Journal of School of Public Health and

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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.

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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.
 

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Background and Aim: Congenital hypothyroidism is the most common metabolic disease and endocrine disorder in children and a major cause of mental retardation, which can be prevented only through early diagnosis and treatment. This study aimed to determine the prevalence of congenital hypothyroidism in newborns referred to Shahid-Ghodsi Health Center in Mashhad, Iran.
Materials and Methods: This cross-sectional study, including 4484 newborns referred to Shahid-Ghodsi Health Center for congenital hypothyroidism screening, was conducted during the first six months of 2015. Data were collected from the screening forms and analyzed using the statistical software SPSS 21, the tests being the two-sample T-test, analysis of variance, Chi-square and Fisher's exact tests; in all the tests the significance level was 5%.
Results: Of the 4484 neonates screened, 51% and 48% were males and females, respectively. The recall rate was estimated to be 2.6% and prevalence of the disease 1 in 370 neonates. There were statistically significant associations between hypothyroidism on the one hand and birthweight, type of feeding (nutrition), primary and serum TSH levels of the neonate on the other.
Conclusion: Based on the findings, the prevalence of congenital hypothyroidism in Mashhad is significantly higher than that national and global averages. It is essential to conduct more comprehensive research to determine the associated factors and design suitable interventions in order to prevent the disease.
 

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Background and Aim: Adolescents' attitude to suicide is one of the major problems in mental health.  Thus, research in this area is of utmost importance. The objective of this study was to determine the effectiveness of an integrated protocol in reducing the negative attitude toward problem solving as a determinant of suicidal tendency in adolescents and young people 15-24 years old in Ilam, Iran.
Materials and Methods: In this semi-experimental pretest-posttest study with a control group, a sample of 40 adolescents 15-24 years old were selected by random cluster sampling in Ilam city, Iran. All of the participants completed a suicidal attitude questionnaire, as well a negative- attitude-toward-problem solving questionnaire. Data were analyzed using the SPSS-V19 software, the statistical test being the multivariate covariance analysis (MANCOVA).
Results: Multivariate analysis of variance analysis showed that there was a significant difference in the attested scores of the two groups (P <0.01, F = 0.408, Wilk's Lambda = 0.506). The differences between the experimental and control groups were significant as regards all of the components of the negative attitude. The training based on the integrated approach to negative attitude in problem solving was found to have been effective. The post-test scores of two variables, namely, problem tendency-avoidance and personal control, decreased in the experimental group; however, one other variable, namely, trust in problem-solving, increased.
Conclusion: Based on the findings it can be concluded that education based on an eclectic (integrated) approach towards the negative attitude to problem solving can be effective in adolescents and the youth 15-24 years old with suicidal tendencies ─ suicidality. Hence, it is recommended to administer training programs such as problem-solving, emotional regulation and mindfulness to help psychologists, parents, adolescents, health professionals and social pathologists to reduce and prevent suicide in adolescents.

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Background and Aim: Ixodidae (hard ticks) are obligate blood-feeders of vertebrates with majorroles in transmission of pathogenic microorganisms including theileriosis, babesiosis and CCHF virus, as well as relapsing fever, to domestic animals and humans. This study was conducted to determine the distribution of ixodidae species, vectors of Crimean-Congo hemorrhagic fever (CCHF), in the border areas in North West of Iran.

Materials and Methods: This was a descriptive cross-sectional study conducted in Ahar and Kaliybar Counties, East Azarbaijan Province, Iran. Randomized cluster sampling was done in villages in the forest and mountainous regions. Ticks were isolated by forceps from the animals, kept in sampling tubes and transferred to the laboratory. Then the tick samples were identified using taxonomical keys.
Results: A total of 2022 hard ticks were isolated from 1400 head of livestock (1000, 200, 180 and 20 head of sheep, goat, cow and buffalo, respectively).  On the average, the infestation rate was 1.44 per head of cattle ─ 0.11% in goats, 0.32% in sheep, 0.90% in buffaloes, 9.25% cows. Out of the ticks isolated, 498 (24.63%) were male, 741 (36.65%) were female and 782 (38.67%) nymph, plus one larva. The ticks belonged to the lxodidae family, including four genera:  Hyalomma (88.82%, with the following three species: Hyalommaanatolicum (39.22%), Hyalommamarginatum (9.15%) and Hyalommaasiaticum (0.69%)); Rhipicephalus (8.8%); Dermasentor (1.58%); and Haemaphisalis (0.8%). The others identified were Hyalomma nymph (38.67%), Hyalomma sp. (1.04%) and Hyalomma larva (0.05%), Rhipicephalus bursa (5.19%), Rhipicephalussanguineus (3.61%), Dermasentor marinates(1.58%), Haemaphisalissulcata (0.59%), and Haemaphisalispunctata (0.15%), as well as Haemaphisalisconcinae (0.05%).  Hyalommaanatolicum was the dominant species.                                                                                                                                          
  Conclusion: The dominant tick species in the regions studied was Hyalommaanatolicum, a tick having a major role in transmission of many disease vectors including CCHF, ovin babesiosis, theileriosis, anaplasmosis, ehrlichiosis, etc. It is essential that the provincial Contagious Disease Center and Veterinary Department take appropriate action with the collaboration of other relevant departments to combat the tick. 

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Background and Aim: Carbon footprint is an important health, safety and environmental issue that has received much attention by many researchers and studied during the last decade. This research was conducted to assess the carbon footprint and investigate the relationship between carbon dioxide emissions released in the atmosphere and energy consumption in Yadavaran oil field, Iran in 1396.
Material and Methods: Data were collected during the working hours and office hours in the spring and during the month of June, in 64 area offices, operating units, residential camps, and administrative and executive offices. Data for determination of energy consumption were collected and classified using an information-gathering form and field surveys, as well as interviewing the contractors (three interviews to ensure accuracy and precision of the results).
Results: Based on the data analysis the following results were obtained: 1. The total carbon dioxide emissions resulting from electricity consumption, generators consumption and transportation during one month were 1072794/24 KgCO2/Kwh, 5435478 KgCO2/L and 9342704/36 KgCO₂/L, respectively; 2. The total amount of carbon dioxide emissions was estimated in the Yadavaran oil field to be 190211719.2 KgCO₂/year; 3. The total energy consumption in one year was 52229043.92 GJ; 4. The monthly and annual energy consumption levels (BOE) were found to be 8.60 and 103.20 GJ/tone, respectively.
Conclusion: Based on the findings, it is recommended to do the following: 1. Provision of a transportation service for the personnel in Yadavaran oil field; 2. Training of the Yadavaran oil field contractors in the area of optimum energy consumption; 3. Proper management of fossil fuels and transportation in the Yadavaran oil field; 4. Connecting all the regions in the Yadavaran oil field to the city electricity system.

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Background and Aim: Food-borne diseases, with an upward trend worldwide, are a major public health issue. On the other hand, resistance to antimicrobial agents is also a global problem. Thus, a knowledge of antibiotic resistance is vital for the proper treatment of food-borne diseases. The aims of this study were to determine the frequency, antimicrobial resistance and serotyping of Shigella-contaminted food samples in foodborne disease outbreaks in Iran.
Materials and Methods: This was a descriptive study including 1012 fecal swab samples from 239 foodborne disease outbreaks in different provinces of Iran during the period 2005-6. The isolated Shigella samples were transferred to a microbiology laboratory for microbial culture, serogrouping and antibiogram tests.
Results: Out of the1012 fecal swabs collected 29 (2.86%) isolates contained Shigella. The largest Shigella outbreaks (20.6%) were found to have ocurred in 3 provinces, namely,Esfahan, Kurdistan and Semnan. The most common clinical symptoms were abdominal cramping, vomiting, nausea and non-bloody diarrhea. Th frequency of contamination with Shigella Sonnei and  Shigella flexneri was 16 (55.2%) and 13 (44.8%), repectively. The rate of resistance to ciprofloxacin was reported to be 3.4%.
Conclusion: Considering the frequency of food contamination with Shigella in the summer and its  in resistence to ciprofloxacin, assessment of its antimicrobial resistance are very important as regards reduction in treatment costs and taking action to control and prevent the disease.

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Background and Aim: Accreditation is one of the important measures in the evaluation of health services. Today, the issue of accreditation has been established with the aim of creating and promoting a safety culture and quality of patient care. The purpose of this study was to determine the effect of accreditation on key and performance indicators of public hospitals in Zahedan before and after its implementation.
Materials and Methods: This descriptive-analytic cross-sectional study was conducted in 1396 in governmental hospitals of Zahedan University of Medical Sciences (Khatam-ol-Anbia and Ali ibn Abi Talib, AS). All of the key indicators of hospital performance were evaluated two years before the implementation of the accreditation (years 1391-1392) and two years after the implementation of the accreditation (1394-1395) in these hospitals. Data was collected using a form designed for study purposes. Descriptive statistics, tables and descriptive charts were used to draw information.
 Results: Based on the results of the study, the duration of stay of patients after the implementation of the accreditation scheme in hospitals has improved somewhat and decreased by 0.5 days to 4 days in 1395. The rate of cesarean delivery has risen from 49.2% in 1391 to 56.8 in 1395. The percentage of flat occupancy has risen to over 90 percent in 1395. The bed rotation distance was reduced by 31.1%, and releasing by personal desire in 1395 was 9% lower than in 1394. The personal satisfaction score of the emergency releasing by personal desire also dropped by 7%. It should be noted that there was no change in the net mortality index before and after the validation.
Conclusion: Accreditation has had a favorable impact on hospital performance indicators of course, the implementation of the healthcare reform plan may also have an impact on this. In general, the implementation of accreditation in the hospitals of the country can reduce the problems in this sector and provide more quality services to clients. Also, for better implementation of this program, emphasis on mortality and cesarean section rates can lead to improved hospital performance.

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Background and Aim:This research was conducted of determining and comparing the heavy metals of zinc, iron, manganese, copper, nickel and vanadium in summer in waters and sediments of Naseri wetland in Khuzestan province, 2017.
Material and Methods:Sampling of water and sediments from three areas of north, central and southern Naseri wetland was carried out in summer. In order to measure heavy elements, the ICP-OES model Varian 710-ES was used to measure the induction plasma (ICP) and its composition by mass spectrometry (ICP-MS).
Results:The average concentration of heavy metals in Naseri wetland water was obtained at station 3 above the first and second stations. Zinc, iron, copper and vanadium were lower in the wetland water than national and international standards, but higher levels of manganese and nickel were obtained. The average of the concentrations of the studied metals except the nickel in the surface sediments of the wetland in the second station was higher than the first and third stations. Ni was found higher in the sediments of the third station.
Conclusion:The results of calculating the contamination factor showed that heavy metals were zinc, iron, manganese, nickel, vanadium and copper in low pollution levels. The degree of contamination of the studied metals also showed that pollution of Nasseri wetland sediments was low. The degree of contamination of modified heavy metals indicates very low contamination of sediments of Naseri wetland. The ecological risk of zinc, iron, manganese, nickel, vanadium, and copper was in the low-risk category. The total ecological risk of heavy metals at the stations was also classified as low risk.

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Background and Aim: In recent years bullying behaviors among school adolescent have risen and have raised concerns for psychologists, teachers and their families around the world. The use of bullying control methods in schools is important. Therefore, the purpose of this study was to evaluate the effectiveness of bullying control training program on health promotion behaviors in bullying adolescents in Tehran.
Materials and Methods: The statistical population consisted of students aged 12 to 17 years old in public schools in Tehran. A total of 40 subjects (20 controls and 20 experimental groups) were randomly assigned into two groups of experimental and control groups. Using a pilot, pre-test, post-test and one month follow up with the control group, Hartler's bullying questionnaire and health promotion behaviors were implemented on both groups. Then, experimental testing of bullying control training was performed in 8 sessions on the experimental group and after the completion of the sessions the post-test was presented to both groups. After that, a month's follow-up was carried out. For data analysis, multivariate analysis of repeated measurements was performed using SPSSV22 software.
Results: The results showed that the cognitive-behavioral bullying control training program on health promotion behaviors between the two groups was significantly different in three stages (p<0.05).
Conclusion: According to the results of this study, bullying control education can be effective on health promotion behaviors of adolescents aged 12 to 17 years and can be used to improve their health. Parents, teachers, managers and other professionals can learn from these trainings.

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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.                  

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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.
 

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Background and Aim: Man, as the Creator of God and the Creator of Creatures, has a right, one of which is the right to a healthy life, and this type of life can only be achieved through useful training. In this regard, comprehensive health education in schools is one of the most important pillars for the health of the next generation of the country. Therefore, the purpose of this study was to analyze the content of health components and promote the health of primary school books based on the assumptions of the health system with emphasis on education to increase the quality of primary school health.
Materials and Methods: In this descriptive study, content analysis method was used. The statistical population of this study was all second grade elementary school books of 2016-2017 (5 volumes). Statistical sample is equal to statistical population. The research tool was Shanon Entropy, which presents data processing in the context of content analysis in a new and quantitative way.
Results: The results of Shannon's entropy content analysis showed that the review of the 5 primary elementary second-level mental health books had the highest frequency with 236, and the least amount of disability with 10. The highest coefficient of importance among health components in elementary second grade was related to the components of nutrition health (0/21) and the lowest coefficient of prevention to high risk behaviors was (0/019).
Conclusion: Findings show that attention to each component of health education and health promotion is different; therefore, it can be concluded that some components of primary education textbooks pay less attention to some components of health education, while that health education and consequently health promotion is the most important factor in the advancement and guarantee of community survival. Designing, implementing, and managing health development programs is more than any other underlying concept such as health.

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Background and Aim: For achievement of equity in the population health the implementation of health in all policies is essential. The most crucial intervention in this approach is inter-sectoral collaboration.
 Materials and Methods: This was a qualitative study based on the national policy framework. Data were collected using literature review, in-depth interviews and focus group discussions with the stakeholders. The results were categorized into three sections, namely, situational analysis and factors affecting it, developing goals and objectives, and requirements and interventions.
 Results: Currently inter-sectoral collaboration in the Iranian health system potentially allows to have health in all policies policy in terms of explicit legislative support, national macro-policies/upstream documents and organizational structure. It will require proper planning as regards designing and institutionalizing appropriate mechanisms for collaboration, as well as cultural and skills capacity building, for stakeholders within and outside the health sector.
Conclusion: The findings of this study can be used in annual operational planning of the High Council of Health and Food Security secretariat.

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Background and Aim: Economic evaluation of health interventions by comparing the relevant costs and benefits will result in optimum allocation of resources and increasing the effectiveness of the health system and, through improving equity and increasing accessibility to health services, will lead to increased effectiveness of the health system. The purpose of this study was to critically evaluate the Cost Effectiveness Analysis (CEA) studies on health interventions worldwide.
Materials and Methods: A critical review of the published CEA studies on health interventions was conducted. Seven databases including PubMed, Cochrane Database of Systematic Reviews, Web of science, Science Direct, Scopus, Springer Link, and SID were searched between 1975 and 2018, using appropriate keywords. The retrieved articles were evaluated using the Drummond (2005) quality assessment checklist. Overall, 173 articles met the entry criteria and were included in this study.
Results: CEA of health-related interventions were classified into six categories, namely, studies on immunization, education, nutrition, sexually transmitted diseases prevention, gynecological diseases prevention and vector-borne diseases and, eventually, cost-effective interventions were identified. Further analysis of the data showed that the methods used in health intervention CEA studies are very heterogeneous and lack sufficient scientific quality especially in developing countries. Researchers working in this area should pay more attention when designing studies and follow valid guidelines for CEA, particularly as regards research methods, sample size, CEA model, cost and benefit calculations, determining effectiveness, timeframe and, finally,  analysis of  the sensitivity and validity the research data.
Conclusion: The number of cost effectiveness analysis and cost utility studies has increased greatly during the last two decades. In order to improve the quality of these studies it is essential to revise the guidelines and procedures for economic evaluation of health interventions and train and update researchers in this area.

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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.    

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Background and Aim: It is essential to take action to strengthen the national primary health care (PHC) system. The purpose of this study was to conduct a comprehensive review to find ways to strengthen the PHC system in Iran based on the experiences of different countries.
Materials and Methods: This was a comprehensive review study. The relevant studies were retrieved using Science Direct, PubMed, Google Scholar, Scopus, Web of Science, Magiran, Iranmedex and SID databases. Inclusion criteria included all the studies that specifically focused on the factors enhancing the PHC system between 1998 and 2017. Finally, 30 articles were selected.
Results: Strategies for strengthening the PHC system were examined from two different angles: factors that facilitate the performance of the health care team, and ways to improve the implementation of PHC. In addition, strategies have been recommended for the following in order to strengthen the PHC system in Iran: trust-based relationships; widespread implementation of the National PHC Program with a focus on personnel training; teaching healthy lifestyle behaviors and drug side-effects; investing in information technology in the health sector in areas such as immunization, child care and prevention of chronic diseases.
Conclusion: Strengthening primary health care requires coordination and inter-sectoral collaboration; involvement and will of a wide range of health and non-health organizations; government support; strengthening of the referral system and the family physician; strengthening the health team; self-care and community participation; a public health-oriented and preventive approach in macro-policies; and, finally,  allocating more resources to the health sector.

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Background and Aim: The “Package for mental and social health promotion and drug abuse prevention” was developed in response to the importance of, and concerns relate to, the mental and social health in the population. Since any policy and plan needs to be assessed to find its weaknesses, strengths and challenges to ensure its successful implementation, this study aimed to find and explain the executive leadership challenges of this service package from the service provider's perspective.
Materials and Methods: This study was a qualitative research, the data being collected through interviews and reviewing the relevant documents. The research population included experts from Kerman University of Medical Sciences, Kerman, Iran, those in charge of the package implementation, urban community health center officials and health care providers. The interviewees were selected using a targeted sampling method.
Results: Based on the interviews, the findings were categorized into four main themes: low public cooperation, difficulty in communication, missing links in design and implementation of packages, and methods of payment to service providers. In addition, the findings based on reviewing the documents were grouped as objectives, plans, activities, target groups, and interventions related to this service package.
Conclusion: Based on the findings of this study, it can be concluded that the implementation challenges of the mental health care package fall into three categories, namely, policy-making, facilities, and personal challenges. Proper changes and reforms at the public policy-making level, creating individual awareness and providing proper facilities for the implementation of the package can help overcome these challenges.

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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.