A qualitative study on human resources for primary health care in Iran

Prevalence of depression, anxiety, and stress and associated reasons among Iranian primary healthcare workers: a mixed method study

BACKGROUND

Different mental disorders may be associated with many work-related factors to which primary health care workers (PHCWs) are exposed. The current research aims to measure the rates of depression, anxiety, and stress among PHCWs, and their associated causes in primary health care (PHC) settings.

METHODS

An explanatory sequential mixed methods design was employed in this research from January 2021 to January 2022 in Tabriz, Iran's PHC centers. First, this study followed an online-based cross-sectional survey using a self-reported questionnaire. The Depression, Anxiety and Stress Scale-21 Items (DASS-21) and questions on demographic and work-related characteristics were completed by 303 frontline PHCWs during the quantitative phase. In the qualitative phase, a semi-structured interview was held with 12 PHCWs who had the highest level of depression, anxiety, and stress to identify the reasons and sources of mental health prevalence. Quantitative data were analyzed using descriptive statistics via SPSS-26. A content analysis was performed to analyze qualitative data.

RESULTS

The results showed that self-reported stress, anxiety, and depression had a prevalence of 40.3%, 42.9%, and 42.6%, respectively. Symptoms of at least one mental disorder were experienced by 54% of respondents, while 28% had all three. Major sources of stress, anxiety, and depression among PHCWs were working environment conditions, organizational policies, job-related reasons, and interpersonal relations.

CONCLUSIONS

The results of current study indicated that PHCWs experienced high levels of depression, anxiety, and stress. The main factors and reasons that contributed to these mental health issues among PHCWs were work environment conditions, organizational policies, job-related reasons and interpersonal relations. Therefore, interventions should be implemented to promote mental health of PHCWs. This can include measures such as psychological screening, supportive care, workload management, flexible scheduling, and access to mental health resources. Additionally, training programs can be implemented to enhance resilience and coping skills among healthcare professionals.

Development and validation of primary health care quality assessment tool

BACKGROUND

Assessing the quality of health services gives insights to managers about the status of services delivered by them, especially from the client's perspective. Although various tools have been developed to measure the quality of primary health care (PHC), no specific tool was found in this field in Iran. Therefore, the present study was conducted to develop and validate the quality assessment tool of PHC in Iran.

METHODS

This methodological study was conducted in 2021. In the first step, based on a literature review, an initial questionnaire was designed, and its face validity, content validity, construct validity, and reliability were evaluated. Descriptive tests, Kolmogorov-Smirnov, exploratory factor analysis, Kaiser-Myer-Olkin (KMO), and Cronbach's alpha were performed by using SPSS 22.

RESULTS

The initial questionnaire included 33 items, of which three items were removed due to inconsistency with factorization. The final questionnaire consisted of 30 items and nine dimensions: interaction, efficiency, timeliness, accuracy, consultation, tangibility, safety, accessibility, and environment. The KMO and Cronbach's alpha index values were 0.734 and 0.82, respectively, indicating acceptable reliability and validity. The developed dimensions represented about 73% of the total variance.

CONCLUSION

The designed questionnaire has relatively good validity and reliability and can be used to measure the quality of PHC and to identify weaknesses in service delivery. However, researchers should carefully examine it to enhance its applicability as a standard tool for measuring PHC quality.

Recruitment and selection of community health workers in Iran; a thematic analysis

BACKGROUND

In Iran, community health workers (CHWs) are selected and employed according to the instructions of the Ministry of Health (MOH). The present study aimed to investigate the views of different stakeholders regarding the selection criteria, as well as the competency of CHWs.

METHODS

This study was conducted using a qualitative thematic analysis in Golestan Province, Iran. Data were collected using semi-structured interviews with managers, supervisors, CHWs, and common people in 2021. The interviews were recorded and then transcribed. To extract key themes, the six-step Brown model was used, which involved becoming acquainted with the data, meaningful organization of transcripts, extracting primary open codes, searching for themes in an iterative approach, theme extraction, defining themes, and preparing a report. The relationships between codes and sub-themes and themes were represented using ATLAS.ti version 8.

RESULTS

Data saturation was achieved after interviewing 22 people. The extracted data included 340 open codes, two main sub-themes of "CHW effectiveness" and "CHW sustainability", and three main themes of "criteria for employing competent people", "barriers to employing competent people", and "identifying the barriers to employing competent people", according to the MOH instructions.

CONCLUSION

In the present study, local hiring was one of the major challenges in the competency-based selection of CHWs. One of the most repeated codes was expanding the local hiring concept and its requirements. Since different regions of Iran have different climatic, economic, cultural, and social conditions, the selection and hiring criteria for CHWs should be tailored to the needs of the community.

Iranian primary health care network: challenges and ways forward

AIM

This study aimed to explore the current challenges of Iran's Iranian Primary Health Care (PHC) network and possible ways forward.

BACKGROUND

PHC network was established in 1985. It remains a core instrument of health care delivery. However, it faces several challenges that can threaten its effective functioning.

METHODS

We conducted face-to-face semi-structured interviews with 26 key stakeholders. We used the deductive content analysis approach. World Health Organization's health system framework guided our analyses. Data were analysed using MAXQDA software. To enhance data triangulation, we reviewed PHC national related plans, bylaws, and national and international published reports.

FINDINGS

PHC network experiences financial challenges and fails to respond fully to the emerging population's needs due to unfair distribution of resources and a lack of community health workers for PHC and a sustainable financing model for PHC. Furthermore, the insurance package is not well integrated into the PHC network system. Policy interests and resource commitments for innovative, preventive, and health promotion initiatives are lacking. Innovative, preventive, and health promotion initiatives should become the highest priority for policymakers. Well-trained community health professionals, active community participation, private sector engagements and active involvement of non-government organisations are fundamental for a well-functioning PHC network in Iran, especially to foster the delivery of evidence-based initiatives.

Integrating rehabilitation services into primary health care: policy options for Iran

BACKGROUND

Providing rehabilitation services in primary health care (PHC) is associated with numerous health, social, and economic benefits. Therefore, low and middle-income countries, such as Iran, should benefit from the advantages of integrating rehabilitation services into PHC. We conducted a qualitative study to determine policy solutions that could facilitate the integration of rehabilitation services into Iran's PHC network.

METHODS

Semi-structured interviews were conducted with 38 participants, including health policymakers, rehabilitation managers, faculty members, and rehabilitation practitioners. Purposive and snowball sampling strategies were adopted to recruit participants. The WHO Health System building blocks framework analysis was applied to analyze the collected data.

RESULTS

Participants' perspectives and experiences outlined potential policy options including: (1) stewardship: increasing political support, strengthening the leadership of the rehabilitation sector, and promoting inter-sectoral collaborations; (2) service delivery: increasing the knowledge of healthcare professionals, using local volunteers, deploying mobile rehabilitation teams, using telerehabilitation, and improving referral pathways; (3) financing: increasing government funding, preparing a package of rehabilitation services, and using appropriate payment mechanisms; (4) human resources: expanding rehabilitation workforce, training rehabilitation assistants, and enhancing employment and social opportunities; (5) information systems: establishing a comprehensive information system and an effective surveillance system; and (6) technologies: facilitating access to a range of rehabilitation equipment and raw materials, especially for prosthetics and orthotics services.

CONCLUSION

Based on the WHO six building blocks framework, this study identified several policy options for integrating rehabilitation services into the Iranian PHC Network. Some of the policy options include increasing political support, promoting inter-sectoral collaborations, increasing the skills and knowledge of healthcare workers, establishing effective referral pathways, strengthening team-working, and increasing government funding.

Inequality in households' access to primary health care (PHC): a case study in Kerman, southeast Iran

Background

Fair access to health services is a vital issue in low-and middle-income countries. Therefore, the present study was conducted to evaluate the equity in access to primary health care (PHC) services in southeastern Iran.

Methods

This household-based survey was conducted on 1128 households in Kerman, southeastern Iran in 2019-20. A multistage probability method was used to select the samples. The online questionnaire was designed and its link was provided to the questioners. After receiving the training, the questioners went to the door according to the sampling guide. The collected data were analyzed at a significance level of 0.05, using the STATA software. The concentration index (CI) was also used to measure inequality in access to PHC services.

Results

The results showed that there was a significant difference between gender and location in access to PHC services (P < 0.05). However, no significant difference was found between the access rates to PHC services and the variables of age, marital, education, health insurance, and Supplementary insurance (P > 0.05). The mean rate of access to PHC services was 3.51 ± 0.53. Cultural access (3.76 ± 0.54) and timely receipt of PHC services (2.51 ± 0.72) accounted for the highest and the lowest access rates, respectively. The concentration index for the distribution of PHC services among the income-adjusted population was 0.014 (CI 95%: -0.022 to 0.051), indicating pro-rich inequalities in access to PHC services.

Conclusion

The results indicated that pro-rich inequality, but it was close to the equality line. Also, the access level was assessed as moderate to high. Therefore, planning and policy-making seems essential for reduce inequality, and development and promotion of access to PHC services, especially timely provision of services and organizational access.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08467-4.

A qualitative study of challenges affecting the primary care system performance: Learning from Iran's experience

Background and Aims

Primary care and the use of a referral system are essential components of any health system. The aim of this study was to investigate and identify the challenges affecting the performance of the primary health-care system in Iran.

Methods

This qualitative study was carried out consisting of 14 interviews with experts and those familiar with the primary care system and its function. Purposive and snowball sampling was used to identify the samples. The recorded files were transcribed and entered into the MAXQDA-11 software to be analyzed. The conventional content analysis approach was used for data analysis.

Results

The findings of this study included 72 initial codes classified into 7 main themes and 18 subthemes. Seven main themes consist of governance, manpower, resources, financial management, services delivery, trans-sectional, and social and cultural. The greatest challenges for Iran's primary health care (PHC) system are governance and human resources problems.

Conclusion

Various dimensions of Iran's primary care system especially governance and human resources are facing several challenges that threaten its performance and efficiency. Policymakers and planners must address challenges fundamentally and do not get satisfied with superficial reforms that have short-term and soothing effects. In this regard, enhancing governance functioning can profoundly solve numerous challenges of Iran's primary care system. We also suggest the strengthening of intersectoral collaboration.

Requirements for Creating a Position for Community Health Nursing Within the Iranian Primary Health Care System: A SWOT Analysis

Background: Accepting community health nursing in the primary care system of each country and focusing on creating a position for community health nurses is of significant importance. The aim of this study was to examine the stakeholders' perception of the requirements for establishing a position for community health nursing in the Iranian primary health care system. Methods: This qualitative study was done using 24 semi-structured interviews conducted from May 2020 to February 2021 in Iran. The participants were selected through purposive sampling and consisted of nursing policy makers, the policy makers of the Health Deputy of Ministry of Health, the managers and the authorities of universities of medical sciences all across the country, community health nursing faculty members, and community health nurses working in health care centers. After recording and transcribing the data, data analysis was performed in MAXQDA10 software, using Elo and Kyngas's directed content analysis approach and based on WHO's community health nursing role enhancement model. The statements for each main category were summarized in SWOT classification. To examine the trustworthiness of the data, Lincoln & Guba's criteria were used. Results: By analyzing the interviews 6 main categories identified consist of creating a transparent framework for community health nursing practice, enhancing community health nursing education and training for practice in the primary health care system and community settings, seeking support, strengthening the cooperation and engagement among the key stakeholders of the primary health care system, changing the policies and the structure of the health system, and focusing on the deficiencies of the health system. Each main categories including the subcategories strengths, weaknesses, opportunities and threats (SWOT). Conclusions: Based on the participants' opinions, focusing on the aforementioned dimensions is one of the requirements of developing a position for community health nursing within the Iranian PHC system. It seems that correct and proper implementation of these strategies in regard with the cultural context of society can help policymakers manage challenges that prevent the performance of community health nursing in the health system.

Community health workers at the dawn of a new era: 6. Recruitment, training, and continuing education

BACKGROUND

This is the sixth of our 11-paper supplement entitled "Community Health Workers at the Dawn of New Era". Expectations of community health workers (CHWs) have expanded in recent years to encompass a wider array of services to numerous subpopulations, engage communities to collaborate with and to assist health systems in responding to complex and sometimes intensive threats. In this paper, we explore a set of key considerations for training of CHWs in response to their enhanced and changing roles and provide actionable recommendations based on current evidence and case examples for health systems leaders and other stakeholders to utilize.

METHODS

We carried out a focused review of relevant literature. This review included particular attention to a 2014 book chapter on training of CHWs for large-scale programmes, a systematic review of reviews about CHWs, the 2018 WHO guideline for CHWs, and a 2020 compendium of 29 national CHW programmes. We summarized the findings of this latter work as they pertain to training. We incorporated the approach to training used by two exemplary national CHW programmes: for health extension workers in Ethiopia and shasthya shebikas in Bangladesh. Finally, we incorporated the extensive personal experiences of all the authors regarding issues in the training of CHWs.

RESULTS

The paper explores three key themes: (1) professionalism, (2) quality and performance, and (3) scaling up. Professionalism: CHW tasks are expanding. As more CHWs become professionalized and highly skilled, there will still be a need for neighbourhood-level voluntary CHWs with a limited scope of work. Quality and performance: Training approaches covering relevant content and engaging CHWs with other related cadres are key to setting CHWs up to be well prepared. Strategies that have been recently integrated into training include technological tools and provision of additional knowledge; other strategies emphasize the ongoing value of long-standing approaches such as regular home visitation. Scale-up: Scaling up entails reaching more people and/or adding more complexity and quality to a programme serving a defined population. When CHW programmes expand, many aspects of health systems and the roles of other cadres of workers will need to adapt, due to task shifting and task sharing by CHWs.

CONCLUSION

Going forward, if CHW programmes are to reach their full potential, ongoing, up-to-date, professionalized training for CHWs that is integrated with training of other cadres and that is responsive to continued changes and emerging needs will be essential. Professionalized training will require ongoing monitoring and evaluation of the quality of training, continual updating of pre-service training, and ongoing in-service training-not only for the CHWs themselves but also for those with whom CHWs work, including communities, CHW supervisors, and other cadres of health professionals. Strong leadership, adequate funding, and attention to the needs of each cadre of CHWs can make this possible.

Resources management impact on neonatal services performance in the United Kingdom: A system dynamics modelling approach

Demand for neonatal care in the United Kingdom (UK) has increased in recent years. This care is provided by neonatal services, which are chronically saturated due to years of budget austerity in the UK. The aim of this paper is to investigate the possible impact of increasing resources to these services to improve their operational performance and alleviate the pressure they are facing. To achieve this aim, a system dynamics (SD) simulation model was built and validated in a UK neonatal unit. The SD model was used initially to evaluate the impact of increasing resources on the unit performance and the results showed that this policy will have a limited effect on performance. The model was then extended to predict the effect of reducing the length of stay (LoS) in conjunction with increasing resources. These joint interventions will have a positive impact on the unit performance if LoS is reduced for all care categories and resources are slightly increased. Results' implications and SD's modelling usefulness to guide decision making in complex health settings are discussed.

Future Trends of the Primary Healthcare System in Iran: A Qualitative Study

Background

Primary healthcare system in Iran has played an extensive role in promoting people health in the past decades. However, regarding universal developments in the different global aspects effective on health, the performance of this system has been influenced significantly. The aim of the present research is to identify the future trends of the primary health care in Iran.

Methods

The participants of this qualitative case study were experts in primary healthcare, which were selected and interviewed through purposive sampling method. The interview process was saturated after 25 interviews, so we stopped the process at this point. Framework analysis based on STEEP model used to analysis the interviews.

Results

The most important social/value, technological, economic, environmental, and political future trends of primary healthcare in Iran included demographic transition, epidemiological transition, social and cultural changes, emergence of modern and advanced technologies, internet and cyberspace, budgeting limitations, resource management, changing paradigm from volume to value in providing health services, environmental pollutions, natural disasters, health governance, intellectual paradigm of senior officials, regional security, international development, and other internal factors of the health system.

Conclusions

The identified factors can be turned into opportunities for Iran primary healthcare system if health planners and policymakers have a deep and accurate look at these influential factors and manage them properly.

Prevalence of Burnout among Primary Health Care Staff and Its Predictors: A Study in Iran

Burnout, which is an emerging challenge in health systems, is very common among primary health care (PHC) workers. The aim of this study was to investigate the level of burnout among PHC workers, and its predictive factors, in a region in the west of Iran. In this cross-sectional study, all the health network staff (n = 539) were enrolled. The data collection instrument was the Maslach Burnout Inventory (MBI), which consists of 22 items and the three subscales of emotional exhaustion (EE), depersonalization (DP), and personal achievement (PA). High scores in EE and DP and low scores in PA are indicative of high burnout. Logistic regression was used to determine the predictors of high burnout. The data were analyzed using SPSS version 16. The findings showed that 90.5% of the staff had high DP, 55.3% had high EE, and 98.9% had low PA scores. Also, 52.9% (277 people) of the staff suffered from high burnout. Single people (OR = 3.33), less experienced employees (OR = 9.09), people aged over 35 years (OR = 2.35), physicians (OR = 1.72), and staff with permanent employment (OR = 5.0) were more likely to suffer high levels of burnout. We conclude that burnout is a common problem in PHC workers. Less experienced, younger, single employees and physicians were more at risk of suffering from high burnout. Preventive measures, such as strengthening social skills, communication competencies, and coping strategies, and reduction of risk factors such as job stress, are suggested for reducing employees’ risk of burnout.

Health services utilisation and responsiveness profiles in Iran: a provincial household study

Objective

The aim of this study was to describe health services utilisation and responsiveness in East Azerbaijan province, Iran.

Design

A cross-sectional household study as part of a larger research on primary healthcare system.

Setting

We carried out the study in East Azerbaijan Province, northwest Iran from July to September 2015.

Participants

A total of 1318 households were included.

Results

Most of the participating households had social security health insurance. Heart failure or hypertension care, general outpatient care and arthritis care were the most used services. High services cost and inadequate medicine and medical equipment were introduced to be the main barriers to health services utilisation in Tabriz and province representative sample (PRS), respectively. Health system responsiveness mean score (the maximum is 100) was 33.71±16.15 (95% CI 32.45 to 34.97) in Tabriz and 32.02±14.3 (95% CI 30.9 to 33.13) in PRS, which showed significant difference (p≤0.02).

Conclusions

Differences in the utilisation and responsiveness of health services and distribution of health resources were observed between Tabriz and PRS. Evidently, health system responsiveness in both Tabriz and PRS was at low level. The results demonstrate the need for changing resource distribution policies and employing reactive health policies to response the public health.

Evaluation of the primary healthcare program in Iran: a systematic review

Evaluation of programs and determining its challenges to improve and implement reforms is essential in a healthcare system. A primary healthcare program was conducted since 1984 in Iran and faces various challenges after several decades of its life. The aim of this study is to evaluate Iran's primary healthcare program and determine its challenges and weaknesses. In the present systematic review study, the published articles related to Iran's primary healthcare were searched and collected from Iranian databases (SID, Magiran, Noormags and Irandoc) and international databases (Pubmed, Scopus, Web of Knowledge and Google Scholar). The Iranian grey literature was also explored. In total, from 336 papers identified, 25 papers were deemed relevant after the step-by-step review of articles and removal of non-related articles. The results of this study show that primary healthcare in Iran has different challenges and weaknesses. Most of these challenges and weaknesses relate to the structure and process of primary healthcare. The Iranian primary healthcare system has achieved many successes in community health promotion, but today, because of social, economic, political and environmental changes, it does not meet the needs of the people; therefore, this system requires structural reforms.