A blueprint for success: lessons learned from developing the official guide to Iranian undergraduate medical education accreditation.

We are excited to contribute our thoughts and insights to the discussion initiated by Gandomkar et al. in their article on the accreditation system in Iran (Gandomkar et al., BMC Med Educ 23:379, 2023). As individuals who have been directly involved in the process of meta-accreditation and possess a comprehensive understanding of the various stages of Undergraduate Medical Education (UME) accreditation in Iran, we would like to highlight additional points that were identified through a rigorous hermeneutic phenomenology process proposed by Gadamer (Gadamer, Truth and Method, 2013) and offer a complementary point of view to the previous work. By sharing our insights, we hope to contribute to the ongoing discourse surrounding UME accreditation.

Financial challenges in the family physician programme in Iran: A systematic review of qualitative research.

Introduction: The family physician programme (FPP) was implemented nearly two decades ago as a major health reform. Since the health system and FPP function in a rapidly changing social and economic environment, successful expansion of the programme requires a detailed analysis of its multiple major challenges, including the crucial aspect of its funding system. This systematic review aimed to assess the challenges in the FPP relative to its financing. Method: All published articles related to the FPP in Iran were included in this study. In particular, original qualitative studies published in English or Persian from 2011 to 2021 were included. In January 2022, international credible scholarly databases and Persian databases were searched. All selected articles were carefully studied, and the data were extracted using the sample, phenomenon of interest, design, evaluation and research type technique. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used in preparing the study report. Results: Among 491 articles retrieved from the search strategy, 50 met the inclusion criteria after their titles and abstracts were screened. Twenty-nine studies were excluded after their full texts were reviewed. A total of 11 eligible empirical studies were finally included. Based on the results, six broad categories (budget and funding, insurance system, tariffs, payments, accountability and injustice) were identified as financial challenges. Conclusion: This study identified the challenges associated with financing among family physicians, and the results could provide guidance for policy-making in the expansion of the FPP.

The Roles of the Nurses in Family Physician Team: A Qualitative Systematic Review.

Background: There are various approaches in primary health care regarding the key role of nurses. This systematic review investigates the roles of nurses, as part of the family medicine team. Materials and Methods: All published articles related to the role of nurses in the family medicine team from January 2000 to March 2022 were the subjects of this study. The eligibility criteria included original articles published in English or Persian in the last two decades. International credible scholarly databases (PubMed, Scopus, Magiran, IranMedex, and SID) were searched using keywords and syntax. Some of the keywords included "Family Health Nurse," "Nurses in Primary Care," "Family Medicine," "Family Physician Care Program," "General Physician Program," "Role," and "Nurse." Data were extracted based on Sample, Phenomenon of Interest, Design, Evaluation, Research type (SPIDER) technique and reported based on the structure of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Results: Of 147 identified publications by the search strategy, eight eligible empirical studies were included. The results showed that besides providing nursing care, nurses play vital roles in communication and teamwork, assessment, securing health services relevant to communities' needs, education, empowerment, clinical practice, health promotion, prevention, reflective research practice, and counseling. Conclusions: This study identified different roles nurses could play in providing primary health care. These findings are helpful for the replanning or reform of primary health care in countries, which aimed to expand the Family Physician Program (FPP) in their countries, including Iran.

Priority strategic directions in adolescent health in Iran based on the WHO's Global Accelerated Action for the Health of Adolescents.

OBJECTIVES: In line with the World Health Organization's Global Accelerated Action for the Health of Adolescents (AA-HA!) guidance, the goal of the current research was to identify critical strategies for adolescents' health and to determine the role and distribution of responsibilities among the leading players in the field of adolescent health in Iran. METHODS: The current qualitative and applied study is part of the Ministry of Health and Medical Education's "Adolescent, Youth and School Health" plan to develop the "National Adolescent Health Plan Document" in 2020. First, stakeholder analysis was done, then a pool of nationally appropriate strategies was selected from the list of priority strategies recommended by the WHO in the AA-HA! through several group sessions. After that, the experts selected priority strategies based on the criteria of feasibility, acceptability, effectiveness, guaranteed resources, coordination with other plans and temporal priority, scoring, and executive priorities. Eventually, the priority strategies were assigned to different players/stakeholders in the field over several sessions bearing in mind the methods of implementation and the target groups. RESULTS: The experts identified 58 priority strategies/actions for adolescent health under the seven priority areas of positive development, sexual protection, reproductive health, mental health, substance abuse, self-harm, violence, unintentional injury, communicable and non-communicable diseases, nutrition, and physical activity. CONCLUSIONS: The highest identified priority areas were in the areas of vaccination; special health care package for service providers; training and education to promote health literacy and self-care, life skills, sexual awareness, and prevention/protection against violence; community-based mental health services, planning for adolescents' spare time, substance use prevention.

Referral System Challenges of the Family Physician Program in Iran: A Systematic Review.

Background: Iran has implemented the Family Physician Program (FPP) in 2005 in 4 provinces. This program was supposed to be expanded across the country; however, it faced various challenges. Considering the impact of the referral system on the quality of the FPP implementation, different studies were conducted to evaluate the performance of this system. Therefore, this systematic review of the literature was conducted to investigate the challenges of the referral system of the FPP in Iran. Methods: All published original articles, reviews, or case studies published in English or Persian related to the challenges in the referral system FPP in Iran from 2011 to September 2022 were included in this study. International credible scholarly databases were searched. The search strategy was defined based on keywords and the search syntax. Results: Out of 3910 articles identified by the search strategy, considering the inclusion and exclusion criteria and relevance of the study, and accreditation of the studies, 20 studies were included. The referral system suffers from different challenges in the areas associated with policy and planning, management, referral process, and health service recipients. Conclusion: The inefficient gatekeeping role of family physicians was one of the most important challenges of the referral system. The referral system should be improved by having evidence-based guidelines and policy documents, unified stewardship, integrated insurance schemes, and effective communication between different levels of care.

Near Two Decades of the Family Physician Program in Iran and the Structural Challenges: A Systematic Review.

The family physician program (FPP) is one of the most significant health care reforms in Iran; however, many studies showed that this program has not been able to achieve its intended objectives because of a variety of challenges. This program, despite the existing challenges, is going to be expanded across the country. To improve the likelihood of its success, identification of the structural and infrastructural challenges is necessary. This systematic review was conducted to assess the structural and infrastructural challenges of FPP in Iran. This systematic review of the literature was conducted in order to investigate the infrastructure and structure needs of the current program in Iran. All published articles related to the FPP in Iran were the subject of this study. The eligibility criteria included original articles, reviews, or case studies published in English or Persian during 2011-2021 related to the challenges in the referral system of FPP in Iran. Data were extracted based on Sample, Phenomenon of Interest, Design, Evaluation, Research type technique and were reported based on the structure of Preferred Reporting Items for Systematic Reviews and Meta-Analyses. International credible scholarly databases were searched. The search strategy was defined based on keywords and the search syntax. This study identified different challenges of the referral system in the areas associated with legal structure, administration, and social structure. The identified challenges in this program should be addressed in order to ensure that this program will lead to improved quality of care and equity in Iran health care system.

Reactogenicity within the first week after Sinopharm, Sputnik V, AZD1222, and COVIran Barekat vaccines: findings from the Iranian active vaccine surveillance system.

BACKGROUND: This study aimed to evaluate the reactogenicity effects of COVID-19 vaccines, used in Iran. METHODS: At least 1000 people were followed up with phone calls or self-report in a mobile application within 7 days after vaccination. Local and systemic reactogenicities were reported overall and by subgroups. RESULTS: The presence of one or more local and systemic adverse effects after the first dose of vaccines was 58.9% [(95% Confidence Intervals): 57.5-60.3)] and 60.5% (59.1-61.9), respectively. These rates were reduced to 53.8% (51.2-55.0) and 50.8% (48.8-52.7) for the second dose. The most common local adverse effect reported for all vaccines was pain in the injection site. During the first week after the first dose of vaccines, the frequency of the pain for Sinopharm, AZD1222, Sputnik V, and Barekat was 35.5%, 86.0%, 77.6%, and 30.9%, respectively. The same rates after the second dose were 27.3%, 66.5%, 63.9%, and 49.0%. The most common systemic adverse effect was fatigue. In the first dose, it was 30.3% for Sinopharm, 67.4% for AZD1222, 47.6% for Sputnik V, and 17.1% for Barekat. These rates were reduced to 24.6%, 37.1%, 36.5%, and 19.5%, in the second dose of vaccines. AZD1222 had the highest local and systemic adverse effects rates. The odds ratio of local adverse effects of the AZD1222 vaccine compared to the Sinopharm vaccine were 8.73 (95% CI 6.93-10.99) in the first dose and 4.14 (95% CI 3.32-5.17) in the second dose. Barekat and Sinopharm had the lowest frequency of local and systemic adverse effects. Compared to Sinopharm, systemic adverse effects were lower after the first dose of Barekat (OR = 0.56; 95% CI 0.46-0.67). Reactogenicity events were higher in women and younger people. Prior COVID-19 infection increased the odds of adverse effects only after the first dose of vaccines. CONCLUSIONS: Pain and fatigue were the most common reactogenicities of COVID-19 vaccination. Reactogenicities were less common after the second dose of the vaccines. The adverse effects of AZD1222 were greater than those of other vaccines.

Effectiveness of COVID-19 vaccines on hospitalization and death in Guilan, Iran: a test-negative case-control study.

OBJECTIVES: The present study was conducted to estimate the effectiveness of (BBIBP)-CorV (Sinopharm), ChAdOx1-S/nCoV-19 (AZD1222, Oxford-AstraZeneca), rAd26-rAd5 (Gam-COVID-Vac, Sputnik V), and BIV1-CovIran (COVIran Barekat) and BBV152 COVAXIN (Bharat Biotech) vaccines against hospitalization and death of COVID-19 in Guilan Province of Iran from May 22 to December 21, 2021. METHODS: This test-negative case-control study was conducted on the population aged 5 years and above by extracting information from local databases (The Medical Care Monitoring Center and The Integrated Health System). A logistic regression analysis was performed to estimate the effectiveness of the vaccines against COVID-19 hospitalization and death. RESULTS: The total study population was 42,084, including 19,500 cases (with a positive Reverse Transcriptase-Polymerase Chain Reaction test admitted to hospitals in Guilan Province) and 22,586 controls (with a negative Reverse Transcriptase-Polymerase Chain Reaction test). Among the admitted patients, 1887 deaths occurred. The maximum effectiveness of BBIBP-CorV (Sinopharm) in preventing temporary hospitalization and regular hospitalization was observed 151 days after receiving the second dose, 95% (95% CI: 67-99.4%) and 85% (95% CI: 77-91%) respectively. The maximum effectiveness of the BBIBP-CorV (Sinopharm) vaccine 91-120 days after receiving the second dose against death was showed 56% (95% CI: 33-71%). The maximum effectiveness of ChAdOx1-S/nCoV-19 (AZD1222, Oxford-AstraZeneca) and BIV1-CovIran (COVIran Barekat) in preventing regular hospitalization and death was observed 121-150 and 61-90 days (respectively) after receiving the second dose, reaching 98% (95% CI: 94-99%) and 92% (95% CI: 48-99%), respectively for ChAdOx1-S/nCoV-19 and 95% (95% CI: 91-97%) and 89% (95% CI: 55-98%) respectively, for BIV1-CovIran. CONCLUSION: For almost all vaccines, the study observed an increase in effectiveness against hospitalization and death over time.

COVID-19 cases, hospitalizations and deaths after vaccination: a cohort event monitoring study, Islamic Republic of Iran.

Objective: To investigate the incidence of coronavirus disease 2019 (COVID-19) cases, hospitalizations and deaths in Iranians vaccinated with either AZD1222 Vaxzevria, CovIran® vaccine, SARS-CoV-2 Vaccine (Vero Cell), Inactivated (lnCoV) or Sputnik V. Methods: We enrolled individuals 18 years or older receiving their first COVID-19 vaccine dose between April 2021 and January 2022 in seven Iranian cities. Participants completed weekly follow-up surveys for 17 weeks (25 weeks for AZD1222) to report their COVID-19 status and hospitalization. We used Cox regression models to assess risk factors for contracting COVID-19, hospitalization and death. Findings: Of 89 783 participants enrolled, incidence rates per 1 000 000 person-days were: 528.2 (95% confidence interval, CI: 514.0-542.7) for contracting COVID-19; 55.8 (95% CI: 51.4-60.5) for hospitalization; and 4.1 (95% CI: 3.0-5.5) for death. Compared with SARS-CoV-2 Vaccine (Vero Cell), hazard ratios (HR) for contracting COVID-19 were: 0.70 (95% CI: 0.61-0.80) with AZD1222; 0.73 (95% CI: 0.62-0.86) with Sputnik V; and 0.73 (95% CI: 0.63-0.86) with CovIran®. For hospitalization and death, all vaccines provided similar protection 14 days after the second dose. History of COVID-19 protected against contracting COVID-19 again (HR: 0.76; 95% CI: 0.69-0.84). Diabetes and respiratory, cardiac and renal disease were associated with higher risks of contracting COVID-19 after vaccination. Conclusion: The rates of contracting COVID-19 after vaccination were relatively high. SARS-CoV-2 Vaccine (Vero Cell) provided lower protection against COVID-19 than other vaccines. People with comorbidities had higher risks of contracting COVID-19 and hospitalization and should be prioritized for preventive interventions.

Study protocol: cohort event monitoring for safety signal detection after vaccination with COVID-19 vaccines in Iran.

BACKGROUND: New vaccines that are initially approved in clinical trials are not completely free of risks. Systematic vaccine safety surveillance is required for ensuring safety of vaccines. This study aimed to provide a protocol for safety monitoring of COVID-19 vaccines, including Sputnik V, Sinopharm (BBIBP-CorV), COVIran Barekat, and AZD1222. METHODS: This is a prospective cohort study in accordance with a template provided by the World Health Organization. The target population includes citizens of seven cities in Iran who have received one of the available COVID-19 vaccines according to the national instruction on vaccination. The participants are followed for three months after they receive the second dose of the vaccine. For each type of vaccine, 30,000 people will be enrolled in the study of whom the first 1,000 participants are in the reactogenicity subgroup. The reactogenicity outcomes will be followed seven days after vaccination. Any hospitalization, COVID-19 disease, or other minor outcomes will be investigated in weekly follow-ups. The data are gathered through self-reporting of participants in a mobile application or phone calls to them. The study outcomes may be investigated for the third and fourth doses of vaccines. Other long-term outcomes may also be investigated after the expansion of the follow-up period. We have planned to complete data collection for the current objectives by the end 2022. DISCUSSION: The results of this study will be published in different articles. A live dashboard is also available for managers and policymakers. All data will be available on reasonable requests from the corresponding author.The use of the good and comprehensive guidelines provided by WHO, along with the accurate implementation of the protocol and continuous monitoring of the staff performance are the main strengths of this study which may be very useful for policymaking about COVID-19 vaccination.

Selecting the Appropriate Method of Training Family Physicians in Iran to Achieve EMRO-Declared Perspective by 2030.

BACKGROUND: To achieve universal health coverage (UHC), the World Health Organization (WHO) Regional Committee for the Eastern Mediterranean (EMRO) reported that the standard requirement for family physicians by 2030 is three family physicians per 10,000 people. The purpose of this study was to select the appropriate method of training family physicians in Iran to achieve this goal. METHODS: The present qualitative study was conducted in conjunction with the method of agreement, during three sessions of focus group discussion (FGD) with 13 key persons at the national level to answer two research questions on choosing the most appropriate method of training family physicians and the criteria for this selection. After analyzing the data by content analysis method, a table was designed including family physicians' training methods and selection criteria and evaluated by participants in a 10-point spectrum. Then, the scores were summed and the mean was calculated for each method. RESULTS: The participants cited four methods, as well as 13 criteria. The Family Medicine Residency Program (FMRP) with a score of 93.4 and the Family physician bridging Program (FPBP) with a score of 68.38 were selected as the most appropriate training methods for the family physician to achieve the EMRO-declared perspective by 2030, respectively. CONCLUSION: According to the results of the study, the training of family physician specialist is the best method; but due to the long course and low output of this method, to meet the immediate needs of the health system and achieve the desired perspective, the FPBP approach was agreed as the most appropriate method of training the family physicians in Iran.

The Importance of Happy Hypoxemia in COVID-19.

BACKGROUND: Nowadays, the new coronavirus (SARS-CoV-2) and its complications are one of the main concerns of the world. One of the most severe complications of COVID-19 is hypoxemia. OBJECTIVES: This study aimed to assess the importance of happy hypoxemia in COVID-19. METHODS: We systematically searched web of science, PubMed, and Google scholar databases to find articles related to COVID-19 and happy hypoxemia. RESULTS: COVID-19 causes a type of hypoxemia named silent (happy) hypoxemia, which has an atypical clinical presentation. This type of hypoxemia has not been noted before in viral pneumonia, and there is no specific treatment for this serious complication. Patients with silent hypoxemia may develop severe hypoxemia without dyspnea and with near-normal lung compliance. These patients are awake, calm, and responsive. Although their lungs are not oxygenated efficiently, they are alert and cooperative. Their condition may be deteriorated rapidly without warning and causes death. CONCLUSIONS: According to the findings, paying attention to happy hypoxemia is important for improving the health status of COVID-19 patients.

Study on SARS-CoV-2 strains in Iran reveals potential contribution of co-infection with and recombination between different strains to the emergence of new strains.

We aimed to describe SARS-CoV-2 strains in Iranians from nine distributed cities infected during two months expanding late 2020 and early 2021 by genotyping known informative single nucleotide in five PCR amplicons. Two variants associated with haplotype H1 (clade G) and nine additional variants associated with other haplotypes were genotyped, respectively, in RNA isolates of 244 and 85 individuals. The variants associated with the H1a (GR) and H1b (GH) haplotypes were most prevalent, indicating a significant change in infection pattern with passage of time. The most important findings were that recombinant genomes and co-infection, respectively, were surmised in 44.7% and 12.9% of the samples extensively genotyped. Partners of many of the recombinations were relatively common strains. Co-existing viruses were among those currently circulating in Iran. In addition to random mutations, co-infection with different existing strains and recombination between their genomes may significantly contribute to the emergence of new SARS-CoV-2 strains.

Seroprevalence of SARS-CoV-2 in Guilan Province, Iran, April 2020.

We determined the seroprevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in an affected area in northern Iran in April 2020. Antibodies to SARS-CoV-2 were detected in 528 persons by using rapid tests. Adjusted prevalence of SARS-CoV-2 seropositivity was 22.2% (95% CI 16.4%-28.5%).

Intraperitoneal Instillation of Lidocaine for Postoperative Pain Relief after Total Abdominal Hysterectomy: A Double Blinded Randomized Placebo-controlled Trial.

Pain after total abdominal hysterectomy (TAH) is a major concern. Pain management is very important issue after TAH. This study aimed to assess the efficacy of intraperitoneal instillation of lidocaine for postoperative pain relief after TAH. A double-blinded randomized placebo-controlled trial was conducted on patients undergoing total abdominal hysterectomy in Al-zahra hospital from June 2007 to July 2008. Forty patients were randomly assigned with equal number in two lidicaine (N = 20) and normal saline (N = 20) groups. The lidocaine group received 50 mL of 0.8% lidocaine with epinephrine and placebo group received 50 ml of saline 0.9%. We used 10 cm visual analog scale (VAS) for assessing pain at 8, 12, and 24 h at rest and 48 h on movement. Opioid consumption, patient' satisfaction with pain control, and incidence of postoperative nausea and vomiting were assessed. Means of pain score at different times in lidocaine group were significantly lower than placebo group (P ˂ 0.05) the difference between mean dose of opioid consumption over 24 h between two groups was not significant (P = 0.785). Patient's satisfaction score in lidocaine group was significantly higher than saline group (P = 0.034). Differences in incidence of postoperative nausea and vomiting between two groups were not significant (P = 1.0). Intraperitoneal instillation of 50 mL of 0.8% lidocaine with epinephrine is an effective and safe technique for postoperative pain management after TAH. But this technique cannot reduce opioid consumption over 24 h after TAH.

Strengths and Weaknesses of Family Physician MPH Course in Iran: The Viewpoints of Managers and Physicians.

BACKGROUND: Since 2009, the MPH course has been implemented in Iran. After eight years, this study aimed to evaluate family physician MPH program in Iran. METHODS: This cross-sectional study was conducted on 255 graduates of family physician MPH, selected through simple random sampling and 95 managers who were involved in the design and implementation of the course in 13 universities, selected by census method, in 2017. Data collection tools were two researcher-made questionnaires, delivered to the subjects through emails. Data analysis was performed in SPSS version 21 using central and dispersion indices, Chi-square, and independent t-test. RESULTS: Approximately half of the participants considered the course length as appropriate, 14.5% of them considered the duration of the course short, and 28.9% of them considered it long and there was no significant difference between the views of managers and physicians in this regard. On the other hand, there was a significant difference between managers and physicians regarding the variables of cost-effectiveness, motivation to participate in the course, the necessity of presenting the thesis, applicability of the content, comprehensibility of the content of the course, and desirability of the course load. Thus, a higher percentage of managers acknowledged the necessity of theses and duties as well as the applicability of the content, and a higher percentage of physicians referred to cost-effectiveness and the motivation to participate in the course. CONCLUSIONS: According to the results of the study, the participants have proposed some strategies, such as revising the educational content, clarifying the future position of the trained physicians and granting privileges, specifying the program goals, being accurate in selecting motivated applicants with an interest in this field in order to improve the quality of educational courses.

Persian version of Patient-Reported Outcome Measure for Urethral Stricture Surgery (USS-PROM) Questionnaire, Validation and Adaptation Study.

PURPOSE: The aim of the present study was translation, cross cultural adaptation and face validity evaluation of the Persian version of Patient-Reported Outcome Measure for Urethral Stricture Surgery (USS-PROM) Questionnaire. MATERIALS AND METHODS: This study was assessed: translation, translation quality, reverse translation and comparison of the english version, Content validity, internal consistency and stability. Content validity presents by index of content validity (CVI) and the content validity ratio (CVR). Internal consistency reliability was tested by Cronbach's ?, and test-retest reliability was evaluated by Intraclass Correlation Coefficient (ICC) assessed by Guttman two way mixed absolute agreements. RESULT: Frothy males with history urethroplasty and mean age of 41.4±9.08 (range of 19 to 52) years old; enrolled.  In the case of mean scores of difficulty from the 16 translated items, 80% had easy translation. In terms of translation quality, 92% were the satisfactorily clear. In terms of similar concept, 92% were satisfactory. The overall quality of the translation was satisfactory at 88%. The translated questionnaire has a good internal consistency (Cronbach's alpha as 0.84). CVI and the CVR, test-retest ICC evaluation were appropriate/acceptable in all questions. The questionnaire ICC was .791(CI 95%, .678-.876). Two main different aspects of the questionnaire consisted of urinary symptoms (question 1-10) and Quality of life (question 11-15) Cronbach's alpha were .800 and .671 respectively. CONCLUSION: The Persian version of the questionnaire has acceptable cultural adaptation and face Validity. Further studies should be done using this translated tool to determine its applicability in the urethroplasty patients.