Journal of School of Public Health and

---

Natural disasters cause millions of death and disability and major financial losses world wide every year. The major concern of our health system has already been to reduce physical mortality and morbidity. While such events may be a considerable source of stress for the survivors and cause serious and long-lasting psychiatric complications. The purpose of this study was to assess the function of rescuers in mental health service delivery to survivors of Bam earthquake in four steps Rescuing, Emergency services, Transportation of the injured survivors and Treatment in the first 2 weeks after the earthquake. For reaching the purpose 4 groups of the survivors were selected: first group was the healthy survivors (>15 years) living in Bam after the earthquake, the second group was healthy survivors (<15 years) living in Bam after the earthquake, the third group was the injured survivors admitted in Kerman and Tehran hospitals and the last group was the Relatives who accompanied the injured survivors. 2 weeks after the earthquake a questionnaire including questions about, demographic data, function of rescuers in rescuing and emergency services steps, informing the survivors of their relatives condition and Condoling with the survivors and mental health services delivery was filled for each of the cases. In all groups, more than 85% of the cases who needed help and rescued from the load of the earthquake were rescued by their relatives and rescuers of the Red Crescent Society or other governmental organization just had a little portion (5%)in this field. Only 25%of the cases who needed help and rescuing from the load of the earthquake were rescued in the first hour after the earthquake. Only 40% of the cases were sympathized by their rescuers. About 65% of the cases had enough information about their relatives. 40% of the cases were prevented from crying by rescuers. Only 30% of the cases said that they knew addict individuals who were hot given alternative materials. 30/% of the children had played during 2 weeks after earthquake and 42/% of them had facilities for playing. Regarding to all studied groups rescue activities, primary care services and transfers have been performed by relatives and domestic people , therefore general training and organizing CBO (community Based organization) for providing services in disasters especially in regions which are at high risk of earthquake will be useful for reducing the injuries. According to this research rescuers are in serious need of training in mental health services and that major areas of education need are: using counseling techniques, providing the necessary information for the survivors and stress management techniques.

---

Background and Aim: By definition, the ratio of output to input in any firm is called efficiency. In general, there are two main approaches for measuring efficiency ─ parametric and non-parametric. The objective of this study was to assess the efficiency of Health Services Workshops in Iran in 2006.

Methods and Materials: The efficiency of Health Services Workshops in Iran in 2006 was assessed using the non-parametric method, based on linear programming. More specifically, the Data Envelopment Analysis (D.E.A) was used. The most important feature of the Data Envelopment Analysis (D.E.A) is its applicability for the firms that operate under a multiple input-and-output framework. Assessment of efficiency was based on 2 assumptions, namely, fixed and variable efficiency.

Results: The data show that, based on fixed efficiency, the efficiency in the Bushehr, Fars, Kerman, Mazandaran and Yazd provinces is the highest, the average being 80%, which means that the idle capacity is 20% . Based on the variable efficiency. assumption, in Ilam, Chahar Mahal-and-Bakhtiari, Semnan, and Kohgiluyeh Boyerahmad provinces the efficiency is 85% (idle capacity = 20%).

Conclusion: On the whole, the Chaharmahal-Bakhtiyari province is the most efficient in holding Health Services Workshops in Iran. Therefore, other provinces should follow this province as an example when planning to increase their efficiency.

---

Background and Aim: Despite the fact that the proportion of youth population is very high in Iran, there is no well designed, comprehensive reproductive health program for the youth. This prompted the health planners to evaluate all the existing centers that deliver reproductive health services to the youth in the country in order to identify the weaknesses and strengths of the services and the centers.

Materials and Methods: A descriptive analytic study was conducted from March 2006 to March 2007, in coordination with the Vice-chancellor for Health of Universities of Medical Sciences, through Offices for Health of the Youth and Schools (OHYS). Five health centers, namely, Tehran, Semnan, Bam, Chabahar, and Fassa Health Centers (the only centers delivering reproductive health services to the youth) were included in the study. They were assessed for structure and physical facilities, job satisfaction of the personnel, satisfaction of the youth consulting them, and the services (including consultative services) delivered. The data were gathered through questionnaires using a checklist and analyzed by the SPSS-13 software.

Results: The health center personnel thought that the quality of services delivered at the centers was low. They also believed that the physical facilities, including equipment in the clinical examination room, furniture, cleanliness of the premises, and entertainment facilities, were not of an acceptable standard. About 64% of the personnel of the health centers personnel expressed job satisfaction. On the other hand, 39% of the young people consulting the centers expressed full, and 54% relative, satisfaction with the services they were receiving the remaining 7% were not content at all. The highest rate of satisfaction was with the psychologist, physician, and midwife, so that 95% of the clients recommended the centers to other young people seeking reproductive health services. Finally, the clients said that in most of the centers paramedical personnel, including nutrition officers (50%) and midwives with a Master's degree (17.5%), were insufficient.

Conclusion: It is suggested that a comprehensive service package be developed to be used in all the health centers, rather than each center deliver services based on the existing facilities and individual preferences. Such a package should be based on the national reproductive health programs (according to the medical education curricula). Intersectoral collaboration (particularly from the Ministry of Education and cultural organizations) is also very essential.

---

Background and Aim: Pressure ulcer is a common problem and a large drain on hospital resources, especially in wards such as ICU where patients stay for a long time. The aim of this study was to explore the likely factors contributing to pressure ulcers in the ICU units of Tehran University of Medical Sciences teaching hospitals, Tehran, Iran.

Materials and Methods: This project was conducted in all the seven ICUs of four teaching hospitals affiliated to Tehran University of Medical Sciences. In the first phase the researcher performed a direct observation of all the 90 patients who were admitted to the ICU units to check the presence of any pressure ulcer. In the second phase, 310 patients discharged from the same ICU units between March 2007 and February 2008 was randomly selected and their medical records reviewed. A structured questionnaire was used to collect the data.

Results: Pressure ulcer occurred more frequently in the elderly women patients who were less active and had less mobility, hospitalized for a long time, or those with fever, diabetes, high blood pressure, paralysis, or respiratory diseases. In addition, pressure ulcer was seen more frequently in the patients hospitalized in the general ICUs, as well as in those with infections and different types of tumors.

Conclusion: Using a standard risk assessment tool and paying attention to the main risk factors of pressure ulcer can be a useful method for identifying the high-risk patients before admission in order to prevent them from developing such ulcers.

---

 Background and Aim: Global growth in the elderly population for both health care providers and families and also the community is an important challenge . Elders are the largest and fast factor for increasing hospital admissions in Society . Increasing costs of aging is the most concern to elders and their families. This study aimed to investigate the health team s approach about cost–effective alternatives for aging health services.

  This study is a qualitative research which was done through content analysis.

  18 people consisting of five faculty members , 6doctors , 3 nurses and 4health public health expert were participated. Samples were selected based on purposive sampling . Data were collected through interviews .

  Results: Four core themes derived from this study which included: 1- Emphasis on training for aging care ( including training doctors, nurses , health professionals , public health experts, elder sand their family caregivers). 2- Emphasis on proper implementation of primary health care for the elderly. 3- Emphasis on home care for elderly.4-attntion to mental health of elderly.

  Conclusion: It seems effectiveness of tree alternatives emphasis to training, home care and mental health for elderly are obvious and evident, so implementing and applying these suggestions would be helpful.

  But the second alternative emphasis on proper implementation of primary health care for the elderly must be performed based on a comprehensive needs assessment in elders population. Finally it is stressed that calculating and comparing actual costs of each alternative in elders caring must be measured through quantitative researches.

---

  Background: Sexually transmitted infections are one of the most prevalent infections all over the world that impose significant morbidity on people. There are an increasing number of sexually transmitted infections in Islamic Republic of Iran during recent years. So developing and implementing programs for STIs prevention and control is considered as a health priority. While the role of gender based power in sexual relationships has in recent years been acknowledged, the understanding has largely lacked practical considerations in the STIs/HIV/AIDS prevention fields. This study aims to explore gender sensitive STIs/HIV/AIDS prevention services concepts and dimensions.

  Method : This study employed content analyzes research design. Semi-structured in-depth interviews were conducted with 37 expert reproductive health managers and providers that selected purposively and then continued by snow ball method. Data collected by using semi-structured interview guide. The interviews were transcribed and typed. Data was analyzed according to content analysis.

  Results: 2 categories emerged as the result of data content analysis: 1) gender sensitive structure including employers, facilities and management dimensions 2) gender sensitive process including care and educational processes.

  Conclusion: providing gender sensitive STIs/HIV/AIDS prevention services need gender sensitive management, facilities and providers and gender sensitive care and educational design.

---

Background and Aim: The Pars Energy-Economic Special Zone, as the energy capital of Iran, needs a healthy productive workforce. In order to be able to promote equitable health indicators of the Zone, it is essential to first obtain information about the situation of the health system in the region.

Material and Methods: This was a cross-sectional qualitative study. Data were collected using an essential public health services (EPHS) performance assessment questionnaire and a researcher-developed questionnaire for strengths, weaknesses, opportunities and threats (SWOT) analysis of the Zone health system. In the next phase, stakeholder analysis was done:  the major stakeholders were invited and asked, after explaining the methodology to them, to complete, individually, the EPHS performance assessment and the SWOT analysis questionnaires, followed by grouping and summarizing the results. Finally, content analysis of results of the group discussions was done and the main domainsا extracted.

Results: The EPHS overall average score was 37.8 (out of 100, the standard score). The greatest weakness was allocated to information functioning. Delivering public health services by the district health networks was the most important strength. Further analysis of the data showed that the far external environment in all the subdomains was the major threat to the public health in the zone.

Conclusion: Based on the findings, it can be said that the organizational status of the Zone is in a weak and threat position. One of the root causes is poor functioning of the public health system. It is essential that the Ministry of Petroleum and the Ministry of Health and Medical Education find effective ways for integrated leadership of the public health services in the Zone.                 

---

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: Delivering health services to the elderly is one of the most important responsibilities of the health care system of any country. In order to improve the provision of health services to the elderly population under its coverage, the National Social Security Organization conducted this study with the aim of designing, implementing and evaluating a model for providing outpatient health care services to the elderly population under the coverage of its Tehran Province Office. 
Materials and Methods: This was a sequential-exploratory mixed-method study. The initial model was developed and validated using the integrated review method and the final model using the Delphi technique and group discussions with experts. Then the educational program was developed and implemented for the health team. Assessment of the effectiveness of the program was done using a researcher-made knowledge and attitude questionnaire (pre- and post-test). The model was then implemented in the Khandan-e-Hakim Clinic. The effectiveness of the model implementation was determined based on the qualitative content analysis of the interviews with the elderly and qualitative content analysis of the health team comments.
Results: The outpatient care model of the elderly included an organized clinical process consisting of 6 phases. The mean age of the health team members was 45.7±15.11 years. The difference between the health team satisfaction total scores before and after participating in the educational program was statistically significant (P≤0.05). Further analysis of the data showed, based on the interviews with the elderly, the main categories to be "assessment of cognitive function, mood and behavior", "physical assessment", "appreciation of the health and dignity of the elderly" and "satisfaction of the elderly and their companions". Analysis of the comments of the health team revealed their satisfaction with the implementation of the model.
Conclusion: The introduced model can make possible rapid identification of health problems and timely intervention in the elderly population. This implementation model will help disease prevention and complications at different levels. The findings of this study can help service providers to provide better care and health services for the elderly.
 

---

Background and Aim: The health system is trying to prevent unnecessary referrals to higher levels by providing tiered services and thus reduce the cost of health care. Therefore, this study was conducted in Zahedan City, Iran with the aim of finding the causes of referrals from level 1 to higher tiers in rural areas.
Materials and methods: This cross-sectional study was conducted on 458 rural patients referred to the second level in the rural areas of Zahedan City, Iran. Data were collected from the family health files available in the Sib system and analyzed using the SPSS-16 statistical software, the statistical tests being descriptive statistics (percentage, frequency) and Chi-square test.
Results: The highest (57.6%) and lowest (4.1%) proportions of referrals to the second level of service provision were found to have been in 2018 and 2016, respectively. From among the referred patients nearly 50% had been referred due to the need for a higher expertise, thus most referrals (67.2%) were to specialists. Further analysis of the data showed that only in 23.6% of the cases there was a feedback from the higher level to the first level.
Conclusion: The findings show that referrals from family physicians to higher levels in the health system requires higher medical expertise and patient insistence. In addition, feedback to the first level of service provision has not received proper attention. Establishing interactions between physicians and other health service levels, refresher training of physicians, emphasizing the importance of providing feedback and promoting the awareness of patients can reduce to a large extent inappropriate referrals.