Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis.

BACKGROUND: What constitutes respectful maternity care (RMC) operationally in research and programme implementation is often variable. OBJECTIVES: To develop a conceptualisation of RMC. SEARCH STRATEGY: Key databases, including PubMed, CINAHL, EMBASE, Global Health Library, grey literature, and reference lists of relevant studies. SELECTION CRITERIA: Primary qualitative studies focusing on care occurring during labour, childbirth, and/or immediately postpartum in health facilities, without any restrictions on locations or publication date. DATA COLLECTION AND ANALYSIS: A combined inductive and deductive approach was used to synthesise the data; the GRADE CERQual approach was used to assess the level of confidence in review findings. MAIN RESULTS: Sixty-seven studies from 32 countries met our inclusion criteria. Twelve domains of RMC were synthesised: being free from harm and mistreatment; maintaining privacy and confidentiality; preserving women's dignity; prospective provision of information and seeking of informed consent; ensuring continuous access to family and community support; enhancing quality of physical environment and resources; providing equitable maternity care; engaging with effective communication; respecting women's choices that strengthen their capabilities to give birth; availability of competent and motivated human resources; provision of efficient and effective care; and continuity of care. Globally, women's perspectives of what constitutes RMC are quite consistent. CONCLUSIONS: This review presents an evidence-based typology of RMC in health facilities globally, and demonstrates that the concept is broader than a reduction of disrespectful care or mistreatment of women during childbirth. Innovative approaches should be developed and tested to integrate RMC as a routine component of quality maternal and newborn care programmes. TWEETABLE ABSTRACT: Understanding respectful maternity care - synthesis of evidence from 67 qualitative studies.

Implementation of a critical care outreach service: a qualitative study.

AIM: The aim of this study was to explore hospital staff perceptions of the perceived challenges and outcomes of implementing a critical care outreach service. BACKGROUND: A nurse-led critical care outreach service was designed and implemented to identify and treat acutely ill patients in a large tertiary care hospital in Iran. METHODS: A qualitative analysis of data from two focus groups and seven interviews was carried out using conventional content analyses techniques. A total of 24 hospital staff members participated, including critical care outreach team members, physicians, ward head nurses and ward staff. FINDINGS: Two main categories described the perceived challenges to the implementation of the critical care outreach service: 1) the hospital context, with four subcategories related to staff shortages, the instability of physician positions, the lack of specialized essential services and the absence of a system to establish do-not-resuscitate orders, and 2) staff resistance to different nursing priorities, routines and extra work. In two additional main categories, participants also described positive and negative perceived outcomes. The positive perceived outcomes included three subcategories of alleviating equipment shortages, improving nursing knowledge and patient care and improving patient and healthcare professional satisfaction. DISCUSSION: While critical care outreach has the potential to improve patient perceived outcomes and both patient and provider satisfaction with care, the contextual and clinical realities in hospitals are significant and must be examined during the planning and implementation of future outreach. CONCLUSION AND IMPLICATIONS FOR NURSING AND HEALTH POLICY: A critical care outreach service in the context of an Iranian hospital has the potential to improve ward nurse familiarity with the care of acutely ill patients and the quality of palliative care. However, attention ought to be paid to the hospital's structural and contextual factors. Alleviating nursing shortages, reducing staff resistance and preparing goals of care guidelines that address restrictions on resuscitation could facilitate implementation of critical care outreach services.

Effectiveness of regionalization of trauma care services: a systematic review.

OBJECTIVES: Improving trauma systems in various forms has always been an important aspect of health policy. While several papers have reported the implementation of a structured trauma system of care, research evidence on the effectiveness of such regionalization for improvement in trauma outcome is limited. STUDY DESIGN: Systematic review. METHOD: Medline, EMbase, EconLit and Health Management Information Consortium were searched, using sensitive search terms, for interventional studies that reported a trauma regionalization system as their intervention, and compared important outcomes such as mortality and preventable deaths. At least two authors assessed eligibility for inclusion and risk of bias, and extracted data from the included studies. As meta-analysis was not possible for all studies, two controlled before-after studies were included in the meta-analysis, and a narrative analysis was conducted for the other studies. RESULTS: After title and abstract sifting, 66 papers were retrieved. After reading the full texts, a total of 24 studies from the USA, UK, Canada, Australia, and the Netherlands were included in this review. In spite of variation in study specifications, most were before-after studies with a high risk of bias. Although a reduction in mortality was shown in most studies, only two studies were eligible for meta-analysis, and the results showed a significant reduction in mortality after implementation of an organized trauma system (odds ratio 0.840, 95% confidence interval 0.756-0.924; P = 0.00). CONCLUSION: Correlation was found between a regionalized network of trauma care and a reduction in trauma-related mortality, based on studies that did not exclude the effects of other concurrent changes on observed reductions. It is recommended that more studies with robust research designs should be conducted in a more diverse range of countries to assess the effectiveness of regionalization. Despite this limitation, the present findings support the regionalization of trauma care services.

Developing a conceptual framework and a tool for measuring access to, and use of, medicines at household level (HH-ATM tool).

OBJECTIVE: To develop a valid and reliable tool to evaluate access to, and use of, medicines at household level (HH-ATM tool). STUDY DESIGN: The Behavioral Model of Health Services Use was adapted and used as the conceptual framework for developing the HH-ATM tool. Questionnaires were designed (individual and household) based on the conceptual framework and existing tools, including items that captured the characteristics of predisposing, enabling and need factors; health care behaviours; outcomes and impacts. METHODS: Face validity, content validity and test-retest reliability were assessed using inter-rater agreement, item and scale content validity indices, comprehensiveness indices, and intra-class correlation, kappa and weighted-kappa coefficients. RESULTS: The household and individual questionnaires demonstrated appropriate validity and reliability. The content validity of household questionnaire was favourable, with inter-rater agreement of 86% and 91% for relevance and clarity, respectively. Scale content validity indices for relevance and clarity were 89% and 91%, respectively, and comprehensiveness was scored at 100%. These indices were also favourable for the individual questionnaire, all scoring 94% or higher. CONCLUSION: The questionnaires showed excellent validity and reliability for use in Iran. The HH-ATM tool can be implemented to evaluate access to, and use of, medicines in Farsi-speaking communities, and may be useful in other communities if adapted appropriately.

The effectiveness of regionalization of perinatal care services--a systematic review.

BACKGROUND: Several reports recommend the implementation of perinatal regionalization for improvements in maternal and neonatal outcomes, while research evidence on the effectiveness of perinatal regionalization has been limited. The interventional studies have been assessed for robust evidence on the effectiveness of perinatal regionalization on improving maternal and neonatal health outcomes. METHODS: Bibliographic databases of Medline, EMbase, EconLit, HMIC have been searched using sensitive search terms for interventional studies that reported important patient or process outcomes. At least two authors assessed eligibility for inclusion and the risk of biases and extracted data from the included studies. As meta-analysis was not possible, a narrative analysis as well as a 'vote-counting' analysis has been conducted for important outcomes. RESULTS: After initial screenings 53 full text papers were retrieved. Eight studies were included in the review from the USA, Canada and France. Studies varied in their designs, and in the specifications of the intervention and setting. Only three interrupted time series studies had a low risk of bias, of which only one study reported significant reductions in neonatal and infant mortality. Studies of higher risk of bias were more likely to report improvements in outcomes. CONCLUSIONS: Implementing perinatal regionalization programs is correlated with improvements in perinatal outcomes, but it is not possible to establish a causal link. Despite several high profile policy statements, evidence of effect is weak. It is necessary to assess the effectiveness of perinatal regionalization using robust research designs in a more diverse range of countries.

Health observatories in iran.

BACKGROUND: The Islamic Republic of Iran, in her 20 year vision by the year 2025, is a developed country with the first economic, scientific and technological status in the region, with revolutionary and Islamic identity, inspiring Islamic world, as well as effective and constructive interaction in international relations. Enjoying health, welfare, food security, social security, equal opportunities, fair income distribution, strong family structure; to be away from poverty, corruption, and discrimination; and benefiting desirable living environment are also considered out of characteristics of Iranian society in that year. Strategic leadership towards perceived vision in each setting requires restrictive, complete and timely information. According to constitution of National Institute for Health Researches, law of the Fifth Development Plan of the country and characteristics of health policy making, necessity of designing a Health Observatory System (HOS) was felt. Some Principles for designing such system were formulated by taking following steps: reviewing experience in other countries, having local history of the HOS in mind, superior documents, analysis of current production and management of health information, taking the possibilities to run a HOS into account. Based on these principles, the protocol of HOS was outlined in 3 different stages of opinion poll of informed experts responsible for production on management of information, by using questionnaires and Focus Group Discussions. The protocol includes executive regulations, the list of health indicators, vocabulary and a calendar for periodic studies of the community health situation.

Regional Odontodysplasia: Report of a case.

Regional odontodysplasia is a rare dental anomaly affecting both primary and adult dentitions in the maxilla or mandible or both jaws, whilst involvement of the maxilla is more common [1-2]. In most cases, one quadrant is affected. One of the characteristics of this anomaly is discolored and soft teeth that can be accompanied by swelling or abscess. In this anomaly, enamel and dentin are thin and hypoplastic, therefore, the teeth give the impression of "ghost teeth" [2, 8]. In radiography, the delineation between enamel and dentin is not clear and pulp chamber is wide. Histologically, areas of hypocalcified enamel are observed and the enamel prisms appear to be irregular in direction [2]. There is a disturbance in dentin formation and dentinal tubules are reduced in number. The etiology of regional odontodysplasia is still unknown [8]. Managements of these cases should be based on the esthetics and functional needs as well as the degree of involvement. This report describes a case of regional odontodysplasia in a 3.5 year old Iranian girl whose chief complaint was the abscess formation in the left maxillary primary molar region. This case study aims to report the clinical and radiological findings of the current case.

The Effect of Service Quality on Patient loyalty: a Study of Private Hospitals in Tehran, Iran.

BACKGROUND: Service quality is perceived as an important factor for developing patient's loyalty. The aim of this study was to determine the hospital service quality from the patients' viewpoints and the relative importance of quality dimensions in predicting the patient's loyalty. METHODS: A cross-sectional study was conducted in 2010. The study sample was composed of 943 patients selected from eight private general hospitals in Tehran. The survey instrument was a questionnaire included 24 items about the service quality and 3 items about the patient's loyalty. Exploratory factor analysis was employed to extracting the dimensions of service quality. Also, regression analysis was performed to determining the relative importance of the service quality dimensions in predicting the patient's loyalty. RESULT: The mean score of service quality and patient's loyalty was 3.99 and 4.16 out of 5, respectively. About 29% of the loyalty variance was explained by the service quality dimensions. Four quality dimensions (Costing, Process Quality, Interaction Quality and Environment Quality) were found to be key determinants of the patient's loyalty in the private hospitals of Tehran. CONCLUSION: The patients' experience in relation to the private hospitals' services has strong impact on the outcome variables like willingness to return to the same hospital and reuse its services or recommend them to others. The relationship between the service quality and patient's loyalty proves the strategic importance of improving the service quality for dragging and retaining patients and expanding the market share.

Malaria Status in Economic Cooperation Countries; Achievement and Gaps toward United Nations Millennium Development Goals.

BACKGROUND: Evaluating the malaria status of the Economic Cooperation Organization (ECO) member countries relation to goal 6 of 3rd Millennium Development Goals (MDGs) which includes have halted by 2015 and begun to reverse the incidence of malaria. METHODS: By 2009, we reviewed the MDGs reports, extracted the data from surveillance system, published, and unpublished data. The main stakeholders, from both governmental and international organizations in the country have been visited and interviewed by the research team as part of the data validation process. RESULTS: The malaria incidence is very heterogeneous among ECO countries, which differ less than 200 cases in total country in Kazakhstan, Kyrgyzstan, Turkey, Turkmenistan, Uzbekistan, and Azerbaijan to 82,564 cases (2,428/100,000) in Afghanistan and 59,284 cases (881/100,000) in Pakistan and about 18/100,000 in Iran in 2008. Malaria has been a major public health problem in Pakistan and Afghanistan and will continue to pose serious threat to millions of people due to poor environmental and socioeconomic conditions conducive to the spread of disease. The main malaria endemic areas of Iran are in southeastern part of the country; consist of less developed provinces that are bordered in the east by Afghanistan and Pakistan. There are little valid information about proportion of population in malaria-risk areas using effective malaria prevention and treatment measures indicators. CONCLUSION: All ECO countries could achieve MDGs malaria indicators by 2015 except Pakistan and Afghanistan, unless preparing urgent intervention programs to fulfill the goals.

Estimating the frequency and rate of first 50 common types of invasive procedures in iran healthcare system.

BACKGROUND: The aim of this study was to estimate the frequency and rate of the first 50 common types of invasive procedures in Iran. METHODS: Data about the number of all invasive procedures and each type of procedure that were conducted in Iran in 2010 were collected using the main insurance organizations database. These numbers were sorted in an excel database, and the first 50 invasive procedures with the most common frequency were selected. Then according to the population covered by the given insurance organizations, and based on the total population of Iran in 2011, we estimated the number and rate of each invasive procedure for the selective procedures. RESULTS: It was estimated that a total of 769,500 (1,026 per 100,000 population) natural vaginal delivery (NVD) was performed in Iran in 2011, followed by 416,790 cataract operation (556 per 100,000 population), 401,436 cesarean delivery (535 per 100,000 population), 260,514 coronary angiography disease (347 per 100,000 population), 181,836 varicocele (242 per 100,000 population), 144,918 appendectomy (193 per 100,000 population), 134,766 rhinoplasty (180 per 100,000 population) and 105,912 pilonidal cyst (141 per 100,000 population). CONCLUSION: The result could be used to identify and select the most frequent invasive procedures in Iran, to calculate the average cost of each procedure and to use these costs to estimate hospital budget and improve policy-making.

Knowledge, attitudes and practices regarding malaria control in an endemic area of southern Iran.

Iran is in the malaria pre-elimination stage. In this situation community based strategies are important for malaria control. In order to intensify elimination activities we need to have a better understanding of the knowledge, attitudes and practices (KAP) of malaria prevention in the community. We carried out a KAP study in one malaria endemic district in southern Iran in 2009 using a structured questionnaire. Five villages with indigenous malaria cases during the previous year and a high potential for anopheline mosquito breeding were selected. All the households in each village were visited and the head of the household or other responsible adult was interviewed. Data were analyzed using SPSS 11.5. A total of 494 respondents from the five villages participated. More than 33% of people in the study area were living in sheds with poor facilities. The illiteracy level of the studied population was high (44.2%) and significantly affected the knowledge and practices of the respondents about malaria control (p<0.05). Descriptive analysis showed significant differences between sex, job and history of malaria infection of the respondents and their knowledge and practices about malaria control (p<0.05). Knowledge of the respondents about the route of transmission in malaria was good; 72.1% knew mosquitoes were the vector. Most people knew at least one symptom of the disease. The practices of respondents were 59.5% for bednet use and 9.3% for screening windows. The knowledge, attitudes and practices of respondents in this survey about malaria control were good in some cases, but in general needed to be improved with educational programs.

Patients' Perspectives on Factors that Influence Diabetes Self-Care.

BACKGROUND: Although diabetes mellitus is of high concern in Iran, and the level of control is unacceptable, few qualitative studies have been carried out to reflect the experiences of patients on the barriers and motivators to self-care. This study aimed to explore a culturally based experience of Iranian diabetic patients regarding the personal and environmental barriers to and facilitating factors for diabetes self-care. METHODS: Six focus groups were conducted among type 2 diabetic patients in the Charity Foundation for Special Diseases' diabetes clinic. Purposeful sampling was used. Newly diagnosed patients (less than six months) and all type 1 diabetic patients were excluded. Three focus groups were held on for each sex. A total of 43 patients participated in the study. Frame-work analysis was used to extract the themes from the data. RESULTS: DATA ANALYSIS SHOWED FIVE MAIN BARRIERS: physical barriers (such as physical effects of diabetes); psychological barriers (such as health beliefs); educational barriers (such as lack of knowledge about diabetes); social barriers (such as group pressure); and care system barriers (such as service availability). Along with the barriers, there were some motivators that the participants mentioned as a stimuli to control their diabetes. They include beliefs about diabetes, perceived responsibility for family, religious beliefs, and the views of significant others. CONCLUSION: Culturally based interventions are needed to improve diabetes care management in Iran. In addition to personal factors, diabetes health educators should pay attention to the environmental factors when they develop programs.

Assessing health system responsiveness: a household survey in 17th district of tehran.

BACKGROUND: Responsiveness is an indicator by WHO to evaluate the performance of health systems on nonmedical expectations of consumers. This study measures the health system responsiveness and the factors affecting responsiveness in Iran health system. METHODS: World Health Survey (WHS) questionnaire was used to collect data on a two-stage cluster sampling in 17th District of Tehran in 2003. Of a sample of 773, 677 and 299 individuals who respectively had outpatient or inpatient services utilization responded to the responsiveness module of WHS questionnaire. RESULT: More than 90% of respondents believed that responsiveness issues were very important. Performance of outpatient services was better than hospital services in terms of responsiveness. "Prompt attention" and "quality of basic amenities" received low score for outpatient services. Service user variables had no significant effect on responsiveness, while type of centers was significantly related to responsiveness. Principal component analysis found three factors for both outpatient and inpatient services that explained 62% and 61% of total variances respectfully. CONCLUSION: Iran health system should pay more attention to responding non-medical expectations of service users. It sounds that health system interventions are main determinant of responsiveness score compared to demographic or user variables. Training health staff, allocating more resources and reengineering some processes may play a role in improving responsiveness. Responsiveness domains seems to be tailored based on each society's cultural factors.

Patients' length of stay in women hospital and its associated clinical and non-clinical factors, tehran, iran.

BACKGROUND: Length of Stay (LOS) is an appropriate hospital indicator to evaluate hospital resource utilization rate, efficiency, and quality of services delivered. In this survey, we aimed to study hospital LOS and determine its association with clinical and non-clinical factors in Women Hospital in Tehran. METHODS: In this cross-sectional study, we reviewed all 3421 charts of patients admitted in Oncology, Surgery and Obstetrics units in 2008. We used a data collection sheet and conducted interviews to collect the following data: distance from living area, medical insurance coverage types, admission and discharge months, days and times, inpatient units, final diagnoses and the number of diagnostic tests. RESULTS: The overall median of the LOS in the studied hospital was 50.8 hours. The medians were 48.5, 54.4, and 94.2 hours in the Obstetrics, Surgical and Oncology units, respectively. Results showed that the associated factors with the LOS were patient admissions on Thursdays, admitting by residents, the number of performed diagnostic tests (p<0.001), suffering from neoplastic diseases (p=0.005) and spouse jobs. CONCLUSION: Among the associated factors, policy makers and managers can only change the admission days and the number of diagnostic tests to decrease the LOS. Further researches are needed to find other factors associated with LOS.

What do patients expect from their physicians?

BACKGROUND: To identify the most important expectations that patients have from their physicians. METHODS: We collected data from 199 hospitalized and 201 ambulatory patients (response rates 88% and 93% respectively). We used random sampling for selection of hospitalized patients and systematic sampling for the ambulatory ones. The questionnaire consisted of 18 different expectation items categorized in 5 domains. The participants scored each item from 1 to 9 using a VAS scale and ranked domains based on their importance. We analyzed the data using univariate and regression analyses. RESULTS: Among the ambulatory patients, the mean±standard error of the most important expectations was as follows: competency (8.9±0.01), courteousness (8.8±0.04), consultation in case of need (8.8±0.4), clear explanation of the disease (8.8±0.05) and attentiveness (8.8±0.04). In hospitalized patients, the following items were the most important: competency (8.4±0.08), courteousness (8.4±0.09), availability of physician (8.4±0.09), consultation in case of need (8.2±0.11), setting following appointments (8.2±0.1), and disease follow-up (8.2±0.09). In both groups, the most important domain of expectations was "competency and quality of care" followed by "availability" in hospitalized and "giving information and patient autonomy" among ambulatory patients. CONCLUSIONS: Our findings are similar to what reported in the literature from other countries and cultures. In addition to physician expertise and knowledge, patients value giving information and efficient doctor-patient relationship.

Iranian Female Adolescent's Views on Unhealthy Snacks Consumption: A Qualitative Study.

BACKGROUND: Given the increasing prevalence of obesity among Iranian adolescents and the role of consumption of unhealthy snacks in this issue, interventions that focus on factors influencing food choice are needed. This study was designed to delineate factors associated with unhealthy snack use among female Iranian adolescents. METHODS: The theory of Planned Behavior served as the framework of the study. Qualitative data were collected via nine focus group discussions in two middle schools (6(th) to 8(th) grades) in a socio-economically diverse district in the city of Tehran in spring 2008. The study sample included 90 female adolescents aged 12-15 years. The sampling strategy was purposive method. Data analyzed using the "framework" method. RESULTS: Major factors identified by the respondents were taste, peer pressure, parental influence, easy access to unhealthy snacks, limited availability of healthy snacks, appeal of snacks, habit, high price of healthy snacks, and media advertisements. Nutritional value and healthiness was not one of the first priorities when buying snacks, as adolescents thought it was too early for them to worry about illness and adverse consequences of eating junk foods. CONCLUSIONS: For developing culturally sensitive evidence-based interventions that can motivate adolescents to choose healthy snacks, a broad range of factors should be taken into account.