What competencies do environmental health graduates need to manage social determinants of health?

BACKGROUND: Graduates of environmental health engineering should be able to manage Social Determinants of Health (SDH) and acquire the essential competencies during their studies at university. This study was performed to determine the expected competencies of environmental health graduates in a way to be able to manage environmental and Social Determinants of Health according to their job description. METHODS: This descriptive cross-sectional study was performed using Delphi technique. First, the literature review was done and the Delphi technique was performed in three rounds. The purposeful sampling was used and 50 people were selected among the specialists in the field of environmental health engineering and SDH. Participants answered an open-ended question, for the first round. Then, a questionnaire with 8 areas was designed based on the results of the first round and distributed for the second round. Data analysis was performed using descriptive statistics. The third round was done to reach the agreement on final items. RESULTS: The agreement on the items of the third round of Delphi was more than 70%. The final results showed eight competency areas under which 29 competencies were defined. Competency areas included expert knowledge, reasoning and planning, advocacy, system-based practice, professionalism, instructional expertise, social and personal skills and, research and self-development. The first three priorities of the required competency areas were expert knowledge (4.46 ± 0.55), professionalism (4.42 ± 0.64), and advocacy (4.32 ± 0.77). CONCLUSIONS: It is necessary that environmental health engineers achieve necessary competencies regarding managing SDH, upon their graduation. It is suggested to integrate these competencies into the curriculum of environmental and health engineering in Iran universities.

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.

Joint Disease Mapping of Breast, Uterine, and Ovarian Cancers in Cities of Isfahan Province from 2005 to 2010 Using Spatial Shared Component Model.

BACKGROUND: Breast, uterine, and ovarian cancers are the most prevalent types of cancers among women. The aim of this study was to estimate the relative risk of these cancers and recognizing spatial patterns of their shared and specific risk factors in cities of Isfahan province, one of the most populated provinces of Iran, using spatial shared component model. METHODS: In this ecological study, the population consisted of all the registered patients having breast, ovarian, and uterine cancers in the cities of Isfahan from 2005 to 2010. In order to simultaneously analyze these diseases and clarify common and specific patterns of disease, spatial Shared component model was applied. Model fitting was done using Bayesian inference in OpenBUGS software. RESULTS: The highest relative risk of breast cancer was seen in Isfahan (4.96), Shahreza (2.37), Dehaghan (5.01), Lenjan (2.33), and Najafabad (2.68), respectively. For ovarian cancer, Isfahan (4.29), Shahreza (2.51), Dehaghan (5.02), Lenjan (2.06), Najafabad (2.00), and Borkhar (2.39) had the highest relative risk, respectively. However, no significant difference was seen among the cities for uterine cancer (P > 0.05). CONCLUSIONS: Since ovarian and uterine cancers are the less prevalent disease in comparison with breast cancer, the preciseness of these estimates were improved remarkably over simple mapping models. Based on this model, the estimates were done according to the correlation between the diseases. After recognizing the spatial patterns of the shared and specific risk factors and reviewing of previous studies, regardless of risk factors data, environmental pollution arises as a potential risk factor.

Evaluating the responsiveness of higher education system in relation to social determinants of health.

BACKGROUND AND AIM: To answer the society's health-care needs related to social determinants of health (SDH), higher education system must be responsive in training knowledgeable students and faculty members. Therefore, this study was carried out to determine the responsiveness of higher education system in relation to the SDH. METHODS: This is a content analysis study carried out using qualitative approach. Semi-structured interviews were used to gain access to the knowledge of experts in the fields of health care, education, and SDH. Sampling was carried out until data saturation was achieved during which 15 experts were selected using purposeful sampling method with highest possible variety. Data were categorized using qualitative content analysis approach. RESULTS: In total, 11 themes and 43 categories of codes were identified in semi-structured interviews with experts. A total of two approaches were identified for the training of responsive students including educational-research approach and cultural-social approach; five approaches were identified for the development of faculty members including cognitive development, executive development, evaluation, promotion and incentives, and revisions; two approaches were identified for provision of theoretical and practical education including education in a real and active environment and structural education; and finally, two approaches were identified for evaluation of students and faculty members in regard to their responsiveness to society's health needs and SDH including content and operational approaches. CONCLUSION: In general, the results of the current study indicate the need for the higher education system to use educational, research, and society-based approaches in real and social environments along with an incentive system and use of evaluation for responsiveness to society's health needs and SDH. These results can be useful for the health-care system and the higher education system.

Outsourcing in Health Facilities: Challenges in Medical University of Isfahan in Focus.

INTRODUCTION: Outsourcing is one of the major strategies for keeping competitive gain in today's highly varying markets, especially in health systems. This study endeavored to identify operational challenges of outsourcing health facilities affiliated to Isfahan University of Medical Sciences in the academic year 2019. METHODS: This qualitative study was conducted with content analysis approach. To conduct the interview, key informants were from the managers of health facilities and decision makers of health deputy and managers from private sector were selected through purposive sampling. The saturation point was reached at 12 semi-structured interviewees; this way, data were collected through interviews with experts. A thematic analysis was employed to analyze the transcriptions by MAX QDA10. RESULTS: According to the results of thematic analysis, seven major themes identified as operational challenges of outsourcing health services in health facilities with 40 sub-themes. CONCLUSIONS: Outsourcing health services in health facilities needs to be done more scientifically and logically. Decision makers must predict the challenges and apply solutions before outsourcing, supervise, and evaluate the impacts of outsourcing after at least 1 year.

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.

Investigating the service provision challenges by healthcare providers in selected comprehensive health centers.

INTRODUCTION: The healthcare program has opponents and supporters with its multiple policies and also its difficult implementation, which requires that its barriers and problems be addressed comprehensively and extensively. This study was conducted aimed to determine the service provision challenges by healthcare providers, from their point of view, in selected comprehensive health centers of Isfahan. MATERIALS AND METHODS: The present study is a descriptive-analytic one. One-hundred and ninety-seven healthcare providers were selected by census sampling method from the population of female healthcare providers in Isfahan comprehensive health centers in 2017. The data collection tool was a researcher-made questionnaire in the field of individual-professional, managerial-organizational, and executive challenges. Data analysis was done by repeated measures ANOVA and post hoc test. RESULTS: The findings indicated that there was a significant difference between the mean score of individual-professional, managerial-organizational, and executive challenges (P < 0.001) from the point of view of healthcare providers. According to least significant difference post hoc test, the mean score of individual challenges was significantly lower than that of managerial and executive challenges (P < 0.001). However, there was no significant difference between the mean score of managerial-organizational and executive challenges (P = 0.46). CONCLUSION: Based on the results, healthcare providers have put forward several challenges during the implementation of the healthcare program. Meanwhile, executive and managerial challenges have been considered more than individual challenges. Considering that this could lead to improper service provision to the clients, the role of policymakers in this program to remove obstacles and to provide satisfaction to healthcare providers is emphasized.

Death Portrait of Isfahan Province in Years 2007-2011.

BACKGROUND: The rapid rise in noncommunicable diseases (NCDs) is one of the main health challenges affecting the global development in the present era. This raising challenge is a major threat to countries' socioeconomic development as well as millions of people health. METHODS: It was a retrospective study with analysis of reported death in Isfahan Province during a 5-year period from 2007 to 2011. Required data were collected from statistics provided by Deputy of Health in Kashan and Isfahan Universities of Medical Sciences in 2012. Excel software was used for data analysis. RESULTS: During this period, the cardiovascular events, cancers and tumors, unintentional injuries, respiratory diseases, and prenatal mortality were the main reasons of mortality in Isfahan Province. The overall rate of cardiovascular events rose 5.10% in the 5-years of the study observation, and Khor - Biabanak was on the top of the list; while in cancer rating Khor - Biabanak, Golpayegan, and Khansar both stood at the outset (per 1,000 people). For injuries, the highest rate belonged to Golpayegan, Tiran-Kervan, and Chadegan. Meanwhile, for mental illnesses, the highest rate was observed in Khomeini Shahr. Moreover, the highest maternal and fetal mortality was reported in Fereydunshahr, Khor - Biabanak and Mobarakeh. CONCLUSIONS: Given the sharp rise of NCD, programs by health care system should be directed toward lifestyle modification while a proper framework should be determined to deal with these kinds of disease. Furthermore, optimal allocation of resources based on needs can provide better facilities for different cities.

Women health heart project: Methodology and effect of interventional strategies on low education participants.

BACKGROUND: Cardiovascular diseases (CVD) are the most common cause of mortality and morbidity in women. Intervention programs aimed at improving the lifestyle can reduce the incidence of these diseases and their factors. The purpose of this study was to evaluate the difference of the interventions impact on CVD risk factors and the women's physical and biochemical indicators based on education levels. MATERIALS AND METHODS: As part of Isfahan Healthy Heart Program after identifying the status of women over the age of 18 and over five years, a large educational or environmental intervention was performed in different methodologies and in order to improve the lifestyle. Some organizations such as health care centers and the Literacy Campaign Organization have cooperated for low educated women. Demographic data and risk factors such as obesity, hypertension, diabetes and serum lipids were investigated and compared during the first and last phase. Data were entered in SPSS-15 software and were analyzed by using T-test in two independent samples, Chi-square test and Fisher exact test. RESULTS: Findings of this study showed that performing the five years interventions could reduce physical and biochemical indexes such as nutrition, lipid profile, waist circumference and waist-to-hip ratio in both groups (P < 0.005). In the pre-intervention phase, 6391 subjects and after the intervention 4786 women participated. After Interventions, women with higher educational levels were showed significant decrease in Body Mass Index (BMI) (P = 0.01) and dyslipidemia (P = 0.02). CONCLUSION: The present study showed that the community-based interventions even in low-literate women could cause effective changes on improving lifestyle and CVD risk factors. Due to the greater impact of interventions in literate women, effective interventions should be considered in the society to decrease the prevalence of Non-Communicable Diseases (NCDs).

Reviewing the effectiveness of pre-pregnancy counseling protocol on pregnancy and labor indices.

BACKGROUND: Pre-pregnancy care is considered as the services assessing and reducing the pregnancy risks through providing medical care and mental support. Therefore, a pre-pregnancy counseling protocol was prepared based on a series of guidelines. This study aimed to determine the effect of the protocol on pregnancy and labor indices. METHODS: This was a four-phase field study conducted in four randomly selected urban and rural health centers in Shahreza. In the first phase, the information including pregnancy and labor indices was extracted. The participants were all the women who had a delivery in the year before the study (census). In the second and third phases (3 and 6 months after implementing the protocol in the case centers), the process of implementing the protocol was assessed. In the fourth phase (a year later), pregnancy and labor indices were determined in case and control centers (on all the women who had labor in the year before) again and the results were compared in case and control groups as well as before and after implementing the protocol. Data was collected by reviewing documentations and using data collection forms. It was then analyzed by descriptive and analytical statistics using SPSS13. RESULTS: The obtained results indicated the positive effects of pre-pregnancy cares on cesarean indices, percentage of underlying diseases, pregnancy over the age of 35, and pregnancy intervals of less than 3 years. In addition, the protocol had been implemented correctly in 8.2% of the cases in the second phase, and in 30.2% of the cases in the third phase. CONCLUSIONS: The positive effects of pre-pregnancy cares on some of the indices raised the necessity of seriously considering and integrating this program in the routine women's health care programs. Considering that less than one-third of the staff members of the case centers had completely conducted the pre-pregnancy cares, monitoring the staff's performance is essential for improving the effectiveness of the care.

Do Intervention Strategies of Women Healthy Heart Project (WHHP) Impact on Differently on Working and Housewives?

BACKGROUND: The purpose of this study is to evaluate the possible difference of the impact of Women Healthy Heart Project on lifestyle, as well as physical/biochemical parameters of working women and housewives. METHODS: This was a community-based intervention study conducted over 5 years (2002-2007) in the counties of Isfahan and Najafabad (intervention areas) and Arak (control). Pre-study situation analysis of women was followed by 5 years of wide-ranging interventions (educational/environmental) conducted by various organizations using different methodologies. The interventions were aimed at modifying/improving lifestyle by increasing physical activity, encouraging healthy eating, and tobacco use cessation. The organizations involved in performing the interventions included the local radio and television authority, health/treatment centers, the Red Crescent Society, Municipalities, the Relief Committee, the Center for Retirees' Welfare, and the Literacy Campaign Organization. After 5 years, final phase same as first phase was planed. The subjects studied in all phases' the pre- and post-intervention phases consisted of 10586 women aged above 18 years. Demographic data, obesity index, smoking, physical activity and eating habit were assessed before and after the study. Data were analyzed using SPSS-15 using Student's t-test, chi-square test, the general linear model of ANOVA, and logistic regression. RESULTS: We studied 10586 women (6105 and 4481 women, pre- and post-intervention, respectively). Mean age of working women was 34.14±10.09 and 34.08±9.35 years before and after the study, respectively. Mean age of housewives before and after the study was 40.05±14.61 and 40.36±15.32 years, respectively. Interventions conducted during 5 years improved eating habits and decreased tobacco use in working women and housewives. In every phase of the study, there was a significant age difference between housewives and working women (P<0.001). Hence data were adjusted according to age in each phase. Overall physical activity of housewives and working women increased, but the percentage of passive smokers among housewives remained unchanged. Waist circumference and waist-to-hip ratio changed significantly in housewives following interventions (P<0.001). The parameter which improved significantly in working women was waist circumference (P<0.05). However, after adjusting for age, no significant difference was seen between working women and housewives following interventions. CONCLUSION: Community-based interventions, especially those directed at housewives, can lead to significant improvements in lifestyle and cardiovascular risk reduction. It seems that working women require tailored interventions to suit their conditions. Although short-term outcomes may seem insignificant, persistence and continuity of lifestyle changes may lead to reduced prevalence of cardiovascular diseases. Then longer-term studies are warranted.