Key factors affecting health promoting behaviors among adolescents: a scoping review.

BACKGROUND: Health-promoting behaviors have been noticed recently as one of the most critical factors in raising life expectancy, which can be formed during adolescence. Thus, the current scoping review aimed to identify the key factors affecting health-promoting behaviors among adolescents. METHODS: In this scoping review, we searched multiple English online databases, including PubMed, Web of Science, Science Direct, ProQuest, and Scopus, for articles published between 1977 and 2020. All eligible studies describing health-promoting behaviors in adolescents were included. We followed the JBI guideline for conducting a scoping review and increasing the study's rigor. Extracted data were synthesized through inductive approaches. RESULTS: A total of 3199 articles were identified during the first phase. After the screening process, 20 articles were found eligible for final inclusion. Educational factors (individualized education and school health promotion programs), Economic factors (income, economic incentives and national health insurance), Social factors (support system, responsibility and peers), Spiritual, Psychological and Personal factors (gender, family structure, patterns of living, and medical problems) were found effective in health-promoting behaviors among adolescents. CONCLUSIONS: Health-promoting behaviors among adolescents require careful consideration. The current review identified some fundamental factors affecting health-promoting behaviors in adolescents. Based on the findings, it is recommended that policymakers and healthcare providers develop several interventions based on identified factors to increase adolescent's health-promoting behaviors among adolescents.

Exploring hospitals' functional preparedness effective factors in response to disasters: a qualitative study in a lower middle-income country.

BACKGROUND: Medical services are among the most urgent needs of the disaster-affected population. Consequently, hospital preparedness -as the main health services provider- is one of the vital factors in effective response to disasters. The present study aims to explore the perspectives of study participants about the influential factors of hospital functional preparedness in a lower middle-income country. METHODS: In this qualitative study, data were collected through 17 semi-structured interviews with disaster management authorities selected by purposive sampling. Content-Analysis was used to analyze the data. RESULTS: 138 codes were developed and categorized into ten categories and 34 subcategories. The main categories were: 1- leadership, command, and coordination (4 subcategories); 2- risk assessment (3 subcategories); 3- legislating and developing protocols, guidelines, and programs (3 subcategories); 4- estimating and storing the necessary supplies and equipment (3 subcategories); 5- human resource management (4 subcategories); 6- education, training, and development of staff (6 subcategories); 7- vital routes and facilities (3 subcategories); 8- communication (3 subcategories); 9- security, safety and locating of safe zones (3 subcategories); 10- underlying disaster risk factors (2 subcategories). CONCLUSION: According to the participants of this study, ten categories of factors can affect hospitals' functional preparedness; hospital managers and decision-makers can consider these factors to ensure the proper provision of medical services during disasters.

Prioritizing population-based nutrition-related interventions to prevent and control hypertension in Iran: a multi-criteria decision-making approach.

BACKGROUND: Numerous nutrition-related policy options and strategies have been proposed to tackle hypertension and other risk factors of non-communicable diseases (NCDs). In this study, we developed a comparative analysis using a multi-criteria decision-making (MCDM) model for prioritizing population-based nutrition-related interventions to prevent and control hypertension in Iran. METHODS: We employed a combination of Delphi technique and Analytic Hierarchy Process (AHP) method as the methodological tool to prioritize decision alternatives using multiple criteria. The prominent assessment criteria and intervention strategies were derived using a literature review, focus group discussion (n = 11), and a 2-round modified Delphi technique with specialists and experts involved in different stages of health policy-making (round 1: n = 50, round 2: n = 46). Then, the AHP was used to determine the weightage of the selected interventions and develop the decision-making model. The sensitivity analysis was performed to test the stability of the priority ranking. RESULTS: Nine alternative interventions were included in the final ranking based on eight assessment criteria. According to the results, the most priority interventions to prevent and control hypertension included reformulation of food products to contain less salt and changing the target levels of salt in foods and meals, providing low-sodium salt substitutes, and reducing salt intake through the implementation of front-of-package labeling (FOPL). The results of the sensitivity analysis and a comparison analysis suggested that the assessment model performed in this study had an appropriate level of robustness in selecting the best option among the proposed alternatives. CONCLUSION: MCDM techniques offer a potentially valuable approach to rationally structuring the problem, along with the opportunity to make explicit the judgments used as part of the decision-making model. The findings of this study provide a preliminary evidence base to guide future decisions and reforms aiming to improve appropriate population-based interventions for tackling hypertension and other risk factors of NCDs.

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

BACKGROUND: Despite significant achievements in the prevention and control of NCDs in Iran, these conditions are still the biggest challenges to Iran's healthcare system and are estimated to account for 78.1 percent of all deaths. Therefore, this study aimed to reflect on the potential challenges standing in the way to implement the relevant policies, empower the dimensions of governance, and react in an effective and timely manner by Iran's healthcare system to NCDs. METHODS: This study was conducted with a qualitative approach using the conventional content analysis method. A total of 46 senior managers involved in the prevention and control of NCDs at the medical sciences universities across Iran were recruited through the purposive sampling method and were interviewed via semi-structured interviews. Graneheim and Lundman's approach was utilized to analyze the data. RESULTS: According to the analysis of the senior managers' viewpoints, current challenges to implement the program for the prevention and control of NCDs in Iran could be placed into six main categories, including financing, human resources, infrastructure and inputs, legal, executive, administrative, as well as inter-sectoral collaboration, and management and policy-making challenges with their own sub-categories. CONCLUSION: The results revealed that financing was the biggest challenge to successfully implementing the program for the prevention and control of NCDs in Iran. However, strengthening Iran's healthcare system in the field of the prevention of NCDs demanded more innovative measures and strategies, such as the empowerment of human resources, the effective use of intra- and inter-sectoral collaboration, and non-governmental organizations and charities, along with the exploitation of evidence-based studies during policy-making and decision-making processes, with no need for financial resources.

Weight of Risk Factors for Adjusting Capitation in Primary Health Care: A Systematic Review.

Background: Capitation payment is the best-known strategy for paying providers in primary health care. Since health care needs and personal characteristics play an essential role in health care utilization and resource spending, there is a growing tendency on risk adjustment models among health researchers. The objective of this systematic review was to examine the weights used for risk adjustment in primary health care capitation payment. Methods: We systematically searched Scopus, ProQuest, Web of Science, and PubMed in March 2018. Two authors independently apprised the included articles and they also evaluated, identified, and categorized different factors on capitation payments mentioned in the included studies. Results: A total of 742 studies were identified and 12 were included in the systematic review after the screening process. Risk factors for capitation adjustment included age, gender, and income with the weighted average being 1.76 and 1.03, respectively. Moreover, the weighted average disease incidence adjusted clinical groups (ACGs), diagnostic cost groups (DCGs), principal in patient diagnostic cost groups (PIP-DCGs), and hierarchical coexisting conditions (HCCs) were reported as 1.31, 24.7-.99, 10.4-.65, and 11.7-1.01, respectively. Conclusion: In low-income countries, the most effective factors used in capitation adjustment are age and sex. Moreover, the most applied factor in high-income countries is adjusted clinical groups, and income factors can have a better impact on the reduction of costs in low-income countries. Each country can select its most efficient factors based on the weight of the factor, income level, and geographical condition.

Public-private partnerships in primary health care: a scoping review.

BACKGROUND: The Astana Declaration on Primary Health Care reiterated that PHC is a cornerstone of a sustainable health system for universal health coverage (UHC) and health-related Sustainable Development Goals. It called for governments to give high priority to PHC in partnership with their public and private sector organisations and other stakeholders. Each country has a unique path towards UHC, and different models for public-private partnerships (PPPs) are possible. The goal of this paper is to examine evidence on the use of PPPs in the provision of PHC services, reported challenges and recommendations. METHODS: We systematically reviewed peer-reviewed studies in six databases (ScienceDirect, Ovid Medline, PubMed, Web of Science, Embase, and Scopus) and supplemented it by the search of grey literature. PRISMA reporting guidelines were followed. RESULTS: Sixty-one studies were included in the final review. Results showed that most PPPs projects were conducted to increase access and to facilitate the provision of prevention and treatment services (i.e., tuberculosis, education and health promotion, malaria, and HIV/AIDS services) for certain target groups. Most projects reported challenges of providing PHC via PPPs in the starting and implementation phases. The reported challenges and recommendations on how to overcome them related to education, management, human resources, financial resources, information, and technology systems aspects. CONCLUSION: Despite various challenges, PPPs in PHC can facilitate access to health care services, especially in remote areas. Governments should consider long-term plans and sustainable policies to start PPPs in PHC and should not ignore local needs and context.

Two decades of Iranian midwives' activities as a health care provider under supervision in a multidisciplinary team in reducing maternal mortality.

Iran is amongst the countries that have achieved the fifth goal of the United Nations Millennium Development Goal. The maternal mortality ratio (MMR) in Iran has declined from 48 cases per 100,000 in 2000 to 16 cases per 100,000 in 2017, showing an annual decline rate of about 6.3%. In the International Year of the Nurse and the Midwife (year 2020), this commentary highlights two decades of Iranian midwives' activities as a health care provider under supervision in a multidisciplinary team in reducing maternal mortality.

Nationwide population-based surveys of Iranian COVID-19 Serological Surveillance (ICS) program: The surveys protocol.

Background: Serological surveillance of COVID-19 through conducting repetitive population-based surveys can be useful in estimating and monitoring changes in the prevalence of infection across the country. This paper presents the protocol of nationwide population-based surveys of the Iranian COVID-19 Serological Surveillance (ICS) program. Methods: The target population of the surveys is all individuals ≥6 years in Iran. Stratified random sampling will be used to select participants from those registered in the primary health care electronic record systems in Iran. The strata are the 31 provinces of the country, in which sampling will be done through simple random sampling. The sample size is estimated 858 individuals for each province (except for Tehran province, which is 2574) at the first survey. It will be recalculated for the next surveys based on the findings of the first survey. The participants will be invited by the community health workers to the safe blood sampling centers at the district level. After obtaining written informed consent, 10 mL of venous blood will be taken from the participants. The blood samples will be transferred to selected reference laboratories in order to test IgG and IgM antibodies against COVID-19 using an Iranian SARS-CoV-2 ELISA Kit (Pishtaz Teb). A serologically positive test is defined as a positive IgG, IgM, or both. After adjusting for the measurement error of the laboratory test, nonresponse bias, and sampling design, the prevalence of COVID-19 will be estimated at the provincial and national levels. Also, the approximate incidence rate of infection will be calculated based on the data of both consecutive surveys. Conclusion: The implementation of these surveys will provide a comprehensive and clear picture of the magnitude of COVID-19 infection and its trend over time for health policymakers at the national and subnational levels.

Psychometric properties of the Iranian version of self-care ability scale for the elderly.

BACKGROUND: Measuring self-care ability in elderly people needs specific instruments. The Self-care Ability Scale for Elderly (SASE) is one of the common instruments used for assessing self-care ability. The aim of this study was to assess the psychometric properties of the SASE among Iranian elderly population. METHODS: This cross-cultural adaptation study was carried out at Shahid Chamran and Shadpour Health Complex in Tabriz, Iran. The forward-backward procedure was applied to translate the SASE from English into Persian. Then, it was completed to 220 elderly people. A systematic random sampling method was used for sampling. Content validity was calculated through modified Kappa coefficient (modified CVI) based on clarity and relevance criteria. Reliability was measured by internal consistency and test-retest analysis. The construct validity also was assessed using Exploratory Factor Analysis (EFA). All the statistical analyses were performed using SPSS 21 statistical software package. RESULTS: The mean of self-care ability was 61.14 ± 21.08. The CVI and modified kappa were 0.91 and 0.92 for relevance and clarity, respectively. The Cronbach's alpha coefficient was 0.73 and Intra-class correlation coefficient was 0.97. The results of EFA revealed a three-factor solution ('ability to take care of personal responsibility', 'ability to take care for the goals', and 'ability to take care of the health') that jointly explained for 64.61% of the total variance. CONCLUSION: Results of the study showed that the Iranian version of the SASE has good psychometric properties and can be used in assessing the self-care ability of elderly people.

Forty years after Alma-Ata: how people trust primary health care?

BACKGROUND: Primary Health Care (PHC) was introduced as the first level of health services delivery after Alma-Ata declaration. However, after forty years, it needs to be more trustful to achieve its predefined objectives. Public trust in PHC is one of the neglected issues in the context. The aim of this study is to evaluate public trust in PHC in Iran. METHODS: The present investigation is a household survey conducted in East Azerbaijan Province, Iran. Two-stage cluster sampling method with Probability Proportional to Size (PPS) approach was used. Totally, 1178 households were enrolled in the study. PHC trust questionnaire and Ultra-short version of Socio-Economic Status assessment questionnaire (SES-Iran) was used for data collection. Data were analyzed using STATA software (version 15) through descriptive statistics and linear regression. RESULTS: The mean ± SD age of the participants was 41.2 ± 15.1 and most (53.7%) were female. Mean score of PHC trust was 56.9 ± 24.7 (out of 100). It was significantly different between residents of Tabriz (the capital of province) and other cities in the province (p < 0.001). Linear regression showed that younger age, gender, insurance type, being married, and households higher socio-economic status had a significant positive effect on PHC trust level with R2 = 0.14383. CONCLUSIONS: Public trust in PHC system in Iran needs to be improved. Individual variables had a small but key role in trust level. PHC trust cannot be only affected by individual's variables and experiences but also by health system and health providers' characteristics and public context in which PHC system exists. PHC trust level could be used as a public indicator in health systems especially in Low and Middle Income Countries (LMIC) to contribute in system strengthening policies at the national and international levels.

Association of major dietary patterns and different metabolic phenotypes: a population-based study of northwestern Iran.

BACKGROUND: Finding the relationship between the major dietary patterns and cardiometabolic phenotypes could be used for planning prevention programs based on the cultural and dietary habits to prevent transient from a metabolically healthy state to an unhealthy state. So, we aimed to assess the association between dietary patterns and cardiometabolic phenotypes in the northwestern population of Iran. METHOD: In the present cross-sectional and population-based study, 504 adults sampled by cluster sampling in East-Azerbaijan, Iran. Factor analysis was used for determining the dietary pattern. Metabolic phenotypes were determined according to body mass index (BMI) cut-off point (25 kg/m2), and the presence of the metabolic syndrome. The independent sample t-test, one-way ANOVA, chi-square, and multinomial regression were used for statistical analysis. RESULTS: In both adjusted (OR: 2.24, 95% CI: 1.17, 4.31) and unadjusted models (OR: 3.14, 95% CI: 1.54, 5.42), the last tertile of the animal dietary pattern was associated with metabolically healthy obese (MHO) phenotypes. After adjusting, the last tertile of the animal dietary pattern was significantly associated with an increase of metabolically unhealthy obese (MUHO) phenotype (OR: 2.61, 95% CI: 1.18, 5.76). CONCLUSION: In the present study, the animal dietary pattern was associated with MHO and MUHO phenotypes. It is suggested that some measures should be taken to strengthen nutrition education for the population and advocate a balanced diet to improve the condition.

Developing Iranian primary health care quality framework: a national study.

BACKGROUND: Providing comprehensive and high-quality services is one of the most important goals of the health systems and a basic principle for Universal Health Coverage (UHC). Fulfilling this important task would be feasible through continuous evaluation and improvement of the health services quality. The aim of this study was to develop a framework for quality assessment of Primary Health Care (PHC) in Iran's health system. METHODS: This study is a literature review which continued by a qualitative research. The extracted quality dimensions and indicators for initial screening were reviewed and discussed in two panel meetings attended by the experts with regard to the current package of health system in Iran. Using Delphi method, the dimensions and Quality Indicators(QIs) were evaluated and approved by 39 national health professionals in two rounds. Finally, after 4 panel sessions at ministerial level, the selected QIs were categorized in form of the final dimensions of the quality of care. RESULTS: The literature review emerged 13 Primary Health Care Quality Assessment Frameworks (PHCQAF) including 20 and 698 QIs. Delphi study resulted in developing Iranian PHCQAF comprising 7 dimensions and 40 QIs. Among these, 8 QIs of the dimension of access and equity, 5 QIs of safety dimension, 2 QIs of efficiency dimension, 13 QIs of effectiveness dimension, 2 QIs of patient-centeredness dimension, 3 QIs of governance dimension and 7 QIs of appropriateness dimension were presented. CONCLUSIONS: The presented PHCQAF can be used as a comprehensive and practical tool for continuous improvement of the quality of PHC services at local, national and regional levels. Moreover, it can give some useful information to the health managers and policy makers on how the services are provided.

Psychometric properties of primary health care trust questionnaire.

BACKGROUND: Trust has been introduced as the cornerstone of the public and health providers' relation. Public trust in primary health care (PHC) is crucial and must be measured. The aim of this study was to develop and validate PHC trust measurement tool. METHODS: This was a psychometric study to develop PHC trust measuring tool done in Tabriz, East-Azerbaijan with participation of 600 households in 2016. Item generation was done through literature review and experts opinions. The content validity, reliability and construct validity of the PHC trust tool were assessed using several statistical methods including modified Kappa, Kendall's Tau and intra-class correlation coefficient (ICC) as well as exploratory factor analysis (EFA). Data were analyzed using STATA 14 statistical software package. RESULTS: A 30-item questionnaire was developed. The Modified Kappa coefficient as an indicator of content validity assessment was 0.94. With respect to reliability assessment, a high internal consistency was observed with 0.98 Cronbach-Alpha score and the test-retest reliability for overall scale (assessed by ICC) was 0.94 (CI: 0.87-0.97). Exploratory factor analysis emerged 2 factors. Factor 1 consisted of 25 items accounting for 74.1% of the variance (eigenvalue = 22.47) followed by Factor 2 consisting of 5 items accounting for 19.2% of the variance (eigenvalue = 1.6). CONCLUSION: PHC trust measuring tool could be used as a valid and reliable tool by health systems in Iran and similar contexts to investigate how they are trustful from the public viewpoint.

Effects of Food Supplementation During Pregnancy on Maternal Weight Gain, Hemoglobin Levels and Pregnancy Outcomes in Iran.

Objectives In this study, the effects of food supplementation during pregnancy on maternal weight gain, hemoglobin (Hb) levels, and pregnancy outcomes were evaluated. Methods In this randomized controlled trial, we recruited 1360 pregnant women with a gestational age of 10 weeks who had BMI < 18.5 and hemoglobin < 10.5/dL from rural areas of the east Azerbaijan province in Iran. Rural areas were randomly assigned into two groups: food-supplemented and control areas. In food-supplemented areas the food supplement was provided (1500 kcal/d) from 10 weeks of pregnancy through to the end. Information on demographic data were collected and anthropometric and Hb measurements were taken using standard instruments. Results The average weight gain was 9.1 ± 1.8 kg and 7.9 ± 1.6 kg in supplemented and control groups respectively, which was significantly different (p = 0.001). Also, a significant time × treatment interaction in maternal average weight gain (p = 0.001) was observed. The mean Hb decreased from 12 mg/dl and 12.1 mg/dl in week 10 to 11.9 mg/dl and 11.7 mg/dl in week 20 in the supplemented and control groups respectively, which was significant only for the control group. Between-group comparisons revealed significant differences in the rates of low birth weight (LBW) infants (p = 0.001) and preterm births (p = 0.013). Conclusion for practice Food supplementation significantly reduced the prevalence of poor maternal weight gain, infants with low birth weight, and preterm births compared to no intervention.

Development of age-sex adjusted capitation payment: The experience of Iranian public health complexes.

BACKGROUND: Flat capitations are not necessarily able to compensate health providers equitably due to the variability of resource consumption among different age and sex groups. The aim of this study is to develop a risk adjusted capitation formula as a base for primary health care payment in Health Complexes of Tabriz, in Iran. METHOD: This cross-sectional study was conducted in four stages: (1) determining health service package, (2) calculating unit cost of services, (3) estimating service utilization, and (4) calculating age/sex weighted capitation. We calculated unit cost of services with and without building and equipment expenses. Data collection was carried out through a data extraction checklist. Data management and analysis was carried out via Microsoft Excel 2007. RESULT: A list of 99 services and their processes were identified and then assigned each to one of 10 categories according to their resource consumption. The lowest and highest unit cost, respectively, belonged to prenatal care and group training by family physicians. The risk adjusted capitation was calculated with and without renting cost of building and equipment, respectively, 347 000 and 332 000 Rials (1 US$ worth 35 000 Iranian Rials). CONCLUSION: The development of health risk adjusted capitation could improve equity in payment system and the efficiency of delivering primary health care services. Estimated weights proposed with our study can be adapted then applied in contexts with similar characteristics.

Primary healthcare accreditation standards: a systematic review.

PURPOSE: Accreditation is an essential component in primary healthcare (PHC) systems. The purpose of this paper is to investigate the most suitable PHC accreditation models and standards, worldwide, and to prepare a comprehensive and unbiased summary from research on these models. DESIGN/METHODOLOGY/APPROACH: A systematic search was undertaken using Web of Science, Scopus, Science Direct, Springer, PubMed and ProQuest databases in August 2016 and updated in January 2018. English language studies addressing PHC accreditation standards and models, published between 1995 and January 2018, were included, resulting in 9051 citations. After excluding duplicates and irrelevant studies, 19 were included in the final review. Two independent reviewers critically appraised the studies. Consequently, accreditation standards in the models were extracted and compared. FINDINGS: Results indicate that USA, Australia, Canada, UK and New Zealand (non-eastern Mediterranean regions (EMR)) and Jordan, Saudi Arabia, Lebanon and Egypt (EMR) had well-developed and high-quality PHC accreditation models. The Jordanian, Egyptian and Saudi models had the highest diversity in their PHC standards domains. Community-oriented care, safe care, high-quality care, care continuity and human resource management had the highest priority among PHC accreditation programs. ORIGINALITY/VALUE: The authors provide PHC accreditation benchmarks and determine high priority practical domains in accreditation standards. The findings should help health system managers and policymakers design new PHC accreditation programs and promote PHC service quality.

Improvement of the quality payment program by improving data reporting process: an action research.

BACKGROUND: Successful implementation of pay-for-quality (P4Q) programs mostly depends upon a valid, timely, and reliable data about quality measures generated by providers, and interpreted by payers. The aim of this study was to establish a data reporting method for P4Q program through an action research. METHODS: Qualitative method was used to align theory with action through a three-cycle action research. The study was conducted in September 15, 2015 to March 15, 2017, in East-Azerbaijan, Iran. The purposeful sampling was used to select participants. The participants included healthcare providers, staff in district health centers (DHC), experts, and managers in the provincial primary health center (PPHC). Data was collected by interviews, focus group discussions, and expert panels. Content analysis was used to synthesize the data. In each step, decisions about data reporting methods were made through a consensus of expert panel members. RESULTS: The most important dimensions of data reporting method were data entry and accuracy, data reporting, data analysis and interpretations, the flexibility of method, and training. By establishment of an online data reporting system for the P4Q program, a major improvement was observed in the documentation of performance data, the satisfaction of health care providers and staff (e.g. either in DHCs or PPHC), improvement of the P4Q program and acceptance of the P4Q program by providers. Following the present study, the online system was expanded in Iran's public health system for data collection and estimating the amount of incentive payments in P4Q program. Moreover, more improvements were achieved by linking the system to EMRs and also, providing automated feedback to providers about their own performance. CONCLUSIONS: A web-based computerized system with the capability of linking medical record and also its ability to provide feedback to healthcare providers was identified as an appropriate method of data reporting in the P4Q program from the viewpoints of participants in this study.

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

OBJECTIVE: To investigate managerial barriers and challenges facing East Azerbaijan Province health system. METHODS: This qualitative study was conducted in Tabriz, Iran, from August 2014 to August 2015, and comprised professionals, experts and informants working at the East Azerbaijan Health Centre. Data was collected through focus group discussions and semi-structured, face-to-face, individual and group interviews were conducted. Interviews and focus group discussions were taped, transcribed and analysed using content analysis method.. RESULTS: Of the 46 participants, 29(63%) were male and 17(37%) were female. Moreover, 15(33%) participants were head of their respective units and 8(17%) were district health managers. Managerial barriers witnessed during the study period differed between the three managerial levels of interest, i.e., district health centres, provincial health centre departments and top levels of provincial health centre and macro-management systems outside the health centre. Lack of management training, inadequate resources, unclear duties and responsibilities were considered to be the most common barriers facing district health centres. Unclear budgeting mechanisms, instability of management positions and shortage of trained staff on provincial and district levels were reported to be managerial barriers in provincial health centre departments. Political interference in technical decisions, treatment-based approaches, lack of clear career paths on all levels of health system management, unnecessary bureaucracy lying within inter-organisational relationships and ineffective employment legislation were identified as managerial barriers on top levels of the provincial health system and in macro-management systems independent of the health system. CONCLUSIONS: Diverse challenges influenced the performance of health managers.

Positive Association Between Serum 25-Hydroxy-Vitamin D and Liver Enzymes Levels in Healthy Individuals: A Population-Based Study from Iran.

OBJECTIVE: The relationship between serum 25-hydroxy-vitamin D and within normal range liver enzymes in a population-based study in the northwest of Iran was investigated. METHOD: This cross-sectional study was comprised of 700 apparently healthy Iranian adults (287 men & 413 women) who participated in the major lifestyle promotion project (LPP) conducted in East Azarbaijan-Iran in 2015. The ultraviolet method and chemiluminescent immunoassay technology were respectively used for determination of the serum levels of liver enzymes (alanine aminotransferase (ALT) and aspartate aminotransferase (AST)) and 25-hydroxy-vitamin D. The one-way ANOVA and the linear regression analysis were used for statistical analysis. RESULTS: There were not significant differences in mean ALT and AST levels regarding different serum 25-hydroxy- vitamin D status. In the unadjusted model, serum 25-hydroxy-vitamin D was significantly associated with ALT (p = 0.008). The participants in the fourth quartile of 25-hydroxy-vitamin D had significantly higher level of ALT compared with participants in the first quartile (p = 0.002). After adjustment for age, sex, BMI, waist circumference, fasting blood glucose, lipid profile, and dietary vitamin D, this association remained significant. For AST, in the unadjusted model, the association between serum 25-hydroxy-vitamin D and AST was marginally significant (p = 0.08). The participants in the third quartile of 25-hydroxy-vitamin D had significantly higher levels of AST compared with participants in the first quartile (p = 0.01). CONCLUSION: According to results, there was a positive association between 25-hydroxy-vitamin D and ALT in individuals without liver diseases. Additional prospective studies were needed to confirm this observation and also elucidate the underlying mechanisms.

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

OBJECTIVE: To assess districts health managers educational needs and develop management training programmes. METHODS: This mixed-method study was carried out between August 2014 and August 2015 in Tabriz, Iran. Four focus group discussion sessions and three semi-structured face-to-face interviews were conducted among district health managers and experts of a health centre. Besides, 52 questionnaires were completed to weigh and finalise management education module and courses. Interviews and focus group discussions were tape-recorded, transcribed and analysed using content analysis method. Data was analysed using SPSS17. RESULTS: There were 52 participants, of whom 40(78.8%) were men and 12(21.2%) were women. All of the subjects (100%) took part in the quantitative phase, while 25(48.08%) participated in the qualitative phase. In the qualitative section, 11(44%) participants were heads of unit/departments in provincial health centre and 14(56%) were district health managers. In the quantitative phase, 30(57.7%) participants were district health managers and 8(28.8%) were heads of units/departments. Moreover, 33(63.4%) participants had medical education. The job experience of 3(5.8%) participants in the current position was below five years. Districts health management training programme consisted of 10modules with 53 educational topics. The normalised score out of a total of 100 for rules and ethics was 75.51, health information management 71.19, management and leadership 69.27, district management 68.08, human resources and organisational creativity 67.58,quality improvement 66.6, health resources management 62.37, planning and evaluation 61.87, research in health system 59.15, and community participation was 53.15. CONCLUSIONS: Considering district health managers' qualification in health and medicine, they had not been trained in basic management. Almost all the management and leadership courses were prioritised as most necessary.