Identifying the challenges of policy content related to high-risk sexual behaviors, stimulant drugs, and alcohol consumption in adolescents.

BACKGROUND: This study aims to identify policy content challenges related to high-risk sexual behaviors, stimulant drugs, and alcohol consumption in Iranian adolescents. METHODS: This qualitative study analyzed high-level and national documents pertaining to adolescent health, high-risk sexual behaviors, stimulant, and alcohol consumption in adolescents. The documents, which were published by public organizations between January 1979 and February 2023 and publicly available, were complemented by interviews with policymakers and executives. The study involved reviewing 51 papers and conducting interviews with 49 policymakers and executives at the national, provincial, and local levels who were involved in addressing adolescent behaviors related to high-risk sexual behaviors, stimulant, and alcohol consumption. The data collected was analyzed using conventional content analysis. RESULTS: The study's results involved examining policy content and identifying challenges related to policy content. The analysis revealed that from the beginning of the Iranian revolution in 1979 until the late 1990s, the dominant approach in Iran was to deny the existence of high-risk behaviors among adolescents. However, in the early 2000s, the country began to adopt a new approach that acknowledged the social harms and ineffectiveness of previous strategies. As a result, a new policy framework was introduced to address high-risk behaviors among adolescents. The study's interviews with policymakers and executives identified 12 challenges related to policy content, including parallel programs, lack of institutional mapping, lack of evidence-based policymaking, lack of integrated approach regarding training, late parent training, lack of consideration of all occurrence reasons in adolescents' high-risk behaviors policymaking, and the existence of many abstinence policies regarding high-risk behaviors. CONCLUSIONS: The study's findings suggest that high-risk behaviors among adolescents in Iran are primarily a health issue, rather than a social or ideological one. Unfortunately, ideological approaches, stigma, and policymaking based on anecdotes rather than evidence have had a significant impact on this area. To improve policymaking in this domain, it is crucial to address these challenges by tackling stigma, adopting an integrated and holistic approach, and implementing evidence-based policies that consider all relevant aspects, including adolescents' subcultures and policy audiences. Such an approach can also be useful for other countries facing similar conditions.

Key factors in the future of oral and dental health in Iran using scenario writing approach.

BACKGROUND: Oral and dental health can significantly impact individuals' quality of life. The World Health Organization introduces oral health as one of the essential priorities of public health worldwide. Given the lack of studies on the future of oral and dental health in Iran, this study used a futures studies approach to identify the factors in oral and dental health in Iran through scenario writing. METHODS: This study was conducted in three stages including the scenario writing approach, qualitative methods, and exploratory future research. First, potential variables affecting future oral and dental health systems were extracted through interviews. The focus group discussion determined the uncertainty and importance of the variables. Then, the cross-impact balance matrix was imported into the Scenario Wizard software to identify the different states of the scenario generator variables and compatible scenarios were extracted. RESULTS: Seventy variables were extracted as key variables affecting the future of oral and dental health. Regarding the importance and uncertainty, seventeen variables scored higher and fell into policy and governance, economy and financing, social, service delivery, and technology, serving as five categories of scenario generators. Fifteen scenarios with weak consistency and three with strong consistency were obtained using the Cross-Impact Balance matrix in Scenario Wizard software. CONCLUSION: The probability of a pessimistic scenario where all five categories of the scenarios were in the worst possible state was higher due to its consistency. The government's support policies and commitment to oral and dental health were two key factors in the future. Achieving an optimistic and favorable scenario for the future of the country's oral and dental health system depends on the government and policymakers in the health sector adopting a positive attitude towards the role of oral and dental health services in improving societal health. In this scenario, the five categories of the scenario generators were in the best condition.

Investigating the quality of hemovigilance process using the first two steps of Six Sigma model: a cross-sectional study.

BACKGROUND AND PURPOSE: Hemovigilance is a set of monitoring methods that covers the blood transfusion chain, from collecting blood and blood products to monitoring the blood recipients. To this end, any error in this process can have serious and irreparable consequences for patients. The present study aimed to investigate the quality of hemovigilance process in Iran, using the first two steps of Six Sigma model. METHODS: This was a quantitative cross-sectional study that was conducted over 6 months (from August 20, 2021, to February 20, 2022) at Afzalipour Hospital in Iran, using the first two steps of Six Sigma model. The study population comprised of all inpatients who needed blood or blood product transfusion in various departments of Afzalipour Hospital, among whom 477 patients were selected via stratified sampling in three shifts (morning, evening, and night). The datasheet was used to record errors in the three shifts. This research was conducted, using the DMAIC cycle's "define" and "measure" steps. RESULTS: In the define step, the hemovigilance process at Afzalipour Hospital was divided into two categories of normal process and emergency process. Each of these processes consists of several sub-processes, including "phlebotomy," "requesting blood and blood products from the department," "preparation of application by the blood bank," " sending a request from the blood bank to the blood transfusion center," "transfusing blood and blood products," and "returning the blood and blood products to the blood bank and waste disposal." In the measure step, the quality of hemovigilance process was evaluated based on sub-processes and labels at morning, evening and night shifts. The sub-process of sending a request from the blood bank to the blood transfusion center had the highest error rate with a sigma level of 1.5. Also, the evening and night shifts had a sigma level of 1.875, and the clinical and registration labels had a sigma level of 1.875. The overall sigma level of hemovigilance process was calculated to be 2. CONCLUSION: The results of this study showed that the quality of hemovigilance process at Afzalipour Hospital was poor. By employing the first two steps of Six Sigma method, we identified the existing errors in the hemovigilance process of Afzalipour hospital in order to assist hospital managers to take the necessary measures to improve this process.

Agenda-setting in policies related to high-risk sexual behaviours, stimulants, and alcohol abuse in Iranian adolescents.

BACKGROUND: This research article retrospectively analyses the agenda-setting approach of policies concerning high-risk sexual behaviours, stimulant and alcohol abuse among Iranian adolescents. METHODS: This qualitative case study policy analysis involved analysing 51 national documents and conducting interviews with 49 policy-makers and executives. Purposive sampling with a snowball strategy and semi-structured interviews were used. The data was analysed using the framework analysis method, with Kingdon's multiple streams framework serving as the analytical framework. RESULTS: The study has identified the confluence of several factors, including the problem stream, the policy stream and the political stream. Within the problem stream, several factors contributed, such as the prevalence of high-risk behaviours, strong scientific evidence on these behaviours, changes in human immunodeficiency virus (HIV) transmission patterns, increased statistics of poisoning and deaths related to alcohol abuse, and the visit of Iran's supreme leader to the slums of Mashhad city. The policy stream has two periods of denial and acceptance. The denial period includes considering these high-risk behaviours to be the consequences of western culture, emphasis on the religious aspects and sinfulness of these behaviours, resisting the prevalence of anomalous behavioural patterns, abstinence and religious obligation of chastity, and avoiding ethical corruption. The acceptance period includes adolescents training, fear messages, promotional and cultural activities, parent training, school staff training, providing psychiatric services for withdrawal, counselling and reference to receive specialized services. The political stream involves global attention towards non-communicable diseases and high-risk behaviours, and the significant impact of preventing these behaviours during adolescence on the health status of society. Also, the supreme leader's attention to social harms, and the establishment of the National Committee for Prevention and Control of Alcohol, have played significant roles. CONCLUSIONS: While the problem stream helped to highlight the problem and increase policy-makers' attention, the politics stream played a significant role. Despite international evidence on the effectiveness of training in sexual issues in reducing high-risk behaviours, it did not succeed in being added to the agenda. The policy stream was heavily influenced by ideology and the political parties in power, affecting evidence-based policy-making. In countries with an ideological approach, the political stream plays a vital role in setting problems on the agenda.

Identification of Key Components in Health System Using System Thinking Approach: A Scoping Review.

Background: The dynamic and systemic planning and targeting in the health system require attention to all the system's components and investigation of their causal relationship in order to form a clear view and image of it. Therefore, the present study was designed with the aim of identifying the comprehensive dimensions of the system within a specific framework. Methods: Key components in the health system were identified through the scoping review method. For this purpose, 61 studies with selected keywords were extracted from international databases, including Scopus, Web of Science, PubMed and Embase, and Persian language databases including Magiran and SID. Inclusion and exclusion criteria in this study were languages, time range, repeated studies, studies related to the health system, appropriateness of studies with the subject and purpose of the present study and the method used. The content of the selected studies and extracted themes were analyzed and categorized in the Balanced Scorecard (BSC) framework. Results: In health system analysis, key components were divided into 18 main categories and 45 categories. Also, they were categorized according to the BSC framework into five dimensions of population health, service delivery, growth and development, financing, and governance & leadership. Conclusion: For health system improvement, policymakers and planners should consider these factors in a dynamic system and a causal network.

Drivers, uncertainties, and future scenarios of the Iranian health system.

BACKGROUND: Health promotion is an essential dimension of sustainable development in any country. It has a high degree of complexity, with numerous components interacting both inside and outside of the system, so having a systemic and forward-looking approach is essential to planning for the future. METHODS: The research has been designed based on scenario-based planning in three main stages. The data gathering was qualitative by working group meetings and compiling an importance-uncertainty questionnaire to complete the cross-impact analysis matrix. The MicMac and scenario Wizard has been used for data analysis. RESULTS: The scoping review and upstream document evaluation lead to 54 key variables for analyzing the Iranian health system (HS). The MicMac analysis ends by determining seven key variables: power, politics, and communication network; lifestyle and behavioral factors; quality of human resources training and education; environmental and occupational risk factors, payment and tariff system, and allocation pattern; support society / individuals health; and services effectiveness, especially para-clinical and outpatient ones. Finally, six main scenario spaces are depicted using Scenario Wizard. collective equity was the priority of the HS vision in the desirable scenario, consisting of the most favorable state of the uncertainties. The second, third, and fourth scenarios are also considered desirable. In the disaster scenario, which is the most pessimistic type of consistent scenario in this study, health and equity are not significant either in the social or individual dimensions. In the sixth scenario, the individual dimension of health and equity is the most critical perspective of the HS. CONCLUSIONS: Due to the unsustainability and high complexity of the Iran's HS, the development and excellence of the HS governance based on the Iran context and health advocacy improvement (applying good governance); creating sustainable financial resources and rational consumption; and human resources training and education are three main principles leading the HS to the images of the desired scenarios.

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

BACKGROUND: One of the major reforms in the health system of any country is the financing reform. Network analysis as a practical method for investigating complex systems allows distinguishing prominent actors in the relation networks. Leading to the identification of the effective actors and key links between them, the analysis of financial networks helps policymakers to implement reformations by providing appropriate evidence. This study aimed to design and analyze the network of National Health Accounts (NHA) and the cost network in the Iran health insurance ecosystem. METHODS: The present study is a network analysis study based on the data from NHA, and both cost and referral rates that was conducted in 2021. Data, which was for the years 2014 to 2018 and related to NHA, was collected from the Statistical Center of Iran, and cost data and referral rates, which were both related to Basic Insurance Organizations (BIOs), were collected from statistical yearbooks. To analyze the network and identify the key actors, macro indicators, such as network size and density, and micro indicators, such as centrality indicators and the combined importance index, were used. RESULTS: In the financing of the health system in Iran, insurance organizations, as agents and sources of financing, do not have a very good position, so direct payments have become a key element in the network of NHA. Providing treatment-oriented services is quite prior. Regarded to health services, hospitals and outpatient services, such as pharmacies and physicians are the key elements of cost and referral rates respectively. CONCLUSION: Consisting of several organizations with different insurance policies and being supervised under different ministries, Iran's health financing system lacks a coherent structure. It is suggested to create a coherent insurance system by creating a single governance system and paying more attention to health-oriented instead of treatment-oriented services. The health insurance ecosystem has become a health-oriented system to reduce the direct payments as well as cost management.

Setting the policy agenda for the treatment of substance use disorders in Iran.

BACKGROUND: Drug use is one of the most common public health problems globally. This study was done to analyze the agenda-setting of policies related to substance use disorder treatment in Iran since 1979. METHODS: The current qualitative study was done through document review and interviews with policymakers and executives. Purposive sampling with snowball strategy was considered for sampling. Semi-structured interviews were done. A total of 22 documents were examined, and the data were saturated with 32 interviews. Kingdon's Multiple Streams Framework was used to analyze the data. RESULTS: The results indicated the intersection of problem stream, policy stream, political stream, and opening the opportunity window. In the problem stream, the rapid growth of AIDS among people who inject drugs (PWID), the decrease in the average age of first drug use, the increase in the prevalence of substance use disorder in women, the ineffectiveness of compulsive treatment, and criminological perspectives played key roles. The policy stream included criminological perspective and war on drugs, and harm reduction. The political stream included announcing general anti-narcotics policies by the Supreme Leader of Iran and understanding the need for treatment, rehabilitation, harm reduction, and social support for substance use disorder by officials and policymakers. CONCLUSIONS: For a long time in Iran, policies based on the war on drugs were the dominant approach, and then, policies based on harm reduction and patient-centeredness were considered. The ideology and political parties influenced the executive apparatus's policy stream in this area. In countries with an ideological approach, the political stream plays a critical role in setting issues on the agenda. Therefore, policy entrepreneurs can put the points on the agenda by attracting the attention of political forces to the issue.

Safety and Efficacy of Remdesivir for the Treatment of COVID-19: A Systematic Review and Meta-Analysis.

PURPOSE: To evaluate the safety and efficacy of remdesivir in adult patients with COVID-19. METHODS: PubMed, Embase, Scopus, Web of Science, Cochrane Library, ClinicalTrials.gov, and medRxiv databases were searched using a search strategy tailored to each database. The Consolidated Standards of Reporting Trials (CONSORT) and Strengthening the reporting of observational studies in epidemiology (STROBE) checklists were used for the studies' qualitative assessment. The outcomes studied were mortality, all adverse events, serious adverse events, and clinical improvement. The quantitative synthesis was conducted using fixed and random effects models in the CMA 2.2. Heterogeneity was tested using the I-squared (I2) measure. RESULTS: In general, six studies, including five randomized controlled trials and one cohort study were found eligible. Comparison of the findings related to both groups receiving remdesivir (10-day remdesivir group) and placebo/control group showed that remdesivir treatment had no significant effect on mortality at day 14 of the treatment (RR=0.769; 95% CI :0.563-1.050; p=0.098), and all adverse events (RR= 1.078; 95% CI: 0.908-1.279; p= 0.392). However, remdesivir had a significant effect on clinical improvement at day 14 compared to placebo/control (OR= 1.447; 95% CI: 1.005-2.085; p= 0.047) and reduced serious adverse events (RR= 0.736; 95% CI: 0.611-0.887; p= 0.001). CONCLUSION: Remdesivir has positive effects on clinical improvement, and reduction of the risk of serious adverse events. However, it does not influence the mortality at day 14 of treatment.

Underlying factors and challenges of implementing the urban family physician program in Iran.

BACKGROUND: The family physician program was launched in 2005 in rural areas of Iran and then piloted in 2012 in the cities of Fars and Mazandaran provinces due to insufficient health coverage in these cities. However, despite its pivotal role in the health system, this program has not progressed according to the policies. This study aimed to explain the underlying factors and challenges of implementing the urban family physician program in Iran. METHODS: This qualitative study was conducted on 44 policy-makers and managers at national and provincial levels selected via snowball and purposive sampling with maximum variation. The data were managed in MAXQDA 2020 and analyzed by directed content analysis. A triangulation method was adopted for this purpose. RESULTS: A total of 10 categories, 18 sub-categories, and 29 codes were formed. Most challenges related to underlying factors included precipitancy, economic sanctions, belief in traditional medicine, belief in the expertise of previous physicians, and global ranking of countries. For program implementation, most challenges included a diversity of insurance organizations, budget allocation, referral system, electronic file, educational system, and culture building. CONCLUSIONS: The major challenges pertaining to underlying factors included international pressure for reforms and precipitancy in program implementation due to management changes. The challenges associated with program implementation included budget provision and interaction with insurance organizations. Therefore, to expand this program to other provinces in Iran, the identified factors should be carefully considered so that sufficient confidence and commitment can be guaranteed for all stakeholders.

Development and validation of a questionnaire to determine medical orders non-adherence: a sequential exploratory mixed-method study.

BACKGROUND: Patients' non-adherence with medical orders of physicians in outpatient clinics can lead to reduced clinical effectiveness, inadequate treatment, and increased medical care expenses. This study was conducted to develop and validate a questionnaire to determine the reasons for patients' non-adherence with physicians' medical orders. METHODS: A sequential exploratory mixed-method study was conducted in two stages. The first stage comprised a qualitative stage to generate the primary items of the questionnaire. This stage provided findings of two sub-stages comprising a literature review and the findings of a qualitative conventional content analysis of 19 semi-structured interviews held with patients, physicians, and managers of the outpatient clinics in Kerman, an area located in southeastern Iran. The second stage comprised a quantitative study aiming evaluation of the instrument psychometric properties, including the face, content, construct, and reliability assessment of the questionnaire. Construct validity assessment was evaluated using exploratory factor analysis (EFA). The reliability assessment was done using assessing internal consistency (Cronbach's alpha). To assess the construct validity of the questionnaire, four hundred and forty patients referred to outpatient clinics in Kerman were selected using stratified convenience sampling to fill out the questionnaire. The sample size was calculated using the Cochran formula. Qualitative and quantitative data were analyzed by MAXQDA 10 and Stata version 14, respectively. RESULTS: The primary items contained 57 items, of which 42 met the minimum acceptable value of 0.78 for item-level content validity index (I-CVI = 1 for 24 items and I-CVI = 0.8 for 18 items). Item-level content validity ratio (I-CVR) was confirmed for 18 items with a minimum acceptable value of 0.99 for five experts. Finally, 18 items obtained the acceptable value for both I-CVI and I-CVR indicators and were confirmed. Using EFA, four factors (intrapersonal-psychological, intrapersonal-cognitive, provider-related, and socio-economic reasons) with 18 items and Cronbach's alpha coefficient of 0.70, 0.66, 0.73, and 0.71, respectively, were identified and explained 51% of the variance. The reliability of the questionnaire (r = 0.70) was confirmed. CONCLUSION: The questionnaire with four dimensions is a valid and reliable instrument that can help determine the perceived reasons for non-adherence with medical orders in the outpatient services system.

Health service delivery models for elderly people: A systematic review.

Background: Current Health care delivery systems are not effective for the elderly. Countries with high elderly populations are expected to design special models to serve their elderly population. The aim of this study is to investigate the models of health care delivery to the elderly in different countries. Methods: The present study is a systematic review based on PRISMA standard guidelines. The search for related studies was conducted in electronic databases (Cochran Library, Scopus, PubMed, Embase, Web of Science) and the Google Scholar search engine without time limits until May 2019. Keywords were extracted based on MeSH strategies. At first, 16243 articles were found. After the screening phase (elimination of duplicated articles, title screening, abstract screening, and full-text screening) 19 articles remained. Two articles deleted after text appraisal using the CASP checklist. In the next stage, after reviewing the gray literature and reviewing the references of remaining articles, three new articles were added (Included studies = 20). Results: Twenty articles (models) corresponding to the study objectives were finally extracted. These models are limited to nine countries and most have local scopes. These models mainly use a case manager, an intra- or inter-disciplinary team, and an elderly assessment tool in their structure. In addition to the use of an information system, these models provide a wide range of services to the elderly. Conclusion: Most of the models mentioned are local models. Smaller models to become applicable at the national level, they need to be reviewed and evaluated by policymakers and experts. Given the inefficiency of current systems in providing services to the elderly, it is recommended that countries use an integrated model of health care provision for the elderly.

Measuring inequalities in the selected indicators of National Health Accounts from 2008 to 2016: evidence from Iran.

BACKGROUND: Increase in total health expenditures is one of the main challenges of health systems worldwide, and its inequality is considered as a concern in global arena especially developing countries. This study aims to measure inequality in the distribution of selected indicators of national health accounts across the Iranian provinces. METHODS: In this study, the data on health financing agents from provincial health accounts from 2008 to 2016 were collected. Gini coefficient (GC) was used to measure inequality. The population and the number of service providers in each province were the bases to measure the GC. The Coefficient of Variation (CV) and the Rate Ratio (RR) were used to determine the dispersion and variation across the provinces. Disparity index was employed to measure the average deviation of the out-of-pocket (OOP) proportion from the desired OOP proportion presented in national development plans (NDPs) of Iran. RESULTS: The distribution of resources using both bases were unequal, especially in OOP, with the highest rate over the years studied, ranging from 0.50 to 0.59. The inequality in public resources was lower, with Health Insurance Organization dropping from 0.42 to 0.40 over the years. CV and RR also confirmed the inequality in health resources distribution. In the years 2014 and 2015, the lowest and highest levels were 0.22 and 0.39, respectively. The values of disparity index for OOP had a fluctuating trend ranging from 37.01 to 65.85%. CONCLUSION: Inequality in the distribution of public health expenditures was moderate to high. Moreover, inequality in private health expenditures was higher than public one. Distribution of OOP spent by households at provincial level showed a high inequality. It is suggested that inequality measures to be considered in NDPs to illustrate how resources are distributed at the geographical level. NHA framework can help to provide robust evidence base for policymaking.

The concept of virginity from the perspective of Iranian adolescents: a qualitative study.

BACKGROUND: Premarital sex can increase the risk of sexually transmitted diseases (STDs) in adolescents, and lack of premarital sex can be considered as a reliable policy for STD prevention, which is used by some countries such as Iran. Since the success of this policy is related to the concept of virginity, the present study was conducted to determine the concept of virginity from the perspective of Iranian adolescents. METHODS: In this qualitative study with phenomenological approach, the research team visited public places, including parks and coffee shops, and interviewed a number of 15-19-year-old adolescents. The data were collected using in-depth interviews with semi-structured questions and analysed using thematic analysis method. RESULTS: Several themes, including virginity as the lack of emotional relationship with the opposite sex, lack of physical contact, nonpenetrative relationship, virginity as a myth, virginity as a commitment, having an intact hymen, and not knowing the meaning of virginity, were extracted from the data. CONCLUSION: The most reliable policy on STD prevention is the lack of premarital sex. The success of this policy is related to the concept of virginity. The findings of this study showed that the participants did not consider physical contact as the breach of virginity. This may indicate that the policy of not having sex before marriage or lack of premarital sex is not enough and Iranian adolescents are at risk of STDs. Therefore, policymakers must take steps towards modifying the concept of virginity in the adolescents' value system and provide and implement educational programs on sexual health for adolescents.

The challenges of ethical behaviors for drug supply in pharmacies in Iran by a principle-based approach.

BACKGROUND: Pharmacists as the trustee of pharmacy services must adhere to ethical principles and evaluate their professionalism. Pharmacists may sometimes show different unethical behaviors in their interactions, so it is essential to understand these behaviors. The present study aimed to determine the challenges of ethical behaviors based on a principles-based approach in the area of drug supply in pharmacies. METHODS: This qualitative content analysis was conducted in Kerman in 2018. A number of key players in the field of medication supply were selected using snowball sampling to interview. An effort was made to select samples with maximum variation. Exclusion criteria include having less than 3 years of work experience in pharmacy and supervision, not willing to participate in the interview, and not participating in the interview for 3 times. The participants in this study consisted of pharmacy technicians (n = 5), patients (n = 6), pharmacists (n = 8), inspectors of insurance companies (n = 4), and inspectors of food and drug administration (n = 3). Data were analyzed using directed content analysis by Maxqda software version 10 (VERBI Software, Berlin, Germany). The principles of "Beauchamp and Childress Ethics" theory including autonomy, beneficence, non-maleficence, and justice were selected as the main principles. RESULTS: After data analysis, 8 main categories and 26 subcategories were obtained. The main categories include patient privacy, patient independence, communication principles, patient-centered services, drug supplier, patient harm avoidance, supervision, and distributive, procedural, and interactional justice. The subcategories include increasing patient awareness, culturizing prescription, and rational drug use, confidentiality and privacy, and pharmacist-patient relationship/communication, which were the main ethical challenges in the area of drug supply at pharmacies. CONCLUSIONS: According to a principle-based approach, the greatest challenges were related to two principles of autonomy and beneficence. The policymakers in the healthcare system should emphasize patient independence, patient privacy, and patient-centered services. The results of this study can be used as a tool to introduce ethical challenges to policymakers and develop educational contents, the chart of professional ethics in pharmacies, and accreditation measures of pharmacies.

Effective factors and drivers of Iran's health care financing system.

Background: Different factors affect Iran's health care financing system, and regardless of this impact, the future of this system will face fundamental challenges. In this environment, a health system is successful if it is able to anticipate the effects of these factors in the future of health care financing and preplan appropriate interventions towards health care financing system. The present study aims to identify these factors and trends. Methods: This study compiled a round view of the experts on the subject, with a future studies approach through a qualitative method. To collect data, a deep and semi-structured interview was performed. The results of the interviews were analyzed using content analysis method, and the primary and secondary themes were extracted using the Micmac software. Results: A total of 71 variables were identified in the form of 12 groups with titles of stewardship, service provision, resource gathering, purchasing and resource allocation, sociocultural, technological, environmental, economic, political, and managerial, and laws and values. Four variables, including distant-service provision, administrative bureaucracy, administrative focus and corruption, low-support decision-making, economic blockade, and sales of oil were among the influential factors and drivers. Conclusion: The findings showed Iran's financing system is relatively stable but fragile and 3 areas of technology, politics, and economics have the most impact on structuring Iran's financing system.

A paradoxical situation in regressivity or progressivity of out of pocket payment for health care: which one is a matter of the health policy maker's decision to intervention?

BACKGROUND: Equity in health financing as one main aspect of health equity plays an essential role on the path toward universal health coverage. Out of pocket payment (OOP), a source with high share to total health expenditure, is an inequitable mechanism for health financing. MAIN BODY: The OOP has been considered regressive (Kakwani index with a negative value) in nature. However, in some studies especially in developing countries, it is reported to be progressive (Kakwani index with a positive value). The main questions are: Is the progressive OOP equitable? What causes this contradiction? What can we do for the proper interpretation? And what are policy implications of this issue? In this commentary we briefly elaborate on these issues. We present several reasons for progressivity of OOP, and several methodological and policy issues for addressing it. CONCLUSIONS: Even if the OOP is progressive and the share of poor people is low, this may financially limit their access to health services, increase their risk of incurring catastrophic health expenditure (CHE), and even pushing them more into poverty. In order to provide a comprehensive picture of equity in health financing, other financial protection indicators such as the redistributive effect, re-rating, exposure to CHE, and impoverishment due to health expenditure should also be estimated and reviewed.

Effective factors in non-compliance with therapeutic orders of specialists in outpatient clinics in Iran: a qualitative study.

BACKGROUND: Non-compliance with prescribed treatment is an important cause of preventable mortality and economic burden. Recognition of the factors for non-compliance with the therapeutic orders of specialists from the perspective of patients and health care providers sheds more light on the issue for policymakers and stakeholders. The current study aimed at determining the factors for non-compliance with therapeutic orders in outpatient clinics in Kerman, Iran. METHODS: The current qualitative study was conducted using the phenomenological method and semi-structured interviews with 10 patients, five specialists, and four health care managers and treatment officials in outpatient clinics in Kerman. The interviewees were selected by purposive sampling. The codes extracted from the interviews were transcribed using conventional content analysis to identify the viewpoints. The MAXQDA 10 software was used to analyze the data. RESULTS: The reasons for non-compliance with specialists' orders were categorized into five themes including patient-related (patient-centered), disease-related, therapy-related, the healthcare provider related (healthcare system), and socioeconomic factors. Themes were composed of fifteen categories and forty-one sub-categories. The dominant sub-categories extracted from interviews were health literacy and knowledge of the patient, communication and patients' trust in physicians and direct costs of treatment. CONCLUSION: This study identified a wide range of different individual, disease, treatment, health care provider, and socio-economic factors and the interactions between them which may result into non-compliance with therapeutic orders prescribed by specialists. Therefore, specific attention should be paid to integrate the service provision system into the collaborative approach of the patient and his/her family in order to promote the level of compliance with therapy and care in planning and policy-making to improve the health service provision system.

Determinants of risky sexual practice, drug abuse and alcohol consumption in adolescents in Iran: a systematic literature review.

BACKGROUND: Evidence shows that the prevalence of risky sexual practice, drug abuse, and alcohol consumption behaviors in low and middle income countries such as Iran is not in a favorable condition. Preventive programs against these behaviors in Iran are very rare, and the results are unclear, which may be due to the lack of deeply and systematically understanding of the determinants of these behaviors. Evidence suggests that these behaviors are coincidence. So all of these behaviors were examined together. The present study was conducted aiming at determining the reasons for the occurrence of these behaviors among 15-19-year-old adolescents in Iran. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to review published and unpublished studies in Iran. The databases used were Scopus, PubMed, Web of Science, and Cochrane Library. The query terms were "Synthetic Drug" OR "Designer Drug", AND Adolescents OR Teenagers OR Juvenile, AND Iran. The Joanna Briggs Institute Critical Appraisal Checklist was employed for critical appraisal. The quantitative studies using the regression model to analyze the factors affecting these behaviors were studied as the form of the theme. For analyzing the data, narrative synthesis and thematic analysis were used. RESULTS: Twelve studies were meticulously reviewed. The findings were classified into five main themes (including individual, family, friends, school, and community) and 26 sub-themes. The most frequent main theme and sub-themes were respectively Family, Higher age, Male gender, Weak religious beliefs, Low self-esteem, Anti-social behaviors in family, Mother's employment, Parenting style, Poor intimacy of parents, Absence of parents, Peer pressure, and Lack of appropriate recreation. No primary study has referred to the political, economic, or policy factors affecting such behaviors. CONCLUSIONS: The most identified sub-themes belong to family factors. Iran is a country with ideology of Islam; however, being Muslim does not guarantee adherence to all Islamic guidelines. So being Muslim is not a good reason to prevent these behaviors. Iran needs precise policy making in this area through considering family structure. It is also suggested that primary studies referring to the political, economic, or policy factors affecting such behaviors should be carried out.

Challenges of implementation: Strategic purchasing in Iran Health Insurance Organization.

BACKGROUND: Strategic purchasing has been introduced as a key strategy for solving the problems faced by insurance companies. In Iran, the government has mandated the Iran Health Insurance Organization (IHIO) to implement this strategy. However, there are serious challenges to achieving that. The present study aims to identify these challenges. METHODS: In this qualitative study, a semi-structured interview was conducted on 27 health managers and experts at the national level. The dimensions of the A. Preker model were used to analyze the data. RESULTS: Challenges of strategic purchasing in the IHIO were categorized into five concepts-political economy, policy design, organizational structure, organizational environment, and management capacity; within these concepts, 22 challenges were identified. CONCLUSIONS: Improving strategic purchasing in Iran requires adopting a coherent approach and taking into account all the affecting factors. By revising some policies, and modifying and defining the rules needed to solve the infrastructural problems, the success of strategic purchasing can be obtained.