Mental Health Services Integration in Primary Health Care in Iran: A Policy Analysis.

Objective: The National Mental Health Services (N-MHSs) in Iran was integrated with Primary Health Care (PHC) in 1988. This study aimeds to analyze the policy of integrating N-MHSs in PHC, focusing on the analysis of the current situation, pathology, and the existing challenge. Method : This qualitative research was conducted in 2020 using a case study approach. This study used the policy triangle model to analyze the policy. The required data were collected via interviews, literature review, and document analysis. The interviews were conducted with 23 experts, stakeholders across the country who were selected through purposive sampling, and the data were analyzed using the content-analysis method. Results: The main goals of this policy were to raise mental health literacy among the people and eliminate its stigma in the society, while implementing the referral system for N-MHSs. Twenty weaknesses were extracted in eight areas, including negative views of mental health, weaknesses in human resource training, compensation for the service of psychologists, unfavorable working conditions of the workforce, inappropriate service delivery facilities, lack of meaningful communication between different levels of service delivery, poor inter-sectorial communication, and the challenging nature of mental health care. De-stigmatizing psychological disorders in the society and identifying hidden patients are some of the most significant achievements of this policy. Conclusion: Despite the successful implementation and significant achievements in integrating N-MHSs in PHC, the results of the present study indicate that there are many challenges in this field that require serious planning and attention from relevant authorities.

Public-private partnership in primary health care: an experience from Iran.

AIM: The aim of this paper is to introduce the experience of applying public-private partnership (PPP) in providing primary health care (PHC) in East Azerbaijan Province (EAP), Iran. BACKGROUND: Moving toward the Universal Health Coverage (UHC) involves using of all health-related resources. Certainly, one of the key strategies for achieving UHC is PPP. Since 2015, a PPP in PHC policy has begun in EAP as a major strategy for strengthening the health system and achieving UHC. METHODS: In this case study, data were collected through interviews with stakeholders, document analysis, reviewing of health indexes and published studies. The data were analyzed using content analysis. FINDING: PPP in PHC policy was designed and implemented in EAP with the aim of social justice, strengthening the health system and achieving UHC in the framework of health complexes (HCs). HCs provide a defined service package according to the contract. The reimbursement method is a combination of per capita, fee for services and bonus methods. Part of the payments is fixed and the other part is based on the pay for quality system and paid according to the results of monitoring and evaluation. According to the study results, the most important strength of the plan is to improve access to services, especially in marginalized areas. The main weakness is not providing infrastructures before the implementation of the plan, and the most important challenges are financial, political and organizational unsustainability and, sometimes, poor cooperation by the other organizations. The findings show that PPP in PHC in EAP is an effective strategy to provide social justice, implement family practice and achieve UHC.

Designing a Surveillance System to Monitor the Adverse Health Effect of Environmental Disasters: A Case Study of Drying Lake Urmia-Iran.

Background: Through designing a surveillance system, steps to policy making and designing measures needed to reduce the potential risks of environmental disasters on human health could be taken. Therefore, this study aimed to develop a model for Environmental Disasters Diseases Surveillance System (EDDS) to monitor Adverse Health Effects (AHEs) of Environmental Disasters (AHEEDs). Methods: As the first step, the literature review was conducted to identify the AHEEDs. Then, using the results of the first step and analyzing the existing documents, the AHEEDs were identified, and, based on the experts' opinions, high-priority effects were included in the EDDS. Then, using semi-structured interviews, 20 experts' views on the appropriate model of EDDS were investigated. To design the initial model, a panel of experts was formed with six participants. Finally, the Delphi technique was used for expert opinion and model finalization. Results: As a result of the literature review and document analysis, 41 hazards/diseases were identified. Finally, ten diseases were suggested to enter the EDDS. In the experts' view, it is better that communicable diseases be reported actively and urgently and Non-Communicable Diseases (NCD) actively and non-urgently. From the participants' point of view, the most significant achievements of the EDDS can be organizational and managerial, health promotion, and economic achievements. Conclusion: Developing a dedicated EDDS for AHEEDs can be very helpful for better management of these effects. To this end, the model proposed in this study can serve as a guide for national and local policymakers to implement surveillance systems for AHEEDs.

Polypharmacy Pattern in Iran: A Comprehensive Analysis of a Large Prescription Database.

Background: Polypharmacy is a significant patient safety concern. Objectives: This study aims to estimate the prevalence of polypharmacy, its continuity and associated factors, and common medication classes among a large outpatient population in East Azerbaijan province, Iran. Methods: A retrospective prescription data analysis was performed. The cohort included all ≥ 20 years old subjects with at least one prescription filled during the main three-month study period (2020 March 1 - 2020 May 31). Polypharmacy was defined as being exposed to more than four different medications during the main study period, and continuous polypharmacy was defined as being exposed to more than four medications during both the main study period and follow-up period (2020 October 1 - 2020 December 31). The frequency and prevalence of polypharmacy, along with predictive factors, were estimated. We performed multivariate logistic regression and estimated odds ratios (ORs) to investigate the risk factors for polypharmacy. Results: 307,820 patients included (mean age 49.8 years, 62.9% female, mean drug use 3.7 (SD = 2.6). Polypharmacy was observed in 28.3% (CI: 28.1 - 28.4), of which 36.6% experienced continuous polypharmacy. The odds of being exposed to polypharmacy increased with being female, increasing age, and exposure to chronic conditions. The groups of medications most utilized by polypharmacy patients were those indicated for gastro-esophageal reflux diseases, beta-blocking agents, antidepressants, blood glucose-lowering drugs, and antithrombotic agents. Conclusions: Strategies should be formulated to inform healthcare policymakers and providers about the magnitude of the polypharmacy phenomenon, associated factors, and the common medication classes involved.

Role of Health Sector in Road Traffic Injuries Prevention: A Public Health Approach.

BACKGROUND: Although the main burden of the Road Traffic Injuries (RTIs) is on the health sector, compared with other sectors, no clear definition is available about its role in the prevention of the RTIs. So this study has been performed to define the role of the health sector in the prevention of RTIs -before the incidence. METHODS: In this qualitative study with a grounded theory approach, the possible roles of the health sector in the prevention of the RTIs were identified in three phases. At the first stage of the study, the roles of the health system in the prevention of the RTIs identified from the literature. In the next step, semi-structured interviews (ranged from 45 to 90 minutes) with 42 experts were done for identifyingroles. Finally, Consensus attained on the identified roles by using the Delphi technique and with the participation of 30 experts. RESULTS: Literature review and interviews resulted in 42 and 86 roles for the health sector in the prevention of the RTIs, respectively. After removing the duplicates and merging the similar, 46 roles were entered into Delphi. Five roles excluded in the Delphi leaving 41 roles in 7 dimensions of communications (6 roles), intra-sector cooperation (9 roles), inter-sector leadership (6 roles), evaluation (6 roles), research (5 roles), education (3 roles), and health-specific issues (6 roles). CONCLUSIONS: It seems that the health sector can help an impressing reduction of the RTIs by playing the roles identified in this study, which the most important of them is Communication/Informing role. So first the general public and then the health sector itself would benefit from it.

Impact of the Iranian Health Sector Evolution Plan on Rehospitalization: An Analysis of 158000 Hospitalizations.

BACKGROUND: In May 2014, Iran launched the most far-reaching reform for the health sector, so-called Health Sector Evolution Plan (HSEP), since introduction of the primary health care network, with a systematic plan to bring about Universal Health Coverage. We aimed to analyze the time to first all-caused rehospitalization and all-caused 30-day readmission rate in the biggest referral hospital of Northwest of Iran before and after the reform. METHODS: We retrospectively analyzed discharge data for all hospitalization occurred in the six-year period of 2011-2017. The primary endpoints were readmission-free survival, and overall 30-day readmission rate. Using multivariate cox proportional hazards regression and logistic regression, we assessed between-period differences for readmission-free survival time and overall 30-day rehospitalization, respectively. RESULTS: Overall, 157969 admissions were included. After adjusting for available confounders including age; sex; ward of admission; length of stay; and admission in first/second half of year, the risk of being readmitted within 30 days after the reform was significantly higher (worse) compared to pre-reform hospitalization (odd ratio 1.22, P<0.001, 95% CI, 1.15-1.30). Adjusting for the same covariates, after-reform period also was slightly significantly associated with decreased (deteriorated) readmission-free time compared with pre-HSEP period (HR 1.06, P=0.005, 95% CI 1.01-1.11). CONCLUSION: HSEP seems insufficient to improve neither readmission rate, nor readmission-free time. It is advisable some complementary strategies to be incorporated in the HSEP, such as continuity of care promotion, self-care enhancement, effective information flow, and post-discharge follow up programs.

Nurses' perception of patient safety culture and its relationship with adverse events: a national questionnaire survey in Iran.

BACKGROUND: Patient safety culture is an important factor in determining hospitals' ability to address and reduce the occurrence of adverse events (AEs). However, few studies have reported on the impact of nurses' perceptions of patient safety culture on the occurrence of AEs. Our study aimed to assess the association between nurses' perception of patient safety culture and their perceived proportion of adverse events. METHODS: A cross-sectional survey was carried out among 2295 nurses employed in thirty-two teaching hospitals in Iran. Nurses completed the Persian version of the hospital survey of patients' safety culture between October 2018 and September 2019. RESULTS: Positive Response Rates of overall patient safety culture was 34.1% and dimensions of patient safety culture varied from 20.9 to 43.8%. Also, nurses estimated that the occurrence of six adverse events varied from 51.2-63.0% in the past year. The higher nurses' perceptions of "Staffing", "Hospital handoffs and transitions", "Frequency of event reporting", "Non-punitive response to error", "Supervisor expectation and actions promoting safety", "Communication openness", "Organizational learning continuous improvement", "Teamwork within units", and "Hospital management support patient safety" were significantly related to lower the perceived occurrence at least two out of six AEs (OR = 0.69 to 1.46). CONCLUSIONS: Our findings demonstrated that nurses' perception regarding patient safety culture was low and the perceived occurrence of adverse events was high. The research has also shown that the higher level of nurses' perception of patient safety culture was associated with lowered occurrence of AEs. Hence, managers could provide prerequisites to improve patient safety culture and reduce adverse events through different strategies, such as encouraging adverse events' reporting and holding training courses for nurses. However, further research is needed to assess how interventions addressing patient safety culture might reduce the occurrence of adverse events.

Development of quality indicators to measure pre-hospital emergency medical services for road traffic injury.

BACKGROUND: Pre-Hospital Emergency Care (PEC) is a fundamental property of prevention of Road Traffic Injuries (RTIs). Thus, this sector requires a system for evaluation and performance improvement. This study aimed to develop quality indicators to measure PEC for RTIs. METHODS: Following the related literature review, 14 experts were interviewed through semi-structured interviews to identify Quality Measurement Indicators (QMIs). The extracted indicators were then categorized into three domains: structure, performance, and management. Finally, the identified QMIs were confirmed through two rounds of the Delphi technique. RESULTS: Using literature review 11 structural, 13 performance, and four managerial indicators (A total of 28 indicators) were identified. Also, four structural, four performance, and three managerial indicators (A total of 11indicators) were extracted from interviews with experts. Two indicators were excluded after two rounds of Delphi's technics. Finally, 14 structural, 16 performance and, seven managerial indicators (A total of 37indicators) were finalized. CONCLUSION: Due to the importance and high proportion of RTIs compared to other types of injuries, this study set out to design and evaluate the QMIs of PEC delivered for RTIs. The findings of this research contribute to measuring and planning aimed at improving the performance of PEC.

The Effect of Health Evolution Plan on Health System Responsiveness: An Experience of Health System Reform from Iran.

The purpose of this study was to investigate the effect of the Health Evolution Plan (HEP) on Health System Responsiveness (HSR) in hospitals of Hamadan, Iran. Data were collected before and after the implementation of the HEP by interviewing hospital inpatient referrals about factors relating to responsiveness. The difference between the mean responsiveness scores before (2014) and after (2018) implementation of the HEP was not significant. The study findings demonstrate that, even though one of the most important goals of the HEP was the improvement of HSR, the responsiveness of hospitals was unchanged.

Public-Private Partnership Policy in Primary Health Care: A Scoping Review.

BACKGROUND: Given the challenges of governments to deliver primary health care (PHC), engaging private sector in the form of public-private partnership (PPP) can be effective policy. The aim of present study is to review the experiences of implementing PPP policy in PHC. METHODS: This scoping review study was conducted in 2019 using the framework proposed by Arkesy and O'Malley. Required data were collected through search the related keywords in databases, manual search of some journals, websites, and other sources of information and through references check, from January 2000 to May 2019. All studies, which focused on the results of PPP in PHC, and published in English or Persian were included in the study. RESULTS: A total of 108 articles were included in the study. The studies were mostly conducted in low- and middle-income countries. The quantitative studies have demonstrated the success of this policy in improving PHC indicators. Based on the qualitative studies PPP in PHC has many benefits, including access improvement, economic benefits, and service quality enhancement. CONCLUSIONS: The present study provides useful information on the experiences of different countries in the field of PPP in PHC that can be used by experts and decision makers to decide whether to engage the private sector in the form of PPP model.

Experts' perspectives on the application of public-private partnership policy in prevention of road traffic injuries.

PURPOSE: Successful application experiences on public-private partnership (PPP) in different countries, suggest that PPP could be an option in road traffic injury (RTI) prevention. The present study aims at investigating the applicability of PPP policy in RTI prevention in Iran based on the experts' perspectives. METHODS: This is a qualitative study with grounded theory approach which has been conducted in Tabriz University of Medical Sciences, Iran in 2018. The participants were 22 experts in the field of RTIs selected using purposive sampling method. Data were collected by semi-structured interviews and analyzed with content-analysis method. RESULTS: The results were classified under 5 main themes (applicability, scopes and services, challenges, advantages, and strategies) for applying PPP policy and 37 sub-themes. Due to the prevalence of RTIs, the present challenges in public sector, existence of qualified private sector, and successful experiences in other areas, there are opportunities for private sector partnership in prevention of RTIs. Private sector could participate in different scopes and services regarding RTI prevention, including road construction and maintenance, maintenance and provision of vehicles safety and public education. The main challenges including legislation issues, ambiguities in collaboration, political and organizational unsustainability, government's financial hardship and lack of experienced experts in the field of RTI. However, there are significant advantages including high efficiency in program implementation, covering the weaknesses of public sector, effective and efficient management on application of PPP in RTI prevention. The strategies include identifying and prioritizing the assignable activities, identifying the qualified private sector, developing PPP policies and legal frameworks, creating a common language between public and private parties, trying to meet the expectations of the private sector by public sector, developing a comprehensive and sound contract, and cultivating public culture to accept private sector in the field of RTI prevention. CONCLUSION: This study sought to determine whether PPP could be used as strategy to reduce the burden of RTIs in Iran. But it requires a lot of preliminary studies to provide the context and conditions for applying this policy.

Analysis of Public-Private Partnership in Providing Primary Health Care Policy: An Experience From Iran.

Background: This study aims to analyze the public-private partnership (PPP) policy in primary health care (PHC), focusing on the experience of the East Azerbaijan Province (EAP) of Iran. Methods: This research is a qualitative study. Data were gathered using interviews with stakeholders and document analysis and analyzed through content analysis. Results: Participants considered political and economic support as the most important underlying factors. Improving system efficiency was the main goal of this policy. Most stakeholders were supporters of the plan, and there was no major opponent. Implementing the health evolution plan (HEP) was an opportunity to design this policy. Participants considered the lack of provision of infrastructure as the main weakness, changing the role of the public sector as the main strength, and promoting social justice as the main achievement of policy. The results of the quantitative data review showed that following the implementation of this policy, health indicators have been improved. Conclusions: Based on the results of this study, the PPP model in EAP is a new and successful experience in PHC in Iran. Supporting and developing this policy may improve the quality and quantity of providing care.