Service quality: perspective of people with type 2 diabetes mellitus and hypertension in rural and urban public primary healthcare centers in Iran.

OBJECTIVE: This study aimed to assess the service quality (SQ) for Type 2 diabetes mellitus (T2DM) and hypertension in primary healthcare settings from the perspective of service users in Iran. METHODS: The Cross-sectional study was conducted from January to March 2020 in urban and rural public health centers in the East Azerbaijan province of Iran. A total of 561 individuals aged 18 or above with either or both conditions of T2DM and hypertension were eligible to participate in the study. The study employed a two-step stratified sampling method in East Azerbaijan province, Iran. A validated questionnaire assessed SQ. Data were analyzed using One-way ANOVA and multiple linear regression statistical models in STATA-17. RESULTS: Among the 561 individuals who participated in the study 176 (31.3%) were individuals with hypertension, 165 (29.4%) with T2DM, and 220 (39.2%) with both hypertension and T2DM mutually. The participants' anthropometric indicators and biochemical characteristics showed that the mean Fasting Blood Glucose (FBG) in individuals with T2DM was 174.4 (Standard deviation (SD) = 73.57) in patients with T2DM without hypertension and 159.4 (SD = 65.46) in patients with both T2DM and hypertension. The total SQ scores were 82.37 (SD = 12.19), 82.48 (SD = 12.45), and 81.69 (SD = 11.75) for hypertension, T2DM, and both conditions, respectively. Among people with hypertension and without diabetes, those who had specific service providers had higher SQ scores (b = 7.03; p = 0.001) compared to their peers who did not have specific service providers. Those who resided in rural areas had lower SQ scores (b = -6.07; p = 0.020) compared to their counterparts in urban areas. In the group of patients with T2DM and without hypertension, those who were living in non-metropolitan cities reported greater SQ scores compared to patients in metropolitan areas (b = 5.09; p = 0.038). Additionally, a one-point increase in self-management total score was related with a 0.13-point decrease in SQ score (P = 0.018). In the group of people with both hypertension and T2DM, those who had specific service providers had higher SQ scores (b = 8.32; p < 0.001) compared to the group without specific service providers. CONCLUSION: Study reveals gaps in T2DM and hypertension care quality despite routine check-ups. Higher SQ correlates with better self-care. Improving service quality in primary healthcare settings necessitates a comprehensive approach that prioritizes patient empowerment, continuity of care, and equitable access to services, particularly for vulnerable populations in rural areas.

Global and regional quality of care index (QCI) by gender and age in oesophageal cancer: A systematic analysis of the Global Burden of Disease Study 1990-2019.

BACKGROUND: The aim of this study was to examine the quality of care by age and gender in oesophageal cancer using Global Burden of Disease (GBD) database. METHODS: Patients aged 20 and over with oesophageal cancer were included in this longitudinal study using GBD 1990-2019 data. We used the Socio-Demographic Index (SDI) to classify the regions. We used Principal Component Analysis (PCA) method to calculate the Quality of Care Index (QCI). The QCI was rescaled into a 0-100 single index, demonstrating that the higher the score, the better the QC. RESULTS: The age-standardized QCI for oesophageal cancer dramatically increased from 23.5 in 1990 to 41.1 in 2019 for both sexes, globally. The high SDI regions showed higher QCI than the rest of the regions (45.1 in 1990 and 65.7 in 2019) whereas the low SDI regions had the lowest QCI, which showed a 4.5% decrease through the years (from 13.3 in 1990 to 12.7 in 2019). Globally, in 2019, the QCI showed the highest scores for patients aged 80-84, reported 48.2, and the lowest score for patients aged 25-29 reported 31.5, for both sexes. Globally, in 2019, age-standardized Gender Disparity Ratio (GDR) was 1.2, showing higher QCI in females than males. CONCLUSION: There were fundamental differences in the QCI both globally and regionally between different age groups as well as between males and females. To achieve the goal of providing high-quality services equally to people in need in all over the world, health systems need to invest in effective diagnostic services, treatments, facilities, and equipment and to plan for screening and surveillance of high-risk individuals.

Costs of inpatient care and out-of-pocket payments for COVID-19 patients: A systematic review.

OBJECTIVE: To identify the costs of hospital care for patients with COVID-19 and the amount of out-of-pocket payments. METHODS: We conducted a systematic review using Scopus and WEB OF SCIENCE and PubMed databases in April 5, 2022 and then updated in January 15, 2023. English articles with no publication year restrictions were included with study designs of cost-of-illness (COI) studies, cost analyses, and observational reports (cross-sectional studies and prospective and retrospective cohorts) that calculated the patient-level cost of care for COVID-19. Costs are reported in USD with purchasing power parity (PPP) conversion in 2020. The PROSPERO registration number is CRD42022334337. RESULTS: The results showed that the highest total cost of hospitalization in intensive care per patient was 100789 USD, which was reported in Germany, and the lowest cost was 5436.77 USD, which was reported in Romania. In the present study, in the special care department, the highest percentage of total expenses is related to treatment expenses (42.23 percent), while in the inpatient department, the highest percentage of total expenses is related to the costs of hospital beds/day of routine services (39.07 percent). The highest percentage of out-of-pocket payments was 30.65 percent, reported in China, and the lowest percentage of out-of-pocket payments was 1.12 percent, reported in Iran. The highest indirect cost per hospitalization was 16049 USD, reported in USA, and the lowest was 449.07 USD, reported in India. CONCLUSION: The results show that the COVID-19 disease imposed a high cost of hospitalization, mainly the cost of hospital beds/day of routine services. Studies have used different methods for calculating the costs, and this has negatively impacted the comparability costs across studies. Therefore, it would be beneficial for researchers to use a similar cost calculation model to increase the compatibility of different studies. Systematic review registration: PROSPERO CRD42022334337.

Barriers to community participation in primary health care of district health: a qualitative study.

INTRODUCTION: Community participation is one of the principles of primary health care (PHC). However, it has not been adequately institutionalized due to numerous barriers. Therefore, the present study is conducted to identify barriers to community participation in primary health care in the district health network from the perspectives of stakeholders. METHODS: This qualitative case study was conducted in 2021 in Divandareh city, Iran. A total of 23 specialists and experts experienced in community participation, including nine health experts, six community health workers, four community members, and four health directors in primary health care programs, were selected using the purposive sampling method until complete saturation. Data was collected using semi-structured interviews and analyzed simultaneously using qualitative content analysis. RESULTS: After data analysis, 44 codes, 14 sub-themes, and five themes were identified as barriers to community participation in primary health care in the district health network. The themes included community trust in the healthcare system, the status of community participation programs, the community and system's perception of participation programs, health system management approaches, and cultural barriers and institutional obstacles. CONCLUSION: Based on the results of this study most important barriers to community participation relate to community trust, the organizational structure, community and the health profession's perception regarding the participatory programs. It seems necessary to take measures to remove barriers in order to realize community participation in primary healthcare system.

Perceptions of the Professionals and Parents of Children with Autism Spectrum Disorders About Autism Services; A Qualitative Study.

In this qualitative study, we aimed to explore the challenges of providing services and supports for children with autism spectrum disorders (ASD) and their families from the perceptions of professionals and parents of children with ASD. We classified the results of the study into three key categories including shortcomings in the management of children with ASD; shortcomings of supportive programs and facilities for children with ASD and their families; and organizational challenges in providing services for these children. We analyzed data using the content analysis method. The results showed that there is a wide range of challenges in providing sufficient and high-quality services for children with ASD and empowerment programs for their parents.

Factors Associated with Information Breach in Healthcare Facilities: A Systematic Literature Review.

This systematic review aimed to identify the factors associated with information breaches in healthcare settings. We searched electronic databases, including PubMed, Embase, Scopus, and Wiley, for all publications until March 6, 2022 (no start date restriction) and outlined the eligibility criteria framework using Population, Concept, and Context (PCC). Our search strategies yielded 2,156 results, with nine studies included in the final review. We grouped the factors attributed to data breaches into four categories: organizational, information technology (IT), professionals/employees, and clients/patients. Hospital type, hospital size (more beds), higher operationalexpenses and revenue, higher admissions and discharges, and higher Electronic Medical Record (EMR) use, being at earlier phases of EMR adoption, were associated with higher information breaches. Professional factors such as the type of personnel involved and the hospital area can potentially impact the breaches' frequency and magnitude. Patients' sociodemographic, clinical, and behavioral characteristics, such as gender and educational attainment, appear to influence the perceived breach of confidentiality in healthcare settings. Identifying different factors contributing to health information breaches is crucial to protecting healthcare organizations and patients from the devastating consequences of data breaches.

The Characteristics and Results of Parent Training Interventions in Children with Autism Spectrum Disorder: A Systematic Review.

Background: The role of parents in taking care of children with Autism Spectrum Disorder (ASD) is critical. This systematic review aimed to investigate the characteristics and results of parent training interventions for autistic children. Methods: All relevant studies were searched using Boolean operators such as "AND" and "OR" with the keywords such as "Autism Spectrum Disorders," "Autism," "Autistic disorder," "Asperger syndrome," "Rett's syndrome", "Childhood disintegrative disorder", "Non-specific pervasive disorder", Parent*, Education*, train*, teach*, indoctrinate*, and instruct* in electronic databases such as PubMed, Scopus, Google Scholar, Cochrane Library, Science Direct, Web of knowledge, and also via manual searching in relevant journals, checking the reference list of articles, expert contact, and grey literature from 1 Jan 2000 to 30 Feb 2020. The retrieved studies were screened and reviewed then quality assessed by CONSORT checklist. The qualitative data were analyzed using content analysis method. Results: Eventually, 53 articles were considered in which 1758 parents with autistic children participated. Overall, 49 studies were conducted in high-income countries, 19 at home, 25 in training centers, 14 carried out only in training way, 39 in training along with practices and assignments, 30 individual interventions, and 21 in groups. Moreover, the effectiveness of interventions was studied in both parents and children groups. The results for parents show direct and indirect favorable impacts of interventions on them. The results for the children indicate direct and indirect favorable effects of the parents-based interventions on the child and the symptoms of their disorder. Conclusion: According to the included studies, parents-based training interventions significantly impact parents and their children's behavior.

A Qualitative Study on the Establishment of an Interpersonal Violence Registry System in Iran.

Establishment of an interpersonal-violence registry system (IPVRS) is a promising initiative to tackle violence. This qualitative study aimed to fill the gap in knowledge regarding the feasibility of establishing the IPVRS in the East-Azerbaijan province of Iran. This qualitative study using content analysis was conducted to explore the importance, challenges, and facilitating factors of establishing the IPVRS from the viewpoints of stakeholders. Forty-six individuals from the Forensic Medical Organization, the University, the Welfare Organization, the Training and Education Organization, hospitals, and primary health centers participated in the study. Six themes and 13 sub-themes were identified. The importance of the establishment of the IPVRS was sub-categorized into two main themes, including violence as a public health priority and severe consequences of violence including intensive health and social outcomes and high use of medical services. The most critical challenges of establishing the IPVRS were categorized into two main themes including victims' under-reporting due to financial difficulties as well as psychosocial barriers and structural barriers such as organizational barriers and methodological challenges. Inter-sectoral partnership was identified as the main facilitating factor in the successful establishment of the IPVRS. The participants recommended improving the development of the IPVRS by stepwise development of the program, resource absorption from other beneficiary organizations, and making more coverage in the registry system. In conclusion, the establishment of the IPVRS is identified as an effective strategy to tackle violence-related issues. Close collaboration with different governmental and non-governmental sectors and the gradual development of the registry system can pave the way for establishing the IPVRS. This study has several implications for identifying potential challenges and facilitators of the IPVRS applicable to other developing countries with similar contexts.

Development, validation, and pilot implementation of the minimum datasheet for a domestic violence registry system: The case of a developing country.

BACKGROUND: Domestic violence (DV) is a universal issue and an important public health priority. Establishing a DV Registry System (DVRS) can help to systematically integrate data from several sources and provide valid and reliable information on the scope and severity of harms. The main objective of this study was to develop, validate, and pilot-test a minimum datasheet for a DVRS to register DV victims in medical facilities. MATERIALS AND METHODS: This study was conducted in two main phases. Phase one includes developing the datasheet for registration of DV in the DVRS. In phase two, the datasheet designed in the previous step was used in a pilot implementation of the DVRS for 12 months to find practical challenges. The preliminary datasheet was first developed using information on similar registry programs and guidelines of the World Health Organization (WHO) and then reviewed by four expert panels. Through a two-round Delphi technique, experts evaluated the instrument using the Content Validity Index (CVI) and Content Validity Ratio (CVR). The consistency of the responses was evaluated by test-retest analysis. Finally, two physicians in two forensic medical clinics registered the victims of physical and/or sexual violence perpetrated by a family member. RESULTS: Preliminary datasheet consisted of 31 items. In the first round of Delphi, fifteen items had good content validity (I-CVI and CVR) and were kept, and seven items were moved to the next round. Also, in the first round of Delphi, experts suggested adding three items, including history of the violence, custody of the child, and custody of the elderly. All items evaluated in the second round were kept due to good CVR and CVI scores. As a result of Test-retest correlation coefficients for self-reprted items, two items including perpetrator's alcohol and drug use status were excluded (r(30) = +.43, and +.38, p< .01, two-tailed, respectively). Finally, 24 items were included in the datasheet including 15 items for individuals' characteristics (victims' characteristics and perpetrators' characteristics), eight items for incidents' characteristics, and one item for past history of violence experience. A total of 369 cases were registered from September 23, 2019, to July 21, 2020. The majority of the reported cases were female (82%) and were 19-40 years old. No physical and/or sexual violence was reported from rural areas, which calls upon researchers to explore how services for detecting and treating the victims can be made accessible to these areas. CONCLUSION: DVRS can show trends in DV by age, sex, the context of the violence, and incidence characteristics at every point in time. This is particularly valuable in planning and prioritizing research areas and interventions for DV prevention. Additionally, DVRS can be linked to other disease registry programs which can contribute to continuity and coordination of care, and major research in the future. Although a DVRS can be a promising initiative in identifying the areas in need of urgent interventions, there is no guarantee for its proper implementation due to limited resources and other challenges.

A systematic review of racial/ethnic and socioeconomic disparities in COVID-19.

BACKGROUND: Preliminary evidence from the COVID-19 pandemic shows the presence of health disparities, especially in terms of morbidity and mortality. This study aimed to systematically review the evidence on the association of racial/ethnic and socioeconomic status (SES) with health outcomes and access to healthcare services during the COVID-19 pandemic. METHODS: We retrieved published evidence from late December 2019 through March 1, 2021. The target population was the population of the countries during the COVID-19 pandemic. The exposures were defined as belonging to racial/ethnic minority groups and/or low SES. The primary outcomes of interest include (1) death from COVID-19, (2) COVID-19 incidence/infection, (3) COVID-19 hospitalization, (4) ICU admission, (5) need for mechanical ventilation, (6) confirmed diagnosis, and (7) access to testing. We systematically synthesized the findings from different studies and provided a narrative explanation of the results. RESULTS: After removing the duplicate results and screening for relevant titles and abstracts, 77 studies were selected for full-text review. Finally, 52 studies were included in the review. The majority of the studies were from the United States (37 studies). Despite the significant incongruity among the studies, most of them showed that racial/ethnic minority groups had higher risks of COVID-19 infection and hospitalization, confirmed diagnosis, and death. Additionally, most of the studies cited factors such as low level of education, poverty, poor housing conditions, low household income, speaking in a language other than the national language in a country, and living in overcrowded households as risk factors of COVID-19 incidence/infection, death, and confirmed diagnosis. However, findings in terms of the association of lack of health insurance coverage and unemployment with the outcome measures as well as the association of requiring mechanical ventilation, ICU admission, and access to testing for COVID-19 with race/ethnicity were limited and inconsistent. CONCLUSION: It is evident that racial/ethnic minority groups and those from low SES are more vulnerable to COVID-19; therefore, public health policymakers, practitioners, and clinicians should be aware of these inequalities and strive to narrow the gap by focusing on vulnerable populations. This systematic review also revealed a major incongruity in the definition of the racial/ethnic minority groups and SES among the studies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020190105.

Effectiveness of non-pharmaceutical public health interventions against COVID-19: A systematic review and meta-analysis.

Non-Pharmaceutical Public Health Interventions (NPHIs) have been used by different countries to control the spread of the COVID-19. Despite available evidence regarding the effectiveness of NPHSs, there is still no consensus about how policymakers can trust these results. Studies on the effectiveness of NPHSs are single studies conducted in specific communities. Therefore, they cannot individually prove if these interventions have been effective in reducing the spread of the infection and its adverse health outcomes. In this systematic review, we aimed to examine the effects of NPHIs on the COVID-19 case growth rate, death growth rate, Intensive Care Unit (ICU) admission, and reproduction number in countries, where NPHIs have been implemented. We searched relevant electronic databases, including Medline (via PubMed), Scopus, CINAHL, Web of Science, etc. from late December 2019 to February 1, 2021. The key terms were primarily drawn from Medical Subject Heading (MeSh and Emtree), literature review, and opinions of experts. Peer-reviewed quasi-experimental studies were included in the review. The PROSPERO registration number is CRD42020186855. Interventions were NPHIs categorized as lockdown, stay-at-home orders, social distancing, and other interventions (mask-wearing, contact tracing, and school closure). We used PRISMA 2020 guidance for abstracting the data and used Cochrane Effective Practice and Organization of Practice (EPOC) Risk of Bias Tool for quality appraisal of the studies. Hartung-Knapp-Sidik-Jonkman random-effects model was performed. Main outcomes included COVID-19 case growth rate (percentage daily changes), COVID-19 mortality growth rate (percentage daily changes), COVID-19 ICU admission (percentage daily changes), and COVID-19 reproduction number changes. Our search strategies in major databases yielded 12,523 results, which decreased to 7,540 articles after eliminating duplicates. Finally, 35 articles qualified to be included in the systematic review among which 23 studies were included in the meta-analysis. Although studies were from both low-income and high-income countries, the majority of them were from the United States (13 studies) and China (five studies). Results of the meta-analysis showed that adoption of NPHIs has resulted in a 4.68% (95% CI, -6.94 to -2.78) decrease in daily case growth rates, 4.8% (95 CI, -8.34 to -1.40) decrease in daily death growth rates, 1.90 (95% CI, -2.23 to -1.58) decrease in the COVID-19 reproduction number, and 16.5% (95% CI, -19.68 to -13.32) decrease in COVID-19 daily ICU admission. A few studies showed that, early enforcement of lockdown, when the incidence rate is not high, contributed to a shorter duration of lockdown and a lower increase of the case growth rate in the post-lockdown era. The majority of NPHIs had positive effects on restraining the COVID-19 spread. With the problems that remain regarding universal access to vaccines and their effectiveness and considering the drastic impact of the nationwide lockdown and other harsh restrictions on the economy and people's life, such interventions should be mitigated by adopting other NPHIs such as mass mask-wearing, patient/suspected case isolation strategies, and contact tracing. Studies need to address the impact of NPHIs on the population's other health problems than COVID-19.

Impacts of high-deductible health plans on patients with diabetes: A systematic review of the literature.

BACKGROUND AND OBJECTIVES: High-deductible health plans (HDHPs) as a type of consumer-directed health insurance plan aim to control unnecessary service utilization and share the responsibility in payments and care with the patient. Our objective was to systematically pool the medical and non-medical impacts of HDHPs on patients with diabetes. METHODS: We searched databases, including PubMed, Scopus, Embase, and Wiley, to identify relevant published studies. We outlined the eligibility criteria based on the study population, intervention, comparison, outcome, and types of studies (PICOT). We included peer-reviewed quantitative studies published in English, including quasi-experimental, observational, and cross-sectional studies in this review. We used the narrative data synthesis method to categorize and interpret the results. RESULTS: Initial search yielded 149 results. After removing duplicates and screening for relevant titles and abstracts, and reviewing full texts, 11 studies met eligibility criteria. Overall, diabetic patients with HDHP were less likely to adhere to treatment and prescription refills, utilize fewer healthcare services and medications, and more likely to have acute emergency visits than their counterparts enrolled in low-deductible plans. However, the results on overall healthcare costs and the final health outcome were unclear. CONCLUSIONS: It appears that HDHPs negatively impact low-income diabetic patients by leading them to forgo preventive and primary care services and experience excessive preventable emergency department visits. The socioeconomic characteristics of patients must be considered when developing HDHP policies, and adjustments should be made to HDHPs accordingly.

Disparities in the quality of and access to services in children with autism spectrum disorders: a structural equation modeling.

BACKGROUND: Socioeconomic disparities in health and healthcare are global issues that affect both adults as well as children. Children with exceptional healthcare needs, especially those with developmental impairments, including Autism Spectrum Disorders (ASD), encounter major disparities in access to and quality of health services. However, disparities in the population of children are rarely studied. The main aim of this paper is to study the socioeconomic disparities in children with ASD by examining the association between their Social Determinants of Health (SDH) status and access to and the quality of services. METHODS: This is a cross-sectional study on 202 children with ASD conducted in 2019 in two provinces including Ardabil and East-Azerbaijan, in the North-West of Iran. A structured, valid questionnaire was used to collect data on demographic, SDH status, quality of services, and access to services in a population of children with ASD aged 2-16-year-old. Around 77% participants were male and the mean age of children was 2 years and 6 months. Structural Equation Modeling (SEM) were used to assess the relationship. RESULTS: Based on the results of this study, the overall mean scores of the quality of services, access to services, and SDH status were 61.23 (30.01), 65.91 (21.89), and 29.50 (22.32) out of 100, respectively. All the associations between the quality and access dimensions and quality (B: 0.464-0.704) and access (B: 0.265-0.726) scales were statistically significant (P < 0.001). By adjusting to covariates, the access was also significantly related to service quality (P = 0.004). Finally, the associations between SDH score with service quality (P = 0.039) and access (P < 0.001) were positively significant. CONCLUSIONS: There are socioeconomic disparities in the quality of and access to services among children with ASD, who use ASD services, in the North-West of Iran. We recommend health/medical centers, where children are diagnosed with ASD, conducting SDH screening and providing families of low-SDH status with specific information about the quality of and access to services for children with ASD. Additionally, medical universities must have a plan to routinely monitor the quality of and access to services provided for the children with low SDH.

Considerations about the implementation of an autism screening program in Iran from the viewpoints of professionals and parents: a qualitative study.

BACKGROUND: The aims of this study were to explore to explore the viewpoints of parents of children with Autism Spectrum Disorders (ASD) and professionals regarding the implementation of screening programs for ASD, to explore the challenges of the implementation of a universal screening program for ASD in Iran from their viewpoints, and, to explore their recommendations to overcome the potential challenges. METHOD: This qualitative study was conducted using an inductive content analysis, between June 2018 and December 2018, in East-Azerbaijan province of Iran. Data was collected through in-depth interviews and focus group discussions. The participants were purposively selected among two groups: representatives of health system and representatives of children with ASD. A sample of 32 parents and 30 professionals were recruited in this study. RESULTS: Totally, 9 main themes and 23 sub-themes were extracted in three main areas including: viewpoints of the participants about universal screening for ASD, challenges in implementation of the universal screening program, and participants' recommendations about how to overcome the potential challenges. Main challenges in implementation of the universal screening program included: shortages of ASD screening tools, weakness of the health system, lack of coordination among the ASD service providers, and social and ethical issues. CONCLUSION: The parents and the professionals had different viewpoints about the implementation of ASD universal screening program in Iran. According to the professionals, there is not enough rational to implement ASD screening program for all children. However, the parents believed that universal screening program is inevitable, and it should be implemented in primary health centers during the early child-care visits. The results of this study open up unspoken issues that could help in initiating the screening program not only in Iran but also in other low- and middle-income countries as well.

Effectiveness of the non-pharmaceutical public health interventions against COVID-19; a protocol of a systematic review and realist review.

BACKGROUND: Without any pharmaceutical intervention and vaccination, the only way to combat Coronavirus Disease 2019 (COVID-19) is to slow down the spread of the disease by adopting non-pharmaceutical public health interventions (PHIs). Patient isolation, lockdown, quarantine, social distancing, changes in health care provision, and mass screening are the most common non-pharmaceutical PHIs to cope with the epidemic. However, there is neither systematic evidence on the effectiveness of non-pharmaceutical PHIs in controlling the COVID-19 nor on how these interventions work in different contexts. Therefore, in this study we will address two main objectives: 1) to assess the effectiveness of the non-pharmaceutical PHIs in controlling the spread of COVID-19 using a systematic review and meta-analyses; 2) to explore why, how, and for whom these interventions work using a realist review. MATERIALS AND METHODS: This review study has two main phases. In the first phase of this study, we will extract data from two main types of studies including quasi-experimental studies (such as quasi-randomized trials, controlled before-after studies (CBAs) and interrupted time series studies (ITSs)) and observational studies (such as cohort, case-control, and cross-sectional studies), written in the English language. We will explore effectiveness of the non-pharmaceutical PHIs targeted either suppression or mitigation strategies (or a combination of both) in controlling the COVID-19 epidemics in the community level. Effectiveness will be considered as the changes in mortality rate, incidence rate, basic reproduction number rate, morbidity rate, rates of hospitalization, rates of intensive care unit (ICU) hospitalization, and other health outcomes where possible. We will perform random-effects meta-analyses, if possible, using CMA software. In the second phase, we will conduct a realist review to find out how, why, for whom, and in what circumstances the non-pharmaceutical PHIs work. At the realist review, we will identify and explore Context-Mechanism-Outcome configurations to provide a robust explanation on the effectiveness of the interventions in different contexts using Pawson's 5-step realist review template including: "clarify scope; search for evidence; appraise primary studies and extract data; synthesize evidence and draw conclusions; and disseminate, implement and evaluate". Although the steps are presented in a linear manner, in practice, we will follow them in iterative stages to fill any potential overlap. DISCUSSION: The findings of this research will provide a crucial insight into how and in which context the non-pharmaceutical PHIs work in controlling the spread of COVID-19. Conducting a systematic review and meta-analysis in line with a realist review will allow us to draw a robust conclusion on the effects and the way in which the interventions work. Understanding the role of contextual factors in the effectiveness of non-pharmaceutical PHIs and the mechanism of this process could enable policymakers to implement appropriate policies and manage the COVID-19 epidemics more efficiently. SYSTEMATIC REVIEW REGISTRATION: CRD42020186855.

Modelling the prevalence of diabetes mellitus risk factors based on artificial neural network and multiple regression.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a metabolic disease with complex causes, manifestations, complications and management. Understanding the wide range of risk factors for T2DM can facilitate diagnosis, proper classification and cost-effective management of the disease. AIMS: To compare the power of an artificial neural network (ANN) and logistic regression in identifying T2DM risk factors. METHODS: This descriptive and analytical study was conducted in 2013. The study samples were all residents aged 15-64 years of rural and urban areas in East Azerbaijan, Islamic Republic of Iran, who consented to participate (n = 990). The latest data available were collected from the Noncommunicable Disease Surveillance System of East Azerbaijan Province (2007). Data were analysed using SPSS version 19. RESULTS: Based on multiple logistic regression, age, family history of T2DM and residence were the most important risk factors for T2DM. Based on ANN, age, body mass index and current smoking were most important. To test for generalization, ANN and logistic regression were evaluated using the area under the receiver operating characteristic curve (AUC). The AUC was 0.726 (SE = 0.025) and 0.717 (SE = 0.026) for logistic regression and ANN, respectively (P < 0.001). CONCLUSIONS: The logistic regression model is better than ANN and it is clinically more comprehensible.

Effects of customer self-audit on the quality of maternity care in Tabriz: A cluster-randomized controlled trial.

OBJECTIVE: To study the effects of customer self-audit on the service quality (SQ) and customer quality (CQ) of maternity care. DESIGN: A community-based cluster-randomized controlled trial. SETTING: Twenty-one health centres and health posts in Tabriz, Iran. PARTICIPANTS: Of 21 health centres/health posts, 10 were randomly assigned to the intervention group and 11 randomly assigned to the control group. Participants were 185 pregnant women selected from health centre/post registration lists (intervention group: n = 92; control group: n = 93). INTERVENTIONS: The intervention was a customer self-audit based on the CenteringPregnancy® model of prenatal group care. The intervention group attended group support sessions focused on participants' opinions, questions, and self-management concerns. They also received sessions on experiential learning, coping, problem-solving, and goal-setting by a family health expert, a midwife, and a doctor. Control group participants continued to receive individual care. PRIMARY OUTCOME MEASURES: SQ and CQ were assessed using questionnaires. Patients rated the importance and performance of non-health quality dimensions. SQ was calculated as: SQ = 10 - (Importance × Performance). RESULTS: Total mean SQ scores were 7.63 (0.91) and 8.91 (0.76) for the control and intervention groups, respectively, a statistically significant difference (p<0.001). Compared with the control group, the intervention group scored higher on the SQ aspects confidentiality, communication, autonomy, availability of support group, dignity, safety, prevention, and accessibility. Total mean CQ scores for the control and intervention groups were 82.63(7.21) and 87.47 (6.75), respectively, a statistically significant difference (p<0.001). After intervention, 82.6% of intervention group participants and 50.5% of control group participants reached the highest stage of self-management, showing an ability to take care of themselves under stress and financial constraints. CONCLUSIONS: The group prenatal care customer self-audit improved the SQ and CQ of maternity care by increased involvement of participants and giving them active roles in the care process.

Improvement of the quality payment program by improving data reporting process: an action research.

BACKGROUND: Successful implementation of pay-for-quality (P4Q) programs mostly depends upon a valid, timely, and reliable data about quality measures generated by providers, and interpreted by payers. The aim of this study was to establish a data reporting method for P4Q program through an action research. METHODS: Qualitative method was used to align theory with action through a three-cycle action research. The study was conducted in September 15, 2015 to March 15, 2017, in East-Azerbaijan, Iran. The purposeful sampling was used to select participants. The participants included healthcare providers, staff in district health centers (DHC), experts, and managers in the provincial primary health center (PPHC). Data was collected by interviews, focus group discussions, and expert panels. Content analysis was used to synthesize the data. In each step, decisions about data reporting methods were made through a consensus of expert panel members. RESULTS: The most important dimensions of data reporting method were data entry and accuracy, data reporting, data analysis and interpretations, the flexibility of method, and training. By establishment of an online data reporting system for the P4Q program, a major improvement was observed in the documentation of performance data, the satisfaction of health care providers and staff (e.g. either in DHCs or PPHC), improvement of the P4Q program and acceptance of the P4Q program by providers. Following the present study, the online system was expanded in Iran's public health system for data collection and estimating the amount of incentive payments in P4Q program. Moreover, more improvements were achieved by linking the system to EMRs and also, providing automated feedback to providers about their own performance. CONCLUSIONS: A web-based computerized system with the capability of linking medical record and also its ability to provide feedback to healthcare providers was identified as an appropriate method of data reporting in the P4Q program from the viewpoints of participants in this study.

A framework to assess management performance in district health systems: a qualitative and quantitative case study in Iran.

The aim was to design a district health management performance framework for Iran's healthcare system. The mixed-method study was conducted between September 2015 and May 2016 in Tabriz, Iran. In this study, the indicators of district health management performance were obtained by analyzing the 45 semi-structured surveys of experts in the public health system. Content validity of performance indicators which were generated in qualitative part were reviewed and confirmed based on content validity index (CVI). Also content validity ratio (CVR) was calculated using data acquired from a survey of 21 experts in quantitative part. The result of this study indicated that, initially, 81 indicators were considered in framework of district health management performance and, at the end, 53 indicators were validated and confirmed. These indicators were classified in 11 categories which include: human resources and organizational creativity, management and leadership, rules and ethics, planning and evaluation, district managing, health resources management and economics, community participation, quality improvement, research in health system, health information management, epidemiology and situation analysis. The designed framework model can be used to assess the district health management and facilitates performance improvement at the district level.