Journal of School of Public Health and

---

Background and Aim: Economic evaluation of health interventions is critical for efficient allocation of resources. The aim of this study was to critically review empirical studies on the cost-benefit of health interventions published over the last 40 years.

Materials and Methods: This study was carried out by searching seven  databases (PubMed, Cochrane Database of Systematic Reviews, Web of science, Science Direct, Scopus, Springer Link, and SID) using appropriate keywords to find articles on the cost-benefit of health interventions published during 1975-2015. All the relatedretrieved articles were analyzed after quality assessment using a valid check list.

Results: A total of 33studies on the cost-benefit of health interventions during the last 40 years were included in the review; 39%, 37%, 21% and 3%of the studies had been conducted in Asia, America, Europe and Africa, respectively. The subjects dealt with in most ofthe studies (79%) were related to immunization, education, healthy nutrition and use of health technologies. Further analysis of the data showed mental health education, healthy nutrition, use of safety equipment while driving, vaccination, diagnostic and screening tests, and oral and dental healthto have considerable clinical and economic benefits.

Conclusion: The number of studies on the cost-benefit analysis of health interventions is increasing. Preventive and promotive interventions can help planners and policy-makers to better utilize the limited resources in the health sector aiming at promoting health of the people.

---

Background and Aim: This study was conducted to identify deterrents to women's participation in sport activities in Alborz Province, Iran.  

Materials and Methods: This was a descriptive field study. The statistical population was all the working women in Alborz province, Iran, approximately 100000, from among whom a random sample of 384 was drawn based on Morgan table. A standard questionnaire designed with 31 5-choice items, whose reliability had been determined (Cronbach Alpha coefficient 90%), was used for gathering data. The deterrent factors for participation of the women in sports were determined in six areas, namely, cultural and social; economic; specialist manpower; family attitude; equipment and facilities; media and advertisement. The descriptive demographic data on the subjects (age, educational field, etc.) were first analyzed using the SPSS software, followed by nonparametric analysis using the Friedman and Kruskal- Wallis tests to prioritize questionnaire items as well as compare priorities in various age groups.

Results: Organizational life creates mental pressure, stress and tiredness in the work environment. Furthermore, women working in an organization are faced with restrictions in many areas, especially as regards participation in sport activities and programs. The resulting immobility among girls and women would mean physical and mental health deprivation, as well as unhappiness and low work efficiency, of an important segment of the society, which would lead to irreparable damage to the whole society.

Conclusion: Based on the findings it can be concluded that the most important deterrent factors for participation of working women in sport activities in Alborz Province are economic factors and equipment and facilities.  Family attitude was found to be the least important deterrent. 

---

Background and Aim: Health literacy implies the achievement, processing and perception of fundamental information and services required for making appropriate health-related decisions. Due to the high significance of health literacy during pregnancy and its direct effect on fetus, the present research was conducted to investigate the health literacy of pregnant women visiting medical centers in Bandar Abbas, Iran in 2015.
Materials and Methods: This was a cross-sectional descriptive-analytic study conducted on 250 pregnant women visiting the healthcare centers in Bandar Abbas, Iran selected by mixed sampling (both clustering and simple random). The data were collected using an adult health literacy questionnaire and analyzed using SPSS version 16, the statistical tests being independent-sample t-test, ANOVA, Tukey test and linear regression.
Results: The average age of the pregnant women was 31.61±7.45 years. The proportions of the women with an adequate, borderline and inadequate level of literacy were 52%, 20.8% and 27.2%, respectively. A statistically significant association was found between health literacy and education (p<0.001), age (p<0.001), occupation (p<0.001) and the quality of healthcare provision during pregnancy (p<0.001).
Conclusion: The results reveal that the mothers’ health literacy is inadequate or at borderline. Based on these results the following are recommended in an attempt to promote health literacy of pregnant women: 1. revising/simplifying teaching materials, including both oral and pictorial, in addition to written materials in the form of posters, pamphlets and brochures; 2. promoting communication skills of health workers/mothers.   
 

---

Background and Aim: Self-care has a vital role in the control and prevention of complications in patients with Type-2 diabetes mellitus (T2DM), two important behaviors in self-care being medication adherence and physical activity. Regular physical activity has been shown to improve glycemic control, reduce blood pressure, reduce lipids and improve cardiorespiratory fitness in individuals with T2DM. In addition, medication adherence is a key factor in controlling and decreasing the risk of related complications. This study aimed to determine and predict the most important factors affecting the levels of physical activity and medication adherence in patients with T2DM based on the theory of planned behavior.

Materials and Methods: This cross-sectional study, based on the planned behavior theory, was performed on 160 selected men and women with T2DM referring to urban health centers in Yasuj, Iran in 2016; the selection was done by random cluster sampling. Data on medication adherence and physical activity were collected using questionnaires and analyzed using SPSS version 20 software, the statistical tests being descriptive statistics, Pearson correlation coefficient and multiple linear regression; a p<0/05 was considered to indicate statistical significance.

Results: Altogether, 45% and 43% of the patients had a low and medium level of physical activity, respectively, only 12% having an acceptable level. The adherence to medication was much better ─ 76% had a good adherence. As regards the planned behavior theory constructs, perceived behavior control had a significant relationship with physical activity and medication adherence. Results of multiple linear regression also showed that perceived behavior control was a predictive variable for physical activity level and medication adherence in the patients.

Conclusion: Based on the findings, which indicate that the most important construct is perceived behavior control as regards medication adherence and level of physical activity, it is concluded that it is vital to strengthen the self-care component of health programs and support such programs.

---

Background and Aim: Quality management, as an organizational strategy, helps enhance hospital effectiveness and efficiency. This study aimed to examine the effect of a quality management model on the efficiency of the respiratory intensive care unit in Labafijejad Hospital, Tehran in 2013-14.
Materials and Methods: This was a participatory action research conducted  in  the respiratory intensive care unit in Labafijejad Hospital, Tehran in 2013-14. A quality improvement team was formed to implement the quality management system and promote working processes.  The team identified and standardized working processes, determined the quality goals for the processes, and improved the processes based on the 10-stage Mosaddeghirad Quality Management model. Performance indicators of the unit  (bed occupancy, bed turnover, and bed interval rates;  patient average length of stay in the ward) were calculated and compared before and after the intervention.
Results: Implementing quality management brought about an increase of 2.8% and 19.2% in bed occupancy rate and bed turnover rate, respectively, as well as a decrease of 14.1% in patient average length of stay and a decrease of 35.6% in bed interval rate in the respiratory intensive care unit of the hospital.
Conclusion: Implementing quality management can increase the efficiency of the respiratory intensive care unit of a hospital. A suitable quality management system and the commitment of the hospital manager and staff can result in enhancement of efficenicy in a hospital.
 

---

Background and Aim: Hospital accreditation is a systematic external evaluation of a hospital’s structures, processes and results (outputs/ outcome) by an independent professional accreditation body using pre-established optimum standards. This study aimed to examine the relationship between accreditation and hospital performance. In addition, the most important accreditation constructs affecting hospital performance were identified and ranked.
Materials and Methods: This descriptive, correlational and cross-sectional study was conducted using the data related to accreditation scores and nine performance indicators of 121 hospitals in 2014 and 123 hospitals in 2015 in Tehran province, Iran. Shannon entropy method was used for calculating the weights of the hospital indicators. Then, Feature Selection method in data mining was used to explore the relationship between accreditation scores and hospital indicators. Data were analyzed using IBM SPSS Modeler software. Analyses were carried out at the 0.05 significance level
Results: The mean of hospitals’ accreditation scores were 61.98% and 69.56% in 2014 and 2015 respectively. All performance indicators except the number of outpatients were increased in 2015 compared to 2014. There was no significant difference in the scores between 2014 and 2015 data. Hospitals’ accreditation scores were not associated with their performances. However, accreditation scores of leadership and management; accident and emergency; and procurement departments had the most effect on hospitals’ performance.
Conclusion: Accreditation was not correlated with hospital performance. Thus, improving accreditation system including standards, methods and surveyors and using quality management strategies in hospitals are necessary for improving hospital’ performance.
 

---

Background and Aim: Diabetes mellitus is one of the most prevalent and important health problems in the world.Considering the high prevalence of metabolic syndrome in diabetic patients and the potential effects of its components on HbA1C in these patients, the present study was conducted to determine the effect of metabolic syndrome components on HbA1C in type-2 diabetic patients.
Materials and Methods: This retrospective cohort study was conducted on 157 diabetic patients regularly referring to the Diabetes Control Center in Qazvin City during 2014, where complete data about theirmetabolic syndrome components, as well as HbA1C levels were available. The data were analyzed using multiple linear regression (α=0.05 for statistical significance).
Results: Based on the regression model, the effects of age, HDL-C and fasting blood glucose on HbA1C were statistically significant; the effects of other variables were nonsignificant. The R²value for the variables entered for prediction of HbA1C was found to be 0.45 (R² = 45%).
Conclusion: Considering the significant relationship between some components of the metabolic syndrome such as HDL-C and fasting blood glucose on HbA1C in diabetic patients, it is essential to design and implement programs to reduce the level of HbA1C in these patients.

---

Background and Aim: Developing appropriate programs for community problem solving and community development and prosperity will be possible only after realistic identification of the community’s problems. Community health assessment is a process by which researchers and community members understand the health care system and community concerns through data collection and analysis, determining strengths and weaknesses and defining the community’s resources and demands. Basmenj is a town located 10 kilometer from the metropolitan City of Tabriz, Iran and on the verge of adjoining this metropolis. This paper reports results of the community assessment of this town.
Materials and Methods: This study was conducted in autumn 2017. The methodology used for community assessment was based on the eight-stage model of North Carolina. In the first seven stages the Basmenj community problems were identified and prioritized, followed, in the eighth stage, by developing an action plan for solving the problems in order of priority.
Results: Approximately 100 different problems were identified at the end of the first stage. Based on the Hanlon classification model, the top prioritized problems of the region were found to be, in that order, youth addiction, urban trashes, stray dogs, environmental pollution caused by Pars Color Company, narrowness of the main street, inner-city livestock farming, early marriage among girls, wastewater problems, youth unemployment, and high consumption and self-administration of anti-biotics.
From among these problems, the urban trashes problem was studied briefly. Factors playing a role in its causation were found to be as follows: lack of waste reduction and waste sorting programs, low citizens’ knowledge about trash gathering, absence of an appropriate urbane wastewater system, and, finally, lack of participation of citizens and the private sector in trash gathering and burying
Conclusion: A wide range of social, cultural and economic problems was identified.  The top priority was found to be focusing on problems related to urban trashes. However, it should be noted that solving all the community problems identified requires the co-operation and support of all the governmental organizations, as well as involvement of the community at large.

---

Background and Aim: Condom use in extramarital sexual relations is a major tool, protecting the two partners against venereal diseases. Therefore, it is essential to investigate this matter. This study aimed to determine the reasons for using and not using the condom by the Iranian youth
in their extramarital sexual relations and the related cultural issues.
Materials and Methods: This was a national cross-sectional survey using multistage sampling in 13 provinces in Iran, including 3246 participants 19-29 years old, conducted in 2014, using a questionnaire to collect data.
Results: The proportion of males in the sample was 51% and that of females 49%. On the whole, 19.5% of the participants (31.7% of the males and 6.9% of the females) had had extramarital sex relations. The proportions of the participants with a history of extramarital sex using the condom at every intercourse, almost at every intercourse, sometimes and never were 21.7%, 15.4%, 35.3% and 27.6%, respectively. The reasons for not using the condom regularly were unavailability of the condom, not liking it, its high price, it not being necessary and using other tools.
Conclusion: The major reasons for not using the condom had cultural roots or were related to personal and cultural preferences. Encouraging condom use widely would require appropriate cultural policy-making

---

Background and Aim: Burn injuries cause severe devastating losses and early death. Care and treatment of burns patients is very costly. The purpose of this study was to calculate the economic burden of care and treatment of burn injuries in a hospital in Ahvaz, Iran.
Materials and Methods: This descriptive and cross-sectional study was carried out in 2015 in Taleghani Hospital, Ahvaz, Iran. A total of 315 patients participated in the study. Data was collected, using a valid and reliable questionnaire, through interviews with patients or their relatives on the day of discharge and examining their medical records. Data analysis was done using standard statistical tests and the SPSS (V.22) software.
Results: The mean total cost of care and treatment of an inpatient with burns was 117,071,803.00 Iranian Rials (equivalent to US$ 4,063.00), the mean daily cost being 8,501,946.00 Iranian Rials (equivalent to US$ 295.00). Direct medical costs, direct non-medical costs and indirect costs accounted for 94.1%, 1.4% and 4.5% of the total cost, respectively. The patients’ out-of-pocket payment was 7.7% of the total direct costs. Surgery, drug and diagnosis costs accounted for the largest fraction of the total treatment cost.
Conclusion: The total cost of care and treatment of burns patients in the hospital is very high, imposed on patients, their relatives, government and health insurance companies. The government and insurance companies should provide financial protection to facilitate the process of care and treatment of burns patients.
 

---

Background and Aim: Iran is experiencing a very fast population ageing, ranking 3^rd globally in terms of pace of population ageing. The increase in the elderly population has been accompanied by an increase in demand for health services. A knowledge and understanding of the utilization of health services by the elderly are essential for resource allocation and health planning. This study aimed to investigate the utilization of in-patient services by the Iranian elderly and explore its determinants.             
Materials and Methods: This study was a secondary analysis of the data of a cross-sectional National Study on the Utilization of Health Services in Iran, including 22470 households across the country. The study population was people aged 60 years and over, the sample size being 8205 individuals selected by stratified random sampling from provinces, towns and villages. A questionnaire was used to collect information on the need of the individuals to hospitalized services during the last one year and receiving the required services and analyzed using multilevel logistic regression to identify the factors related to the utilization of inpatient health services.            
Results: Of the 8205 participants, 1411 (17%) reported that they needed in-patient services at least once during the previous year, about 93% of whom referred to a hospital, of whom about 1288 (97%) finally had finally received the required services. The factors related to inpatient service utilization were age (p=0.03) and having insurance status (p<0.001), such that the older individuals and those with no insurance, although they had higher inpatient service needs, received less services. The most important cause of dissatisfaction in the towns was related to the behavior of nurses and non-physician personnel and in villages long waiting time for receiving a service.  Finally, the most important causes being not willing to be hospitalized were the high service cost and no health insurance coverage.
Conclusion: The older people and those with no insurance should be priority groups in health service utilization policy-making and planning, so that they can access and receive better services. The causes of low inpatient service utilization and dissatisfaction should be taken into consideration seriously by health service providers and managers.                  

---

Background and Aim: Good governance results in better health outcomes for the society thorugh improving health system performance. The governance of Iran health stsyem faces some challenges. Hence, this study aimed to propose and verify a model for strengthening Iranian health system governance.
Materials and Methods: This descriptive study was conducted in 2016 using the Delphi method. A health governance model with six dimentions including sturucture, communication, regulation, policy making and planning, stewardship and evaluation and accreditation has been proposed. Then, the proposed model verified using 25 Iranian healthcare experts’ opinions in two rounds.
Results: Developing an integrated health system model comprising health system enablers and results, downsizing and reducing the number of directorates in ministry of health,determining basic principles for regulation, enhancing communication with other external organizations affecting people health, using more evidence in policy making and planning, developing a strategic plan and national health policy, enhancing leadership, management and stewardship; and developing comprehensive systemic standards for evaluation and accreditation of healthcare organizations are recommended to enhance the effectiveness and efficiency of Iran health system governance.
Conclusion: Iran health system governance faces numerous challenges. Using successful countries’ experience and internal health care experts’ opinions help to reduce the current challenges and achieve health system goals.
 

---

Background and Aim: Salmonella species is one of the important pathogens causing food poisoning and gastroenteritis. The aim of the present study was to assess the quality of traditional creams as regards bacterial contamination.
Materials and Methods: This was a cross-sectional study including a total of 250 traditional cream and 50 pasteurized cream samples collected in the south of Tehran retail shops. The samples were diluted in a phosphate-buffered saline, transferred to a rappaport-vassiliadis salmonella (rvs) enrichment broth according to the CDC procedures and incubated at 37° C in Hektoen enteric agar and bismuth sulfite agar media for 24 hours. Antimicrobial susceptibility testing was done using the Clinical and Laboratory Standards Institute (CLSI) procedures. On the following day the suspected colonies were examined for phenotype and finally confirmed by the API 20 E test.
Results: Of the 250 unpasteurized cream samples 15 (6%) were contaminated with Salmonella. Of the 7 serotypes identified, the most frequent Salmonella serotype was the infantis serotype with 7 cases (33.3%). Furthermore, Coliform bacteria such as Escherichia coli, Enterobacter, Klebsiella and Citrobacter were also isolated. The highest antibiotic resistance was to nalidixic acid (93.3%), tetracycline (73.3%) and trimethoprim (66.7%). None of the pasteurized cream samples was contaminated with Salmonella.
Conclusion: The results confirm the need for more effective control and monitoring of the traditionally prepared cream marketed in the city by the Food Control Authority. In addition, educating the public about the consumption of pasteurized cream can play a good role in reducing foodborne illnesses.

---

Background and Aim: Nowadays foodborne diseases are a serious concern globally. Due to unsound use of antibiotics various pathogens are involved in foodborne diseases, S. aureus being the most common cause of food poisoning. Methicillin-resistant Staphylococcus aureus (MRSA) strains are a serious threat for the public’s health worldwide. The objective of this study was to determine the extent of contamination of foods offered in the South of Tehran, Iran with MRSA strains in 2018-19.
Materials and Methods: In this descriptive study, 560 food samples were collected from different regions in the south of Tehran, Shahr-e-Rey and Islamshahr between June 2018 and May 2019 and sent to a laboratory to determine the presence of S. aureus according to the Iranian National Standard No.1194 methods. In addition, the antibiotic sensitivity of the S. aureus species was determined using the Disk Diffusion Test.
Results: Of the 560 samples, 49 (8.7%) were found to be contaminated with S.aureus. Pastry, traditional ice cream and raw protein foods were the most contaminated foodstuffs. Four 4 (8.2%) of the 49 S. aureus isolates were found to be resistant to methicillin.
Conclusion: Considering the importance of S. aureus in causing food poisoning and the possibility of transfer of species resistant to antibiotics, especially methicillin, through foods, it is vital to pay special attention to sound use of antibiotics.    

---

Background and Aim: One of the dimensions of health is social health. Social health indicates, in a way, the inviolability of the identity aspects of individuals in the community. From among the factors affecting social health, a sense of social security both in its objective and mental dimensions has a particularly significant effect, and also a fundamental impact, on the efficiency of individuals in the society. In this study the relationship between the two variables ─ social security and social health ─ was investigated empirically.
Materials and Methods: This was a quantitative survey including a sample of 400 residents in Lende City, Kohgiluyeh and Boyer-Ahmad Province, Iran in 1398. Data were collected using questionnaires.
Results: The findings showed that there were statistically significant relationships between the sense of social security and social health in most of their domains (P <0.05). Modeling of structural equations between these two variables also showed that the sense of social security with a regression weight of 0.54 had an effect on social health in a way that this variable alone explained 29% of changes in social health, while gender had no effect in this regard.
Conclusion: On the basis of the findings it can be concluded that the sense of social security has significant effects on social health and efficiency of people in the society. Therefore, if a society can protect the identity components of its citizens in its different ethnic, religious, linguistic and national aspects and increase their level of social tolerance, then it will be possible to create better conditions for promoting the social health of individuals in that society.

---

Background and Aim: Rheumatoid arthritis is the most common and most important type of arthritis caused by interaction of genetic, immunologic, psychological and social factors and is accompanied by chronic pains. The aim of this study was to investigate the effectiveness of treatment based on acceptance and commitment to the perception of pain and functional disability of women with rheumatoid arthritis in Khorramabad, Iran.
Materials and Method: This was a semi-experimental study with a pre- and post-test design with experimental and control groups, the statistical population being all the women with rheumatoid arthritis in Khorramabad, Iran. A sample of 40 women were selected using the available sampling method and randomly assigned to either an experimental (n = 20) or a control (n= 20) group. Under similar circumstances a pre-test was conducted using the pain perception and functional disability questionnaires in both groups. Admission- and commitment-based treatment interventions were then performed in the experimental group in eight 90-minute sessions, but the control group did not receive any intervention. At the end, post-tests were done in both groups.
Results: The multivariate and univariate analysis of covariance showed that the intervention based on acceptance and commitment had a significant effect on reducing the patients' perception of pain and functional disability (P <0.001).
Conclusion: Based on the results of this study, it can be said that treatment based on acceptance and commitment can reduce the perception of pain and functional disability in women with rheumatoid arthritis. Therefore, along with medical treatment, this type of treatment can be used to reduce the perception of pain and functional disability of such patients.
 

---

Background and Aim: The health system financing is the process of collecting, pooling and managing financial resources and purchasing healthcare services. Health financing plays an important role in achieving the health system goals and objectives specially universal health coverage. The aim of this study was to strategically analyze the Iranian health financing system and recommend strategies to strengthen it.
Materials and Methods: Using the scoping review method, all published studies about the strengths, weaknesses, opportunities and threats of the Iranian health financing system were searched in eight databases including "PubMed", "Scopus", "Science Direct", "Embase", "ProQuest", "SID" and "Magiran", as well as the "National Database of Medical Science Theses" and two search engines, namely, "Google" and "Google scholar". Finally, 29 studies were selected and analyzed using the framework analysis method and MAXQDA software. 
Results: Extended health insurance coverage, reduced out-of-pocket payments following the national health transformation plan, and increased healthcare tariffs were the strengths of the Iranian health financing system. On the other hand, regressive financing, high out-of-pocket payments and increased number of health insurance companies were the weaknesses of Iran’s health financing system. Political sanctions, financial crises and increased healthcare demands were the threats, while supportive laws, the NGO’s financial support, increased number of health care organizations and modern technologies were among the important opportunities for the Iranian health financing system. Increasing the health system financial resources through prepayments, structural and policy unification of health insurance system, health service tariff reform and enhancing health system efficiency and healthcare services quality are essential to strengthen the Iranian health financing system.
Conclusion: The Iranian health financing system is not resilient and faces several challenges. The health system policy-makers and senior managers should adopt the recommended strategies to strengthen the national health financing system.

---

Background and Aim: The realist review has been introduced to review and synthesize the evidence related to the implementation of complex healthcare interventions. This method interprets the results of an intervention by explaining the causal relationships between the intervention and the results. This study aimed to explain the methodology of realist review in the health system.
Materials and Methods: This study was conducted using the scoping review. The following databases were used to find articles using appropriate search strategies and relevant key words: Pubmed, Scopus, Science Direct, and Embase electronic databases, as well as Google Scholar and Google search engines. Finally 49 articles were selected (in the period between January 1990 and December 2020) for review.
Results: The realist review is a theory-based approach to synthesize evidence related to the complex interventions, explaining the reasons for the successes or failures of interventions based on the causal relationships between the interventions, contexts, mechanisms and outcomes. A protocol was introduced to conduct a realist review composed of three phases ─ explaining, development and correcting the intervention program theory ─ and including seven steps of determining research questions; explaining the initial program theory; developing search strategies; collecting, evaluating and selecting evidence; synthesizing evidence; modifying the initial theory; and making suggestions. In addition, the structure of a realist review article was described and a checklist for evaluation of a realist review study was introduced.
Conclusion: The realist review is a suitable method for reviewing the complex health system interventions, explaining how an intervention relates to the results obtained. A realist review explains how, under what conditions and for whom a health and therapeutic intervention works.

---

Background and Aim:  The health financing system is the process of collecting, pooling and managing financial resources to purchase health services. Sustainable financing of the Iranian health system is crucial for achieving universal health coverage. The purpose of this study was to identify strategies for sustainable financing of the Iranian health system.
Materials and Methods:  This study was conducted using the scoping review in 2020. The following databases and search engines were searched systematically between 21.03.2002 and 21.09.2020 to find studies related to sustainable financing strategies for the Iranian health system: PubMed, Web of Science, Scopus and Embase, Magiran, Iranmedex and SID databases, and two search engines; i.e., "Google" and "Google scholar”. Finally, 47 studies were selected and analyzed using the MAXQDA software and the framework analysis method.
Results: A total of 40 strategies were identified for strengthening the sustainability of Iran's health financing system, which were grouped into three categories: collecting funds, pooling funds and purchasing health services. The most frequently cited strategies for sustainable financing of the Iranian health system were the following: increasing the health share of gross domestics product, expanding tax revenues, pre-payment methods of health financing, strengthening public-private partnership, increasing the efficiency of the health system, reducing health system costs, consolidating insurance funds, eliminating insurance overlaps, value-based health service tariffs, optimizing health services support packages, and fixed payment methods based on  the performance of the health service providers.
Conclusion: The Iran's health financing system must be strengthened in such a way as to make it possible to collect, pool and manage sufficient financial resources to be used to purchase health services for the people to ultimately ensure universal health coverage leading to the promotion of the public’s health.

---

Background and Aim: The Primary Health Care (PHC) system is the most comprehensive, equitable and efficient way to promote people's health and social welfare by providing preventive, curative, rehabilitative and palliatvie services in a place close to where people live and work. Iran's PHC system faces challenges that limit its effectiveness and efficiency. The aim of this study was to identify strategies to strengthen Iran's PHC system.
Materials and Methods: A realistic review method was used in this research. Published articles on strategies to strengthen the PHC system between 1978 and 2019 were searched in eight databases and Google scholar search engine. Finally, 29 articles were found to be eligible for inclusion in this study; framework analysis was done using the MAXQDA-10 software. 
Results: Twenty-nine strategies were identified for strengthening the PHC system. A well designed PHC system is one with the following characteristics: realistic goals and appropriate strategies  equipped with necessary resources, organized in multidisciplinary teams that provide comprehensive and quality health services (intervention program), with strong governance and leadership, financing, work force, equipment and medicines, information systems and robust health services delivery processes and well adpated to the external environment (context). Such a PHC system will increase healthcare providers’ satisfaction and commitment, as well as the  patients’ trust, participation and satisfaction (the mechanism) and, finally, promotes, restores, and maintains the people health (result).
Conclusion: A strong PHC system is a pre-requisite for strengthening a health system. Various strategies such as strengthening management and leadership, improving organizational structure and culture, improving the information system, empowering human resources and increasing population coverage can lead to an improved PHC system. Historical, social, cultural and economic factors affecting the health system should be considered in redesigning and stregtening a PHC system.