Association between living in the endemic area and level of knowledge of visceral leishmaniasis.

BACKGROUND: Iran is a country with a high prevalence of visceral leishmaniasis (VL) and seven endemic provinces. In this study, we tried to identify unobserved classes of knowledge among Iranians toward VL and assess the predictors of each latent class. METHODS: This cross-sectional study was conducted among randomly selected participants from endemic and non-endemic areas of VL in Iran in 2020 and 2021. The collected data included demographic characteristics and questions about knowledge, attitude, and practice toward VL. We performed latent class analysis using a procedure for latent class analysis (PROC LCA) in SAS to identify the class membership of knowledge of participants toward VL. RESULTS: Five latent classes were identified: very low (38.9%), low (15.5%), moderate (6.2%), high (14.1%), and very high (25.2%) knowledge about VL. Living in endemic areas significantly increased the odds of belonging to the low (adjusted OR (AOR = 7.23; 95% confidence interval (CI):4.52-11.58), high (AOR = 2.71; 95%CI: 1.73-4.23), and very high (AOR = 8.47; 95%CI: 5.78-12.41) classes compared to the very low class. Also, having academic education increased the odds of membership in the very high class (AOR = 2.36; 95%CI: 1.61-3.47) compared to the very low class. CONCLUSION: This study revealed that more than 50% of the participants fell into the latent classes of very low and low knowledge toward VL. Some educational workshops in the endemic areas could be effective in enhancing knowledge about VL.

Characteristics of suicide attempts in Northwestern Iran: a five-year population-based survey.

BACKGROUND: Suicide is a serious public health problem in the world. This study aims to describe the characteristics of suicide attempters in North-Western Iran and identify latent classes of suicide attempts. METHODS: This cross-sectional study was conducted in Ardabil Province (Northwest Iran) during 2017-2021 based on a registration system for suicide attempts. We performed latent class analysis (LCA) using a procedure for LCA (PROC LCA) in SAS to investigate the subgroups of suicide attempters based on their characteristics and method, history, and outcome of suicide. RESULTS: Three latent classes were identified for males and females; the first class (non-lethal attempters with lower educational levels) comprised 41.3% of males and 55.4% of females. The second class (non-lethal attempters with higher educational levels) described 52.4% of males and 42.7% of females. Finally, the third class (lethal attempters) included 6.4% of males and 1.9% of females. The main method of suicide attempts was poisoning with medications (87.3%). The results show that only 2.8% of people have a history of suicide attempts. Also, the suicide rate reached 8.26 per 100,000 population in 2021. CONCLUSION: The present study showed an increasing trend of suicide attempt incidence rate in Ardabil Province from 2017 (99.49 per 100,000 population) to 2021 (247.41 per 100,000 population). This means that the rate of change was 147.92 per 100,000 population during the study period. The findings of LCA, stress the necessity of identification and prioritization of unmet needs of people who had an incomplete suicide in Ardabil.

The COVID-19 pandemic's true death toll in Iran after two years: an interrupted time series analysis of weekly all-cause mortality data.

INTRODUCTION: This study aimed to investigate overall and age group/region/sex-specific excess all-cause mortality from the inception of the COVID-19 pandemic in Iran until February 2022. METHODS: Weekly all-cause mortality data were obtained for the period March 2015 until February 2022. We conducted interrupted time series analyses, using a generalized least-square regression model to estimate excess mortality after the COVID-19 pandemic. Using this approach, we estimated the expected post-pandemic death counts based on five years of pre-pandemic data and compared the results with observed mortality during the pandemic. RESULTS: After the COVID-19 pandemic, we observed an immediate increase (1,934 deaths per week, p = 0.01) in weekly all-cause mortality. An estimated 240,390 excess deaths were observed in two years after the pandemic. Within the same period, 136,166 deaths were officially attributed to COVID-19. The excess mortality was greatest among males compared with females (326 versus 264 per 100k), with an increasing trend by age group. There is a clear increased excess mortality in the central and northwestern provinces. CONCLUSION: We found that the full mortality burden during the outbreak has been much heavier than what is officially reported, with clear differences by sex, age group, and geographical region.

The probability of diagnostic delays for tuberculosis and its associated risk factors in northwest Iran from 2005 to 2016: a survival analysis using tuberculosis surveillance data.

OBJECTIVES: Early diagnosis is essential for effective tuberculosis (TB) control programs. Therefore, this study examined the risk of delays in TB diagnosis and associated factors in Ardabil Province in northwest Iran from 2005 to 2016. METHODS: This longitudinal retrospective cohort study was conducted using data obtained from the Iranian National Tuberculosis Control Program at the provincial level between 2005 and 2016. The total delay in diagnosis was defined as the time interval (days) between the onset of symptoms and TB diagnosis. Survival analysis was conducted to analyze the delay in diagnosis. Associated factors were identified using a Cox proportional hazards model. RESULTS: A total of 1,367 new TB cases were identified. The 12-year median diagnostic delay was 45 days (interquartile range [IQR], 30-87). The annual median diagnostic delay decreased from 68 days (IQR, 33-131) in 2005 to 31 days (IQR, 30-62) in 2016. The probability of a delay in TB diagnosis decreased by 5.0% each year (hazard ratio [HR], 1.05; 95% confidence interval [CI], 1.04 to 1.07). Residence in a non-capital county (HR, 0.83; 95% CI, 0.74 to 0.92) and referral from the private health system (HR, 0.74%; 95% CI, 0.65 to 0.84) were significantly associated with an increased risk of delay in TB diagnosis over the 12-year study period. CONCLUSIONS: The median delay decreased during the study period. We identified factors associated with a longer delay in TB diagnosis. These findings may be useful for further TB control plans and policies in Iran.

Health beliefs and behaviors of livestock industry workers regarding Crimean-Congo hemorrhagic fever in Northwest of Iran.

BACKGROUND: Crimean-Congo hemorrhagic fever (CCHF) is an acute, feverous disease that is caused by tick bites or humans' direct contact with the blood and tissues of infected livestock and humans. The transmission of the disease is also possible via human-to-human contacts and nosocomial transmission is well described. The majority of patients suffering from this disease are slaughterhouse workers (including butchers), farmers, veterinarians and hospital staff. Thus, this study aimed to investigate the health behaviors of butchers regarding CCHF and study factors affecting such behaviors based on the health belief model. METHODS: This is a descriptive cross-sectional study conducted on 500 butchers in Ardabil Province in 2020 by a multistage sampling method. The participants of the study completed the researcher-made questionnaire of health belief model and health behaviors model relevant to CCHF. The collected data were then analyzed by descriptive statistical tests and linear regression analysis. RESULTS: The mean (SD) age of the participants was 44.4 (10.5) years, and 96% were males. Only 11.1% of the participants displayed acceptable disease-preventive behaviors. The validity and reliability of the developed questionnaire were confirmed. The results of the exploratory factor analysis showed that the constructs of the model explained 84% of the total variance. The results of the study revealed that among the variables of the health belief model, perceived susceptibility (p-value = 0.006, ß = 0.152) and perceived barriers (p-value = 0.023, ß = 0.14) were the strongest factors predicting disease-preventive behaviors regarding CCHF. CONCLUSION: The results of the study showed that the health belief model can predict preventive behaviors for CCHF. Therefore, designing and executing interventions based on the results of this study may encourage such preventive behaviors in butchers.

Latent class analysis of initial nicotine dependence among adult waterpipe smokers.

Waterpipe (WP) tobacco smoking increases the risk of smoking-related health problems. In this study, we sought to identify the unobserved class memberships of WP-associated initial nicotine dependence (ND) symptoms and assess the predictors of each latent class. This cross-sectional study was conducted among a convenience sample of 900 current (past 30-day) WP smokers who were recruited from 94 WP-serving venues surrounding Tehran and Ardebil metropolitans in Iran. All participants completed a self-administrated questionnaire. We performed latent class analysis using PROC LCA in SAS to identify class memberships of initial ND symptoms using 10-item Hooked on Nicotine Checklist. Five latent classes were identified as non-dependent (25.4 %), low dependent (7.1 %), low-moderate dependent (19.6 %), moderate dependent (15.6 %), and high dependent (32.2 %). Using flavored WP tobacco significantly increased the odds of belonging to low-moderate dependent class [adjusted OR (aOR) = 1.89; 95 % confidence interval (CI): 1.07-3.34] compared to non-dependent class. Also, having academic education decreased the odds of belonging to low-moderate dependent (aOR = 0.43; 95 %CI: 0.26-0.67) and moderate dependent (aOR = 0.39; 95 %CI: 0.23-0.67) class in comparison to non-dependent class. Also, WP smoking initiation at an older age was associated with belonging to high dependent (OR = 2.05; 95 %CI: 1.39-3.03) class compared to non-dependent. This study revealed that nearly half of WP smokers fell under moderate and high-dependent classes. Our findings showed that some items of HONC had more role in the clustering of participants based on ND symptoms. The WP-specific cessation programs and targeted clinical trials should consider the diversity of ND levels among smokers to achieve successful quit rates among these smokers. Additionally, limiting flavors would be a strong strategy to limit the rate of ND, especially among young people who are eager to smoke flavored WP tobacco.

Characteristics of flavored and non-flavored waterpipe tobacco users: a real-world setting study.

We aimed to compare sociodemographic characteristics, smoking patterns, beliefs and perceptions, nicotine dependence, and psychological indicators between flavored waterpipe (WP) tobacco (FWT) and non-flavored WP tobacco (non-FWT) smokers in Iran. A cross-sectional study was conducted in 94 WP-serving venues surrounding Tehran and Ardabil metropolitans in Iran. Convenience sampling was applied to select 900 current WP smokers [508 (56%) FWT-only and 392 (44%) non-FWT-only smokers] aged 18 years and older. Multivariable logistic regression was used to examine the independent characteristics of FWT and non-FWT smokers. Compared to non-FWT smokers, FWT smokers were younger (adjusted odds ratio [AOR]=0.88, 95% confidence interval [CI]: 0.87-0.90) and more likely to have ≥ 1 sibling who smoked WP (AOR=1.54, 95% CI: 1.06-2.24), share WP with others (AOR=2.52, 95% CI: 1.68-3.77), report current cigarette smoking (AOR=2.05, 95% CI: 1.23-3.42), and report confidence in quitting at any time (AOR=3.64, 95% CI: 2.45-5.39). FWT smokers were less likely to have seen (AOR=0.40, 95% CI: 0.27-0.60) or read (AOR=0.44, 95% CI: 0.24-0.80) warning messages on WP tobacco packages relative to non-FTW smokers. The most common self-reported reason for smoking WP was entertainment for both groups, followed by stress relief for non-FWT smokers and the escape from loneliness for FWT smokers. FWT-only smokers differ from non-FWT-only smokers in several aspects including being younger, having more positive beliefs and perceptions regarding WP use, and having higher cigarette smoking prevalence. These findings will help in developing more effective and targeted policies and cessation interventions for WP smokers according to flavor type they use, especially in the Middle East.

Epidemiological characteristics and mortality risk factors among COVID-19 patients in Ardabil, Northwest of Iran.

BACKGROUND: Coronavirus disease highly contagious, is prevalent in all age and sex groups infecting the respiratory system. The present study seeks to investigate the epidemiology and effective factors in mortality of patients with COVID-19 in Ardabil province, northwestern Iran. METHODS: In a retrospective study, the hospitalized patients with laboratory-diagnosed COVID-19 between February to August 2020 were enrolled. The data registration portal was designated according to Iranian Ministry of Health and Medical Education guidelines. In this portal, demographic information, clinical presentation, laboratory and imaging data were registered for patients in all hospitals in the same format. The Hosmer-Lemeshow strategy was used for variable selection in a multiple model. RESULTS: Of the patients involved 2812(50.3%) were male and 150 (2.7%) had contact with a confirmed case of COVID-19 in the last 14 days. Pre-existing comorbidity was reported in 1310 (23.4%) patients. Of all patients, 477(8.5%) died due to COVID-19. the result of the multiple logistic regression model indicated that after adjusting for other factors, higher age (OR = 3.11), fever or chills (OR = 1.61), shortness of breath (OR = 1.82), fatigue (OR = 0.71), headache (OR = 0.64), runny nose (OR = 1.54), Skeletal muscle pain (OR = 1.53), hospitalization (OR = 5.66), and hospitalization in ICU (OR = 5.12) were associated with death. CONCLUSIONS: Hospitalization had the strongest effect on mortality followed by hospitalization in ICU, and higher age. This study showed that having some extra-pulmonary symptoms in contrast with pulmonary symptoms can predict as good prognostic factors.

Pattern of Crimean-Congo hemorrhagic fever related high risk behaviors among Iranian butchers and its relation to perceived self-efficacy.

BACKGROUND: Crimean-Congo hemorrhagic fever (CCHF) is highly fatal to humans and an acute viral disease. The CCHF disease has been reported in occupations such as butchers, slaughterhouse butchers and workers. The aim of this study was to investigate the pattern of CCHF related high risk behaviors among butchers and determine the effects of perceived self-efficacy of the participants on their membership in latent classes. METHODS: The participants of this cross-sectional study were recruited from all the meat distribution centers in Ardabil Province in 2019-2020. The LCA approach was used to observe the CCFH related high risk behaviors patterns. RESULTS: The statistical significance level was assigned at P-value < 0.05 in all the analyses. Three latent classes were identified; namely, 1) low risk (16.1%), 2) high risk (53.6%), and 3) very high risk (30.2%). After adjusting for other possible confounders higher score of perceived self-efficacy significantly decrease the odds of membership in high risk class (OR = 0.74) and very high risk class (OR = 0.62) compared to the low risk class. Also, age (OR = 1.07) and experience (OR = 0.91) associate with very high risk class. CONCLUSIONS: This study revealed the co-occurrence of CCHF related high risk behaviors in the majority of workers in the livestock and meat industry. It is necessary to provide butchers and slaughterhouse workers with general education, force them to use protective equipment and investigate the rate of tick bites in risky occupations.

A Comprehensive Database and Geographical Distribution Model of Vectors and Vector Borne Diseases in Ardabil Province, Borderline of Iran and Azerbaijan Republic 2001-2018.

Background: Vector borne diseases (VBDs) are the infectious diseases reported from all parts of the world and Iran. The main vectors of VBDs belong to the phylum of arthropod and insects. The aim of this study was providing the database of important VBDs and vectors and geographical distribution model in Ardabil, northwest of Iran. Methods: This retrospective cross-sectional study was conducted from 2001-2018. All the earlier published studies, reports and documentations related to vectors and vector-borne diseases searched systematically as well as the data of diseases was collected from the Center for Disease Control (CDC) of Ardabil University of Medical Sciences. ArcGIS 10.4.2 (http://www.esri.com/arcgis) were used to spatial analysis mapping, Normalized Difference Vegetation Index (NDVI) index and high/low clustering. Results: Totally 110076 cases of VBDs reported in Ardabil Province during the past 18 years including malaria, visceral leishmaniasis (VL), cutaneous leishmaniasis (CL), Crimean Congo hemorrhagic fever (CCHF), tick-borne relapsing fever (TRF), pediculosis, scorpionism, scabies and anthrax. These diseases were transmitted in Ardabil Province by eight arthropod families, 19 genera and 70 spices of arthropods. Most species belonged to Culicidae with 24 species followed by Psycodidae with 22 and Ixodidae with 16 species. The incidence rate of VBDs was 63/100000 in 2001 which decreased to 7/100000 in 2010 and then increased to 21 /100000 in 2018. Conclusion: The distribution model of the VBDs was plotted based on the geographical and ecological of the vectors will help the authorities for decision.

COVID-19 and beliefs about tobacco use: an online cross-sectional study in Iran.

There is mixed evidence surrounding the relationship between tobacco use and COVID-19 infection/progression. The current study investigates beliefs and tobacco use behaviors and COVID-19 infection among a sample of smokers and never-smokers. Data were collected using an online survey distributed through Telegram, a cloud-based social media networking application in Iran from April 1 to May 31, 2020. The study participants included never-smokers (n = 511), current (past-month) waterpipe smokers (n = 89), current cigarette smokers (n = 158), and ex-smokers (n = 172). Multinomial logistic regression was used to compare tobacco use groups with never- smokers on beliefs, controlling for potential confounders. The study participants (n = 944) was mostly male (64%), had > high school education (76%), and lived in an urban area (91%), with mean ± SD age of 35.3 ± 10.8. Key findings of this study are that compared with never-smokers: (1) cigarette smokers were less likely to believe that smoking cigarette can lead to spreading COVID-19; (2) waterpipe smokers were more likely to believe that smoking waterpipe at home was a safe practice, that waterpipe protects against COVID-19, and smoking waterpipe may lead to a more rapid recovery from COVID-19; (3) both waterpipe and cigarette smokers believed that using e-cigarettes in public places was a safe practice during the COVID-19 pandemic; and (4) more than half of the ex-smokers stopped smoking due to COVID-19 and most of them planned to continue abstaining from smoking after the pandemic. Our findings underscore the need to raise awareness about the unsupported claims of a lower hazard of using tobacco products or possible protective effects against COVID-19 and to promote cessation programs.

Spatial autocorrelation and epidemiological survey of visceral leishmaniasis in an endemic area of Azerbaijan region, the northwest of Iran.

Visceral leishmaniasis (VL) is a common infectious disease that is endemic in Iran. This study aimed to investigate the spatial autocorrelation of VL in the northwest of Iran. In this cross-sectional study, the data of all patients were collected in 2009-2017 and analyzed by SPSS23 and Moran's and General G Index. The MaxEnt3.3.3 software was used to determine the ecological niche. A big hot spot area was identified in five counties in the northwest of Iran. More than 70% of the cases were reported from these regions, and the incidence rate increased in the northwest of Iran from 2013 to 2017. Seasonal rainfall and average daily temperature were the most important climate variables affecting the incidence of VL in this region (p < 0.05). Therefore, it can be concluded that VL in the northwest of Iran is expanding to new areas along the border with the Republic of Azerbaijan, and the northeastern section of this region is a high-risk area.

The Relationship Between Obesity, Overweight, and the Human Development Index in World Health Organization Eastern Mediterranean Region Countries.

OBJECTIVES: Obesity is regarded as one of the most prominent health threats worldwide and a serious risk factor for non-communicable diseases, such as diabetes mellitus type 2, high blood pressure, cardiovascular diseases, and some types of cancer. Given the role that societal development-as reflected by the Human Development Index (HDI)-may play in the prevalence of obesity and overweight, this study aimed to investigate the degree to which the prevalence of obesity and overweight is affected by HDI and its components. METHODS: In this ecological study, the required data on HDI and its components were gathered from the latest report of the United Nations Development Program, and data on obesity and overweight were acquired from the latest reports published on the World Health Organization website. Statistical analyses were conducted using SPSS version 24.0. RESULTS: The prevalence of obesity was determined to be significantly higher among females than males, and the gross national index per capita was found to be significantly higher for males than females (p<0.05). Significant positive correlations were found between HDI and its components and sex, as well as indices of obesity and overweight. CONCLUSIONS: A significant positive correlation exists between HDI and obesity. As policy-makers attempt to improve the general welfare of the people, they should be aware of potential unwanted effects of development on the risk of obesity and overweight among the population.

Forecasting head lice (Pediculidae: Pediculus humanus capitis) infestation incidence hotspots based on spatial correlation analysis in Northwest Iran.

BACKGROUND AND AIM: Pediculus humanus capitis has been prevalent throughout the world, especially in developing countries among elementary students and societies with a weak socio-economic status. This study aimed to forecast head lice (Pediculidae: P. capitis) infestation incidence hotspots based on spatial correlation analysis in Ardabil Province, Northwest Iran. MATERIALS AND METHODS: In this retrospective analytical study, all cases of head lice infestations who were confirmed by Centers for Disease Control office have been studied from 2016 to 2018. Head lice infestation incidence hotspots in the province should be detected based on general G statistics in ArcMap GIS10.4.1. Furthermore, MaxEnt.3.3.3 model was used for modeling the high-risk areas. RESULTS: The prevalence rate of pediculosis was 14.90/100,000 populations. The general G statistics revealed that the head lice infestation in this study area has a high cluster pattern. The analysis showed that the Parsabad and Germi counties were identified as a head lice infestation incidence hotspots. Statistical and spatial analyses of head lice infestation incidence showed a significant positive correlation with head lice infestation incidence hotspots and the altitudes (15-500 m), annual temperature range (14-16.5°C), and slope and average diurnal temperature (12-18°C). CONCLUSION: The results of this study showed that the most ecologically suitable areas of head lice occurrence were identified in two hotspots (Parsabad and Germi) in the Northern areas of Ardabil Province (Parsabad and Germi counties); in the borderline of Iran and the Republic of Azerbaijan.

Causes of conflict between clinical and administrative staff in hospitals.

BACKGROUND: Providing the high-quality services in hospitals depends on to minimize conflict between all members within a health team. This study aimed to identify the causes of conflicts experienced by clinical and administrative staff in hospitals. METHODS: A cross-sectional study was carried out in 2018. The sample included 320 clinical and administrative staff from six hospitals affiliated to Ardabil University of Medical Sciences that were selected using two-step clustering sampling method. Data collection was accomplished by self-administered questionnaires. Descriptive statistics, t-test, and ANOVA were used for data analysis. RESULTS: Total conflict score revealed that clinical staff had higher levels of perceived conflict than administrative staff. In terms of organizational position, the study results showed a significant difference in the reported conflict between nurse groups and other groups (physicians and paramedical, administrative, financial, and logistic staff). The most important causes of conflict in the viewpoint of clinical staff were organizational and job characteristics (3.54 ± 1.28), poor management (3.51 ± 1.12), and inefficient communication system (3.42 ± 1.33). For administrative staff, on the other hand, poor management (3.18 ± 1.33), inefficient communication system (3.17 ± 1.36), and attitudes and perceptions (3.06 ± 1.41) were shown to be paramount factors. CONCLUSION: Clinical and administrative staff of hospitals are like parts of a train track. The irrational relationship between them will result in distortion and lower quality of services. Therefore, effective strategies to decrease staffs' experience of conflict need to be developed. This might create a healthier and more productive work environment which positively affects the care quality.

Ecological Niche Modeling of West Nile Virus Vector in Northwest of Iran.

OBJECTIVES: West Nile virus (WNV) is a microorganism and the leading cause of the spread of fatal diseases in horses, birds, and humans. The etiologic agent of West Nile fever belongs to the genus Flavivirus that is transmitted by Culex mosquitoes in Iran and throughout the world. We aimed to evaluate the distribution of WNV vectors in northwest of Iran ecological niche modeling. METHODS: This cross-sectional study was conducted in Ardabil province in one year, from January to December with the samples captured from May to November 2017. Forty-five locations from all 10 counties of the province were selected randomly to determine the seasonal activity of mosquitoes. Larval collection was carried out twice a month. MaxEnt version 3.3, ArcMap 10.3 software, jackknife, and crew methods were used to determine the impact of climatic change and environmental factors on the distribution of mosquito species. RESULTS: A total of 2000 larva were collected, 1789 (89.5%) of which were Culex larvae. Seven species of Culex genus were identified, including Culex pipiens, Cx. modestus, Cx. theileri, Cx. hortensis, Cx. perexiguus, Cx. tritaeniorhynchus, and Cx. mimeticus. Two important ecological niche areas were identified in the north and south of the province. The annual temperature and rainfall in the cold seasons were the most important factors affecting the distribution of Culex species larva. Cx. pipiens was identified as the main vector of WNV vectors with high frequency in Ardabil province. CONCLUSIONS: Two large areas were found as the ecological niches of larvae of these species. It is recommended that additional investigations be carried out on infection in adult female Cx. pipiens and its hosts in these areas.

Mapping 123 million neonatal, infant and child deaths between 2000 and 2017.

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2-to end preventable child deaths by 2030-we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000-2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.

Referral system in rural Iran: improvement proposals.

Because of insufficient communication between primary health care providers and specialists, which leads to inefficiencies and ineffectiveness in rural population health outcomes, to implement a well-functioning referral system is one of the most important tasks for some countries. Using purposive and snowballing sampling methods, we included health experts, policy-makers, family physicians, clinical specialists, and experts from health insurance organizations in this study according to pre-determined criteria. We recorded all interviews, transcribed and analyzed their content using qualitative methods. We extracted 1,522 individual codes initially. We also collected supplementary data through document review. From reviews and summarizations, four main themes, ten subthemes, and 24 issues emerged from the data. The solutions developed were: care system reform, education system reform, payment system reform, and improves in culture-building and public education. Given the executive experience, the full familiarity, the occupational and geographical diversity of participants, the solutions proposed in this study could positively affect the implementation and improvement of the referral system in Iran. The suggested solutions are complementary to each other and have less interchangeability.