Study of adherence to guidelines and evidence (SAGE) : theory-based analyses of beliefs, attitudes and prescribing outcomes in British primary care

EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Social Values in Health Prioritizing: the analysis of national documents of Iran

Background: Health system, as a part of the wider social system, should consider social values in decisions for health prioritizing. This study was aimed at identifying social values considered in the health-related national documents. Methods: This qualitative study was conducted based on the Clark-Weale framework to identify the social values in health related national documents. Identification of health-related basic documents (11 documents) was performed purposefully. Documents included Iran's Constitution Law, the 5-year development plan, national health insurance law, urban family physician program, health sector development map, Health Ministry foundation law and Health Ministry structure and organizational law. Each value was analyzed based on qualitative content analysis. Results: Different approaches toward considering social values were observed. While some documents had explicitly considered social values, some others had implicitly considered them. The health Road Map was the most comprehensive document in terms of considering social values. Equity was the most repeated value in documents and clinical effectiveness was not mentioned in any of the documents. Conclusion: Although, the importance of social values has been increased in national documents during the recent years, it dose not have the same trend in different documents and each of them have emphasized on different social values. It seems that using national documents, as a practical guide, can be effective in achieving health system goals

Access to essential medicines in Pakistan: policy and health systems research concerns.

NTRODUCTION: Inadequate access to essential medicines is a common issue within developing countries. Policy response is constrained, amongst other factors, by a dearth of in-depth country level evidence. We share here i) gaps related to access to essential medicine in Pakistan; and ii) prioritization of emerging policy and research concerns. METHODS: An exploratory research was carried out using a health systems perspective and applying the WHO Framework for Equitable Access to Essential Medicine. Methods involved key informant interviews with policy makers, providers, industry, NGOs, experts and development partners, review of published and grey literature, and consultative prioritization in stakeholder\u27s Roundtable. FINDINGS: A synthesis of evidence found major gaps in essential medicine access in Pakistan driven by weaknesses in the health care system as well as weak pharmaceutical regulation. 7 major policy concerns and 11 emerging research concerns were identified through consultative Roundtable. These related to weaknesses in medicine registration and quality assurance systems, unclear and counterproductive pricing policies, irrational prescribing and sub-optimal drug availability. Available research, both locally and globally, fails to target most of the identified policy concerns, tending to concentrate on irrational prescriptions. It overlooks trans-disciplinary areas of policy effectiveness surveillance, consumer behavior, operational pilots and pricing interventions review. CONCLUSION: Experience from Pakistan shows that policy concerns related to essential medicine access need integrated responses across various components of the health systems, are poorly addressed by existing evidence, and require an expanded health systems research agenda

An assessment of recent Iranian fertility trends using parity progression ratios

Background In 2013 a draft population bill was introduced in the Iranian Parliament. Based on the presumption that fertility in Iran had fallen to a very low level, the bill proposed a wide range of pronatalist policies with the aim of increasing fertility to 2.5 births per woman. The draft law called for restrictions on the employment of women and young single people and inducements for women to marry in their late teens. New estimates of fertility, such as those provided in this paper, cast doubt upon the view that fertility had fallen to a very low level. In May 2014 a statement issued by the Supreme Leader provided guidelines for a more moderate approach to sustaining fertility at around the replacement level. Objective To measure the trend in fertility in Iran, especially from 2000 onwards. Methods Using the 2010 IDHS, the synthetic cohort parity progression ratio method is used to measure the fertility trend in Iran. Synthetic parity progressions are compared with real cohort parity progressions to examine the presence of tempo effects. Comparison is made with age-based measures from surveys, censuses, and the birth registration system. Results This paper demonstrates that fertility in Iran was constant for the decade 2000-2009, at a level of around 1.8-2.0 births per woman. Conclusions Our findings provide evidence supporting a more moderate approach to sustaining fertility in Iran at around the replacement level. Comments The paper demonstrates the advantages of parity-based measurement over age-based measurement when tempo effects may be involved

The experience of implementing the board of trustees’ policy in teaching hospitals in Iran: an example of health system decentralization

Background: In 2004, the health system in Iran initiated an organizational reform aiming to increase the autonomy of teaching hospitals and make them more decentralized. The policy led to the formation of a board of trustees in each hospital and significant modifications in hospitals’ financing. Since the reform aimed to improve its predecessor policy (implementation of hospital autonomy began in 1995), it expected to increase user satisfaction, as well as enhance effectiveness and efficiency of healthcare services in targeted hospitals. However, such expectations were never realized. In this research, we explored the perceptions and views of expert stakeholders as to why the board of trustees’ policy did not achieve its perceived objectives. Methods: We conducted 47 semi-structured face-to-face interviews and two focus group discussions (involving 8 and 10 participants, respectively) with experts at high, middle, and low levels of Iran’s health system, using purposive and snowball sampling. We also collected a comprehensive set of relevant documents. Interviews were transcribed verbatim and analyzed thematically, following a mixed inductive-deductive approach. Results: Three main themes emerged from the analysis. The implementation approach (including the processes, views about the policy and the links between the policy components), using research evidence about the policy (local and global), and policy context (health system structure, health insurers capacity, hospitals’ organization and capacity and actors’ interrelationships) affected the policy outcomes. Overall, the implementation of hospital decentralization policies in Iran did not seem to achieve their intended targets as a result of assumed failure to take full consideration of the above factors in policy implementation into account. Conclusion: The implementation of the board of trustees’ policy did not achieve its desired goals in teaching hospitals in Iran. Similar decentralization policies in the past and their outcomes were overlooked, while the context was not prepared appropriately and key stakeholders, particularly the government, did not support the decentralization of Iran’s health system

Bibliographic review of research publications on access to and use of medicines in low-income and middle-income countries in the Eastern Mediterranean Region: identifying the research gaps.

BJECTIVES: We assessed the situation of academic publications on access to and use of medicines (ATM) in low-income and middle-income countries (LMICs) of the Eastern Mediterranean Region (EMR). We aimed to inform priority setting for research on ATM in the region. DESIGN: Bibliographic review of published studies. SETTING: LMICs in EMR. INCLUSION CRITERIA: Publications on ATM issues originating from or focusing on EMR LMICs covering the period 2000-2011. Publications involving multinational studies were included if at least one eligible country had been included in the study. INFORMATION SOURCES AND DATA EXTRACTION: We conducted comprehensive searches of the PubMed, Social Science Citation Index and Science Citation Index. We used the WHO ATM framework for data extraction and synthesis. We analysed the data according to the ATM issues, health system levels, year of publication and the countries of origin or focus of the studies. RESULTS: 151 articles met the inclusion criteria. Most articles (77%) originated from LMICs in EMR, suggesting that the majority of evidence on ATM in the region is home-grown. Over 60% of articles were from Iran, Pakistan, Jordan and Lebanon (in order of volume), while we found no studies assessing ATM in Somalia, Djibouti and South Sudan, all low-income countries. Most studies focused on the rational use of medicines, while affordability and financing received limited attention. There was a steady growth over time in the number of ATM publications in the region (r=0.87). CONCLUSIONS: There is a growing trend, over the years, of more studies from the region appearing in international journals. There is a need for further research on the financing and affordability aspects of ATM in the region. Cross-border issues and the roles of non-health sectors in access to medicines in the region have not been explored widely

Improving Injectable Medicines Prescription in Outpatient Services: A Path Towards Rational Use of Medicines in Iran

Injection is one of the most common medical procedures in the health sector. Annually up to 16 billion injections are prescribed in low- and middle-income countries (LMICs), many of them are not necessary for the patients, increase the healthcare costs and may result in side effects. Currently over 40% of outpatient prescriptions in Iran contain at least one injectable medicine. To address the issue, a working group was established (August 2014 to April 2015) to provide a comprehensive policy brief to be used by national decision-makers. This report is the extract of methods that were followed and the main policy options for improving injectable medicines prescribing in outpatient services. Thirty-three potential policy options were developed focusing on different stakeholders. The panel reached consensus on seven policy options, noting effectiveness, cost, durability, and feasibility of each policy. The recommended policy options are targeted at patients and public (2 policies), insurers (2), physicians (1), pharmacies (1), and the Ministry of Health and Medical Education (MoHME) (1)

Factors hindering the adherence to clinical practice guideline for diabetes mellitus in the Palestinian primary healthcare clinics: a qualitative study

Objective Despite a high number of the internationally produced and implemented clinical guidelines, the adherence with them is still low in healthcare. This study aimed at exploring the perspectives and experiences of senior doctors and nurses towards the barriers of adherence to diabetes guideline. Setting The Palestinian Primary Health Care-Ministry of Health (PHC-MoH) and Primary Health Care-United Nations Relief and Works Agency for Palestine Refugees in the Near East (PHC- UNRWA) in Gaza Strip. Participants Individual face-to-face in-depth interviews were conducted with 20 senior doctors and nurses who were purposefully selected. Methods Qualitative design was employed using the theoretical framework by Cabana et al to develop an interview guide. Semi-structural and audio-recorded interviews were conducted. Data were transcribed verbatim and thematically analysed. Results The key theme

Appraising the methodological quality of the clinical practice guideline for diabetes mellitus using the AGREE II instrument: a methodological evaluation

Objectives To evaluate the methodological quality of the Palestinian Clinical Practice Guideline for Diabetes Mellitus using the Translated Arabic Version of the AGREE II. Design Methodological evaluation. A cross-cultural adaptation framework was followed to translate and develop a standardised Translated Arabic Version of the AGREE II. Setting Palestinian Primary Healthcare Centres. Participants Sixteen appraisers independently evaluated the Clinical Practice Guideline for Diabetes Mellitus using the Translated Arabic Version of the AGREE II. Main outcome measures Methodological quality of diabetic guideline. Results The Translated Arabic Version of the AGREE II showed an acceptable reliability and validity. Internal consistency ranged between 0.67 and 0.88 (Cronbach’s α). Intra-class coefficient among appraisers ranged between 0.56 and 0.88. The quality of this guideline is low. Both domains ‘Scope and

Prevention and control of health care–associated infections in Iran: A qualitative study to explore challenges and barriers

Background: Globally, the health and economic burden posed by health care–associated infections (HAIs) remains wide and severe. To curb the burden associated with HAIs, countries, including Iran, aim at HAI prevention and control. This study explores the challenges faced by the Iranian health system in addressing the issues associated with the prevention and control of HAIs. Methods: A qualitative research method was adopted in exploring the phenomenon. We used the purposive sampling approach in reaching 24 key informants at the national and subnational levels. The thematic framework analysis was conducted for analyzing the interviews. Results: Five main themes emerged from our study demonstrating the obstacles toward the prevention and control of HAIs. They include governance and stewardship, resources, safety culture, monitoring and surveillance systems, and inappropriate prescription of antibiotics. Conclusions: Strengthening of reporting and surveillance systems for HAIs coupled with proper governance and stewardship are crucial in order to improve the health and safety of patients. However, the availability of resources, through an intersectoral approach, is essential to achieve sustained output. © 2016 Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control an