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1.
Reprod Health ; 17(1): 68, 2020 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-32434579

RESUMO

BACKGROUND: Studies have shown the impact of female genital mutilation (FGM), especially infibulation (WHO type III), on reproductive health, and adverse obstetric outcomes like postpartum haemorrhage and obstructed labour. However, whether an association exists with maternal hypertensive complication is not known. The present study sought to investigate the role of the different types of FGM on the occurrence of eclampsia. METHODS: The study used data from the 2006 Demographic and health survey of Mali. The proportion of eclampsia in women with each type of FGM and the unadjusted and adjusted odds ratios (OR) were calculated, using women without FGM as reference group. Unadjusted and adjusted OR were also calculated for women who underwent infibulation compared to the rest of the population under study (women without FGM and women with FGM type I, II, and IV). RESULTS: In the 3997 women included, the prevalence of infibulation was 10.2% (n = 407) while 331 women did not report FGM (8.3%). The proportion of women reporting signs and symptoms suggestive of eclampsia was 5.9% (n = 234). Compared with the absence of female genital mutilation and adjusted for covariates, infibulation was associated with eclampsia (aOR 2.5; 95% CI:1.4-4.6), while the association was not significant in women with other categories of FGM. A similar aOR was found when comparing women with infibulation with the pooled sample of women without FGM and women with the other forms of FGM. CONCLUSION: The present study suggests a possible association between infibulation and eclampsia. Future studies could investigate this association in other settings. If these findings are confirmed, the possible biological mechanisms and preventive strategies should be investigated.

2.
East Mediterr Health J ; 26(3): 254-256, 2020 Mar 24.
Artigo em Inglês | MEDLINE | ID: mdl-32281632

RESUMO

The Eastern Mediterranean Region (EMR) confronts unprecedented health challenges, exacerbated by demographic and epidemiologic changes, triple burden of disease, increasing healthcare costs, as well as the effects of contracted emergencies, social conflicts and massive population movements. Such challenges have repercussions on health care delivery and health research systems. Research for health is essential for developing solutions that contribute to health improvements. Investment in research for health contributes to health, economic growth and equity.

3.
BMC Health Serv Res ; 20(1): 231, 2020 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-32192510

RESUMO

In the original publication of this article [1], there are two corrections.

4.
BMC Health Serv Res ; 20(1): 26, 2020 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-31915003

RESUMO

BACKGROUND: Iran's Parliament passed a Law in 2010 to merge the existing health insurance schemes to boost risk pooling. Merging can be challenging as there are differences among health insurance schemes in various aspects. This qualitative prospective policy analysis aims to reveal key challenges and implementation barriers of the policy as introduced in Iran. METHODS: A qualitative study of key informants and documentary review was conducted. Sixty-seven semi-structured face-to-face interviews were conducted, with key informants from relevant stakeholders. Purposive and snowball sampling techniques were used for selecting the interviewees. The related policy documents were also reviewed and analyzed to supplement interviews. Data analysis was conducted through an existing health financing World Bank framework. RESULTS: This study demonstrated that for combining health insurance funds, operational challenges in the following areas should be taken into account: financing mechanisms, population coverage, benefits package, provider engagement, organizational structure, health service delivery and operational processes. It is also important to have adequate cogent reasons to "the justification of the consolidation process" in the given context. When moving towards combining health insurance funds, especially in countries with a purchaser-provider split, it is critical for policy makers to make sure that the health insurance system is aligned with the policies and Stewardship of the broader health care system. CONCLUSIONS: Implementation of major reforms in a health system with fragmented insurance schemes with different target populations, prepayment structures, benefit packages and history of development is inherently difficult, especially when different stakeholders have vetoing powers over the proposed reforms. Solving the differences and operational challenges in the main areas of health insurance system generated in this study may provide a platform for the designing and implementing merging process of social health insurance schemes in Iran and other countries with similar situations.


Assuntos
Administração Financeira/organização & administração , Política de Saúde/legislação & jurisprudência , Seguro Saúde/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Seguro Saúde/organização & administração , Irã (Geográfico) , Masculino , Pessoa de Meia-Idade , Formulação de Políticas , Estudos Prospectivos , Pesquisa Qualitativa , Previdência Social/organização & administração , Participação dos Interessados/psicologia
5.
Artigo em Inglês | MEDLINE | ID: mdl-31797428

RESUMO

BACKGROUND: Physician's dual practice is a common phenomenon in both developing and developed countries. This study aimed to investigate the rate and factors affecting the dual practice of general practitioners (GPs) as the most important primary care providers in Iran. METHODS: This cross-sectional study was conducted on the data of 666 Iranian GPs, derived from a national survey. In this work, a researcher-made checklist was used to collect the required information. Multinomial logistic regression was used to examine the factors affecting concurrent employment in both public and private sectors and the factors affecting employment in more than one place (either public or private). RESULTS: About 23.51% of the GPs were only working in the public sector, and 57.84% only in the private sectors. Also, 18.65% were working in both the private and public sectors. Results also indicated that 26.17% of the GPs were working in two or more places (whether public or private). Male GPs (p < .1) as well as the GPs with higher earnings expectations (p < .01) were more likely to have dual practice. Besides, the GPs working in small towns and villages (compared with Tehran, as capital of Iran; p < .05) were less likely to have dual practice. Gender (male) and earnings expectations had a significant effect on working in more than one place (p < .01). CONCLUSION: The most important and significant factor affecting GPs' dual practice in Iran was their financial expectations. Thus, appropriate policies to modify physicians' income expectations and reforms such as improving tariffs setting should be adopted in the health systems.

6.
East Mediterr Health J ; 25(10): 728-743, 2019 Nov 04.
Artigo em Inglês | MEDLINE | ID: mdl-31774139

RESUMO

Background: Measuring scientific outputs allows for objective evaluation of established health research systems and ranking countries according to scientific achievements. To our knowledge, attempts for systematic mapping health research output in the Eastern Mediterranean Region (EMR) are limited. Aims: We aimed to conduct a detailed bibliometric analysis of EMR biomedical and health research productivity during the period 2004-2013, considering country of first author. Methods: We applied an improved PubMed search strategy to obtain precise data on EMR research productivity, limiting articles to reviews, original research and case reports. Data were normalized to global research output, represented by total articles indexed in PubMed per year from 2004-2013, according to population size of each country. Second order polynomial trend lines were calculated and comparing 5-year periods: 2004-2008 with 2009-2013. Results: Inspecting overall raw data, a clear increasing trend is observed. Regional share of global health related research ranged from 0.85-2.36% of total PubMed indexed publications during the study period. Five countries contributed to 80% of all published articles during study period; i.e., Islamic Republic of Iran (39%), Egypt (14%), Saudi Arabia (11%), Tunisia, and Pakistan (8% each). Overall, 2.35 articles are published per 100 000 population per year. While Kuwait maintained the highest per capita publication (followed by Tunisia, Lebanon, Qatar and Islamic Republic of Iran), Qatar, Islamic Republic of Iran and Saudi Arabia demonstrated the highest "per capita" population growth in publications. Three academic institutions accounted for over 10% of all publications that were led by an investigator from the Region. Collectively, most prolific 25 EMR institutions published 44% of all published biomedical and health research in the EMR. Conclusions: The overall global share of EMR health research publication is smaller than its global share of population or wealth. Biomedical and health research needs greater encouragement and supporting many EMR countries and/or institutions, especially those found to be least prolific in our analysis. The increase in academic publication on health has been more prominent in a few countries only. It is anticipated that the concentration of biomedical and health research in EMR academic institutions would help in translating knowledge into public health outcomes, if more suitable conditions are provided.

7.
East Mediterr Health J ; 25(7): 445-446, 2019 Oct 04.
Artigo em Inglês | MEDLINE | ID: mdl-31612975

RESUMO

Urbanization has been rapidly increasing during the past two decades and it is estimated that by 2030, two thirds of the world's population would be living in urban areas, exposing the population to a large number of environmental, social, cultural, economic and behavioural factors that impact population health and wellbeing.In response to such challenges, the Healthy Cities concept was instigated in 1977 that, along with the Alma Ata Declaration and commitment of countries at the Thirtieth World Health Assembly in Geneva, Switzerland, would empower communities to lead socially and economically productive lives. A number of policy documents from the World Health Organization (WHO) and other bodies suggested introducing new approaches to managing cities and addressing health challenges, focusing more on health determinants and prevention than medical interventions.

8.
BMC Health Serv Res ; 19(1): 620, 2019 Sep 02.
Artigo em Inglês | MEDLINE | ID: mdl-31477097

RESUMO

BACKGROUND: General practitioners (GPs) are among the most important resources of healthcare system and public health is considerably influenced by the function of this group. Income inequality among GPs considerably affects the motivation and performance of this group. The present study aims to examine the income inequality among Iranian GPs in order to provide the necessary evidence for health human resource policy. METHODS: In this cross-sectional study, the distribution of income and wage inequality among GPs was investigated using income quintiles. We also used the Dagum's model to analyze the inequality between different groups of GPs through the decomposition of the Gini coefficient. Moreover, a regression model was used to determine the effective factors on GPs' income. RESULTS: The results of this study indicated that income and wages of GPs in the highest quintile were eight times more than those of doctors at the lowest quintile. Regression estimates showed that factors such as gender, practice setting, and activity as the family physician (P < 0.001) were effective on income of GPs; and also male and self-employed GPs had significantly more wage (P < 0.001). Total Gini coefficient of GPs' income and wage were estimated at 0.403 and 0.412, respectively. Highest monthly income was found in GPs with 16-20 years practice experience ($8358) based on Purchasing Power Parity (PPP), male ($8339 PPP), and self-employed GPs ($8134 PPP) subgroup. However, the female ($5389 PPP) and single ($5438 PPP) GPs had the lowest income. Population share; income/wage share; income/wage mean; Gini coefficient; and within, between and overlap decomposed components of Gini coefficient are also reported for each GPs subgroups. CONCLUSIONS: We found significant inequalities in income and wages among Iranian GPs. Adjustment of income based on working hours indicated that one of the most common causes of income inequality among GPs in Iran was different workloads among different groups. Since the motivation and function of physicians can be influenced by income inequality, policymakers in the health system should consider factors increasing such inequalities.


Assuntos
Clínicos Gerais/economia , Renda , Fatores Socioeconômicos , Adulto , Estudos Transversais , Assistência à Saúde , Feminino , Política de Saúde , Humanos , Entrevistas como Assunto , Irã (Geográfico) , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa
9.
BMC Health Serv Res ; 19(1): 614, 2019 Aug 30.
Artigo em Inglês | MEDLINE | ID: mdl-31470849

RESUMO

BACKGROUND: This study aims to assess geographical distribution of hospitals and extent of inequalities in hospital beds against socioeconomic status (SES) of residents of five metropolitan cities in Iran. METHODS: A cross-sectional analysis was conducted to measure geographical inequality in hospital and hospital bed distributions of 68 districts in five metropolitan cities during 2016 using geographic information system (GIS), and Gini and Concentration indices. Correlation analysis was performed to show the relationship between the SES and inequality in hospital beds densities. RESULTS: The study uncovered marked inequalities in hospitals and hospital beds distributions. The Gini indices for hospital beds were greater than 0.55. The aggregated concentration indices for public and private hospital beds were 0.33 and 0.49, respectively. The GIS revealed that 216 (70.6%) hospitals were located in two highest socioeconomic status classes in the cities. Only 29 (9.5%) hospitals were located in the lowest class. The public, private, and the cumulative hospitals beds distributions in Tehran and Esfahan showed significant (p < 0.05) positive correlation with SES of the residents. CONCLUSIONS: The high inequalities in hospital and hospital beds distributions in our study imply an overlooked but growing concern for geographical access to healthcare in rapidly urbanizing metropolitan cities in Iran. Thus, regardless of ownership, decision-makers should emphasize the disadvantaged areas in metropolitan cities when need arises for the establishment of new healthcare facilities in order to ensure fairness in healthcare. The metropolitan cities and rapid urbanization settings in other countries could learn lessons to reduce or prevent similar issues which might have hampered access to healthcare.


Assuntos
Ocupação de Leitos/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Hospitais Urbanos/provisão & distribução , Cidades , Estudos Transversais , Geografia , Humanos , Irã (Geográfico) , Densidade Demográfica , Classe Social , Fatores Socioeconômicos
10.
Med J Islam Repub Iran ; 33: 70, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31456994

RESUMO

Background: According to the Global tuberculosis (TB) Report 2014, released by World Health Organization (WHO), difference between estimated number of TB patients and the number of patients who are registered by the National Tuberculosis Programs (NTBP) is about 3 million annually in the world. In the current study, we investigated the level of under-reporting of TB cases between labs with poor collaboration background with NTBP in Tehran. Methods: In the context of TB, this is an inventory study that evaluating the level of under-reporting of TB cases. To do inventory study, first, after selecting laboratories based on poor collaboration background with NTBP and developing patient's list we matched the patient's list with the MoHME's database then, patients that were not recorded in NTBP's list were identified, and those with available telephone numbers were called. Results: Out of 23 selected labs, 10 (5 private, 5 public (other than PHC)) had individuals with positive results. 71.6% of all samples are tested in public labs. Out of 23633 performed tests, 1396 individuals were positive. The under-reporting was, 62.5% and 39% in public and private laboratories, respectively. Conclusion: Public and private sector laboratories will be able to significantly reduce their failure to report if they comply with the recommended requirements and standards of the NTBP in their Processes and software for registering patient information.

11.
Iran J Public Health ; 48(6): 1124-1132, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31341855

RESUMO

Background: Considering the importance of high out-of-pocket (OOP) payment (OOPP), as a marker of health system performance, and affordability of medications in the elderly, this study was conducted to determine these issues. Methods: In this cross-sectional study, prescriptions of patients aged 65 yr or older from 5 university-affiliated pharmacies in Tehran, Iran were evaluated from Jan to Mar 2014. Prescriptions were selected from four insurance organizations. We used the prescriptions data regarding patients' demographics and the prescribers as well as the sales data for OOP. Affordability was calculated by considering the daily salary of an unskilled worker. Results: Totally, 1467 prescriptions were analyzed. Mean age of patients was 73.89(6.66) yr. Mean (SE) of reimbursable and OOPP of the prescriptions were 203820 (10831) and 230252 (10634) IRR (Iranian Rials) respectively (equivalent to 81.6 (4.33) and 92.17 (4.33) US$ respectively). Subspecialists imposed higher expenditures for patients and insurance organizations. Patients referred to the ophthalmologists paid less OOP. Nearly 50% of the total prescription costs was paid as OOP. The mean OOPP was averagely equal to 1.41(0.065) daily salary. These prescriptions were unaffordable for 36.2% of patients. Conclusion: The OOPP was higher than the insurance goal of 30% for outpatients in Iran. More than one-third of elderly patients could not afford their single prescription. Due to the health consequences of the unaffordability of medications, corrective actions are needed by the insurance organizations and the health system.

12.
Public Health Nutr ; 22(12): 2179-2188, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31199208

RESUMO

OBJECTIVE: The present study aimed to assess and decompose the socio-economic inequality in unhealthy snacks consumption among adolescent students in Kerman, Iran. DESIGN: The data were obtained from a cross-sectional study. Principal component analysis was done to measure the socio-economic status (SES) of the adolescents' families and the normalized concentration index (NCI) was used to measure the inequality in unhealthy snacks consumption among adolescent students of different SES. The contributions of environmental and individual explanatory variables to inequality were assessed by decomposing the concentration index. SETTING: Forty secondary schools of Kerman Province in Iran in 2015. PARTICIPANTS: Eighth-grade adolescent students (n 1320). RESULTS: The data of 1242 adolescent students were completed for the current study. Unhealthy snacks consumption was unequally distributed among adolescent students and was concentrated mainly among the high-SES adolescents (NCI = 0·179; 95 % CI 0·056, 0·119). The decomposition showed that higher SES (62 %) and receiving pocket money allowance (31 %), as environmental variables, had the highest positive contributions to the measured inequality in unhealthy snacks consumption. Taste and sensory perception (7 %) as well as cost sensitivity (5 %), as individual variables, followed them in terms of their contribution importance. CONCLUSIONS: It is highly suggested that both environmental and individual factors should be addressed at different settings including schools, families and suppliers of unhealthy snacks. These findings can help future health promotion strategies in Iran to tackle the observed inequality in unhealthy snacks consumption.

13.
East Mediterr Health J ; 25(4): 254-261, 2019 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-31210346

RESUMO

Background: In recent decades, the rate of caesarian section (C-section) has increased in the Islamic Republic of Iran. A reform in the Iranian health system - the Health Transformation Plan (HTP) - was launched in 2014 in which one of the objectives of HTP is decreasing the rate of C-section. Aims: This study aimed to assess the effects of the Health Transformation Plan (HTP) on the C-section rate in the Islamic Republic of Iran. Methods: This study was an interrupted time series analysis that used segmented regression analysis to assess the immediate and long-term effects of the HTP on C-section rate in two groups of hospitals affiliated and not affiliated to the Ministry of Health and Medical Education (MoHME) in Kurdistan province. Study samples were selected using the data on monthly C-section rate collected over a period of four years. Results: We observed significant decreases in C-section rate immediately after the HTP in both groups of hospitals by 0.0629 and 0.0013, respectively (P < 0.05). In the long run, we observed no significant decrease in the regression slope of C-section rate in both groups. Conclusions: The implementation of HTP decreased the C-section rate. However, the reduction does not meet expectations.


Assuntos
Cesárea/estatística & dados numéricos , Reforma dos Serviços de Saúde/estatística & dados numéricos , Cesárea/economia , Humanos , Análise de Séries Temporais Interrompida , Irã (Geográfico)
14.
Lancet ; 393(10184): 1984-2005, 2019 05 11.
Artigo em Inglês | MEDLINE | ID: mdl-31043324

RESUMO

Being the second-largest country in the Middle East, Iran has a long history of civilisation during which several dynasties have been overthrown and established and health-related structures have been reorganised. Iran has had the replacement of traditional practices with modern medical treatments, emergence of multiple pioneer scientists and physicians with great contributions to the advancement of science, environmental and ecological changes in addition to large-scale natural disasters, epidemics of multiple communicable diseases, and the shift towards non-communicable diseases in recent decades. Given the lessons learnt from political instabilities in the past centuries and the approaches undertaken to overcome health challenges at the time, Iran has emerged as it is today. Iran is now a country with a population exceeding 80 million, mainly inhabiting urban regions, and has an increasing burden of non-communicable diseases, including cardiovascular diseases, hypertension, diabetes, malignancies, mental disorders, substance abuse, and road injuries.


Assuntos
História da Medicina , Doenças não Transmissíveis/epidemiologia , Transição Epidemiológica , História Antiga , Humanos , Irã (Geográfico)/epidemiologia , Pérsia , Anos de Vida Ajustados por Qualidade de Vida
15.
J Ayub Med Coll Abbottabad ; 31(2): 201-206, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31094117

RESUMO

BACKGROUND: The objective of this study is to explore the factors which influence the health seeking behaviour and utilization of healthcare services of the community in context of geographical, socio-demographic, cultural, economic and educational background. METHODS: A community based cross-sectional survey was performed on 900 households in five districts of Punjab from 1st February to 2nd March, 2016. In each of the selected district random sampling method was used for selection of six primary health facilities. Nine hundred household purposively selected around each selected PHCF in opposite direction at distance of 5, 10, 15 km. A pretested questionnaire, WHO operational package (for assessing, monitoring and evaluating country pharmaceutical situations Level IIb) was acquired, and analysed by SPSS 23. RESULTS: In 900 households visited, total population was 5024, out of which females and males were 47.7% and 52.3% respectively. About 95% of community had source of income. The male respondents and females were 95% and 5% respectively. 43.3% of patients visited PHCF, were with the serious complaints. 37% patients in households didn't take medicines when got sick. Females who completed their primary education were same in number as male but after primary education, males were more who perused further education. For 14% of the respondents, PHC was too far and for 61.9% of the respondents, PHC was close to reach.74.5% of the respondents were not satisfied with timings. 42.7% got medicines they need from PHC. Community with access <15 min to PHCF were 57.2%, and >1 hour was 5%. 49.1% of respondents could get free medicines from PHC. 64.4% respondent found medicines expensive at private pharmacies. In 53.3% of the cases, prescriber was doctor and for 47.6% were trained health assistant. CONCLUSIONS: There is a potential to improve the health seeking behaviour and PHC utilization by addressing the demandside (community) factors created by geographical access, socio-economic factors, level of education, cultural beliefs and by healthcare system itself. Male dominance was found. Level of education was more among males. Physical access was a significant barrier. Availability of medicines was low. There was absence of doctor at PHCF..


Assuntos
Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Estudos Transversais , Características da Família , Feminino , Humanos , Masculino , Paquistão/epidemiologia
16.
Value Health Reg Issues ; 18: 170-175, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31096140

RESUMO

BACKGROUND: The EuroQol 5-dimension (EQ-5D) is a standard instrument that is widely used for measuring health-related quality of life and quality-adjusted life years in economic evaluation of healthcare interventions. OBJECTIVE: To estimate a preference valuation set for EQ-5D 3-level (3L) health states from the perspective of the general population in the capital of Iran. METHODS: Eight hundred seventy adults aged ≥18 years were interviewed in Tehran (Iran's capital) from July to November 2013. The participants were selected by a stratified random sampling method and were interviewed face-to-face at their usual residence. Forty-two health states were selected and valued from the 243 states derived from the EQ-5D-3L instrument. Each respondent valued 11 health states using the time trade-off method. Generalized least squares regression with random effect was used to predict values for health states. RESULTS: The analysis was performed for 846 respondents. The final model yielded the best fit for the time trade-off value at the individual level with an overall R2 of 0.45 and a mean absolute error of 0.214. The mean values for the 42 health states ranged from 0.934 for state 11121 to -0.142 for state 33333. CONCLUSIONS: This study provided for the first time a value set for calculating quality-adjusted life years from the EQ-5D instrument in Iran. The Iranian EQ-5D-3L value set slightly differs from the value sets of the UK and the United States.


Assuntos
Nível de Saúde , Anos de Vida Ajustados por Qualidade de Vida , Adolescente , Adulto , Idoso , Feminino , Humanos , Irã (Geográfico) , Masculino , Pessoa de Meia-Idade , Psicometria/instrumentação , Psicometria/métodos , Qualidade de Vida/psicologia , Inquéritos e Questionários , Fatores de Tempo
17.
Cochrane Database Syst Rev ; 4: CD010412, 2019 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-30982950

RESUMO

BACKGROUND: Having nurses take on tasks that are typically conducted by doctors (doctor-nurse substitution, a form of 'task-shifting') may help to address doctor shortages and reduce doctors' workload and human resource costs. A Cochrane Review of effectiveness studies suggested that nurse-led care probably leads to similar healthcare outcomes as care delivered by doctors. This finding highlights the need to explore the factors that affect the implementation of strategies to substitute doctors with nurses in primary care. In our qualitative evidence synthesis (QES), we focused on studies of nurses taking on tasks that are typically conducted by doctors working in primary care, including substituting doctors with nurses or expanding nurses' roles. OBJECTIVES: (1) To identify factors influencing implementation of interventions to substitute doctors with nurses in primary care. (2) To explore how our synthesis findings related to, and helped to explain, the findings of the Cochrane intervention review of the effectiveness of substituting doctors with nurses. (3) To identify hypotheses for subgroup analyses for future updates of the Cochrane intervention review. SEARCH METHODS: We searched CINAHL and PubMed, contacted experts in the field, scanned the reference lists of relevant studies and conducted forward citation searches for key articles in the Social Science Citation Index and Science Citation Index databases, and 'related article' searches in PubMed. SELECTION CRITERIA: We constructed a maximum variation sample (exploring variables such as country level of development, aspects of care covered and the types of participants) from studies that had collected and analysed qualitative data related to the factors influencing implementation of doctor-nurse substitution and the expansion of nurses' tasks in community or primary care worldwide. We included perspectives of doctors, nurses, patients and their families/carers, policymakers, programme managers, other health workers and any others directly involved in or affected by the substitution. We excluded studies that collected data using qualitative methods but did not analyse the data qualitatively. DATA COLLECTION AND ANALYSIS: We identified factors influencing implementation of doctor-nurse substitution strategies using a framework thematic synthesis approach. Two review authors independently assessed the methodological strengths and limitations of included studies using a modified Critical Appraisal Skills Programme (CASP) tool. We assessed confidence in the evidence for the QES findings using the GRADE-CERQual approach. We integrated our findings with the evidence from the effectiveness review of doctor-nurse substitution using a matrix model. Finally, we identified hypotheses for subgroup analyses for updates of the review of effectiveness. MAIN RESULTS: We included 66 studies (69 papers), 11 from low- or middle-income countries and 55 from high-income countries. These studies found several factors that appeared to influence the implementation of doctor-nurse substitution strategies. The following factors were based on findings that we assessed as moderate or high confidence.Patients in many studies knew little about nurses' roles and the difference between nurse-led and doctor-led care. They also had mixed views about the type of tasks that nurses should deliver. They preferred doctors when the tasks were more 'medical' but accepted nurses for preventive care and follow-ups. Doctors in most studies also preferred that nurses performed only 'non-medical' tasks. Nurses were comfortable with, and believed they were competent to deliver a wide range of tasks, but particularly emphasised tasks that were more health promotive/preventive in nature.Patients in most studies thought that nurses were more easily accessible than doctors. Doctors and nurses also saw nurse-doctor substitution and collaboration as a way of increasing people's access to care, and improving the quality and continuity of care.Nurses thought that close doctor-nurse relationships and doctor's trust in and acceptance of nurses was important for shaping their roles. But nurses working alone sometimes found it difficult to communicate with doctors.Nurses felt they had gained new skills when taking on new tasks. But nurses wanted more and better training. They thought this would increase their skills, job satisfaction and motivation, and would make them more independent.Nurses taking on doctors' tasks saw this as an opportunity to develop personally, to gain more respect and to improve the quality of care they could offer to patients. Better working conditions and financial incentives also motivated nurses to take on new tasks. Doctors valued collaborating with nurses when this reduced their own workload.Doctors and nurses pointed to the importance of having access to resources, such as enough staff, equipment and supplies; good referral systems; experienced leaders; clear roles; and adequate training and supervision. But they often had problems with these issues. They also pointed to the huge number of documents they needed to complete when tasks were moved from doctors to nurses. AUTHORS' CONCLUSIONS: Patients, doctors and nurses may accept the use of nurses to deliver services that are usually delivered by doctors. But this is likely to depend on the type of services. Nurses taking on extra tasks want respect and collaboration from doctors; as well as proper resources; good referral systems; experienced leaders; clear roles; and adequate incentives, training and supervision. However, these needs are not always met.


Assuntos
Necessidades e Demandas de Serviços de Saúde , Designação de Pessoal , Atenção Primária à Saúde/normas , Pesquisa Qualitativa , Qualidade da Assistência à Saúde , Humanos , Profissionais de Enfermagem , Enfermeiras e Enfermeiros , Atenção Primária à Saúde/organização & administração
18.
Artigo em Inglês | MEDLINE | ID: mdl-30867654

RESUMO

Background: Recent years have witnessed a strong tendency to apply economic evidence as a guide for making health resource allocation decisions, especially those related to reimbursement policies. One such measure is the use of the cost-effectiveness threshold as a benchmark. This study explored the threshold for use in the health system of Iran by determining society's preferences. Methods: A cross-sectional household survey based on the contingent valuation method was administered to a representative general population of 1002 in Tehran, Iran from April to June 2015. The survey was intended to estimate the respondents' willingness-to-pay (WTP) preferences for one quality-adjusted life year (QALY) gained. The valuation scenarios featured 12 vignettes on mild to severe diseases that can change people's quality of life. The mean of WTP for QALY was estimated using different health instruments, and the determinants of such willingness were analyzed using the Heckman selection model. Results: WTP for QALY varied depending on the severity of a disease and the instrument used to determine health preferences. Mean low health state value were associated with high valuation. The best estimated WTP values ranged from US$1032 to US$2666 and 0.22-0.56 of Iran's local gross domestic product (GDP) per capita in 2014. Except for educational level, significant variables differed across different disease scenarios. Generally, a high health state valuation for target diseases, high income, high educational level, and being married were associated with high WTP for QALY. Conclusion: From the general public's perspective, the monetary value of QALY for mild to severe diseases with no risk of death was less than one GDP per capita. Therefore, the obtained valuation range is recommended as reference only for the adoption of interventions designed to improve quality of life. Future studies should estimate the threshold of interventions for life-threatening diseases or formulate transparent policies in such contexts.

19.
J Ayub Med Coll Abbottabad ; 31(1): 90-97, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30868792

RESUMO

BACKGROUND: Household storage of medicines is a world-wide practice that triggers the irrational use of medicines and consequent threats. The purpose of this research is to explore sources of medicines availability, utilization and reasons of medicines storage in household.. METHODS: A community-based survey was performed on 900 households in five districts of Punjab, Pakistan from 1st February to 2nd March, 2016. Data was collected through employing a pretested questionnaire, the World Health Organization (WHO) operational package (for assessing, monitoring and evaluating country pharmaceutical situations Level IIb), and analysed by SPSS-23. RESULTS: A mean of 2.94 medicines per household were observed in 900 households visited with 2,648 of total medicines found. Significant number of medicines was analgesics (58.6%) and antibiotics (12.97%). Out of total, 20.4% of household medicines were for current treatments. Left over medicines from past treatments were 8.7%, and 70.9% were anticipated for future use. Household medicines existed in the form of oral tablets, were 89%. Household medicines of 91.2%, were satisfactorily labelled in acute cases and majority were obtained from private pharmacies. Household medicines of 80% were acquired by respondents with post-graduation qualification and 61.2% of the medicines were obtained by respondents with no formal education and in both cases source of medicines was private pharmacies. While overall, 61.5% of respondents took medicines from the private pharmacy. In general, patients got 3.4% of medicines from the primary healthcare facilities. Adherence to medical treatment was very poor. In chronic cases 35.7% of patients left treatment when symptoms improved, while in acute cases 41.1% of the patients showed non-adherence to the treatment. Patients who knew about use of medicines were 92.32%. CONCLUSIONS: Maximum medicines stored were for the future use. The main source of medicines found in households was private pharmacies. Antibiotics and analgesic were in common in use. Patient's nonadherence to the treatment was one of the reasons of presence of medicines at home.


Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Armazenamento de Medicamentos/estatística & dados numéricos , Preparações Farmacêuticas , Estudos Transversais , Características da Família , Humanos , Paquistão/epidemiologia
20.
Daru ; 27(1): 101-109, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30788839

RESUMO

Overprescribing of antibiotics and injectable medicines is common in ambulatory care in many low- and middleincome countries. We evaluated the effects of three different interventions in improving physician prescribing. We conducted a four-armed randomized controlled trial with one-month and three- months follow-up. General physicians, pediatricians, and infectious disease specialists were included in this study if they had an outpatient office in Tehran, Iran. The study involved two behaviorally guided interventions: "new-design audit and feedback (NA&F)"; "printed educational material (PEM)" and an existing intervention of "routinely conducted audit and feedback (RA&F)". The theoretical framework underpinning the intervention was the theory of planned behavior. Main outcome measures were the percentage change in the proportion of prescriptions containing injectable dexamethasone; oral amoxicillin and cefixime. NA&F reduced the proportion of prescriptions particularly those containing dexamethasone injectable and cefixime (1.64, 0.99 absolute percentage change, p = 0.006, p = 0.01 respectively). PEM reduced the proportion of prescriptions containing cefixime (0.93 absolute percentage change p = 0.04). Other primary outcomes had no significant differences. A secondary outcome measure showed overall prescribing of injectables also reduced (absolute risk reduction: 3%). Overally, the study provides strong evidence that using theoretical insights in the development of the intervention improved prescribing behavior that lasted at least three months after the intervention. The design, format, and presentation of messages in feedback forms significantly influence the impact of audit and feedback on physician prescribing. While the interventions were effective, the impacts on inappropriate prescribing were modest and limited. In settings with rampant problems of overprescribing, intensive interventions are required to substantially improve prescribing patterns. Graphical abstract Graphical abstract.


Assuntos
Amoxicilina/administração & dosagem , Antibacterianos/administração & dosagem , Cefixima/administração & dosagem , Dexametasona/administração & dosagem , Prescrição Inadequada/estatística & dados numéricos , Auditoria Médica/métodos , Administração Oral , Assistência Ambulatorial , Feminino , Clínicos Gerais , Humanos , Prescrição Inadequada/tendências , Injeções , Irã (Geográfico) , Masculino , Pediatras , Avaliação de Programas e Projetos de Saúde , Fatores Socioeconômicos
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