Households catastrophic health expenditure among older people with noncommunicable diseases: A cross-sectional study from Iran.

Background and Aims: Noncommunicable diseases are one of the main difficulties faced by older adults in many countries. The study aimed to investigate the households' catastrophic health expenditure (CHE) among older people with noncommunicable diseases. Methods: This cross-sectional study was conducted between October and December 2022 in Semnan, Iran, with the participation of 400 older individuals suffering from diabetes and hypertension. The Content Validity Ratio (which is calculated based on necessity criterion) and Content Validity Index (which calculated based on relevance, transparency, and simplicity criteria) values of 0.94 and 0.89, respectively, confirmed the content validity of the researcher-made questionnaire. The occurrence of CHE was estimated using the World Health Organization's rule of "allocating at least 40% of non-food household costs to healthcare." Due to the qualitative nature of the data, the χ 2 test was utilized to assess the statistical association between demographic and background variables and occurrence of CHE. Results: Older people with diabetes and hypertension had an annual direct medical costs of $821 averagely, which includes 9.7% for diagnosis, 23.9% for doctor visits, and 66.4% for treatment. Direct medical costs account for around 0.26 of nonfood costs, with 12.5% of seniors facing high medical charges. Age, marital status, type of basic health insurance, diabetes, the time elapsed since initial diabetes diagnosis, the severity of diabetes complications, and the development of diabetes-related visual impairments, are associated with CHE (p < 0.05). Conclusion: While the prevalence of CHE among elderly individuals with diabetes and hypertension is reasonably manageable, targeted promotional efforts are still necessary to protect those at high risk.

Challenges of Implementing an Effective Primary Health Care Accreditation Program: a qualitative study in Iran.

BACKGROUND: Accreditation is a prerequisite for scientific management of the health system, owing to its numerous benefits on health centres' performance. The current study examined Iran's primary healthcare accreditation program to ascertain the challenges to its successful implementation. METHODS: This qualitative study examined the perspectives of 32 managers and staff members in the pilot accreditation program (from the Ministry of Health and Medical Education, Semnan University of Medical Sciences, and Aradan District Health Network). Three in-depth group interviews were conducted using a semi-structured questionnaire, and the data obtained were assessed using thematic analysis. As a result of this investigation identified six themes, 29 sub-themes, and 218 codes as challenges to the successful accreditation of primary health care in Iran. RESULTS: Six main themes, including "organisational culture", "motivational mechanisms", "staff workload", "training system", "information systems", and "macro-executive infrastructure", were identified as the main domain of challenges, with seven, five, two, four, three, and eight sub-themes respectively. CONCLUSION: Accreditation of PHC in Iran faces significant challenges and obstacles that, if ignored, can jeopardise the program's success and effectiveness. By identifying challenges and obstacles and making practical suggestions for overcoming them, the findings of this study can aid in the program's successful implementation and achievement of desired outcomes.

Impacts of accreditation on the performance of primary health care centres: A systematic review.

Introduction: Evidence on the impacts of accreditation on primary health care (PHC) services is inconsistent. Thus, this study aimed to assess the impacts of accreditation on the performance of PHC centres. Method: This study systematically reviewed articles published from 2000 to 2019 in the Web of Science, Scopus, ScienceDirect, Springer, PubMed and ProQuest. The following keywords were used: ((primary care OR primary health care) AND (accreditation) AND (impact OR effect OR output OR outcome OR influence OR result OR consequences)). The database search yielded a total of41256 articles, among which 30 articles were finally included in the review. Results: Accreditation showed the most positive impacts on the quality, effectiveness, human resource management and strategic management of PHC services. Accreditation also positively affected safety, responsiveness, accessibility, customer satisfaction, documentation, leadership, efficiency and continuity of care. Few negative impacts were noted, including the possibility of accreditation being used as a bureaucratic tool, high cost of acquiring accreditation, difficulties in understanding the accreditation process, high staff turnover rate in accredited PHC centres and weak sustainability of some accreditation programmes. Conclusion: Given its numerous positive impacts, accreditation could be used to effectively improve the performance of PHC centres.

Catastrophic health expenditures in hospitalized patients with delta variant of COVID-19: A cross-sectional study.

Background: Financial protection of populations against healthcare costs is one of the fundamental responsibilities of governments. This study aimed to investigate the incidence of catastrophic health expenditures (CHE) and it's affecting factors in hospitalized patients with delta variant of COVID-19. Methods: In this cross-sectional study, we included 400 hospitalized COVID-19 patients at Kosar Hospital of Semnan in 2022, using a researcher-made checklist. Based on qualitative nature of the variables, chi-square test was used to investigate the statistical associations between the demographic/background characteristics and the incidence of CHE. Results: On average, COVID-19 imposed 1833.43 USD direct medical costs per one hospitalized patient. The ratio of direct-medical costs to household's non-food expenses was 2.35, and 61% (CI:±4.78%) of the patients were subject to CHE. Besides, residence place, basic insurance type, benefitting from supplementary insurance, suffering from underlying diseases, hospitalization in ICU, falling into a coma, facing pulmonary failure, and performing hemoperfusion had significant associations with CHE (P<0.05). Conclusion: The incidence of CHE in hospitalized COVID-19 patients was undesirable, which may be due to geographical, economical, and occupational inequalities apart from the factors related to the severity of the disease. So, health policymakers should pay attention to the provision of proper financial risk protection policies to make the health insurance system more efficient and appropriate.

Care services for older persons: A scoping review.

Introduction: With an increasing life expectancy and proportion of older adults, the number of people in need of care services is also increasing. This study aimed to determine and describe various available care services for older persons reported in literature. Methods: English-language articles published between the years of 1990 and 2018 in Scopus, ProQuest, PubMed, and Google Scholar databases or search engines were reviewed. The search resulted in 46,927 articles. All selected studies were systematically evaluated and screened based on title, abstract, and full text related to the study's objective. Finally, 246 articles were included in the study. The care services in older persons care systems were identified from the selected articles and were presented in extraction tables. Final conclusions were made based on the types of services provided and their frequency of citation. Results: The research results showed that numerous systems exist to provide care services for older adults, including long-term care services, home care services, housing for the aged, day care centres, senior centres, nursing homes, and hospice care services. Regarding older adults' care needs and the objectives and missions of each care system, different care services, such as personal care, social support services, medical care services, and nutrition services, have been identified in the service packages. Conclusion: This study describes the diverse care services available for older persons that have been reported in the literature. Further research in different healthcare systems is required regarding what is most essential and lacking in each setting.

Prevalence and related factors of intimate partner violence among married women in Garmsar, Iran.

BACKGROUND: Intimate partner violence (IPV) is the most common type of domestic violence often used by men against their wives. Due to the destructive and widespread social and health consequences of IPV, the present study aimed to investigate the prevalence and related factors of IPV among married women in Garmsar, Iran. METHODS: Using multi-stage clusters sampling method, this cross-sectional study included 400 married women in Garmsar, Iran. The data collection process was conducted during October and December 2019 using a researcher-made questionnaire. The content validity of the questionnaire was confirmed using content validity ratio (CVR) and content validity index (CVI) indicators (0.85 and 0.88, respectively). Also, the reliability was confirmed by examining the internal consistency and obtaining a score of 0.93 for Cronbach's alpha. Descriptive and analytical statistics were performed using t-test, analysis of variance (ANOVA), and Tukey's post-hoc test. RESULTS: Most participants were in the age range of 20-40 years (mean age: 34.9 years). The overall exposure of women to IPV was 56.11%. In addition, the most prevalent types of IPV included legal (24%), social (24%), financial (22%), verbal (16%), physical (13%), emotional (12%), and sexual (11%). The effective factors on the prevalence of IPV included number of children, education level, occupation, and age (P less than 0.05). CONCLUSIONS: We witnessed that women living in Garmsar faced different types of IPV and their overall exposure to this phenomenon was higher than the national and global average. To resolve the problem, the following measurements are recommended: a careful investigation of the reasons for the spread of IPV, implementing interventions based on reliable evidence, and serious cooperation of the experts and relevant governmental and non-governmental institutions, particularly citizens.

The catastrophic out-of-pocket health expenditure of multiple sclerosis patients in Iran.

BACKGROUND: The present study was designed and conducted to evaluate multiple sclerosis (MS) treatment costs and the resulting economic impact imposed on MS patients in Iran. METHODS: This was a cross-sectional study, among randomly selected 300 MS patients, registered in the MS Association of East Azerbaijan Province, Iran (1 year after their treatment began). The regression analysis, ANOVA, T-test, and chi-square were used. RESULTS: The average amount of out-of-pocket payments (OOPs) by MS patients during the previous year was 1669.20 USD, most of which was spent on medication, rehabilitation care, and physician visits. Their mean annual income was 5182.84 USD. Fifty four percent of families with an MS patient suffer from catastrophic health expenditure (CHE) and 44% experience poverty caused by the OOPs. Occupational status, having supplemental health insurance, and being residents of Tabriz significantly affect OOPs, CHE, and the resulting poverty (P < 0.05). CONCLUSION: The catastrophic financial burden of health care costs on MS patients and their families justifies health policymakers to promote pre-payment systems and provide subsidies to less well-off patients to protect them from the unfairness of OOPs and its resulting CHE and poverty.

Developing National Functional Accreditation Model for Primary Healthcares with Emphasis on Family Practice in Iran.

BACKGROUND: Accreditation is an approach toward quality improvement which has been increasingly implemented in healthcare. This study aimed at developing a national functional accreditation model for primary healthcare with emphasis on family practice in Iran. METHODS: This mixed-method study utilizes a set of research methods purposefully. Initially, the reference models were used for benchmarking accreditation standards through a systematic review. Then, the primary accreditation standards were developed and then they were assessed and approved by the experts of the field via Delphi technique. In the following and after developing essential parts of the standards, the necessary changes in developed model were done according to the pilot test results. RESULTS: The results of systematic review suggested the superiority of accreditation models of the United States, Australia, Canada, and the United Kingdom globally; and the models of Jordan, Saudi Arabia, Lebanon, and Egypt in Eastern-Mediterranean region. Then, the primary standards including 39 functional standards with 231 measures were developed according to the benchmarked models, and were approved by the experts in Delphi-based study. In pilot test step, the compliance rate of developed standards by primary healthcare centers was calculated 61.61% and 26.37% for self-evaluation and external evaluation phases, respectively. CONCLUSION: Regarding the comprehensiveness of developed accreditation model due to its focus on all functional dimensions and the consensus over the developed standards by the experts, it can be an underlying ground for the establishment and evaluation of functional improvement programs in Iranian primary healthcare system.

Economic costs incurred by the patients with multiple sclerosis at different levels of the disease: a cross-sectional study in Northwest Iran.

BACKGROUND: Multiple sclerosis (MS) causes significant economic burden to the patients, families, health systems and society. This study aimed to estimate the annual economic costs incurred by patients with multiple sclerosis (pwms) at different levels of the disease. METHOD: This was a cross-sectional study, using the Expanded Disability Status Scale (EDSS) tool for assessing the disease level of 300 (=N) pwms in East Azerbaijan province, Iran. To estimate the cost of MS, a questionnaire with its validity and reliability (CVR 92% and CVI 87%) and pilot test (Cronbach's alpha score 0.89) was used. The data were collected by interviewing pwms and reviewing their clinical records. Multivariate linear regression was used to assess the relationship between disease levels and incurred costs. RESULTS: The results revealed that the mean annual cost for pwms in Iran is 97,521,740 IRR (equivalent to 2321.94 USD; 1978.93 EURO) and the mean score of EDSS in pwms was 3.14. The annual cost incurred by pwms with mild, moderate and severe levels of disease were 83,918,150 IRR (1998.05 USD; 1702.88EURO), 137,772,660 IRR (3280.30 USD; 2795.71 EURO) and 119,962,670 IRR (2856.25 USD;2434.30 EURO), respectively. Also, on average, each increase in EDSS score in pwms in Iran led to increase 8,139,260 IRR (equivalent to 193.79 USD; and 165.16 EURO) in total annual cost which must paid from pwms and their households exclusively. Also, there was a significant relationship between total annual cost and disease severity in such a way that any increase in EDSS degree is led to 8,139,260 IRR (193.79 USD; 165.16 EURO) added cost for pwms. CONCLUSION: The study results could be helpful for Iranian health managers to solve problems which are facing by the patients with multiple sclerosis and their families.

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.

Development of an accreditation model for health education and promotion programs in the Iranian primary healthcare system: a Delphi study.

Background: Considering the lack of accreditation models for health education and promotion(HEP) activities in the Iranian primary health care (PHC) system we conducted the present study to develop a national accreditation model for HEP actions in the Iranian PHC system. Methods: After a comprehensive review on the accreditation models in PHC field, especially those concentrated on the HEP programs, an initial HEP accreditation model was developed.Then, applying the Delphi technique, 18 experts in the Iranian PHC system with field experience in HEP programs were invited to assess the initial model. In the two-round Delphi study,aggregation was provided on the opinions and the standards and indicators were finalized.Conventional content analysis was applied to make sense of the data collected in the study. Results: The developed HEP accreditation model encompassed 62 indicators and five standards.The standards were as follow: "resources for HEP programs", "educational needs assessment of the target groups", "methods of providing a community with education", "management of health volunteers' actions" and "evaluation of HEP programs". Conclusion: The standards and indicators found in the present study may serve as an educational rationale for health educators while designing high-quality health education/promotion programs. This model may be helpful for health policy-makers and stakeholders while planning to assess the continuous quality improvement of HEP services delivered in the PHC systems.

The Technical Quality of Delivered Care for People with Inflammatory Bowel Disease in Tabriz Gastroenterology Clinics.

BACKGROUND: The Inflammatory Bowel Disease (IBD) is considered as one of the chronic diseasesre-quiring complicated treatment. This study aimed to assess technical quality of providing care for pa-tients with IBD. METHODS: This cross-sectional study was conducted on 94 people with IBD using interviews and simple random sampling methods in Gastroenterology, Endoscopy and clinic of Imam Reza Hospital and Golgasht Clinic in Tabriz in 2012. The data collection tool was a researcher-designed questionnaire whose validity and reliability had been confirmed. In order to investigate the statistical relationship between the background variables and compliance with the standards the Chi-square test was applied using SPSS 17 Software. RESULTS: "visit by the physician" and "diet advice by the dietitian" have had the highest and the lowest levels of compliance with the standard respectively, and "the care related to the disease exacerbation" and "the care provided by the other physicians" were not compatible with the standards in 80% of the cases. Data analyses also showed that there was a significant relationship between participant's age, job, education and the smoking status and compliance of some care with the relevant standards (P<0.05). CONCLUSION: The results indicate a substantial gap between provided care for the people with IBD and the relevant standards. This indicates the areas that need of improvement and requires the serious attention of the authorities.

Effective interventions on service quality improvement in a physiotherapy clinic.

BACKGROUND: Service quality is considered as a main domain of quality associ-ated with non-clinical aspect of healthcare. This study aimed to survey and im-proves service quality of delivered care in the Physiotherapy Clinic affiliated with the Tabriz University of Medical Sciences, Tabriz, Iran. METHODS: A quasi experimental interventional study was conducted in the Physiotherapy Clinic, 2010-2011. Data were collected using a validated and reli-able researcher made questionnaire with participation of 324 patients and their coadjutors. The study questionnaire consisted of 7 questions about demographic factors and 38 questions for eleven aspects of service quality. Data were then analyzed using paired samples t-test by SPSS16. RESULTS: In the pre intervention phase, six aspects of service quality including choice of provider, safety, prevention and early detection, dignity, autonomy and availability achieved non-acceptable scores. Following interventions, all aspects of the service quality improved and also total service quality score improved from 8.58 to 9.83 (P<0.001). CONCLUSION: Service quality can be improved by problem implementation of appropriate interventions. The acquired results can be used in health system fields to create respectful environments for healthcare customers.

Developing of National Accreditation Model for Rural Health Centers in Iran Health System.

BACKGROUND: The primary health care has notable effects on community health and accreditation is one of the appropriate evaluation methods that led to health system performance improvement, therefore, this study aims to developing of national accreditation model for rural health centers in Iran Health System. METHODS: Firstly the suitable accreditation models selected to benchmarking worldwide via systematic review, the related books and medical university's web site surveyed and some interviews hold with experts. Then the obtain standards surveyed from the experts' perspectives via Delphi technique. Finally, the obtainedmodel assessedvia the experts' perspective and pilot study. RESULTS: The researchers identified JCAHO and CCHSA as the most excellent models. The obtained standards and their quality accepted from experts' perspective and pilot study, and finally the number of 55 standards acquired. CONCLUSION: The designed model has standards with acceptable quality and quantity, and researchers' hopeful that its application in rural health centers led to continues quality improvement.

Advantages and Disadvantages of Health Care Accreditation Mod-els.

BACKGROUND: This systematic review seeks to define the general advantages and disadvan-tages of accreditation programs to assist in choosing the most appropriate approach. METHOD: Systematic search of SID, Ovid Medline & PubMed databases was conducted by the keywords of accreditation, hospital, medical practice, clinic, accreditation models, health care and Persian meanings. From 2379 initial articles, 83 articles met the full inclusion criteria. From initial analysis, 23 attributes were identified which appeared to define advantages and disadvantages of different accreditation approaches and the available systems were compared on these. RESULTS: Six systems were identified in the international literature including the JCAHO from USA, the Canadian program of CCHSA, and the accreditation programs of UK, Australia, New Zealand and France. The main distinguishing attributes among them were: quality improve-ment, patient and staff safety, improving health services integration, public's confi-dence, effectiveness and efficiency of health services, innovation, influence global standards, information management, breadth of activity, history, effective relationship with stakeholders, agreement with AGIL attributes and independence from government. CONCLUSION: Based on 23 attributes of comprehensive accreditation systems we have defined from a systematic review, the JCAHO accreditation program of USA and then CCHSA of Can-ada offered the most comprehensive systems with the least disadvantages. Other programs such as the ACHS of Australia, ANAES of France, QHNZ of New Zealand and UK accredita-tion programs were fairly comparable according to these criteria. However the decision for any country or health system should be based on an assessment weighing up their specific objec-tives and needs.