Direct and indirect effects of economic sanctions on health: a systematic narrative literature review.

BACKGROUND: Economic sanctions are defined as restrictions imposed by other countries against individuals, groups, or governments of other countries. These sanctions have a detrimental impact on the economies of countries and can also limit access to healthcare services for people as a secondary consequence. This study aims to systematically review the literature to examine the direct and indirect effects of economic sanctions on health through a narrative synthesis. METHODS: This systematic literature review was limited to papers published between January 1990 and July 2023. Relevant documents published in English and Persian were searched for in databases including Cochrane Library, PubMed, Embase, Scopus, Web of Science, SID, Magiran, and Irandoc. The direct and indirect effects of sanctions on health were classified using two frameworks proposed by the World Health Organization (WHO): the Health System Building Blocks and "Social Determinants of Health". RESULTS: Out of a total of 18,219 articles, 59 were selected based on inclusion criteria. The effects of sanctions were divided into direct and indirect groups. Direct effects encompassed seven main themes: access to essential medicine, medical products, vaccines and technologies; financing; health workforce; service delivery; research and health information systems; health outcomes; and financial risk protection. Indirect effects also were classified into six main themes: socioeconomic status; food and agricultural products; stress; early life conditions; high-risk behaviors and addiction; and transport. Most studies focused on the access to medicines, food, economic and social status. CONCLUSIONS: Economic sanctions have had profoundly negative impacts on all aspects of the healthcare system. The international community must address these effects on health and take necessary measures to prevent or mitigate them, particularly in ensuring the provision of basic and essential healthcare needs for individuals and communities.

Development and validation of a questionnaire to determine medical orders non-adherence: a sequential exploratory mixed-method study.

BACKGROUND: Patients' non-adherence with medical orders of physicians in outpatient clinics can lead to reduced clinical effectiveness, inadequate treatment, and increased medical care expenses. This study was conducted to develop and validate a questionnaire to determine the reasons for patients' non-adherence with physicians' medical orders. METHODS: A sequential exploratory mixed-method study was conducted in two stages. The first stage comprised a qualitative stage to generate the primary items of the questionnaire. This stage provided findings of two sub-stages comprising a literature review and the findings of a qualitative conventional content analysis of 19 semi-structured interviews held with patients, physicians, and managers of the outpatient clinics in Kerman, an area located in southeastern Iran. The second stage comprised a quantitative study aiming evaluation of the instrument psychometric properties, including the face, content, construct, and reliability assessment of the questionnaire. Construct validity assessment was evaluated using exploratory factor analysis (EFA). The reliability assessment was done using assessing internal consistency (Cronbach's alpha). To assess the construct validity of the questionnaire, four hundred and forty patients referred to outpatient clinics in Kerman were selected using stratified convenience sampling to fill out the questionnaire. The sample size was calculated using the Cochran formula. Qualitative and quantitative data were analyzed by MAXQDA 10 and Stata version 14, respectively. RESULTS: The primary items contained 57 items, of which 42 met the minimum acceptable value of 0.78 for item-level content validity index (I-CVI = 1 for 24 items and I-CVI = 0.8 for 18 items). Item-level content validity ratio (I-CVR) was confirmed for 18 items with a minimum acceptable value of 0.99 for five experts. Finally, 18 items obtained the acceptable value for both I-CVI and I-CVR indicators and were confirmed. Using EFA, four factors (intrapersonal-psychological, intrapersonal-cognitive, provider-related, and socio-economic reasons) with 18 items and Cronbach's alpha coefficient of 0.70, 0.66, 0.73, and 0.71, respectively, were identified and explained 51% of the variance. The reliability of the questionnaire (r = 0.70) was confirmed. CONCLUSION: The questionnaire with four dimensions is a valid and reliable instrument that can help determine the perceived reasons for non-adherence with medical orders in the outpatient services system.

Effective factors in non-compliance with therapeutic orders of specialists in outpatient clinics in Iran: a qualitative study.

BACKGROUND: Non-compliance with prescribed treatment is an important cause of preventable mortality and economic burden. Recognition of the factors for non-compliance with the therapeutic orders of specialists from the perspective of patients and health care providers sheds more light on the issue for policymakers and stakeholders. The current study aimed at determining the factors for non-compliance with therapeutic orders in outpatient clinics in Kerman, Iran. METHODS: The current qualitative study was conducted using the phenomenological method and semi-structured interviews with 10 patients, five specialists, and four health care managers and treatment officials in outpatient clinics in Kerman. The interviewees were selected by purposive sampling. The codes extracted from the interviews were transcribed using conventional content analysis to identify the viewpoints. The MAXQDA 10 software was used to analyze the data. RESULTS: The reasons for non-compliance with specialists' orders were categorized into five themes including patient-related (patient-centered), disease-related, therapy-related, the healthcare provider related (healthcare system), and socioeconomic factors. Themes were composed of fifteen categories and forty-one sub-categories. The dominant sub-categories extracted from interviews were health literacy and knowledge of the patient, communication and patients' trust in physicians and direct costs of treatment. CONCLUSION: This study identified a wide range of different individual, disease, treatment, health care provider, and socio-economic factors and the interactions between them which may result into non-compliance with therapeutic orders prescribed by specialists. Therefore, specific attention should be paid to integrate the service provision system into the collaborative approach of the patient and his/her family in order to promote the level of compliance with therapy and care in planning and policy-making to improve the health service provision system.