discussing bad news with hematopoietic stem cell transplantation patients. RESEARCH OBJECTIVE: The aim of this study was to explore the experiences and strategies used by Iranian nurses related to truth-telling and communicating bad news to hematopoietic stem cell transplantation patients. RESEARCH DESIGN: A qualitative approach using content analysis of interview data was conducted. PARTICIPANTS AND RESEARCH CONTEXT: A total of 18 nurses from the main hematopoietic stem cell transplantation center in Iran participated in semi-structured interviews. ETHICAL CONSIDERATIONS: The Institutional Review Board of the Tabriz University of Medical Sciences and the Hematology-Oncology and Stem Cell Transplantation Research Center affiliated with the Tehran University of Medical Sciences approved the study. FINDINGS: In the first main category, not talking about the disease and potential negative outcomes, the nurses described the strategies of not naming the disease, talking about the truth in indirect ways and telling gradually. In the second main category, not disclosing the sad truth, the nurses described the strategies of protecting patients from upsetting information, secrecy, denying the truth and minimizing the importance of the problem. The nurses used these strategies to minimize psychological harm, avoid patient demoralization, and improve the patient's likelihood of a fast and full recovery. DISCUSSION: The priority for Iranian hematopoietic stem cell transplantation nurses is to first do no harm and to help patients maintain hope. This reflects the Iranian healthcare environment wherein communicating the truth to hematopoietic stem cell transplantation patients is commonly considered inappropriate and avoided. CONCLUSION: Iranian nurses require education and support to engage in therapeutic, culturally appropriate communication that emphasizes effective techniques for telling the truth and breaking bad news, thereby potentially improving patient outcomes and protecting patient rights.

A Burden Assessment of Occupational Exposures in Iran, 1990-2010: Findings from the Global Burden of Disease Study 2010.

BACKGROUND: The present study describes the burden of occupational diseases in Iran based on the results of the Global Burden of Disease study conducted in 2010 (GBD 2010). This study aimed to determine the burden of occupational diseases in Iran based on the results of GBD 2010. It is a cross-sectional study. METHODS: Disability-adjusted life years (DALYs) of occupational diseases were calculated based on the prevalence rates obtained through model estimation, as well as GBD 2010 disability weights and mortality rates obtained from different data registry systems of Iran. Causal association criteria application to select risk outcome pairs, estimation of exposure to each risk factor in the population, estimation of etiological effect size, selection of a counterfactual exposure distribution, risk assessment, and identification of burden attributable to each risk factor were the main conducted statistical steps. RESULTS: There was an increasing trend of DALYs (710.08/100,000 people in 1990 and 833.00/100,000 people in 2005) followed by a slight decrease (833.00/100,000 in 2005-784.55/100,000 people in 2010). A total of 50.4% and 36% of total DALYs per 100,000 people were due to the adverse effects of musculoskeletal disorders and work-related injuries, respectively. CONCLUSIONS: Musculoskeletal disorders and work-related injuries are the most important adverse consequences of work-related risks that require urgent interventions to be controlled. Male workers (15-25 years and over 60) with the highest DALYs and mortality rates need more training programs, safety regulations, and higher level of protection support. In spite the decreasing trend of occupational disease related DALYs and death rates in Iran in recent years, a long-term effort is required to maintain the currently decreasing trend.

Evaluation of Appropriateness Admission and Hospital Stay at Educational Hospital.

BACKGROUND: Appropriate admissions and patients' length of stay are two of the most important indicators of efficient health care delivery in hospitals. Paying due attention to these indicators may lead to optimal use of hospital resources as well as provision of ambulatory services to a larger population of patients. The purpose of the current study is to quantify the rate of inappropriate hospital admissions and days of hospital stay to identify factors affecting them. METHODS: Data were collected regarding admissions and length of stay of 1815 patients admitted to an educational hospital in Tehran, Iran, with a total 12,629 days of hospitalization using the Appropriateness Evaluation Protocol. A qualitative study was conducted using content analysis method by analyzing data from interviews with the hospital personnel about the factors affecting patients' length of stay. RESULTS: The results indicated that the average length of stay in medical and surgical wards was 9.4 to 6.3 days, and 8.5% of admissions and 3.4% of stays were inappropriate. The necessity to receive nursing care and/or to receive medical services and/or the patients' conditions accounted for 57.6% of total hospitalization days, followed by the need to receive nursing care alone (36.6%). Planning/Procedures/ Personnel factors were responsible for 77.3% of inappropriate stays. The qualitative study revealed that in addition to sound in house policy setting, abundance of suitable equipment and facilities at the hospital site had positively affected the appropriateness of hospital stay while incoordination of health care delivery groups, rotation of residents and other wards personnel and lack of a proper complementary patient follow-up system, had a negative impact on the same indicator. CONCLUSION: Inappropriate admissions and inappropriate stays are influenced by numerous factors, both inside and outside of the hospitals; the results of the current study indicate that structural factors such as techniques adopted in the studied hospital, contributed significantly to decreasing inappropriate stays. Improving and upgrading these techniques will make optimal use of hospital beds possible.

Diseases and Health Outcomes Registry Systems in I.R. Iran: Successful Initiative to Improve Public Health Programs, Quality of Care, and Biomedical Research.

Registration systems for diseases and other health outcomes provide important resource for biomedical research, as well as tools for public health surveillance and improvement of quality of care. The Ministry of Health and Medical Education (MOHME) of Iran launched a national program to establish registration systems for different diseases and health outcomes. Based on the national program, we organized several workshops and training programs and disseminated the concepts and knowledge of the registration systems. Following a call for proposals, we received 100 applications and after thorough evaluation and corrections by the principal investigators, we approved and granted about 80 registries for three years. Having strong steering committee, committed executive and scientific group, establishing national and international collaboration, stating clear objectives, applying feasible software, and considering stable financing were key components for a successful registry and were considered in the evaluation processes. We paid particulate attention to non-communicable diseases, which constitute an emerging public health problem. We prioritized establishment of regional population-based cancer registries (PBCRs) in 10 provinces in collaboration with the International Agency for Research on Cancer. This initiative was successful and registry programs became popular among researchers and research centers and created several national and international collaborations in different areas to answer important public health and clinical questions. In this paper, we report the details of the program and list of registries that were granted in the first round.

Evaluation of a critical care outreach service in a middle-income country: A stepped wedge cluster randomized trial and nested qualitative study.

PURPOSE: This trial evaluates implementation of critical care outreach in a middle-income country. MATERIALS AND METHODS: Critical care outreach delivered by a team of intensive care nurses was implemented across general hospital wards in an Iranian university hospital. The order of implementation was randomized with wards stratified by predicted mortality rates. Effectiveness was evaluated using a stepped wedge cluster randomized controlled trial design, comparing outcomes between patients admitted before and after implementation. The primary outcomes were inhospital mortality and cardiopulmonary resuscitation. A nested qualitative study explored challenges to implementation and contextualized the trial outcomes. RESULTS: Between July 2010 and December 2011, 13 wards were sequentially randomized to implement the critical care outreach: 7802 patients were admitted before implementation and 10 880 after implementation. There were 370 deaths (4.74%) among patients admitted before implementation and 384 deaths (3.53%) after implementation. Adjusting for clustering and temporal trends, the odds ratio for mortality was 1.03 (95% confidence interval, 0.68-1.53). Results for other outcomes were broadly similar. Focus groups revealed a lack of endorsement of the intervention by management and ward nurses. CONCLUSIONS: This pragmatic evaluation of critical care outreach in a middle-income country did not show a reduction in mortality or other outcomes.

Epidemiological Profile of Hepatitis B Virus Infection in Iran in the Past 25 years; A Systematic Review and Meta-analysis of General Population Studies.

BACKGROUND Chronic hepatitis B virus (HBV) infection is one of the most important health problems worldwide with a high rate of morbidity and mortality. It is a major risk factor for cirrhosis and liver cancer. Currently, Iran is located in the intermediate HBV zone; however, recent studies have provided some evidence indicating an epidemiological change in the country. The aim of this study was to estimate the prevalence of HBV in Iran. METHODS A systematic review was conducted to evaluate the studies performed in the past 25 years that have reported the prevalence of HBV infection and its associated factors in the Iranian general population (1990-2014). Any study assessing and reporting serum Hbs Ag levels was included in this review. RESULTS After excluding all impertinent studies, 19 eligible studies were included in the analysis. The overall prevalence of HBV was 3% (95% CI 2% to 3%). Its distribution showed that the prevalence of HBV varies in different provinces from 0.87% to 8.86%. The HBV rate was highest in the Golestan (8.86%) and lowest in the Kurdistan (0.87%) provinces. CONCLUSION This study provides some evidence about the prevalence of HBV in Iran. However, the collected data was very heterogenic, even within a single province, which made it hard to estimate a single-point prevalence. High quality studies are needed to find reliable information about HBV prevalence and to decrease the heterogeneity of results in the country.

Birth seasonality in rural areas of Iran, analysis of 5,536,262 births from 1992 to 2007.

PURPOSE: We conducted this study to investigate birth seasonality in rural parts of Iran. METHODS: In this study, patterns of 5,536,262 live births in rural parts of Iran between 1992 and 2007 were studied. Information about birth numbers, environmental factors, and sociocultural status of participants was obtained from previous works. Visually inspecting the seasonal variation of birth, studying its trend using autocorrelation analysis, examining the trend of birth seasonality using the seasonality coefficient, a newly introduced index, studying correlations between birth seasonality and possible associated factors, and analyzing associations between these variables and birth seasonality using multiple regression model were performed in this study. RESULTS: In this study, we showed birth seasonality in rural parts of Iran, with the highest births in the first two seasons, winter and spring, mostly before the year of 2002. Latitude and mean temperature of districts, wealth status of families, education of women, and mothers' ages were associated with birth seasonality. However, latitude, temperature, and mothers' ages lost their associations after adjusting for sociocultural factors in the regression model. CONCLUSIONS: Birth numbers in rural areas of Iran follow a rhythmic seasonal pattern; however, the ordering of seasons changes in the last years of the study period.

Effect size of contributory factors on adverse events: an analysis of RCA series in a teaching hospital.

BACKGROUND: One of the most important concerns of health care systems in the world is the patient safety issues. Root Cause Analysis is a systematic process for identifying root causes and contributory factors of problems or events. The objective of this study is to review RCA reports to determine the effect size of contributory factors on adverse events through an organizational perspective. METHODS: This study was conducted in a tertiary care teaching hospital in 2014. The process of root cause analysis was taken from National Patient Safety Agency framework. We calculated descriptive statistics to determine the frequency distribution of contributory factors on each adverse event. RESULTS: Having the process of 16 adverse events reviewed, 38 care or service delivery problems were identified which showed that 317 contributory factors and underlying causes had led to these problems. Accordingly, the most important contributory factors included the following: Task factors (20 %), education and training factors (16 %), communication factors (14 %), and team and social factors (13 %). CONCLUSIONS: RCA is an effective method of problem solving used for identifying the root causes of initial errors and finding ways to prevent the recurrences. In this study, lack of effective communication skills of nurses and other clinical staff when interacting with colleague and communicating with patients, failure to comply with health care provision standards, lack of adequate supervision on implementation of clinical guidelines and issues related to the organizational culture were the main determining factors which have been considered for implementing preventive measures with regard to the hospital specifications.

Life in limbo: experiences of Iranian hematopoietic stem cell transplantation recipient patients and nurses in a qualitative study.

BACKGROUND: This study explored the state of hematopoietic stem cell transplantation (HSCT) recipient patients and problems experienced by them and nurse about these state and problems, in Iran. METHODS: Qualitative content analysis was used for analyzing semi-structured interviews with 12 HSCT recipient patients and 18 nurses. RESULTS: THREE MAIN CATEGORIES DESCRIBED THE HSCT STATE AND PROBLEMS: shadow of death, living with uncertainty, and immersion in problems. Patients treated with risk variety in continuity with probability of death. The patients lived with uncertainty. Consequently these resulted immersion in problems with four sub-categories including: (a) Physical problems, (b) money worries, (c) life disturbances, and (d) emotional strain. CONCLUSION: HSCT patients live in a state of limbo between life and death with multidimensional problems. Establish centers for supporting and educating of patients and their families, education of health care providers, enhancement of public knowledge about HSCT along with allocating more budgets to take care of these patients can help patients for passing from this limbo.

Views of patients undergo hematopoietic stem cell transplantation on their basic needs.

BACKGROUND: Today, hematopoietic stem cells transplantation (HSCT) has been accepted as a therapeutic approach and is widely applied in many patients with disorders of hematopoietic systems or patients with malignancies. Concomitant use of this therapeutic approach with long term chemotherapeutic procedures and hospitalization requires special care. This study was conducted to examine basic needs of patients after HSCT. METHODS: In this study, 171 hospitalized patients were selected after transplantation, using convenience sampling method. They completed a questionnaire formulated on the basis of Yura and Walsh Theory of Basic Needs. RESULTS: Most of the needs reported in the areas of vital functions, functional health status, and reaction to functional health status were chills (76.8%), insomnia (68.5%), and dissatisfaction with changes of lifestyle/habits (53.6%), respectively. Furthermore, 94.1% of the patients were aware of their disease. CONCLUSION: This study identified a broad spectrum of the needs in HSCT patients. Given the importance of determining needs to reach thorough nursing care, paying attention to the provided list can facilitate the achievement of the goals of the care program for these patients.

Emotional labour of caring for hematopoietic stem cell transplantation patients: Iranian nurses' experiences.

PURPOSE: The purpose of this study was to describe the emotional labour experienced by nurses who care for hematopoietic stem cell transplantation (HSCT) patients in Iran. METHODS: Eighteen nurses participated in semi-structured interviews. The interviews were analyzed using qualitative content analysis methods. RESULTS: Three main categories described the emotional labour involved, namely, emotional intimacy, feeling overwhelmed with the sadness and suffering, and changing self. Nurses had compassion for their patients, contributing to a close nurse-patient relationship. The nurses' emotional labour resulted in their feeling overwhelmed with sadness and suffering. Five subcategories described this emotional toll: (a) witnessing suffering, (b) struggling mentally, (c) hurting emotionally, (d) feeling drained of energy, and (e) escaping grief. Dealing with death and dying on an ongoing basis promoted the nurses' changing self. CONCLUSION: Iranian nurses who care for HSCT patients experience a range of positive and negative emotions. Establishing appropriate support systems for nurses might help mediate the negative aspects of emotional labour. thereby improving nursing work life and ultimately the quality of patient care.